October 2014

Here’s what you need to know about our PPO program policies and members’ rights, responsibilities

We want to ensure that you understand the following about our preferred provider organization plans and programs:

Our members’ rights and responsibilities
Statement about incentives

We also make this information and additional resources available at bcbsm.com/importantinfo.

Member rights and responsibilities
Blue Cross Blue Shield of Michigan members have the right to:

Receive clear and understandable written information about Blue Cross Blue Shield of Michigan, its service, practitioners and providers and their member rights and responsibilities
Receive information about their care that is easy to understand
Receive medically necessary care as outlined in the New Member Handbook and Summary of Benefits and Coverage
Receive considerate and courteous care with respect to their privacy and human dignity
Candidly discuss appropriate medically necessary treatment options for their health conditions, regardless of cost or benefit coverage
Participate in decision-making regarding their health care
Expect confidentiality regarding their care and that Blue Cross Blue Shield of Michigan adheres to strict internal and external guidelines concerning their personal health information. This includes the use, access and disclosure of that information or any other information that is of a confidential nature.
Refuse treatment to the extent permitted by law and be informed of the consequences of their actions
Voice concerns or complaints about their health care by contacting the Customer Service department or submitting a formal, written grievance through the Blue Cross Blue Shield of Michigan appeals process
Review their medical records at your office by scheduling an appointment during regular business hours
Make recommendations regarding the member rights and responsibilities policies of Blue Cross Blue Shield of Michigan
Request the following information from Blue Cross Blue Shield of Michigan:

The current provider network in their region
The professional credentials of the health care practitioners who are participating with Blue Cross Blue Shield of Michigan, including participating practitioners who are board-certified in the specialty of pain medicine and the evaluation and treatment of pain
The names of participating hospitals where individual participating physicians have privileges for treatment
How to contact the appropriate Michigan agency to obtain information about complaints or disciplinary actions against a health care practitioner
Any prior authorization requirement and limitation, restriction or exclusion by service, benefit or type of drug
Information about the financial relationships between Blue Cross Blue Shield of Michigan and a participating practitioner

Blues members have the responsibility to:

Read all Blue Cross Blue Shield of Michigan materials provided for members, and call our Customer Service department with any questions
Coordinate all nonemergency care through their primary care doctors
Use the Blue Cross Blue Shield of Michigan provider network unless otherwise approved by Blue Cross and their primary care physicians
Comply with the plans and instructions for care that they agreed to with their providers
Provide, to the extent possible, complete and accurate information that Blue Cross Blue Shield of Michigan and its providers need in order to provide care
Make and keep appointments for nonemergency medical care. They must call their doctor’s offices to cancel appointments.
Participate in the medical decisions regarding their health
Be considerate and courteous to practitioners, providers, their staff and other patients
Notify Blue Cross Blue Shield of Michigan of address changes and additions or deletions of dependents covered by their contracts
Protect their identification cards against misuse and contact Customer Service immediately if their cards are lost or stolen
Report all other health care coverage or insurance programs that cover their health and their family’s health
Participate in understanding their health problems and the development of mutually agreed upon treatment

Statement about incentives

Medical decisions are based only on appropriateness of care and service and existence of coverage.
Blue Cross Blue Shield of Michigan does not specifically reward doctors or other individuals for issuing denials of coverage.
Financial incentives for doctors and other health professionals do not encourage decisions that limit treatment for our members.

If you have any questions about any of this information, contact your provider consultant.

3.6 million Blue Cross members now receive EOBs in easy-to-understand format

As part of our commitment to improving the customer experience, millions of Blue Cross Blue Shield of Michigan members are receiving a newly designed Explanation of Benefits statement. So when you see your patients, they may comment that their EOB has changed. This article provides details about the changes.

For a first phase of the project, which took place earlier this year, Blue Cross enhanced the EOB for 1.7 million of our members. During phase two in September, 1.9 million more members moved to the enhanced format.

The new EOB design improves clarity and usefulness, making the EOB statement easier to read and understand. And when members understand how claims and billing work, including their cost share, there’s less confusion. The end result? A more streamlined claims and billing process for your office.

Members will benefit from the following improvements:

Addition of procedure description and procedure code
Claims shown in summary (by provider) and detail (by individual claim)
Modified titles and labels, following Clear and Simple^® principles
More logical organization of data and consistent use of terms
Elimination of acronyms, redundancy and unnecessary words
Enhanced glossary of terms
Additional highlighting of amounts for which the member is responsible

We’re confident that the changes we’re making for our members will lead to additional benefits for your office. Please note that the reporting we provide to health care providers will not change at this time, although we continue to explore initiatives that help improve the experience for our members, customers and providers.

Timely responses are important as medical record reviews continue through 2014

Verisk Health will continue through 2014 to gather medical records for individual and small group members on behalf of Blue Cross^® and Blue Shield^® Association plans nationwide. The purpose of gathering these records is to support risk adjustment and government requirements related to the Affordable Care Act.

Blue plans are using Verisk to retrieve medical records for members or from providers in other plans’ service areas.

Health plans are also required by the Department of Health and Human Services to accurately report members’ health conditions. HHS will be auditing the plans’ reported conditions.

Please respond to these requests within the requested time frame. This includes requests from Verisk on our behalf.

It’s also important to know that:

The reviews are in addition to the risk adjustment and HEDIS^® medical record review process performed by Inovalon™ on behalf of Blue Cross Blue Shield of Michigan.

Effective medical record retrieval services help drive optimal quality reporting outcomes and ensure appropriate risk scores. Those factors contribute to enhanced health care delivery and affordability.
Verisk is contractually bound to preserve the confidentiality of health plan members’ protected health information obtained from medical records. This is in accordance with Health Insurance Portability and Accountability Act regulations.

Patient-authorized information releases aren’t required to comply with these requests for medical records when both the provider and health plan had a relationship with the patient and the information relates to the relationship (45 CFR 164.506(c)(4)).

For more information regarding privacy rule language, please visit hhs.gov/ocr/privacy.**

If you have any questions, contact Verisk Health at 1-877-489-8437.

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

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

Register today for live webinars on Oct. 15, 29 and Nov. 5

Blue Cross Blue Shield of Michigan will host webinars for health care providers to discuss two topics related to Medicare star ratings:

Here’s an overview:

Clinical considerations for the use of nonbenzodiazepine hypnotics in patients 65 years and older
This webinar was rescheduled from Sept. 24.

Date: Oct. 15, 2014

Time: 7:30 a.m.

Length: 30-minute webinar, followed by a question-and-answer session.

Speaker: Karen E. Hall, M.D., Ph.D. Dr. Hall is a clinical professor in the Division of Geriatric and Palliative Medicine at the University of Michigan Healthcare System, the medical director at U. of M. St. Joseph Hospital’s Acute Care for Elders Unit, and a research scientist at the V.A. Geriatric Research Education and Clinical Center. She is board-certified in internal medicine, with subspecialties in geriatric medicine, and hospice and palliative medicine.

Is it time to stop prescribing glyburide?
The webinar was rescheduled from Oct, 1.

Date: Oct. 29, 2014

Time: 7:30 a.m.

Length: 30-minute webinar, followed by a question-and-answer session.

Speaker: Jeffrey A. Sanfield, M.D., F.A.C.P., C.D.E. Dr. Sanfield is board-certified in internal medicine with subspecialties in endocrinology and metabolism. He is the department chair of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, medical director of the St. Joseph Mercy Hospital Center for Diabetes and Nutrition, and president of Ann Arbor Endocrinology and Diabetes.

Clinical considerations for the use of skeletal muscle relaxants in patients 65 years and older

Date: Nov. 5, 2014

Time: 7:30 a.m

Length: 30-minute webinar, followed by a question-and-answer session.

Speaker: Carl Christensen, M.D., Ph.D., F.A.S.A.M., F.A.C.O.G. Dr. Christensen is a board-certified OB/GYN and a clinical associate professor in the Department of Obstetrics-Gynecology at the Wayne State University School of Medicine. He is the medical director of the James Wardell Women’s Recovery Center, the Tolan Medical Research Clinic in the Department of Psychiatry at WSU, and the Michigan Health Professional Recovery Program. He is also the past president of the Michigan Society of Addiction Medicine.

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.

Note: At the conclusion of each webinar, we’ll provide attendees with an email address for additional questions.

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

Use of Groupon^® prohibited by terms of participation agreements

The terms of Blue Cross Blue Shield of Michigan’s participation agreements require providers to bill Blue Cross directly for all covered services provided to our members. Under these agreements, participating providers must accept BCBSM’s reimbursement as payment in full for covered services, except for applicable copayments and deductibles. The agreements require accurate cost-sharing amounts to be collected, and prohibit, except in certain limited situations, the waiving of member cost-sharing amounts.

That’s why accepting a Groupon as payment for a covered service violates the terms of the Blue Cross participation agreements. A Groupon is generally a discounted gift certificate usable at local or national companies. An example of a Groupon in a health care setting would be a provider offering services to be rendered for a flat dollar amount. Such a practice violates our participation agreements because it involves charging a member up front for services that the provider should be billing to Blue Cross for after the services are rendered.

More information about member eligibility, benefits and cost sharing is available through web-DENIS and PARS (formerly CAREN)**. Providers should check this information at each patient visit to determine the appropriate cost-sharing amounts.

**The Federal Employee Program^® won’t transition to PARS until 2015.

BlueCard^® program offers plenty of support options for provider community

Members of several different teams — including Provider Inquiry, Provider Enrollment and Data Management, Claims and Blue Card System Support, and BlueCard Host Program Support — work together to support the BlueCard program. Back row, from left: Erica Jones, Paul Ozdarski, Susan Lawrence, Rodney Ross, Paul Nettles, Kisha Horton and John Murnik. Front row, from left: Lisa Washington, Melanie Floyd and Therese Kushnir.

This is part of a series designed to improve your experience with the BlueCard program.

In previous editions of The Record, we’ve provided you with overviews of the BlueCard program and the online tools that can help you provide services to BlueCard members. This month we’d like to make sure you’re aware of the support system at Blue Cross Blue Shield of Michigan that helps our providers in the BlueCard Host program:

BlueCard provider advocates assist provider consultants in educating the provider community about the program. They also work on projects to improve BlueCard processes, resolve issues and support our provider community at corporate and national workgroup meetings.

