May is Mental Health Month

May is Mental Health Month, a time to bring awareness to the importance of good mental health and to fight the stigma associated with mental health treatment.

At Blue Cross Blue Shield of Michigan, we understand the role that mental health plays in overall health and wellness. That’s why we launched our Integrating Behavioral Health into General Medical Care initiative three years ago, as part of our Physician Group Incentive Program.

New Directions Behavioral Health, a Blue Cross vendor that administers behavioral health services, has provided a toolkit of resources to help promote Mental Health Month. The resources include posters, infographics and articles on subjects such as “Four ways to enjoy life more” and “Addressing substance abuse in the workplace.”

We encourage you to check out the “Mind” section of A Healthier Michigan at ahealthiermichigan.org/mind for blogs highlighting mental health issues and the mind-body connection. Also, you can follow Blue Cross on Facebook and Twitter for Mental Health Month information.

Educate patients about how to safely dispose of unused drugs year-round

Prescription drug takeback days are often widely publicized, but many patients are unsure of how to dispose of unused pills at other times of the year. Unused pills in the home, especially opioids, can be dangerous or even deadly.

Your patients can find a disposal site in their local community through the Drug Enforcement Agency or Michigan Opioid Prescribing Engagement Network, called Michigan-OPEN. Both websites include a ZIP code locator to find a location nearby that provides a safe, convenient and anonymous way to dispose of medications year-round.

If no medication takeback program or facility is available for your patients, they can follow some simple steps from the Food and Drug Administration to dispose of most medications in their home as a last resort. However, the ideal way to dispose of unused drugs is to participate in a takeback event, such as National Prescription Drug Take Back Day, or take them to a drug disposal facility.

“It can be tempting for patients to keep unused pills on hand for future use, but they can easily get into the wrong hands of a curious teen or someone already addicted,” said Jody Gembarski. Pharm.D., a clinical pharmacy manager with Blue Cross Blue Shield of Michigan. “More than three out of four people who misuse prescriptions use drugs that are prescribed to friends and family.”

Remind your patients that while medications play an important role in treating many health conditions, it’s important to dispose of them properly to avoid harm to others when they’re no longer needed.

MAPS’ new technology may help providers identify substance abuse disorders

The Michigan Automated Prescription System, or MAPS, began using a new technology platform late last year. This resulted in changes in the type of information provided and how it’s displayed.

MAPS is a tool used by prescribers and dispensers to assess patient risk. It also helps to prevent drug abuse and diversion at the prescriber, pharmacy and patient levels.

The new technology will help providers make better informed decisions when it comes to identifying, preventing and managing substance use disorders.

Here’s an overview of what you’ll currently find on MAPS:

Battling the opioid epidemic: A roundup of news and information

We hope this information is useful as you continue your efforts to combat the opioid epidemic.

Resources help providers communicate about risks, benefits of opioid therapy

The Centers for Disease Control and Prevention offers resources to support its CDC Guideline for Prescribing Opioids for Chronic Pain. The resources were designed to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose and death. You can access them by clicking here.

Reminder: MQIC guideline for opioid use in adults

Here’s a recap of key recommendations from the Michigan Quality Improvement Consortium’s guideline called Opioid Use in Adults Excluding Palliative and End-of-Life Care:

• Treat pain with non-drug therapy and non-opioid medications when possible.
• Screen for risk of dependence.
• Obtain a Prescription Drug Monitoring Program report.
• Perform urine drug testing when warranted.
• Discuss risks of dependency, overdose and death.
• Prescribe the lowest effective dose — three days or fewer for acute pain.
• Discuss realistic goals for pain and function, including discontinuing therapy if benefits don’t outweigh the risks; re-evaluate pain and function throughout the treatment period.
• Avoid prescribing opioids with benzodiazepines, muscle relaxants or hypnotics.
• Consider offering the patient or family member naloxone when there are risk factors for overdose. (Following naloxone use, the patient should be seen immediately in a hospital emergency department.)
• When considering increasing dosage to > 90 MME/day, reassess evidence of individual benefits and risks.
• Avoid renewal without clinical reassessment.

