|
June 2014
PGIP primary care physicians who perform well on HEDIS® quality measures can earn new fee uplift
Not in PGIP? Here’s your chance
We’ll be accepting applications from physician organizations that would like to join our Physician Group Incentive Program from July 1 through Aug. 29, 2014.
This innovative program, developed with input from physicians across Michigan, is helping improve the quality, value and efficiency of health care in the state. PGIP facilitates change through a wide variety of initiatives, and rewards physician organizations for improving health care delivery.
If you represent a physician organization and would like to complete an application, email the Value Partnerships staff at providerpartnerships@bcbsm.com. The Blues must receive completed application packets by Aug. 29, 2014.
Keep in mind that physicians must join PGIP as part of a physician organization. Details on the requirements for participating and instructions on how to join are in the health care provider area of our website.
If you’re an individual practitioner with questions about participating in PGIP, contact your provider consultant. Not sure who that is? Check our website.
All primary care physicians in the Physician Group Incentive Program will have the chance to earn a new 5 percent fee uplift, effective July 1, 2014.
The fee uplift is available to physicians who perform well on evidence-based care measures in the Healthcare Effectiveness Data and Information Set or HEDIS®. It will apply to select evaluation and management and preventive service codes in the office or outpatient setting for PPO and Traditional commercial claims.
"The goal of the new fee uplift is to support and reward those practitioners for providing high quality, evidence-based health care services that help our members achieve and maintain optimal health," said Tom Leyden, director of Value Partnerships.
The fee uplift will be added to any other uplift they’re currently receiving. For example, if a physician is receiving a 10 percent fee uplift recognizing their Patient-Centered Medical Home designation, he or she would receive a 15 percent total fee uplift.
The HEDIS performance measures for the new fee uplift include eleven adult measures and four pediatric measures. Internal medicine physicians will be scored based on the adult measures, pediatricians will be scored on the pediatric measures and family practice physicians will be scored either on the adult only or the adult and pediatric measures, depending on the makeup of their patient population.
Following are the adult and pediatric measures included in the new fee uplift:
Adult
- Avoidance of antibiotic treatment in adults with acute bronchitis
- Use of spirometry in the assessment and diagnosis of chronic obstructive pulmonary disease
- Persistence of beta blocker treatment after a heart attack
- LDL-C screening in patients with coronary artery disease
- HbA1c testing in patients with diabetes
- LDL-C screening in patients with diabetes
- Nephropathy screening in patients with diabetes
- Use of imaging studies in low back pain
- Treatment of major depression with antidepressant medication
- Annual monitoring for patients on persistent medications
- Use of appropriate medication for adults with asthma
Pediatric
- Appropriate treatment for children with an upper respiratory infection
- Use of appropriate medications for children with asthma
- Appropriate testing for children with pharyngitis
- Follow-up care for children prescribed medication for attention deficit hyperactivity disorder
Initially, the fee uplift will be implemented for a one-year period from July 1, 2014, through June 30, 2015. It will be calculated using BCBSM claims data with dates of service from Jan. 1, 2013, to Dec. 31, 2013.
The practices will be ranked according to the appropriate measures; those practices at or above the 80th percentile of PGIP primary care practices will receive the 5 percent fee uplift. The HEDIS fee uplift analysis and selection process will occur annually.
If you’re a PGIP primary care physician and want more information about your performance on the HEDIS measures and opportunities for improvement, contact your physician organization. For more details on the measures included in the new fee uplift, contact your PO or send us an email at providerpartnerships@bcbsm.com
If you’re not currently a member of PGIP and would like to join, contact your provider consultant. Check out our PGIP flier by clicking here.
To learn more about PGIP, go to the Physician Group Incentive Program section of valuepartnerships.com.
HEDIS is a registered trademark of the National Committee for Quality Assurance.
Notice: PGIP specialist fee uplifts
In 2015, most specialty types (except anesthesiology) will be eligible for a fee uplift. To be considered for a 2015 fee uplift, a practitioner must be a member of a physician organization that participates in the Physician Group Incentive Program. The PO must ensure that the practitioner is enrolled in PGIP by July 1, 2014. If you have questions about joining PGIP, contact your provider consultant.
Reminder: Statewide summer training
We’d like to remind you that training opportunities will take place this summer at 11 locations around the state.
For information on the Upper Peninsula training sessions, see article titled "Upper Peninsula facility training set for August," also in this issue. For information on other classes, see the May Record article.
To register for training, send an email to Jeff Holzhausen at JHolzhausen@bcbsm.com. In the subject line, type "RMRA/Stars" and indicate the city where you want to attend the class. In the body of the email message, put the date of the class you want to attend and the names and number of attendees expected from your facility.
You’ll receive a confirmation within 72 hours of registering. It’s important that you register so we have an accurate headcount for lunch.
The Blues will provide continuing education credits through the AAPC. For more information, please contact your provider consultant.
Upper Peninsula training classes set for August
We’ve scheduled facility and professional training classes in Marquette this August.
The facility class will offer billing tips, web-DENIS information and plenty of time for questions and answers. The professional class will cover such topics as coding and documentation, risk adjustment, the diagnostic closure incentive program, the performance recognition program, Health e-BlueSM and ICD-10.
Classes will begin one hour later than usual:
- Full-day classes start at 10 a.m. and end at 4 p.m., with registration at 9:30 a.m.
- A lunch break will be provided between noon and 1 p.m., with lunch served on both dates.
- Classes might extend later or end earlier, depending on participant questions.
Following are the dates of the sessions and the class location:
| Location |
Class |
Date |
Holiday Inn Marquette
1951 U.S. 41 West |
Professional |
Tuesday, Aug. 19 |
| Facility |
Wednesday, Aug. 20 |
For the facility class, type "Facility Marquette" in the subject line. For the professional class, type "RMRA Marquette." In the body of the email, include the date of the class and the number and names of attendees expected from your facility.
You’ll receive a confirmation within 72 hours of registering. It’s important that you register so we have an accurate headcount for lunch.
For more information, please contact your provider consultant.
Changes to emergency room benefits coming to Michigan Conference of Teamsters Welfare Fund group
Effective immediately, the Michigan Conference of Teamsters Welfare Fund’s medical director is reviewing emergency room records for claims that exceed three visits in a 12-month period for members and their covered dependents to determine if the condition treated was an emergency. Members are responsible for obtaining and providing the medical record information for review.
Conditions that may require emergency care are limited to sudden and unexpected medical problems that, if not immediately treated, may result in death or serious bodily harm. The medical director will determine if the claim is covered under the group’s plan, and the decision cannot be appealed to Blue Cross Blue Shield of Michigan.
