Here’s what you need to know about participating in Value Partnerships Quality Programs

The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to better align provider reimbursement with quality of care standards, improved health outcomes and controlled health care costs for Blue Cross customers. We refer to reimbursement earned through quality programs as “value-based reimbursement,” formerly called “fee uplifts.”

Select primary care and specialist physicians who participate in the Physician Group Incentive Program and meet the standards of particular quality programs developed under PGIP will, for a designated period, be eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule. The VBR Fee Schedule sets reimbursement rates for particular codes at >100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule. The VBR Fee Schedule rates apply to commercial payments only.

The following are participation guidelines for Quality Programs. Providers who have questions about participating in a Quality Program, or who would like more information about the opportunities described in this article, should contact their provider consultant, provider organization or email valuepartnerships@bcbsm.com. All requirements are subject to change annually.

Primary care physicians

There are five ways a primary care physician can participate in Blue Cross’ PGIP Quality Programs and be eligible to earn value-based reimbursement in accordance with the VBR Fee Schedule.

1. Primary care physicians designated as a Patient-Centered Medical Home are eligible for reimbursement at the rates applicable to such designations on the VBR Fee Schedule. Primary care physicians can receive designation as a PCMH through nomination from their physician organization by demonstrating the following:
• Meeting the PCMH minimum capability requirement. PCMH capabilities are tasks physician organizations and medical practices undertake to change their care processes and become more patient-centered. Examples of PCMH capabilities include, without limitation, providing 24-hour access to a clinical decision-maker so patients can avoid emergency room visits, creating patient registries or offering access to patient web portals. In 2015, the capability requirement for PCMH designation was 40 out of 145 PCMH capabilities. The extent to which a provider has implemented PCMH capabilities represents 50 percent of the PCMH designation score.
• Meeting the minimum PCMH percentile ranking for quality and use criteria. Quality and use criteria are analyzed using claims data from the prior calendar year for a doctor’s attributed patient population, and the metrics include emergency room use, high- and low-tech radiology use, high- and low-tech standard cost per member per month, primary care sensitive emergency room visits, generic dispensing rate, and ambulatory care sensitive inpatient discharges. In 2015, the minimum percentile ranking was 20 percent. This represents the other 50 percent of the designation score.
2. Primary care physicians with PCMH designation who are also part of a physician organization that meets Blue Cross’ cost-benchmarking criteria are eligible for reimbursement at the rates for such designations on the VBR Fee Schedule. For 2015, cost benchmark performers are defined as sub-physician organizations or Organized Systems of Care that are in the top 15 percent for total per member per month cost or trend based on Blue Cross claims data. Specific cost-benchmarking metrics include:
• Cost of care
• Overall cost of care per member per month for the previous calendar year
• Overall monthly trend in cost of care per member per month for the calendar year two years prior
• Combined performance measure for cost of care per member per month and monthly trend in cost of care per member per month
3. Primary care physicians with PCMH designation who have continuously taken part in the Michigan Primary Care Transformation Project since 2012 are eligible for reimbursement at the rates for such designations on the VBR Fee Schedule.
4. PCMH designated and non-PCMH designated primary care physicians who Blue Cross determines are performing well on measures of clinical quality performance related to preventive service use, chronic condition management and medication adherence are eligible for reimbursement at rates for such designations on the VBR Fee Schedule. There are 28 measures in this value-based reimbursement opportunity, based on the Healthcare Effectiveness Data and Information Set measures used for National Committee on Quality Assurance accreditation. All measures use claims data from the prior calendar year for the providers’ attributed patient population.

