BCBSM to change professional provider fees July 1

BCBSM will change practitioner fees, effective with dates of service on or after July 1, 2014, for services provided to our Traditional, TRUST and Blue Preferred Plus^SM members, regardless of customer group.

BCBSM will use the 2014 Medicare resource-based relative value scale for all relative value unit-priced procedures for dates of service on and after July 1. Most fees are currently priced using the 2013 values.

Changes in resource-based relative values can impact fees. Procedure code maximum fees will increase or decrease based on the new relative value units and BCBSM’s conversion factors.

At the same time, the non-relative value unit-based anesthesia services will be increased by 1.5 percent in West Michigan and the rest of the state.

We conduct a comprehensive analysis of professional provider performance and current economic indicators annually to calculate practitioner fees, with consideration for corporate and customer cost concerns. BCBSM remains committed to reviewing professional provider performance to determine the need for increases or decreases in our maximum payments.

Fee schedules with the new fees that are effective July 1, 2014, will be available on web-DENIS April 1. Click on Entire Fee Schedules and Fee Changes on the web-DENIS BCBSM Provider Publications and Resources page to find fee information. Only claims submitted with dates of service on or after July 1 will be reimbursed at the new rates.

Please note that the Physician Group Incentive Program physician organization reward component of professional fees remains the same this year.

For more information, contact your BCBSM provider consultant.

Professional groups can register for online enrollment tool

Did you know Blue Cross Blue Shield of Michigan and Blue Care Network have a Provider Enrollment and Change Self-Service online application? It makes it easier for professional group administrators to update group information and enroll new practitioners within their groups.

Experience the advantages of the Blues' new Provider Enrollment and Change Self-Service application. Register now.

The benefits of self-service
This application benefits practice group administrators in several ways:

• Easy — The self-service application is more streamlined and electronic, making it easier to keep your group records up to date.
• Fast — Your enrollment and change requests are processed quickly, with some transactions completed within minutes.
• Secure — Your data remains secure since the practice group determines its users and their access levels, and the application provides an audit trail for every transaction.
• Accurate — You control the data entered for enrollment and change requests. You’ll be able to check your group information and the status of your enrollment and change requests online anytime with a few mouse clicks.
• Green — The need to print and fax forms is greatly reduced, which saves money and is more environmentally friendly.

Provider Enrollment and Change Self-Service is available for the following transactions:

Register for Provider Enrollment and Change Self-Service
Group administrators with responsibility for maintaining data of professional groups of health care practitioners and allied providers are eligible to register for access to the Provider Enrollment and Change Self-Service application. These registered group administrators and their designated staffs will be able to maintain information only for their group providers enrolled with the Blues who use Type 2 (group) national provider identifiers.

Register now so you can experience the benefits of online enrollment and change processing. The self-service application is available within 10 days of submitting your registration request.
Registration steps:

1. All users must have access to BCBSM Provider Secured Services. If you do not have this access, you must first register for Provider Secured Services.
2. Your group then completes Addendum G to select a practice administrator and designate users and the level of access for each user.

Independent physicians or practitioners who are solo practitioners (not part of a group) and facility providers must continue to follow current enrollment and change processes.

For more information, go to the enrollment page or contact your BCBSM provider consultant.

Old version of CMS-1500 claim form discontinued

As you’ve read in previous issues of The Record, Blue Cross Blue Shield of Michigan is no longer accepting the 08/05 version of the CMS-1500 claim form or the Status Claim Review Form, effective April 1, 2014.

You need to use the revised CMS-1500 form, version 02/12. This form replaces both the old CMS-1500 (version 08/05) and the Status Claim Review Form.

If you submit an old CMS-1500 form (version 08/05) or Status Claim Review Form, it will be returned.

You can order the revised CMS-1500 claim form (version 02/12) by completing the Facility and Professional Supply Requisition form. There are two ways to access the form.

1) Through your provider manual:

• From web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Click on Provider Type and select yours from the “Make Selection” box.
• Click on the Search button and then on the Blue Pages Directory chapter.
• Click on Forms and supplies and then on Facility and Professional Supply Requisition.
• Print and complete the form and mail it, along with a check for the total amount of your order, to the address provided on the form.

2) Through the Newsletters & Resources page:

• From web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Facility and Professional Supply Requisition form, which you can access from the list of frequently used forms on the right side of the screen.
• Print and complete the form and mail it, along with a check for the total amount of your order, to the address provided on the form.

