Enrollment for BCBSM’s new freestanding radiology center network begins Oct. 1

Blue Cross Blue Shield of Michigan is establishing a freestanding radiology center network to recognize and reimburse freestanding providers of diagnostic imaging services.

Eligible hospital and nonhospital-owned FRCs can enroll in the BCBSM Traditional network, beginning Oct. 1, 2014. Enrollment materials will be available on bcbsm.com in late September.

The FRC network will go into effect on Jan. 1, 2015.

All participating FRCs will be considered in-network for PPO members, and out-of-network sanctions will be waived.

Establishing this network will make it easier for BCBSM members to find these providers. It will also help us enhance the provider- and service-related cost transparency information available to our members.

Under this new network, we will:

• Designate FRCs as a unique provider type.
• Include FRCs in a provider directory on bcbsm.com and on the Blue Cross and Blue Shield Association^® website.
• List cost information, by procedure, for each of the freestanding radiology centers in the provider directories.

Billing information
Freestanding radiology centers will be reimbursed for all diagnostic imaging services that are covered benefits. The covered benefits must be in compliance with Certificate of Need rules and within the approved scope of practice of the rendering provider.

Diagnostic imaging services performed in freestanding radiology centers will be subject to the current Radiology Management program pre-authorization and privileging requirements.

It’s also important to know that:

• Freestanding radiology centers must bill all services on a CMS-1500 professional claim form or the electronic equivalent. Freestanding radiology centers will be allowed to bill for the professional or technical component or the full fee, depending on the provided service. 
• Applicants who are currently enrolled as physician group practices may qualify as freestanding radiology centers. In order to be designated as a FRC, these providers will be asked to terminate their current provider identification number and enroll under a new PIN. The existing National Provider Identifier will be mapped to the new FRC record.

Look for more information about our freestanding radiology center network in future Record articles.

Preauthorization changes to Radiology Management Program become effective Jan. 1, 2015

We’re notifying you of two upcoming changes to our PPO Radiology Management Program, administered through AIM Specialty Health. Starting Jan. 1, 2015, we will:

1. Require preauthorization for the following cardiac imaging procedures:
• Stress echocardiography
• Transesophageal echocardiography
• Resting transthoracic echocardiography
• These services do not require preauthorization today, either in the office or in a hospital outpatient location
2. Enforce preauthorization for radiological procedures that are part of the Radiology Management Program and are performed in hospital outpatient locations.
• Today, claims for services performed in the office location are adjudicated based on the results of the preauthorization process. If preauthorization has not been obtained for the service, the service is rejected and the provider is responsible for the charges.
• After Jan. 1, 2015, hospital outpatient and professional services performed in the outpatient hospital setting — without required authorization — will be denied as a provider liability. Once this change becomes effective, we will no longer issue quarterly hospital-specific compliance letters and related reports.

Standard PPO Radiology Management Program guidelines apply to both these changes.

We’ll provide additional details in The Record later this year. In the meantime, contact your provider consultant if you would like more information.

New requirements to take effect for facilities submitting BCBSM, FEP^® adjustment claims

We’re working to fully automate the process facilities use to submit Blue Cross Blue Shield of Michigan and Federal Employee Program adjustment claims by early 2015.

Our goal is to:

• Improve the accuracy of 835 remittances.
• Speed up claims processing time.
• Reduce the time spent on manual adjustments.
• Reduce facilities’ account receivables.

To prepare for the transition, new requirements are expected in November 2014 for:

• Late charges (facility type of bill XX5)
• Replacement claims (facility type of bill XX7)
• Void and cancel claims (facility type of bill XX8)

When billing late charge TOB XX5 claims, you should only report the charges for the additional services that weren’t on the original claim. If you’re replacing the original claim, all charges should be reported with TOB XX7, whether it was originally paid, rejected or applied to member cost sharing.

All TOB XX7 and XX8 claims will require the 14- or 17-digit Internal Control Number of the original claim. ICNs are reported with a qualifier of F8 in the REF segment of Loop 2300 in 837 claim transactions.
 
Claims submitted without the 14- or 17-digit ICN will be rejected by the Electronic Data Interchange Department using a 277CA report or transaction. If the claim was submitted with an ICN, it may still reject on a voucher if the processing system is unable to locate a match.

For questions regarding electronic 837 transactions, contact the EDI Helpdesk at 1-800-542-0945. For assistance with billing guidelines, contact your BCBSM provider consultant.

Reminder: Hospital transfer policy

We’d like to remind you of Blue Cross Blue Shield of Michigan’s policy on transferring a patient from one hospital to another. When patients are discharged or transferred to another hospital, please indicate the appropriate discharge disposition as follows:

• 02 (Discharged/transferred to another short-term general hospital)
  
  or

• 07 (Left against medical advice or discontinued care). 