Provider Inquiry representatives handle phone calls and written inquiries about professional and facility claims submitted to ITS BlueCard Host. The department uses many resources to help you resolve claim issues. And you can also call Provider Inquiry to hear automated messages that include important information from the BCBSM BlueCard department.

Provider Enrollment is responsible for collecting and updating your billing department’s contact fax number and address. We use that information to send you any medical record requests we receive from other Blue plans for claims you’ve submitted to us. Providing us with your billing department’s fax number allows us to forward responses to you quickly and accurately. If you haven’t already responded to our outreach, please contact Provider Enrollment at 1-800-822-2761.

BlueCard Host claims processers are dedicated to processing thousands of BlueCard professional and facility claims received from Michigan providers. The team also works directly with other Blue plans to resolve claim inquiries and process BlueCard claim adjustments.

Claims and BlueCard System Support provides assistance to the BlueCard Host claims department with complex claims analysis. The department serves as a liaison between the Information Technology department and the Claims Operations team. It focuses on improving member and provider experiences by performing root cause analysis on problematic claims and implementing improvements.

ITS Host Program Support is responsible for the system processing and quality of BlueCard Host claims. The department supports small system enhancements, projects, mandates, BlueCard plan program audits and production support to ensure that Inter-Plan Programs policies are met.

There is a BlueCard executive at every Blue plan in the Blue Cross^® and Blue Shield^® Association. Kim Jones-Schneider, the director of our BlueCard Operations and Service department, is also our BlueCard executive. Jones-Schneider represents BCBSM on projects, and she works with other Blue plans and the Association to ensure that our providers’ and member’s interests are met. BCBSM takes a leading role on many Blue projects and the implementation of Association mandates.

Do you have any suggestions or comments regarding BlueCard? If so, please contact your provider consultant to provide us with feedback. We welcome your input as we work to improve your BlueCard experience.

Keep these coding tips in mind to improve medical record documentation

This is part of a series of articles on coding tips that has been running in The Record since May 2013. This month, we’re focusing on coding for pregnancy complications.

Documentation and coding complications for pregnancy is a challenge for many coders and providers. Understanding some of the definitions and the official ICD-9 CM guidelines can simplify this complicated topic.

Complications in pregnancy may range from the mother smoking during the pregnancy to the worst-case scenario, death.

Routine outpatient prenatal visits with no complications should be coded with an ICD-9-CM V Code to indicate if the patient is in her first pregnancy or if she’s been pregnant more than once:

V22.0: Supervision of normal first pregnancy
V22.1: Supervision of other normal pregnancy

These codes are not to be used in conjunction with Chapter 11 codes for complications of pregnancy, childbirth and the puerperium.

If the encounter is for a condition totally unrelated to the pregnancy, assign the condition code first, along with code V22.2, Pregnant state, incidental. The code is a secondary code only for use when the pregnancy is in no way complicating the reason for the visit. Otherwise, a code from the obstetric chapter is required. It’s the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.

For example, if a pregnant woman visits a health care provider to receive a cast for a fractured arm, then the pregnancy is considered incidental.

Report a code from category V23.X for routine prenatal outpatient visits for patients with high-risk pregnancies. Secondary chapter 11 codes may be used in conjunction with these codes if appropriate.

ICD-9-CM guidelines state that obstetric codes 630–679 take precedence over all other codes.

Ectopic and molar pregnancies (630-633)
Report code 630, hydaridiform mole, for a molar pregnancy. Molar pregnancies occur when tissue that normally becomes a fetus develops into an abnormal mass of cysts. The embryo is unformed or malformed and cannot survive.

Ectopic pregnancy means “out of place” or occurring outside the womb (uterus). It’s life-threatening to the mother. A fourth digit indicates the extrauterine location of the ectopic pregnancy. The fifth digit "0" indicates there is no intrauterine pregnancy in addition to the ectopic pregnancy. A fifth digit of "1" indicates there’s an intrauterine pregnancy in addition to the ectopic pregnancy.

633.00 and 633.01 Abdominal pregnancy
633.00 and 633.10 Tubal pregnancy
633.20 and 633.21 Ovarian pregnancy
633.80 and 633.81 Other ectopic pregnancy

Other pregnancy with an abortive outcome (634-639)
This category includes spontaneous abortion, legally-induced abortion, illegally-induced abortions, unspecified abortion and failed attempted abortion. An informational box is provided for categories 634-638 in the ICD-9-CM that identifies subterms for various complications by division. An informational box is also provided that indicates fifth-digit stages for abortion unspecified (0), incomplete (1) and complete (2):

Report 634.XX for spontaneous abortion, including miscarriage. Spontaneous abortions occur naturally at less than 22 weeks gestation.

Pregnancy categories 640-648 and 651-676 require a fifth-digit code to indicate whether the episode is antepartum or postpartum, and if a delivery has occurred. For the purpose of this article, we’re focusing on antepartum conditions with the fifth digit 3:

Antepartum — Occurring during pregnancy before childbirth, with reference to the mother
Postpartum — Immediately after delivery and continues six weeks following delivery, with reference to the mother.

The fifth digits are listed in brackets under each code heading to denote the current episode of care:

0 — Unspecified as to episode
1 — Delivered with or without antepartum condition
2 — Delivered with postpartum condition
3 — Antepartum condition or complication
4 — Postpartum condition or complication

When coding multiple pregnancy complications, all fifth digits should be consistent with each other.

Current conditions complicating pregnancy
For patients with a current condition that affects management of the pregnancy, childbirth or puerperium, assign a code from subcategory 648.XX. An additional secondary code is required from other chapters to identify the current conditions.

For example, a pregnant woman who has a diagnosis of hypothyroidism would be coded with:

648.1X Thyroid dysfunction
244.9X Unspecified hypothyroidism

Diabetes in pregnancy
Diabetes is a significant complication in pregnancy. Before coding, you must first determine if the condition is gestational or predates the pregnancy.

For example, a woman diagnosed with Type 2 diabetes before becoming pregnant should be assigned code 648.03 (diabetes mellitus complicating pregnancy), in addition to a second code from category 250.XX (primary diabetes mellitus) to identify the type of diabetes.

A woman not diabetic prior to pregnancy may develop gestational diabetes during the second and third trimesters. Gestational diabetes may cause complications similar to those of a woman with pre-existing diabetes mellitus. Gestational diabetes is coded 648.83, abnormal glucose tolerance.

Report V58.67 (long-term, current) if either condition is being treated with insulin. It’s important to remember codes 648.0X and 648.8X should never be used together on the same record.

Hypertension in pregnancy
Hypertension is the most common complication during pregnancy. Hypertension complicating pregnancy should be assigned a code from 642.X3:

642.03 — Benign essential hypertension
642.13 — Hypertension secondary to renal disease
642.23 — Other pre-existing hypertension
642.33 — Transient hypertension of pregnancy
642.93 — Unspecified hypertension

Preeclampsia is a condition that starts after the 20th week of pregnancy. Preeclampsia is related to increased blood pressure and protein in the mother’s urine. The condition affects the placenta and it can threaten the lives of both the mother and baby.

642.4 — Mild or unspecified preeclampsia is when a pregnant woman develops high blood pressure and protein in the urine late in the second or third trimester.
642.5 — Severe preeclampsia requires the basic features of mild preeclampsia as well as some indication of an additional problem with either the mother or baby.
642.6 — Eclampsia follows the condition preeclampsia and causes seizures in a pregnant woman.
642.7 — Preeclampsia or eclampsia superimposed on pre-existing hypertension presents in a patient with chronic hypertensive vascular or renal disease. When hypertension precedes the pregnancy as established by previous blood pressure recordings. A rise in systolic pressure of 30mmHg or a rise in diastolic pressure of 15mmHg and the development of proteinuria and edema are required during pregnancy to establish this diagnosis.

The only way to resolve preeclampsia is to deliver the baby.

Placenta previa
Placenta previa is when the placenta is lying unusually low in the uterus. This condition usually occurs around 27 to 32 weeks of gestation. In a case of partial placenta previa, it may resolve on its own; however, if the placenta covers the cervix completely, it’s called complete or total previa. If present at time of delivery, a cesarean section will need to be performed. Placenta previa is coded as 641.03 (without hemorrhage) and 641.13 (with hemorrhage).

Oligohydramnios
Report 658.XX for oligohydramnios. This is a complication when there’s not enough amniotic fluid. If oligohydramnios happens in the first two trimesters of pregnancy, it’s more likely to cause serious problems than if it occurs in the last trimester.

It’s important to review the official ICD-9-CM guidelines for Chapter 11, as well as any instructional notes under the codes in the tabular list of the ICD-9-CM manual, to ensure correct code selection and sequencing.

If you have questions or need more information, contact your provider consultant.

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

HCPCS codes added

The Centers for Medicare & Medicaid Services has added 16 new HCPCS codes as part of its regular quarterly HCPCS updates.

The new codes are listed below.

Code	Change	Coverage comments	Effective date
C9023	Added	Not covered by BCBSM	Oct. 1, 2014
C9025	Added	Not covered by BCBSM	Oct. 1, 2014
C9026	Added	Not covered by BCBSM	Oct. 1, 2014
C9135	Added	Not covered by BCBSM	Oct. 1, 2014
C9741	Added	Not covered by BCBSM	Oct. 1, 2014
G0466	Added	Not covered by BCBSM	Oct. 1, 2014
G0467	Added	Not covered by BCBSM	Oct. 1, 2014
G0468	Added	Not covered by BCBSM	Oct. 1, 2014
G0469	Added	Not covered by BCBSM	Oct. 1, 2014
G0470	Added	Not covered by BCBSM	Oct. 1, 2014
G0471	Added	Covered by BCBSM	Oct. 1, 2014
K0901	Added	Covered by BCBSM	Oct. 1, 2014
K0902	Added	Covered by BCBSM	Oct. 1, 2014
Q9972	Added	Covered by BCBSM	Oct. 1, 2014
Q9973	Added	Covered by BCBSM	Oct. 1, 2014
S8032	Added	Covered by BCBSM	Oct. 1, 2014

Prescription drug lists updated, check our website

Blue Cross Blue Shield of Michigan has updated its prescription drug lists, also called formularies. We periodically update these lists to help ensure patient safety and assist prescribers in selecting the most effective and affordable drug therapy for patients.