This benefit change — which Michigan Conference of Teamsters Welfare Fund members and their covered dependents have been notified about — was made to help ensure that members and their dependents use their emergency room benefit appropriately.
If members aren’t experiencing an emergency, but still need immediate medical care, they should seek treatment from a local urgent care center if their doctor isn’t available.
For more information about this benefit change, please contact the Michigan Conference of Teamsters Welfare Fund’s Member Services at 313-964-2400.
MESSA removes compounded hormones from commercial drug coverage
Effective July 1, 2014, MESSA will no longer cover compounded hormone products for new members who have MESSA prescription drug coverage.
These products include compounds that contain any of the following ingredients:
- Estradiol
- Estrone
- Hydroxyprogesterone caproate
- Methyltestosterone
- Progesterone
- Testosterone
Compounded drugs may expose members to risks from products that have not been tested for safety or effectiveness by the Food and Drug Administration.
MESSA members who are currently prescribed any compounded hormone products are excluded from this change.
Compound hormones were excluded from coverage in November 2013 for members who have Blue Cross Blue Shield of Michigan commercial (non-Medicare) prescription drug coverage.
BCBSM updating refill requirements for DME/P&O, medical supplies
Effective July 1, 2014, Blue Cross Blue Shield of Michigan will align with the Centers for Medicare & Medicaid Services’ policy on refill requirements for all durable medical equipment, prosthetics and orthotics, and other medical supplies.
For DME, P&O and supplies that are provided as refills to the original order, suppliers must contact the patient prior to dispensing the refill. Suppliers aren’t allowed to automatically ship the products on a predetermined basis, even if authorized by the patient or designee. This will be done to ensure that:
- The refilled item remains reasonable and necessary
- Existing supplies are nearly expired
- Any changes or modifications to the order are confirmed
Contact with the patient or designee regarding refills must take place no sooner than 10 calendar days prior to the delivery or shipping date.
The supplier must deliver refills of DME, P&O and supplies prior to the expiration of the current product. This is regardless of which delivery method is used. Suppliers must follow BCBSM billing guidelines for dispensing supplies.
Inclusionary guidelines
For all DME, P&O and supplies that are provided on a recurring basis, suppliers are required to have contact with the patient, caregiver or designee prior to dispensing a new supply of items. Suppliers aren’t allowed to deliver refills without a refill request from a patient. Items delivered without a valid, documented refill request will be denied as unreasonable and unnecessary.
Suppliers aren’t allowed to dispense a quantity of supplies exceeding a patient’s expected usage. Suppliers must be aware of any patients whose usage patterns have changed or become atypical. Suppliers must verify with the ordering physicians that any changed or atypical usage is warranted. Regardless of usage, a supplier isn’t allowed to dispense more than the approved monthly quantity at a time.
Documentation requirements
A new prescription isnt required for routine refills. A new prescription is needed when:
- There is a change of supplier.
- There is a change in the treating physician.
- There is a change in the item(s), frequency of use or amount prescribed.
- There is a change in the length of need or a previously established length of need expires.
- State law requires a prescription renewal.
For items that the patient obtains in person at a retail store, the signed delivery slip or copy of itemized sales receipt is sufficient documentation of a refill request.
For items that are delivered to the patient, the refill request must occur and be documented before shipment. The documentation of a refill request must be either:
- A written document received from the patient
- A recent written record of a phone conversation or contact between the supplier and patient
A retrospective attestation statement by the supplier or patient isn’t sufficient. The refill record must include:
- The patient’s name or authorized representative for the patient
- A description of each requested item
- The date of the refill request
- The quantity of each item that the patient still has remaining
This information must be kept on file and be available upon request.
We’re clarifying documentation requirements for physician office infusion therapy
In a September 2013 Record article, we said we’d begin processing individual provider medical drug claims at the National Drug Code level on Feb. 1, 2014. Because this was a major change for health care providers, we’re clarifying the documentation requirements associated with this change.
The person administering the medication is responsible for documenting the NDC number of the actual drug being administered, along with the quantity. During an audit, the NDC number billed will be compared to the NDC number documented in the medical record. Keep in mind that while BCBSM pays for the wastage of single-dose vials, the wastages must be documented as well.
Providing this information expedites the audit process and helps providers avoid any potential financial recoveries.
Here’s an update on how we’re processing behavioral health claims
In previous Record articles and web-DENIS messages, we told you about the American Medical Association’s release of new procedures codes, effective Jan. 1, 2013. Since then, we’ve made some system changes to support AMA requirements.
Here’s an update on how we’re currently managing behavioral health claims:
- Some codes have been replaced with new codes. For example, *90804 (outpatient psychotherapy, 20-30 minutes) is replaced with *90832 (psychotherapy, 30 minutes).
- Some codes that were previously "bundled" to include both evaluation and management services, along with therapy services, have been unbundled. So E&M with therapy services now may require the use of more than one code. For example, *90807 (outpatient psychotherapy with E&M services, 45-50 minutes) has been replace with *90836 (45 minutes, psychotherapy add-on) and an appropriate E&M base code. The E&M code must meet appropriateness of service.
Procedure code *90862 for pharmacologic management was end-dated and now evaluation and management codes can be billed in its place. To address this, we temporarily allowed procedure code M0064 to replace code *90862.
However, effective Aug. 1, 2014, we will no longer allow M0064 to be reimbursed. Instead, an appropriate E&M code must be billed.
How members are affected
The revised AMA procedure codes also affect Blue Cross members. We’ve highlighted below the changes members might experience.
- Evaluation and management services can be billed with either a primary medical or primary behavioral health diagnosis code and will be processed according to the member’s benefits. For example, if an E&M procedure code is billed with a behavioral health diagnosis, the claim will be processed against the member’s behavioral health cost share.
Because of these changes, members’ cost-sharing responsibilities may have changed between 2013 and 2014.
Keep the following guidelines in mind:
- A member who receives services for both therapy and evaluation and management will only have one copay.
- If a member’s group has its behavioral health benefits carved out, these services now must be processed by the group’s third-party vendor. The voucher will identify who should be billed.
If you have any questions, contact your provider consultant.
Have you subscribed to BCN Provider News?
If you participate with Blue Care Network, you’ll want to make sure you subscribe to BCN Provider News.
It offers all the BCN news and information you need, including network updates, information about billing and claims, referral requirements, clinical practice guidelines, chronic condition management programs and more.
You can subscribe to BCN Provider News and other provider publications by clicking here. Fill out the necessary information and check the box to the left of BCN Provider News and BCN Alerts. And if you sign up by June 20, you’ll be sure to get the next issue.