You would enter the discharge disposition on the UB-04 claim form in locator 17 (Patient Discharge Status). The transferring hospital should receive full payment only when the patient’s length of stay meets or exceeds the maximum number of days allowed under the diagnosis related group assigned to the admission.

If a patient is transferred to a second hospital prior to using all days allowed at the first hospital, the transferring hospital should receive only a per diem payment based on the length of stay.

The Blues review paid claims from the previous year to identify patients who were discharged or transferred to another acute care facility. You will receive a letter if we identify claims that may be transfers. If you agree, we’ll adjust your payment. If you disagree, you’ll need to follow the directions on the letter and send in your documentation. Either way, you’ll receive a letter notifying you of our decisions.

For multiple transfers, you may want to refer to the article in the January 2010 Record.

Do not resubmit claims involved in audits

Blue Cross Blue Shield of Michigan is asking providers not to resubmit claims that are involved in our audits. This includes any inpatient or outpatient facility audits including:

• Readmissions
• Diagnosis related group
• Catastrophic cost outliers
• Transfers
• Focus
• Emergency room
• High dollar
• Hospital physical therapy, occupational therapy and speech language pathology
• Ambulatory surgery facility
• Freestanding outpatient physical therapy facilities
• End stage renal disease
• Skilled nursing facility
• Home health care
• Hospice

Once you receive a letter notifying you of an audit, including a patient listing, don’t adjust these claims any further. Please let your billing and finance departments know which claims are being audited so they won’t submit any further claims unless you’re notified by the Blues to do so.

Catastrophic cost outlier claims have an additional exception; please see the article in the December 2011 Record. These claims can only have charges rebilled up to 30 days prior to the audit.

Rebilling charges are time-consuming and can create additional problems once the audit process is complete and claims are sent for adjustment.

For more information, please contact your provider consultant.

Reminder: Statewide facility and professional training

We’d like to remind you that training opportunities will take place this summer at five remaining locations around the state.

For information on the facility and professional Upper Peninsula training sessions, see the June Record article. For information on other professional classes in the Lower Peninsula, see the May Record article.

To register for training:

• Send an email to Jeff Holzhausen at JHolzhausen@bcbsm.com.
• For the professional class in the UP, in the subject line, type "RMRA Marquette."
• For the facility class in the UP, type "Facility Marquette" in the subject line.
• For professional classes in the Lower Peninsula, 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, contact your provider consultant.

BlueCard^® program: Learn the basics

We want to improve your experience with the BlueCard program. So this month we’re launching a series of articles that will provide you with important information about the program, including a look at the online tools available to help you handle claims for members enrolled outside of Michigan. Our first article gives you an overview of BlueCard and how it works.

What is BlueCard?
BlueCard is a national program that allows members of a Blue plan to receive health care services while traveling or living in another Blue plan's service area. The program links participating health care providers with independent Blue Cross and Blue Shield plans across the U.S. and in more than 200 countries and territories worldwide.

The BlueCard program lets you submit claims for members from other Blue plans, including international ones, directly to Blue Cross Blue Shield of Michigan. Your claim is routed to the appropriate plan based on the member’s three-letter alpha prefix, which is visible on their Blue Cross ID card.

How does BlueCard work?
To make sure that claims processing is consistent among plans, the Blue Cross and Blue Shield Association^® developed “host” and “home” definitions to distinguish plan types and a list of responsibilities for each one.

For services received in Michigan, our BCBSM plan would be considered the host plan. We would be responsible for:

• Servicing Michigan providers
• Receiving and pricing their claims
• Routing claims with the pricing data to the member’s home plan
• Paying providers

The home plan is the plan where a member is enrolled. The home plan is responsible for:

• Servicing the member
• Determining eligibility
• Confirming member benefits per their contract
• Determining authorization requirements for provider services
• Determining medical and benefit policy as it applies to the services reported on claims 
• Determining the coordination of benefit policy when a claim is reported for secondary or tertiary benefits. 

You can find more information about the BlueCard program in our provider manuals located on web-DENIS. To find the manuals, log in to web-DENIS and click on BCBSM Provider Publications and Resources.

Do you have article ideas for our BlueCard series?
We want to hear from you if there’s specific information about the BlueCard program that you’d like to see featured in The Record. If you have any suggestions or any questions about the program, contact your provider consultant or send an email to ProvComm@bcbsm.com. Put “BlueCard series” in the subject line.

Be sure to check out next month’s issue of The Record to learn more about BlueCard.

Professional phone line hours changing for West Michigan Provider Servicing

To better align provider servicing call centers across the state, the professional phone line hours of West Michigan Provider Servicing (formerly West MI Provider Inquiry) are changing, effective Sept. 1.