Specialists

Specialists are eligible for the VBR Fee Schedule if they meet all of the following:

1. Are a physician, chiropractor, podiatrist or fully licensed psychologist
2. Are a member of a PGIP physician organization for at least one year
• Every PGIP-participating doctor is entered into a database by his or her PO. At regular intervals, Blue Cross takes a snapshot of the database. For value-based reimbursement, a specialist is considered to be in a PGIP physician organization for at least one year if the doctor is listed on the winter and summer snapshot of the year before the quality program year. In the 2016 quality program year only, anesthesiologists are exempt from the one-year requirement.
3. Are nominated by and have a signed a primary care-specialist agreement with his or her member PO. (Blue Cross has a template agreement but doesn’t require its use. Standard employment agreements don’t constitute primary care-specialist agreements.) Also, if a substantial proportion of the specialist’s patients are attributed to a PO other than his or her member PO, nominated by and have a signed primary care-specialist agreement with a non-member PO (i.e., a principal-partner PO).
   • Each PO establishes its own criteria for nominating member and principal partner specialist practices within broad parameters set by Blue Cross. Nominated member practices must be actively engaged with their nominating member PO. Active engagement can be demonstrated by progress toward one or more of the following:
     • Involvement in managing the use of services and optimizing the quality of care
     • Collaboration with primary care physicians to develop and improve shared processes of care
     • Collaboration on efforts to coordinate care across settings and over time
     • Implementing Patient-Centered Medical Home-Neighbor capabilities in the specialist practice

   The PO’s criteria for principal partner practices may be the same as or different than those for member practices. All specialist practices — regardless of their membership status — must have an equal opportunity to be considered for nomination. Each PO must document the nomination criteria and process in writing and disclose it to the other physician organizations on the shared PO website maintained by Blue Cross. And, POs must make the documented process available to practices upon request. Blue Cross reviews the documented nomination criteria and process to make sure it’s fair to principal partner practices.

4. Meet the population-based performance rankings on measures of quality, cost and efficiency set by Blue Cross
• Blue Cross uses population-based measures of quality, cost and efficiency to evaluate and rank nominated practices. Each performance measure is assigned a weight. Within each specialty type and within all pediatric specialties, specialist practices are ranked based on the weighted average of the relevant performance measures. For specialists who treat adult patients, the top two-thirds of ranked, nominated specialists are eligible for reimbursement at the rates for such designation on the VBR Fee Schedule. For specialists who primarily serve pediatric patients, all ranked, nominated specialists are eligible for reimbursement at the rates for such designation on the VBR Fee Schedule.
  
  In 2016, Blue Cross will use three population-based performance measures to determine eligibility for VBR Fee Schedule reimbursement for all specialty types:
  • A population-level per member per month cost measure
  • A population-level cost difference measure (the change in population-level cost from the prior measurement year)
  • A population-level global quality index, a single composite score based on numerous measures of quality of care

  Also, Blue Cross has developed specialty-specific performance measures for 13 specialties: allergy, cardiology, emergency medicine, endocrinology, gastroenterology, nephrology, neurology, obstetrics and gynecology, oncology, orthopedics, otolaryngology, pulmonology and rheumatology.

Note: Oncologists participating in the Provider Delivered Care Management–Oncology program are eligible for reimbursement at the rates for such designation on the VBR Fee Schedule. To be eligible for the PDCM-O program, practices must have a physician champion for care management and a lead oncology care manager who has gone through Blue Cross-sponsored training. Also, the practice must meet a minimum number of core PCMH-N capabilities and be submitting claims for at least 2 percent of its eligible attributed members.

A look at the Value-Based Reimbursement Fee Schedule, effective March 1, 2016

Value-based reimbursement is one of the ways Blue Cross Blue Shield of Michigan is working with providers to create value for users of the health care industry. The following details the Value-Based Reimbursement Fee Schedule that is effective March 1, 2016.

Primary care physicians

Primary care physicians in the Physician Group Incentive Program will receive value-based reimbursement at 105 percent to 130 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for certain evaluation and management and preventive procedure codes depending on the program(s) in which they participate.

Reimbursement for PGIP primary care physicians who are not designated as Patient-Centered Medical Home providers but who perform well on measures of clinical quality will be 105 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the following procedure codes:

• 99201-99215
• 99381-99397

Reimbursement for primary care physicians who are and remain designated as PCMH providers will be 110 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the procedure codes listed above.

