Register today to begin ICD-10 professional testing

The ICD-10 implementation date is Oct. 1, 2015. To assist you with the transition, Blue Cross Blue Shield of Michigan encourages you to use our ICD-10 testing tool for professional health care providers. The testing tool will not only give you an opportunity to work with ICD-10, but it also will provide us with a better idea of ICD-10 readiness.

Here are a few notes about the tool:

• The testing tool is available through the ICD-10 implementation date of Oct. 1, 2015.
• Testing is done through a Web-based assessment; no special software or lengthy test requirements will be needed.
• It is “content based” and “specialty specific,” which means that professional health care providers will be presented with several unique health care encounters to code in ICD-10.
• Providers will need to register for each specialty they are interested in testing.

To register for the ICD-10 professional test tool, use this link.

For more information about ICD-10, see the frequently asked questions document.

Blues award providers with distinction

For the second year, BCN Advantage^SM and Blue Cross Blue Shield of Michigan’s Medicare Plus Blue^SM have recognized health care providers for their outstanding contributions to our star ratings from the Centers for Medicare and Medicaid Services. Click here to view our list of the Provider Distinction Award honorees.

Plaques were awarded in the following categories:

• BCN Advantage only
• Medicare Plus Blue only
• Joint BCN Advantage and Medicare Plus

Providers also received gifts for their office staff that perform administrative work. These gifts included travel coffee mugs, lunch bags and containers and a combination stylus, pen and flashlight.

Our partnership with providers is critical to the continued achievement of the star ratings we receive from the Centers for Medicare and Medicaid Services. CMS uses a five-star rating system to measure the quality, performance and member outcomes of each Medicare Advantage plan and line of business.

To be eligible for a 2014 Provider Distinction Award:

• The provider had to achieve a score of 80 percent or above on star measures — such as diabetes care, colorectal cancer screening and others — with Blue Cross Blue Shield of Michigan members only and BCN Advantage members only, or jointly with patients from both plans. If providers achieve greater than 80 percent in any of those categories, then they pass the first eligibility test for the award.

• Providers must have a minimum of five services that count toward the
  star rating (for example, a diabetes test, colorectal screening). The star measure rating is determined by the number of services completed divided by the number of eligible services.

• Providers must be currently credentialed and contracted with Blue Cross Blue Shield of Michigan and BCN Advantage and in good standing.

• Providers may not have low quality ratings based on the quality score reports generated by Blue Cross and BCN Advantage. Providers with low quality ratings will be eligible for future awards once they have completed our quality score rating program.

Blue Cross updates requirements for specialist fee uplifts

Effective Feb. 1, 2016, anesthesiologists participating in the Physician Group Incentive Program will be eligible for specialist fee uplifts. All other specialist physicians, podiatrists, chiropractors and fully licensed psychologists in PGIP are currently eligible for specialist fee uplifts.

Here are the criteria practitioners must meet in order to be considered for a specialist fee uplift in 2016:

• Practitioners must be a member of a PGIP physician organization for at least one year (that is, the practitioner must be on both the PGIP practitioner list “snapshots” taken on July 1, 2014, and June 30, 2015). This is a new requirement designed to ensure that practitioners are fully engaged with their PGIP physician organization prior to nomination for a specialist fee uplift. Anesthesiologist will be exempt from this requirement for the 2016 fee uplifts. However, anesthesiologists must be a member of a PGIP physician organization and be nominated by the member PO by June 30, 2015, to be considered for a 2016 fee uplift.
• At least one physician organization (and, in some cases, two POs) must nominate the specialist practice.
• Once nominated, specialist practices must meet population-level performance metrics and thresholds developed by Blue Cross Blue Shield of Michigan.

Physician organizations can nominate specialist practices that:

• Include at least one practitioner from the eligible specialties
• Have displayed a high level of engagement with the physician organization
• Are actively involved in managing and optimizing the use of services and quality of care
• Are partnering with primary care physicians to improve care processes and coordination
• Have signed their PO’s primary care-specialist agreement

Nominations for the specialist fee uplifts will occur between April 20, 2015, through June 29, 2015.

Nomination by a physician organization does not guarantee that a practice will be selected for a specialist fee uplift.

Selected practices will receive the fee uplift for one year — from Feb. 1, 2016, through Jan. 31, 2017. The nomination and selection process are repeated annually.

The specialist fee uplifts currently apply to the Relative Value Units-based procedure codes. Any revisions or updates to these codes will be published in future editions of The Record.

For more information, contact your provider consultant.

