BCBSM to use McKesson ClaimsXten™ for outpatient facility claims

As you may know, Blue Cross Blue Shield of Michigan has used McKesson ClaimsXten for the clinical editing of our professional claims since 2012. During the first quarter of 2016, we will begin using McKesson ClaimsXten clinical code editing for outpatient facility claims as well.

This change will help us meet the challenges of our ever-changing health care environment and provide faster, more flexible business processes for additional health care providers.

ClaimsXten will not only apply the Blue Cross payment application for outpatient facility services but will:

• Provide enhanced technical functionality.
• Improve overall claims management.
• Assist with maintaining consistent payment policy in alignment with state and national mandates.

More information about ClaimsXten outpatient facility claim processing will be provided in future issues of The Record.

Interested in becoming a Blue Cross freestanding radiology center? Enroll today

Blue Cross Blue Shield of Michigan is continuing to enroll freestanding radiology centers as a new type of provider that offers diagnostic imaging services. The freestanding radiology center provider type became effective Jan. 1, 2015.

Creating this new provider type allows Blue Cross to uniquely recognize and reimburse freestanding providers of diagnostic imaging services. It also supports customer and market demands for enhanced access to provider- and service-related cost transparency information for Blue Cross members.

Blue Cross members can now find FRCs in provider directories at bcbsm.com and on the Blue Cross^® and Blue Shield^® Association website, including where they are located and average cost information for diagnostic imaging services and their estimated out-of-pocket costs. The enhanced ability to view and compare cost information will continue to be leveraged in Blue Cross benefit and product designs.

Eligible providers are encouraged to apply for enrollment in Blue Cross’ Traditional network. All participating FRCs will be considered in-network for PPO members, and out-of-network sanctions will be waived.

If you have any questions, contact your provider consultant.

Provider automated response system makes getting patient benefit information easier

Blue Cross Blue Shield of Michigan knows that your time is valuable and we want to make it as easy as possible for you to get benefits for your patients. Here’s information about a recent change and answers to some frequently asked questions about PARS:

Effective July 1, 2014, residential psychiatric benefits can be obtained by calling the Facility PARS phone line at 1-800-249-5103 and pressing benefit prompt number six (hospital inpatient).

Note: The Federal Employee Program^® does not currently use PARS.

Frequently asked questions

Q. Where can I find benefit information for diabetic supplies and testing?
A. Diabetic supplies and diabetes testing benefit information can be found by calling 1-800-344-8525, the professional provider IVR phone line, and pressing benefit prompt number six for durable medical equipment, orthotics and prosthetics. Please note that this benefit will not be found under benefit prompt number three for general practice.

Q. Why aren’t age limits referenced on PARS when I am checking benefits?
A. Due to recent mandates and the Health Care Reform law, there are now only a few benefits that have an age limitations. If you’re checking benefits and you do not hear an age limit specified on PARS, this means that there is no age limit for that benefit.

Q. What is the difference between precertification and preauthorization, and why can’t I call for precertification directly?
A. Precertification is a review of a patient’s symptoms and proposed treatment to determine, in advance, whether he or she meets BCBSM criteria for treatment in an inpatient setting. There are only three benefits that may require precertification and they are only on the facility provider IVR: acute inpatient, skilled nursing and rehabilitation setting. With these three benefit phone prompts, the IVR will indicate that precertification may be required, what benefits will be given and then the system will give the option for you to say “precertification.”

Preauthorization is a process that allows physicians and other professional providers to determine, before treating a patient, if BCBSM will cover a proposed service. BCBSM requires pre-authorization for services that may be experimental, investigational, cosmetic or not always medically necessary. This preauthorization is not done through the phone. Providers must submit clinical documentation in writing explaining why the proposed procedure is medically necessary. If you are having a procedure code pre-authorized, you will need to send a medical review request to BCBSM, only if a patient does not meet the criteria for a procedure. You can check the medical criteria in web-DENIS.

For services that require preauthorization, the professional PARS line will indicate this on the applicable benefit. For example, radiology services often require preauthorization through American Imaging Management. The professional provider IVR will advise this when checking benefits.

Update: Blue Distinction^® Centers designation

As you read in the March Record, Blue Cross Blue Shield of Michigan recently recognized 10 health care facilities for distinction in bariatric surgery. Since then, three additional health care facilities in Michigan have been recognized: Spectrum Health – Blodgett Hospital, Spectrum Health – Zeeland Community and William Beaumont Hospital – Royal Oak.

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.

For a look at the other 10 facilities that were recently designated, see the March Record.

Reminder: Register today for annual hospital forum in Frankenmuth

Blue Cross Blue Shield of Michigan invites you to attend the annual hospital morning forum, sponsored by the Benefit Administration Committee. This year’s forum is scheduled for Tuesday, May 19, 2015.

The event will include information on web-DENIS, BlueCard^®, Medicare Advantage and ICD-10. The forum starts with an information fair during registration, followed by classroom-style presentations. A lunch featuring Frankenmuth’s famous chicken will be served following the event.

RSVP to jholzhausen@bcbsm.com by Friday, May 15. In the subject line, indicate “BAC Forum.” In the email, list your name, facility and the total number of people attending from your facility. Your response is also an RSVP for lunch.

If you have other agenda topic suggestions, please include them in your email, and we’ll attempt to address them at the forum.

Documentation guidelines for anesthesia services updated

Effective April 1, 2015, we updated the medical-record documentation requirements for anesthesia services.