The MQIC guideline was based on the CDC Guideline for Prescribing Opioids for Chronic Pain. To read the MQIC guideline, click here

Mi-CCSI to offer basic and advanced pain management training

The Michigan Center for Clinical Systems Improvement, or Mi-CCSI, in collaboration with its members and community organizations, has developed a comprehensive training program to address patients with acute and chronic pain. The curriculum includes the foundations of pain management, which addresses:

• Basics of pain management mechanisms
• Pathophysiology
• Biopsychosocial aspects of pain
• Pharmacotherapy
• Non-pharmacy treatment approaches

The advanced practical workshops include:

• Approaches for medication tapering
• Conducting difficult conversations with patients
• Comprehensive assessment of biopsychosocial aspects of pain
• Basics of addiction
• Referral and communications strategies with specialty providers
• Using the new automated prescription system

The intended audience includes primary care practice teams or individual providers and clinical and nonclinical staff, including care managers, social workers, medical assistants, office managers and staff, pharmacists and behavioral health specialists.

The dates, locations and registration link are in the table below.

For more information about efforts to address the opioid epidemic, see the articles on appropriate drug disposal and the Michigan Automated Prescription System, also in this issue.

None of the information included in this article is intended to be legal advice.

HCPCS update: New codes added

The Centers for Medicare & Medicaid Services has added several new codes as part of its quarterly Health Care Procedure Coding System updates. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Medicine/professional — Miscellaneous/data gathering

Temporary codes — Durable medical equipment

Medicine supplementary — Injections

Modifiers

Outpatient Prospective Payment System — Injection

Outpatient Prospective Payment System — Surgery

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

Here are more details about changes to our professional provider consultant model

In the March Record, we told you we’d give you more details about upcoming changes to the Blue Cross Blue Shield of Michigan and Blue Care Network professional provider consultant servicing model in future issues. Here’s an overview of what’s changing and how we believe these changes will benefit health care providers going forward.

What’s changing

• We’re encouraging professional providers to always use the standard methods of communicating with us when first contacting us for information or assistance. These are outlined in our resource guides for Blue Cross and BCN.
• We’re improving our processes to better answer your questions and direct you to helpful tips and online information when you contact us the first time.
• We’ll soon be assigning our professional consultants to serve specific Blue Cross Physician Group Incentive Program physician organizations, known as POs, and Blue Care Network medical care groups, or MCGs, to provide education and training on our policies and programs.

How this will help you

• By directing health care providers to standard sources of information, such as Provider Inquiry, we can better identify problems, prioritize efforts and fix problems affecting multiple providers versus addressing issues one practice at a time.
• By improving our processes, we expect you’ll see incremental improvements, resulting in higher levels of satisfaction over time.
• By partnering more closely with POs and MCGs, group administrators can help us focus our educational efforts where they’re needed most.

What you need to know

Here are some important points to keep in mind.

• Contact Provider Inquiry for all claims issues. All professional claims inquiries must be directed to Provider Inquiry (1-800-344-8525 for medical providers; 1-800-482-4047 for vision and hearing providers), even complex claims issues. If your issue isn’t satisfactorily resolved, ask the representative to escalate your inquiry to their leadership.
• Consider joining a physician organization or a medical care group if you’re not already part of one. With the evolution of value-based reimbursement programs, you’ll receive the support you need to transition to a population management-based health care delivery system. Take a look at the groups that are available and see which one is a good fit for your practice.
• Learn how to join a Blue Cross Physician Group Incentive Program physician organization. (Scroll down to find a list of physician organizations.)
• Learn how to join a BCN medical care group.
• Our hospital and facility consultants haven’t changed. Most provider consultant assignments for hospitals and facilities haven’t changed, and the assistance they provide remains the same. If you’re with a hospital or facility, here’s how you can check your assigned provider consultant:
• Go to bcbsm.com/providers.
• Click on Contact Us in the right-hand corner of the page.
• Under Hospitals and facilities, click on either Blue Cross Blue Shield of Michigan provider contacts or Blue Care Network provider contacts.
• Click on Provider consultants.

We value your input about these changes. If you have specific comments or suggestions, contact provideroutreach@bcbsm.com.

We know it will take some time to transition to this new service model and perfect it, and ask for your patience over the next few months as we implement these changes.

