Providers could be financially responsible for not obtaining preservice reviews for Blue Cross members prior to inpatient admissions

As we wrote in a July 2014 Record article, all participating facilities are financially responsible for obtaining an inpatient preservice review when it’s required by the member’s plan. This requirement, part of the Blue Cross and Blue Shield Association Provider Financial Responsibility Mandate, became effective July 1, 2014. 

Effective Sept. 1, 2015, Blue Cross Blue Shield of Michigan is amending its inpatient authorization reimbursement policy for all inpatient admissions that require preservice review as part of this mandated policy. Participating facilities that do not obtain a required preservice review prior to the admission will be financially responsible if an authorization cannot be obtained within 60 days of the date of the admission.

If the retro service review is not obtained within 60 days from the date of the patient’s admission, our contracted reimbursement for the claim will be reduced to 70 percent of the allowed amount, with a 30 percent provider sanction.  This reimbursement policy applies to inpatient facility claims for both Blue Cross Blue Shield of Michigan members and members enrolled in out-of-state BCBS commercial contracts processed through BlueCard.

This policy also applies to Blue Cross Blue Shield of Michigan Medicare Advantage PPO members for inpatient claims with the exception of admissions to skilled nursing facilities, long-term acute care hospitals and inpatient rehabilitation. Blue Care Network is excluded from this policy.

For services provided to out-of-area members, the home plan’s authorization guidelines apply.

Keep the following in mind:

• Facilities should complete the required preservice review prior to the admission of any Blue Cross Blue Shield of Michigan member or a Blue member enrolled in an out-of-area plan.
• Facilities should continue to use our current processes to request a preservice review for Michigan members to include:
• Using our electronic prenotification process for all acute care admissions for both Blue Cross Blue Shield of Michigan members and BCBSM Medicare Advantage members who reside in Michigan
• Contacting Blue Cross or the required mental health provider for medical rehabilitation, skilled nursing, psychiatric or substance abuse admissions 
• Facilities should contact the member’s home plan by calling 1-800-676-2583 for the required authorization or using the Electronic Provider Access tool. See the October 2013 Record article for information on the tool.
• Facilities are required to notify the home plan within 48 hours of a change to the original approved authorization. Changes could include clinical complications resulting in a change to the admission type or days approved. 
• Facilities are required to request preservice review within 72 hours of an emergency or urgent care admission.
• Facility claims for inpatient admissions billed to Blue Cross Blue Shield of Michigan without the required authorization to admit the patient into the facility will continue to be rejected as they are today.
• Blue Cross Blue Shield of Michigan does not manage the preservice review process of other Blue plans and cannot ensure the timeliness or the decision to allow a retroactive service review. We will, however, let other Blue plans know that a 30 percent sanction can be applied to out-of-state claims if the required preservice review is not performed or the retroactive service review has not been obtained within 60 days of the date of admission. For Medicare Advantage members, the 30 percent sanction will only apply to inpatient acute care hospital claims.   
• The current policy for contacting the member’s home plan to request an appeal for an adverse preservice review (authorization) decision — or to appeal a retroactive service review — remain in place. You can reference the BlueCard chapter of any of our online provider manuals for additional information on appeals.
• Members are held harmless for any rejected claims or the 30 percent provider sanction.

If additional information about this process needs to be communicated, we will include it in a future Record article.

Certificate of Medical Necessity requirements for home infusion therapy program

The home infusion therapy program requires a Certificate of Medical Necessity for each therapy type, with a dated physician signature within 90 days of the start-of-care date. Each CMN must meet the guideline requirements as stated in the HIT manual, with no exceptions.

A CMN lasts 120 days. When the therapy is ordered beyond the 120-day limit, the CMN must be renewed with all the required information and signed within 90 days of the renewal date.

The pharmacist may take a verbal order related to the drug therapy without a physician co-signature; however a CMN renewal must be signed by the ordering physician within 90 days of the renewal date. Claims can’t be billed until the physician returns the signed and dated CMN to the infusion provider.

If the patient is hospitalized or admitted to a nursing home, the current CMN is automatically discontinued. The patient will need a new CMN when he or she returns to service. When the current services are discontinued and a new service is started, a new CMN is needed. An order change of the same therapy type during a 120-day CMN limit doesn’t need a new CMN.

The major therapy types are specified by the Healthcare Common Procedure Coding System, as indicated below:

Failure to meet these requirements may result in an audit recovery. If you have any questions, contact your provider consultant.

Blue Cross reimburses home infusion therapy on per-day basis for implanted pumps

Blue Cross Blue Shield of Michigan began reimbursing home infusion therapy providers on Jan. 1, 2015, for $15 per diem for S code S9363. This code is used to indicate anti-spasmodic intravenous therapy.

ClaimsXten™ coming to outpatient facilities claims in 2016

Blue Cross Blue Shield of Michigan will begin using McKesson’s clinical coding solution, ClaimsXten, for outpatient facility claims beginning in the first quarter of 2016. This change will apply to services that require Healthcare Common Procedure Coding System reporting.

We will include detailed information in the August 2015 edition of The Record.

Here’s an overview of how ClaimsXten will process claims for outpatient facility services:

Incidental and mutually exclusive services:

• Identifies a HCPCS code performed at the same time as a more complex procedure and that’s clinically tied to the outcome of the primary procedure.
• Identifies procedures that differ in technique and approach but lead to the same outcome.

Same-day medical services:

• Identifies certain HCPCS codes billed by the same facility on the same date of service as a code with a global period.

Clinical daily recommended allowance — all allow once per date of service:

• Identifies claim lines that contain a HCPCS code that allows the service once for a single date of service and the maximum number of times allowed has been exceeded.

Clinical Daily Recommended Allowance — allow multiple times per date of service:

• Identifies claim lines that contain a HCPCS code where the maximum number of times the service may be submitted per date of service has been determined, is more than one and has been exceeded.

Multiple code rebundling:

• Identifies claims containing two or more HCPCS codes used to report a service when a single, more comprehensive procedure code exists that more accurately represents the service performed.

Multiple radiology reduction:

• Identifies certain radiology procedures performed during the same session that are eligible for a reduction when submitted by the same facility.

CMS always bundled:

• Identifies claim lines that contain a Centers for Medicare and Medicaid Services HCPCS code that’s always bundled when billed with another procedure.

Modifiers:
Keep in mind that in certain cases, modifiers may change the payment decision. When appropriate, Blue Cross will support the use of modifiers that indicate unique circumstances for individual patients. The use of modifiers should be documented in the patient’s medical record.

• Modifiers 25, 59, XE, XS, XU and site specific modifiers will identify the claim line as a separate and distinct service or anatomic site to override the incidental and mutually exclusive result.
• Modifiers 25 and 57 will identify the service as a separate service or a decision for surgery to override the same-day medical service result.
• Modifiers 26, TC, 76, 91, LC, LD, LM, RC, RI and site modifiers will identify the claim line as a separate and distinct service or anatomic site to override the Clinical Daily Recommended Allowance - allow once per date of service result.
• Modifiers 76, 91 and site modifiers will identify that a service has been repeated or anatomic site to override the Clinical Daily Recommended Allowance - allow multiple times per date of service result.
• Modifiers 59, XE, XS and XU will identify the claim line as a separate and distinct service to override multiple radiology reduction result.

If you have questions about a ClaimsXten payment decision, you may:

• Request a clinical edit review. We’ll work with our medical consultant to determine if the clinical edit should be changed. Contact Provider Inquiry or your provider consultant.
• Pursue an individual case review. Follow the same process as you would for any claim rejection.

Watch for more information about what ClaimsXten will mean for outpatient facilities in future issues of The Record.

Blue Cross launching call program to help members improve their medication adherence

Blue Cross Blue Shield of Michigan will begin the Blue Cross Quality Rating System Adherence Call Program this month. This program will help members who do not adhere to their medication regimen for these chronic conditions: cholesterol, diabetes and hypertension.