For more information about the revised form, refer to your BCBSM provider manual, contact your provider consultant or check out the article in the March Record.

Find out the latest BCBSM guidelines for home, in-lab sleep testing

Home sleep testing has become an alternative to in-lab polysomnography for the diagnosis and management of moderate to severe sleep apnea.

Blue Cross Blue Shield of Michigan is discussing a program for the appropriate use of home and in-lab sleep testing with the help of the professional sleep community.

In the meantime, here are some guidelines for sleep testing that BCBSM aligns with:

• The American Medical Association’s sleep testing guideline revisions featured in the November 2011 edition of CPT Assistant (Pages 3-4)
• The CPT 2014 Professional Edition manual
• The Centers for Medicare & Medicaid Services coverage guidelines**
• The American Academy of Sleep Medicine’s guidelines for attended polysomnogram

In addition, BCBSM has its own policies for sleep testing:

• Polysomnography is provided in the laboratory setting and is attended by a technician, with the patient sleeping in the laboratory at the time of testing. The place of service must be designated as either an outpatient hospital facility or a doctor’s office. The CPT codes for in-lab testing are *95782, *95783, *95805, *95808, *95810 and *95811, which are listed in the CPT manual.

• Home sleep tests are unattended by a technician. The patient is sleeping at home, and the data is recorded and stored on the home sleep testing device for professional analysis at a later time. These home sleep studies are also known as remote studies, and the place of service must be designated as home. Most providers use the CPT code *95806 for this service, however BCBSM is in the process of expanding the codes used for home sleep testing, including the G codes. We will implement these codes at a later date.

• BCBSM defines the place of service as where the patient is located at the time the service is performed.

• The real-time remote recording and transmission of sleep testing data, including audio-visual patient recordings to a central monitoring station, does not meet BCBSM’s telemedicine policy.

**BCBSM does not control this website or endorse its general content.

Follow these guidelines to avoid errors on medical record entries for physician office infusion therapy services

By following the “BCBSM Documentation Guidelines for Physicians and Other Professional Providers,” available through your online provider manual, you’ll avoid mistakes that could result in a potential audit recovery. The current guidelines for medical record entry, as they apply to physician office infusion therapy services, are summarized and expanded upon below. Each medical record entry, including verbal orders, instructions and dictation, must include:

• The date and actual time of infusions or injections
• A signature, which should be legible and easily authenticated. (By using a first name only, the entry is considered incomplete.)
• BCBSM accepts written (cursive or printed) or computer (electronic) signatures. We don’t accept stamped signatures.
• Electronic signatures:
• The system must verify the electronic signature at the end of each note. An acceptable signature should have one of the following lead-in phrases: “electronically signed by,” “authenticated by,” “approved by,” “completed by,” “finalized by” or “validated by.” This should be followed by the provider’s name, credentials and date signed.
• The process must be password-protected and used exclusively by the individual physician.
• Credentials of the person administering the drug (for example, “Mary Jones, P.A.”)
• A patient ID on each page of the medical record, including test data and reports

Documentation created after the first notification (by phone, mail or fax) of an audit won’t be accepted as part of the medical record.

For more information, please see the “Documentation Guidelines for Physicians and Other Professional Providers” chapter in your online provider manual. To view the chapter:

• From web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Click on Provider Type and select yours from the “Make Selection” box.
• Click on the Search button and then on the "Documentation Guidelines for Physicians and Other Professional Providers" chapter.

Procedures eligible for bilateral (modifier 50) available through Clear Claim Connection™

The bilateral modifier 50 fees will no longer be displayed on Entire Fee Schedules, published on web-DENIS, for effective dates on or after July 1, 2014. Also, beginning April 1, 2014, they won’t be displayed on fee change schedules.

The Entire Fee Schedules are published annually and there are procedure code changes related to modifier 50 occurring quarterly. That means providers can determine procedure codes and verify modifier 50 eligibility by accessing Clear Claim Connection™, also known as C3.  

C3 is our provider-facing claim simulation tool. Be sure to review the terms and conditions page for applicable services this tool relates to. Clinical edits and rationale contained within C3 must not be used as a guarantee of payment or a source of benefit policy information.