We’ve modified provider appeal time frames, effective June 1

In a March Record article, we let you know that changes were coming to how we’re handling provider audits and appeals. Here are the time frames associated with the provider audit appeals process for professional and non-hospital facility providers, beginning June 1, 2018.

For reconsideration appeal:

• The health care provider must request an appeal within 30 calendar days of the date on the reporting letter.
• The provider will receive a response to his or her appeal within 30 calendar days of the date the appeal is received.
• We’ll adjust claims as needed if we don’t receive a reconsideration appeal within 30 calendar days of the date of the audit finding.

For independent external review:

• We must receive the request for a review within 30 calendar days of the date of the reconsideration appeal letter.
• An external peer review of records will take place within 45 calendar days.
• The provider will be notified of the peer review decision within 30 calendar days of the date that the peer review decision is received.
• The provider will pay the cost of the peer review if our audit decision is upheld. If our audit decision is reversed, then we’ll absorb the cost. If our findings are partially reversed and partially upheld, we will share the peer review cost proportionate to the results.
• We’ll adjust claims as needed if we don’t receive a request for an independent external review within 30 calendar days of the date of the appeal uphold letter.

Note: Providers may incur attorney fees and other expenses in preparation for the external peer review; these costs are the providers’ responsibility. The external review ends the appeal process for both Blue Cross Blue Shield of Michigan and the provider.

Benefit Explainer e-learning available

We’ve created a 25-minute, online training presentation for Benefit Explainer. It includes a general overview of the application and how to:

• Perform a Benefit Package Report search.
• Read and interpret BPR search screens.
• Search for general medical and payment policy rules and provider manuals.

The presentation also highlights the new Online Benefits Information tab and other recent upgrades announced in the August 2017 Record article titled “We’re making changes to Benefit Explainer.”

To access the presentation, go to brainshark.com/bcbsm.com/bcbsm/benefit-explainer or visit the Provider Training section of web-DENIS.

• From the home page of web-DENIS, click on BCBSM Newsletters and Resources.
• Click on Newsletters and Resources.
• Click on Provider Training. (The presentation is in the Featured Links section.)

When you access the presentation for the first time, you’ll be asked to sign a guestbook. Check the “Remember Me” box so you can pick up where you left off if you need to stop watching at any point.

Note: Blue Cross Blue Shield of Michigan won’t send solicitation emails or provide your information to anyone for other purposes.

Providers to have one contact for post-acute care authorizations

As Blue Cross Blue Shield of Michigan continues to align functions across our organization, we’ve created a single point of contact for providers to request an authorization for post-acute care admissions, including skilled nursing facilities and long-term acute care hospitals.

As of April 30, 2018, all these requests should be routed to the Precertification Utilization Management team by faxing them to 1-866-411-2573. The process for requesting authorizations can be found here and the forms for faxing can be found on this page, under Forms. As part of the process, all benefits must be verified before you request services.

The Precertification Utilization Management team provides authorizations for acute inpatient hospital settings, inpatient rehabilitation, SNF and Medicare Advantage PPO LTACH cases.

Case Management won’t process requests for enhanced benefits for SNF, LTACH or other extra-contractual benefits as of April 30. These requests will be processed by Precertification Utilization Management. Case Management will continue to process cases for care coordination only. The number for the Blue Cross Engagement Center is 1-800-775 2583.

MESSA is excluded from the precertification and case management programs outlined in this article. All other commercial employer groups, including the auto groups and the URMBT, are included, as well as individual members and Federal Employee Program^® members.

If you have any questions, check out the links above.

Take this advice to help ensure your Medicare patients take their medications

Medication adherence is critical to Medicare patient quality outcomes. The Centers for Medicare & Medicaid Services has stressed the importance of medication adherence by including three triple-weighted clinical pharmacy measures in the star ratings program for Medicare Advantage health care plans.

The three medication adherence measures cover medications for diabetes, hypertension and cholesterol. Member compliance for these three measures is based on the percentage of plan members who fill their diabetes, hypertension or cholesterol prescriptions often enough to cover 80 percent or more of the time they’re supposed to be taking the medication.

Why are patients non-adherent and what can you do to help them?
Here are common reasons why patients don’t take their medication as prescribed and ways you can encourage their compliance.