This program only includes our commercial, individual and small group plan members with Blue Cross pharmacy coverage. Medication adherence is one of the quality measures included in the Centers for Medicare & Medicaid Services quality rating system applicable to commercial individual and small group plans.

The call program identifies commercial members who have not consistently filled their medications beyond the initial prescription. Blue Cross pharmacists and pharmacist interns will call these members and offer to assist members in understanding their medication regimen.

After the initial phone call, our pharmacist or pharmacist intern will follow up by sending personalized letters and informational fliers to designated members. They will also send personalized letters to the member’s doctor, noting the reason the patient is not taking the prescribed medication.

How the program works

1. First, a Blue Cross pharmacist identifies a member with pharmacy coverage who is not adhering to his or her medication regimen for these chronic conditions: cholesterol, diabetes and hypertension.
2. A pharmacist or pharmacist intern calls the member.
3. If a member refuses to speak to the pharmacist or pharmacist intern, the member will receive informational fliers about his or her specific condition.
4. If a member participates in the call, the pharmacist or pharmacist intern tries to discover the reason that he or she is not adhering to the regimen. This reason falls into one of the following categories:
• Side effects: The member identifies specific concerns about or side effects from taking the medicine.
• Education: The member is unsure of the importance of taking prescription medication.
• Financial: The member identifies medication as too expensive.
• Forgetfulness: The member forgets to take medicine.
• Other: The member identifies other barriers such as transportation, dexterity and impairment.
5. The pharmacist or pharmacist intern counsels the member and sends a personalized letter about the discussion to the member and the member’s prescribing physician.
6. If a member requests more information, the pharmacist or pharmacist intern will send informational fliers about the member’s cholesterol, diabetes or hypertension condition.

Our pharmacists are available to support, not replace, the ongoing quality care you provide to our members. We encourage your patients to discuss suggested clinical recommendations and their barriers in adhering to medications with you at their next face-to-face appointment. Blue Cross realizes that each patient is unique, so we value your clinical judgment regarding drug therapy and patient care. Ultimately, the decision is up to you and your patient.

We appreciate your continued commitment to our members. If you have any questions, call our pharmacists at 313-448-4193, between 8 a.m. and 4 p.m., Monday through Friday.

Blue Cross electronic qualification form gets some new features

On Jan. 1, 2015, the Blue Cross Blue Shield of Michigan qualification form became available electronically for Michigan health care providers. Many Michigan providers have submitted the form electronically for Blue Cross members with wellness plans that require the form. We are pleased to announce some new features that will make submission much easier:

• You can now easily select a patient from a drop-down list.

• You can also view patient health measure values from previously submitted qualification forms.

To access the form and revised instructions:

• Log in to the Provider Secured Services page at bcbsm.com.

• Scroll down to the BCBSM Qualification Form section.

• Click on the BCBSM Qualification Form link, which will send you to the online form.

• For instructions for completing the form, click on the BCBSM Qualification Form Instructions link located below the BCBSM Qualification Form link.

• After completing the electronic qualification form for your patient, make sure you print two copies of the form.

• 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.

We strongly encourage submitting Blue Cross qualification forms electronically to improve processing time.

Note: Continue to use the Healthy Blue Living^SM qualification form for Blue Care Network members.

Aim for the stars: Learn how to increase your payments by improving quality, coding and documentation while focusing on ICD-10

We’re coming to you. We’ve scheduled a series of professional training opportunities this summer, with classes to be held at 14 locations across the state. The classes will cover such key topics as:

• ICD-10 (professional)
• HEDIS** and Medicare star ratings
• Performance recognition program
• Improving patient satisfaction
• Coding and documentation
• Diagnostic evaluation incentive program
• Health eBlue^SM
• Member care alerts

Here’s a schedule of events:

• Full-day classes start at 9 a.m. and end at 4 p.m., with registration at 8:30 a.m.
• To accommodate driving schedules to the Upper Peninsula, classes will begin one hour later than usual. Registration for the Marquette and Sault Ste. Marie classes will be at 9:30 a.m., with the class starting at 10 a.m. (These times are for Upper Peninsula classes only.)
• A lunch break will take place from noon to 1 p.m., with lunch served at all 14 locations.
• Classes might extend later or end earlier, depending on the number of participant questions.

To register, send an email to Jeff Holzhausen, JHolzhausen@bcbsm.com. In the subject line, write “HEDIS/RMRA” and the city where you wish to attend the class. Include the class date and the names and number of attendees expected from your facility. You will receive a confirmation within 72 hours of registering. It’s important that you register so we can have an accurate headcount for lunch.

Blue Cross will provide continuing education credits through AAPC for attendance at these classes.

Here’s a look at class locations and dates:

For more information, contact your provider consultant.

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

Certificate of Medical Necessity requirements for home infusion therapy program

The home infusion therapy program requires a Certificate of Medical Necessity for each therapy type, with a dated physician signature within 90 days of the start-of-care date. Each CMN must meet the guideline requirements as stated in the HIT manual, with no exceptions.

A CMN lasts 120 days. When the therapy is ordered beyond the 120-day limit, the CMN must be renewed with all the required information and signed within 90 days of the renewal date.

The pharmacist may take a verbal order related to the drug therapy without a physician co-signature; however a CMN renewal must be signed by the ordering physician within 90 days of the renewal date. Claims can’t be billed until the physician returns the signed and dated CMN to the infusion provider.

If the patient is hospitalized or admitted to a nursing home, the current CMN is automatically discontinued. The patient will need a new CMN when he or she returns to service. When the current services are discontinued and a new service is started, a new CMN is needed. An order change of the same therapy type during a 120-day CMN limit doesn’t need a new CMN.

The major therapy types are specified by the Healthcare Common Procedure Coding System, as indicated below:

Failure to meet these requirements may result in an audit recovery. If you have any questions, contact your provider consultant.

Blue Cross reimburses home infusion therapy on per-day basis for implanted pumps

Blue Cross Blue Shield of Michigan began reimbursing home infusion therapy providers on Jan. 1, 2015, for $15 per diem for S code S9363. This code is used to indicate anti-spasmodic intravenous therapy.

ClaimsXten™ coming to outpatient facilities claims in 2016

Blue Cross Blue Shield of Michigan will begin using McKesson’s clinical coding solution, ClaimsXten, for outpatient facility claims beginning in the first quarter of 2016. This change will apply to services that require Healthcare Common Procedure Coding System reporting.

We will include detailed information in the August 2015 edition of The Record.

Here’s an overview of how ClaimsXten will process claims for outpatient facility services:

Incidental and mutually exclusive services:

• Identifies a HCPCS code performed at the same time as a more complex procedure and that’s clinically tied to the outcome of the primary procedure.
• Identifies procedures that differ in technique and approach but lead to the same outcome.

Same-day medical services:

• Identifies certain HCPCS codes billed by the same facility on the same date of service as a code with a global period.

Clinical daily recommended allowance — all allow once per date of service:

• Identifies claim lines that contain a HCPCS code that allows the service once for a single date of service and the maximum number of times allowed has been exceeded.

Clinical Daily Recommended Allowance — allow multiple times per date of service:

• Identifies claim lines that contain a HCPCS code where the maximum number of times the service may be submitted per date of service has been determined, is more than one and has been exceeded.

Multiple code rebundling:

• Identifies claims containing two or more HCPCS codes used to report a service when a single, more comprehensive procedure code exists that more accurately represents the service performed.

Multiple radiology reduction:

• Identifies certain radiology procedures performed during the same session that are eligible for a reduction when submitted by the same facility.

CMS always bundled:

• Identifies claim lines that contain a Centers for Medicare and Medicaid Services HCPCS code that’s always bundled when billed with another procedure.

Modifiers:
Keep in mind that in certain cases, modifiers may change the payment decision. When appropriate, Blue Cross will support the use of modifiers that indicate unique circumstances for individual patients. The use of modifiers should be documented in the patient’s medical record.