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

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

Physician Group Incentive Program now accepting applications for new Organized Systems of Care

PGIP recently changed the 2015 enrollment period for new Organized Systems of Care. We began accepting applications from newly formed OSCs April 15, 2015, and will continue accepting them through May 29, 2015.

OSCs whose applications are approved will become PGIP-contracted OSCs, effective Jan. 1, 2016. Participation in the PGIP OSC program provides the opportunity to earn financial rewards for developing OSC integrated care processes and infrastructure through OSC initiatives.

PGIP-contracted OSCs are also eligible to participate in the new Blue Cross Blue Shield of Michigan tiered OSC PPO product that will be launched in mid 2016.

To receive the OSC application packet, send an email to valuepartnerships@bcbsm.com.

Blue Cross changing how nonpayable codes are displayed in fee schedules

As you may know, Blue Cross Blue Shield of Michigan pays for covered services based on the lower of either the billed charges or the Blue Cross-approved amount. In the past, Blue Cross hadn’t established fees for services that were considered nonpayable for our members but that may be covered for members of other Blue plans who received services in Michigan. Previously, nonpayable codes in our fee schedules were listed as “NP” in the fee columns.

Effective July 1, 2015, we’ll no longer display the nonpayable codes as “NP.” Instead, either our Blue Cross Blue Shield of Michigan fee will be listed or, in instances where a fee could not be established, the fee will be listed as “No fee.” In these instances, we’ll base our approved amount on the fee that is listed. When the fee listed is “No fee,” we’ll base our approved amount on the charged amount.

The change described above applies to the following professional fee schedules:

• Independent LAB Fee Schedule
• Traditional Fee Schedule
• TRUST PPO Fee Schedule
• Local Network (EPO) Fee Schedule
• BPP Fee Schedule
• DME/P&O Fee Schedule

Entire fee schedules and fee change schedules are available on web-DENIS. Click on BCBSM Provider Publications and Resources and then on Entire Fee Schedules and Fee Changes.

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

Guidelines for cosmetic and reconstructive surgery reviewed, updated

The Joint Uniform Medical Policy committee has reviewed and updated the guidelines for the cosmetic and reconstructive surgery medical policy. The revised guidelines take place starting May 1, 2015.

Medical policy statement
Reconstructive surgery is an established service when it involves the restoration of a patient to a normal functional status, or when it is done to repair a defect caused by congenital defects, developmental abnormalities, trauma, infection, involutional defects, tumors or disease. It may be a therapeutic option when indicated.

Cosmetic surgery is performed solely to preserve or enhance appearance or self-esteem. It is considered not medically necessary.

Guidelines
In the absence of a functional deficit, reconstructive surgery may be used to restore a patient’s appearance to the normal state that existed before an illness, traumatic injury or surgery.

Declaration of medical necessity to justify surgery should be supported by medical documentation. Categories of conditions that are part of the contractual definition of reconstructive services include:

• Post-surgery (including breast reconstruction)
• Accidental trauma or injury
• Diseases
• Congenital anomalies
• Post-chemotherapy
• Massive weight loss causing functional impairment, including but not limited to, severe rashes or intertrigo, skin ulceration or pain (such as backache due to a large panniculus) or other related conditions that have not responded to conventional therapy

The following procedures may be considered either cosmetic or reconstructive based on the indications for the surgery (list is not all-inclusive):

Air ambulance services must be billed based on pickup ZIP code

We’d like to inform our ambulance providers who offer air ambulance services about an important change. Effective Aug. 1, 2015, claims for air ambulance services must be filed with the Blue plan in the area where the point of pickup ZIP code is located. This applies to all Blue Cross Blue Shield of Michigan and Blue Care Network business.

For example, if the point of pickup ZIP code is in Michigan, you would file the claim with Blue Cross Blue Shield of Michigan. If the point of pickup ZIP code is in Ohio, you would file with the local Blue plan in Ohio.

To help you file, see the guidelines below.

For air ambulance services:

• CMS 1500 form: Include the five-digit zip code of the point of pickup in Box 23

• CMS 1450 (UB-04): If air ambulance service is not included with local hospital charges, include Value Code A0 in FL 39-41and the five-digit ZIP code of the location where the beneficiary was placed on board the ambulance in the related value amount field for FL39

• 837 electronic claims:
• Professional: Report all information in the entire Loop 2310E, including the point of pickup ZIP code.
• Facility: Report Value Code A0 in Loop 2300, HI Segment with a BE qualifier and the five-digit point of pickup ZIP code as the value amount.

Air ambulance claims submitted to the wrong plan will be rejected.

If possible, we encourage you to verify member eligibility and benefits by contacting the phone number on the back of the member’s ID card. For more information be sure to check the provider manuals or contact your provider consultant.

Attention chiropractors: performance data and clinical resources available on provider support website

Since 2003, OptumHealth Care Solutions, Inc. and Blue Cross Blue Shield of Michigan have partnered to provide network chiropractors with access to evidence-based clinical resources with the goal of obtaining optimal outcomes for your patients. Keep in mind that you can use your provider ID and password to gain access to the Optum™ provider support website at myoptumhealthphysicalhealth.com — a site that provides access to your clinical profile and clinical resources.

Chiropractors were given a password and ID when they received their initial welcome letters. They can also get their password and ID by going on the website or by calling 1-800-873-4575, ext. 53121.