New Blue Cross electronic qualification form instructions now available

We’ve uploaded new step-by-step instructions for the Blue Cross qualification form to the provider portal.

If you previously printed the qualification form instructions, please destroy or shred any old copies and begin using the new instructions. Dispose of the old copies in a secure manner as you would with any protected health information.

To access the new instructions:

1. Log in as a provider at bcbsm.com.
2. Scroll down and click on the BCBSM Qualification Form Instructions link located below the BCBSM Qualification Form link.

To complete a qualification form for your patients:

1. Click on the BCBSM Qualification Form link immediately above the link for the BCBSM Qualification Form Instructions.
2. After completing the electronic qualification form for your patient, make sure you print two copies of the form.
3. Give one completed and signed copy to the patient for his or her records, and keep a copy of the form with the patient’s medical records.

Note: For Blue Care Network members, you should continue to submit the Healthy Blue Living qualification form.

For additional information or if you have questions, contact your provider consultant.

We’ve changed billing instructions for postpartum global maternity

In an effort to capture data required by HEDIS^®, Blue Cross Blue Shield of Michigan has changed the postpartum global maternity reporting requirements.

Health care providers are now required to report procedure code *0503F in conjunction with a global maternity code (*59400, *59410, *59510, *59515, *59610, *59614, *59618 or *59622) when billed by the same provider. The global code must be reported on a separate service line with the date (MM/DD/YYY) postpartum care was rendered. This change took effect Jan. 1, 2015.

In addition, you should report a penny ($0.01) on the 0503F line as the charge billed. Providers will not receive reimburement of the penny, as the fee for postpartum care is already included in the global procedure code.

HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, will use the reporting of the code to quantify the number of days between the actual delivery date and postpartum visit.

For questions regarding this process, contact your provider consultant.

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

Emergency transport services exempt from Advance Notice of Member Responsibility Policy

In previous issues of The Record, we’ve discussed our Advance Notice of Member Responsibility Policy. (Click here to see the November 2014 Record article on this topic.) This policy helps communicate any potential cost liability between Blue Cross members and network providers.

We wanted to let you know that our Advance Notice of Member Responsibility rules do not apply to emergency transport services.

Reminder: Providers should refer PPO members to other TRUST providers

If it is necessary to refer out-of-network, physician assistants can now make these referrals for PPO members when the appropriate documentation is provided.

According to Blue Cross Blue Shield of Michigan’s referral policy, TRUST providers should refer PPO members to other TRUST providers whenever possible. Because the TRUST network encompasses a large scope of participating providers, referrals to out-of-network providers should occur only in rare cases.

Also, keep in mind:

• Out-of-network referrals are acceptable only when covered services are medically necessary and are not reasonably available within the TRUST network.

• If medically necessary services are not available within the TRUST network, you may advise PPO members that out-of-network deductible and copayments will not apply. However, some member contracts may have in-network deductible and copayments that would still apply.

• PPO members must pay additional out-of-pocket costs when receiving out-of-network services without a referral by a TRUST provider.

Referrals by physician assistants

Now that physician assistants can refer TRUST members to out-of-network providers, the PAs must always include the following:

• TRUST supervising provider’s license number
• Ten-digit National Provider Identifier number that appears on the TRUST Preferred Provider Organization (PPO) Program Referral Form (form number WP 9147) and the CMS-1500 claim form.

If you refer a PPO member to an out-of-network provider, you must complete these steps:

• Advise the PPO member that he or she could be liable for extra cost if the referral is to a health care provider who does not participate in the TRUST network.

• All TRUST providers, including those at facilities and laboratories, must complete the TRUST Preferred Provider Organization (PPO) Program Referral Form prior to a PPO member being referred for services to a non-PPO practitioner, facility, ancillary provider or laboratory. Referrals are only valid up to 60 days after the date of referral and covered services must be performed within one year of the referral date.

• The signature of the TRUST PPO provider or physician assistant, the out-of-network provider and the member must be on the referral form in order for the referral to be valid.

• If submitting paper claims:

• A signed copy of the referral form must be attached to the claim.

• On the CMS-1500 claim form, record the referring provider’s National Provider Identifier number in field 17B of the CMS-1500 claim form. Or, if billing electronically, enter the NPI number in the appropriate field.

• On the UB-04 claim form hospital services, record the referring provider’s NPI number on. Or, if billing electronically, enter the NPI number in the appropriate field.

Retrospective referrals by TRUST providers will not be approved without documentation from the patient’s medical record that indicates the referral was initiated prior to the PPO member receiving services from the out-of-network provider.