• Modifiers 25, 59, XE, XS, XU and site specific modifiers will identify the claim line as a separate and distinct service or anatomic site to override the incidental and mutually exclusive result.
• Modifiers 25 and 57 will identify the service as a separate service or a decision for surgery to override the same-day medical service result.
• Modifiers 26, TC, 76, 91, LC, LD, LM, RC, RI and site modifiers will identify the claim line as a separate and distinct service or anatomic site to override the Clinical Daily Recommended Allowance - allow once per date of service result.
• Modifiers 76, 91 and site modifiers will identify that a service has been repeated or anatomic site to override the Clinical Daily Recommended Allowance - allow multiple times per date of service result.
• Modifiers 59, XE, XS and XU will identify the claim line as a separate and distinct service to override multiple radiology reduction result.

If you have questions about a ClaimsXten payment decision, you may:

• Request a clinical edit review. We’ll work with our medical consultant to determine if the clinical edit should be changed. Contact Provider Inquiry or your provider consultant.
• Pursue an individual case review. Follow the same process as you would for any claim rejection.

Watch for more information about what ClaimsXten will mean for outpatient facilities in future issues of The Record

ClaimsXten™ to identify certain radiology procedures for multiple radiology editing in 2016

In the first quarter of 2016, Blue Cross Blue Shield of Michigan will begin using McKesson’s clinical coding solution, ClaimsXten to identify certain radiology procedures performed during the same session that are eligible for a reduction in payment when submitted by the same physician.

Keep in mind that Blue Cross will support the use of modifiers 59, XE, XS and XU, which indicate that unique circumstances exist for certain patients. The need for the use of a modifier should be documented in the patient’s medical record.

See other article on ClaimsXten in this issue of The Record.

Update: revision to specialist fee uplift program

In the March Record, we outlined several updates to eligibility requirements for specialist fee uplifts under the Physician Group Incentive Program, effective February 2016.

Since then, we’ve revised the timeframe of the one-year requirement. The following definition supersedes any previous communications about this topic:

To be considered for the 2016 specialist fee uplifts, practitioners must be on
both of the following PGIP practitioner “snapshot” lists: Jan. 13, 2015, and June 30, 2015.

Anesthesiologists remain exempt from this requirement for the 2016 fee uplifts and need only be on the June 30, 2015, PGIP practitioner snapshot.

For more information, contact your PGIP physician organization or your provider consultant.

Reminder: four specialty drugs to be added to prior authorization program July 1

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

The prior authorization is only a clinical review approval, not a guarantee of payment. Health care practitioners will need to verify the necessary coverage for medical benefits.

These updates will help ensure proper drug use while addressing potential safety issues.

You can find medication request forms within the list of medications that require prior authorization on web-DENIS. To access the forms:

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

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

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

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

Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Are you using the right Internet browser to access bcbsm.com?

You must use the latest version of your Internet browser to access bcbsm.com after June 19, 2015. According to our research, following are the most commonly used Internet browsers:

• Internet Explorer 7.0
• Google Chrome 33.0
• Mozilla Firefox 34.0

Where can I find version information for my browser?
Internet Explorer

• Click on the wheel/gear in the upper right corner.
• Click on About Internet Explorer.
• The version will be displayed right below the words “Internet Explorer.”

Chrome

• Click on the three bars in the upper right corner.
• Click on About Google Chrome.
• The page will show if your version of Chrome is up-to-date.

Firefox

• In the upper right corner, click on the three bars.
• Click on the “?” to open the help menu.
• Click About Firefox.
• The page will show if your version of Firefox is up-to-date.

How do I update my browser?

• If your computer system can access any website on the Internet, go to the browser’s website and download the most current version; e.g., firefox.com or chrome.com.
• If the system is controlled by your Information Technology department, then contact IT to perform the update.

What will happen if my browser is not up to date?
When accessing bcbsm.com after June 19, 2015, you’ll see a message that the site is not available and your browser needs to be updated.

Why should I update my browser?
Blue Cross is continually working to improve member data security. Because of our ongoing efforts, we are no longer able to support browser versions with known security issues.

If you have any additional questions, call 877-258-3932.

Blue Cross following CMS guidelines for ICD-10 billing information

By now, everyone knows that the federal government is requiring the health care industry to begin using ICD-10 codes in place of ICD-9 codes, beginning with dates of service Oct. 1, 2015.

For months now, Blue Cross Blue Shield of Michigan has been offering our health care providers information about the transition through seminars, conference calls and many other avenues to spread the word about this extremely important initiative.

One of the most common questions we receive about billing for ICD-10 codes is: How will our billing guidelines compare to those from the Centers for Medicare and Medicaid Services?

Blue Cross will follow guidelines from CMS when it comes to billing ICD-10 codes. Those guidelines are found here.**

Below we’ve listed other common questions from health care providers about ICD-10 codes:

Frequently asked ICD-10 questions

Q: When is implementation?
A: Oct. 1, 2015

Q: When should I begin to use ICD-10 codes?
A: ICD-10 is based on the date of service.

• Dates of service before Oct. 1, 2015, would use ICD-9 codes and qualifiers.
• Dates of service on or after Oct. 1, 2015, would use ICD-10 codes and qualifiers.

Q: What are the major changes for ICD-10?
A: Some of the major changes are:

• The ICD-10 implementation affects diagnosis and inpatient procedure codes. (It does not affect CPT and HCPCS codes used for outpatient procedures and physician services.)

• ICD-10 codes differ in length and structure from ICD-9 codes. (The maximum number of digits in ICD-10 is seven as opposed to five for ICD-9.)

• The code set contains more details about conditions, injuries and illnesses.

• It includes the concept of laterality (codes for left and right side of body), combination codes (for conditions and associated symptoms) and uses updated language and terminology.

• Approximately 150,000 ICD-10 codes replace 17,000 ICD-9 codes.

• The ICD-10 implementation introduces the use of a seventh character encounter code for obstetrics, injuries and external causes of injuries.

Q: What happens if a provider does not switch to ICD-10?
A: Claims with dates of service on or after the Oct. 1, 2015, implementation date that do not use the appropriate ICD-10 diagnosis or inpatient procedure code will be rejected in EDI front-end edits. Remember that claims for services provided before Oct. 1, 2015, must use ICD-9 diagnosis and inpatient procedure codes or they will be rejected in EDI front-end edits. A complete list of the EDI front-end edits were included in an article in the May Record.

Q: Can a submitter send ICD-10 codes prior to Oct. 1, 2015?
A: No, they cannot.

Q: Can a submitter send both ICD-9 and ICD-10 codes on the same claim?
A: No, they cannot.

Q: What about testing?
A: Blue Cross is also offering a medical scenario-based testing tool for professional health care providers. This web-based tool provides hand-on ICD-10 coding practices for different specialties. It is accessible through this link and will be available through Oct. 1, 2015. More information about the testing tool is available on bcbsm.com/icd10.

For more information, refer to previous issues of The Record or go to: roadto10.org,** cms.gov/icd10** and bcbsm.com/icd10.

**This website is cited for informational purposes only. Blue Cross Blue Shield of Michigan does not control this website or endorse its general content.

What you need to know about ancillary providers participating in Metro Detroit EPO network

As you’ve read in The Record, Blue Cross Blue Shield of Michigan launched the Blue Cross ^® Metro Detroit EPO on Jan.1, 2015. Consumers were able to purchase plans, both on and off the Health Insurance Marketplace, that use this network for coverage effective Jan. 1, 2015, or later.

Blue Cross does not require ancillary providers or other non-physician providers to sign a contract to participate in the Metro Detroit EPO network. Ancillary providers and other non-physician providers in good standing with a current TRUST PPO or TRAD contract (where the TRUST PPO is not available) are deemed participating providers in the EPO network and should render services for eligible EPO members.