Keep these coding tips in mind to improve medical record documentation
Leukemia is cancer of the white blood cells that will affect an estimated 44,790 new patients in 2014 alone, according to Medscape. A basic understanding of this neoplastic disorder will help with coding and documentation accuracy. The body is constantly producing new blood cells to stay healthy. Blood cells are produced by blood stem cells found within bone marrow and occasionally the blood itself.
Blood stem cells produce three specific types of blood cells: red blood cells, platelets and white blood cells. Each blood cell has a unique function within the body, aiding in healing and healthy living. When normal blood cells are old or damaged they die off and new ones are produced.
Graphic taken from National Cancer Institute website/2014 |
Blood cell functions
Red blood cells: Oxygen transporters
Platelets: Clot formers, slow or stop bleeding
White blood cells: Infection fighters |
Leukemia occurs when the bone marrow starts producing abnormal white blood cells known as leukemia cells or leukemia blast cells. The production of the abnormal white blood cells takes over cell production, causing normal blood cell production to be halted. Leukemia cells multiply quickly and dont die off like normal blood cells. Without the production of normal blood cells the body works harder to get oxygen, control bleeding and fight infections.
Leukemia is divided into two types based on origin: myeloid or lymphoid. The two types are further classified based on an acute or chronic designation.
- Acute myeloid leukemia
- Acute lymphoblastic leukemia
- Chronic myeloid leukemia
- Chronic lymphocytic leukemia
Leukemia occurrences
Acute lymphoblastic leukemia
- Most common in children ages 2 to 10
- Comprises 20 percent of adult acute leukemia (more aggressive than childhood type)
Acute myeloid leukemia
- Comprises 15-20 percent of acute leukemia in children
- Incidence increases with age
Chronic myeloid leukemia
- Constitutes less than 5 percent of childhood leukemia
- Slow increase till age 40, then incidence rises rapidly
Chronic lymphocytic leukemia
- Most diagnoses made around age 60
Understanding the differences between acute and chronic leukemia is important. Within ICD-9-CM, leukemia is broken down into acute, chronic and sub-acute designations. Acute leukemia is when the bone marrow cells fail to mature properly and the outcome is poor if left untreated. But with the right treatment most cases can be cured.
Chronic leukemia differs slightly. The bone marrow cells mature some but not entirely and might look OK under examination, yet are unable to fight off infections. The outcome on life is longer however, chronic leukemia is much harder to cure. ICD-9-CM also contains a sub-acute designation, which is identified as a state between acute and chronic, leaning more towards acute, yet usually less severe than acute.
Tips to remember when coding leukemia
Leukemia codes are found throughout the neoplasm chapter and specific types are categorized in sections 204 through 208.
- Physicians must clearly document the specific type of leukemia and whether it is acute, chronic or, in some cases, sub-acute.
- Chronic leukemia may enter a blast phase meaning the symptoms or manifestations are close to that of an acute leukemia. The tabular contains an EXCLUDES note that indicates "acute exacerbations of chronic leukemia." Do not report both an acute and chronic code — unlike other conditions, only the chronic code is reported.
- Relapse refers to the recurrence of the disease after being successfully treated. A relapse can occur at any time during treatment or after treatment is completed. The provider must clearly document the patient is "in remission" or "in relapse" so the appropriate fifth digit may be assigned.
- 0 — Without mention of having achieved remission (includes failed remission): According to American Hospital Association Coding Clinic fourth quarter, 2008, page 83 through 84, failed remission refers to remission induction therapy where the patient is given a course of chemotherapy to produce a complete remission and the treatment fails.
- 1 — In remission: Currently not showing any signs or symptoms of the disease.
- 2 — In relapse: Signs and symptoms of the disease have reoccurred after being treated successfully.
- If the reason for a patient encounter is chemotherapy, report V58.11 or V58.12 as the primary diagnosis code (encounter for antineoplastic chemotherapy/immunotherapy) followed by the correct leukemia code.
- Leukemia is classified in the neoplasm chapter, yet its not found within the neoplasm table. In order to accurately code leukemia it must first be located in the alphabetical list, under the correct subcategory. Code verification in the tabular is essential for accurate fifth-digit reporting.
If you have questions or need more information, please contact your provider consultant.
CPT codes added
The American Medical Association has added three new CPT codes as part of its regular quarterly HCPCS updates.
The new codes are listed below.
Code* |
Change |
Coverage comments |
Effective date |
0007M |
Added |
Not covered by BCBSM |
July 1, 2014 |
0008M |
Added |
Not covered by BCBSM |
July 1, 2014 |
3126F |
Added |
Not covered by BCBSM |
July 1, 2014 |
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.
| Code* |
BCBSM Changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines
|
| NEW PAYABLE PROCEDURES |
Established
81240, 81241
Experimental
81291 |
Basic Benefit and Medical Policy
Medical Policy has determined that genetic testing for factor V Leiden mutations and prothrombin gene mutations for inherited thrombophilia has been established in select patient populations who meet clinical criteria. This testing may be a useful diagnostic option when indicated.
Genetic testing for mutations in the MTHFR gene is considered experimental. There is limited published evidence on the utility of testing for MTHFR mutations for inherited thrombophilia. This policy is effective Jan. 1, 2014.
Inclusionary Guidelines
Genetic testing for factor V Leiden gene mutations and prothrombin gene mutations for inherited thrombophilia should only be performed if the results are likely to direct or alter medical management in any of the following:
- Patients with VTE occurring at 50 years of age or younger
- Patients with VTE at any age who have a first-degree family member with a history of VTE
- Asymptomatic or symptomatic family members (first-degree relatives) of patients with a known familial thrombophilia
- Patients with VTE in unusual sites, such as hepatic, mesenteric, renal or cerebral veins
- Women with recurrent pregnancy loss or unexplained severe preeclampsia, placental abruption, intrauterine growth retardation or stillbirth when the knowledge of inherited thrombophilia carrier status will influence the management of future pregnancies
- Patients with VTE provoked by pregnancy, the puerperium (post-partum period), oral contraceptive use or hormone replacement therapy
Exclusionary Guidelines
- Genetic testing for mutations in the MTHFR gene
- As a general population screen
- Asymptomatic patients with no personal or familial history of VTE
- As a routine test prior to the use of oral contraceptives, hormone replacement therapy, selective estrogen receptor modulators or tamoxifen
- As a routine prenatal or newborn test, or as a routine test in asymptomatic children
- As a routine test in individuals with arterial thrombosis
|
J7199 |
Basic Benefit and Medical Policy
Tretten is established as safe and effective for its FDA-approved indication: to prevent bleeding in adults and children with congenital factor XIII A subunit deficiency. This policy is effective Dec. 23, 2013.
Tretten should be reported with the not-otherwise-classified code J7199 until a permanent code is established.