You can view the most recent prescription drug list updates, including updates to the Custom Select Drug List, at bcbsm.com/rxinfo. You can also view other pharmacy-related information at the site.

Our prescription drug lists can help prescribers make better-informed prescribing decisions that can lead to increased medication adherence and can help other providers explain prescription drug coverage to our members.

Reminder: Payment decisions require supporting documentation

Claims are denied when there is not enough information available for us to make a payment decision. When this occurs, a new claim must be submitted with supporting documentation.

For more detailed descriptions of the Blue Cross Blue Shield of Michigan policies for these procedures, please check the benefit policy on web-DENIS. To access it, log in to web-DENIS, click on BCBSM Provider Publications and Resources, choose Benefit Policy for a Code and enter the procedure code.

Below is a list of some common services where payment is denied due to insufficient information, and what is needed to make a payment decision:

If your patient has Medicare coverage, a copy of the Medicare voucher for the denied services must always be included with the new claim, along with other documentation as specified for the services below.
All not-otherwise-classified codes, such as surgery, radiology, durable medical equipment, etc., should always be accompanied by a narrative description of the service.

Service	What is needed
Ambulance	A copy of the ambulance record and the discharge or transfer summary from the referring hospital, indicating the medical necessity of the transfer
Anesthesia	A copy of the anesthesia report and operative notes when a not-otherwise-classified procedure code is reported.
Drug code	The national drug code and the appropriate quantity when reporting a drug procedure code on a professional claim
Durable medical equipment	A copy of the prescription, statement of medical necessity, invoice and complete description when an NOC procedure code is reported
Emergency services	A copy of the entire emergency room record and physician’s notes describing the patient’s condition and treatment provided when service was denied as a non-emergency condition
Inpatient admissions	A copy of the complete inpatient records
Laboratory/Pathology	A copy of the pathology report and complete description of the pathology procedure performed when reporting an NOC pathology or lab procedure code
Medical care	A copy of relevant clinic notes or evaluations that support the medical necessity of the treatment
Medical supplies	Clinical rationale that justifies exceeding the maximum supply quantity allowed. Limitations or restrictions to services need a statement of medical necessity. For example, if a reported quantity exceeds the maximum, documentation must include clinical rationale from the provider that justifies the exception. A copy of the prescription, statement of medical necessity, invoice and complete description when reported with an NOC code
Physical therapy and occupational therapy	A copy of the physician’s order for therapy, initial evaluation, treatment notes from each visit, progress notes and summaries and, if applicable, the discharge summary when denial indicates supportive documentation is necessary for payment determination
Pre-existing conditions	A copy of the patient’s complete medical records with the medical records routing form to determine if the patient received treatment for the condition denied as pre-existing before the effective date of coverage
Private duty nursing	A copy of the physician’s certification, nurse’s license and photo ID, as well as hour-by-hour nursing or observation note
Prosthetics and orthotics	A copy of the prescription, statement of medical necessity, invoice and complete description when the item is reported with an NOC procedure code
Radiology	A copy of the radiology report and a complete description of the radiology procedure performed when reporting an unlisted or NOC radiology procedure code
Skilled nursing facility and home health care	A copy of medical records covering dates of service denied for SNF or HHC benefits
Speech therapy	A copy of physician’s order for therapy, initial evaluation, treatment notes from each visit, progress notes and summaries and, if applicable, the discharge summary when denial indicates supportive documentation is necessary for payment determination
Surgery	A copy of the operative report when an NOC procedure code is reported and a statement separate from the operative report that clarifies the actual surgical procedure reported under the NOC code. A copy of the operative report when the reported surgical procedure has been denied as ineligible for co-surgery, team surgery or technical surgical assistant benefits.

For additional information about claims or payable services, see your online provider manual on web-DENIS.

Reminder: Preauthorization for abdomen and pelvis CT scans

As part of Blue Cross Blue Shield of Michigan’s radiology management program, physicians must obtain preauthorization through AIM Specialty Health^® for any nonemergency outpatient CT scans. The procedure performed must match the preauthorized procedure in order for the imaging claim to be paid.

Blue Cross recently received questions about CT abdomen (*74150, *74160, *74170), CT pelvis (*72192-*72194), and CT abdomen pelvis combination tests (*74176-*74178). It’s important to note that the preauthorization process for these exams includes some specific rules:

When the imaging service is performed and it’s determined that a procedure other than the one preauthorized is more appropriate, the imaging facility must contact the ordering physician to change the order. The ordering physicians’ staff should then withdraw the original request and obtain authorization for the new procedure.
In these specific circumstances, we provide a 48-hour, post-procedure window for the ordering physician to obtain the new authorization.

Before rendering any imaging services, providers should validate the authorized exams from the ordering physician by calling AIM at 1-800-728-8008 or accessing this information online through AIM’s provider portal at aimspecialtyhealth.com.**

These rules apply to Medicare Advantage and commercial members in Michigan. If you have any questions, contact your provider consultant.

