Interested in joining PGIP? Here’s your chance

We will be accepting applications from physician organizations that would like to join our Physician Group Incentive Program from July 1 through Aug. 31, 2015.

This innovative program, developed with input from physicians across Michigan, is helping improve the quality, value and efficiency of health care in the state. PGIP facilitates change through a wide variety of initiatives and rewards physician organizations for improving health care delivery.

If you represent a physician organization and would like to complete an application, email the Value Partnerships staff at valuepartnerships@bcbsm.com. Blue Cross must receive completed application packets by Aug. 31, 2015.

Keep in mind that physicians must join PGIP as part of a physician organization. Details about the requirements for participating and instructions on how to join are in the PGIP section of bcbsm.com/providers.

If you’re an individual practitioner with questions about participating in PGIP, contact your provider consultant. Not sure who that is? Check out the Contact Us section of bcbsm.com/providers.

OSC program continuing to expand, evolve

As you’ve read before, our Organized Systems of Care program brings primary care doctors, specialists, and hospitals together to more closely and effectively manage populations of patients.

The program works hand-in-hand with our value-based reimbursement arrangements with hospitals to support health care transformation. A major component of these arrangements is providing hospitals with the necessary infrastructure funding to develop OSC capabilities, ranging from patient registries to performance measurement.

Over the past year, the OSCs have placed a greater focus on bringing more hospitals into the OSC fold. Currently, more than 106 hospitals are affiliated with one or more of our current 39 OSCs.

New product coming
In addition, Blue Cross is developing a new PPO product, Blue Cross Personal Choice PPO, expected to launch in July 2016. This product will use our existing TRUST PPO network and offers lowest out-of-pocket costs for members who choose a primary care physician from a higher performing OSC.

We’re excited about these new developments and look forward to providing more details over the next 12 months. By working closely together with our physician partners and hospitals, we can make significant strides toward controlling health care costs and improving population health.

Subscribe to email version of Hospital and Physician Update

Many of you already receive the print or e-mail version of Hospital and Physician Update, a bimonthly newsletter that gives you a high-level look at how we’re transforming health care in the state. If not, you and your colleagues can subscribe to the email version of the newsletter — or other provider-focused newsletters — at bcbsm.com/providernews.

Hospital and Physician Update includes columns by our staff physicians and information about trends in health care, our quality initiatives, hospital and physician incentive programs, NCQA guidelines, and much more. Here’s a link to our current issue.

You may want to share information about this newsletter — and how to subscribe — with physicians in your practice or with hospital leadership. You can also access all our provider-focused newsletters at bcbsm.com/providers. Simply click on the Newsletters box on the right side of the page.

If you have any questions or comments, send an email to ProvComm@bcbsm.com.

Aim for the stars: Register today for summer educational sessions

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

• HEDIS** and Medicare star ratings
• ICD-10 (professional)
• 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:

• Registration – 8:30 a.m. (9:30 a.m. for Upper Peninsula classes)
• Class begins – 9:30 a.m. (10 a.m. for Upper Peninsula classes)
• Lunch – noon to 1 p.m.
• Class ends – 4 p.m. (approximate)

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.

Training classes set for Upper Peninsula

We’ve scheduled facility and professional training classes in Marquette and Sault Ste. Marie this August.

The facility class will feature billing tips, web-DENIS information and a question-and-answer session.

The professional class will cover such topics as coding and documentation, risk adjustment, the diagnostic closure incentive program, the performance recognition program, Health e-Blue^SM and ICD-10.

The professional class was first announced in the June Record. For professional training opportunities at other locations across the state, see the article titled "Aim for the stars," also in this issue.

U.P. training classes will begin one hour later than usual:

• Full-day classes start at 10 a.m. and end at 4 p.m., with registration at 9:30 a.m.
• A lunch break will be provided between noon and 1 p.m., with lunch served at all locations.
• Classes might extend later or end earlier, depending on participant questions.

Following are the dates of the sessions and the class location:

To register, email jholzhausen@bcbsm.com. For the facility class, type “Facility Marquette” or “Facility Sault Ste. Marie” in the subject line. For the professional class, type “HEDIS/RMRA Marquette” or “HEDIS/RMRA Sault Ste. Marie.” In the body of the email, include the date of the class and the number and names of attendees expected from your facility.

You’ll receive a confirmation within 72 hours of registering. It’s important that you register so we have an accurate headcount for lunch.

For more information, contact your provider consultant.

Chiropractors invited to attend July webinar to learn about changes to payable procedures

We’re expanding the number of services payable to chiropractors, effective for dates of service Aug. 1, 2015, or after.

To learn about these important changes, we’re inviting chiropractors to attend one of our Chiropractic Update Webinars on Tuesday, July 21, and Thursday, July 23. The webinars will take place at 10 a.m. and 1 p.m. both days. They will include a discussion about expanded payable procedures and more.

To register, download the invitation, complete the information requested and respond via email or fax by July 17.

Blue Cross updates its concierge medicine policy

Blue Cross Blue Shield of Michigan has made some changes to its concierge medicine policy since we wrote about it in a July 2014 Record article.

In a concierge, or “retainer,” practice, patients pay membership fees to a health care provider or third-party vender for enhanced services or amenities. As a benefit of paying this fee, members typically receive:

• Easy appointment access
• Extended office visits
• Enhanced email and telephone communication with doctors
• Care coordination (including referrals) between the concierge practice and specialists
• Wellness programs and plans, genetic and nutritional counseling, risk appraisals

Health care practitioners who wish to use this model in their practice must ensure that its requirements are permitted by their affiliation agreements with Blue Cross. Providers may charge a concierge fee if:

• Patients are not required to pay the concierge fee to become or continue to be a patient in the practice
• Patients are not required to pay the concierge fee to obtain access to the provider and are only permitted access to ancillary providers, such as physician assistants or nurse practitioners, if they do not pay the concierge fee
• The services or products being offered as part of the concierge fee are not considered “covered services” under our affiliation agreements, but instead are not covered under a member’s benefit plan. Because benefit structures vary significantly among our members, providers are expected to understand each member’s benefit structure to ensure that covered services are not included in the concierge fee.
• Patients who don’t pay the concierge fee continue to receive the same level of access and services as they previously received.
• Providers continue to meet Blue Cross and Blue Care Network performance standards regarding access and service.
• The concierge level of service is clearly over and above usual practice in Michigan. Complaints from members who experience a decline in service level may result in Blue Cross concluding that the practice is noncompliant with the nondiscrimination clause of our affiliation agreements.