As a physician, you can have a huge effect on medication adherence. Your insight can help identify reasons why patients struggle with medication adherence, and your expertise can help guide them to healthier outcomes.

Sources:

• Annals of Internal Medicine — annals.org/aim**
• World Health Organization — who.int**
• The American Journal of Managed Care — ajmc.com**

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all medical services are done in accordance with all applicable state and federal laws and regulations.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Here’s what you need to know about colorectal cancer screening

Colorectal cancer screening, a HEDIS^® measure, examines the percentage of adults ages 50 to 75 who get the appropriate screening for colorectal cancer. It excludes patients with a history of colorectal cancer or a total colectomy as well as those in hospice.

Important reminders:

• Begin colorectal screening at age 50 and monitor screening in accordance with screening guidelines. For high-risk patients, begin screenings sooner.
• Perform patient outreach to ensure they complete testing.
• Once the patient is screened for colorectal cancer, submit a claim and document the name of the test, date performed and results in the patient’s medical record.

How to ensure you’re meeting HEDIS specifications (closing the gap):
These preventive screenings meet HEDIS specifications for an appropriate screening for colorectal cancer:

HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance.

Here’s how to accurately code for immunosuppression and immunodeficiency

Patients on immunosuppressant medications are commonly assigned a diagnosis code for immunodeficiency. However, in the American Hospital Association’s manual on ICD-10-CM codes, immunosuppression and immunodeficiency are not synonymous. They’re represented by distinctly different ICD-10-CM codes.

Immunodeficiency
Immunodeficiency is caused by a malfunction of the immune system. This malfunction can be either congenital (primary) or acquired.

Congenital immunodeficiency
There are more than 100 primary immunodeficiency disorders, classified by the specific part of the immune system they affect. Examples include:

• Common variable immunodeficiency
• Bruton’s disease
• Severe mixed immunodeficiency syndrome
• Deficiency of a specific antibody
• Cyclic neutropenia

Acquired immunodeficiency
This can occur in one of two ways:

1. As a side effect or adverse effect of a medication that’s correctly prescribed and properly administered. The medicine is used to treat an underlying disease without the intent to alter the immune state, such as antineoplastic chemotherapy drugs or radiation.**
   
   Example: The physician documents that the patient is immune deficient due to chemotherapy used for treating cancer. The correct code assignment would be T45.1X5-, adverse effect of antineoplastic and immunosuppressive drugs. The required 7th digit is dependent on if the patient is receiving active treatment (A), routine care during the healing or recovery phase (D) or treatment for complications or conditions that arise directly from the condition (S).
   
   
2. As the result of a disease or disorder, such as:
• Cancer
• A human immunodeficiency virus infection leading to acquired immunodeficiency syndrome, or AIDS

Immunosuppression
Immunosuppression is caused by medications prescribed to intentionally suppress the immune system. These medications are used to treat various autoimmune diseases, including:

• Rheumatoid arthritis
• Sjogren’s syndrome
• Psoriasis
• Crohn’s disease

By suppressing the overreactive immune system in patients with these conditions, the immune response triggering the disease process is weakened. Weakening the immune response helps promote remission in afflicted patients.

Immunosuppressant medications are also required for patients who have had an organ transplant. Since the immune system is designed to attack anything foreign within our body, transplanted organs are no exception. By suppressing the immune system, the body is less likely to reject the transplanted organ.

Example: A physician documents that a patient has an immune deficiency and is taking immunosuppressants. The doctor should use code Z79.899 to represent the patient’s long-term immunosuppressant medication therapy. The ICD-10-CM code for immunodeficiency doesn’t provide a specific code to identify these drugs. Since this patient is taking the immunosuppressant medication, with the intent to suppress the immune system, codes for immunodeficiency that’s caused by an adverse effect of drug treatment or from an underlying disease should not be assigned.**

**AHA Coding Clinic for ICD; 2015; third quarter

Provider forums kick off in May

As you read in The Record last month, Blue Cross Blue Shield of Michigan and Blue Care Network’s 2018 provider forums will be held from May through June at various locations across the state.