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

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
83037	Basic Benefit and Medical Policy Medical Policy has determined that Hemoglobin A1c testing, using an FDA-approved point of care device in the physician’s office is considered established. It may be used as an alternative to laboratory-measured hemoglobin A1c. Hemoglobin A1c testing device for home use in the management of diabetes is considered experimental. Its incremental benefit above home glucose monitoring has not been established. This policy is effective March 1, 2014.
96900, 96910, 96912, 96913, 96999	Basic Benefit and Medical Policy The Light Therapy for Vitiligo Policy is established. This policy is effective Nov. 1, 2014. Medical Policy Statement Psoralen plus ultraviolet A, narrowband ultraviolet B and targeted phototherapy with excimer laser, with or without the use of oral or topical medications for the treatment of vitiligo, are considered established treatments. They may be useful therapeutic options when indicated. Inclusionary Guidelines Vitiligo that is not responsive to other forms of conservative therapy (e.g., topical corticosteroids and coal or tar preparations). NB-UVB and excimer laser phototherapy in individuals ≥ 3 years of age. Topical PUVA can be performed in children ≥ 2 years of age when up to 20 percent of their body surface area. Systemic PUVA or oral PUVA is restricted to children > 12 years who have widespread vitiligo ( ≥ 20 percent body surface area). Treatment of vitiligo is restricted to the face, neck, trunk and extremities. Exclusionary Guidelines Systemic PUVA or oral PUVA is contraindicated in children < 12 years of age. Treatment of vitiligo of the acral areas (fingers, palms, soles of feet)
UPDATES TO PAYABLE PROCEDURES
Established procedures S3854, 84999 Experimental procedures 0008M, 84999	Basic Benefit and Medical Policy Genetic Testing – Assays of Genetic Expression to Determine the Prognosis of Breast Cancer Patients The safety and effectiveness of the use of the 21-gene reverse transcriptase-polymerase chain reaction assay (e.g., Oncotype DX^®) to determine recurrence risk for deciding whether or not to undergo adjuvant chemotherapy have been established. It is a useful diagnostic test for determining the likelihood of distant cancer recurrence in women for patients who meet the inclusionary guidelines. Other genetic testing for determining the likelihood of distant cancer recurrence in women are considered experimental. (Refer to exclusions below.) Procedure code S3854 is payable when used for billing the Oncotype DX^® test. Procedure code 84999 is payable when used for billing the Oncotype DX^® test for Medicare12345. Procedure code 0008M is considered experimental when used for billing the ProSigna™ test. Procedure code 84999 is considered experimental when used for billing for gene expression tests for breast cancer other than the Oncotype DX^®. Criteria has been updated, effective Nov. 1, 2014. Inclusionary Guidelines* (must meet all) The use of Oncotype DX^® to determine recurrence risk for deciding whether or not to undergo adjuvant chemotherapy may be considered established in women with breast cancer meeting all of the following characteristics: Unilateral tumor Hormone receptor positive (that is, estrogen-receptor positive or progesterone-receptor positive) Human epidermal growth factor receptor2 negative Tumor size 0.6-1 cm with moderate or poor differentiation or unfavorable features or tumor size larger than 1 cm Node negative (lymph nodes with micrometastases less than 2 mm in size are considered node negative for this policy). Who will be treated with adjuvant endocrine therapy, e.g., tamoxifen or aromatase inhibitors When the test result will aid the patient in making the decision regarding chemotherapy (e.g., when chemotherapy is a therapeutic option) When ordered within six months after diagnosis, since the value of the test for making decisions regarding delayed chemotherapy is unknown. Note: The 21-gene RT-PCR assay Oncotype DX^® should only be ordered on a tissue specimen obtained during surgical removal of the tumor and after subsequent pathology examination of the tumor has been completed and determined to meet the above criteria (i.e., the test should not be ordered on a preliminary core biopsy). The test should be ordered in the context of a physician-patient discussion regarding risk preferences when the test result will aid in making decisions regarding chemotherapy. For patients who otherwise meet the above characteristics but who have multiple ipsilateral primary tumors, a specimen from the tumor with the most aggressive histological characteristics should be submitted for testing. It is not necessary to conduct testing on each tumor; treatment is based on the most aggressive lesion. Exclusionary Guidelines All other indications for the 21-gene RT-PCR assay (e.g., Oncotype DX^®), including determination of recurrence risk in invasive breast cancer patients with positive lymph nodes or patients with bilateral disease, are considered experimental. Use of a subset of genes from the 21-gene RT-PCR assay for predicting recurrence risk in patients with noninvasive ductal carcinoma in situ (e.g., Oncotype DX^® DCIS) to inform treatment planning following excisional surgery is considered experimental. The use of other gene expression assays (e.g., MammaPrint 70-gene signature, Mammostrat^® Breast Cancer Test, the Breast Cancer Index^SM, the BreastOncPx™, NexCourse^® Breast IHC4, Prosigna™, BreastPRS™, EndoPredict™, etc.) for any indication is considered experimental. The use of gene expression assays in men with breast cancer is considered experimental. The use of gene expression assays to molecularly subclassify breast cancer (e.g., BluePrint^®) is considered experimental. The use of gene expression assays for quantitative assessment of ER, PR and HER2 overexpression (e.g., TargetPrint^®) is considered experimental.
0051T-0053T, 33975-33983, 33990-33993	Basic Benefit and Medical Policy Total artificial hearts and implantable ventricular assist devices. The safety and effectiveness of implantable ventricular assist devices and total artificial hearts have been established. They are useful therapeutic options for patients meeting specified selection criteria. The safety and effectiveness of the use of a percutaneous ventricular assist device have been established for a subset of patients. They are useful therapeutic options for patients meeting specified selection criteria. All other uses for pVADs are considered experimental. The evidence on the use of pVADs does not support the conclusion that these devices improve health outcomes for any other situations. Criteria has been updated, effective Nov. 1, 2014. Implantable ventricular assist devices must have FDA approval or clearance Inclusionary Guidelines For post-cardiotomy setting and bridge to recovery For patients in the post-cardiotomy setting who are unable to be weaned off cardiopulmonary bypass. For use as a bridge to transplantation Implantable ventricular assist devices with FDA approval or clearance when used as a bridge to heart transplantation patients who are currently listed as heart transplantation candidates and not expected to survive until a donor heart can be obtained, or are undergoing evaluation to determine candidacy for heart transplantation Implantable ventricular assist devices with FDA approval or clearance, including HDEs, in children 16 years of age or younger who are currently listed as heart transplantation candidates and not expected to survive until a donor heart can be obtained, or are undergoing evaluation to determine candidacy for heart transplantation. For use of implantable ventricular assist devices with FDA approval or clearance as destination therapy For patients with end-stage heart failure who are ineligible for human heart transplant and who meet the following “REMATCH Study” criteria: New York Heart Association (NYHA) Class IV heart failure for >60 days, or NYHA Class III/IV heart failure for 28 days, received with over 14 days’ support with intra-aortic balloon pump or dependent on IV inotropic agents, with two failed weaning attempts In addition, patients must not be candidates for human heart transplant for one or more of the following reasons: Age over 65 years Insulin-dependent diabetes mellitus with end-organ damage Chronic renal failure (serum creatinine >2.5 mg/dL for >90 days) Presence of other clinically significant condition Exclusionary Guidelines Patients not meeting the above patient selection guidelines. The use of non-FDA approved or cleared ventricular assist devices. For patients under age 16, HDE approval is acceptable Percutaneous ventricular assist device must be FDA-approved Inclusionary Guidelines For providing short term circulatory support for patients with severe cardiogenic shock who are unstable to the point where IABP support would not be tolerated or effective. As an adjunct to percutaneous coronary intervention in the following high-risk patients: Patients with a cardiac ejection fraction of less than 35 percent who are undergoing unprotected left main or last-remaining-conduit PCI. Patients with three-vessel disease and ejection fraction less than 30 percent. The Impella^® 2.5 Circulatory Support System is intended for partial circulatory support using an extracorporeal bypass control unit, for periods up to six hours. It is also intended to be used to provide partial circulatory support (for periods up to six hours) during procedures not requiring cardiopulmonary bypass. Exclusionary Guidelines The use of a pVAD for any other indication not listed above. Total artificial hearts (must have FDA approval or clearance) Bridge to transplantation only Inclusionary Guidelines When used as a bridge to heart transplantation for patients with biventricular failure who have no other reasonable medical or surgical treatment options and Who are ineligible for other univentricular or biventricular support devices and Who are currently listed as heart transplantation candidates or undergoing evaluation to determine candidacy for heart transplantation and not expected to survive until a donor heart can be obtained Exclusionary Guidelines Patients not meeting the above patient selection guidelines The use of non-FDA approved or cleared implantable ventricular assist devices or total artificial hearts The use of total artificial hearts as destination therapy
83993	Basic Benefit and Medical Policy The clinical utility of fecal calprotectin testing has been established for pediatric patients. It can be a useful option when used as an adjunctive non-invasive test for confirming a diagnosis of inflammatory bowel disease and in determining if an endoscopy may be needed. Fecal calprotectin testing in non-pediatric patients is considered experimental. Further prospective trials and the establishment of appropriate cut-off values are needed to determine the clinical utility of this testing for non-pediatric patients. Group Variations Payable for GM hourly and salaried enrollees, effective July 1, 2014
A9520	Basic Benefit and Medical Policy Effective June 13, 2014, the FDA-approved LYMPHOSEEK™ (Technetium tc-99m, tilmanocept) will be recognized under NDC 52579-1695-01 when billed with procedure code A9520 along with 78195 as indicated for: Lymphatic mapping with a hand-held gamma counter to assist in the localization of lymph nodes draining a primary tumor site in patients with breast cancer or melanoma. Guiding sentinel lymph node biopsy, using a hand-held gamma counter in patients with clinically node negative squamous cell carcinoma of the oral cavity.
POLICY CLARIFICATIONS
Counseling procedures 96040, S0265 Genetic test procedures 0001M-0008M, 81161, 81200-81203, 81205-81217, 81220-81229, 81235, 81240-81245, 81250-81257, 81260-81268, 81270, 81275, 81280-81282, 81290-81299, 81300- 81304, 81310, 81315- 81319, 81321-81326, 81330- 81332, 81340-81342, 81350, 81355, 81370-81379, 81380- 81383, 81400-81408, 81479, 81500, 81503, 81504, 81506-81512, 81599, 83950, 83951, 87152, 87153, 87493, 88245, 88271- 88273, G0452, G9143, S0265, S3800, S3841, S3842, S3844-S3846, S3849, S3850, S3853-S3855, S3861, S3865, S3866, S3870	Basic Benefit and Medical Policy The safety and effectiveness of genetic testing and counseling services have been established. They may be considered useful diagnostic options only if the testing results are expected to establish or verify a diagnosis, initiate a treatment plan and alter the patient’s health care management. Prenatal genetic testing by chromosomal microarray analysis is considered experimental. Policy updates are effective Nov. 1, 2014 Group Variations Please reference group benefits for coverage status Inclusionary Guidelines If there is a medical policy for a specific genetic test, that policy must be used in order to make a policy determination. For conditions that do not have a separate policy, the patient must meet the general inclusionary guidelines below. Genetic testing is established only if the test has been proven valid (i.e., has regulatory agency approval [including CLIA certification] or its clinical validity and utility has been demonstrated following randomized clinical trials). Requests for genetic testing must meet all of the following criteria: After history, physical examination, pedigree analysis, genetic counseling and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain, and The patient displays clinical features of a genetic disease, or is at direct risk of inheriting the mutation in question (pre-symptomatic), and The disease is treatable or preventable or the result of the test will directly influence the treatment being delivered to the patient, including increasing the intensity of surveillance or treatment of that disease. Note: For carrier testing only For non-affected patients with a confirmed family history of a gene mutation (e.g., sickle-cell trait) or for patients in certain ethnic groups with an increased risk of specific genetic conditions (e.g., Ashkenazi for those of Jewish heritage), carrier testing is appropriate to determine whether the patient possesses one copy of a gene mutation that, when present in two copies, causes a genetic disorder. In addition to the above criteria, it is assumed that: The patient must provide informed consent for the testing. The Michigan Public Health Code Act 368 of 1978, section 333.17020, “Genetic test; informed consent,” states that a physician or an individual to whom the physician has delegated authority to perform a selected act, task or function under section 16215 shall not order a presymptomatic or predictive genetic test without first obtaining the written, informed consent of the test subject, pursuant to this section. There are a number of components to this informed consent. Details that must be included are of this public act are available at legislature.mi.gov/(S(jrq4hpf2c1j3n045f0vejr45))/mileg. aspx?page=getobject&objectname=mcl-333-17020 > Genetic counseling is strongly recommended prior to testing to explain the significance of anticipated test results except for those tests commonly performed on amniotic fluid. For genetic testing to determine appropriateness of specified drug therapy: Genetic testing is considered appropriate prior to initiating a drug therapy regimen if the United States Food and Drug Administration requires that a specific heritable condition be confirmed prior to starting the drug. Exclusionary Guidelines Genetic testing in the general population for patients at low risk of having a heritable condition Gene expression testing with algorithmic analysis to predict cancer susceptibility or chance of cancer recurrence except for the Oncotype DX^® test for breast cancer recurrence (please refer to the policy “Genetic Testing - Assays of Genetic Expression to Determine the Prognosis of Breast Cancer Patients”) Genetic testing, including chromosomal microarray analysis of products of conception, to determine genetic causes of miscarriage Prenatal CMA Next-generation sequencing panels for cancer or other conditions Whole genome or exome sequencing for any reason Forensic testing for legal purposes BCBSM does not control this website or endorse its general contenet.