Note: The referral process does not apply to Federal Employee Program members. Health providers should ask members to call the FEP Customer Service number at 1-800-482-3600 for information about out-of-network exceptions.

Referrals for out-of-network services are not allowed for the following: Flexible Blue^SM, Simply Blue^SM, Community Blue^SM Group Benefits Certificate SG, all Healthy Blue Achieve products and all products with heath savings accounts. Out-of-network services will be paid as out-of-network.

Behavioral health vendor brings new directions to member care management, provider satisfaction

As announced in last month’s edition of The Record, New Directions LLC will begin managing Blue Cross Blue Shield of Michigan’s behavioral health services on April 1, 2015. New Directions will replace Magellan Behavioral of Michigan Inc.

New Directions will assume behavioral health management of 2.5 million Blue Cross commercial members nationwide. Services include preauthorization and case management for members who receive behavioral health through Blue Cross.

Please note that providers do not need to contract with New Directions to be part of the network: Our existing Traditional and PPO network and fees will continue.

It’s also important to note that the State of Michigan group account and other accounts that have behavioral health currently managed by another vendor arrangement (e.g., autos, UAW retirees, DENSO and others) are not affected by this change. The transition to New Directions does not affect these customer groups or network providers.

About New Directions
New Directions is a managed behavioral health organization accredited by the National Committee for Quality Assurance. It has more than 20 years of experience in utilization and case management services, in addition to extensive experience working with Blue plans nationwide.

With its offices located in Kansas City, Missouri, New Directions currently manages Blue Cross’ employee assistance program.

Blue Cross members and providers are expected to benefit from a number of program and service enhancements that were previously unavailable, including:

• An award-winning service center providing 24/7 toll-free access for members and providers
• Integrated care programs that use an evidence-based approach to services for members across the continuum of care
• Discharge planning and follow-up appointment scheduling (for members admitted to inpatient and residential levels of care) that is closely monitored to ensure supportive transitions to and within the community.
• Case managers that work one-on-one with members to improve care transitions, foster self-management and remove barriers to care
• Use of claims data to build predictive models that identify members at-risk for relapse or readmission, and which subsequently enable targeted outreach efforts to these members

Streamline authorizations with WebPass
New Directions will continue current authorization practices that waive the initial four days of inpatient care when admission notification is submitted, with clinical review required after day four. In addition, providers will be able to take advantage of authorization process enhancements intended to decrease unnecessary phone calls and minimize less secure communications such as e-mails and faxing. Among these improvements is the use of an online authorization application called WebPass.

WebPass is a secure Internet portal that enables providers to document and submit clinical information online to New Directions for higher level of care initial authorizations and continued stay reviews. Providers should note, however, that authorization requests for autism services and repetitive transcranial magnetic stimulation, or rTMS, treatments will continue to be processed by phone.

Following a one-time facility registration process at the WebPass website, facility providers will receive individual user names and passwords used to log in to WebPass. As of March 10, 2015, facilities can register as a user on WebPass.  After logging in to the website, providers can enter a Blue Cross member ID (or name and date of birth information) to perform a variety of tasks related to the member. These tasks include admission requests and reviews, case management and quality reviews. Regardless of the task performed, member information is preloaded into requested documentation.

Learn more online
Blue Cross has scheduled a number of informational events about the transition to New Directions. A WebPass training webinar is scheduled for mid-March.

Please watch for notifications on web-DENIS about the following:

• Availability of New Directions’ medical necessity criteria
• WebPass training webinar date
• Finalizing and sharing the case transition plan from the current behavioral health vendor to New Directions for all levels of care

Blue Cross Blue Shield of Michigan recognizes 10 health care facilities for distinction in bariatric surgery

As part of the Blue Distinction^® Centers for Specialty Care program, we recently recognized 10 health care facilities in Michigan for excellence.

These facilities have been designated as either Blue Distinction^® Centers — for delivering quality care resulting in better overall outcomes for bariatric patients — or as Blue Distinction^® Centers+ for delivering the same quality care as Blue Distinction Centers while also meeting key requirements for cost efficiency. See list of designated facilities at the end of this article.

To receive a Blue Distinction Center for Bariatric Surgery designation, a health care facility must demonstrate success in meeting patient safety measures, as well as bariatric-specific quality measures. The latter includes complications and readmissions for gastric stapling or gastric banding procedures. A health care facility must also have earned national accreditations at both the facility level and the bariatric care-specific level.