These ancillary providers participate in the Metro Detroit EPO:

• Ambulance
• Ambulatory infusion center
• Ambulatory surgical facilities
• Audiologists
• Board certified behavioral analysts (autism services)
• Certified nurse anesthetists, nurse practitioners, nurse midwives
• Clinical laboratories
• Clinical licensed social workers
• Durable medical equipment; prosthetics & orthotics
• End-stage renal centers
• Home infusion therapy
• Home health care (Blue Care Network, Medicare Supplemental and MAPPO contracts)
• Hospice
• Long-term acute care facilities
• Optometrists
• Outpatient psychiatric Care
• Physician assistants
• Rehabilitation therapy - outpatient
• Skilled nursing facilities
• Substance abuse facilities
• Urgent care centers

Key points to keep in mind:

• Check eligibility and benefits — As always, check eligibility and benefits before providing services by using web-DENIS or the Provider Automated Response System (PARS, formerly CAREN). The Metro Detroit EPO plan name will be listed on web-DENIS, in PARS and on the member’s ID card.
• Respond to patient inquiries — Make sure that your office staff knows that you are in the Metro Detroit EPO network so they can respond accurately to inquiries from patients.

To find more information about the new Metro Detroit plans:

• View a presentation at brainshark.com/bcbsm/metro-detroit-epo-hmo.

If you have any questions, contact your provider consultant or call Blue Cross Provider Inquiry at 1-800-344-8525.

Reminder: Keep Blue Cross updated about changes to your practice

We want to remind professional health care providers, other health care practitioners and non-hospital facilities that you must notify Blue Cross Blue Shield of Michigan within 30 days of changes made to ownership, name, tax identification number, practice location, practice phone number or medical group affiliations, as well as whether or not your practice is accepting new patients.

For practitioners:
To update provider information (name, individual practice address, phone number or credentialing information), physicians and other professional providers must update information online through the CAQH ProView^®**. For help, practitioners and professional providers can call the CAQH Support Desk at 1-888-599-1771 or email providerhelp@ProViewCAQH.org.

To update your practice location information, when under a professional medical group, you must use the change notification process for organizational providers. Changing your practice address in CAQH does not change your practice location information for any medical group affiliations.

To update tax information (tax name, tax ID, mailing or remittance address or accepting new patients), submit the information using the appropriate change form available at bcbsm.com/provider by clicking on Enrollment and Changes and following the prompts. Fax the form to Provider Enrollment and Data Management at 1-866-900-0250.

For organizational provider and non-hospital facilities:
Professional organizational providers and non-hospital facilities must complete the appropriate change form available at bcbsm.com/provider by clicking on Enrollment and Changes and following the prompts. Fax the form to Provider Enrollment and Data Management at 1-866-900-0250.

For hospitals:
Hospitals can go to bcbsm.com/provider when updating existing provider information (name, phone number, tax name, tax ID, remittance address or any other information). If you’re making an address change and you have questions regarding how it may affect your Blues affiliation, please call Provider Enrollment and Data Management, at 1-800-822-2761, or call your provider consultant.

It’s a good idea to occasionally review your address information using the Find a Doctor tool on bcbsm.com. Contact your provider consultant if you find any incorrect data. Professional groups should use the enrollment self-service application to change their information.

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

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.

When a BlueCard claim rejects, is that a Blue Cross Blue Shield of Michigan decision or is the rejection I see on the claim coming from the out-of-state plan?

A BlueCard claim can be rejected either by Blue Cross Blue Shield of Michigan or by the out-of-state plan, depending on the situation. Blue Cross may reject the claim before it is sent electronically to the plan for processing if the claim isn’t billed according to our reporting requirements, or the claim has inaccurate or missing information. All BlueCard claims should be reported as you would report a claim for a Michigan member. The claim is then electronically sent to the out-of-state plan. If the BlueCard claim is approved by the out-of-state plan, the claim will be reimbursed according to your contracted Blue Cross Blue Shield of Michigan rate less any member contracted cost sharing.

Examples of why we may reject your Bluecard claim before we electronically transmit it to the member’s home plan include:

• Claims with any missing or inappropriate coding based on Blue Cross Blue Shield of Michigan reporting requirements
• Reporting a service that’s not billable based on your provider contract
• Reporting a three-letter alpha prefix with the member’s ID that’s not active and therefore the BlueCard plan could not be identified

Out-of-state plans may reject your BlueCard claim if:

• The member’s eligibility cannot be confirmed or isn’t active for the date of service reported
• The service reported isn’t a contracted benefit per the member’s contract
• The information on the claim doesn’t support medical necessity or doesn’t meet the out-of-state plan’s medical or benefit policy
• A required authorization or pre-service review wasn’t obtained according to the plan’s policy
• The member’s home plan requires medical records to determine the plan’s benefit or medical policy, or the member’s contracted benefits for the services reported
• Benefits may have been exhausted for the service you reported per the member’s contract

If you need additional information on the rejected BlueCard claim, contact our Provider Inquiry department for assistance. For additional information on the BlueCard program, refer to the BlueCard chapter in the online provider manuals.

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.

Coding corner: importance of properly documenting major depressive disorder

Also known as clinical, unipolar or recurrent depression, major depressive disorder is defined as a mood disorder having a clinical course involving one or more episodes of serious psychological depression lasting two or more weeks per episode with no intervening episodes of mania.

The additional characteristics used to diagnose this condition should always be documented in the medical record in order to substantiate the diagnosis for coding, billing and reimbursement purposes. These characteristics should always detail the most recent episode that the patient has experienced. At least five of the nine symptoms listed need to be present almost daily for the patient to be diagnosed with major depressive disorder, including at least one of the first two listed at right.

Major depressive disorder is assigned to ICD-9 subcategories 296.2 and 296.3, depending on whether the condition is a single episode (296.2) or a recurrent episode (296.3). The fifth digit subclassifications are used to specify the severity of the condition and to identify the presence of related psychotic features, if applicable. A fifth-digit is always necessary when coding major depressive disorder. For more details, see information about fifth-digit classifications at right.

The terms for the fifth-digit subclassifications of major depressive disorder are used in conjunction with specific diagnostic criteria listed below. Refrain from coding to a specific severity level if that level isn’t stated in the medical record, even if documentation of the clinical requirements for that level of severity are noted in the exam.

• Unspecified: When the information in the medical record is insufficient to assign a more specific code.
• Mild: The patient experiences at least five of the symptoms needed for a diagnosis of major depressive disorder, which also pose a mild overall functional impairment.
• Moderate: The patient experiences seven to eight of the symptoms, or the symptoms pose a moderate overall functional impairment.
• Severe without psychotic features: The patient experiences most or all of the symptoms, or the symptoms they do experience pose a severe functional impairment but present without any psychotic features.
• Severe with psychotic features: The patient experiences most or all of the symptoms, the symptoms pose a severe functional impairment or the symptoms present with delusions or hallucinations.
• In remission: The patient previously had two or more episodes but has been free from symptoms for at least two months.
• In partial remission: Either some symptoms can still be present, but the full criteria are no longer met, or there are no longer any significant symptoms of an episode, but the patient hasn’t been in remission for at least two months.

ICD-10 transition
There are few changes for coding MDD with the transition to ICD-10. The 14 codes that were used for ICD-9 will transition to 15 codes for ICD-10, including a code for MDD, recurrent episode in unspecified remission. This will require physicians to document whether the remission status is partial or complete in order to avoid use of an unspecified code choice.

The most significant change for ICD-10 is that documentation stating “depression,” with nothing further documented, will now be coded as major depression, ICD-10 code F32.0. With ICD-9, it was coded as depression NOS code 311.

Here are the ICD-10 code choices for major depressive disorder:

• F32.0 - MDD, single episode, mild
• F32.1 - MDD, single episode, moderate
• F32.2 - MDD, single episode, severe without psychotic features
• F32.3 - MDD, single episode, severe with psychotic features
• F32.4 - MDD, single episode, in partial remission
• F32.5 - MDD, single episode, in full remission
• F32.9 - MDD, single episode, unspecified
• F33.0 - MDD, recurrent episode, mild
• F33.1 - MDD, recurrent episode, moderate
• F33.2 - MDD, recurrent episode, severe without psychotic features
• F33.3 - MDD, recurrent episode, severe with psychotic features
• F33.40 - MDD, recurrent episode, in remission, unspecified
• F33.41 - MDD, recurrent episode, in partial remission
• F33.42 - MDD, recurrent episode, in full remission
• F33.9 - MDD, recurrent episode, unspecified

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.