38242	Basic Benefit and Medical Policy The inclusionary and exclusionary guidelines for the Donor Lymphocyte Infusion for Malignancies Treated with an Allogeneic Hematopoietic Stem-Cell Transplant Policy were updated. This policy is effective Nov. 1, 2014. Inclusionary Guidelines Donor lymphocyte infusion may be considered established following allogeneic-hematopoietic stem cell transplantation that was originally considered medically necessary for the following indications: Treatment of a hematologic malignancy that has relapsed or is refractory to treatment Prevention of relapse in the setting of a high risk of relapse To convert a patient from mixed to full donor chimerism. Settings considered high risk for relapse include T cell depleted grafts or nonmyeloablative (reduced-intensity conditioning) allogeneic HSCT. Exclusionary Guidelines Donor lymphocyte infusion following allogeneic hematopoietic stem-cell transplantation that was originally considered experimental for the treatment of a hematologic malignancy. Donor lymphocyte infusion as a treatment of nonhematologic malignancies following a prior allogeneic HSCT. Genetic modification of donor lymphocytes.
Established procedures 44700	Basic Benefit and Medical Policy The safety and effectiveness of exclusion of small bowel from pelvis by mesh or other prosthesis, or native tissue (e.g., bladder or omentum) have been established. It is a useful therapeutic option for a select subset of patients that require extensive abdominal radiation who are not candidates for more targeted therapies, such as intensity-modulated radiation therapy. This policy became effective May 1, 2014. Inclusionary Guidelines Patients undergoing radical pelvic surgery who will require postoperative radiation and who are not appropriate candidates for targeted radiotherapy (e.g., IMRT, etc.)
61885, 61886, 64553, 64568-64570, 95970, 95974, 95975	Basic Benefit and Medical Policy The safety and effectiveness of vagus nerve stimulation has been established. It may be considered a useful therapeutic or diagnostic option when indicated. Non implanted and transcutaneous vagal nerve stimulators are considered experimental. Their positive impact on clinical outcomes has not been definitively demonstrated. Exclusionary criteria have been updated, effective Nov. 1, 2014. Inclusionary Guidelines Partial-onset seizures that are refractory to conventional and newer anticonvulsant drugs A history of at least four to six identifiable partial onset seizures each month A diagnosis of intractable epilepsy for at least two years Patients with epilepsy who experience breakthrough seizures or suffer from debilitating adverse effects of antiepileptic drugs Patients with partial-onset seizures who are ineligible for epilepsy surgery or who have a history of previous epilepsy surgery that was unsuccessful in controlling the seizures Patients with mental retardation or psychosis may be candidates for VNS if it is possible to measure the benefit to the recipient in spite of their comorbid condition Exclusionary Guidelines Other types of epilepsy in patients with seizures other than partial-onset seizures Patients with partial-onset seizures who are candidates for epilepsy surgery A progressive seizure disorder Non implantable and transcutaneous vagus nerve stimulation devices Other disorders not listed in the inclusions, including, but not limited to: Heart failure Fibromyalgia Depression Essential tremor Obesity Headaches Tinnitus Traumatic brain injury
86304	Basic Benefit and Medical Policy Measurements of CA-125 are established for patients meeting the patient selection guidelines. Measurement of CA-125 is considered experimental in asymptomatic, average-risk women as a screening technique for ovarian cancer. The inclusionary and exclusionary criteria have been updated, effective Nov. 1, 2014. Inclusionary Guidelines (must meet one) CA-125 testing is appropriate when used in conjunction with transvaginal ultrasound and a rectal and pelvic exam. Testing for CA-125 levels is appropriate in the following situations: For patients with symptoms suggestive of ovarian cancer (i.e., women with new symptoms (bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, or urinary frequency and urgency) that have persisted for three or more weeks, where the clinician has performed a pelvic and rectal examination and suspects ovarian cancer). For use as a preoperative diagnostic aid in women with ovarian masses that are suspected to be malignant, such that arrangements can be made for intraoperative availability of a gynecological oncologist if the CA 125 is increased For patients with known ovarian cancer, as an aid in the monitoring of disease, response to treatment, detection of recurrent disease, assessing value of performing second-look surgery or determining a patient’s prognosis As a screening test for ovarian cancer when there is a history of hereditary cancer syndrome (a pattern of clusters of ovarian cancer within two or more generations) For individual patients with other malignancies, such as endometrial cancer, in whom baseline levels of CA-125 have been shown to be elevated Testing of CA-125 levels at the completion of chemotherapy as an index of residual disease For monitoring a patient's response to therapy in the presence of advanced or recurrent disease. In this setting, CA-125 levels may be obtained prior to each treatment cycle. Exclusionary Guidelines Measurement of CA-125 is considered experimental in asymptomatic patients as a sole screening technique for ovarian cancer. Its use as a sole screening test in asymptomatic patients is considered to be an off-label use of the test.
92065, 99199**	Basic Benefit and Medical Policy The safety and effectiveness of orthoptic training and vision therapy for specific medical conditions have been established. It may be considered a useful therapeutic option for the treatment of any of the following: Amblyopia for which occlusion therapy is administered Acquired esotropia that involves the use of prism adaptation prior to corrective surgery Strabismus, intermittent exotropia, convergence insufficiency and accommodative deficiencies (such as accommodative insufficiency and infacility), which also involves the use of orthoptics or prisms Orthoptic training (including “optometric vision therapy”) for the treatment of learning disabilities, dyslexia, mild traumatic brain injury and other conditions not listed above is considered experimental. It has not been scientifically demonstrated to improve patient clinical outcomes. The policy has been updated, effective Nov. 1, 2014. Payment Policy *Use procedure code 99199 to report “vision therapy” (i.e., behavioral optometry or optometric vision therapy) Inclusionary Guidelines Office-based vergence or accommodative therapy may is considered established for patients whose symptoms of convergence insufficiency have failed to improved following a minimum of 12 weeks of home-based therapy, including, but not limited to: Push-up exercises (pencil push-ups) using an accommodative target Push-up exercises (pencil push-ups) with additional base-out prisms Jump to near convergence exercises; stereogram convergence exercises; Recession from a target, and Maintaining convergence for 30-40 seconds Conditions treated by pleoptic therapy include: Accommodative dysfunction disorders (focusing problems) Acquired esotropia (the turning inward of the eye) that involves the use of prism lenses prior to corrective surgery Amblyopia (lazy eye) for which eye-patching therapy is being used Amblyopia (poorly developed vision in one or both eyes) Convergence insufficiency Intermittent exotropia Non-strabismus binocular dysfunction disorders (inefficient eye teaming) Nystagmus (rapid, involuntary eye movement) Strabismus (misalignment of the eyes) Documentation should include the following: The initial evaluation must include measurable data supporting the diagnosis in order to establish a baseline against which follow-up evaluations can be measured. There should be a written treatment plan that includes the projected period of treatment. There should be reasonable expectation that vision therapy will produce improvement that can be measured in a reasonable period of time. If there is no improvement after the first two months of therapy, the need for further therapy should be questioned. There should be monthly re-evaluations with documentation of percentage of improvement from the start of therapy. There should be written documentation of any changes in the patient’s treatment plan. All progress should be documented. Vision therapy includes both office visits and a home treatment program. There should be documentation of the patient’s compliance or noncompliance. Because all patients are different, each vision therapy program may differ in the number of visits per week and the total number of visits. Vision therapy programs may require from 24 to 32 visits over the course of a few months, with follow up instructions for continuing the program in the home. Vision therapy is performed in an optometrist or ophthalmologist’s office once or twice a week for a number of months with instructions for a follow-up program to continue at home. Exclusionary Guidelines Any other conditions not listed under the inclusions listed above, including but not limited to learning disabilities, dyslexia and mild traumatic head injury. Orthoptic training (including “optometric vision therapy”) for the treatment of learning disabilities, dyslexia, mild traumatic brain injury and other conditions not listed above
G0453, 95940, 95941 (add-on procedures) Base procedures 92585, 92586, 95829, 95867, 95868, 95925, 95926, 95927, 95938, 95955 Non-payable procedures with intraoperative monitoring: 95907-95913, 95928-95930, 95939, 95941**	Basic Benefit and Medical Policy Intraoperative monitoring, which includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, EMG of cranial nerves, EEG, and electrocorticography (ECoG), is established during spinal, intracranial or vascular procedures Intraoperative monitoring of visual-evoked potentials is considered experimental. Intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation is considered experimental. This policy was updated, effective Sept. 1, 2013. Payment Policy *Procedure code 95941 will no longer be payable. Bill service with procedure code 95940 or G0453. Inclusionary Guidelines* The following types of intraoperative monitoring are appropriate when performed during spinal, intracranial or vascular surgeries or procedures. Note: Only qualified persons can perform this type of monitoring. Somatosensory-evoked potentials Motor-evoked potentials using transcranial electrical stimulation Brainstem auditory-evoked potentials Electromyogram of cranial nerves Electroencephalogram EEG Electrocorticography Exclusionary Guidelines Intraoperative monitoring of visual-evoked potentials Intraoperative monitoring of motor-evoked potentials using transcranial magnetic stimulation Intraoperative EMG and nerve conduction velocity monitoring during surgery on the peripheral nerves Intraoperative monitoring performed during any surgical procedure not specified in the inclusions
Established procedures A4222, A4230, A4231, A4232, A9274, E0784, J1817, K0552, K0601-K0605 Experimental procedures 99091, E1399, S9145	Basic Benefit and Medical Policy The safety and effectiveness of external insulin pumps have been established for patients meeting specific patient selection criteria. They are useful therapeutic options when indicated. Procedure codes 99091, E1399 and S9145 are considered experimental for the Continuous Subcutaneous Insulin Infusion and Transdormal Insulin Delivery Systems Policy. Transdermal insulin delivery systems (e.g., V-Go Transdermal Basal-Bolus Insulin Delivery Device) are considered experimental. There is insufficient evidence in medical literature to determine if the use of these devices result in improved patient clinical outcomes. This policy is effective Nov. 1, 2014. Inclusionary Guidelines External infusion pumps and related drugs and supplies are established in the home setting for the treatment of diabetes in the following situations, if determined to be medically necessary and prescribed by an allopathic or osteopathic physician. Patients must meet all the following criteria: The patient must complete a comprehensive diabetes education program. The patient has been on a regime of at least three injections daily with frequent self-adjustments for at least six months prior to the initiation of the pump. The patient has documented the frequency of glucose self-testing on average at least four times per day during the two months prior to initiation of the insulin pump. The patient also meets one of the following criteria on a multiple daily injection regimen: Glycosylated hemoglobin level (HbA1c) > 7.0 percent History of recurring hypoglycemia Wide fluctuations in blood glucose before mealtime “Dawn” phenomenon with fasting blood sugars frequently exceeding 200 mg/dL History of severe glycemic excursions For gestational diabetics, only the following criteria must be met to qualify for insulin pump therapy: Insulin injections are required greater than or equal to three times per day and The patient cannot be controlled by the use of intermittent dosing. Exclusionary Guidelines Patients with major psychiatric disorders such as psychosis and severe depression Patients with eating disorders Young children who cannot tolerate the cannula or refrain from changing pump settings Patients who fail to comply with treatment regimen Patients who, in the judgment of the diabetic specialist, are non-responsive to a trial of insulin pump therapy Transdermal insulin delivery devices (e.g., V-Go)
J3490	Basic Benefit and Medical Policy Verapamil is approved for the off-label treatment of Peyronie’s disease through penile injections. This policy is effective retroactive to Jan. 1, 2014. Report Verapamil with NOC code J3490, until a permanent code is established. Dosage and administration: Total dose 2.5-10 mg per session given as multiple injections distributed within the plaque using 25G needle Injections are usually every other week (occasional doses may be provided weekly) Allow for up to 12 total injection sessions. Requests for longer periods of therapy require physician review. A standardized dose of 10 mg of verapamil (5 mg/2 cc) diluted to 10 cc total volume with injectable saline is used. Prior to drug injection, a penile block is performed with 10 cc 0.5 percent bupivacaine without epinephrine. In some cases, a second penile block may be required. The plaque is grasped between index finger and thumb, and a single skin puncture is performed. The needle is then passed in and out of the plaque while leaving the drug within the needle tracts. In men with large plaques, the needle may be removed and the process repeated. After the injections are complete, the patient is asked to lightly compress the penis with both thumbs over the puncture sites to reduce the likelihood of ecchymosis or hematoma. Each patient's blood pressure is monitored for 10 minutes after drug injection before discharge from the office. Patients are asked to abstain from intercourse for a minimum of 24 hours after each procedure.
EXPERIMENTAL PROCEDURES
86152, 86153	Basic Benefit and Medical Policy The clinical utility of testing for the detection and quantification of circulating tumor cells has not been demonstrated. The peer reviewed medical literature has not shown that the test has sufficient diagnostic accuracy to provide clinically relevant information when compared to other available diagnostic studies. This test is considered experimental, policy effective Nov. 1, 2014.
A7002, A7047, E0600	Basic Benefit and Medical Policy Negative oral pressure therapy for the treatment of obstructive sleep apnea is considered experimental, effective Nov. 1, 2014. There is insufficient scientific evidence in the current medical literature to support its efficacy and use in clinical practice. **Procedure codes A7002 and E0600 may be payable when used to report another service.