The morning sessions will have content specifically geared to physician office staff who are responsible for closing gaps related to quality measures and coding. A special morning presentation on understanding the patient experience will be targeted to office managers and staff.

Topics for the morning sessions will include:

• The patient experience — why it’s important to your practice and how you can improve it
• HEDIS^® measures
• 2018 CPT updates and coding scenarios for primary care physicians and specialists

Afternoon sessions will be geared toward all office personnel and will cover topics such as:

• New provider service model
• Authorizations
• e-referral
• The opioid epidemic
• Behavioral health
• Updates for Provider Enrollment and Data Management and the Provider Automated Response System

Here’s the schedule of events:

• Registration begins at 7:30 a.m.
• The morning session starts at 8 a.m., includes a continental breakfast and ends at 11:30 a.m.
• The afternoon session begins at noon, includes lunch and ends at 4 p.m.

You can register for the full day or choose to attend just the morning or afternoon session.

These forums provide valuable information to keep your staff up to date on the latest developments. We look forward to seeing you soon.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

We now cover digital breast tomosynthesis

Blue Cross Blue Shield of Michigan and Blue Care Network now cover digital breast tomosynthesis, or 3-D mammography, as a screening or diagnostic modality to assess and manage breast cancer for individuals meeting certain criteria, effective March 1, 2018.

Digital breast tomosynthesis may be considered when used in combination with digital screening mammography in high-risk individuals, or a qualified health care provider (ordering provider or radiologist) determines that it should be the primary mammographic study.

For the medical policy, see the billing chart in the April Record.

ClaimsXten™ will include additional professional and outpatient facility editing in July

ClaimsXten will edit additional services for professional and outpatient providers starting in July 2018. These new edits will promote correct coding and simplify our claims payment systems.

Here are highlights:

• New patient services billed for established patients by professional providers within the established time frames will deny for correct established patient code.
• Anesthesia services reported with non-anesthesia codes that aren’t eligible to be reported for anesthesia providers will deny for resubmission with the correct anesthesia code.
• Procedures that allow global component billing that are reported by more than one provider for the same component will deny. Blue Cross’ payment policy only pays up to the global component fee.
• Claim lines containing services that are unbundled, according to the Centers for Medicare & Medicaid Services National Correct Coding Initiative, aren’t recommended for reimbursement and will deny.

When appropriate, Blue Cross will support the use of modifiers that indicate unique circumstances for individual patients. The use of modifiers should be documented in the patient’s medical records.

Here’s what you need to know about CAQH ProView

To ensure your CAQH ProView^TM credentialing and recredentialing applications are processed efficiently, follow the guidelines below.

Retirement status

• When answering the question “Are you retired” on your application, you should only select “Yes” if you have completely retired from providing medical or behavioral health services to members. Answering “Yes” signifies that you’re retired from practicing.

• If you move to a new location, practice group or physician organization, you should include this information in your demographic responses on ProView where indicated. Don’t answer “Yes” to indicate you’ve retired from a location, practice, etc.

Health plan authorization

As previously shared, Blue Cross Blue Shield of Michigan utilizes CAQH to obtain credentialing verifications for physicians during recredentialing cycles. To avoid delays, you must list Blue Cross as one of the health plans authorized to obtain and receive your information from CAQH.

Update your practice information

Review the demographic information for your practices this quarter to ensure its up to date. Pay close attention to the following:

• If you’re an individual practitioner, review all your practice locations and ensure they’re updated in CAQH Proview, including address, suite numbers and phone numbers.
  
  
• If you’re a practice group, ensure all your practice locations are updated, including suite numbers and phone numbers, through the Provider Self-Service tool.
  
  
• Locations and providers that don’t see patients for appointments should be suppressed so they’re not visible to members in the online directory. Emergency room physicians and administrative addresses are examples of information that shouldn’t be displayed in the directory.

For more information

Here are some resources for providers and their practice managers:

• For help with CAQH ProView, go to caqh.org/solutions/caqh-proview or call CAQH at 1-888-599-1771.
• For help with the Provider Self-Service tool, go to bcbsm.com/providers. To sign up for self-service, follow these steps:
• Click on the Join Our Network tab and then Enrollment and Changes.
• Click on self-service FAQ.
• Click on How do I sign up?