For your convenience, in addition to the link currently available through web-DENIS, we’ve added a link to C3 to the Entire Fee Schedules and Fee Changes front page. That will allow you to validate modifier 50 eligibility by entering the procedure code and modifier 50 in C3.

You can calculate the bilateral fee this way:

• If the code is radiology or an add-on code, the modifier 50 fee will be 200 percent of the non-modifier 50 (single procedure) fee.
• Otherwise, the modifier 50 fee will be 150 percent of the non-modifier 50 (single procedure) fee.

For more information about Clear Claim Connection™, see the article in the February 2012 Record or contact your provider consultant.

Don’t forget to reattest with CAQH^®every 120 days

Did you know that if you don’t reattest with CAQH every 120 days, you won’t be included in our provider directories, including our “Find a Doctor” search tool?

That’s one of the main reasons it’s so important to take the time to perform this important task.

Here are some other reasons to reattest with CAQH, a nonprofit alliance of health plans and trade associations focused on simplifying health care administration:

• To ensure that your affiliation with the Blues isn’t interrupted
• To update your CAQH information if you change your practice location.
• To ensure that claims payment isn’t interrupted.

Blue Cross Blue Shield of Michigan uses CAQH to gather and coordinate our practitioner credentialing information. All health care practitioners, including hospital-based health care providers and nurse practitioners, need to be registered with CAQH.

If you have any questions about CAQH, call the CAQH help desk at 1-888-599-1771 or go to CAQH.org.**

For information about the credentialing process, contact your provider consultant.

**BCBSM does not control this website or endorse its general content.

MMBA annual billing expo set for May 8, 9

The Michigan Medical Billers Association’s Seventh Annual Billing Expo will take place May 8-9, 2014, at the Soaring Eagle Casino and Resort in Mt. Pleasant.

Blue Cross Blue Shield of Michigan representatives will attend this new two-day format and Blue Care Network will be a vendor at this year’s expo. Topics include ICD-10, worker’s compensation, clinical documentation improvement, health care exchange, HIPAA and more.

Registration is open to MMBA members and non-members alike. You can register online at mmbaonline.org**.

**Blue Cross Blue Shield of Michigan does not control this website or endorse its general content.

Speech pathologists, physical therapists, occupational therapists may apply to participate with BCBSM and BCN before Medicare approval letter received

As of March 1, 2014, independent occupational therapists, independent physical therapists and independent speech language pathologists may be considered for temporary participation with Blue Cross Blue Shield of Michigan and Blue Care Network.

The provider must have applied as a supplier to Medicare and must comply with our provisional agreement process.

A therapist will be considered for temporary participation only if they submit:

• The New Practitioner Enrollment Form
• A signature document for each network the provider is applying for
  
  Note: You can access both the New Practitioner Enrollment Form and the signature documents by going to bcbsm.com/providers:
• Click on the Join the Blues Network tab.
• Click on Enrollment and Changes.
• Click on Provider Enrollment and follow the prompts.
 
• A BCBSM and BCN Medicare Supplier Provisional Agreement. (Contact Provider Enrollment and Data Management at 1-800-822-2761 to obtain this document.)
• All other required documents
• For IOTs and IPTs:
• State of Michigan professional license
• Type 1 national provider identifier
• Social Security Number
• Tax identification number and Internal Revenue Service document identifying TIN and associated payee name (W-9s not accepted)
• Council for Affordable Quality Healthcare number if available
• For ISLPs:
• State of Michigan professional license if available
• Certificate of Clinical Competence from the American Speech-Language Hearing Association
• Type 1 national provider identifier
• Social Security Number
• Tax identification number and Internal Revenue Service document identifying TIN and associated payee name (W-9s not accepted)
• Council for Affordable Quality Healthcare number if available

If you have any question regarding provider enrollment, contact Provider Enrollment and Data Management at 1-800-822-2761.

Countdown begins for Blues retiring local system

	Countdown to local system retirement
	5 months
All claims filed on the local system must be submitted and received by Sept. 15, 2014, in order to be processed. For more details, please see the March 2014 Record article.

The Blues will retire its local system on Oct. 31, 2014. Since we will no longer process claims on that system, all claims filed on the local system must be submitted and received by Sept. 15, 2014, in order to be processed.

It’s imperative that all health care providers follow claim-filing deadlines. If you submit a claim after the filing limits, Blue Cross Blue Shield of Michigan will not offer any special handling or filing extensions, and no payment will be due from BCBSM or the subscriber.