Coding corner update: Keep these coding tips in mind for diabetes

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. In the next several issues of The Record, you’ll find a series of revised “Coding corner” articles that include updated codes to align with the transition to ICD-10-CM.

Diabetes is one of the most common and costly conditions in the U.S. This complex disease causes long-term complications affecting the renal, nervous and peripheral vascular systems, as well as the feet and eyes. According to 2012 Centers for Disease Control and Prevention statistics, diabetes continues to be the leading cause of kidney failure, nontraumatic lower-extremity amputations and blindness among adults age 20 to 74.

It’s no surprise that documentation and coding for this complicated condition is a challenge to both providers and coders. Here are some tips to help improve medical record documentation for diabetes.

Common documentation and coding challenges for diabetes mellitus:

• Documentation in the medical record does not support a link between diabetes and its associated complications.

• Documentation supporting a specific diabetic complication is present, but the proper codes are not reported.

• Electronic medical record search engines may provide long lists of codes for diabetes, making selection of the most specific diagnosis code a challenge.

• Electronic billing systems limit number of diagnoses for patients with multiple diabetes complications and chronic conditions.

Coding of diabetes in ICD-10-CM has changed significantly. There are several pieces of information which must be documented to aid in selection of the correct code:

• E08 — Due to underlying condition
• E09 — Drug or chemical induced
• E10 — Type 1
• E11 — Type 2
• E13 — Other specified diabetes mellitus

The complications are then listed consistently:

DM = diabetes mellitus

Fifth and sixth characters are used for some categories to provide additional specificity regarding the complication. Example: E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema.

Additional coding tips

• Document if the diabetes is Type 1 or Type 2 every time you treat the patient. Documentation of insulin usage alone does not support a diagnosis of Type 1 diabetes. If the type of diabetes is not documented, then use the unspecified code, Type 2.

• ICD-10 does not include the terminology of controlled or uncontrolled. If appropriate, use the codes for hypoglycemia or hyperglycemia with fourth and fifth characters of “64” and “65.”

• Assign code Z79.4, long-term (current) use of insulin for patients that use insulin to control their diabetes. This code shouldn’t be assigned if insulin is only given temporarily to bring a patient’s blood sugar under control during an encounter.

• Assign a code from category E08, DM due to underlying condition, when diabetes is caused by another condition or event such as cystic fibrosis, malignant neoplasm of the pancreas or pancreatectomy. Code first the underlying condition.

• Report a code from category E09, drug or chemical-induced DM, when the diabetes is due to a drug or toxin poisoning. Also include a code for adverse effects, if applicable to identify the drug.
• Assign a code from category O24.4 for gestational diabetes and report a code from categories O24.0 to O24.3 for obstetric patients with pre-existing diabetes. Additional codes from the E10 to E11 categories should be assigned to indicate the type of diabetes.

• Many patients will have complications in more than one subcategory. Assign as many subcategory codes as needed to communicate the complexity of a patient’s condition.

• Report a code from category T38.3X for an underdosing or overdose of insulin for any reason. Next report appropriate codes from categories E08 to E13.

• Use concise words and abbreviations in search engines for electronic medical records for help in coding diabetes to the highest specificity. For example, searching for “dm with renal” or “retinopathy due to dm” instead of “diabetes mellitus” could yield a shorter and more specific list of code choices.

ICD-10-CM coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

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

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.

Coding corner update: Keep these coding tips in mind for complications related to diabetes

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. In the next several issues of The Record, you’ll find a series of revised “Coding corner” articles that include updated codes to align with the transition to ICD-10-CM.

Detailed and concise medical record documentation is important in order to select the correct codes for renal, ophthalmic, neurological and peripheral circulatory complications of diabetes.

Selection of diabetic complication codes
A common coding error for diabetes is the selection of the wrong complication code. In some cases, the code reported when the condition is a complication of diabetes isn’t the same code that’s reported when the condition exists independently.

This is an easy distinction for a coder to make by referencing the index or tabular sections of ICD-10-CM code books. But providers who select their own codes through search engines in an electronic medical record may often select the wrong code for the complication.

For example, idiopathic progressive neuropathy is coded as G60.3 if it’s the patient’s primary condition. However, if the patient has neuropathy due to diabetes, it’s coded to the diabetes codes in the E08 to E13 range with a fourth character of “4” (neurological complications in diabetes).

Tips for diabetes with renal complications — E08 to E13 with a fourth character of “2”

• With ICD-10-CM, the only diabetic nephrology complication that requires an additional code is CKD (N18.1 to N18.6). The specific stage of the disease must be stated in the documentation. CKD stages cannot be coded based on the glomerular filtration rate.

• Patients who have both diabetes and hypertension may develop CKD as a result. In this case, three codes are required. One code for diabetes with renal complication (E08.22, E09.22, E10.22, E11.22, E13.22); a second code from category I12 (or I13) with a fourth character of “0” or “9”; and a third code from category N18 to indicate the specific stage of the chronic kidney disease.

• If documentation indicates both a stage of CKD and end-stage renal disease, report code N18.6 only.
  

Tips for diabetes with ophthalmic complications — E08 to E13 with a fourth character of “3”

DM = diabetes mellitus

• Don’t confuse a diabetic cataract with a senile cataract. Diabetic cataracts or “snowflake cataracts” are rare and occur only in diabetes. Although a senile cataract might occur earlier and more frequently in diabetes, it’s not classified as a complication of diabetes.

Tips for diabetes with neurological complications — E08 to E13 with a fourth character of “4”

• Documentation specifying “diabetic peripheral neuropathy” or “loss of protective sensation” due to diabetes should be assigned to polyneuropathy (codes E08 to E13 with “42” as the last two characters). This is the most common form of diabetic neuropathy, affecting the feet, legs and sometimes the hands and arms.

• Autonomic neuropathy affects the autonomic nervous system, which controls the heart, bladder, lungs, stomach, intestines, sex organs and eyes. Many conditions are attributed to autonomic neuropathy and should be reported with codes from E08 to E13 with “43” as the last two characters. No additional code is required to identify the specific complication.

• Report E08 to E13 with “44” as the last two characters for diabetic amyotrophy, also known as radiculoplexus neuropathy, femoral neuropathy or proximal neuropathy. This condition affects nerves in the thighs, hips, buttocks or legs.

• Report the appropriate code from E08 to E13 with “41” as the last two characters for diabetic mononeuropathy, also known as focal neuropathy. This condition involves damage to a specific nerve in the face, torso or leg. It can also occur when a nerve is compressed, like in the case of carpal tunnel syndrome.

Tips for diabetes with peripheral circulatory disorders — E08 to E13 with a fourth character of “5”

Tips for diabetes with other specified complications — E08 to E13 with a fourth character of “6”

• Diabetic hypoglycemia or hypoglycemic shock is reported with E08.6 to E13.6 with last two characters of “41” or “49” to identify with or without coma.

• Code E08.6 to E13.6 with last two characters of “21” or “22” for diabetic skin ulcers, depending on location. Report an additional code to identify the specific location of the ulcer from the L97 and L98 range of codes.

• Code E08.6 to E13.6 with last two characters of “10” for diabetic neuropathic arthropathy (Charcot’s joint), which occurs when a joint deteriorates because of nerve damage, usually in the ankle or foot.

Other tips for diabetes and ulcers

• If the ulcer is caused by a superimposed infection, it shouldn’t be coded as a complication of diabetes. Not all ulcers in diabetic patients are related to the condition.

• Pressure ulcers, ICD-10 category L89, also known as decubitus ulcers, shouldn’t be coded as a complication of diabetes.