Primary care physicians with PCMH designation can receive additional value-based reimbursement:

• Primary care physicians who are part of a physician organization that meets Blue Cross’ cost-benchmarking criteria receive an additional 10 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the procedure codes listed above.
• Primary care physicians who perform well on measures of clinical quality receive an additional 5 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the procedure codes listed above.
• Primary care physicians who participate in the Michigan Primary Care Transformation Project receive an additional 5 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the procedure codes listed above, plus the following additional procedure codes:
• G9001-G9002
• 98961-98962
• 98966-98968
• G9007
• 99487
• 99489
• S0257

The total amount of value-based reimbursement depends upon the programs in which the primary care physicians participate. For instance, primary care physicians who are PCMH designated, are a member of a physician organization that meets Blue Cross’ cost benchmark criteria, participate in MiPCT and perform well on measures of clinical quality will receive reimbursement at 130 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule.

The table below summarizes the potential value-based reimbursement available under the VBR Fee Schedule to primary care physicians for the procedure codes indicated above:

Specialists

Specialists in PGIP will, depending on their ranking, receive value-based reimbursement at 105 percent or 110 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for all relative value unit-based procedure codes (relative value unit codes are most procedure codes billed by specialists, except those for ambulance service, durable medical equipment, prosthetics and orthotics, anesthesia, immunizations, hearing, routine vision services, lab, dental and most injections).

Reimbursement for specialists treating adult members and ranked in the top third will be 110 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for relative value unit-based procedure codes. Those ranked in the second third will receive 105 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for relative value unit-based procedure codes.

Reimbursement for specialists treating primarily pediatric members and ranked in the top half of pediatric practices will be 110 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for relative value unit-based procedure codes. Those ranked in the second half will receive 105 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for relative value-unit based procedure codes.

For oncologists only: Reimbursement for oncologists who participate in the Provider Delivered Care Management-Oncology Program and are not receiving any other value-based reimbursement will be 105 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for relative value unit-based procedure codes and the following care management procedure codes:

• G9001-G9002
• 98961-98962
• 98966-98968
• G9007
• 99487
• 99489
• S0257

Oncologists who are receiving other value-based reimbursement and participate in PDCM-O will receive an additional 5 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedule for the relative value unit-based procedure codes and the care management procedure codes listed above.

Here are 3 things to know about emerging cholesterol therapies

As new therapies emerge, it’s important for physicians to consider guidelines and evidence as part of their efforts to provide patient-centered care. One new class of high-cost injectable medications, recently approved by the FDA, includes PSCK9 inhibitors. Currently there are two products available: Praluent^® (alirocumab) and Repatha™ (evolocumab). Here’s what you need to know:

1. Unlike statins, there are no cardiovascular outcomes data for PCSK9 inhibitors that shows a reduction in cardiovascular events or mortality.
• PCSK9 inhibitors were approved because they can reduce the surrogate marker LDL-C.
• For statins, there is data on cardiovascular event reduction (morbidity and mortality).
2. Cholesterol guidelines recommend statins (oral medications) as the standard of care for high cholesterol, including familial hypercholesterolemia.
• FH is a rare condition in which inherited genetic mutations alter cholesterol metabolism. Statins are currently considered first-line therapy.
• Patients may not accept PCSK9 inhibitors because of the required injections.
• Adherence to statins (a PGIP clinical quality measure) is important for long-term reduction in the risk for cardiovascular events.
• Guidelines recommend statins based on outcomes from trials in which patients took statins every day.
• When statin intolerance is suspected, there are many strategies to avoid, minimize or manage the intolerance. Often, the reason for the intolerance is a drug interaction.
3. Blue Cross will require prior authorization for approval of PCSK9 inhibitor use. The following are needed for prior authorization:
• A prescription from a cardiologist, endocrinologist or a physician who specializes in lipid disorders
• A diagnosis of familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease
• You must document that other treatments have been “tried and failed.” These include concurrent lifestyle modifications, use of a high-intensity statin, ezetimibe and a bile acid sequestrant. Patients with a statin intolerance should try at least three different statins if they don’t have a drug interaction

Note: Keep in mind that dispensing drug samples can negatively impact quality scores for physician organizations, especially if a medication doesn’t meet specific criteria or isn’t approved for a particular use.