Because all health care providers in our TRUST PPO network contractually agree to provide members with efficient, cost-effective care, we monitor provider utilization performance. This is done with the understanding that unique aspects of your individual practice may affect your ability to perform within the averages established by your professional peers.

Unexplained high use and cost of care will result in your tier category being changed from “meets criteria” to “does not meet criteria.” Continued unexplained high variance from your peers may affect your continued participation in our PPO programs, and you may be contacted with concerns about your profile.

If you haven’t already done so, log on to the Optum website and familiarize yourself with some of the functions and clinical information presented. Key features include:

• Convenient access to the Optum website at any time
• Clinical resources available on the website include:

• Your individual clinical profile where your performance is compared to the averages established by your chiropractic peers in our TRUST PPO program for the timeframe indicated.
• How to read your clinical profile
• Tiering criteria. Performance of each chiropractor will be compared to the averages established by your chiropractic peers in the TRUST PPO program for the same 12-month timeframe.
• Education tutorials
• Other useful links to evidence-based references

If you have any questions about the information in this article or want to discuss a Blue Cross clinical case, contact an Optum support clinician at 1-800-873-4575, ext. 53121. If you have any other questions, call our profile analyst at 313-448-7371.

We look forward to your success as a Blue Cross Blue Shield of Michigan network provider.

BCBSM to use McKesson ClaimsXten™ for outpatient facility claims

As you may know, Blue Cross Blue Shield of Michigan has used McKesson ClaimsXten for the clinical editing of our professional claims since 2012. During the first quarter of 2016, we will begin using McKesson ClaimsXten clinical code editing for outpatient facility claims as well.

This change will help us meet the challenges of our ever-changing health care environment and provide faster, more flexible business processes for additional health care providers.

ClaimsXten will not only apply the Blue Cross payment application for outpatient facility services but will:

• Provide enhanced technical functionality.
• Improve overall claims management.
• Assist with maintaining consistent payment policy in alignment with state and national mandates.

More information about ClaimsXten outpatient facility claim processing will be provided in future issues of The Record.

Interested in becoming a Blue Cross freestanding radiology center? Enroll today

Blue Cross Blue Shield of Michigan is continuing to enroll freestanding radiology centers as a new type of provider that offers diagnostic imaging services. The freestanding radiology center provider type became effective Jan. 1, 2015.

Creating this new provider type allows Blue Cross to uniquely recognize and reimburse freestanding providers of diagnostic imaging services. It also supports customer and market demands for enhanced access to provider- and service-related cost transparency information for Blue Cross members.

Blue Cross members can now find FRCs in provider directories at bcbsm.com and on the Blue Cross^® and Blue Shield^® Association website, including where they are located and average cost information for diagnostic imaging services and their estimated out-of-pocket costs. The enhanced ability to view and compare cost information will continue to be leveraged in Blue Cross benefit and product designs.

Eligible providers are encouraged to apply for enrollment in Blue Cross’ Traditional network. All participating FRCs will be considered in-network for PPO members, and out-of-network sanctions will be waived.

If you have any questions, contact your provider consultant.

Here’s how an onsite physician office infusion therapy audit works

Blue Cross Blue Shield of Michigan conducts physician office infusion therapy audits to verify if paid claims are appropriate by reviewing medical records onsite at a provider’s office. To ensure minimal disruption to your practice and help you prepare for an audit, we’re outlining the following steps in the auditing process:

1. An auditor will contact your office to schedule a start date for the audit. This contact will be followed by a fax confirmation appointment letter, which will include a questionnaire and a partial patient list.
2. Upon arrival, the auditor will ask for a brief meeting, referred to as the entrance conference, with the practice representative. During this meeting, the auditor may request additional records or a “direct pull list.” A questionnaire, sent with the appointment letter, should be completed and available for review by the auditor during the entrance conference. Any questions you have regarding this questionnaire can be addressed by the auditor during this conference.
3. It’s important that a staff member familiar with your office charting system is available to explain your office’s charting format and any other important information that could assist the auditor’s chart review.
4. The auditor will scan all your office’s records into their secure laptop. But if your records are stored in an electronic medical record system, they must all be printed before the auditor arrives. It’s important that the auditor is provided with documentation that supports the paid claims, such as physician orders, administration sheets, progress notes, etc.
5. When the audit is done, the auditor will ask for a brief exit conference with the practice representative to discuss preliminary audit findings. The auditor will also provide a missing documentation list that identifies records that weren’t available during the audit. This report requires the practice representative’s signature confirming the report was submitted to the practice.
6. A second review of the scanned documentation will be performed by the auditor before the mailing of the provider’s initial result reporting letter. When the second review is done, the initial results reporting letter is sent via certified mail. This letter contains additional reports and an explanation of the appeal process that a provider can use to dispute audit results. It also includes the name and contact information for auditor and the manager in case you need to call with questions.

Provider automated response system makes getting patient benefit information easier

Blue Cross Blue Shield of Michigan knows that your time is valuable and we want to make it as easy as possible for you to get benefits for your patients. Here’s information about a recent change and answers to some frequently asked questions about PARS:

Effective July 1, 2014, residential psychiatric benefits can be obtained by calling the Facility PARS phone line at 1-800-249-5103 and pressing benefit prompt number six (hospital inpatient).

Note: The Federal Employee Program^® does not currently use PARS.