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Enrollment for BCBSM’s and BCN’s new freestanding radiology center networks begins on Oct. 1

Blue Cross Blue Shield of Michigan and Blue Care Network are establishing freestanding radiology center provider networks. These FRC networks will create the capability to uniquely recognize and reimburse freestanding providers of diagnostic imaging services.

Eligible FRCs, including those owned by hospitals, are encouraged to begin applying for enrollment in the Blue Cross Traditional and Blue Care Network FRC networks on Oct. 1, 2014. All FRCs participating in the Blue Cross Traditional network will be considered in-network for PPO members, and out-of-network sanctions will be waived.

Members will be able to search for participating FRCs in provider directories at bcbsm.com and on the Blue Cross^® and Blue Shield^® Association website.
Provider-specific FRC cost information, by procedure, will be available using the provider search function on bcbsm.com.
FRCs will be reimbursed for all diagnostic imaging services that are approved by the plan and are covered benefits using the applicable plan’s professional fee schedule.
Diagnostic imaging services performed in FRCs in the BCBSM Traditional network will be subject to the current Radiology Management Program preauthorization and privileging requirements for members whose groups have the Radiology Management Program.
FRCs participating in the BCN network will follow requirements specified in the Blue Care Network Referral and Clinical Review Program for standard radiology services. In addition, BCN FRCs will be subject to high-tech radiology services preauthorization requirements administered by Care Core National.

As part of the Blue Cross FRC enrollment process, providers will be required to enroll in the AIM Specialty Health OptiNet^® assessment tool. OptiNet collects information on the provider’s imaging equipment, staffing credentials, and safety and quality assurance programs. The AIM OptiNet online assessment tool supports informed decision-making by consumers and providers by supplying accurate and current information about imaging facilities and contracted imaging providers. Providers may begin accessing the OptiNet assessment tool on Oct. 1, 2014.

To access the OptiNet assessment tool, freestanding radiology centers may visit the AIM website at www.aimspecialtyhealth.com/marketing/goweb.**

Providers who haven’t registered their center’s information for BCBSM will begin by selecting BCBSM from the drop-down menu.
Freestanding radiology centers that have already registered within AIM’s provider portal will have the ability to pre-populate the OptiNet registration data fields with corresponding information previously entered.
Providers with multiple freestanding radiology center locations will need to complete the assessment for each unique location. If the information in the assessment is similar for more than one location, once the OptiNet assessment is completed for one site, it can be copied for other sites.
Freestanding radiology centers that have completed the assessment for another health plan or payer will also need to complete it for BCBSM, but providers may copy and paste the information to their BCBSM record.
BCBSM’s provider enrollment page for freestanding radiology centers has a frequently asked questions document that can be referenced for more detailed information.

AIM will host a series of webinars to help BCBSM providers register and complete the OptiNet assessment. The webinars will take place 12 to 1 p.m. Oct. 21 and Oct. 30, and 2 to 3 p.m. Nov. 3. All times are Eastern time.

Providers interested in participating in the AIM webinars can access them here:

For more details about the Blue Cross Traditional FRC network, see the August and September Record articles on this topic or contact your BCBSM provider consultant.

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

The Blue Cross and Blue Shield Association is an association of independent locally operated Blue Cross and Blue Shield plans.

Preauthorization required for in-lab sleep studies

Reminder: Sleep study referral requirements

TRUST physicians must refer patients with a suspected sleep disorder to other TRUST board certified sleep medicine physicians for all sleep study services. Certified sleep specialists can be identified by using the Find a Doctor feature on bcbsm.com.

All TRUST M.D.s and D.O.s performing sleep study services for our PPO members must be certified in sleep medicine by a board recognized by Blue Cross. We recognize the American Board of Sleep Medicine and the sleep medicine boards approved by the American Board of Medical Specialties and the American Osteopathic Association. The sleep specialist is the physician responsible for obtaining preauthorization for sleep testing when required and performing the testing in an accredited sleep laboratory.

Non-board certified physicians submitting sleep study claims for PPO members will be subject to audit and recovery based on the physicians failure to meet a necessary privileging credential. Such claim submissions are considered a violation of the TRUST Provider Agreement and any non-credentialed physicians submitting sleep study claims may be subject to termination of their TRUST contract.

Effective for dates of service on or after Feb. 1, 2015, Blue Cross Blue Shield of Michigan will require preauthorization for in-lab sleep testing by instate providers for non-Medicare Blue Cross PPO members. Specifically, preapproval must be obtained for the following Current Procedural Terminology codes: *95805, *95807, *95808, *95810 and *95811. All authorized attended sleep study services should be performed at a laboratory or center accredited by the American Academy of Sleep Medicine or The Joint Commission.

CPT codes *95782 and *95783 are excluded from preauthorization. In addition, providers are not required to obtain preauthorization for *95806. Home sleep testing followed by auto positive airway pressure is a viable alternative to in-lab sleep diagnostic studies and CPAP titration for many patients with a high pretest probability of obstructive sleep apnea. HST can be a more affordable, comfortable and convenient option for such patients. In spite of this, we find HST significantly underutilized in our patient population. Preauthorization of in-lab sleep testing and the shifting of select patients to the home setting will provide more efficient utilization of resources for the management of obstructive sleep apnea and other sleep disorders.

Preauthorization process
Only board certified sleep medicine physicians are allowed to submit a preauthorization request. Preauthorization requests are managed by AIM Specialty Health. Requests should be submitted online 24/7 through AIM’s ProviderPortal^SM at AIMSpecialtyhealth.com**. Alternatively, providers may submit a request via phone at 1-800-728-8008, 8 a.m. to 5 p.m. Eastern time Monday through Friday.

AIM will perform a clinical evaluation of the request and provide a determination to the provider. The clinical criteria used by AIM are available on AIM’s website.

Providers are expected to obtain an authorization before administering the service. Retrospective authorization requests are permitted, but only up to 60 days past the date of service. Such requests must be done by phone, and there is no guarantee that an already administered test will be authorized.

Providers are able to request a preauthorization up to 30 days before the scheduled date of service. Sleep specialists may begin submitting preauthorization requests to AIM as of Jan. 1, 2015.

Please note that authorizations are only valid for a time period of up to 30 days before to 30 days after the anticipated date of service identified to AIM in the authorization request. Should an authorized sleep study get rescheduled, the provider must contact AIM again if the new date of service is going to be outside the valid time range for the initial anticipated date of service.

It is very important that providers, including hospitals billing for the sleep study technical component, confirm an authorization has been issued before the service is rendered. Preauthorization requests can be checked by logging into AIM’s provider online portal or by phone.

AIM registration and training opportunities
To register with AIM’s ProviderPortal, visit AIMSpecialtyhealth.com** and click on Register Now under the ProviderPortal login page. Providers will need to supply the following information:

Valid email address
A tax ID number
Blue Cross PIN
Phone and fax numbers
A username and password for your account

Providers already registered with AIM do not need to register again.

AIM will be hosting online training webinars for providers on the registration and preauthorization request process. The training webinar schedule is listed below.

If you’re interested in participating, you can register by clicking here**.

Nov. 4, 2014, from noon to 1 p.m. Eastern time
Nov. 5, 2014, from noon to 1 p.m. Eastern time
Nov. 11, 2014, from noon to 1 p.m. Eastern time
Nov. 12, 2014, from noon to 1 p.m. Eastern time

Note: The preauthorization requirements described in this article do not apply to State of Michigan members, Federal Employees Program^® members, Ascension or Medicare Advantage PPO members or non-Michigan residents. In addition, authorization is not required for non-attended sleep testing codes or studies performed in inpatient, observation or emergency room settings.

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

Blue Cross’ PPO Radiology Management Program expands to include echocardiography services

On Jan. 1, 2015, Blue Cross Blue Shield of Michigan will expand its radiology management program for its commercial PPO product. The program will include preauthorization for nonemergency outpatient echocardiography performed in a physician’s office, freestanding radiology center or hospital outpatient setting.

Ordering providers must contact AIM Specialty Health^SM to request authorization prior to scheduling echocardiography procedures with the following CPT codes:

*93303, *93304, *93306, *93307, *93308, *93312, *93313, *93314, *93315, *93316, *93317, *93350, *93351.

The following are “add-on,” or secondary, codes for echo services that don’t require independent review:

*93320, *93321, *93325, *93352

Echocardiography services are already included in the radiology management program for BCBSM Medicare Advantage members. With this new change, preauthorization for the above CPT codes will now become a requirement for instate commercial PPO members as well.

The following are excluded from preauthorization:

Services performed in the hospital inpatient, observation or emergency room setting
Out-of-state PPO members
State of Michigan members, prisoners or Federal Employee Program^® members.

Ordering providers may begin requesting prior authorization for stress echocardiography, resting transthoracic echocardiography or transesophageal echocardiography beginning Dec. 1, 2014. Requests may be submitted in one of these ways:

Online through AIM’s ProviderPortal^SM at aimspecialtyhealth.com/goweb** .
By phone Monday through Friday from 8 a.m. to 5 p.m. Eastern time at 1-800-728-8008.