Tretten is for intravenous use only.
Dose:
- 35 international units per kilogram body weight once monthly to achieve a target trough level of FXIII activity at or above 10 percent using a validated assay.
- Consider dose adjustment if adequate coverage is not achieved with a 35 IU/kg dose.
- Once reconstituted, tretten may be diluted with 0.9 percent sodium chloride to facilitate measurement of small volumes.
Inclusionary Guidelines
Tretten (coagulation factor XIII A-subunit (recombinant)) indicated for:
- Routine prophylaxis of bleeding in people with congenital FXIII A-subunit deficiency.
Exclusionary Guidelines
- Tretten is not approved for use in patients with congenital FXIII B-subunit deficiency
|
| UPDATES TO PAYABLE PROCEDURES |
0005M, 81599 |
Basic Benefit and Medical Policy
Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 may be considered established in women with high-risk singleton pregnancies undergoing screening for trisomy 21. Karyotyping would be necessary to exclude the possibility of a false positive nucleic acid sequencing-based test. Before testing, women should be counseled about the risk of a false positive test.
Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 in women who do not meet the above criteria is considered experimental.
Group Variations
Payable for GM hourly and salaried enrollees, effective Sept. 20, 2013. |
20982, 32998 |
Basic Benefit and Medical Policy
The safety and effectiveness of radiofrequency ablation of osteoid osteomas have been established. It may be considered a useful therapeutic option when indicated.
The safety and effectiveness of radiofrequency ablation to palliate pain in patients with osteolytic bone metastases have been established. It may be considered a useful therapeutic option when indicated.
The safety and effectiveness of radiofrequency ablation of renal tumors have been established. It may be considered a useful therapeutic option when indicated
Radiofrequency ablation is an established treatment option in selected patients with primary, non-small cell lung cancer and metastatic pulmonary tumors who are not candidates for surgical intervention.
Group Variations
Payable for Chrysler salaried groups, effective Jan. 1, 2014. |
83861 |
Basic Benefit and Medical Policy
Tear osmolarity testing may be considered established as indicated for the diagnosis and monitoring of Dry Eye Syndrome if slit lamp, as well as two other tests, fail to establish the suspected diagnosis of dry eye syndrome.
Additional tests may include:
- Schirmer’s test
- Tear evaporation test
- Tear break up time
- Ocular staining
Tear osmolarity testing is considered experimental for all other indications.
Group Variations
Payable for GM hourly and salaried enrollees, effective Sept. 20, 2013. |
90471, 90736 |
Group Variations
Effective Jan. 1, 2014, direct reimbursement is allowed to a pharmacy for procedure codes *90471 and *90736 for Ford salaried non-Medicare members. |
| POLICY CLARIFICATIONS |
22856, 22861, 22864 |
Basic Benefit and Medical Policy
The safety and effectiveness of the insertion of cervical artificial intervertebral discs have been established. It is a useful therapeutic option for patients meeting patient selection criteria. This policy is effective May 1, 2013.
Group Variations
Not payable for GM, Delphi, Ford, Chrysler and URMBT
Inclusionary Guidelines (Must meet all)
- The device being used must have final FDA approval.
- Patients must:
- Be skeletally mature (no further growth in height is anticipated) and
- Have one level disk disease, such as a herniated disc or spondylosis, as defined by the presence of osteophytes, in the region of C3-7, confirmed by imaging (X-ray, MRI, etc.) and
- Exhibit symptomatic cervical disc disease, including neck or arm (radicular) pain that may include functional or neurological deficits and
- Have undergone a minimum of six weeks’ active conservative therapies, including:
- Formal active physical therapy program and
- The use of prescription oral analgesic medications or anti-inflammatories and
- Interventional steroid injection (if indicated)
Exclusionary Guidelines
- Patients not meeting the above patient selection criteria.
- Use of implants in multi-level disc repair
- More than one vertebral level with SCDD
- Isolated axial neck pain
- Prior fusion surgery at an adjacent vertebral level
- Prior surgery at the level to be treated
- Patients with progressive symptoms and signs of spinal cord or nerve root compression with less than six weeks of conservative treatments
- Facet joint disease, arthropathy or degeneration at the level to be treated
- Neck or arm pain of unknown etiology
- Paget’s disease, osteomalacia, osteoporosis or other metabolic bone disease
- Pregnancy
- Current medications known to interfere with bone or soft tissue healing (e.g., steroids)
- Rheumatoid arthritis or other autoimmune disease
- Ankylosing spondylitis
- Insulin dependent diabetes mellitus
- Systemic disease including AIDS, HIV and hepatitis
- Active malignancy
|
55875, 77326-77328, 77402-77404, 77406, 77776-77778, **G0458, Q3001
** Procedure requires individual consideration, documentation required |
Basic Benefit and Medical Policy
Brachytherapy for clinically localized prostate cancer using permanently implanted seeds policy has been updated. This policy is effective March 1, 2014.
Medical Policy Statement
Brachytherapy using permanent transperineal implantation of radioactive seeds has been established as a safe and effective treatment of localized prostate cancer when used as monotherapy or in conjunction with external beam radiation therapy.
Focal or subtotal prostate brachytherapy is considered experimental in the treatment of prostate cancer. Its effectiveness in this clinical indication has not been scientifically determined.
Inclusionary Guidelines
Permanent brachytherapy using only implanted seeds is generally used in patients whose prostate cancer is considered low risk. Active surveillance is generally recommended for very low risk prostate cancer. Permanent brachytherapy combined with EBRT is used (sometimes along with androgen deprivation) to treat higher-risk disease.
Prostate cancer risk is often defined using the following criteria:
- Low risk: prostate-specific antigen 910 ng/mL or less 0, Gleason score 6 or less and clinical stage T1c (very low risk) or T1-T2a
- Intermediate risk: PSA greater than 10 but 20 ng/mL or less, or Gleason score 7 or clinical stage T2b-T2c
- High risk: PSA >20 ng/mL or Gleason score 8-10, or clinical stage T3a for clinically localized disease and T3b-T4 for locally advanced disease
The procedure is usually performed in two stages: a prostate volume study followed at a later date by the implant itself, which is performed in the operating room with the patient under general or epidural anesthesia. Iodine and palladium are the typical isotopes used; the selection of isotope is usually based on physician preference. A computed tomography scan is usually performed at some stage after the procedure to determine the accuracy of the seed placement.