To receive a Blue Distinction Center+ for Bariatric Surgery designation, a health care facility must not only demonstrate success in meeting patient safety and bariatric-specific quality measures, but also demonstrate better cost efficiency relative to its peers. Quality is key: only those facilities that first meet Blue Distinction’s nationally established, objective quality measures will be considered for Blue Distinction Center+ designation.

This year’s bariatric surgery designation also includes facilities that are recognized for gastric banding, in addition to thoses being recognized for gastric stapling.

Background
Bariatric surgeries are among the most common elective surgeries in the U.S., providing a significant opportunity to improve quality and efficiency within the health care system.There were 179,000 bariatric surgeries performed in 2013, according to the American Society of Metabolic and Bariatric Surgery, and the average cost is more than $28,000 per episode, according to the Journal of the American Medical Association.

Furthermore, it’s estimated that 72 million Americans are obese and 24 million suffer from morbid obesity, according to the U.S. Centers for Disease Control and Prevention.The estimated annual health care costs of obesity-related illnesses are $190.2 billion, or nearly 21 percent of annual medical spending in the U.S., according to the Journal of Health Economics.

Research shows that facilities designated as Blue Distinction Centers and Blue Distinction Centers+ demonstrate better quality and improved outcomes for patients compared with their peers.On average, Blue Distinction Centers+ are also 20 percent or more cost efficient than non-Blue DistinctionCenter+ facilities.

Specialty types
Since 2006, the Blue Distinction Centers for Specialty Care program has helped patients find quality providers for their specialty care needs in such areas as cardiac care, complex and rare cancers, knee and hip replacements, spine surgery, transplants and bariatric surgery

Designated bariatric facilities
Here is the list of Michigan facilities that received distinction in the area of bariatric surgery as of Feb. 9, 2015:

For more information about the new Blue Distinction Centers designations for bariatric surgery, visit bcbs.com/bluedistinction. You may also contact Jawwad Baig of Blue Cross Blue Shield of Michigan Value Partnerships at 313-448-5038 or JBaig@bcbsm.com.

Update: St. Joseph Mercy–Port Huron Hospital in Metro Detroit EPO network

We have an update about the participation of St. Joseph Mercy-Port Huron Hospital in the Blue Cross^® Metro Detroit EPO network.

St. Joseph Mercy-Port Huron Hospital has been participating in the Metro Detroit EPO network since Jan. 1, 2015. Members enrolled in a Metro Detroit EPO plan are in-network if they receive services from the hospital.

If you have any questions, contact your Blue Cross provider consultant.

Behavioral health vendor brings new directions to member care management, provider satisfaction

As announced in last month’s edition of The Record, New Directions LLC will begin managing Blue Cross Blue Shield of Michigan’s behavioral health services on April 1, 2015. New Directions will replace Magellan Behavioral of Michigan Inc.

New Directions will assume behavioral health management of 2.5 million Blue Cross commercial members nationwide. Services include preauthorization and case management for members who receive behavioral health through Blue Cross.

Please note that providers do not need to contract with New Directions to be part of the network: Our existing Traditional and PPO network and fees will continue.

It’s also important to note that the State of Michigan group account and other accounts that have behavioral health currently managed by another vendor arrangement (e.g., autos, UAW retirees, DENSO and others) are not affected by this change. The transition to New Directions does not affect these customer groups or network providers.

About New Directions
New Directions is a managed behavioral health organization accredited by the National Committee for Quality Assurance. It has more than 20 years of experience in utilization and case management services, in addition to extensive experience working with Blue plans nationwide.

With its offices located in Kansas City, Missouri, New Directions currently manages Blue Cross’ employee assistance program.

Blue Cross members and providers are expected to benefit from a number of program and service enhancements that were previously unavailable, including:

• An award-winning service center providing 24/7 toll-free access for members and providers
• Integrated care programs that use an evidence-based approach to services for members across the continuum of care
• Discharge planning and follow-up appointment scheduling (for members admitted to inpatient and residential levels of care) that is closely monitored to ensure supportive transitions to and within the community.
• Case managers that work one-on-one with members to improve care transitions, foster self-management and remove barriers to care
• Use of claims data to build predictive models that identify members at-risk for relapse or readmission, and which subsequently enable targeted outreach efforts to these members

Streamline authorizations with WebPass
New Directions will continue current authorization practices that waive the initial four days of inpatient care when admission notification is submitted, with clinical review required after day four. In addition, providers will be able to take advantage of authorization process enhancements intended to decrease unnecessary phone calls and minimize less secure communications such as e-mails and faxing. Among these improvements is the use of an online authorization application called WebPass.