Frequently asked questions

Q. Where can I find benefit information for diabetic supplies and testing?
A. Diabetic supplies and diabetes testing benefit information can be found by calling 1-800-344-8525, the professional provider IVR phone line, and pressing benefit prompt number six for durable medical equipment, orthotics and prosthetics. Please note that this benefit will not be found under benefit prompt number three for general practice.

Q. Why aren’t age limits referenced on PARS when I am checking benefits?
A. Due to recent mandates and the Health Care Reform law, there are now only a few benefits that have an age limitations. If you’re checking benefits and you do not hear an age limit specified on PARS, this means that there is no age limit for that benefit.

Q. What is the difference between precertification and preauthorization, and why can’t I call for precertification directly?
A. Precertification is a review of a patient’s symptoms and proposed treatment to determine, in advance, whether he or she meets BCBSM criteria for treatment in an inpatient setting. There are only three benefits that may require precertification and they are only on the facility provider IVR: acute inpatient, skilled nursing and rehabilitation setting. With these three benefit phone prompts, the IVR will indicate that precertification may be required, what benefits will be given and then the system will give the option for you to say “precertification.”

Preauthorization is a process that allows physicians and other professional providers to determine, before treating a patient, if BCBSM will cover a proposed service. BCBSM requires pre-authorization for services that may be experimental, investigational, cosmetic or not always medically necessary. This preauthorization is not done through the phone. Providers must submit clinical documentation in writing explaining why the proposed procedure is medically necessary. If you are having a procedure code pre-authorized, you will need to send a medical review request to BCBSM, only if a patient does not meet the criteria for a procedure. You can check the medical criteria in web-DENIS.

For services that require preauthorization, the professional PARS line will indicate this on the applicable benefit. For example, radiology services often require preauthorization through American Imaging Management. The professional provider IVR will advise this when checking benefits.

Update: Blue Distinction^® Centers designation

As you read in the March Record, Blue Cross Blue Shield of Michigan recently recognized 10 health care facilities for distinction in bariatric surgery. Since then, three additional health care facilities in Michigan have been recognized: Spectrum Health – Blodgett Hospital, Spectrum Health – Zeeland Community and William Beaumont Hospital – Royal Oak.

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.

For a look at the other 10 facilities that were recently designated, see the March Record.

Documentation guidelines for anesthesia services updated

Effective April 1, 2015, we updated the medical-record documentation requirements for anesthesia services.

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

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

Reminder: Document requirements for physician office infusion therapy medication orders

It’s important that all orders for medication, including physician office infusion therapy, are documented in a patient’s record and signed by the physician.

During recent POIT audits, many of providers overlooked the necessity of rewriting orders or co-signing verbal orders. Medication changes, which are calculated based on either the patient’s weight or condition that can result in an increase or decrease in the dosage, require an order.

Medications requiring rounding the dose up or down to the next whole unit also require an order. All medications orders must be documented in the patient’s chart with the ordering physician’s dated signature. Verbal orders must be co-signed promptly to confirm the dosage change.

Physicians’ offices referencing drug protocols or standing orders must maintain the order, with a yearly physician review, confirmed by a physician’s dated signature. When drug protocols or standing orders are used for the treatment of a patient, the document should be placed in patient’s chart and include the patient’s name.

If the document can’t be placed in the patient’s chart, a physician-signed order referencing the drug protocol or standing order must be documented in the chart. The person administering the drug must document the name of the protocol or standing order referenced in the administration record.

As specified in BCBSM Documentation Guidelines for Physicians and Other Professional Providers, “For all diagnostic and therapeutic services, the performing physician must: Document the required procedure details for each diagnostic and therapeutic service.” It also states: “The documentation for diagnostic and therapeutic services must be sufficiently detailed so that another health care professional can review the patient’s medical record and clearly understand the nature and extent of the service.”

Follow these guidelines to help avoid a potential audit recovery.

Reminder: freestanding urgent care center billing

Participating Blue Cross Blue Shield of Michigan freestanding urgent care centers are required to include information about the rendering provider on all claim submissions. If this information is not included, claims may not process correctly and provider payment may be denied.

For more details, see the “Urgent Care Center Services” chapter of the Blue Cross UCC provider manual. If you have any questions after consulting the manual, contact your provider consultant.

Home infusion therapy increases day supply for life-sustaining medications

Blue Cross Blue Shield of Michigan’s home infusion therapy benefit currently allows up to a seven-day supply of medication (10 day supply if a holiday weekend is involved). However, this supply limitation may not be sufficient for life-sustaining infusions. (A life-sustaining infusion medication is one where if the infusion is stopped for any reason, the patient would require immediate hospitalization or the stoppage could lead to loss of life.)

Therefore, effective May 1, 2015, Blue Cross will allow an initial 30-day supply to be dispensed for the life-sustaining infusion medications listed below. Blue Cross will then allow an additional 15 day supply every 15 days. This will provide a large enough supply of infusion in the patient’s home to cover any interruption of delivery that may occur due to natural or unnatural causes.

**This list of drugs will be updated as additional drugs are identified as life-sustaining infusion medications (24/7 infusions) by Blue Cross Blue Shield of Michigan.