Exclusionary Guidelines
Focal or subtotal prostate brachytherapy |
59025 |
Basic Benefit and Medical Policy
When billing two fetal non-stress tests on the same day, report each service on separate service lines. On consecutive service lines, modifier 76 must be reported to denote that the service was repeated. |
64561, 64581, 64585, 64590, 64595, 95970-
95973, A4290, E0745, E1399, L8680, L8685-L8688 |
Basic Benefit and Medical Policy
The criteria for the sacral nerve neuromodulation/stimulation policy have been updated. This policy is effective Nov. 1, 2013.
Urinary Incontinence and Non-obstructive Retention
Inclusionary Guidelines
- A trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead is established in patients who meet all of the following criteria:
- There is a diagnosis of at least one of the following:
- Urge incontinence
- Urgency-frequency syndrome
- Non-obstructive urinary retention
- There is documented failure or intolerance to at least two conventional therapies (e.g., behavioral training, such as bladder training, prompted voiding or pelvic muscle exercise training, pharmacologic treatment for at least a sufficient duration to fully assess its efficacy or surgical corrective therapy).
- The patient is an appropriate surgical candidate.
- Incontinence is not related to a neurologic condition.
- Permanent implantation of a sacral nerve neuromodulation device is established in patients who meet all of the following criteria:
- All of the criteria in A (1-4) above are met.
- A trial stimulation period demonstrates at least 50 percent improvement in symptoms over a period of at least one week
Exclusionary Guidelines
Other urinary or voiding applications of sacral nerve neuromodulation are considered experimental, including, but not limited to, treatment of stress incontinence or urge incontinence due to a neurologic condition, e.g., detrusor hyperreflexia, multiple sclerosis, spinal cord injury or other types of chronic voiding dysfunction.
Fecal incontinence
Inclusionary Guidelines
Sacral nerve neuromodulation is established for the treatment of fecal incontinence when all of the following criteria are met:
- A trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead may be considered established in patients who meet all of the following criteria:
- There is a diagnosis of chronic fecal incontinence of greater than two incontinent episodes on average per week with duration greater than six months or for more than 12 months after vaginal childbirth.
- There is documented failure or intolerance to conventional conservative therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment for at least a sufficient duration to fully assess its efficacy, performed more than 12 months [or 24 months in the case of cancer] previously).
- The patient is an appropriate surgical candidate.
- The condition is not related to an anorectal malformation (e.g., congenital anorectal malformation, defects of the external anal sphincter over 60 degrees, visible sequelae of pelvic radiation, active anal abscesses and fistulae) or chronic inflammatory bowel disease.
- Incontinence is not related to a neurologic condition.
- Permanent implantation of a sacral nerve neuromodulation device may be considered established in patients who meet all of the following criteria:
- All of the criteria in A (1-5) above are met.
- A trial stimulation period demonstrates at least 50 percent improvement in symptoms over a period of at least one week.
Exclusionary Guidelines
Sacral nerve neuromodulation is considered experimental for the treatment of chronic constipation or chronic pelvic pain. |
Established
78608, 78609, 78811-78813, G0235
Experimental
G0219, G0252 |
Basic Benefit and Medical Policy
The effectiveness of positron emission tomography scanning for selected oncologic applications have been established. It is a useful diagnostic option for patients meeting selection criteria. This policy is effective July 1, 2014.
Inclusionary and Exclusionary Guidelines
All inclusionary and exclusionary statements apply to both positron emission tomography scans and PET/computed tomography scans, such as PET scans with or without PET/CT fusion.
A PET or PET/CT may be appropriate for a patient with known diagnosis of a malignancy in order to determine the optimal anatomic site for a biopsy or other invasive diagnostic procedure if standard imaging is equivocal. It also may replace conventional imaging when conventional imaging would be inadequate for accurate staging, and when clinical management will depend upon the stage of disease. In general, for most solid tumors, a tissue diagnosis is made prior to the performance of PET scanning. PET scans following a tissue diagnosis are performed for the purpose of staging, not diagnosis. If the results of the PET scan will not influence treatment decisions, these situations would be considered not medically necessary.
PET scans may be considered appropriate for the following oncologic conditions:
Anal cancer
Inclusionary Guidelines
- For the diagnosis, staging, restaging and monitoring of anal cancer
Exclusionary Guidelines
- Conditions not listed above
Bone cancer
Inclusionary Guidelines
- For the staging of Ewing sarcoma and osteosarcoma
Exclusionary Guidelines
- For the staging of chondrosarcoma
Brain cancer
Inclusionary Guidelines
- For diagnosis and staging, where lesions metastatic from the brain are identified but no primary is found
- For restaging, to distinguish recurrent tumor from radiation necrosis
Exclusionary Guidelines
- Conditions not listed above
Breast cancer
Inclusionary Guidelines
For the initial and subsequent treatment strategy:
- In the evaluation of a patient with axillary nodal metastasis of unknown primary origin
- For the detection of distant (non-axillary) metastatic disease in high-risk patients with known breast cancer. This includes, but is not limited to:
- Patients with clinically suspicious axillary lymph nodes (palpable, matted or highly suspicious on imaging study), to avoid the need for an unnecessary lymph node procedure in a patient who might already have metastatic disease or would require chemotherapy prior to surgery and
- Patients with locally advanced disease prior to planned neoadjuvant therapy (prior to surgery), particularly when standard imaging is equivocal or suspicious
Exclusionary Guidelines
- For the differential diagnosis in patients with suspicious breast lesions or an indeterminate or low suspicion finding on mammography
- For predicting pathologic response to neoadjuvant therapy for locally advanced disease.
Cancers of unknown primary
Inclusionary Guidelines
- Patients with an unknown primary who meet all of the following criteria:
- In patients with a single site of disease outside the cervical lymph nodes
- Patient is considering local or regional treatment for a single site of metastatic disease
- Patient has received a negative workup for a occult primary tumor
- The PET scan will be used to rule out or detect additional sites of disease that would eliminate the rationale for local or regional treatment.
Exclusionary Guidelines
- For patients with an unknown primary, including, but not limited to, the following:
- As part of the initial workup of an unknown primary
- As part of the workup of patients with multiple sites of disease
Cervical cancer
Inclusionary Guidelines
- For the initial staging of patients with locally advanced cervical cancer
- For the evaluation of known or suspected recurrence
Exclusionary Guidelines
- For the initial diagnosis of cervical cancer in all other situations
Colorectal cancer
Inclusionary Guidelines
- Staging and restaging (initial and subsequent treatment strategy) to detect and assess resectability of hepatic or extrahepatic metastases of colorectal cancer and
- To evaluate a rising and persistently elevated carcinoembryonic antigen level when standard imaging, including CT scan, is negative
Exclusionary Guidelines
- When used as a technique to assess the presence of scarring versus local bowel recurrence in patients with previously resected colorectal cancer.
- When used as a technique contributing to radiotherapy treatment planning.