The new hours for West Michigan professional servicing will be 8:30 a.m. to 5 p.m. Their call center continues to be open Monday through Friday. The phone number remains 1-800-255-1878.

West Michigan’s facility call center hours continue to be 7:30 a.m. to 4 p.m. The phone number is 1-800-643-2583.

Both areas are closed for lunch from 12 to 1 p.m.

Register today to attend webinar on estrogen utilization in the 65 and older population

Blue Cross Blue Shield of Michigan is conducting a series of educational webinars for health care providers to discuss two pharmacy-related Medicare star measures — high-risk medications in older adults and the use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in hypertensive diabetics.

The next webinar, to be held on Aug. 27, 2014, at 8 a.m., will address the use of estrogen utilization in the 65 and older population. It will be conducted by Patricia A. Ferguson, M.D., F.A.C.O.G, a board-certified OB/GYN who practices in Bingham Farms and is affiliated with Providence Hospital. The 30-minute webinar will be followed by a question-and-answer session.

To register, email SEprofessionaleducationregistration@bcbsm.com. Include the date, time and name of the class you wish to attend, as well as your national provider identifier. You’ll receive a confirmation email within 72 hours of registering. Instructions on how to access the webinar via WebEx will be sent in the confirmation email or prior to the webinar.

If you have questions about the content of the webinar or the registration process, contact Lawrence Beal at 313-225-8981.

If you have technical issues or questions, call the BCBSM Web support help desk at 1-877-258-3932.

Additional webinars in this series will be announced in future issues of The Record and on web-DENIS.

Keep in mind these coding tips to improve medical record documentation

According to the Centers for Disease Control and Prevention, one in every three adults has hypertension and only half of those adults have it under control. If left uncontrolled for too long, hypertension can damage the heart, kidneys and other organs.

The hypertension table in the ICD-9-CM Alphabetic Index is the first point of reference when coding hypertension. It classifies hypertension by type, primary or secondary, and by nature, benign, malignant or unspecified. There are codes which are used for reporting hypertension in its simple vascular state, without manifestations, and combination codes that illustrate the affect of hypertension on other organs. This allows providers to communicate the complexity of their patient’s condition to the greatest specificity — whether the condition exists alone or with other diseases.

Coding tips for hypertension
Here are common codes for hypertension:

• Primary, or essential, hypertension is considered idiopathic — occurring without apparent cause. Code categories 401 to 404 are used for primary hypertension.
• Secondary hypertension is due to an underlying cause and is reported with codes from category 405.
• Documentation of hypertension should also specify if it’s benign or malignant:
• According to the National Institutes of Health, malignant hypertension is defined as high blood pressure that comes on suddenly and quickly. Malignant hypertension often causes organ damage. Other terms for malignant hypertension include accelerating or necrotizing.
• Benign hypertension is mild to moderate elevation in blood pressure of prolonged or chronic duration without target organ damage.
• If hypertension is not documented as benign or malignant, it’s reported as unspecified hypertension (401.9). Coders can’t determine if hypertension is benign or malignant; it must be documented in the progress note by the provider.
• Documentation should indicate hypertension, benign, or hypertension, malignant. Documentation that states only elevated or high blood pressure could be misinterpreted as transient or incidental hypertension.
• Use of the words controlled or uncontrolled to describe hypertension refers to the status of the condition, not whether it’s benign or malignant. Status indicates if it’s responding to medication, diet or other therapy, not if it’s benign or malignant. For example, documentation that states hypertension, controlled should be coded as 401.9 (hypertension, unspecified), not 401.1 (malignant hypertension).   
• Documentation that indicates elevated or high blood pressure, or borderline hypertension, but doesn’t state a diagnosis of hypertension, is reported with 796.2 (elevated blood pressure reading with no mention of hypertension). 

Hypertension and correct coding
There are three codes for primary (essential) hypertension in its most simple vascular state:

Hypertensive heart disease
Hypertension may increase the workload of the left ventricle of the heart due to the higher systemic vascular resistance. This can result in hypertrophy of the heart or combined hypertrophy and dilation, also known as heart disease. 

When documentation indicates a cardiac condition is due to hypertension, caused by hypertension or hypertensive, report a combination code from category 402. Providers must establish causality in the documentation. Causality can’t be assumed.

Conditions classifiable to category 402 are indicated in the subterms and include cardiomyopathy, myocarditis, myocardial degeneration, cardiovascular disease, cardiomegaly, heart disease and conditions from 429.81 to 420.89 (other ill-defined heart diseases).