WebPass is a secure Internet portal that enables providers to document and submit clinical information online to New Directions for higher level of care initial authorizations and continued stay reviews. Providers should note, however, that authorization requests for autism services and repetitive transcranial magnetic stimulation, or rTMS, treatments will continue to be processed by phone.

Following a one-time facility registration process at the WebPass website, facility providers will receive individual user names and passwords used to log in to WebPass. As of March 10, 2015, facilities can register as a user on WebPass.  After logging in to the website, providers can enter a Blue Cross member ID (or name and date of birth information) to perform a variety of tasks related to the member. These tasks include admission requests and reviews, case management and quality reviews. Regardless of the task performed, member information is preloaded into requested documentation.

Learn more online
Blue Cross has scheduled a number of informational events about the transition to New Directions. A WebPass training webinar is scheduled for mid-March.

Please watch for notifications on web-DENIS about the following:

• Availability of New Directions’ medical necessity criteria
• WebPass training webinar date
• Finalizing and sharing the case transition plan from the current behavioral health vendor to New Directions for all levels of care

Blue Cross Blue Shield of Michigan recognizes 10 health care facilities for distinction in bariatric surgery

As part of the Blue Distinction^® Centers for Specialty Care program, we recently recognized 10 health care facilities in Michigan for excellence.

These facilities have been designated as either Blue Distinction^® Centers — for delivering quality care resulting in better overall outcomes for bariatric patients — or as Blue Distinction^® Centers+ for delivering the same quality care as Blue Distinction Centers while also meeting key requirements for cost efficiency. See list of designated facilities at the end of this article.

To receive a Blue Distinction Center for Bariatric Surgery designation, a health care facility must demonstrate success in meeting patient safety measures, as well as bariatric-specific quality measures. The latter includes complications and readmissions for gastric stapling or gastric banding procedures. A health care facility must also have earned national accreditations at both the facility level and the bariatric care-specific level.

To receive a Blue Distinction Center+ for Bariatric Surgery designation, a health care facility must not only demonstrate success in meeting patient safety and bariatric-specific quality measures, but also demonstrate better cost efficiency relative to its peers. Quality is key: only those facilities that first meet Blue Distinction’s nationally established, objective quality measures will be considered for Blue Distinction Center+ designation.

This year’s bariatric surgery designation also includes facilities that are recognized for gastric banding, in addition to thoses being recognized for gastric stapling.

Background
Bariatric surgeries are among the most common elective surgeries in the U.S., providing a significant opportunity to improve quality and efficiency within the health care system.There were 179,000 bariatric surgeries performed in 2013, according to the American Society of Metabolic and Bariatric Surgery, and the average cost is more than $28,000 per episode, according to the Journal of the American Medical Association.

Furthermore, it’s estimated that 72 million Americans are obese and 24 million suffer from morbid obesity, according to the U.S. Centers for Disease Control and Prevention.The estimated annual health care costs of obesity-related illnesses are $190.2 billion, or nearly 21 percent of annual medical spending in the U.S., according to the Journal of Health Economics.

Research shows that facilities designated as Blue Distinction Centers and Blue Distinction Centers+ demonstrate better quality and improved outcomes for patients compared with their peers.On average, Blue Distinction Centers+ are also 20 percent or more cost efficient than non-Blue DistinctionCenter+ facilities.

Specialty types
Since 2006, the Blue Distinction Centers for Specialty Care program has helped patients find quality providers for their specialty care needs in such areas as cardiac care, complex and rare cancers, knee and hip replacements, spine surgery, transplants and bariatric surgery

Designated bariatric facilities
Here is the list of Michigan facilities that received distinction in the area of bariatric surgery as of Feb. 9, 2015:

For more information about the new Blue Distinction Centers designations for bariatric surgery, visit bcbs.com/bluedistinction. You may also contact Jawwad Baig of Blue Cross Blue Shield of Michigan Value Partnerships at 313-448-5038 or JBaig@bcbsm.com.

BCBSM’s Utilization Review department schedules June clinical review audits

Starting in June 2015, Blue Cross Blue Shield of Michigan’s Utilization Review department will begin scheduling and conducting retrospective clinical review audits for hospitals with inpatient rehabilitation services.

These audits will focus on the level of care using InterQual^® Rehabilitation Adult and Pediatric Criteria. For more information, refer to the "Audits and Other Post-Services" chapter in the Hospital Inpatient Provider Manual, beginning in April 2015.