Esophageal cancer
Inclusionary Guidelines
- Staging and restaging of esophageal cancer and
- Determining response to preoperative induction therapy
Exclusionary Guidelines
- Detection of primary esophageal cancer.
Gastric (stomach) cancer
Inclusionary Guidelines
- Diagnosis, staging and restaging of gastric carcinoma if other imaging is inconclusive
- Determining response to preoperative induction therapy.
Exclusionary Guidelines
- Conditions not listed above
Head and neck cancer
Inclusionary Guidelines
- For the evaluation of the head and neck in the diagnosis of suspected head and neck cancer
- For the initial staging of the disease
- For restaging of residual or recurrent disease during follow up after treatment for their head and neck cancer
Exclusionary Guidelines
- Conditions not listed above
Lung cancer
Inclusionary Guidelines
- Patients with a solitary pulmonary nodule as a single-scan technique (not dual-time) to distinguish between benign and malignant disease when prior CT scan and chest X-ray findings are inconclusive or discordant
- To determine resectability for patients with a presumed solitary metastatic lesion from lung cancer
- As a staging or restaging technique in those with known non-small-cell lung cancer
Exclusionary Guidelines
- As a staging or restaging technique of small cell lung cancer
- Conditions not listed above.
Lymphoma, including Hodgkin’s disease
Inclusionary Guidelines
- PET scanning as a technique for staging lymphoma either during initial staging or for restaging at follow-up
Exclusionary Guidelines
- Conditions not listed above
Melanoma
Inclusionary Guidelines
- Assessing extranodal spread of malignant melanoma at initial staging or at restaging during follow-up treatment.
Exclusionary Guidelines
- When used as a technique to detect regional lymph node metastases in patients with clinically localized melanoma who are candidates to undergo sentinel node biopsy
Multiple myeloma
Inclusionary Guidelines
- For the initial and subsequent treatment strategy of multiple myeloma
Exclusionary Guidelines
Neuroendocrine tumors
Inclusionary Guidelines
- For the diagnosis, staging, restaging and monitoring of neuroendocrine tumors
Exclusionary Guidelines
- Conditions not listed above
Ovarian cancer
Inclusionary Guidelines
- Initial staging of ovarian cancer
- For the evaluation of patients with signs or symptoms of suspected ovarian cancer recurrence (restaging) when standard imaging, including CT scan, is inconclusive.
Exclusionary Guidelines
- For the initial evaluation (not staging) of known or suspected ovarian cancer in all other situations
Pancreatic cancer
Inclusionary Guidelines
- For the initial diagnosis and staging of pancreatic cancer when other imaging and biopsy are inconclusive.
Exclusionary Guidelines
- Evaluating other aspects of pancreatic cancer
Penile cancer
Inclusionary Guidelines
- Staging inguinal lymph nodes in patients with squamous cell carcinoma of the penis.
Exclusionary Guidelines
Prostate cancer
Inclusionary Guidelines
Exclusionary Guidelines
- For the diagnosis and management of known or suspected prostate cancer.
Soft tissue sarcoma
Inclusionary Guidelines
- For initial staging prior to resection of an apparently solitary metastasis
- When the grade of a unresectable tumor remains in doubt after biopsy
- Differentiation of suspected tumor from radiation or surgical fibrosis
- Determination of response to therapy
- Gastrointestinal stromal tumor for initial staging and re-staging when there is documented recurrence
Exclusionary Guidelines
- When used in evaluation of soft tissue sarcoma, including, but not limited to, the following applications:
- Distinguishing between benign lesions and malignant soft tissue sarcoma
- Distinguishing between low grade and high grade soft tissue sarcoma
- Detecting locoregional recurrence
- Detecting distant metastasis
Testicular cancer
Inclusionary Guidelines
- For initial treatment strategy when testicular cancer is strongly suspected based on other diagnostic testing and imaging results are required to determine treatment options
Exclusionary Guidelines
Thyroid cancer
Inclusionary Guidelines
- For the initial treatment strategy of thyroid cancer types known not to concentrate radioactive iodine
- For subsequent treatment strategy for differentiated thyroid cancer of follicular cell origin, which is known to concentrate radioactive iodine in the following situations:
- When done following prior treatment with thyroidectomy and radioiodine ablation and
- With a current serum thyroglobulin > 10 ng/ml (except in the setting of documented anti-thyroglobulin antibodies,) and
- With a negative whole body RAI scan in the past
Exclusionary Guidelines
- For the evaluation of known or suspected differentiated or poorly differentiated thyroid cancer in all other situations
Cancer Surveillance
Inclusionary Guidelines
Exclusionary Guidelines
- When used as a surveillance tool for patients with cancer or with a history of cancer. A scan is considered surveillance if performed more than six months after completion of cancer therapy (12 months for lymphoma) in patients without objective signs or symptoms suggestive of cancer recurrence
Other Oncologic Applications
Inclusionary Guidelines
Exclusionary Guidelines
- Other oncologic applications of PET scanning are considered experimental, including, but not limited to:
- Staging inguinal lymph nodes in patients with squamous cell carcinoma of the penis.
|
Established
82172, 86141
Experimental
82610, 83695, 83701, 83704, 83880 |
Basic Benefit and Medical Policy
The safety and effectiveness of measuring apolipoprotein B have been established. It may be a useful diagnostic option when indicated for individuals at intermediate or high- risk for a cardiovascular event.
The safety and effectiveness of high sensitivity C-reactive protein measurement have been established. It may be a useful diagnostic option when indicated for individuals at intermediate-risk for a cardiovascular event.
The peer-reviewed medical literature has not demonstrated the clinical utility of laboratory testing of other novel biomarkers to assess cardiovascular risk, including, but not limited to apolipoprotein A-I, apolipoprotein E, LDL subclass, HDL subclass and lipoprotein[a]). Therefore, these services are considered experimental.
This policy is effective July 1, 2014.
Inclusionary Guidelines
Apolipoprotein B
Apolipoprotein B (apo B) measurement is established for individuals at intermediate- or high-risk for a cardiovascular event who meet the following criteria:
For individuals at intermediate risk** of CVD, those with recurrent events or a family history of premature CVD or
High-risk*** individuals with hypercholesterolemia to assess whether additional interventions are necessary when LDL-C and/or non-HDL-C goals are reached
High-sensitivity C-reactive protein
High-sensitivity C-reactive protein testing is established for individuals who meet any of the following criteria:
Individuals at intermediate risk** (5-7.5 percent risk of CVD over 10 years), in whom the physician may need additional information to guide further evaluation or therapy
For the selection of patients for statin therapy:
Men ≥ 50 years of age or women ≥ 60 years of age and
With low-density lipoprotein cholesterol < 130 mg/dL and
Not on lipid-lowering, hormone replacement or immunosuppressant therapy and
Without clinical CVD, diabetes, chronic kidney disease, severe inflammatory conditions, or contraindications to statins
In asymptomatic, intermediate-risk** men ≤ 50 years of age or women ≤ 60 years of age, measurement of hs-CRP may be reasonable for CVD risk assessment.