• For ulcers caused by diabetic neuropathy, report the appropriate diabetic complication code, followed by a code from categories L97 and L98 for the location of the ulcer. If gangrene is present, also code diabetic peripheral angiopathy with gangrene, E08 to E13 with last two characters of “52.”

ICD-10 coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

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

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.

Coding corner update: Improve medical record documentation for fractures and osteoporosis

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. In the next several issues of The Record, you’ll find a series of revised “Coding corner” articles that include updated codes to align with the transition to ICD-10-CM.

Coding fractures can be a challenge considering the different types of fractures and certain bone diseases that can impact a fracture. These conditions can vary from serious, requiring immediate treatment, to chronic conditions that may call for treatment other than just a cast or strapping procedure.

In this article, you’ll find coding tips for traumatic and pathologic fractures (including aftercare for both) and osteoporosis, the most common bone disease. There were many new features added to the coding of fractures in ICD-10-CM. Fracture codes now include anatomical site, laterality and the addition of a required seventh character that describes the encounter or other information regarding the fracture. This article will explain these new features.

Documentation and coding tips for traumatic fractures
Codes for traumatic fracture are located in Chapter 19. The codes are grouped by body part or anatomical location rather than type of injury, so that fracture codes are located throughout the chapter. The first three characters of the ICD-10-CM fracture codes identify the bones involved, while the next three characters provide more specific information regarding location and type of fracture. If a code isn’t a full six characters in length, a place-holder “X” must be used to fill in the empty characters when a seventh character extension is required.

In ICD-10-CM a seventh character is required to identify additional information such as whether this is the initial or subsequent encounter, open or closed fracture, type of healing or other information.

Because the seventh character values for fractures can be significantly different it’s important to review the Tabular List at each category level to determine the appropriate value. Review the information on coding fractures in the ICD-10-CM official guidelines in Section 1.C.19.c. It’s important to note that a fracture diagnosis is invalid if it hasn’t been coded to the full number of seven characters required for that code.

 Common fracture terms

• Closed fracture: Commonly used terms may include simple, comminuted, depressed, elevated, fissured, greenstick, impacted, linear, slipped epiphysis or spiral.
• Open fracture: Terms may include compound, infected, puncture or “with foreign body.”

To code multiple fractures, make sure the specific sites are coded individually and list the most serious fracture first, as determined by the attending physician. If the note isn’t clear, please don’t assume and assign an incorrect code, instead ask the physician.

Pathologic fractures
Pathologic fractures are assigned codes from ICD-10-CM categories and subcategories M80 and M84.4 through M84.6 according to the underlying cause. These codes are used for reporting both the active treatment of the fracture and for routine care for the condition during the healing or recovery phase. In ICD-10-CM, there are code categories for pathological fractures in neoplastic disease, other diseases, diseases not elsewhere classified as well as in osteoporosis.

Unlike fractures of normal bone, pathologic fractures occur during normal activity or from minor trauma due to weakening of the bone by disease, such as osteoporosis, neoplasms and osteomalacia.

Review the information on coding pathologic fractures in the ICD-10-CM Official Guidelines in Section 1.C.13.c. It’s important to note that just because the patient has a bone weakening disease doesn’t mean a fracture is pathologic. Only the physician can determine whether the fracture is traumatic or pathologic.

Terms synonymous with pathological fractures may include spontaneous fracture, non-traumatic compression, non-traumatic fracture or insufficiency fracture.

Coding for fracture aftercare
In ICD-10-CM, for aftercare of a fracture, assign the acute fracture code with the seventh character identifying “subsequent encounter” with additional information such as routine or specified healing issues including delayed healing, malunion or non-union.

“Subsequent encounter” is used after the patient has received active treatment of the condition, during the healing or recovery phase. For proper selection of the seventh character for subsequent encounter it’s important to review the Tabular List at each category level to determine the appropriate value.

Examples of subsequent fracture care include:

• Change or removal of cast
• Removal of external or internal fixation device
• Medication adjustment
• An X-ray to check the healing status of the fracture

Proper coding for osteoporosis
Osteoporosis is the most common bone disease. It’s an abnormal loss of bone tissue that results in fragile or porous bones. It typically has no symptoms until a fracture occurs, usually in the wrist, hip or vertebra. The code selection for osteoporosis is from categories M80 and M81, depending on whether there’s a current pathological fracture present. Review the ICD-10-CM manual for the appropriate code selection.

Coding tip when term "rule out" used
A challenge in the outpatient setting occurs when the term “rule out” is used. For example, a patient has swelling and pain in the wrist and is sent to a radiologist to rule outa fracture. It would be inappropriate to code a fracture until the condition is confirmed by the radiology report and the attending physician makes the determination. The physician also can determine whether the fracture is traumatic or pathologic. Coding signs and symptoms is acceptable when a definitive diagnosis hasn’t been confirmed by the health care provider in the outpatient setting.

Looking ahead to ICD-10-CM
The transition to ICD-10-CM will be easier if there’s a greater understanding of the guidelines, including changes to fracture coding.

Here’s an example of proper coding for a closed and open traumatic fracture of the left wrist:

ICD-10-CM coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

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

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.

Coding corner update: Documentation is key when coding morbid obesity

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. In the next several issues of The Record, you’ll find a series of revised “Coding corner” articles that include updated codes to align with the transition to ICD-10-CM.

With an increasing number of Americans becoming overweight or suffering from obesity, it’s important for physicians to recognize the degree of obesity and how its complications negatively impact a patient’s health.

ICD-10-CM codes for overweight, obesity, morbid obesity and severe obesity, whether they’re due to excess calories, drugs or with alveolar hypoventilation, are distinct diagnoses that should be properly documented.

The Centers for Medicare & Medicaid Services includes morbid (severe) obesity (ICD-10-CM code E66.01) and associated body mass index values (40 and above - ICD-10-CM code range Z68.41 to Z68.45) in its 2015 Hierarchical Condition Categories Model. This categorization impacts the way providers should document the condition. In ICD-10-CM, a provider must document the cause of obesity, whether it occurs from excess calories or it’s drug-induced. Morbid (severe) obesity with alveolar hypoventilation also has its own code, E66.2.

From a coding perspective, documentation of morbid (severe) obesity due to excess calories in the medical record makes it easier to assign code E66.01, with an associated Z code. Problems can appear when “obesity” is documented in the medical record, but evidence shows that the patient is morbidly obese. For example, the patient has a body mass index of 40 with co-morbid conditions.

Can a BMI value of 40, with co-morbid conditions, be used to validate the HCC model for morbid (severe) obesity when there is a different diagnosis? “Yes,” if you use the following guidelines for making a morbid obesity diagnosis:

• Patients, with a BMI greater than 35, who are seen with co-morbid conditions such as osteoarthritis, sleep apnea, diabetes, coronary artery disease, hypertension, hyperlipidemia and gastroesophageal reflux disease
• Patients with a BMI equal to or above 40 (for adults, Z68.41 to Z68.45)

According to Dr. Laurrie Knight, associate medical director for BCBSM, “You should capture all of the medical complications associated with an obesity diagnosis. For example, sleep apnea, uncontrolled diabetes, hypertension and hyperlipidemia, among others. This will prompt you to define and document the specific clinical condition, for example, morbid or severe obesity due to excess calories.”

“The BMI value is a key element to consider when assessing morbid obesity,” Knight added. “Clinical complications should also be evaluated and treated. Sometimes many interventions are needed to evaluate and identify a clinical condition like morbid obesity. Seeing the impact of weight on other medical conditions is often a clear indicator.”

A provider may recommend several interventions, including seeing a dietician, incorporating an exercise regiment and education about managing other co-morbidities, which can impact the patient’s overall health.

“Morbid obesity may not be documented early in the year as you may opt to evaluate the patient over time,” said Knight. “However, once you’ve determined the patient is morbidly obese, and you code it that way, the diagnosis must continue to be coded as morbid obesity on future visits.”