You can also call Provider Enrollment at 1-800-822-2761.

Clarification: Authorizations for outpatient infusions

In previous Record articles (October 2017, December 2017 and March 2018), we indicated that certain medical drugs can no longer be administered in an outpatient hospital facility without authorization for the medical drug and location. We wanted to clarify the following:

This authorization requirement only applies to groups that are currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

You can find the list of groups that opted out of the Medical Drug Prior Authorization Program on web-DENIS by following these steps:

1. After logging in to web-DENIS, click on BCBSM Provider Publications and Resources.
2. Click on Newsletters & Resources.
3. Under Other Resources,click on Forms.
4. Click on Physician administered medications.
5. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

Be sure to review the message and notes that precede the list.

We’ve modified provider appeal time frames, effective June 1

In a March Record article, we let you know that changes were coming to how we’re handling provider audits and appeals. Here are the time frames associated with the provider audit appeals process for professional and non-hospital facility providers, beginning June 1, 2018.

For reconsideration appeal:

• The health care provider must request an appeal within 30 calendar days of the date on the reporting letter.
• The provider will receive a response to his or her appeal within 30 calendar days of the date the appeal is received.
• We’ll adjust claims as needed if we don’t receive a reconsideration appeal within 30 calendar days of the date of the audit finding.

For independent external review:

• We must receive the request for a review within 30 calendar days of the date of the reconsideration appeal letter.
• An external peer review of records will take place within 45 calendar days.
• The provider will be notified of the peer review decision within 30 calendar days of the date that the peer review decision is received.
• The provider will pay the cost of the peer review if our audit decision is upheld. If our audit decision is reversed, then we’ll absorb the cost. If our findings are partially reversed and partially upheld, we will share the peer review cost proportionate to the results.
• We’ll adjust claims as needed if we don’t receive a request for an independent external review within 30 calendar days of the date of the appeal uphold letter.

Note: Providers may incur attorney fees and other expenses in preparation for the external peer review; these costs are the providers’ responsibility. The external review ends the appeal process for both Blue Cross Blue Shield of Michigan and the provider.

Here’s an update on the two-midnight rule and provider audits

As of July 31, 2017, Blue Cross Blue Shield of Michigan implemented a prior authorization request process to determine coverage for inpatient care. Using evidence-based criteria, this process focuses on reducing costly overutilization of inpatient services and admissions while providing safe, high-quality care. The prior authorization request process, outlined in the Medicare Plus Blue^SM PPO manual, takes precedence over the original Medicare coverage determination process and the “two-midnight” rule.

As such, Provider Audit, through HMS^®, a Blue Cross vendor, is not currently conducting short-stay or place-of-service audits. We’re still conducting documentation and compliance audits of valid inpatient orders and Medicare Outpatient Observation Notice, or MOON, forms. In accordance with Centers for Medicare & Medicaid Services and Blue Cross rules, providers should follow documentation and compliance requirements closely to avoid possible recovery of funds during claims processing and post-payment audits.

We’ll continue to audit for procedures on the CMS inpatient-only list. However, because CMS has deferred the enforcement of joint replacement surgery reviews for two years, Provider Audit has no plans to review those admissions in the near term.

If you have any general questions about the audit process, reach out to your provider consultant.

Also, we’re modifying the provider appeals time frames for non-hospital facility and professional providers. For information, see this article.

Benefit Explainer e-learning available

We’ve created a 25-minute, online training presentation for Benefit Explainer. It includes a general overview of the application and how to:

• Perform a Benefit Package Report search.
• Read and interpret BPR search screens.
• Search for general medical and payment policy rules and provider manuals.

The presentation also highlights the new Online Benefits Information tab and other recent upgrades announced in the August 2017 Record article titled “We’re making changes to Benefit Explainer.”

To access the presentation, go to brainshark.com/bcbsm.com/bcbsm/benefit-explainer or visit the Provider Training section of web-DENIS.

• From the home page of web-DENIS, click on BCBSM Newsletters and Resources.
• Click on Newsletters and Resources.
• Click on Provider Training. (The presentation is in the Featured Links section.)

When you access the presentation for the first time, you’ll be asked to sign a guestbook. Check the “Remember Me” box so you can pick up where you left off if you need to stop watching at any point.