If you have any questions about the concierge medicine policy or need clarification, contact your provider consultant.

Updates to Medical Drug Prior Authorization Program taking place in July

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

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

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

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

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

We won’t consider a request for coverage until we receive a physician-signed medication request form either faxed or mailed to Blue Cross or a request uploaded to the online-based tool, NovoLogix. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

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

Blue Cross 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.

Clarification: Clinical guidelines for re-titration studies, APAP treatment

As you may know, Blue Cross Blue Shield of Michigan requires preauthorization for in-lab titration studies. These studies are performed once it’s determined that a patient will need treatment with a continuous positive airway pressure, or CPAP, device.

Preauthorization is also needed for re-titration, or a repeat study, for patients who are already being treated with a CPAP device, but who have a recurrence, worsening of symptoms or poor response to treatment.

If, after evaluating the patient, a board-certified sleep medicine physician believes a new titration study is clinically appropriate, the physician must submit a preauthorization request to AIM Specialty Health^®. AIM will approve an in-lab repeat titration if the clinical guidelines are met. In-lab sleep studies performed solely as routine procedures or to determine employment status are not considered medically necessary.

As part of the sleep study preauthorization program, AIM makes available its clinical guidelines to assist providers in determining whether an in-lab sleep study, including a re-titration study, is appropriate for a patient. AIM’s clinical guidelines, however, are not intended to be an exhaustive list of all the medical reasons for an in-lab sleep study. Under the “Add More Information for Sleep” section on AIM’s ProviderPortal^SM board certified sleep medicine physicians have the opportunity to provide additional medical information to support the need for in-lab testing.

If a preauthorization request is not immediately approved, this does not necessarily mean the request will be denied. Instead, the case may require further review by an AIM physician to make a determination. This includes evaluating all additional information provided on the ProviderPortal or through peer-to-peer discussions with an AIM sleep physician.

Note: FEP^® is excluded from the preauthorization requirement.

APAP titration or treatment
In situations where the request for a new in-lab re-titration study for a CPAP user cannot be immediately approved, the sleep physician should not assume that we are instead suggesting re-testing with an automatic positive airway pressure, or APAP, device. If AIM determines an in-lab titration is not medically necessary, then an APAP titration or APAP treatment is also considered unnecessary. As such, Blue Cross will not cover the cost of the APAP rental, and the sleep physician should not ask a durable medical equipment supplier to provide an APAP machine for free.

Want more information?
For additional information on AIM’s sleep management program or to get answers to clinical questions, click here.** To register with AIM or access its ProviderPortal, visit AIMSpecialtyhealth.com.**

**Blue Cross Blue Shield of Michigan does not own or control the content of this website.

Documentation guidelines updated for mental health, substance abuse services

Effective June 1, 2015, we updated the medical record documentation requirements for mental health and substance abuse services.

For detailed information, 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.

BCBSM to update McKesson ClaimsXten for fourth quarter, 2015

McKesson ClaimsXten, software, which uses the most current Common Procedure Terminology and Health Care Procedure Coding System codes to determine clinical edits, will be updated in October 2015.

McKesson updates the ClaimsXten information base quarterly, using CPT code updates, CMS guidelines, specialty society guidelines and information gathered from industry seminars and publications. In turn, Blue Cross implements changes to ClaimsXten quarterly to ensure we’re following the most current rules.

That’s why it’s important that you report the most current CPT and HCPCS codes on your claims. Doing so will help us process claims and send accurate reimbursement more quickly and efficiently.

Watch upcoming issues of The Record for future ClaimsXten updates. If you have any questions, contact your provider consultant.

ValueOptions to administer mental health, substance abuse claims for FCA non-bargaining unit members

Mental health and substance abuse claims for Fiat-Chrysler Automobiles (FCA US, LLC) non-bargaining unit members will be administered by ValueOptions, effective July 1, 2015. Previously, ValueOptions was only used for precertification.

Members will receive a new identification card with an issue date of June 2015.

Blue Cross Blue Shield of Michigan will reject claims that are not submitted to ValueOptions for dates of service July 1, 2015 and beyond. Health care providers who submit claims for these services will receive a message instructing them to bill ValueOptions. Please note that Blue Cross will assume responsibility for inpatient hospitalization claims if admitted prior to July 1, 2015.

Claims can be submitted directly through ValueOptions’ secure portal, ProviderConnect. If you have any questions about using ProviderConnect, contact the ValueOptions e-support help desk at 1-888-247-9311, Monday through Friday from 8 a.m. to 6 p.m. Eastern time or by email at e-supportservices@valueoptions.com.

The mailing address for paper claims is ValueOptions, P.O. Box 930829, Wixom, MI 48393-0821.

If you have mental health or substance abuse questions about such issues as claims, benefits, eligibility, precertification or cost sharing for FCA non-bargaining unit members, call ValueOptions toll-free at 1-800-346-7651. (This is the same number that was previously used for precertification, and it will continue to be used for precertification for inpatient hospitalization.)

Subscribe to email version of Hospital and Physician Update

Many of you already receive the print or e-mail version of Hospital and Physician Update, a bimonthly newsletter that gives you a high-level look at how we’re transforming health care in the state. If not, you and your colleagues can subscribe to the email version of the newsletter — or other provider-focused newsletters — at bcbsm.com/providernews.

Hospital and Physician Update includes columns by our staff physicians and information about trends in health care, our quality initiatives, hospital and physician incentive programs, NCQA guidelines, and much more. Here’s a link to our current issue.

You may want to share information about this newsletter — and how to subscribe — with physicians in your practice or with hospital leadership. You can also access all our provider-focused newsletters at bcbsm.com/providers. Simply click on the Newsletters box on the right side of the page.

If you have any questions or comments, send an email to ProvComm@bcbsm.com.

Training classes set for Upper Peninsula

We’ve scheduled facility and professional training classes in Marquette and Sault Ste. Marie this August.

The facility class will feature billing tips, web-DENIS information and a question-and-answer session.