Since documentation is key to coding morbid obesity, a coder must review the medical record thoroughly when obesity, with a BMI of 40 or above, is documented with co-morbid conditions affecting the patient’s overall health. In this situation, a code for the BMI (the same HCC as morbid obesity) should be used to support morbid obesity. A provider, such as a dietician, can report the BMI, but only the physician can state the diagnosis of morbid obesity, including the cause.

ICD-10 coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

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

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.

Coding corner update: Use these coding tips to improve medical record documentation for pregnancy

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. In the next several issues of The Record, you’ll find a series of revised “Coding corner” articles that include updated codes to align with the transition to ICD-10-CM.

Documentation and coding for pregnancy complications is a challenge for many coders and providers. With ICD-10, the reporting of pregnancy, childbirth and the puerperium have undergone significant changes. Understanding some of the changes and the official ICD-10-CM guidelines can simplify this complicated topic.

Coding tips
A complication in pregnancy may range from the mother smoking during the pregnancy to the worst-case scenario, death.

Routine outpatient prenatal visits with no complications should be coded with a Z to indicate if the patient is in her first pregnancy or if she’s been pregnant more than once:

These codes are not to be used in conjunction with chapter 15 codes for complications of pregnancy, childbirth and the puerperium.

If the encounter is for a condition unrelated to the pregnancy, assign the condition code first, along with code Z33.1, pregnant state, incidental. It’s the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.

Report a code(s) from category O09 for prenatal outpatient visits for supervision of patients with high-risk pregnancies as the first listed diagnosis. Secondary chapter 15 codes may be used in conjunction with these codes if appropriate.

ICD-10-CM guidelines state that obstetric codes O00-O9A have sequencing priority over codes from other chapters.

Ectopic and molar pregnancies (O00-O02.9)
Report a code from category O01for non-cancerous types of Hydatidiform mole. For a molar pregnancy use code O02.0. Molar pregnancies occur when tissue that normally becomes a fetus develops into an abnormal mass of cysts. The embryo is unformed or malformed and cannot survive.

Ectopic pregnancy means “out of place” or occurring outside the womb (uterus). These pregnancies are not viable except in rare instance and are also very dangerous to the mother due to the risk of internal bleeding. Report a code from O00 category for an ectopic pregnancy. The fourth character indicates the extrauterine location of the ectopic pregnancy. Report complications following an ectopic or molar pregnancy with codes from category O08. If maternal care is provided for a viable fetus in abdominal pregnancy, report a code from category O36.7.

Other pregnancy with an abortive outcome (O03-O08)
This category includes spontaneous abortion, complications following (induced) termination of pregnancy, failed attempted termination of pregnancy, and complications following ectopic and molar pregnancy. ICD-10-CM contains separate codes for each of the types of complications which could occur for spontaneous, induced or attempted termination of pregnancy as well as complications following ectopic or molar pregnancy. An important change to note is that ICD-10-CM no longer uses the terms legally induced or illegally induced abortion.

• Report O03.9 for complete or unspecified spontaneous abortion, including miscarriage without complications. Spontaneous abortions occur naturally at less than 20 weeks gestation. It is important to note that the time frame for abortion versus fetal death changed from 22 weeks in ICD-9-CM to 20 weeks in ICD-10-CM.

Obstetric code trimesters
Coding of pregnancy in ICD-10 changed from the episode of care (indicating whether a condition was antepartum or postpartum or whether a delivery occurred) to identifying which trimester the complication occurred. Trimesters are defined as follows:

• First Trimester (less than 14 weeks 0 days)
• Second Trimester (14 weeks 0 days to less than 28 weeks 0 days)
• Third Trimester (28 weeks 0 days to delivery)
• Unspecified Trimester

Assignment of the final character for trimester should be based on the provider’s documentation of the trimester or number of weeks for the current admission/encounter.

• An additional code from Z3A to be used to identify the specific weeks of gestation

When coding complications specific to multiple gestation, report the 7th characters assigned to specifically identify the fetus for which the code applies. A place holder of X must be reported as the 6th character to make it a valid code. Please refer to the coding rules for these codes, example code category O64.

Current conditions complicating pregnancy
For patients with a current condition that affects management of the pregnancy, childbirth or puerperium, assign a code from Chapter 15 first. A secondary code is required from other chapters to further specify the current conditions.

For example, a pregnant woman at 23 weeks gestation who has a diagnosis of hypothyroidism would be coded with:

• O99.282 Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester
• E03.9 Hypothyroidism, unspecified
• Z3A.23 Weeks of gestation of pregnancy, 23 weeks

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

For example, a pregnant woman at 12 weeks gestation diagnosed with uncomplicated Type 2 diabetes before becoming pregnant should be assigned code O24.111 (Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester), in addition to a second code from category E11.9 (Type 2 diabetes mellitus without complications). Also code the weeks of gestation, which in this case is Z3A.12 (12 weeks of gestation of pregnancy).

A woman, not diabetic prior to pregnancy, may develop gestational diabetes during the second and third trimesters. Gestational diabetes may cause complications similar to those of a woman with pre-existing diabetes mellitus. Gestational diabetes is coded using category O24.4, gestational diabetes mellitus.

Report Z79.4, long-term, current use of insulin if the diabetes is being treated with insulin. It’s important to remember pre-existing and gestational diabetes should not be reported on the same record.

Hypertension in pregnancy, childbirth and the puerperium
Hypertension is the most common complication during pregnancy. Hypertension complicating pregnancy, childbirth and the puerperium should be assigned a code from the categories listed below:

Pre-eclampsia
Pre-eclampsia is a condition that starts after the 20th week of pregnancy. Pre-eclampsia is related to increased blood pressure and protein in the mother’s urine. The condition affects the placenta and it can threaten the lives of both the mother and baby. The only way to resolve pre-eclampsia is to deliver the baby.

Pre-eclampsia is classified to the following categories

• O14.0 — Mild to moderate pre-eclampsia (is when a pregnant woman develops high blood pressure and protein in the urine late in the second or third trimester).
• O14.1 — Severe pre-eclampsia (requires the basic features of mild pre-eclampsia as well as some indication of additional problem with either the mother or baby).
• O11.1 to O11.9 — Pre-existing hypertension with pre-eclampsia (Pre-eclampsia or eclampsia superimposed on pre-existing hypertension presents in a patient with chronic hypertensive vascular or renal disease. When hypertension precedes the pregnancy as established by previous blood pressure recordings. A rise in systolic pressure of 30mmHg or a rise in diastolic pressure of 15mmHg and the development of proteinuria and edema are required during pregnancy to establish this diagnosis.)

Eclampsia is coded to category O15 - Eclampsia, and if the hypertension is unspecified then category O16 - unspecified maternal hypertension is used.

Placenta previa
Placenta previa is when the placenta is lying unusually low in the uterus. This condition usually occurs around 27 to 32 weeks of gestation. In a case of partial placenta previa, it may resolve on its own; however, if the placenta covers the cervix completely, it’s called complete or total previa. If present at time of delivery, a cesarean section will need to be performed. Placenta previa is coded using the O44.0 category of codes (without hemorrhage) and O44.1 category of codes (with hemorrhage).

Oligohydramnios
Report codes from category O41 for oligohydramnios. This is a complication when there’s not enough amniotic fluid. If oligohydramnios happens in the first two trimesters of pregnancy, it’s more likely to cause serious problems than if it occurs in the last trimester. You must report the 6th character of X and the 7th character appropriate for the specific fetus.

It’s important to review the official ICD-10-CM guidelines for Chapter 15, as well as any instructional notes under the codes in the tabular list of the ICD-10-CM manual, to ensure correct code selection and sequencing.

ICD-10-CM coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

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

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.

HCPCS code added to Medical Drug Prior Authorization Program

The following Healthcare Common Procedure Coding System code was added to the list of specialty drugs that require prior authorization, effective April 1, 2015.