Drug lists

Blue Cross Blue Shield of Michigan, Blue Care Network and Medicare Advantage formulary information can be found at: bcbsm.com/pharmacy

As always, guidelines aren’t meant to replace clinical judgment or affect the patient-physician relationship.

Blue Cross prohibits physicians from self-prescribing

Blue Cross Blue Shield of Michigan policy prohibits health care providers from self-prescribing controlled substances to themselves or immediate family members.

Controlled substances are drugs, substances or chemicals that are used to make drugs. They’re classified as Schedule II or Schedule III on the U.S. Drug Enforcement Administration’s drug schedules.

Also, as you read in the September Record, Blue Cross doesn’t cover other services that providers render to themselves or immediate family members.

We define immediate family members as first-degree relatives, including parents, siblings, spouse and children.

For more information, contact your provider consultant.

We’ve got a new fax number for requesting practice profiles

Practice profiles for professional providers in the PPO TRUST and Traditional networks are available by mail, fax and email. We recently changed the fax number and it’s listed below.

To request copies of practice profiles, use one of the following methods to provide your name, signature, address and Blue Cross Blue Shield of Michigan provider ID number:

As a reminder, practice profiles requested by email can be sent either from the physician’s personal or business email address, but they must have the physician’s electronic signature.

Profiles are based on 12 months of paid claims data. Updated data is available every six months as follows:

• Full-year profiles (Jan. 1 to Dec. 31) are available in March of the following year.
• Mid-year profiles (July 1 to June 30) are available in September of the current year.

If your request is received just before new data becomes available, the request will be honored once that data is available. Follow-up inquiries may be faxed to the new number provided above.

Reminder: ClaimsXten™ to perform multiple radiology reduction for professional radiology services

Effective first quarter 2016, when a member receives multiple radiology services on the same date, Blue Cross Blue Shield of Michigan will pay for the first one at the highest allowed amount. Subsequent procedures will be paid at 75 percent of the allowed amount.

The appropriate modifier may be appended to indicate the subsequent service(s) are separate and distinct.

Reminder: Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange PHI electronically with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures that information is routed to the appropriate destination. You don’t need to update the Provider Authorization if your submitter and Trading Partner IDs don’t change.

Keep the following in mind when changes occur. You should review your Provider Authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization if you will send claims using a different submitter ID or route your 835s to a different unique receiver/Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers.

• Click on Quick Links
• Click on Electronic Connectivity (EDI)
• Click on Update your Provider Authorization Form

If you have questions about EDI enrollment, call our help desk at 1-800-542-0945. For assistance with TPA and Provider Authorization form, select the TPA option.

Clarification: August Record article about additional procedure codes payable to chiropractors

In an August Record article, we used incorrect terminology when referring to certain physical rehabilitative services payable to chiropractors. We should have written that additional procedure codes are payable to chiropractors for physical medicine services, effective Aug. 1, 2015. This change applies to groups with standard chiropractic benefits.

Due to this change, medical physicians (M.D.s or D.O.s) may be asked to agree to and sign a physical medicine treatment plan developed by chiropractors. A prescription is not required for a member to receive covered physical medicine services from a chiropractor.

This provision means that Blue Cross Blue Shield of Michigan will pay for the first physical medicine service per patient and not per visit. After the first physical medicine service is provided, Blue Cross will not pay for additional physical medicine services to the patient without the development of a physical medicine treatment plan that is agreed to and signed by the member’s M.D. or D.O.

The only exception to this requirement is for mechanical traction (procedure code *97012), which may be performed at subsequent visits without a physical medicine treatment plan. For mechanical traction, Blue Cross will maintain the current payment structure. A physical medicine treatment plan is not required for this code.

Health care providers should document the use of procedure code *97012 in the physical medicine treatment plan if mechanical traction is performed in addition to other physical medicine services. That way, the M.D. or D.O. is aware of all of the treatment the patient is receiving to help ensure coordination and quality of care.

For a list of reimbursable procedure codes, refer to the August Record article.