Note: Blue Cross Blue Shield of Michigan won’t send solicitation emails or provide your information to anyone for other purposes.

Providers to have one contact for post-acute care authorizations

As Blue Cross Blue Shield of Michigan continues to align functions across our organization, we’ve created a single point of contact for providers to request an authorization for post-acute care admissions, including skilled nursing facilities and long-term acute care hospitals.

As of April 30, 2018, all these requests should be routed to the Precertification Utilization Management team by faxing them to 1-866-411-2573. The process for requesting authorizations can be found here and the forms for faxing can be found on this page, under Forms. As part of the process, all benefits must be verified before you request services.

The Precertification Utilization Management team provides authorizations for acute inpatient hospital settings, inpatient rehabilitation, SNF and Medicare Advantage PPO LTACH cases.

Case Management won’t process requests for enhanced benefits for SNF, LTACH or other extra-contractual benefits as of April 30. These requests will be processed by Precertification Utilization Management. Case Management will continue to process cases for care coordination only. The number for the Blue Cross Engagement Center is 1-800-775 2583.

MESSA is excluded from the precertification and case management programs outlined in this article. All other commercial employer groups, including the auto groups and the URMBT, are included, as well as individual members and Federal Employee Program^® members.

If you have any questions, check out the links above.

Here’s how to accurately code for immunosuppression and immunodeficiency

Patients on immunosuppressant medications are commonly assigned a diagnosis code for immunodeficiency. However, in the American Hospital Association’s manual on ICD-10-CM codes, immunosuppression and immunodeficiency are not synonymous. They’re represented by distinctly different ICD-10-CM codes.

Immunodeficiency
Immunodeficiency is caused by a malfunction of the immune system. This malfunction can be either congenital (primary) or acquired.

Congenital immunodeficiency
There are more than 100 primary immunodeficiency disorders, classified by the specific part of the immune system they affect. Examples include:

• Common variable immunodeficiency
• Bruton’s disease
• Severe mixed immunodeficiency syndrome
• Deficiency of a specific antibody
• Cyclic neutropenia

Acquired immunodeficiency
This can occur in one of two ways:

1. As a side effect or adverse effect of a medication that’s correctly prescribed and properly administered. The medicine is used to treat an underlying disease without the intent to alter the immune state, such as antineoplastic chemotherapy drugs or radiation.**
   
   Example: The physician documents that the patient is immune deficient due to chemotherapy used for treating cancer. The correct code assignment would be T45.1X5-, adverse effect of antineoplastic and immunosuppressive drugs. The required 7th digit is dependent on if the patient is receiving active treatment (A), routine care during the healing or recovery phase (D) or treatment for complications or conditions that arise directly from the condition (S).
   
   
2. As the result of a disease or disorder, such as:
• Cancer
• A human immunodeficiency virus infection leading to acquired immunodeficiency syndrome, or AIDS

Immunosuppression
Immunosuppression is caused by medications prescribed to intentionally suppress the immune system. These medications are used to treat various autoimmune diseases, including:

• Rheumatoid arthritis
• Sjogren’s syndrome
• Psoriasis
• Crohn’s disease

By suppressing the overreactive immune system in patients with these conditions, the immune response triggering the disease process is weakened. Weakening the immune response helps promote remission in afflicted patients.

Immunosuppressant medications are also required for patients who have had an organ transplant. Since the immune system is designed to attack anything foreign within our body, transplanted organs are no exception. By suppressing the immune system, the body is less likely to reject the transplanted organ.

Example: A physician documents that a patient has an immune deficiency and is taking immunosuppressants. The doctor should use code Z79.899 to represent the patient’s long-term immunosuppressant medication therapy. The ICD-10-CM code for immunodeficiency doesn’t provide a specific code to identify these drugs. Since this patient is taking the immunosuppressant medication, with the intent to suppress the immune system, codes for immunodeficiency that’s caused by an adverse effect of drug treatment or from an underlying disease should not be assigned.**

**AHA Coding Clinic for ICD; 2015; third quarter

We now cover digital breast tomosynthesis

Blue Cross Blue Shield of Michigan and Blue Care Network now cover digital breast tomosynthesis, or 3-D mammography, as a screening or diagnostic modality to assess and manage breast cancer for individuals meeting certain criteria, effective March 1, 2018.