Clarification: We received some questions from health care providers after publishing an article on this topic in the March 2014 Record. Please note that both Medicare Advantage and local group numbers contain five digits. If the member’s ID card does not indicate Medicare Advantage on it, it’s a local group number — and it’s among those that will be discontinued as part of the retirement of the local system. If you have any questions, please contact your provider consultant.

Changes to autism procedure codes coming in April, a reminder about billing guidelines

Blue Cross Blue Shield of Michigan has approved three new procedure codes for billing applied behavior analysis services. These new codes can be used when you bill for dates of service on or after April 1, 2014.

Procedure code G9012 (supervision) that’s currently used when billing for ABA services can’t be used for dates of service after March 31, 2014.

The activity details for procedure codes H0031 and H0032 have changed to align with the state of Michigan guidelines for reimbursable autism codes. This change is effective when you submit claims for dates of service on or after April 1, 2014. See the table below for details.

Providers should remember that services for ABA should be billed in whole units only when you submit claims.

More information about billing for ABA services
For more details, refer to the Applied Behavior Analysis Billing Guidelines and Procedure Codes document on web-DENIS.

Log in to web-DENIS.

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• In the left-hand navigation under “Other Resources,” click on Clinical Criteria & Resources.
• Under “Resources,” click on Autism.

Here are answers to some frequently asked questions about ICD-10

By now, everyone knows that the federal government is requiring the health care industry to begin using ICD-10 codes in place of ICD-9 codes, beginning with dates of service Oct. 1, 2014.

For months now, BCBSM has been offering our health care providers information about the transition, seminars, conference calls and many other avenues of information to try and get the word out about this extremely important initiative.

Below we have collected some of the most common questions and answers that we receive about ICD-10 on a regular basis. We will continue to publish questions and answers, as well as other information about ICD-10, each month from now through the end of the year.

Typical ICD-10 questions
Q: When is implementation?
A: Oct. 1, 2014

Q: What billing information can you give me about ICD-10?
A: ICD-10 is based on the date of service.

• Dates of service before Oct. 1, 2014 would use ICD-9 codes and qualifiers.
• Dates of service on or after Oct. 1, 2014 would use ICD-10 codes and qualifiers.
• Dates of discharge for inpatient services on or after Oct. 1, 2014 would use ICD-10 codes.
• Billing date means nothing for use of these codes.
• Files can contain both claims with ICD-9 and ICD-10 claims.
• Individual claims cannot contain both ICD-9 and ICD-10 codes and qualifiers. This includes services that “span the ICD-10 implementation date.” This refers, for example, to a patient who is admitted to a hospital prior to the implementation date and is discharged after Oct. 1, 2014, when ICD-10 codes are in effect. BCBSM is following the Centers for Medicare and Medicaid Services guidelines when it comes to ICD-10 billing information. Look here** for more information about the CMS guidelines.

Q: What are the major changes for ICD-10?
A: The ICD-10 implementation affects diagnosis and inpatient procedure codes.

• ICD-10 does not affect CPT and HCPCS coding for outpatient procedures and physician services
• ICD-10 codes differ in length and structure from ICD-9 codes. (The maximum number of digits in ICD-10 is seven as opposed to five for ICD-9.)
• The code set contains more detail about conditions, injuries and illnesses.
• It includes the concept of laterality (codes for left and right side of body), combination codes (for conditions and associated symptoms) and uses updated language and terminology
• Approximately 150,000 ICD-10 codes replace 17,000 ICD-9 codes.
• Introduces the use of a seventh character encounter code for obstetrics, injuries and external causes of injuries.

Q: What happens if a provider does not switch to ICD-10?
A: Claims with dates of service on or after the Oct. 1, 2014, implementation date that do not use the appropriate ICD-10 code will be rejected in EDI front-end edits. Remember that claims for services provided before Oct. 1, 2014, must use ICD-9 diagnosis and inpatient procedure codes.

Q: Can a submitter send ICD-10 codes prior to Oct. 1, 2014?
A: No

Q: Can a submitter send both ICD-9 and ICD-10 codes on the same claim?
A: No

Q: Where can I get more information on ICD-10?
A: There are several sources for information, a few of the most common include:

• CMS website**
• Blue Cross Blue Shield of Michigan website
• BCBSM ICD-10 team contact: ICD-10providerreadiness@bcbsm.com
• American Hospital Association website**
• American Medical Association website**
• AAPC ICD-10 Coding Crosswalk website**
• American Health Information Management Association website**

Refer to previous issues of The Record for more information or go online to cms.gov/icd10** and bcbsm.com/icd10.