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

Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Chrysler Group, LLC renamed FCA US, LLC

Effective Jan. 1, 2015 Chrysler Group, LLC was renamed FCA US, LLC. Make sure you update your records and materials to reflect this change.

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.

Reminder: four specialty drugs to be added to prior authorization program July 1

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

The prior authorization is only a clinical review approval, not a guarantee of payment. Health care practitioners will need to verify the necessary coverage for medical benefits.

These updates will help ensure proper drug use while addressing potential safety issues.

You can find medication request forms within the list of medications that require prior authorization on web-DENIS. To access the forms:

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

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

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

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

Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Blue Cross setting new quantity limits for Vyvanse^®, Adderall^® and Adderall XR^®; Vyvanse placed in off-label program

On June 15, 2015, Blue Cross Blue Shield of Michigan will implement new quantity limits for the following drugs:

The quantity limits only affect our commercial (non-Medicare) members who have Blue Cross pharmacy benefits that include quantity limits. They don’t apply to MESSA members.

In addition, we will add Vyvanse to the off-label program, also effective June 15, 2015.

If necessary, you can request an override for the quantity limits or off-label program for your patients. The request will need to include documentation that the amount prescribed is medically necessary.

To obtain a form to request a quantity limit or off-label program override, log in as a provider at bcbsm.com or call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.

Our goal is to provide our members with safe, high-quality prescription drug therapies. Adderall, Adderall XR and Vyvanse are controlled substances that are sometimes misused and abused. But we realize that some patients can benefit greatly from these drugs. The quantity limits align with dosing guidelines approved by the U.S. Food and Drug Administration to prevent unsafe use in our members.

We sent letters in May to notify members who may be affected by these quantity limit changes. The letters encourage members to discuss treatment options with their physicians.

If you have any questions about this program, contact the Pharmacy Services Clinical Help Desk.

Certificate of Medical Necessity requirements for home infusion therapy program

The home infusion therapy program requires a Certificate of Medical Necessity for each therapy type, with a dated physician signature within 90 days of the start-of-care date. Each CMN must meet the guideline requirements as stated in the HIT manual, with no exceptions.

A CMN lasts 120 days. When the therapy is ordered beyond the 120-day limit, the CMN must be renewed with all the required information and signed within 90 days of the renewal date.

The pharmacist may take a verbal order related to the drug therapy without a physician co-signature; however a CMN renewal must be signed by the ordering physician within 90 days of the renewal date. Claims can’t be billed until the physician returns the signed and dated CMN to the infusion provider.

If the patient is hospitalized or admitted to a nursing home, the current CMN is automatically discontinued. The patient will need a new CMN when he or she returns to service. When the current services are discontinued and a new service is started, a new CMN is needed. An order change of the same therapy type during a 120-day CMN limit doesn’t need a new CMN.

The major therapy types are specified by the Healthcare Common Procedure Coding System, as indicated below:

Failure to meet these requirements may result in an audit recovery. If you have any questions, contact your provider consultant.

Blue Cross reimburses home infusion therapy on per-day basis for implanted pumps

Blue Cross Blue Shield of Michigan began reimbursing home infusion therapy providers on Jan. 1, 2015, for $15 per diem for S code S9363. This code is used to indicate anti-spasmodic intravenous therapy.

Reminder: four specialty drugs to be added to prior authorization program July 1

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

The prior authorization is only a clinical review approval, not a guarantee of payment. Health care practitioners will need to verify the necessary coverage for medical benefits.

These updates will help ensure proper drug use while addressing potential safety issues.

You can find medication request forms within the list of medications that require prior authorization on web-DENIS. To access the forms:

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

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

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

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

Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Here are most common causes of DME/P&O audit findings in 2014

Blue Cross Blue Shield of Michigan is encouraging our providers to carefully review all claims related to durable medical equipment and prosthetics and orthotics before submitting them to us for processing. A careful review of claims prior to submission should result in a decrease in audit findings.

Here is a list of the most common causes of DME/P&O audit findings in 2014.

Blue Cross implements Member Upgrade Responsibility Policy for DME and P&O

Blue Cross Blue Shield of Michigan implemented a new policy known as the Member Upgrade Responsibility Policy, effective May 1, 2015.

The policy is a written notice that allows durable medical equipment and prosthetics and orthotics providers to bill the member for the difference of a medically necessary item and an upgraded item. Providers will receive reimbursement from Blue Cross for the medically necessary item and bill the member for the difference of prevailing fees for the upgrade item received.

An upgrade is an item with features that goes beyond what is medically necessary. This item can either be more expensive, contain more components or features, or is greater in quantity than what is medically necessary. Blue Cross members will be responsible for paying the difference of the prevailing fees or the retail cost for the medically necessary item and the upgrade item. Providers will present the Member Upgrade Responsibility form to the member before providing the item or service.

The Member Upgrade Responsibility form can be used for all Blue Cross Blue Shield of Michigan members, except for MESSA, Medicare primary and Medicare Advantage members. This policy does not apply to Not Otherwise Classified or to Individual Consideration HCPCS codes. Providers cannot substitute one item for a totally different item (for example, you cannot substitute a wheelchair when the member was prescribed a walker or you cannot substitute a hospital bed when a wheelchair was prescribed).

The provider must bill both items on the same claim form in sequential order with the GA modifier on the first line for the upgrade item and the GK modifier on the second line for the medically necessary item, along with any other applicable modifiers to identify rental or purchase. Rental DME items that have been upgraded should include the upgrade modifiers on the monthly claims (10 months for capped rental). The Member Upgrade Responsibility form should reflect the difference the member is responsible for paying. Only the two claim lines are required on the claim form when billing for an upgrade item; no other procedure codes should be billed on the same claim form.

These modifiers when billed collectively will acknowledge the following:

• The member was informed and agreed to accept total responsibility of the difference between the medically necessary item and the upgraded item
• A Member Upgrade Responsibility form was signed prior to services rendered and is on file
• This policy does not apply to Medicare primary and Medicare Advantage members

Line 1: Modifier GA for upgraded item
Bill the appropriate HCPCS code for the upgraded item that the supplier actually provided to the member with the charge amount and the Blue Cross fee for the upgrade

Line 2: Modifier GK for medically necessary prescribed item
Bill the appropriate HCPCS code for the reasonable and necessary item with the charge amount and the Blue Cross fee for the medically necessary item.

For the Member Upgrade Responsibility form to be acceptable, the provider must:

• Use the designated Blue Cross Member Upgrade Responsibility form (starting with dates of service on or after May 1, 2015).
• Complete the Blue Cross Member Upgrade Responsibility form in its entirety
• Provide a detailed description of the upgrade item received
• Indicate the cost difference between the medically necessary item and the member upgrade item

Modifier GA, when billed alone, has no impact on claims processing, however, if billed on the same claim with a modifier GK, it represents a non-medically necessary upgrade item and will be rejected. The member will be liable.

The purpose of modifier GA is to acknowledge the patient has a signed Member Upgrade Responsibility form on file and accepts liability for the rejected service line for the non-medically necessary upgrade item.

The purpose of modifier GK is to identify the medically necessary item ordered by the physician. Modifier GK, when billed alone, has no impact on claims processing.

Free upgrade: Report modifier GL
When providing a free upgrade, providers should submit the claim with the appropriate HCPCS code for the non-upgraded item or service that the physician ordered. Providers should report modifier GL only with the correct, non-upgraded HCPCS code. The provider should specify the make and model of the upgraded item or service that was provided in Item 19 of the CMS-1500 claim form or as an attachment to the claim.

When providing a free upgrade, the supplier should not have the member sign a Member Upgrade Responsibility Form, because the supplier should not be charging the member more than the normal deductible and co-payment for the non-upgraded item. The upgraded item should not be billed.

Claim form example for free upgrade:
Claim Line 1 HCPCS Code XXXXX Modifier GL...Pay (Free Upgrade Modifier GL is billed alone)

The Member Upgrade Responsibility form can be found on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Search the Frequently Used Forms column.