Here’s how Blue Cross obtains samples for non-hospital facility audits

We occasionally get questions from our providers about our audit process for non-hospital facility audits and how we obtain samples for our audits. To help answer these questions, we’ve outlined our process below:

Why we do what we do
We obtain audit samples in preparation for extrapolating refund recoveries for non-hospital audits. These audits are conducted for:

• End-stage renal disease
• Home health care
• Hospice
• Skilled nursing facility
• Freestanding outpatient physical therapy facilities

According to our participation agreements, Blue Cross Blue Shield of Michigan may project refund recoveries from statistically valid samples involving issues other than medical necessity. These include, but are not limited to, procedure or revenue code billing errors.

Sampling for non-hospital facility audits
The goal of sampling is to get a portion of the patient case population that represents the characteristics of the entire population. The two following fundamental sampling concepts ensure the sample is a good representation of the population:

• The process of random audit case selection
• The size of the sample

Random sampling
The sampling methodology used for non-hospital audits is computer-generated and random. The process places an equal probability of selection on every patient at a facility within a specific timeframe.

Sample size
This is determined by two values: confidence and precision. It’s these values that determine the risk level associated with the sample estimates. The acceptable values are 95 percent for confidence and 10 percent for precision. This means that Blue Cross wants to be 95 percent confident that the sample compliance error rate is not different from the population compliance error rate by more than 10 percent. This produces a sample size large enough that the estimates obtained through the audit accurately represent population characteristics.

Extrapolated overpayment
After the sample is selected and the audit is complete, the sample overpayment per patient is calculated. This number is the sum of the payments associated with compliance errors in the sample, divided by the number of patients in the sample. Since the sample is a good representation of the population, it follows that the overpayment per patient in the sample will not differ much from the overpayment per patient in the population. So the extrapolated overpayment for the population is the average overpayment per patient in the sample, multiplied by the number of patients in the population.

If you have any questions regarding this process, call Rhonda Thomas at 313-448-1286.

Precertification services offers extended hours

To improve the timeliness of precertification requests, Precertification Services has added staff to its Saturday shifts and will also staff certain holidays.

You may submit precertification requests 24 hours a day, seven days a week. Standard turnaround time is usually one business day.

In addition, a Critical Precertification Service Inquiry line was upgraded to mobile service. You can still call 1-313-448-3619 during normal hours of operation, Monday through Friday, from 8 a.m. to 6 p.m. and on Saturdays from 8 a.m. to 4 p.m.

For additional information or questions, contact your provider consultant.

Update: St. Joseph Mercy–Port Huron Hospital in Metro Detroit EPO network

We have an update about the participation of St. Joseph Mercy-Port Huron Hospital in the Blue Cross^® Metro Detroit EPO network.

St. Joseph Mercy-Port Huron Hospital has been participating in the Metro Detroit EPO network since Jan. 1, 2015. Members enrolled in a Metro Detroit EPO plan are in-network if they receive services from the hospital.

If you have any questions, contact your Blue Cross provider consultant.

Training tips and opportunities: Resources to help make your job easier

This is the first article in a series designed to make you aware of the training resources available to health care providers and how to access them. This month we’ll take a close look at the Blue Cross Blue Shield of Michigan provider manuals.

We publish a customized manual for each provider type. The manuals cover a wide variety of topics. Some chapters focus on a particular  type of service — for example, chiropractic services or hospice services — and explain the benefit, as well as related medical policies and payment policies.

The ”Durable Medical Equipment, Medical Supplies, and Prosthetics and Orthotics Services” chapter and the “Physical Therapy, Occupational Therapy, and Speech Therapy Services” chapter are other examples. These “services” chapters also contain billing guidelines specific to their service type.

Other chapters aren’t specific to benefits and types of service but rather explain processes you need to understand in order to do business with us. For example, you need to know how to determine patient eligibility, patient copayments and deductibles; which services and procedures require preapproval and how to request it; how to complete and submit claims, and how to resolve any problems you may encounter; which documentation facts are needed in your patient medical records.

At the end of each chapter you’ll find a section named “Related newsletter articles,” which contains links to articles that have been published in The Record on that chapter’s topic. The chapters are customized to your provider type and clearly named so you can make the correct selection when you’re looking for information.

Each manual begins with a chapter named “Blue Pages Directory,” which contains an alphabetic listing of BCBSM contact information — phone numbers, fax numbers, email and mailing addresses for various departments and agencies affiliated with BCBSM.

To access the BCBSM provider manuals, follow these steps:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Click on Provider Type.
• In the Provider Type Criteria box, click the down arrow next to Make Selection, and select your provider type.
• Click on Search.

If you do not have a user ID and password for web-DENIS:

• Visit bcbsm.com.
• Click on Provider.
• Click on Provider Secured Services and follow the instructions.