**BCBSM does not control this website or endorse its general content.

Here are answers to more questions about electronic fund transfers

This is part of a series of frequently asked questions about EFT.

In December 2013, Blue Cross Blue Shield of Michigan began offering electronic fund transfer as a payment option for our providers. Here are answers to some frequently asked questions that we hope will make this new process more convenient and user-friendly for you.

How do I enroll in EFT?
Enrolling is easy. Log in at bcbsm.com, click on Register Provider and follow the instructions. You also can call our help desk at 1-877-258-3932 or your provider consultant for help with enrolling.     

How do I change my financial institution information?

• Visit bcbsm.com and log in.
• Under Electronic Funds Transfer, click on Update provider.
• Enter the required information and click on submit.

Please allow three to five weeks for the system to update. You’ll receive paper checks and vouchers until that update occurs.

What if the money isn’t in my account when it’s supposed to be?
Before emailing your inquiry, please verify the following information:

• You’ve received the confirmation letter that your registration has been successfully completed.
• You haven’t changed your financial institution since you registered.
• The account on the registration form is open and active.
• Your financial institution hasn’t changed its policy on fund availability.
• You’ve submitted claims and they’re scheduled for payment.

If you’ve confirmed all of the above information and you still haven‘t received a payment for a Blues commercial product, email us at providereft@bcbsm.com.  

If you’ve confirmed all of the above information and the funds are for Blue Cross Complete^SM and you still haven‘t received a payment, call Emdeon at 1-866-506-2830.

How do I tell where my EFT payment was deposited?
Please contact your financial institution and speak with the branch manager for assistance. If they’re unable to locate the deposit, please email providereft@bcbsm.com, and we’ll get back to you as soon as we can.

When are funds transferred to my account?

I can’t access my vouchers electronically. What should I do?
Call our Web support help desk at 1-877-258-3932 and we’ll be happy to help you.

For more information or questions, please contact your provider consultant.

Understanding the cotinine test box on the 2014 Blue Cross Blue Shield of Michigan Qualification Form

Blue Cross Blue Shield of Michigan has received numerous questions about the cotinine test requirement on the 2014 Qualification Form. Only certain members are required to undergo cotinine testing.

To make sure patients are not billed for services that are not covered, it’s important to follow the requirement instructions in the box.

	If the cotinine check box is checked, order the test.
	If the cotinine check box is not checked, do not order the test.

Remember: Cotinine tests are typically not a covered benefit, so please do not order the test for a patient who does not need it.

Keep in mind these diagnosis documentation and coding tips

Accurate diagnosis code selection plays a critical role in communicating a patient’s health status to Blue Cross Blue Shield of Michigan for many purposes, including Medicare risk adjustment, quality measures, government programs and other incentive programs. However, reporting the proper diagnosis code is only possible if the patient’s progress note has complete and accurate documentation to support each condition. 

Here are answers to some frequently asked questions to help ensure a diagnosis is substantiated.
              
How often should a chronic condition be reported on a claim?
Each of a patient’s chronic conditions should be reported at least once a year as part of a face-to-face encounter. Providers are not required to report all of a patient’s chronic conditions on every claim. Instead, document chronic conditions as often as they’re assessed or treated.

What are the documentation requirements?
Each reported diagnosis must be validated by the documentation in the progress note for that specific date of service. 

The progress note must document how the condition was managed, evaluated, assessed or treated, also known as MEAT. At least one component of MEAT must be documented for each condition.

• Manage: Indicate order of labs, diagnostic radiology or other tests.
• Evaluate: Document review of lab or X-ray results and pertinent exam results.
• Assess: Describe the status of a patient’s condition (stable, worsening or improved).
• Treat: Indicate if medications are prescribed or refilled, and surgical treatments or therapy services.

Additionally, each progress note must include a treatment plan that is linked to the chronic condition.
                                                      
What if a diagnosis is not clearly documented?
Providers should report the ICD-9-CM code that identifies the patient’s condition to the greatest specificity. However, documentation in the progress note must support this specificity by explicitly identifying the diagnosis, and the diagnosis can’t be inferred.