The AIM portal is available 24 hours a day, seven days a week, and offers an easy-to-use interface for submitting requests and checking on the status of open requests. There’s a quick registration process to set up an account that will allow you to manage prior authorization requests for one or multiple physicians.

If you’re already registered on the AIM portal, you don’t need to register again. If you have questions about the registration process, call AIM Customer Service at 1-800-252-2021.

Pre-exam questions
Please note that during the prior authorization process, pre-exam questions will be asked for stress echocardiography, as well as coronary CT angiography, cardiac positron emission tomography and myocardial perfusion imaging. The purpose of the questions is to help identify the common risk factors for cardiac disease.

The questions facilitate order review and reduce the time it takes to receive your order number. Pre-exam questions will not be requested for pediatric patients under the age of 19.

As with other outpatient diagnostic services requiring preauthorization, we recommend that providers confirm that an order number has been issued by AIM before rendering services. This can be done by checking online or by phone, as described above.

Payments for billed services with dates of service on or after Jan. 1, 2015, will be denied if preauthorization is not obtained. Members may not be billed for these denied services.

Retrospective authorization requests are permitted, but only up to 60 days past the date of service.

If you have any questions about this change, please contact your provider consultant.

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

BCBSM 101 training class available for new professional billing staff and others looking for a refresher

Are you new to professional office billing within the last two years or would you like a refresher course on Blue Cross Blue Shield of Michigan billing policies and procedures? Then we have just the class for you.

Blue Cross Blue Shield of Michigan will offer BCBSM 101 in four locations across the state in November. The classes will provide information on documentation and coding; self-help tools, such as web-DENIS and PARS; BlueCard^® and other important aspects of working with Blue Cross.

Here’s an overview of the format:

Full-day classes start at 9 a.m. and end at 4 p.m., with registration at 8:30 a.m.
A lunch break will be provided from 12 to 1 p.m., with lunch served at all three locations.
Classes might extend later or end earlier depending on the number of participant questions.

To register, send an email to Jeff Holzhausen at jholzhausen@bcbsm.com. In the subject line, write “New Billing Staff” and the city where you wish to attend the class. Include the class date and the number and names of attendees expected from your office. You will receive a confirmation within 72 hours of registering.

It’s important that you register so we can have an accurate headcount for lunch. If you register, please make every attempt to attend or send an alternate.

Here’s a schedule of the dates and locations:

Location	Address	Date
Southfield – BCN Commons	20500 Civic Center Drive, Southfield	Wednesday, Nov. 5, 2014
Grand Rapids – Meijer Gardens	1000 East Beltline Avenue NE, Grand Rapids	Tuesday, Nov. 11, 2014
Sterling Heights – Sterling Inn	34911 Van Dyke Ave, Sterling Heights	Tuesday, Nov. 18, 2014
Frankenmuth – Frankenmuth Bavarian Inn Lodge	One Covered Bridge Lane, Frankenmuth	Wednesday, Nov. 19, 2014

For more information, contact your provider consultant.

Reminder: Blues to retire Facility and Provider Claims Correction tool

As you read in the July and September Record, Blue Cross Blue Shield of Michigan will remove the PCC tool from Provider Secured Services in October for both facility and professional providers.

This change is due to the low volume of Michigan Operating System edits that are currently in the PCC tool, as well as the migration of all local groups to the NASCO platform.

Because of this change, all claims that were corrected using PCC will now be rejected with the appropriate reason code. This removal won’t affect your access to other tools on the provider portal.

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

Updates to Medical Drug Prior Authorization Program take place Jan. 1

Beginning Jan. 1, 2015, there are 13 additional specialty drugs administered by health care practitioners that will require prior authorization by Blue Cross Blue Shield of Michigan before they will be covered under our members’ medical benefits.

This will help ensure proper utilization and address potential safety issues for these medications.

Note: The prior authorization only represents clinical review approval, and is not a guarantee of payment. Health care practitioners will still need to verify coverage for medical benefits. Also, the prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

You can find the medication request forms and a list of medications that require prior authorization on web-DENIS:

Click on BCBSM Provider Publications and Resources.
Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
Click on Physician administered medications (on the right side under “Frequently used forms”).

We will not consider a request for coverage until a physician-signed medication request form has been faxed or mailed to Blue Cross or the request is uploaded onto the online-based tool, Novologix^®. Standard processing time for a review of a request is 15 days. An urgent request is reviewed within 72 hours.

The following drugs will require prior authorization, beginning Jan. 1, 2015:

Drug name	HCPCS code
Adagen^®	J2504
Aldurazyme^®	J1931
Cerezyme^®	J1786
Elaprase^®	J1743
Elelyso™	J3060
Fabrazyme^®	J0180
Lumizyme^®	J0221
Myozyme^®	J0220
Naglazyme^®	J1458
Tysabri^®	J2323
Vpriv^®	J3385

The following two drugs will have a HCPCS code assigned at a later date.

Drug name	HCPCS code
Entyvio™	J3490, J3590
Vimizim™	J3490, J3590

Blue Cross reserves the right to change this list at any time.

Enrollment for BCBSM’s and BCN’s new freestanding radiology center networks begins on Oct. 1

Members will be able to search for participating FRCs in provider directories at bcbsm.com and on the Blue Cross^® and Blue Shield^® Association website.
Provider-specific FRC cost information, by procedure, will be available using the provider search function on bcbsm.com.
FRCs will be reimbursed for all diagnostic imaging services that are approved by the plan and are covered benefits using the applicable plan’s professional fee schedule.
Diagnostic imaging services performed in FRCs in the BCBSM Traditional network will be subject to the current Radiology Management Program preauthorization and privileging requirements for members whose groups have the Radiology Management Program.
FRCs participating in the BCN network will follow requirements specified in the Blue Care Network Referral and Clinical Review Program for standard radiology services. In addition, BCN FRCs will be subject to high-tech radiology services preauthorization requirements administered by Care Core National.

To access the OptiNet assessment tool, freestanding radiology centers may visit the AIM website at www.aimspecialtyhealth.com/marketing/goweb.**

Providers who haven’t registered their center’s information for BCBSM will begin by selecting BCBSM from the drop-down menu.
Freestanding radiology centers that have already registered within AIM’s provider portal will have the ability to pre-populate the OptiNet registration data fields with corresponding information previously entered.
Providers with multiple freestanding radiology center locations will need to complete the assessment for each unique location. If the information in the assessment is similar for more than one location, once the OptiNet assessment is completed for one site, it can be copied for other sites.
Freestanding radiology centers that have completed the assessment for another health plan or payer will also need to complete it for BCBSM, but providers may copy and paste the information to their BCBSM record.
BCBSM’s provider enrollment page for freestanding radiology centers has a frequently asked questions document that can be referenced for more detailed information.

Providers interested in participating in the AIM webinars can access them here:

For more details about the Blue Cross Traditional FRC network, see the August and September Record articles on this topic or contact your BCBSM provider consultant.

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

The Blue Cross and Blue Shield Association is an association of independent locally operated Blue Cross and Blue Shield plans.

Blue Cross’ PPO Radiology Management Program expands to include echocardiography services

Ordering providers must contact AIM Specialty Health^SM to request authorization prior to scheduling echocardiography procedures with the following CPT codes:

*93303, *93304, *93306, *93307, *93308, *93312, *93313, *93314, *93315, *93316, *93317, *93350, *93351.

The following are “add-on,” or secondary, codes for echo services that don’t require independent review:

*93320, *93321, *93325, *93352

The following are excluded from preauthorization:

Services performed in the hospital inpatient, observation or emergency room setting
Out-of-state PPO members
State of Michigan members, prisoners or Federal Employee Program^® members.

Online through AIM’s ProviderPortal^SM at aimspecialtyhealth.com/goweb** .
By phone Monday through Friday from 8 a.m. to 5 p.m. Eastern time at 1-800-728-8008.

If you’re already registered on the AIM portal, you don’t need to register again. If you have questions about the registration process, call AIM Customer Service at 1-800-252-2021.

The questions facilitate order review and reduce the time it takes to receive your order number. Pre-exam questions will not be requested for pediatric patients under the age of 19.

Payments for billed services with dates of service on or after Jan. 1, 2015, will be denied if preauthorization is not obtained. Members may not be billed for these denied services.

Retrospective authorization requests are permitted, but only up to 60 days past the date of service.

If you have any questions about this change, please contact your provider consultant.

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

We’re shutting down the Exception Admission application on web-DENIS

As we prepare for the retirement of the local system on Oct. 31, we want to let facility users know that the Exception Admission application on web DENIS will shut down at that time. Since member data is no longer being loaded to the local system, the application is no longer needed.

If you have any questions, contact the BCBSM Web Support Help Desk at 1-877-258-3932.

Reminder: Hospitals must follow claims appeals process in provider manual

The hospital claims appeal process has been updated in the online hospital manuals, including the BlueCard^® chapter. If you’ve contracted with a third-party vendor to handle appeals on your behalf, be sure they know that they must follow the process documented in our online manuals.

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

Reminder: Blues to retire Facility and Provider Claims Correction tool

As you read in the July and September Record, Blue Cross Blue Shield of Michigan will remove the PCC tool from Provider Secured Services in October for both facility and professional providers.

This change is due to the low volume of Michigan Operating System edits that are currently in the PCC tool, as well as the migration of all local groups to the NASCO platform.

Because of this change, all claims that were corrected using PCC will now be rejected with the appropriate reason code. This removal won’t affect your access to other tools on the provider portal.

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

Updates to Medical Drug Prior Authorization Program take place Jan. 1

This will help ensure proper utilization and address potential safety issues for these medications.

You can find the medication request forms and a list of medications that require prior authorization on web-DENIS:

Click on BCBSM Provider Publications and Resources.
Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
Click on Physician administered medications (on the right side under “Frequently used forms”).

The following drugs will require prior authorization, beginning Jan. 1, 2015:

Drug name	HCPCS code
Adagen^®	J2504
Aldurazyme^®	J1931
Cerezyme^®	J1786
Elaprase^®	J1743
Elelyso™	J3060
Fabrazyme^®	J0180
Lumizyme^®	J0221
Myozyme^®	J0220
Naglazyme^®	J1458
Tysabri^®	J2323
Vpriv^®	J3385

The following two drugs will have a HCPCS code assigned at a later date.