The professional class will cover such topics as coding and documentation, risk adjustment, the diagnostic closure incentive program, the performance recognition program, Health e-Blue^SM and ICD-10.

The professional class was first announced in the June Record. For professional training opportunities at other locations across the state, see the article titled "Aim for the stars," also in this issue.

U.P. training classes will begin one hour later than usual:

• Full-day classes start at 10 a.m. and end at 4 p.m., with registration at 9:30 a.m.
• A lunch break will be provided between noon and 1 p.m., with lunch served at all locations.
• Classes might extend later or end earlier, depending on participant questions.

Following are the dates of the sessions and the class location:

To register, email jholzhausen@bcbsm.com. For the facility class, type “Facility Marquette” or “Facility Sault Ste. Marie” in the subject line. For the professional class, type “HEDIS/RMRA Marquette” or “HEDIS/RMRA Sault Ste. Marie.” In the body of the email, include the date of the class and the number and names of attendees expected from your facility.

You’ll receive a confirmation within 72 hours of registering. It’s important that you register so we have an accurate headcount for lunch.

For more information, contact your provider consultant.

Clarification: Clinical guidelines for re-titration studies, APAP treatment

As you may know, Blue Cross Blue Shield of Michigan requires preauthorization for in-lab titration studies. These studies are performed once it’s determined that a patient will need treatment with a continuous positive airway pressure, or CPAP, device.

Preauthorization is also needed for re-titration, or a repeat study, for patients who are already being treated with a CPAP device, but who have a recurrence, worsening of symptoms or poor response to treatment.

If, after evaluating the patient, a board-certified sleep medicine physician believes a new titration study is clinically appropriate, the physician must submit a preauthorization request to AIM Specialty Health^®. AIM will approve an in-lab repeat titration if the clinical guidelines are met. In-lab sleep studies performed solely as routine procedures or to determine employment status are not considered medically necessary.

As part of the sleep study preauthorization program, AIM makes available its clinical guidelines to assist providers in determining whether an in-lab sleep study, including a re-titration study, is appropriate for a patient. AIM’s clinical guidelines, however, are not intended to be an exhaustive list of all the medical reasons for an in-lab sleep study. Under the “Add More Information for Sleep” section on AIM’s ProviderPortal^SM board certified sleep medicine physicians have the opportunity to provide additional medical information to support the need for in-lab testing.

If a preauthorization request is not immediately approved, this does not necessarily mean the request will be denied. Instead, the case may require further review by an AIM physician to make a determination. This includes evaluating all additional information provided on the ProviderPortal or through peer-to-peer discussions with an AIM sleep physician.

Note: FEP^® is excluded from the preauthorization requirement.

APAP titration or treatment
In situations where the request for a new in-lab re-titration study for a CPAP user cannot be immediately approved, the sleep physician should not assume that we are instead suggesting re-testing with an automatic positive airway pressure, or APAP, device. If AIM determines an in-lab titration is not medically necessary, then an APAP titration or APAP treatment is also considered unnecessary. As such, Blue Cross will not cover the cost of the APAP rental, and the sleep physician should not ask a durable medical equipment supplier to provide an APAP machine for free.

Want more information?
For additional information on AIM’s sleep management program or to get answers to clinical questions, click here.** To register with AIM or access its ProviderPortal, visit AIMSpecialtyhealth.com.**

**Blue Cross Blue Shield of Michigan does not own or control the content of this website.

ValueOptions to administer mental health, substance abuse claims for FCA non-bargaining unit members

Mental health and substance abuse claims for Fiat-Chrysler Automobiles (FCA US, LLC) non-bargaining unit members will be administered by ValueOptions, effective July 1, 2015. Previously, ValueOptions was only used for precertification.

Members will receive a new identification card with an issue date of June 2015.

Blue Cross Blue Shield of Michigan will reject claims that are not submitted to ValueOptions for dates of service July 1, 2015 and beyond. Health care providers who submit claims for these services will receive a message instructing them to bill ValueOptions. Please note that Blue Cross will assume responsibility for inpatient hospitalization claims if admitted prior to July 1, 2015.

Claims can be submitted directly through ValueOptions’ secure portal, ProviderConnect. If you have any questions about using ProviderConnect, contact the ValueOptions e-support help desk at 1-888-247-9311, Monday through Friday from 8 a.m. to 6 p.m. Eastern time or by email at e-supportservices@valueoptions.com.

The mailing address for paper claims is ValueOptions, P.O. Box 930829, Wixom, MI 48393-0821.

If you have mental health or substance abuse questions about such issues as claims, benefits, eligibility, precertification or cost sharing for FCA non-bargaining unit members, call ValueOptions toll-free at 1-800-346-7651. (This is the same number that was previously used for precertification, and it will continue to be used for precertification for inpatient hospitalization.)

Blue Cross to implement 2015 InterQual^® criteria Aug. 3

Blue Cross Blue Shield of Michigan will implement 2015 InterQual acute care, rehabilitation, skilled nursing, long-term acute care and home health criteria, starting Aug. 3, 2015. The criteria format for rehabilitation, skilled nursing, long-term acute care and home care criteria haven’t changed.

This year, there are still 32 adult and 24 pediatric acute care criteria for specific conditions. General medical and surgical categories will remain in their previous format for patients who don’t fall within a condition-specific subset.

The acute care criteria transition plan section lists conditions associated with a high risk of readmissions. This information can be useful in determining which patients to refer to our case management department.

The acute care quality indicators section lists the quality indicators for improving the quality of hospital care. The National Quality Forum developed these national standard indicators.

InterQual criteria should be applied to all elective or emergency hospital admissions.

Blue Cross modifications, or local rules, of InterQual criteria were published on web-DENIS in June. To access them:

1. Log in to web-DENIS.
2. Click on BCBSM Provider Publications and Resources in the left column.
3. Click on Newsletters and Resources in the left column or at the top of the page.
4. Click on Clinical Criteria and Other Resources.

Reminder: Refer lab services in-network

As you’ve read before, independent laboratories must file claims with the Blue Cross plan in the state where the specimen is drawn, which is determined by where the referring (or ordering) physician is located. That’s why health care practitioners shouldn’t send samples to a lab unless they’ve first verified that the lab participates in the member’s applicable Blue Cross network. These rules apply regardless of whether a Blue Cross plan provides primary or secondary coverage.