** Intermediate-risk persons are defined as those with 5-7.5 percent 10-year atherosclerotic cardiovascular disease event risk. Refer to any of these web-based calculators:
*** High-risk persons are those with one or more of the following:
- Clinically established coronary heart disease
- Cerebrovascular disease
- Peripheral arterial disease
- Abdominal aortic aneurysm
- Diabetes mellitus
- Chronic kidney disease
- 10-year predicted ASCVD risk ≥7.5 percent
Exclusionary Guidelines
- The routine measurement of apolipoprotein B in low-risk individuals (< 5 percent 10 year CV event risk) is not recommended.
- Measurement of apolipoprotein B is excluded for all other indications.
- hs-CRP testing is excluded for all other indications, including use as a routine screening test for the general population and for monitoring response to therapy.
- In asymptomatic, high-risk adults, measurement of CRP is not recommended for CVD risk assessment.
|
| EXPERIMENTAL PROCEDURES |
83987, 95012 |
Basic Benefit and Medical Policy
The clinical utility of exhaled nitric oxide and exhaled breath condensate in the diagnosis and management of pulmonary disease and respiratory manifestations of underlying clinical conditions has not been demonstrated. In addition, there is insufficient evidence that the use of these tests improves health outcomes; therefore, these tests are considered experimental.
This policy is effective July 1, 2014. |
| GROUP BENEFIT CHANGES |
City of Lathrup Village |
Effective June 1, 2014, Medicare-eligible retirees of the City of Lathrup Village will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical, surgical and prescription drug benefits. The group number is 60630 with suffix 601.You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.
For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma. |
Faurecia USA Holdings |
Faurecia USA Holdings, group number 71547, joined the Blues March 1, 2014. The group offers one PPO plan for its medical and surgical benefits, two prescription drug plans, one vision plan and one consumer-directed health plan with a health savings account.
Member ID cards will show alpha prefix AJT for PPO coverage. |
Oakland Stamping |
Oakland Stamping will migrate from the Blues’ Michigan Operating System to the NASCO platform under new group number 71585 on July 1, 2014. The group will offer one PPO plan with medical-surgical coverage, one prescription drug plan and one vision plan.
Member ID cards will show the following alpha prefixes:
JXP – PPO coverage
XYX – CMM |
The Orlans Group |
The Orlans Group, migrated from the Blues’ Michigan Operating System to the NASCO platform under new group number 71584 on May 1, 2014. The group offers one PPO plan for its medical and surgical benefits, one prescription drug plan, one dental plan and one consumer-directed health plan with a health savings account and flexible spending account.
Member ID cards will show alpha prefix HOA for PPO coverage. |
Tuscola County Road Commission |
Effective June 1, 2014, Medicare-eligible retirees of the Tuscola County Road Commission will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical, surgical and prescription drug benefits. The group number is 60619 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.
For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma. |
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, youll 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.
Upper Peninsula training classes set for August
We’ve scheduled facility and professional training classes in Marquette this August.
The facility class will offer billing tips, web-DENIS information and plenty of time for questions and answers. The professional class will cover such topics as coding and documentation, risk adjustment, the diagnostic closure incentive program, the performance recognition program, Health e-BlueSM and ICD-10.
Classes will begin one hour later than usual:
- Full-day classes start at 10 a.m. and end at 4 p.m., with registration at 9:30 a.m.
- A lunch break will be provided between noon and 1 p.m., with lunch served on both dates.
- Classes might extend later or end earlier, depending on participant questions.
Following are the dates of the sessions and the class location:
| Location |
Class |
Date |
Holiday Inn Marquette
1951 U.S. 41 West |
Professional |
Tuesday, Aug. 19 |
| Facility |
Wednesday, Aug. 20 |
For the facility class, type "Facility Marquette" in the subject line. For the professional class, type "RMRA Marquette." In the body of the email, include the date of the class and the number and names of attendees expected from your facility.
You’ll receive a confirmation within 72 hours of registering. It’s important that you register so we have an accurate headcount for lunch.
For more information, please contact your provider consultant.
Reminder: Registration for annual hospital forum in Frankenmuth
The Blues’ annual hospital morning forum, designed for hospital billing staff, managers and directors, will be held June 10, 2014. The forum is sponsored by the Blue Cross Blue Shield of Michigan-Michigan Hospital Association Benefit Administration Committee.
To attend the forum, you must RSVP to jholzhausen@bcbsm.com by June 6. In the subject line, indicate "BAC Forum." In the body of the email, list your name, facility and the total number of people attending from your facility. Your response is also an RSVP for lunch.
For more information, click here.
Changes to emergency room benefits coming to Michigan Conference of Teamsters Welfare Fund group
Effective immediately, the Michigan Conference of Teamsters Welfare Fund’s medical director is reviewing emergency room records for claims that exceed three visits in a 12-month period for members and their covered dependents to determine if the condition treated was an emergency. Members are responsible for obtaining and providing the medical record information for review.
Conditions that may require emergency care are limited to sudden and unexpected medical problems that, if not immediately treated, may result in death or serious bodily harm. The medical director will determine if the claim is covered under the group’s plan, and the decision cannot be appealed to Blue Cross Blue Shield of Michigan.
This benefit change — which Michigan Conference of Teamsters Welfare Fund members and their covered dependents have been notified about — was made to help ensure that members and their dependents use their emergency room benefit appropriately.
If members aren’t experiencing an emergency, but still need immediate medical care, they should seek treatment from a local urgent care center if their doctor isn’t available.
For more information about this benefit change, please contact the Michigan Conference of Teamsters Welfare Fund’s Member Services at 313-964-2400.
MESSA removes compounded hormones from commercial drug coverage
Effective July 1, 2014, MESSA will no longer cover compounded hormone products for new members who have MESSA prescription drug coverage.
These products include compounds that contain any of the following ingredients:
- Estradiol
- Estrone
- Hydroxyprogesterone caproate
- Methyltestosterone
- Progesterone
- Testosterone
Compounded drugs may expose members to risks from products that have not been tested for safety or effectiveness by the Food and Drug Administration.
MESSA members who are currently prescribed any compounded hormone products are excluded from this change.
Compound hormones were excluded from coverage in November 2013 for members who have Blue Cross Blue Shield of Michigan commercial (non-Medicare) prescription drug coverage.