For example:

• If diagnosis 401.1 is reported on a claim, documentation must specify benign hypertension, not just hypertension or high blood pressure.
• If 428.32 is reported on a claim, documentation must specify chronic diastolic heart failure, not CHF.

Terms such as “rule out,” “consistent with” or “probable” should be used with caution. These terms indicate the diagnosis is not definitive and consequently can’t be coded in the outpatient setting.

Should the MEAT components and treatment plan be linked to the specific diagnosis or will an auditor infer the connection?
An auditor can’t infer that orders and results are related to a specific condition. Providers should interpret results and link all tests and orders to a specific condition.

• For example: An auditor can’t assume that a lipid panel is being ordered to address a patient’s hyperlipidemia if the patient is being treated for other chronic conditions.

Always link medications to a specific diagnosis and indicate if the medication is new, to be continued or to be discontinued, and make sure to indicate the specific dose.   

• For example: A statement such as “continue current meds” will not validate a diagnosis. Instead you should say “diabetes, stable. Continue Metformin 850 mg. once daily.”

Each diagnosis should have its own individual treatment plan that indicates tests ordered, referrals made, patient instructions and when the next patient visit should be scheduled.

What are correct linking words to indicate a manifestation of a condition?
A cause-and-effect relationship between a condition and its manifestations may not be assumed. The relationship should be documented with correct “linking” words in the progress note. Here are some examples for diabetes: 

• End stage renal disease secondary to diabetes
• Ulceration caused by diabetes
• Polyneuropathy due to diabetes
• Diabetic polyneuropathy

Please note that the term "with" isn’t an acceptable linking word in medical record documentation to demonstrate causality between two conditions. See the September 2013 Record article for more information.

BCBSM has two resources available on web-DENIS to aid providers in accurate documentation and coding: 

• BCBSM Coding Initiative presentation (available in text or audio)
• Documentation and Coding Tips for Professional Offices, a set of tip cards

Follow these steps to locate the training aids on web-DENIS: 

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Medicare Advantage Resources. The two training documents are located on this page.

For more information, contact your provider consultant.

Reminder: Register now to attend live webinar on commercial version of Health e-Blue^SM

We’re expanding our Health e-Blue tool to help you close diagnosis gaps and identify treatment opportunities for patients enrolled in individual and small group plans, as well as our Medicare Advantage plans.

To support the expansion, Blue Cross Blue Shield of Michigan is offering introductory webinars on a new website that focuses on individual and small group members.

Two webinars remain in early April. Dates of the live webinar are listed below:

How to register
To register, send an email to SEprofessionaleducationregistration@bcbsm.com. Include the date and time of the class you wish to attend as well as your national provider identifier and title or role within your office. You’ll receive a confirmation email within 72 hours of registering, along with instructions on how to access the webinar via WebEx.

For more information

• If you have questions about the webinar or registering for enrollment in Health e-Blue, please contact your provider consultant.
• If your office has technical Web issues or questions, call the Blue Cross Blue Shield of Michigan Web support help desk at 1-877-258-3932.

Reminder: Blues provider servicing changes taking place

As you may have read in the March Record, we’re reorganizing our provider servicing staff to better serve you.

Previously, most providers had one BCBSM provider consultant and one BCN provider representative, but we’re transitioning to a new arrangement that gives you one Blues provider consultant for all your Blues needs.

In some cases, you’ll find that your Blues provider consultant has not changed. And hospitals that currently have separate consultants for professional and facility concerns will continue to have two consultants in the new model.

If you find that our service is not meeting your expectations and your provider consultant is not able to resolve your concerns, please send an email to ProviderOutreach@bcbsm.com or call Dan Martin, director of Provider Outreach, at 313-448-6228.

HCPCS codes added, deleted

The Centers for Medicare & Medicaid Services has added 22 new HCPCS codes and deleted one code as part of its regular quarterly HCPCS updates.

The new codes are listed below.

The deleted code is listed below.

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 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.

Navigating the electronic Record

As part of our efforts to make it easier to do business with us, we’d like to offer some tips for using the electronic Record.

Understanding the format

• The upper portion of the newsletter features up to four articles that relate to the main area of interest you chose when you subscribed to the newsletter (for example, Professional, Facility, DME). If there are no articles in the issue pertaining to your main area of interest, we’ll feature a few articles from our “All providers” section. This is also the version we post to bcbsm.com.