Keep in mind that Blue Cross Blue Shield of Michigan doesn’t have participation agreements with most labs located outside of the state. You can determine if a lab outside of Michigan participates with Blue Cross by going to bcbsm.com and doing the following:

• Click on Find a Doctor.
• Click on I want to find doctor or hospitals.
• Click on Out-of State Independent Laboratories.

If practitioners don’t refer such services to Blue Cross network providers, members may be responsible for additional out-of-network cost-sharing. They may also be subject to balance billing by the out-of-state labs that aren’t participating or in-network with Blue Cross.

As a reminder, Blue Cross PPO practitioner agreements require practitioners to refer services to in-network providers. We regard referring laboratory services to non-participating out-of-state laboratories as a violation of the Participating Provider Agreement and the TRUST Network Agreement. If you do not meet our program requirements for participating laboratory services, you may be subject to corrective action and potential termination from the TRUST Network.

Updates to prescription drug lists available online

Blue Cross Blue Shield of Michigan recently updated its prescription drug lists, or formularies. Blue Cross occasionally updates these lists to help ensure patient safety and to help prescribers select the most effective and affordable drug therapy for patients.

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

These drug lists can help prescribers make better-informed decisions. This can lead to increased medication adherence and help other providers explain prescription drug coverage to members.

Documentation guidelines updated for speech, language pathology services

Effective April 1, 2015, we’ve updated the medical-record documentation requirements for speech and language pathology services.

For detailed information, 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.

Federal Employee Program^® member information transitioned from CAREN to PARS

In June 2015, FEP member benefit information became available through the Provider Automated Response System, also known as PARS.

PARS provides benefit information for medical (professional and facility), dental, hearing and prescription drug lines of business. Vision benefit information is not available.

The phone number to call to obtain benefit information for FEP members remains the same: 1-800-840-4505. To access a member’s information, you’ll be asked to state the eight digits following the letter "R" of the member’s contract number.

The transition to PARS offers these improvements:

• Benefits are categorized as they are with other PARS phone lines. This allows you to hear benefits specific to your provider specialty and limit the amount of time you spend on the phone.

• You also have the option to request a fax or email of the benefit information obtained through PARS. This gives you date- and time-stamped benefit verification. Setup instructions for faxes and emails are provided on the PARS phone lines.

If you have any concerns or questions about the system, email us at pibs@bcbsm.com.

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.

What is the difference between a BlueCard claim reconsideration and a provider appeal?

A claim reconsideration is the first step of our routine claim inquiry process and must be initiated before you appeal a claim processed through Blue Cross Blue Shield of Michigan.

Your first point of contact for the claim reconsideration should be to our Provider Inquiry department. This department can:

• Provide you with the information that we have on file for the claim
• Work with the member’s home plan to initiate your request to have the claim reconsidered

If the outcome of the reconsideration is not favorable, your next point of contact should be to your provider consultant. If the claim denial is maintained after working with your provider consultant, you have the option of appealing the claim.

All claim appeals must be sent to Blue Cross Blue Shield of Michigan in writing and include:

• Any supporting documentation for your appeal
• The documentation that you completed our routine claim inquiry process

Note: If you’re appealing a claim on behalf of a BlueCard member, you must also include the member’s written authorization to do so.

If you need additional information on the BlueCard program, including links to our detailed inquiry process, the process for submitting a claim appeal and the address to send in a claim appeal, refer to the BlueCard chapter of 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: Improve medical record documentation for seizures and epilepsy

According to the Centers for Disease Control and Prevention, epilepsy affects about 2 million adults in the U.S. Epilepsy is sometimes called a seizure disorder, which is a disorder of the brain. A seizure is a short change in normal brain activity and is the main sign of epilepsy, but it could also occur due to other medical problems.

When a person has had two or more seizures, they’re considered to have epilepsy. Symptoms vary according to the part of the brain that’s affected. There can be multiple causes leading to a seizure.

Here are some examples of conditions associated with seizures and epilepsy:

• Developmental problems, such as cerebral palsy
• Head injuries
• Poisoning

Physician documentation must specify the reason for the seizure or convulsion, if known, such as seizure disorder, traumatic brain injury, genetic disorders or epilepsy. If the cause is unknown or documentation is lacking, only the symptoms can be coded, which could result in failure to capture the condition in the patient if present.

For example, if a provider diagnoses a patient with a seizure disorder, the ICD-9-CM code is 780.39. But if the patient has epilepsy, the provider must state epilepsy, which codes to ICD-9-CM 345.90. Documenting the specific condition is key to increasing the accuracy of coding.

Convulsions and seizures occur in certain types of epilepsy, but they can also be symptoms of many other diseases, such as cerebrovascular accident, brain tumor, alcoholism and electrolyte imbalance. Therefore, the code for epilepsy should not be assigned unless the physician specifically states epilepsy as a condition in the diagnostic statement.

The different types of seizures are grand mal, myoclonic, atonic, tonic, clonic and absence. Accurate documentation of the seizure type is important in order to assign the correct ICD-9-CM or ICD-10-CM codes.

Epilepsy and recurrent seizures require a fifth digit code for ICD 9 represented by "X" in the table to describe if intractable epilepsy is present or not. Intractable epilepsy means that it’s difficult to control using anticonvulsant medications such as Phenytoin or Phenobarbital.

By comparison, ICD-10 has a greater number of codes to accommodate higher specificity in capturing diagnoses. This will be important to remember when ICD-10 codes go into effect beginning Oct. 1, 2015.

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 cancer in remission

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 few 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.

It’s important to properly document the status of cancer in the medical record to support the ICD-10-CM diagnosis code selected. Cancer should be documented as active cancer, as personal history of cancer or cancer in remission. Incorrectly coding a cancer diagnosis can be problematic for a patient in the future.

Definitions of each cancer status:

• Active cancer: Cancer that is currently being treated. Various methods could include surgery, radiation, chemotherapy, drugs, alternative medicine or a combination of the various methods.

• Personal history of cancer: Cancer that has been excised or eradicated from its site. No further treatment of the malignancy is being directed at the site and there’s no evidence of any existing cancer.