Additional codes from category 428 may also be documented and reported for the type of heart failure. Hypertensive heart disease doesn’t include conditions classifiable to ischemic heart disease (410 to 414); however, these might also be documented in the medical record and should be coded separately. 

Hypertensive chronic kidney disease
According to the National Kidney Foundation, hypertension is the leading cause of chronic kidney disease. It can also be a complication of CKD, and the association between hypertension and CKD is so strong that ICD-9-CM presumes a cause-and-effect relationship between the two conditions. 

A code from category 585 should also be used to document the stage of CKD.

Only chronic kidney conditions classified to category 585 or 587 can be reported with the hypertensive CKD codes. There isn’t an assumed causal relationship between hypertension and acute renal failure, which usually develops as the result of an event such as dehydration, major blood loss or the affect of medicine, and it’s often reversible. In contrast, chronic kidney disease is caused by the affects of hypertension or other diseases over a long period of time.    

Hypertensive heart and chronic kidney disease
The kidneys play an important role in regulating blood pressure. But when they develop disease, blood pressure increases and the likelihood of heart problems increases, too. Due to their interactive nature, category 404 combines three conditions: heart disease, hypertension and CKD. As previously indicated, a relationship between CKD and hypertension can be assumed, but documentation must indicate a causal relationship between hypertension and heart disease. 

Additional codes should be added to indicate the type of heart failure and stage of CKD. 

Secondary hypertension
Secondary hypertension is coded using category 405. It’s defined as high arterial blood pressure due to another underlying cause or primary disease, such as renal disorder, central nervous system disorders, endocrine or vascular diseases. A code should be reported for the type of secondary hypertension and also a code for the underlying etiology. 

Hypertension may contribute or accelerate the development of many other conditions. Because ICD-9-CM doesn’t provide combination codes for every condition, assign a code for each individual condition to communicate the complexity of a patient’s condition.

Be sure to check out next month’s edition of The Record, which will include an article about coding tips for chronic kidney disease.

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

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.

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 linkat 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.

Enrollment for BCBSM’s new freestanding radiology center network begins Oct. 1

Blue Cross Blue Shield of Michigan is establishing a freestanding radiology center network to recognize and reimburse freestanding providers of diagnostic imaging services.

Eligible hospital and nonhospital-owned FRCs can enroll in the BCBSM Traditional network, beginning Oct. 1, 2014. Enrollment materials will be available on bcbsm.com in late September.

The FRC network will go into effect on Jan. 1, 2015.

All participating FRCs will be considered in-network for PPO members, and out-of-network sanctions will be waived.

Establishing this network will make it easier for BCBSM members to find these providers. It will also help us enhance the provider- and service-related cost transparency information available to our members.

Under this new network, we will:

• Designate FRCs as a unique provider type.
• Include FRCs in a provider directory on bcbsm.com and on the Blue Cross and Blue Shield Association^® website.
• List cost information, by procedure, for each of the freestanding radiology centers in the provider directories.

Billing information
Freestanding radiology centers will be reimbursed for all diagnostic imaging services that are covered benefits. The covered benefits must be in compliance with Certificate of Need rules and within the approved scope of practice of the rendering provider.

Diagnostic imaging services performed in freestanding radiology centers will be subject to the current Radiology Management program pre-authorization and privileging requirements.

It’s also important to know that:

• Freestanding radiology centers must bill all services on a CMS-1500 professional claim form or the electronic equivalent. Freestanding radiology centers will be allowed to bill for the professional or technical component or the full fee, depending on the provided service. 
• Applicants who are currently enrolled as physician group practices may qualify as freestanding radiology centers. In order to be designated as a FRC, these providers will be asked to terminate their current provider identification number and enroll under a new PIN. The existing National Provider Identifier will be mapped to the new FRC record.

Look for more information about our freestanding radiology center network in future Record articles.

Preauthorization changes to Radiology Management Program become effective Jan. 1, 2015

We’re notifying you of two upcoming changes to our PPO Radiology Management Program, administered through AIM Specialty Health. Starting Jan. 1, 2015, we will:

1. Require preauthorization for the following cardiac imaging procedures:
• Stress echocardiography
• Transesophageal echocardiography
• Resting transthoracic echocardiography
• These services do not require preauthorization today, either in the office or in a hospital outpatient location
2. Enforce preauthorization for radiological procedures that are part of the Radiology Management Program and are performed in hospital outpatient locations.
• Today, claims for services performed in the office location are adjudicated based on the results of the preauthorization process. If preauthorization has not been obtained for the service, the service is rejected and the provider is responsible for the charges.
• After Jan. 1, 2015, hospital outpatient and professional services performed in the outpatient hospital setting — without required authorization — will be denied as a provider liability. Once this change becomes effective, we will no longer issue quarterly hospital-specific compliance letters and related reports.