New edit codes, effective Oct. 1, to support ICD-10

As you know, the federal government is requiring the health care industry to use ICD-10 codes in place of ICD-9 codes beginning with dates of service on or after Oct. 1, 2015. To comply with this mandate, Blue Cross Blue Shield of Michigan will use new front-end edit codes for electronic claims that:

• Have invalid ICD-10 codes and qualifiers
• Contain ICD-9 codes for dates of service on or after Oct. 1
• Contain ICD-10 codes for dates of service prior to Oct. 1
• Contain both ICD-9 and ICD-10 codes in the same claim

The edits listed below are effective Oct. 1. Claims receiving any of these edits on 277CA reports or transactions must be corrected and resubmitted.

For questions regarding ICD-10, visit our website. For questions about electronic HIPAA transactions or front-end edits, contact the Blue Cross EDI Helpdesk at 1-800-542-0945.

Contact your software vendor or clearinghouse with questions about ICD-10 code reporting using your practice management claim system.

Dental services may qualify for payment as medical-surgical benefit

There has been confusion regarding benefit coverage when facility, anesthesia and dental procedure charges are interrelated in some way.

Blue Cross Blue Shield of Michigan dental programs are intended to cover treatment of the teeth and supporting structures. Typically, these services are payable as part of a member’s dental benefits and not as a medical-surgical benefit. Dental services may qualify for payment as a medical-surgical benefit if:

• They are part of the member’s benefit design and required criteria are met.
• A member is admitted as an inpatient to the hospital with a medical problem that is negatively impacted by a dental condition. Documentation shows that treating the dental condition is intended to improve the medical condition to facilitate discharge from the hospital.
• A patient requires prophylactic extractions before an organ transplant, cardiac valve surgery or ionizing radiation (5,000 cGy or more) that involves the jaw.
• Procedures are included in the accidental dental injury benefit. This benefit applies when a patient experiences an external force to the lower half of the face or jaw that damages or breaks the teeth, periodontal structures or bone (other than self-inflicted external force of chewing), or a medical condition.

Facility charges are part of the medical-surgical benefit when associated with dental procedures if circumstances prevent the dental procedures from being performed in an office setting. These circumstances include the following:

• A member is an inpatient with a medical problem that is impacted negatively by the dental problem — and treating the dental condition is intended to improve the medical condition to facilitate discharge from the hospital.
• A patient requires dental services and meets the anesthesia criteria for outpatient general anesthesia.

Anesthesia services would be payable to the anesthesiologist or certified registered nurse anesthetist under the medical-surgical benefit — in conjunction with billable procedures on the teeth and supporting structures — when those services are medically necessary and performed in a hospital setting. In such cases, the anesthesiologist or certified registered nurse anesthetist should submit procedure code *00170. The dental services rendered are not payable unless the member has the benefit.

Anesthesia is covered if the following criteria are met:

• The patient is a child younger than 7 years (i.e., through the end of the sixth year).
• For older patients, coverage depends on the extent of procedures required. At a minimum, the patient should have six or more teeth that need to be extracted or other procedures that must be performed in two or more quadrants of the mouth on the same date of service.

One of the following conditions must also be met:

• A concurrent hazardous medical condition that creates a documented medical necessity to safeguard the life of the patient must exist. This condition makes it medically necessary to perform the procedure in a facility under general anesthesia or sedation, such as severe cerebral palsy or labile hypertension with three or more antihypertensive medications must be documented in the patient’s record). Chronic stable medical conditions, behavioral concerns and situational anxiety do not meet the criteria for approval.
• Significant cellulitis or swelling and associated trismus that does not allow the use of local anesthesia
• Extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised

Anesthesia charges are considered a medical-surgical benefit when the service performed is not reported with a procedure code from CPT Appendix G and when modifier 59 is indicated with procedure codes *99143-*99145. Procedure code *41899 and D dental codes are not payable in association with *99143-*99148 unless covered under the patient’s benefit plan.

For specific information about member benefits and eligibility, check web-DENIS or call PARS. Following is a general guide to help you administer the benefit:

**Group specific. Check PARS, web-DENIS or Provider Inquiry.

***Anesthesia is payable to surgeon if procedure codes *99143 through *99145 (appended with modifier 59) are billed with a procedure code not in CPT Apppendix G or with a D dental code or *41899 (unless certificate covers extraction of teeth).

****Facility charges are not payable if anesthesia is performed in the office setting.

Blue Cross extends continuity of care for members whose practitioners leave PPO network

Practitioners, including M.D.s, D.O.s and D.P.M.s, who decide to leave Blue Cross Blue Shield of Michigan’s TRUST, Metro Detroit Exclusive Provider Organization and Blue Preferred Plus^SM networks can care for their members as long as a practitioner’s participation in the network didn’t end as a result of fraud or failure to meet quality standards.

Practitioners who want to continue a member’s care after they leave the TRUST, EPO and BPP networks are required by state law to provide members with a written notice within 15 days of the date they leave the provider network. This notice may be posted in the practitioner’s office or sent to members in a card or letter informing them of the practitioner’s intent to leave the network.

If a member wants to continue care after his or her practitioner leaves the network and enters into a written continuity of care arrangement, the following limitations apply:

Coverage limitations

• For general care, BCBSM will provide coverage for 90 days from the date the 15-day notice is sent out as long as the member has received services from the disaffiliated practitioner at least twice in the last 12 months and is in a current period of active treatment. An active course of treatment is a situation for which a disruption of the current course of treatment could cause a recurrence or worsening of the condition under treatment and interfere with anticipated outcomes

• For maternity care, BCBSM will provide coverage if the member is in the second or third trimester of pregnancy at the time the practitioner leaves the network. This coverage will continue through the postpartum period

• For treatment directly related to a terminal illness diagnosed before the practitioner left the network, BCBSM will provide coverage for the remainder of the member’s life

Payment conditions

• As long as the approved continuity of care period is in effect, the practitioner is required to accept BCBSM’s payment as payment in full, less any in-network copays or deductibles that the member may be required to pay.