• Cancer in remission: Cancer that has been removed; however, there may be cells that are still present but are currently undetectable. There are two kinds of remission: complete remissionand partial remission.

Active cancer status
The following is an example of coding for active cancer that’s currently being treated by the doctor:

The patient has active lung cancer. His or her doctor discusses the treatments available, explains the risks and possible outcomes, and answers any questions the patient has regarding the diagnosis. If the patient decides to start treatment immediately, the doctor documents the assessment as C34.11 — Malignant neoplasm of upper lobe, right bronchus or lung, as the diagnosis. The plan is the patient will begin chemotherapy in a week, with follow up as needed.

In instances such as this, where cancer has been diagnosed and is documented as currently receiving treatment, it should be coded using a current neoplasm code (C00-D49) from the “Neoplasms” chapter.

Personal history of cancer status
When a patient has a personal history of cancer, and the cancer is no longer active and doesn’t need treatment, the doctor needs to specify that using the proper code.

For example, if a patient was diagnosed with prostate cancer five years ago and there’s no current treatment being directed at the prostate cancer, the doctor should use Z code Z85.46 – Personal history of malignant neoplasm prostate. This indicates that the patient has a personal history of prostate cancer and it’s no longer an active cancer that needs treatment directed towards it.

Z-codes can be found in the “Factors Influencing Health Status and Contact with Health Service (Z00-Z99)” section of the ICD-10-CM manual.

In most cases, doctors will still monitor the condition for a certain period of time due to the nature of the cancer. However, it’s incorrect to use an active cancer code (C00-D49) in cases where the doctor has indicated that there’s no evidence of the existing cancer and no treatment is being directed towards the site of the primary malignancy.

Remission status
There are two types of remission:

• Complete remission: There are no signs and symptoms that indicate the presence of cancer.

• Partial remission: A large percentage of the signs and symptoms of cancer are gone, but some still remain.

According to the American Cancer Society, to qualify for either type of remission, the reduction in the size of the tumor must last for at least one month. When a person is in remission, there may be microscopic cancer cells that are unable to be identified by the current techniques and technologies available.

Complete remission is better because there’s a higher rate of recurrence with a partial remission. A person in remission, whether complete or partial, may experience a recurrence of cancer at some point in the future.

ICD-10-CM codes C90-C95 Multiple myeloma and malignant plasma cell neoplasms and Leukemia (multiple types) include remission codes which can be used if the doctor documents the condition as such. The fifth character “1” indicates that the cancer is in remission.

If lymphoma is documented as in remission, it’s still assigned to the appropriate code from categories C81 to C86. Although lymphoma patients may be regarded in remission, they’re still considered to have lymphoma and should be assigned the appropriate code from categories C81-C86.

Other types of cancer can be termed as in remission, but there aren’t specific codes designated like there are for lymphoma and leukemia. Whether to use an active cancer code or a personal history of cancer code for other types of cancer that a doctor documents as in remission, will depend on what the documentation states for that date of service. Keep in mind if there’s no treatment or adjuvant therapy being directed at the primary malignancy at that time, the doctor shouldn’t use an active cancer code.

It’s important to always review the ICD-10-CM Coding Guidelines (Section I.C.2 , Chapter 2: Neoplasms, codes C00-D49) as well as any instructional notes under the codes in the tabular list of the ICD-10-CM manual in order to select the correct code, additional codes required and possible sequencing information as well.

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

For 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 leukemia

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 few 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.

Leukemia is cancer of the white blood cells that will affect an estimated 54,270 new patients in 2015 alone, according to the American Cancer Society. A basic understanding of this neoplastic disorder will help with coding and documentation accuracy. The body is constantly producing new blood cells to stay healthy. Blood cells are produced by blood stem cells found within bone marrow and occasionally the blood itself.

Blood stem cells produce three specific types of blood cells: red blood cells, platelets and white blood cells. Each blood cell has a unique function within the body, aiding in healing and healthy living. When normal blood cells are old or damaged they die off and new ones are produced.

Leukemia occurs when the bone marrow starts producing abnormal white blood cells known as leukemia cells or leukemia blast cells. The production of the abnormal white blood cells takes over cell production, causing normal blood cell production to be halted. Leukemia cells multiply quickly and don’t die off like normal blood cells. Without the production of normal blood cells the body works harder to get oxygen, control bleeding and fight infections.

The major code categories in ICD-10 for leukemia are as follows:

• C90.1 Plasma cell leukemia
• C91 Lymphoid leukemia
• C92 Myeloid leukemia
• C93 Monocytic leukemia
• C94 Other leukemia of specified cell type
• C95 Leukemia of unspecified cell type

The code categories are further categorized by acute or chronic, specified cell types and whether or not remission had been achieved.

Tips to remember when coding leukemia
Leukemia codes are found throughout the neoplasm chapter and specific types are categorized in sections C90.1 through C95.

• Physicians must clearly document the specific type of leukemia, whether it is acute or chronic and state of remission or relapse.
• Relapse refers to the recurrence of the disease after being successfully treated. A relapse can occur at any time during treatment or after treatment is completed. The provider must clearly document the patient is “in remission” or “in relapse” so the appropriate fifth digit may be assigned.
• 0 — Not having achieved remission (includes failed remission): According to American Hospital Association Coding Clinic fourth quarter, 2008, page 83 through 84, failed remission refers to remission induction therapy where the patient is given a course of chemotherapy to produce a complete remission and the treatment fails.
• 1 — In remission: Currently not showing any signs or symptoms of the disease.
• 2 — In relapse: Signs and symptoms of the disease have reoccurred after being treated successfully.
• Note: These same concepts for the coding of leukemia which include not having achieved remission, in remission and in relapse have been carried over to ICD-10-CM. If the reason for a patient encounter is antineoplastic chemotherapy, report Z51.11 or Z51.12 for encounter for antineoplastic immunotherapy as the primary diagnosis code followed by the correct leukemia code.
• Leukemia is classified in the neoplasm chapter, yet it’s not found within the neoplasm table. In order to accurately code leukemia it must first be located in the alphabetical index, under the correct subcategory. Code verification in the tabular is essential for accurate fifth-digit reporting.

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: Improve medical record documentation for lymphoma cancer

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 few 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.