Standard PPO Radiology Management Program guidelines apply to both these changes.

We’ll provide additional details in The Record later this year. In the meantime, contact your provider consultant if you would like more information.

Reminder: Statewide facility and professional training

We’d like to remind you that training opportunities will take place this summer at five remaining locations around the state.

For information on the facility and professional Upper Peninsula training sessions, see the June Record article. For information on other professional classes in the Lower Peninsula, see the May Record article.

To register for training:

• Send an email to Jeff Holzhausen at JHolzhausen@bcbsm.com.
• For the professional class in the UP, in the subject line, type "RMRA Marquette."
• For the facility class in the UP, type "Facility Marquette" in the subject line.
• For professional classes in the Lower Peninsula, 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, contact your provider consultant.

Update: Report national drug code number on professional drug claims for accurate processing

National drug code information is now being used during the claims process to ensure the most accurate and up-to-date pricing for medical drugs, based on the date of service. This applies to all professional offices, clinics and practitioners who provide and bill medical drugs.

Other ancillary providers such as hemophilia network providers, home infusion therapy providers, ambulatory infusion centers, Walgreens Specialty Pharmacy, limited distribution drug specialty pharmacies and durable medical equipment providers are also required to provide the NDC information, as well as the quantity, for claims processing.

Note: Healthcare Common Procedure Coding System and Current Procedural Terminology^® codes and quantities are required on all drug claims, as required by HIPAA.

The claims billing submissions information and formats described below can also be found in the provider manuals on web-DENIS.

Finding the NDC and unit of measure
The national drug code is found on a medication's packaging. An asterisk may appear as a placeholder for any leading zeroes. The container label also displays the appropriate unit of measure for that drug. The unit of measure is by weight (grams: GR), volume (milliliter: ML) or count (unit: UN). Each dispensed dose must be converted into one of these, following the manufacturer's unit of measure. International units (F2) must be converted to standard measurements (GR, ML and UN).

• For drugs that come in a vial in powder form that needs to be reconstituted before administration, bill each vial (UN).
• For drugs that comes in a vial in liquid form, bill in milliliters (ML).
• For topical forms of medicine (e.g., cream, ointment, bulk powder in a jar), bill in grams (GR).

Submitting the NDC on claims
Here are some quick tips and general guidelines to assist you with proper submission of valid NDCs and related information on professional claims:

• The NDC must be submitted along with the applicable HCPCS or CPT code.
• The NDC must follow the “5digit4digit2digit” format (11 numeric characters with no spaces or special characters). The NDC must be active for the date of service.
• To submit electronic claims (ANSI 837P), report the following information:
  
  

Field name	Field description	ANSI (Loop 2410) – Ref Desc
Product ID Qualifier	Enter “N4” in this field.	LIN02
National Drug CD	Enter the 11-digit NDC assigned to the drug administered.	LIN03
NDC Units	Enter the quantity (number of units) for the prescription drug.	CTP04
NDC Unit / MEAS	Enter the unit of measure of the prescription drug given (GR, UN or ML).	CTP05-1



• To submit paper claims, enter the NDC information in field 24 of the CMS-1500 claim form. In the shaded portion of field 24A-24G, enter the qualifier “N4” left-justified, immediately followed by the national drug code. Next, enter the appropriate qualifier for the correct dispensing unit (GR, UN or ML), followed by the quantity and the price per unit, as indicated in the example below.

Here are two claims billing examples:

• The format for billing should be:
  N4 + NDC code + 3 Spaces+ unit of measure + quantity
  Example: N450242005306   ML50

• The format for billing should be:
  N4 + NDC code + 3 Spaces+ unit of measure + quantity
  Example: N468817013450   UN3

 
Keep the following in mind:

• Reimbursement for discarded drugs applies only to single-use vials. Discarded amounts of drugs in multi-use vials are not eligible for payment.
• For home infusion therapy and specialty drugs, health care providers must continue to submit claims with national drug code and National Council for Prescription Drug Programs quantities electronically.
• In previous articles, we mentioned the use of “ME” (milligrams); however, milligrams as a unit of measure will not be accepted.

BCBSM has also expanded the NDC quantity field to house 11 digits, which translates to 8 places before the decimal and 3 places after the decimal to large quantity units. Example: 99999999.999

Clarification: Converting an NDC from 10 to 11 digits
Previously, we communicated the following information about converting a 10-digit NDC to an 11-digit NDC: “If the NDC on the package label has fewer than 11 digits, you must add leading zeroes to total 11 digits.”