• The above rules apply only to members who were in the practitioner’s care before his or her termination from the network. Continuation beyond the designated times will result in out-of-pocket expenses for the member in the form of out-of-network copays and deductibles.

• Continuity of care is not automatic and must be initiated by the practitioner. When billing TRUST/BPP members after the termination is effective, the practitioner will need to include for each claim submission:
• A HCFA 1500 paper claim form
• A copy of the continuity of care arrangement letter, signed by both the patient or subscriber and the provider
• Supporting medical records

• Practitioners should submit all of the forms and correspondence above to:
  Attn: Continuity of Care Senior Analyst
  Blue Cross Blue Shield of Michigan
  600 E. Lafayette Blvd MC 607A
  Detroit, MI 48226-9942

For EPO practitioners

• EPO claims for continuity of care don’t follow the claims submission guidelines listed above. If you have any questions regarding the process, refer to your provider manual

Blue Cross to begin piloting Transition Rx Fill Program

Blue Cross Blue Shield of Michigan will launch a pilot Transition Rx Fill Program this month to help improve new member and provider satisfaction. This program applies only to members new to our individual and small group plans with the Custom Select Drug List.

The program will allow members to receive a one-time, temporary coverage override of up to a 30-day supply. The selected drugs listed below require a prior authorization. This one-time fill will allow the member time to get the prior authorization needed for coverage of the requested medication or switch to a comparable preferred alternative. The program is limited to the first 30 days of eligibility.

Under the Transition Rx Fill Program, no more than a 30-day supply of a prescription can be provided for one copayment. A temporary coverage override is available through participating retail and mail-order pharmacies. Transition fills don’t apply to everyone; only those members included in the pilot.

These medications are included in the program:

• Axert
• Frova
• Relpax
• Zolmitriptan (generic form of Zomig)
• Benicar
• Benicar HCT
• Edarbi

How the program works

• The participating pharmacy submits a claim for a Transition Rx Fill Program member for one of the transition fill drugs.
• The claim will process as a transition supply.
• Blue Cross notifies the member and the prescriber by letter that the medication requires a prior authorization and a one-time temporary coverage override has been authorized.
• The member is advised to work with their prescribing physician to request a prior authorization or switch to an alternative covered drug that does not require prior authorization.
• After the temporary coverage of a prior authorization is not approved for the drug, the claim will reject on a refill attempt.
  

If you receive questions from our members, please instruct them to contact Blue Cross Customer Service by calling the number on the back of their ID card. If you have any questions about our pharmacy programs, call the Pharmacy Services Clinical Help Desk at 1-800-437-3803 and select Option 1.

Blue Cross discontinues reimbursements for medical records requests related to diagnoses submission

Beginning May 1, 2015, Blue Cross Blue Shield of Michigan will no longer reimburse all-network physicians, hospitals or facilities for administrative costs related to medical records retrieval for risk adjustment purposes. This aligns Blue Cross practices with those of Blue Care Network, which does not reimburse for chart requests.

Annually, Blue Cross and BCN requests medical records from our health care providers to meet Centers for Medicare & Medicaid Services’ standards for data submission and diagnosis coding accuracy. These reviews are conducted to evaluate the accuracy of patient diagnoses submitted for payment to CMS.We’ve found that only a small percentage of providers request reimbursement for the administrative costs involved in the copying and faxing or mailing of risk adjustment-related records to Blue Cross. Blue Cross will continue to reimburse for medical records requests related to HEDIS.

Keep in mind that some of our vendor partners offer a secure portal or electronic file transfer that allows you to upload or send medical records electronically, thereby eliminating the cost of copying and mailing records.

Please contact your provider consultant if you have any questions or concerns related to medical record requests. You may also refer to the Medical Records Requests Frequently Asked Questions document for more information.

We’re seeking names of billing companies who do business with Blue Cross

We’re searching for the names of all billing companies that Blue Cross Blue Shield of Michigan and Blue Care Network health care providers use. We’d like to reach out to these companies and include them in future training initiatives. Please send an email with the appropriate contact information to lbeal@bcbsm.com if you’re:

• A company that bills for Blue Cross providers
• A doctor’s office that outsources billing to another company (include the contact information for the company that handles your billing)
• A billing company interested in joining us for a future training session

If you have questions or need more information, send an email to llatvis@bcbsm.com.

Be sure to post notice of privacy practices on websites

In order to stay compliant with the Health Insurance Portability and Accountability Act, all health care providers and independent covered entities are required to prominently post their notice of privacy practices on their websites or homepage of their intranet site.

For more information about this requirement, contact your provider consultant.

HCPCS codes added, deleted

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

Added

Deleted

HCPCS codes coverage decisions changed

As you may recall, Blue Cross Blue Shield of Michigan published new and deleted codes for 2015 on web-DENIS in January. Since that time, two CPT codes that were listed as “Not covered by Blue Cross” are now covered.

Following is the correct information for these codes

We’re updating the HCPCS document on web-DENIS to reflect this new information.