Lymphoma cancer is often coded incorrectly due to misconceptions about the nature of the condition. To be classified as lymphoma, the neoplasm must originate within the lymph nodes. This is different than a solid tumor that has spread to the lymph nodes.

Tips to consider when coding lymphoma
Proper documentation is the key to accurate code selection for lymphomas. If documentation is unclear, ask the physician for more explanation to ensure codes chosen are to the highest level of specificity. Coding for neoplasms classified as lymphomas can be found in ICD-10-CM categories C81-C88.

• A malignant neoplasm must form within the lymph nodes to be classified as lymphoma.
• Neoplasms that form in the lymphatic and hematopoietic tissues do not spread to secondary sites. Rather, the malignant cells may travel and arise in other areas within the associated tissues. These are still classified as primary neoplasms.
• Lymphomas can be benign or malignant; this should be specifically identified in the physician’s documentation.
• When a physician documents that the lymphoma is “in remission,” it is still reported using lymphoma codes C81-C88. Although the condition is in remission, it is still classified as an active condition.
• If the lymphoma is documented as “history of,” indicating the condition is completely cured, select a personal history code from category Z85.7. Personal history of other malignant neoplasms of lymphoid, hematopoietic and related issues The codes in this category are based on the type of lymphoma documented such as Hodgkin lymphoma, Non-Hodgkin lymphomas or other malignant neoplasms of lymphoid, hematopoietic and related tissues.
• Solid tumors that have spread or metastasized to the lymph nodes are not considered lymphoma. They are considered secondary or unspecified malignant neoplasms of the lymph nodes and are reported with categories C00-C80.

Types of lymphoma
Lymphoma is most commonly referenced by two specific types: Hodgkin lymphoma and Non-Hodgkin lymphoma. The type of lymphoma is determined by how it behaves, spreads and responds to treatment.

• Hodgkin lymphoma
  
  Hodgkin lymphoma is an uncommon form of lymphoma involving Reed-Sternberg cells, large abnormal lymphocytes that may contain more than one nuclei. Most are of B-cell origin. Typically, this lymphoma begins in a single node and spreads to other nodes. Hodgkin lymphoma is commonly classified to category C81in ICD-10-CM.
  
  Category C81 provides a 4th character subcategory to identify the pathologic subtype of Hodgkin’s lymphoma and a 5th character that identifies the lymph nodes affected.
  
  The Hodgkin lymphoma pathologic subtype is identified in the following subcategories:
  C81.0 Nodular lymphocyte predominant Hodgkin lymphoma
  C81.1 Nodular sclerosis classical Hodgkin lymphoma
  C81.2 Mixed cellularity classical Hodgkin lymphoma
  C81.3 Lymphocyte depleted classical Hodgkin lymphoma
  C81.4 Lymphocyte-rich classical Hodgkin lymphoma
  C81.7 Other classical Hodgkin lymphoma
  C81.9 Hodgkin lymphoma, unspecified

• Non-Hodgkin lymphoma
  
  There are many different classifications and sub-types of non-Hodgkin lymphoma. To ensure the most specific code is reported, providers should document the most specific subtype of non-Hodgkin lymphoma. Information required to correctly code this condition includes, but is not limited to location, grade, and follicular information. ICD-10-CM provides the following categories for non-Hodgkin lymphomas:
  
  C82 Follicular lymphoma
  C83 Non-follicular lymphoma
  C84 Mature T/NK-cell lymphomas
  C85 Other specified and unspecified types of non-Hodgkin lymphoma
  C86 Other specified types of T/NK-cell lymphoma
  C88 Malignant immunoproliferative disease and certain other B-cell lymphoma

Locating lymphoma codes and digit clarification
Begin searching for the appropriate code in the alphabetical index under lymphoma. For benign lymphomas please reference the neoplasm table. In the table, reference the site of the neoplasm and select the code from the benign column. Many sites are coded to D36.0.

When coding for a malignant neoplasm, reference the sub-term for the site or type, under lymphoma. Once a code is selected, reference the tabular list to ensure the code is correct.

A fifth character is required for lymphomas, classifying the specific nodes and locations affected. When multiple lymph nodes are affected, the use of the fifth character eight is utilized. The table below is a breakdown of required fifth character.

0 – Unspecified site,
1 – Lymph nodes of head, face and neck
2 – Intrathoracic lymph nodes
3 – Intra- abdominal lymph nodes
4 – Lymph nodes of axilla and upper limb
5 – Lymph nodes of inguinal region and lower limb
6 – Intrapelvic lymph nodes
7 – Spleen
8 – Lymph nodes of multiple sites
9 – Extranodal and solid organ sites

Lymphomas need to be coded to the highest level of specificity. Refer to your ICD-10-CM guidelines for more specific information on the differences between benign and malignant.

ICD-10-CM coding for all conditions should always 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 neoplasm

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 few 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.

Neoplasms should be properly documented in the medical record to support the ICD-10-CM diagnosis code selected.

Neoplasm codes are located in chapter two (codes C00-D49) of the ICD-10-CM manual.

Common neoplasm terms include:

• Malignant includes primary, secondary and in situ. Malignant neoplasms can extend beyond the primary site, they can attach to adjacent structures and can spread:
• Primary is the original site (tissue or organ) where the cancer started.
• Secondary is a cancer that refers either to a second primary cancer or to cancer that has spread from one part of the body to another, also known as metastatic cancer.
• “In situ” refers to a cancer that has stayed in the place where it began and has not spread to neighboring tissues.
• Benign is non-invasive and doesn’t spread to adjacent or distant sites.
• Uncertain behavior is behavior that can’t be determined; there’s no distinction between malignant and benign. These codes are reserved only for times when a diagnosis cannot be substantiated after pathologic examination.

In order to properly code a neoplasm, it’s necessary to determine from the documentation if the neoplasm is benign, in situ, malignant or of uncertain behavior. Secondary (metastatic) sites should also be determined when malignant neoplasm is involved.

In the Alphabetical Index of the ICD-10-CM manual, there is a neoplasm table. This should be referenced first when choosing a code. However, coding guideline I.C.2. states “if the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate”. In this instance, refer to the term (example adenoma) in the Alphabetical Index to review the entries under this term, as well as the instructional note — “see also neoplasm, by site, benign” — under the term. After locating the code in the Neoplasm table, the Tabular List should be referenced to verify the correct code has been selected. Remember to always code to the highest specificity per the documentation.