Digital breast tomosynthesis may be considered when used in combination with digital screening mammography in high-risk individuals, or a qualified health care provider (ordering provider or radiologist) determines that it should be the primary mammographic study.

For the medical policy, see the billing chart in the April Record.

ClaimsXten™ will include additional professional and outpatient facility editing in July

ClaimsXten will edit additional services for professional and outpatient providers starting in July 2018. These new edits will promote correct coding and simplify our claims payment systems.

Here are highlights:

• New patient services billed for established patients by professional providers within the established time frames will deny for correct established patient code.
• Anesthesia services reported with non-anesthesia codes that aren’t eligible to be reported for anesthesia providers will deny for resubmission with the correct anesthesia code.
• Procedures that allow global component billing that are reported by more than one provider for the same component will deny. Blue Cross’ payment policy only pays up to the global component fee.
• Claim lines containing services that are unbundled, according to the Centers for Medicare & Medicaid Services National Correct Coding Initiative, aren’t recommended for reimbursement and will deny.

When appropriate, Blue Cross will support the use of modifiers that indicate unique circumstances for individual patients. The use of modifiers should be documented in the patient’s medical records.

Here’s what you need to know about CAQH ProView

To ensure your CAQH ProView^TM credentialing and recredentialing applications are processed efficiently, follow the guidelines below.

Retirement status

• When answering the question “Are you retired” on your application, you should only select “Yes” if you have completely retired from providing medical or behavioral health services to members. Answering “Yes” signifies that you’re retired from practicing.

• If you move to a new location, practice group or physician organization, you should include this information in your demographic responses on ProView where indicated. Don’t answer “Yes” to indicate you’ve retired from a location, practice, etc.

Health plan authorization

As previously shared, Blue Cross Blue Shield of Michigan utilizes CAQH to obtain credentialing verifications for physicians during recredentialing cycles. To avoid delays, you must list Blue Cross as one of the health plans authorized to obtain and receive your information from CAQH.

Update your practice information

Review the demographic information for your practices this quarter to ensure its up to date. Pay close attention to the following:

• If you’re an individual practitioner, review all your practice locations and ensure they’re updated in CAQH Proview, including address, suite numbers and phone numbers.
  
  
• If you’re a practice group, ensure all your practice locations are updated, including suite numbers and phone numbers, through the Provider Self-Service tool.
  
  
• Locations and providers that don’t see patients for appointments should be suppressed so they’re not visible to members in the online directory. Emergency room physicians and administrative addresses are examples of information that shouldn’t be displayed in the directory.

For more information

Here are some resources for providers and their practice managers:

• For help with CAQH ProView, go to caqh.org/solutions/caqh-proview or call CAQH at 1-888-599-1771.
• For help with the Provider Self-Service tool, go to bcbsm.com/providers. To sign up for self-service, follow these steps:
• Click on the Join Our Network tab and then Enrollment and Changes.
• Click on self-service FAQ.
• Click on How do I sign up?

You can also call Provider Enrollment at 1-800-822-2761.

Process for billing DME, custom P&O medical supplies changing, starting July 1

After a few years of development, we’re now in the final stages of updating our claims processing system to align with the Centers for Medicare & Medicaid Services’ off-the-shelf policy.

Starting July 1, 2018, all durable medical equipment and medical supply providers who bill for custom prosthetic and orthotic services will be required to bill claims with a separate, CMS-accredited P&O provider PIN. If you bill for custom P&O HCPCS codes and you don’t submit your claim with a separate, CMS-accredited, P&O PIN, your claims will reject as “provider liable.” If you don’t already have your CMS-accredited P&O provider PIN, you can get more information by visiting the National Supplier Clearinghouse** website.

CMS does allow DME, P&O and medical supply providers to bill for specific off-the-shelf orthotic HCPCS codes without any accreditation requirement.

If you still need to update your provider certification information with Blue Cross Blue Shield of Michigan, contact Provider Enrollment and Data Management at 1-800-822-2761.

** Blue Cross Blue Shield of Michigan doesn’t own or control this website.