• The bottom portion of the newsletter serves as an interactive index, listing the headlines for all the articles in the issue and giving you access to them.

Printing The Record or individual articles

• You can print individual articles in The Record by clicking on the headlines below the gold bar that reads “For the Record” and then clicking on Print this article at the top of the newsletter.

• If you want to print all the articles in the newsletter, click on the Print entire issue link in the upper right-hand corner of the newsletter’s front page.

• Keep in mind that you may not need to access or print all the articles in the newsletter each month. Check out the list of headlines in the bottom section of the newsletter to determine which articles are important to you. For example, if your work location is a doctor’s office, you may not be interested in the articles in the Facility section.

Forwarding The Record

• You can easily forward The Record by using the Forward to a Friend link at the top of the front page.

• If you’re reading an article you’d like to share, you can click on the Forward to a Friend link at the top of the article.

Accessing The Record online

• You can quickly access current and past issues of the newsletter, dating back to January 2010, along with an index, on The Record Archive.

• You can also access the newsletter via web-DENIS by clicking on BCBSM Provider Publications and Resources from the web-DENIS home page. Issues in this archive go back to March 1998.

Subscribing to The Record,
You can subscribe to the electronic Record or invite a colleague to subscribe by clicking here or on the Subscribe link at the top of each page of the newsletter.

Customizing your subscription
As part of the subscription process, you’ll be asked to indicate your main area of interest. You may choose from these topics:

• All providers
• Professional
• Facility
• Pharmacy
• Medicare Advantage
• DME
• Vision
• Auto groups

Once you select a topic, you’ll generally see about four of those articles in that category highlighted at the top of your email each month. All the articles for that topic — and all other articles in that month’s Record — are listed below the gold bar that says “For the Record.” You’ll see the topics reflected in the colored headings.

You may change your topic selection at any time by clicking on the Update Profile link at the very bottom of The Record email. On this page, you may also update your contact information and email address.

OPTs may apply to participate with BCBSM and BCN before Medicare approval letter received

As of March 1, 2014, outpatient physical therapist facilities may be considered for temporary participation with Blue Cross Blue Shield of Michigan and Blue Care Network. The facility must have applied for Medicare certification and must comply with BCBSM’s self-certification process.

OPT providers will be considered for temporary participation only if the facility submits:

• The BCBSM and BCN Facility Application Form, which is available at bcbsm.com/providers.
• Click on the Join the Blues Network tab.
• Click on Enrollment and Changes.
• Click on Provider Enrollment and follow the prompts.
• An OPT Self-Certification statement. (Contact Provider Enrollment and Data Management at 1-800-822-2761 to obtain this document.)
• Proof of application for Medicare certification from the Michigan Department of Consumer and Industry Services.
• All other required documents. You can view a checklist here.

If you have any questions about provider enrollment, contact Provider Enrollment and Data Management at 1-800-822-2761.

Procedures eligible for bilateral (modifier 50) available through Clear Claim Connection™

The bilateral modifier 50 fees will no longer be displayed on Entire Fee Schedules, published on web-DENIS, for effective dates on or after July 1, 2014. Also, beginning April 1, 2014, they won’t be displayed on fee change schedules.

The Entire Fee Schedules are published annually and there are procedure code changes related to modifier 50 occurring quarterly. That means providers can determine procedure codes and verify modifier 50 eligibility by accessing Clear Claim Connection™, also known as C3.  

C3 is our provider-facing claim simulation tool. Be sure to review the terms and conditions page for applicable services this tool relates to. Clinical edits and rationale contained within C3 must not be used as a guarantee of payment or a source of benefit policy information.

For your convenience, in addition to the link currently available through web-DENIS, we’ve added a link to C3 to the Entire Fee Schedules and Fee Changes front page. That will allow you to validate modifier 50 eligibility by entering the procedure code and modifier 50 in C3.

You can calculate the bilateral fee this way:

• If the code is radiology or an add-on code, the modifier 50 fee will be 200 percent of the non-modifier 50 (single procedure) fee.
• Otherwise, the modifier 50 fee will be 150 percent of the non-modifier 50 (single procedure) fee.

For more information about Clear Claim Connection™, see the article in the February 2012 Record or contact your provider consultant.

Medicare Advantage Diagnosis Closure Incentive program continues in 2014 for primary care physicians

Blue Cross Blue Shield of Michigan and Blue Care Network are pleased to announce that the Medicare Advantage Diagnosis Closure Incentive program will continue in 2014.