We’d like to provide additional details, as follows:

Many national drug codes are displayed on drug packaging in a 10-digit format. Proper billing of an NDC requires an 11-digit number in a 5-4-2 format. Converting NDCs require a strategically placed zero, depending on the 10-digit format. The following table shows common 10-digit NDC formats indicated on packaging and the appropriate conversion to an 11-digit format. The correctly formatted additional “0” is in bold and underlined in the following examples.

Note: Hyphens indicated below are only used to illustrate the various formatting examples for NDCs. Do not use hyphens when entering the NDC in your claim.

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

Blue Cross to manage additional benefits for State of Michigan retirees and employees

Starting in October 2014, Blue Cross Blue Shield of Michigan will manage the following benefits for State of Michigan members who reside in Michigan:

• Durable medical equipment
• Prosthetics and orthotics
• Medical supplies

This becomes effective on Oct. 1, 2014, for State of Michigan retirees and on Oct. 12, 2014, for active employees.

Here’s how participating DME/P&O providers should handle billing:

• If the service occurred before the above dates, bill claims to the current vendor DMEnsion.

• If the services occurred after the above dates, bill claims directly to the members’ local Blue plan.

Other important items to note:

• Medicare-approved DME providers that provide services to State of Michigan Medicare members can continue to do so after these changes take place in October. Your secondary balance payments will come from Blue Cross instead of DMEnsion.

• Blue Cross will continue to process State of Michigan DME and P&O claims for members who receive services outside of Michigan through our BlueCard^® program. Suppliers that ship equipment or medical supplies to an out-of-state member must participate with the Blue plan in the member’s state in order for the member to receive his or her full benefits.

• Blue Cross will honor current prescriptions for rental DME and medical supplies as long as the supplier remains the same, the prescription is still valid and the prescription covers the rental period for equipment or supplies being billed.

As a reminder, accrued rental payments for DME items in the vendor program count toward the Blue Cross-approved purchase price.

If you have any questions, contact your provider consultant.

Update: Report national drug code number on professional drug claims for accurate processing

National drug code information is now being used during the claims process to ensure the most accurate and up-to-date pricing for medical drugs, based on the date of service. This applies to all professional offices, clinics and practitioners who provide and bill medical drugs.

Other ancillary providers such as hemophilia network providers, home infusion therapy providers, ambulatory infusion centers, Walgreens Specialty Pharmacy, limited distribution drug specialty pharmacies and durable medical equipment providers are also required to provide the NDC information, as well as the quantity, for claims processing.

Note: Healthcare Common Procedure Coding System and Current Procedural Terminology^® codes and quantities are required on all drug claims, as required by HIPAA.

The claims billing submissions information and formats described below can also be found in the provider manuals on web-DENIS.

Finding the NDC and unit of measure
The national drug code is found on a medication's packaging. An asterisk may appear as a placeholder for any leading zeroes. The container label also displays the appropriate unit of measure for that drug. The unit of measure is by weight (grams: GR), volume (milliliter: ML) or count (unit: UN). Each dispensed dose must be converted into one of these, following the manufacturer's unit of measure. International units (F2) must be converted to standard measurements (GR, ML and UN).

• For drugs that come in a vial in powder form that needs to be reconstituted before administration, bill each vial (UN).
• For drugs that comes in a vial in liquid form, bill in milliliters (ML).
• For topical forms of medicine (e.g., cream, ointment, bulk powder in a jar), bill in grams (GR).

Submitting the NDC on claims
Here are some quick tips and general guidelines to assist you with proper submission of valid NDCs and related information on professional claims:

• The NDC must be submitted along with the applicable HCPCS or CPT code.
• The NDC must follow the “5digit4digit2digit” format (11 numeric characters with no spaces or special characters). The NDC must be active for the date of service.
• To submit electronic claims (ANSI 837P), report the following information:
  
  

Field name	Field description	ANSI (Loop 2410) – Ref Desc
Product ID Qualifier	Enter “N4” in this field.	LIN02
National Drug CD	Enter the 11-digit NDC assigned to the drug administered.	LIN03
NDC Units	Enter the quantity (number of units) for the prescription drug.	CTP04
NDC Unit / MEAS	Enter the unit of measure of the prescription drug given (GR, UN or ML).	CTP05-1



• To submit paper claims, enter the NDC information in field 24 of the CMS-1500 claim form. In the shaded portion of field 24A-24G, enter the qualifier “N4” left-justified, immediately followed by the national drug code. Next, enter the appropriate qualifier for the correct dispensing unit (GR, UN or ML), followed by the quantity and the price per unit, as indicated in the example below.