Correction: coverage comments for some HCPCS codes

Our 2015 HCPCS document, which you read about in the January Record, listed several codes as “Covered by BCBSM.” However, the following codes should have been listed as “Requires manual review” as of Jan. 1, 2015:

*80304
*80323
*80338
*80339
*80340
*80341
*80342
*80343
*80344.

These codes require a complete description and an itemization of charges and will be manually reviewed for payment consideration.

We will update the HCPCS document on web-DENIS to reflect this information.

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

This is the third 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 highlight the different types of provider resources we offer and tell you where to find them.

Educational events
We offer many learning opportunities to help our provider community stay informed about our latest products, policies and procedures. These sessions, which include webinars, classes and forums, are often promoted in The Record and on web-DENIS.

Here are a few of our upcoming events:

• The ICD-10 educational presentations
• The 2015 Michigan Hospital Networking sessions
• The annual hospital forum in Frankenmuth

Online resources
Provider materials, including job aids, forms and training materials, are available on bcbsm.com. Here are some of the resources you can find on our public website at bcbsm.com/providers:

• Value Partnerships: Learn about our Physician Group Incentive Program, Collaborative Quality Initiatives and other innovations that are transforming health care.
• Provider Secured Services: Sign up for access to online Blue Cross applications that make your job easier.
• Medicare Advantage: Reference the Medicare Plus BlueSM PPO Manual and other materials in our provider toolkit.
• Newsletters: View or subscribe to our provider newsletters, and receive updates by email.
• Pharmacy resources: Drug lists, prior authorization and step therapy programs are available under the Help tab under Plan Documents and Forms.
• Contact Us: Click this link in the upper right corner of the home page to find the help you need.

You can find additional useful documents when you log in to Provider Secured Services. Click on web-DENIS and then BCBSM Provider Publications and Resources, and here’s what you’ll find:

• Provider manuals
• Fee schedules and fee changes
• Newsletters and resources — with current and archive issues of provider newsletters, training presentations, frequently used forms and much more

eLearning resources
We’ve created online video presentations to cover a broad range of topics, from Blue Cross products to our business processes.

Here are a few presentations available to view:

• Where to find Blues members’ cost share Information
• Blue Cross^® Metro Detroit EPO and HMO
• web-DENIS: New display for coinsurance max

Additional presentations are available within BCBSM Provider Publications and Resources. Click on Newsletters & Resources and then click on Provider Training and scroll down to eLearning.

Coding corner: proper documentation of hemiparesis and weakness

Coding hemiparesis can be a challenge when the documentation surrounding the diagnosis is too vague. For example, documentation may only note weakness, which doesn’t map to hemiparesis in ICD-9-CM coding terms. The documentation should be descriptive to indicate left-sided or right-sided weakness.

Symptom versus condition
Generalized weakness is a symptom that maps to the ICD-9 CM code 780.79. Hemiparesis is a condition that maps to ICD-9 CM code 342.9X. A physician’s documentation to describe the patient’s diagnoses may not link with the language in the ICD-9 CM alpha and tabular index. If applicable, the documentation should link weakness with hemiparesis; otherwise, the description may only map to a generalized weakness ICD-9-CM code. Hemiparesis is a chronic condition, according to the Centers for Medicare & Medicaid Services, whereas generalized weakness is not.

Types of weakness
It’s important to document the specific type of weakness, which may be all over the body or only in one area. Here are the codes for weakness:

• Generalized weakness: 780.79
• Muscle weakness (generalized): 728.87
• Weakness due to cerebrovascular hemiparesis. Two codes needed: 438.89 (other late effects of a cerebral vascular accident) and: 728.87 (muscle weakness)

Hemiparesis and hemiplegia
Both hemiplegia and hemiparesis (code 342.XX) refer to paralysis of one side of the body. The fourth-digit subcategory conveys the type of hemiplegia. The fifth-digit subclassification conveys whether the side affected is dominant, non-dominant or unspecified. Here are the codes for hemiparesis:

• Hemiparesis, affecting unspecified side: 342.90
• Hemiparesis, affecting dominant side: 342.91
• Hemiparesis, affecting nondominant: side 342.92

Late effects of cerebrovascular hemiparesis
Late effects of cerebrovascular disease, hemiparesis and hemiplegia (code 438.2X) may occur at any time after the onset of the causal condition. The fifth-digit subclassification conveys whether the side affected is dominant, non-dominant or unspecified. Here are the codes for late effects of CVA-hemiparesis:

• Hemiparesis due to CVA-affecting unspecified side: 438.20
• Hemiparesis due to CVA-affecting dominant side: 438.21
• Hemiparesis due to CVA-affecting non-dominant side: 438.22

For example, a physician’s documentation may note “weakness due to CVA,” which maps to ICD-9-CM codes 438.89 (other late effects of cerebrovascular disease) and 728.87 (general muscle weakness), identifying the late effects of the CVA.

Physicians should be specific when documenting whether the patient’s weakness is current or related to conditions, such as a late effect of a previous stroke. Weakness is a vague term, while hemiparesis is specific to diminished function. A physician’s documentation determines the accuracy of the ICD-9-CM code selection for weakness versus hemparesis.

Additionally, specific documentation may result in better outcomes of care, as well as continuity of patient care between providers and the health care plan.

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: answer to a recent question

As part of our ongoing series on the Bluecard program, here’s the answer to a question we recently received.

Sometimes I’m asked to provide information on a BlueCard claim that I would normally not provide when billing claims to Blue Cross Blue Shield of Michigan for an in-state member. Am I required to provide that information to get the claim processed?