Use the Blues provider manuals flier to find any of the Blues provider manuals, including:

• The BCBSM provider manuals described earlier in this article
• The BCBSM Medicare Plus BlueSM PPO Manual
• The BCN Provider Manual
• The Blue Cross Complete Provider Manual

The flier is posted on web-DENIS:

• From the homepage of web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Go to the “What’s New” section of the page. Or click on Provider Training on the left, and then scroll down to the “Job aids, FAQs, brochures and fliers” section of the page. Click on BCBSM and BCN provider manuals: How to find and how to use them.

Coding corner: Accurate medical coding of angina

This is part of an ongoing series of coding tips to help ensure proper documentation.

Angina is pain or discomfort that occurs when your heart doesn’t get enough oxygen. Over time, the coronary arteries that supply blood to your heart can become clogged with plaque. If one or more arteries are partially clogged, not enough blood flows through and can cause chest pain.

Angina is usually an early manifestation of ischemic heart disease known as coronary heart disease, also called coronary artery disease.

Documentation in the medical record must be specific and clear to properly code the condition. Chest pain or abdominal pain are classified as symptoms and are only acceptable for reporting purposes when the provider has not established a confirmed diagnosis.

Often health care providers will document coronary artery disease, the most common heart disease. Even though angina is associated with coronary artery disease, it’s not specific enough for documentation purposes. Therefore, if a patient is diagnosed with angina, you should document the specific type of angina.

Types of angina

• Stable angina (ICD9-CM code 413.9)
• Can occur during physical activity or emotional stress
• Unstable angina (ICD9-CM code 411.1)
• Can occur with or without physical activity, even while at rest or sleeping
• Occurs when plaque in one or more coronary artery ruptures and if the buildup happens rapidly, there’s risk for a heart attack
• Variant angina (Prinzmetal’s angina; ICD9-CM code 413.1)
• A rare type that happens without warning
• Caused by a spasm in a coronary artery in which the artery narrows, reducing blood flow to the heart and causing chest pain
• Microvascular angina (Other and unspecified angina pectoris; ICD9-CM code 413.9)
• Can be a more severe type that lasts longer; the pain is caused by spasms within the walls of small arterial blood vessels

Men and women may experience different symptoms that can vary depending on the type of angina.

Elderly people may experience different symptoms of angina, and these can be easily overlooked. For example:

• Indigestion after meals may be blamed on a stomach ulcer.
• Pain in the back and shoulders may be diagnosed as arthritis.

Keep in mind that dementia can play a role in a person’s ability to communicate the pain they are experiencing.

In summary, it’s important to include specific documentation that angina exists at the time of the patient encounter, and that this diagnosis requires or affects care treatment or management.

For more information about this coding process, contact your provider consultant.

Did you know? ... According to the American Heart Association, heart disease is the No. 1 killer of women, affecting one out of three in the U.S. Women sometimes don’t understand the risks, and this puts them at additional risk for a heart attack.

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

BlueCard^® connection: Answers to recent questions

BlueCard Connection is part of an ongoing series dedicated to helping improve your experience with the BlueCard program.

This month we’re discussing how to appropriately report the following:

• Claims for private rooms when your hospital no longer offers a semi-private room option
• The GY modifier on a professional claim when you are reporting a Medicare-excluded service

Reporting claims for private rooms when no semi-private rooms are available
The same reporting requirement that you are required to follow for Blue Cross Blue Shield of Michigan members applies to claims you bill for BlueCard members.

When reporting a private room because a semi-private room is no longer available at your facility, please report:

• Condition code 38 (form locators 18-26) on the UB claim form
• In the 837 report in the 2300 Loop, HI Segment, a BG Qualifier
• Value code 02 (form locators 18-26) with your private-room rate
• In the 837 report in the 2300 Loop, HI Segment, a BE Qualifier

Reimbursement for the room is based on your contracted diagnosis-related group, or DRG, rate for semi-private rooms or your per diem room rate for all claims, including BlueCard. But reporting the private room correctly may prevent a claim rejection from the member’s home plan for the private room.

Do not report the difference between the private-room rate and the semi-private room rate as a noncovered charge on the claim (form locator 48 or its electronic equivalent). Your BCBSM-contracted reimbursement for the semi-private admission should be considered payment in full and not the member’s responsibility.

Reporting the GY modifier for professional services not covered by Medicare
Professional providers do not have to submit statutorily excluded services to Medicare for consideration.