Here are two claims billing examples:

• The format for billing should be:
  N4 + NDC code + 3 Spaces+ unit of measure + quantity
  Example: N450242005306   ML50

• The format for billing should be:
  N4 + NDC code + 3 Spaces+ unit of measure + quantity
  Example: N468817013450   UN3

 
Keep the following in mind:

• Reimbursement for discarded drugs applies only to single-use vials. Discarded amounts of drugs in multi-use vials are not eligible for payment.
• For home infusion therapy and specialty drugs, health care providers must continue to submit claims with national drug code and National Council for Prescription Drug Programs quantities electronically.
• In previous articles, we mentioned the use of “ME” (milligrams); however, milligrams as a unit of measure will not be accepted.

BCBSM has also expanded the NDC quantity field to house 11 digits, which translates to 8 places before the decimal and 3 places after the decimal to large quantity units. Example: 99999999.999

Clarification: Converting an NDC from 10 to 11 digits
Previously, we communicated the following information about converting a 10-digit NDC to an 11-digit NDC: “If the NDC on the package label has fewer than 11 digits, you must add leading zeroes to total 11 digits.”

We’d like to provide additional details, as follows:

Many national drug codes are displayed on drug packaging in a 10-digit format. Proper billing of an NDC requires an 11-digit number in a 5-4-2 format. Converting NDCs require a strategically placed zero, depending on the 10-digit format. The following table shows common 10-digit NDC formats indicated on packaging and the appropriate conversion to an 11-digit format. The correctly formatted additional “0” is in bold and underlined in the following examples.

Note: Hyphens indicated below are only used to illustrate the various formatting examples for NDCs. Do not use hyphens when entering the NDC in your claim.

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

Update: Report national drug code number on professional drug claims for accurate processing

National drug code information is now being used during the claims process to ensure the most accurate and up-to-date pricing for medical drugs, based on the date of service. This applies to all professional offices, clinics and practitioners who provide and bill medical drugs.

Other ancillary providers such as hemophilia network providers, home infusion therapy providers, ambulatory infusion centers, Walgreens Specialty Pharmacy, limited distribution drug specialty pharmacies and durable medical equipment providers are also required to provide the NDC information, as well as the quantity, for claims processing.

Note: Healthcare Common Procedure Coding System and Current Procedural Terminology^® codes and quantities are required on all drug claims, as required by HIPAA.

The claims billing submissions information and formats described below can also be found in the provider manuals on web-DENIS.

Finding the NDC and unit of measure
The national drug code is found on a medication's packaging. An asterisk may appear as a placeholder for any leading zeroes. The container label also displays the appropriate unit of measure for that drug. The unit of measure is by weight (grams: GR), volume (milliliter: ML) or count (unit: UN). Each dispensed dose must be converted into one of these, following the manufacturer's unit of measure. International units (F2) must be converted to standard measurements (GR, ML and UN).

• For drugs that come in a vial in powder form that needs to be reconstituted before administration, bill each vial (UN).
• For drugs that comes in a vial in liquid form, bill in milliliters (ML).
• For topical forms of medicine (e.g., cream, ointment, bulk powder in a jar), bill in grams (GR).

Submitting the NDC on claims
Here are some quick tips and general guidelines to assist you with proper submission of valid NDCs and related information on professional claims:

• The NDC must be submitted along with the applicable HCPCS or CPT code.
• The NDC must follow the “5digit4digit2digit” format (11 numeric characters with no spaces or special characters). The NDC must be active for the date of service.
• To submit electronic claims (ANSI 837P), report the following information:
  
  

Field name	Field description	ANSI (Loop 2410) – Ref Desc
Product ID Qualifier	Enter “N4” in this field.	LIN02
National Drug CD	Enter the 11-digit NDC assigned to the drug administered.	LIN03
NDC Units	Enter the quantity (number of units) for the prescription drug.	CTP04
NDC Unit / MEAS	Enter the unit of measure of the prescription drug given (GR, UN or ML).	CTP05-1



• To submit paper claims, enter the NDC information in field 24 of the CMS-1500 claim form. In the shaded portion of field 24A-24G, enter the qualifier “N4” left-justified, immediately followed by the national drug code. Next, enter the appropriate qualifier for the correct dispensing unit (GR, UN or ML), followed by the quantity and the price per unit, as indicated in the example below.

Here are two claims billing examples:

• The format for billing should be:
  N4 + NDC code + 3 Spaces+ unit of measure + quantity
  Example: N450242005306   ML50

• The format for billing should be:
  N4 + NDC code + 3 Spaces+ unit of measure + quantity
  Example: N468817013450   UN3

 
Keep the following in mind:

• Reimbursement for discarded drugs applies only to single-use vials. Discarded amounts of drugs in multi-use vials are not eligible for payment.
• For home infusion therapy and specialty drugs, health care providers must continue to submit claims with national drug code and National Council for Prescription Drug Programs quantities electronically.
• In previous articles, we mentioned the use of “ME” (milligrams); however, milligrams as a unit of measure will not be accepted.