The incentive program again applies to Blues Medicare Advantage patients, including those with BCBSM Medicare Plus Blue PPO^SM, Medicare Plus Blue Group^SM PPO, BCN Advantage HMO-POS^SM and BCN Advantage HMO^SM coverage.

Here’s how it works
The Diagnosis Closure Incentive rewards attributed physicians for having annual face-to-face visits with Blues Medicare Advantage patients to evaluate, document and code diagnoses according to standards set by the Centers for Medicare & Medicaid Services. Physicians will receive a financial incentive for closing diagnosis gaps identified by the Blues.

The Diagnosis Evaluation Panel on Health e-Blue^SM lists patients who are suspected of having a condition based on pharmacy claims, medical claims, other supplemental data sources or prior year diagnoses, but the diagnosis hasn’t been submitted to the Blues in the current year. The report will be refreshed monthly so physicians can track their progress in closing these identified diagnosis gaps.

A suspected or historic condition that hasn’t been documented and coded in the current year is considered a “gap.”

The Blues will pay physicians $100 for each Medicare Advantage member with one or more gaps identified between Jan. 1, 2014, and Sept. 30, 2014, and for whom all gaps are closed during a face-to-face encounter by Dec. 31, 2014.

An identified gap can be closed following a face-to-face visit with the patient in 2014. During this visit, the physician should manage, evaluate, assess and treat the condition and the diagnosis should be documented in the patient’s medical record following CMS guidelines. The gap can then be closed through one of the following methods.

• Confirm the diagnosis code:
• By submitting a claim with the diagnosis code
• Through Health e-Blue
• By submitting a paper Member Diagnosis Evaluation and Treatment Opportunities Report (for those without access to Health e-Blue)
• By submitting a patient medical record
• Notify the Blues that the patient does not have the suspected condition:
• Through Health e-Blue
• By submitting a paper Member Diagnosis Evaluation and Treatment Opportunities Report (for those without access to Health e-Blue)

More information about this incentive program will be posted on Health e-Blue for Medicare Advantage primary care physicians in the first quarter 2014. If you don’t have access to Health e-Blue, sign up today on bcbsm.com/provider. Contact your provider consultant if you need assistance.

Web-DENIS member care alerts
When checking patient eligibility and benefits on web-DENIS, be sure to check your member care alerts, which have been updated to include 2014 patient gaps in care. These alerts, color-coded to help you identify patient needs quickly, display a printable list of diagnosis gaps and treatment opportunities for patients.

Training on documentation, coding and closing gaps
The Blues have staff available who can provide training to physicians and their office staff on proper documentation and coding guidelines and the importance of closing gaps for Medicare Advantage patients. Contact your provider consultant for more information.

Ask your provider consultant for a set of tip cards for your office called Documentation and Coding Tips for Professional Offices. The tip cards are also available electronically on web-DENIS. From the web-DENIS home page:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Provider Training.

2013 incentive payment
If you participated in the 2013 Diagnosis Closure Incentive program, your incentive payment will be mailed to you by the end of the second quarter.

Use correct code for outpatient hospital clinic visits

As you read in a January web-DENIS message and the February Record, Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO eliminated evaluation and management Current Procedural Terminology codes *99201-*99205 and *99211-*99215 for outpatient hospital clinic visits. Following is some additional guidance.

Effective Feb. 5, 2014, claims received with these E&M CPT codes will be denied for dates of service on or after Jan. 1, 2014. Providers should use E&M CPT code G0463 instead, as instructed by the Centers for Medicare & Medicaid Services.

If you submit a claim with CPT codes *99201-*99205 and *99211-*99215 instead of G0463, it will trigger message code 10Z. This code indicates we won’t pay for this service. You’ll need to resubmit the claim using the code G0463 and we’ll reprocess it.

If you used the new procedure code for a date of service on or after Jan. 1, 2014 — and submitted the claim prior to the Feb. 5 implementation date — your BCBSM Medicare Advantage PPO claim will automatically be adjusted for payment.

As background, CMS eliminated the use of evaluation and management codes *99201-*99205 and *99211-*99215 for hospital outpatient clinic visits for all Medicare patients. CMS now requires health care providers to bill the new G0463 for E&M hospital outpatient clinic visits for all Medicare patients.