Drug name	HCPCS code
Entyvio™	J3490, J3590
Vimizim™	J3490, J3590

Blue Cross reserves the right to change this list at any time.

Are you billing correctly for these drugs?

The following drugs are often billed with incorrect quantities under the prescription drug benefit. Review the charts below for the appropriate quantities of these drugs so your claims can be processed more accurately and promptly.

Drug name	Incorrect quantity	Correct quantity
Enbrel^® Example: 50 mg per 0.98 mL (4 syringes)	4 syringes	3.92 mL total volume (4 x 0.98 mL)
Androgel^® pump Example: 88 gm pump delivering 75 gm of gel	88 gm pump	75 gm of gel
Premarin^®; vaginal cream Example: 0.625 mg per gm, 30 gm tube	42.50 gm	30 gm
Clobex^® (Clobetasol Propionate) Example: 0.05%; 4 oz bottle	120 mL or 60 mL	118 mL or 59 mL
Hydrocortisone Example: 2.5% cream in 28.35 gm tube or 453.6 gm jar	30 gm or 454 gm	28.35 gm (exact weight) or 453.6 gm (exact weight)
Lactulose Example: 10 g per15 mL (1 pint bottle)	480 mL	473 mL

Victoza^® is a drug that is often billed with incorrect quantities. See the chart below for the accurate information.

Dose	Day’s supply per pen	Package (bill by volume)	Day’s supply per package
0.6 mg per day	15	6 mL (2 pens)	30
0.6 mg per day	15	9 mL (3 pens)	45
1.2 mg per day	10	6 mL (2 pens)	20
1.2 mg per day	10	9 mL (3 pens)	30
1.8 mg per day	5	6 mL (2 pens)	10
1.8 mg per day	5	9 mL (3 pens)	15

For any questions on how to submit claims, call our claims processor, Express Scripts^®, at 1-800-922-1557. If you have questions about this article, call our Pharmacy Services Clinical Help Desk at 1-800-437-3803.

Blue Cross to manage non-Medicare durable medical equipment benefits for MPSERS members

Starting Jan. 1, 2015, Blue Cross Blue Shield of Michigan will manage the following for non-Medicare Michigan Public School Employees Retirement System members who live in Michigan:

Durable medical equipment
Prosthetic and orthotics
Medical supplies

When submitting a claim for DME or P&O services, providers should directly bill:

The current vendor, DMEnsion^SM, for services provided before Jan. 1, 2015
Blue Cross for services provided after Jan. 1, 2015

For members who receive services outside of Michigan, Blue Cross will continue to process MPSERS DME and P&O claims through our BlueCard^® program. Suppliers who ship equipment or medical supplies to an out-of-state member must participate in the Blue Cross plan in that member’s state so that the member can receive full benefits.

Blue Cross will also honor current prescriptions for rental DME and medical supplies as long as:

The supplier remains the same.
The prescription is still valid.
The prescription covers the rental period for equipment or supplies being billed.

Accrued rental payments for DME items in the vendor program will count toward the Blue Cross-approved purchase price.

If you have any questions, contact your provider consultant.

2014 Blues Medicare Advantage Performance Recognition Program updated

Blue Cross Blue Shield of Michigan and Blue Care Network have changed the 2014 BCBSM Medicare Advantage PPO^SM and BCN Advantage^SM Performance Recognition Program for primary care physicians.

The changes are a result of revisions that the National Committee for Quality Assurance recently made to their guidelines for diabetes LDL-C testing and control, cardiovascular disease LDL-C testing and control, and glaucoma screening. The changes are noted below. The complete details can be found in BCBSM Medicare Advantage Health e-Blue^SM or in BCN Health e-Blue^SM in the Resources section.

Blues Medicare Advantage PRP changes
The following measures are being removed:

Comprehensive diabetes care – LDL-C screening
Comprehensive diabetes care – LDL-C control (<100 mg/dl)
Cholesterol management for patients with cardiovascular disease – LDL-C Screening
Cholesterol management for patients with cardiovascular disease – LDL-C control (< 100 mg/dl)
The glaucoma screening bonus as a bonus incentive.

Beginning with dates of service Aug. 1, 2014, or after, the base PRP will be scored on the following five quality measures:

Breast cancer screening
Colorectal cancer screening
Comprehensive diabetes care – A1C control <9%
Comprehensive diabetes care – monitoring for nephropathy
Comprehensive diabetes care – retinal eye exam

As a result of these changes, there will be two pay-as-you-go measurement periods with different incentive amounts this year.

Pay as you go…	Covers dates of service…	Includes…
First payment	January through July 2014	All nine original measures
Second payment	August through December 2014	Five remaining measures

Contact your provider consultant if you have any questions about the Performance Recognition Program.

Reminder: Conduct patient visits by year-end to close diagnosis gaps for 2014 incentive

Important note about closing diagnosis gaps

When using Health e-Blue’s Diagnosis Evaluation panel or other methods to indicate that a diagnosis gap is closed because the condition does not exist, be sure that you are closing a diagnosis gap only if you have conducted an office visit and the patient no longer has the suspected (or historic) condition. A gap cannot be closed solely for the reason that you are not actively treating the condition. The suspected or historic condition must be addressed during a patient visit and you must confirm that the patient no longer has the condition or that the suspected condition does not exist.

Blue Cross Blue Shield of Michigan and Blue Care Network are nearing the conclusion of this year’s Diagnosis Closure Incentive Program for primary care physicians who close diagnosis and treatment opportunity gaps for their Blues Medicare Advantage patients. Here are the details you need to know.

Be sure to see your Blues Medicare Advantage patients before the end of the year to document and close diagnosis and treatment opportunity gaps. It’s important that all member conditions are addressed each year during an office visit, and that diagnosis code data is accurately documented and reported, following M.E.A.T. (manage, evaluate, assess and treat) guidelines to support medical necessity.

Information about gap closures should be submitted via Health e-Blue^SM under Panel – Diagnosis Closure and Treatment Opportunities by Condition/Measure Panel by Jan. 22, 2015. You may also submit a claim as part of your documentation. In addition, if you received a paper Member Diagnosis Closure and Treatment Opportunities report in the mail, you should fax it to 1-866-707-4723.

All the diagnosis gaps included in the 2014 Diagnosis Closure Incentive for Jan. 1 through Sept. 30, 2014, are listed on Health e-Blue^SM under Panel – Diagnosis Evaluation. To earn incentives, physicians must close all the diagnosis gaps (identified through Sept. 30, 2014) that exist for a patient through a face‑to‑face visit before the end of 2014. Following a face-to-face visit, you can also confirm that the patient does not have the condition, if applicable.

Diagnosis gaps will continue to appear on Health e-Blue from Oct. 1 through Dec. 31, 2014. While we’ll continue to display new gaps, physicians are responsible for closing diagnosis gaps identified prior to Oct. 1 for purposes of earning an incentive.

More information is available in the Resources section of Health e-Blue; select 2014 Diagnosis Closure Incentive Program. An FAQ and fact sheet can also be found on web-DENIS in the Newsletters and Resources section by clicking on Medicare Advantage resources.

Diagnosis and treatment opportunity closures must be submitted to the Blues by the following dates:

Method	Deadline
Claim submission	Received by Feb. 27, 2015
Health e-Blue	Entered by Jan. 22, 2015
Paper Member Diagnosis Evaluation and Treatment Opportunities report (for BCBSM out-of-state physicians and in-state physicians without access to Health e-Blue)	Faxed or postmarked by Jan. 30, 2015
Paper medical record (for BCBSM physicians) Diagnosis closure submission Treatment opportunities submission	Faxed or postmarked by Jan. 30, 2015 Faxed or postmarked by Jan. 15, 2015

If you don’t have access to Health e-Blue, sign up today. If you have questions, contact your provider consultant.

Physicians who close 100 percent of all identified gaps for each attributed patient will receive $100 per patient. Your incentive payment will be mailed to you by the end of third quarter 2015.

New information about the Diagnosis Closure Incentive program will be announced next year. In the meantime, physicians are encouraged to continue to check Health e-Blue for patient conditions, schedule face-to-face office visits and close historical or suspected patient diagnosis and treatment opportunity gaps in the coming year.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.

Here’s what you need to know about our PPO program policies and members’ rights, responsibilities

3.6 million Blue Cross members now receive EOBs in easy-to-understand format

Timely responses are important as medical record reviews continue through 2014

Register today for live webinars on Oct. 15, 29 and Nov. 5

Use of Groupon® prohibited by terms of participation agreements

BlueCard® program offers plenty of support options for provider community

Keep these coding tips in mind to improve medical record documentation

HCPCS codes added

Prescription drug lists updated, check our website

Reminder: Payment decisions require supporting documentation

Reminder: Preauthorization for abdomen and pelvis CT scans

Blues highlight medical, benefit policy changes

Navigating the electronic Record

Enrollment for BCBSM’s and BCN’s new freestanding radiology center networks begins on Oct. 1

Preauthorization required for in-lab sleep studies

Blue Cross’ PPO Radiology Management Program expands to include echocardiography services

BCBSM 101 training class available for new professional billing staff and others looking for a refresher

Reminder: Blues to retire Facility and Provider Claims Correction tool

Updates to Medical Drug Prior Authorization Program take place Jan. 1

Enrollment for BCBSM’s and BCN’s new freestanding radiology center networks begins on Oct. 1

Blue Cross’ PPO Radiology Management Program expands to include echocardiography services

We’re shutting down the Exception Admission application on web-DENIS

Reminder: Hospitals must follow claims appeals process in provider manual

Reminder: Blues to retire Facility and Provider Claims Correction tool

Updates to Medical Drug Prior Authorization Program take place Jan. 1

Are you billing correctly for these drugs?

Blue Cross to manage non-Medicare durable medical equipment benefits for MPSERS members

2014 Blues Medicare Advantage Performance Recognition Program updated

Reminder: Conduct patient visits by year-end to close diagnosis gaps for 2014 incentive

Important note about closing diagnosis gaps

Use of Groupon^® prohibited by terms of participation agreements

BlueCard^® program offers plenty of support options for provider community