Some tips to remember when coding neoplasms

• If treatment is directed at the site of the malignancy, the principal or first-listed diagnosis should be the code for the malignancy.
• For example, if a patient comes in for a recheck of his prostate cancer, and the doctor reviews his PSA levels and administers an LHRH drug, you would code C61 — Malignant neoplasm of prostate.

• When a primary malignancy metastasizes and the treatment is directed at the secondary site, the secondary neoplasm is the principal or first-listed diagnosis.
• For example, a patient comes in for treatment of lung cancer, which has metastasized from his primary site of colon cancer. In this instance, you would code C78.01 – Secondary malignant neoplasm of right lung as the principal diagnosis because that’s what’s being treated. The secondary diagnosis would be C18.6 – Malignant neoplasm of descending colon because the treatment for that visit is being directed at the lung cancer.

• If a patient is being seen for the sole purpose of administration of chemotherapy, immunotherapy or radiation therapy, the use of a code from category Z51 should be the principal or first-listed diagnosis.
• For example, if a patient has breast cancer and she is being seen that day for administration of radiation therapy only, you would code Z51.0 – Encounter for antineoplastic radiation therapy first, followed by C50.411 – Malignant neoplasm of upper-outer quadrant of right female breast.

• When coding a malignancy with a complication and management is directed only at the complication, the coding rules vary. Please refer to the Coding Guidelines I.C.2.c.
• An encounter for management of anemia due to sigmoid colon cancer, and the treatment is only for the anemia, the principal/first listed diagnosis code would be C18.7 Malignant neoplasm of sigmoid colon and D63.0 – Anemia in neoplastic disease as the secondary diagnosis.
• An admission/encounter for management of dehydration due to the malignancy and only the dehydration is being treated, sequences the dehydration first followed by the code(s) for the malignancy.

• If a primary malignancy has been eradicated, there is no current treatment directed at the primary malignancy site and there is no evidence of the primary malignancy, please use a code from category Z85 (Personal history of malignant neoplasm).
• If a physician documents “patient diagnosed with breast cancer, 5/2001, surgery. Tamoxifen therapy discontinued 8/2009, no evidence of recurrence of malignancy. Routine yearly mammograms have remained non-eventful.” This would be coded as Z85.3 – Personal history of malignant neoplasm; Breast.

Coding breast cancer
According to the American Cancer Society, it was estimated that there would be 297,000 new female breast cancer cases in 2013 (in situ and invasive combined) and 39,600 women were expected to die from breast cancer. Only lung cancer is responsible for more cancer deaths in women, ahead of breast cancer.

Documenting the specific location of the neoplasm is important because there are codes for the various regions of the breast, as well as an unspecified code. Also, per ICD-10-CM coding conventions, an additional code should be reported to identify the estrogen receptor status (Z17.0, Z17.1).

Coding colon cancer
Colon cancer is the third most common cancer among men and women. The American Cancer Society estimates that there will be 136,000 new colorectal cancer cases in 2014, with approximately 50,000 of those resulting in death.

As with breast cancer, documenting the specific location of the neoplasm is important because there are codes for the various regions of the colon.

It’s important to review the ICD-10-CM Coding Guidelines (Chapter Two: Neoplasms, codes (C00-D49), as well as any instructional notes under the codes in the tabular list of the ICD-10-CM manual, in order to select the correct code, review the additional codes required and find sequencing information.

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 venous thrombosis

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 few 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.

ICD-10-CM diagnosis codes, along with Current Procedural Terminology codes reported on claims, must be supported by documentation in a patient’s medical record. Note that ICD-10-PCS will be used for hospital inpatient records only.

Accurate coding starts with accurate documentation
Clear and concise documentation is essential to providing the best quality of care to patients and ensures health care providers receive their payments in a timely manner. When documentation standards are met and maintained, there shouldn’t be a concern about any impending audit or review.

Some of the most challenging conditions to code are diseases of the vascular system. This includes venous thromboembolism and peripheral vascular disease.

Documentation and coding tips for vascular diseases

• Venous thromboembolism is a disease that includes both superficial and deep vein thrombosis and may result in pulmonary embolism.
• There are specific ICD-10-CM codes to indicate the vessel involved, laterality and to indicate whether the condition is acute or chronic. Make sure you’re specific when you document and code the blood vessel affected, the side of the body and whether it’s acute or chronic for both venous thromboembolism and pulmonary embolism.
• For venous thrombosis, documentation must be provided related to the status of the condition (acute or chronic) even if the vessel affected cannot be specified. Code I82.90 or I82.91 is used in this circumstance: acute/chronic embolism and thrombosis of unspecified vein (respectively).
• There’s no specific timeframe that differentiates an acute pulmonary embolism from a chronic pulmonary embolism. The differentiation is determined by the provider’s documentation. In most patients with pulmonary embolism, the emboli dissolve. However, in a small group of patients, the emboli persist and a state of chronic pulmonary embolism develops.
• If the provider documents “history of venous thrombosis” or “history of pulmonary embolism,” then the codes are Z86.718 and Z86.711, respectively. A “history of” Z code means that the condition no longer exists.
• If known, document and code the cause of the peripheral artery disease as well as the complication. For example, “atherosclerosis of left leg, native arteries, with ulcer of calf , with breakdown of skin” codes to I70.242 and L97.221.
• Unspecified peripheral vascular disease, peripheral artery disease or intermittent claudication are coded with I73.9 (Peripheral vascular disease, unspecified). Please note that there are more specific codes to indicate the area and any comorbid conditions present with the atherosclerosis.

Note: A hyphen (-) is used above to indicate that an additional character is required. Xs are used as part of a valid code in ICD-10-CM.)

Please review the ICD-10-CM coding manual for the fifth and sixth character codes for specifics on code selection.

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 codes added, deleted

The Centers for Medicare & Medicaid Services has added eight new HCPCS codes, deleted one modifier and deleted three codes as part of its regular quarterly HCPCS updates.

The new codes are listed below.

The deleted codes are listed below.

The deleted modifier is listed below.

Correction: New edit codes to support ICD-10

An article in the May Record, titled “New edit codes, effective Oct. 1, to support ICD-10,” contained some incorrect information. We are reprinting a corrected version of the article below. Please use this article for your reference.