BCBSM has also expanded the NDC quantity field to house 11 digits, which translates to 8 places before the decimal and 3 places after the decimal to large quantity units. Example: 99999999.999

Clarification: Converting an NDC from 10 to 11 digits
Previously, we communicated the following information about converting a 10-digit NDC to an 11-digit NDC: “If the NDC on the package label has fewer than 11 digits, you must add leading zeroes to total 11 digits.”

We’d like to provide additional details, as follows:

Many national drug codes are displayed on drug packaging in a 10-digit format. Proper billing of an NDC requires an 11-digit number in a 5-4-2 format. Converting NDCs require a strategically placed zero, depending on the 10-digit format. The following table shows common 10-digit NDC formats indicated on packaging and the appropriate conversion to an 11-digit format. The correctly formatted additional “0” is in bold and underlined in the following examples.

Note: Hyphens indicated below are only used to illustrate the various formatting examples for NDCs. Do not use hyphens when entering the NDC in your claim.

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

BCBSM Medicare Advantage PPO home health care and skilled nursing facility audits begin this month

Starting this August, independent contractors will audit Blue Cross Blue Shield of Michigan Medicare Advantage home health care and skilled nursing facility claim payments.

These audits will be performed at the vendor’s office and modeled after the Centers for Medicare & Medicaid Services home health and skilled nursing facility audits. The contractors that will be performing the audits are HealthDataInsights and SCIO Health Analytics.

Home health care and skilled nursing facility services are defined as home health care services that occur within a BCBSM Medicare Advantage member’s home and are provided by home health care companies, including caregiver services, home health nursing, aides and therapists.

A skilled nursing facility provides health and therapeutic services to patients who require residential and continual nursing care. A licensed physician supervises each patient’s care and a nurse or other medical professional is almost always on the premises. Skilled nursing can be made available 24 hours a day.

Additional information will be included in letters sent to facilities.

If you have questions, contact your provider consultant or send an email to efoster@bcbsm.com.

My Advocate^™ appointment scheduling underway

Member outreach initiatives are underway to encourage select Blue Cross Medicare Advantage members to schedule wellness visits with their physicians. Provider offices should expect an influx of calls from our members and the My Advocate appointment scheduling service.

My Advocate is a suite of member services offered by Altegra Health, an independent company that contracts with BCBSM to provide these services free of charge to our Medicare Advantage members.

These services include locating community programs that may save our members money on various health care needs, such as medical supplies, medications and everyday living expenses. The My Advocate program also provides education to our members on specific health issues and how to effectively communicate health concerns with their doctors.

We also encourage our members to visit their doctor regularly, take medications as prescribed and alert the appropriate doctor when issues arise. It’s our goal to provide our Medicare Advantage members with a quality service to aid them in maintaining their health without any additional out-of-pocket expenses.

What you need to know:

• My Advocate will schedule appointments directly with your office staff while they have the member on the phone.
• A confirmation fax will be sent to your office 24 to 48 hours prior to the member’s visit. The confirmation fax will include the member’s gaps in care and basic medical history.

Please notify your staff members of this outreach initiative in order to better prepare them for the increasing volume of calls and to create a pleasant experience for your patients over the next several weeks.

Blues Medicare Advantage website redesigned to improve customer experience

The Blues recently launched its redesigned Medicare website, bcbsm.com/medicare, to enhance the customer experience for people who shop for Medicare plans.

Key improvements include:

• A new contemporary user interface
• Information about Blue Cross Blue Shield of Michigan and Blue Care Network Medicare plans on one site
• Simplified site navigation that makes it easier to find information about our Medicare plans
• Easy-to-understand content
• Faster and more effective search tools
• A new Medicare 101 tutorial and help center that provide answers to the most commonly asked questions

The site’s helpful tools include:

• The search tool on the home page. Just enter a simple keyword or phrase in the bar in the upper-right corner
• The bottom of each page provides direct links to all the pages on the site.
• The “contact us” link on each page has contact information for both group and individual members.

Over the next few months, the Blues’ Digital Experience team will work with Medicare business units to update the site in time for the 2015 enrollment period.

Site access is available to Medicare insurance shoppers, including those who are aging in, potential Medicare group customers, current members, providers, employers, agents and the general public.

If you have any problems accessing the site, call 1-877-258-3932.

Reminder: Submiting CMS-1500 claim forms for Medicare Advantage patients

To submit paper claims and avoid processing delays, BCBSM Medicare Advantage providers should send their CMS-1500 claim forms to:

Medicare Advantage
Blue Cross Blue Shield of Michigan
P.O. Box 32593
Detroit, MI 48232-0593

If you have any questions, please call your provider consultant.