Instead, they can follow these steps:

• Submit the professional claim for a BlueCard member as you would for a Michigan member. 
• Report the GY modifier on each claim line to advise the plan that the reported service is excluded by Medicare and was not billed. The claim will be forwarded to the member’s home plan with the GY modifier as you reported. In the 837 report in the 2300 Loop, SV101-3 – SV101 – 6.

The decision to pay or reject the claim will be made by the member’s home plan based on the member’s contracted benefits. The member’s home plan does not require a Medicare Explanation of Member’s Benefit Statement. If you report your claim correctly and receive an incorrect rejection requesting a copy of an EOMB, please contact our Provider Inquiry department.

If you submit both covered and noncovered services to Medicare on a combined claim, and the home plan receives the claim as a Medicare crossover, the home plan may deny the crossover claim. The plan may also instruct the provider to split the reporting of the covered and noncovered services on two separate claims. 

Blues highlight medical, benefit policy changes

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

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

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

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

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

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

Navigating the electronic Record

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

Understanding the format

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

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

Printing The Record or individual articles

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

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

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

Forwarding The Record

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

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

Accessing The Record online

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

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

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

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

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

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

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

In sympathy

Kathleen (Kate) Wodecki, 58, manager of Enterprise Information Technology with Blue Cross Blue Shield of Michigan, passed away Jan. 26. Known by many as the mother of web-DENIS, she worked to enhance our provider systems and portal for more than 25 years. She was employed by Blue Cross for nearly 30 years.

“Kate was the best advocate BCBSM providers ever had,” said Jeff Holzhausen, manager of Hospital Contracting and Provider Experience. “Nobody worked harder and did more to make doing business with BCBSM and BCN easier for our physician and hospital partners.”

Blues award providers with distinction

For the second year, BCN Advantage^SM and Blue Cross Blue Shield of Michigan’s Medicare Plus Blue^SM have recognized health care providers for their outstanding contributions to our star ratings from the Centers for Medicare and Medicaid Services. Click here to view our list of the Provider Distinction Award honorees.

Plaques were awarded in the following categories:

• BCN Advantage only
• Medicare Plus Blue only
• Joint BCN Advantage and Medicare Plus

Providers also received gifts for their office staff that perform administrative work. These gifts included travel coffee mugs, lunch bags and containers and a combination stylus, pen and flashlight.

Our partnership with providers is critical to the continued achievement of the star ratings we receive from the Centers for Medicare and Medicaid Services. CMS uses a five-star rating system to measure the quality, performance and member outcomes of each Medicare Advantage plan and line of business.

To be eligible for a 2014 Provider Distinction Award:

• The provider had to achieve a score of 80 percent or above on star measures — such as diabetes care, colorectal cancer screening and others — with Blue Cross Blue Shield of Michigan members only and BCN Advantage members only, or jointly with patients from both plans. If providers achieve greater than 80 percent in any of those categories, then they pass the first eligibility test for the award.

• Providers must have a minimum of five services that count toward the
  star rating (for example, a diabetes test, colorectal screening). The star measure rating is determined by the number of services completed divided by the number of eligible services.

• Providers must be currently credentialed and contracted with Blue Cross Blue Shield of Michigan and BCN Advantage and in good standing.

• Providers may not have low quality ratings based on the quality score reports generated by Blue Cross and BCN Advantage. Providers with low quality ratings will be eligible for future awards once they have completed our quality score rating program.

Blues retain Mobile Medical Examination Services Inc™, Inovalon™ for Home Health Reviews

This month, Blue Cross Blue Shield of Michigan and Blue Care Network will once again retain two independent companies to conduct Home Health Reviews, formerly known as in-home assessments, for eligible Blue Cross and BCN Medicare Advantage members.

The reviews are part of our members’ coverage and are completely voluntary.

Licensed health care professionals from Mobile Medical Examination Services Inc., or MedXM, and Inovalon will provide the personalized Home Health Reviews. These reviews will include a medical history review, brief physical exams and documentation of any existing medical conditions. They don’t replace any care members receive from their physicians. Also, the MedXM and Inovalon health professional can’t access a member’s medical history or write prescriptions.

This type of outreach helps support our members’ health and your ongoing care. It also provides documentation of any current medical conditions, helping to guide our care management programs.

We’ll provide information obtained from these reviews to the Centers for Medicare & Medicaid Services as part of our risk-adjustment initiatives. We’ll also share it with you to support your patient care efforts.

Please place a copy of these reviews in your patients’ medical records. You may also want to encourage patients to schedule an office visit following a Home Health Review to discuss the review with them.

If you have any questions, contact your provider consultant.