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.

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.

Updates to Medical Drug Prior Authorization Program taking place in July

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

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

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

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

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

We won’t consider a request for coverage until we receive a physician-signed medication request form either faxed or mailed to Blue Cross or a request uploaded to the online-based tool, NovoLogix. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

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

Blue Cross 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.

Updates to Medical Drug Prior Authorization Program taking place in July

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

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

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

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

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

We won’t consider a request for coverage until we receive a physician-signed medication request form either faxed or mailed to Blue Cross or a request uploaded to the online-based tool, NovoLogix. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

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

Blue Cross 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.

Clarification: Clinical guidelines for re-titration studies, APAP treatment

As you may know, Blue Cross Blue Shield of Michigan requires preauthorization for in-lab titration studies. These studies are performed once it’s determined that a patient will need treatment with a continuous positive airway pressure, or CPAP, device.

Preauthorization is also needed for re-titration, or a repeat study, for patients who are already being treated with a CPAP device, but who have a recurrence, worsening of symptoms or poor response to treatment.

If, after evaluating the patient, a board-certified sleep medicine physician believes a new titration study is clinically appropriate, the physician must submit a preauthorization request to AIM Specialty Health^®. AIM will approve an in-lab repeat titration if the clinical guidelines are met. In-lab sleep studies performed solely as routine procedures or to determine employment status are not considered medically necessary.

As part of the sleep study preauthorization program, AIM makes available its clinical guidelines to assist providers in determining whether an in-lab sleep study, including a re-titration study, is appropriate for a patient. AIM’s clinical guidelines, however, are not intended to be an exhaustive list of all the medical reasons for an in-lab sleep study. Under the “Add More Information for Sleep” section on AIM’s ProviderPortal^SM board certified sleep medicine physicians have the opportunity to provide additional medical information to support the need for in-lab testing.

If a preauthorization request is not immediately approved, this does not necessarily mean the request will be denied. Instead, the case may require further review by an AIM physician to make a determination. This includes evaluating all additional information provided on the ProviderPortal or through peer-to-peer discussions with an AIM sleep physician.

Note: FEP^® is excluded from the preauthorization requirement.

APAP titration or treatment
In situations where the request for a new in-lab re-titration study for a CPAP user cannot be immediately approved, the sleep physician should not assume that we are instead suggesting re-testing with an automatic positive airway pressure, or APAP, device. If AIM determines an in-lab titration is not medically necessary, then an APAP titration or APAP treatment is also considered unnecessary. As such, Blue Cross will not cover the cost of the APAP rental, and the sleep physician should not ask a durable medical equipment supplier to provide an APAP machine for free.

Want more information?
For additional information on AIM’s sleep management program or to get answers to clinical questions, click here.** To register with AIM or access its ProviderPortal, visit AIMSpecialtyhealth.com.**

**Blue Cross Blue Shield of Michigan does not own or control the content of this website.

Clarification: Blue Cross’ CPAP device replacement policy

In the May 2015 issue of The Record, we wrote that continuous positive airway pressure devices can be replaced every five years. While this is true for our Medicare Advantage products, the policy for Blue Cross commercial products states that a CPAP device can be replaced every three years under the following conditions: 

• After three years of reasonable use
• During the three-year reasonable-use period if a replacement is needed and the device warranty has expired

For more information on CPAP benefit guidelines and billing, refer to your provider manual.

ValueOptions to administer mental health, substance abuse claims for FCA non-bargaining unit members

Mental health and substance abuse claims for Fiat-Chrysler Automobiles (FCA US, LLC) non-bargaining unit members will be administered by ValueOptions, effective July 1, 2015. Previously, ValueOptions was only used for precertification.

Members will receive a new identification card with an issue date of June 2015.

Blue Cross Blue Shield of Michigan will reject claims that are not submitted to ValueOptions for dates of service July 1, 2015 and beyond. Health care providers who submit claims for these services will receive a message instructing them to bill ValueOptions. Please note that Blue Cross will assume responsibility for inpatient hospitalization claims if admitted prior to July 1, 2015.

Claims can be submitted directly through ValueOptions’ secure portal, ProviderConnect. If you have any questions about using ProviderConnect, contact the ValueOptions e-support help desk at 1-888-247-9311, Monday through Friday from 8 a.m. to 6 p.m. Eastern time or by email at e-supportservices@valueoptions.com.

The mailing address for paper claims is ValueOptions, P.O. Box 930829, Wixom, MI 48393-0821.

If you have mental health or substance abuse questions about such issues as claims, benefits, eligibility, precertification or cost sharing for FCA non-bargaining unit members, call ValueOptions toll-free at 1-800-346-7651. (This is the same number that was previously used for precertification, and it will continue to be used for precertification for inpatient hospitalization.)

Reminder: Submit 2015 service dates for Medicare Advantage Diagnosis Closure Incentive program

The 2015 Diagnosis Closure Incentive program is effective for dates of service Jan. 1, 2015, or later. As part of the program, health care providers should complete patient diagnoses, supported by any necessary documentation in their medical records, following M.E.A.T. (manage, evaluate, assess or treat) guidelines.

You’re required to address 2015 diagnosis gaps with a face-to-face visit with your patients by Dec. 31, 2015. You then have until Jan. 31, 2016, to submit results of your 2015 patient visits on Health e-Blue. (See article at right for information on accessing Health e-Blue.)

Your patient’s diagnosis gaps are identified on Health e-Blue’s Diagnosis Evaluation panel. Health care providers may use the monthly reports on Health e-Blue to document that diagnosis gaps have been closed.

Keep in mind that if a prior service year date is entered for a 2015 diagnosis gap, the diagnosis gap will open with the next refresh and the gap closure won’t count toward your 2015 incentive payment.

Physicians who close 100 percent of all identified gaps for each attributed patient will receive $100 per patient. Your incentive payment will be mailed to you by the end of the third quarter in 2016.

See the February Record for details.

For questions about dates of service, diagnosis gap submissions or the Diagnosis Closure Incentive program, contact Tom Rybarczyk at 1-313-225-0445 or Corinne Vignali at 1-313-225-7782, provider consultants on the HEDIS and risk adjustment provider outreach team.