MESSA removes compounded hormones from commercial drug coverage
Effective July 1, 2014, MESSA will no longer cover compounded hormone products for new members who have MESSA prescription drug coverage.
These products include compounds that contain any of the following ingredients:
- Estradiol
- Estrone
- Hydroxyprogesterone caproate
- Methyltestosterone
- Progesterone
- Testosterone
Compounded drugs may expose members to risks from products that have not been tested for safety or effectiveness by the Food and Drug Administration.
MESSA members who are currently prescribed any compounded hormone products are excluded from this change.
Compound hormones were excluded from coverage in November 2013 for members who have Blue Cross Blue Shield of Michigan commercial (non-Medicare) prescription drug coverage.
We’re clarifying documentation requirements for physician office infusion therapy
In a September 2013 Record article, we said we’d begin processing individual provider medical drug claims at the National Drug Code level on Feb. 1, 2014. Because this was a major change for health care providers, we’re clarifying the documentation requirements associated with this change.
The person administering the medication is responsible for documenting the NDC number of the actual drug being administered, along with the quantity. During an audit, the NDC number billed will be compared to the NDC number documented in the medical record. Keep in mind that while BCBSM pays for the wastage of single-dose vials, the wastages must be documented as well.
Providing this information expedites the audit process and helps providers avoid any potential financial recoveries.
BCBSM updating refill requirements for DME/P&O, medical supplies
Effective July 1, 2014, Blue Cross Blue Shield of Michigan will align with the Centers for Medicare & Medicaid Services’ policy on refill requirements for all durable medical equipment, prosthetics and orthotics, and other medical supplies.
For DME, P&O and supplies that are provided as refills to the original order, suppliers must contact the patient prior to dispensing the refill. Suppliers aren’t allowed to automatically ship the products on a predetermined basis, even if authorized by the patient or designee. This will be done to ensure that:
- The refilled item remains reasonable and necessary
- Existing supplies are nearly expired
- Any changes or modifications to the order are confirmed
Contact with the patient or designee regarding refills must take place no sooner than 10 calendar days prior to the delivery or shipping date.
The supplier must deliver refills of DME, P&O and supplies prior to the expiration of the current product. This is regardless of which delivery method is used. Suppliers must follow BCBSM billing guidelines for dispensing supplies.
Inclusionary guidelines
For all DME, P&O and supplies that are provided on a recurring basis, suppliers are required to have contact with the patient, caregiver or designee prior to dispensing a new supply of items. Suppliers aren’t allowed to deliver refills without a refill request from a patient. Items delivered without a valid, documented refill request will be denied as unreasonable and unnecessary.
Suppliers aren’t allowed to dispense a quantity of supplies exceeding a patient’s expected usage. Suppliers must be aware of any patients whose usage patterns have changed or become atypical. Suppliers must verify with the ordering physicians that any changed or atypical usage is warranted. Regardless of usage, a supplier isn’t allowed to dispense more than the approved monthly quantity at a time.
Documentation requirements
A new prescription isn’t required for routine refills. A new prescription is needed when:
- There is a change of supplier.
- There is a change in the treating physician.
- There is a change in the item(s), frequency of use or amount prescribed.
- There is a change in the length of need or a previously established length of need expires.
- State law requires a prescription renewal.
For items that the patient obtains in person at a retail store, the signed delivery slip or copy of itemized sales receipt is sufficient documentation of a refill request.
For items that are delivered to the patient, the refill request must occur and be documented before shipment. The documentation of a refill request must be either:
- A written document received from the patient
- A recent written record of a phone conversation or contact between the supplier and patient
A retrospective attestation statement by the supplier or patient isn’t sufficient. The refill record must include:
- The patient’s name or authorized representative for the patient
- A description of each requested item
- The date of the refill request
- The quantity of each item that the patient still has remaining
This information must be kept on file and be available upon request.
All prescriptions for hospice patients require prior authorization
To ensure drug claims for hospice patients are paid under the correct plan, as of May 1, 2014, all prescriptions for hospice patients require prior authorization. You can obtain prior authorization for hospice patients through the usual process with the Pharmacy Clinic Help Desk. You can access the phone directory with the appropriate help desk numbers by clicking here.
There may be some medications used before the patient’s hospice enrollment that will continue as part of the hospice plan of care. Prior to hospice enrollment, these drugs were paid under Medicare Part D. When the patient enters hospice, coverage switches to Part A as part of the hospice’s bundled per-diem payment.
Prescriptions for conditions unrelated to the terminal illness and its related conditions may be covered under Part D. For Part D payment, in addition to prior authorization, we require supporting documentation confirming that the treatment is unrelated to the terminal illness.
If a hospice patient attempts to fill a prescription at a pharmacy, the claim will be rejected and indicate that prior authorization is required. We notified pharmacies and affected members of this change in mid-April.
If you’re providing health care services to a hospice patient for a nonrelated condition and are not affiliated with the hospice provider, we encourage you to coordinate care with the hospice. This makes it easier for your patient to fill their prescription at a pharmacy in the future.
Medicare Advantage PPO lab network saves money for members
BCBSM has partnered with Quest Diagnostics® and Joint Venture Hospital LaboratoriesSM to create a nonpatient clinical pathology lab network that will help our Medicare Plus Blue PPOSM members decrease out-of-pocket lab costs.
When these members have lab services performed within the Medicare Advantage PPO lab network, services are paid in full.
You can arrange for a Quest Diagnostics or JVHL courier to pick up a lab specimen in your office obtained by a qualified member of your staff. To contact a physician representative at Quest Diagnostics, call 1-866-MY-QUEST (1-866-697-8378) or use their website contact form. To contact JVHL, call 1-800-445-4979 or use their website contact form.
If you prefer, you may direct your Medicare Plus Blue PPO patients to have their laboratory specimens collected at a Quest Diagnostics or JVHL patient service center. You can find a patient service center on Quest Diagnostics’ website** or on JVHL’s website**.
**BCBSM does not control this website or endorse its general content.
Do you have a Medicare Advantage claim from 2012 or before that you think was processed incorrectly?
If a health care provider believes that a Medicare Advantage claim with a date of service in 2012 or before was processed incorrectly, he or she should submit an inquiry as soon as possible.
The first step the provider should take is to call Provider Inquiry at 1-866-309-1719. If the issue is not resolved to the provider’s satisfaction, he or she may submit an appeal in writing to:
Medicare Plus Blue PPO
Provider Inquiry
P.O. Box 33842
Detroit, MI 48232-5842
We appreciate your cooperation in this matter. We want to ensure that we make appropriate adjustments in a timely manner.
|