Blue plans may request more information or ask that you report information on a claim differently than you are required to report to Blue Cross Blue Shield of Michigan for our Commercial business. Although you are not required to report a claim differently than you would for a Michigan member, providing the information can assist in processing the claim. The Blue plan requesting the information may have a system limitation or require the additional information in order to determine the member’s contracted benefits.

If you have questions about a request you received for information on a pended or rejected BlueCard claim, please contact Provider Inquiry. Provider Inquiry can assist you in determining the needed information or contact the plan when necessary.

Effective April 19, 2015, you may be asked to provide additional information on a BlueCard claim for members enrolled in a Medicaid plan administered by another Blue plan. Medicaid claims processed through BlueCard are required to meet Medicaid reporting requirements. Failure to provide the information as requested by the member’s home plan can result in nonpayment of the claim. This policy is documented in the BlueCard chapter of the online provider manuals on web-DENIS under the topic “Medicaid Related Claims.”

If you’re experiencing issues with the information provided in the BlueCard chapter or any of the online tools — or if you’d like more information on a particular topic — contact your provider consultant. If you’d like to suggest a topic to be covered in a future issue of The Record, send an email to ProvComm@bcbsm.com and put “BlueCard series” in the subject line.

Reminder: Combined signature document for each provider type

As you read in the April Record, BCBSM has combined the practitioner signature documents into a single document for each provider type.

We wanted to let you know that a new signature document for each provider type is now available in the Provider Enrollment area of bcbsm.com/providers. To complete a combined signature document, the practitioner must indicate which network or networks he or she wants to apply for and sign the form.

If you have any questions, contact your provider consultant.

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 Record: what you need to know

Here are some tips for using The 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 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.

We’re clarifying our CPAP policy regarding replacement units

We’re providing a clarification of our CPAP policy as it relates to members receiving a replacement unit. This clarification pertains to CPAP replacement devices provided from Oct. 1, 2011, to the present for the following situations:

• Following the five-year reasonable useful lifetime
• During the five-year reasonable useful lifetime if a replacement is required and the warranty on the device has expired

 Provider guidelines when dispensing and billing a replacement CPAP are as follows:

• A new prescription is required for the replacement CPAP.
• Durable medical equipment providers must document in the patient’s record that they have confirmed it is a replacement.
• Replacement units must be submitted as a rental only and will be considered purchased only after 10 consecutive rental months.
• DME providers must bill the KX modifier on all confirmed CPAP replacement claims as well as the supplies and accessories used with them.

It’s important to note that a new sleep test or trial period isn’t required for the replacement CPAP. Providers are still required to document compliance for members who don’t qualify for a replacement CPAP as directed in our policy.

Home infusion therapy increases day supply for life-sustaining medications

Blue Cross Blue Shield of Michigan’s home infusion therapy benefit currently allows up to a seven-day supply of medication (10 day supply if a holiday weekend is involved). However, this supply limitation may not be sufficient for life-sustaining infusions. (A life-sustaining infusion medication is one where if the infusion is stopped for any reason, the patient would require immediate hospitalization or the stoppage could lead to loss of life.)

Therefore, effective May 1, 2015, Blue Cross will allow an initial 30-day supply to be dispensed for the life-sustaining infusion medications listed below. Blue Cross will then allow an additional 15 day supply every 15 days. This will provide a large enough supply of infusion in the patient’s home to cover any interruption of delivery that may occur due to natural or unnatural causes.

**This list of drugs will be updated as additional drugs are identified as life-sustaining infusion medications (24/7 infusions) by Blue Cross Blue Shield of Michigan.

Home infusion therapy increases day supply for life-sustaining medications

Blue Cross Blue Shield of Michigan’s home infusion therapy benefit currently allows up to a seven-day supply of medication (10 day supply if a holiday weekend is involved). However, this supply limitation may not be sufficient for life-sustaining infusions. (A life-sustaining infusion medication is one where if the infusion is stopped for any reason, the patient would require immediate hospitalization or the stoppage could lead to loss of life.)

Therefore, effective May 1, 2015, Blue Cross will allow an initial 30-day supply to be dispensed for the life-sustaining infusion medications listed below. Blue Cross will then allow an additional 15 day supply every 15 days. This will provide a large enough supply of infusion in the patient’s home to cover any interruption of delivery that may occur due to natural or unnatural causes.

**This list of drugs will be updated as additional drugs are identified as life-sustaining infusion medications (24/7 infusions) by Blue Cross Blue Shield of Michigan.

Home infusion therapy increases day supply for life-sustaining medications

Blue Cross Blue Shield of Michigan’s home infusion therapy benefit currently allows up to a seven-day supply of medication (10 day supply if a holiday weekend is involved). However, this supply limitation may not be sufficient for life-sustaining infusions. (A life-sustaining infusion medication is one where if the infusion is stopped for any reason, the patient would require immediate hospitalization or the stoppage could lead to loss of life.)

Therefore, effective May 1, 2015, Blue Cross will allow an initial 30-day supply to be dispensed for the life-sustaining infusion medications listed below. Blue Cross will then allow an additional 15 day supply every 15 days. This will provide a large enough supply of infusion in the patient’s home to cover any interruption of delivery that may occur due to natural or unnatural causes.

**This list of drugs will be updated as additional drugs are identified as life-sustaining infusion medications (24/7 infusions) by Blue Cross Blue Shield of Michigan.