Note: No physician (M.D. or D.O.) agreement or signature is required on a treatment plan for MESSA members.

Clarification: Preauthorization for abdomen and pelvis CT scans

It’s come to our attention that some facility providers aren’t sure how to handle preauthorization for abdomen and pelvis CT scans. We’ve clarified the rules below.

The preauthorization process for CT abdomen (*74150, *74160, *74170), CT pelvis (*72192-*72194), and CT abdomen pelvis combination tests (*74176-*74178) follows some specific rules:

• When the imaging service is performed and it’s determined that a different CPT procedure(s) is more appropriate than the preauthorized CPT, the imaging facility or the ordering physician must contact AIM Specialty Health to change the order. The office that changed the order (imaging facility or ordering physician) must withdraw the original request and obtain authorization for the new procedure.
• In these specific circumstances, we provide a post-procedure window of up to 60 days for the ordering or servicing providers to obtain the new authorization. AIM may perform a retrospective review either by phone or online.  Contact AIM at 1-800-728-8008 or aimspecialtyhealth.com.**
• To prevent retrospective reviews and comply with the preauthorization program, all imaging providers are required to obtain a valid authorization before performing these scans.

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

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

We’re enhancing our claims processing systems to link medical records and claims

Blue Cross Blue Shield of Michigan and Medicare Advantage are enhancing their claims processing systems to better support instances where we require medical records in order to finalize a professional or institutional claim service. We expect that we’ll be able to systematically link a medical record to its corresponding claim before the end of 2016. Note: Blue Care Network, FEP and BlueCard^® claims are excluded from these changes. However, FEP will participate in the use of the Medical Record Routing Form.

Medical records are the supporting clinical documentation (e.g., patient history, lab results and medical reports) that cannot be sent as part of or within the electronic claim (the 837 transaction).

Implementation of this linkage capability will require the following:

• When Blue Cross or Medicare Advantage requires additional documentation (medical records) to finalize a claim service, the electronic claim must indicate that medical records are being sent (the PWK segment of the 837). If the electronic claim doesn’t indicate additional documentation is being sent, the service will automatically reject.
• When Blue Cross or Medicare Advantage requires additional documentation (medical records) to finalize a claim — and you have indicated on the 837 that the information is being sent — it must be received within seven days of the electronic claim receipt. If the medical records aren’t received within seven days, the service requiring documentation will be rejected.
• We’ll be expanding the current use of the Medical Record Routing Form to allow for the submission of medical records related to an original electronic claim for Blue Cross Blue Shield of Michigan, Medicare Advantage and FEP members. The form will be updated to include the new information required for these types of claims.

We’ll include additional information about this new capability in future issues of The Record.

New online training course explains best practices for medical record documentation

Managing patient care begins with accurate documentation and coding. You can now participate in a 30-minute online training module to learn more about proper medical documentation.

After completing the course, if you take a 10-question assessment and score 80 percent or better, you’ll receive one continuing education credit from the American Academy of Professional Coders.

To get to the training module, follow these steps:

1. At bcbsm.com/providers, log in to Provider Secured Services using your user name and password.
2. Click on web-DENIS.
3. Click on BCBSM Provider Publications and Resources.
4. Click Newsletters & Resources.
5. Click Patient Care Reporting.
6. In the Training Resources section, click on New online training: Best Practices for Medical Record Documentation (October 2015).

This new online training tool provides helpful information about medical record documentation, according to the Centers for Medicare & Medicaid Services guidelines, including:

• How to demonstrate the condition of the patient
• Principles of sound documentation
• Tips for maintaining quality medical records

The training module also covers the documentation elements needed for different types of Medicare office visits, such as:

• Initial preventive physical examination, also known as a “Welcome to Medicare visit”
• Annual wellness visit for Medicare beneficiaries
• Preventive medicine services
• Problem-oriented office visit E/M

We strive to ensure all patients with chronic conditions are seen at least once a year and that they receive appropriate care. Your detailed documentation and coding of diagnoses, along with any treatment or care each year, are key to managing patient care.

To properly document and code, doctors must manage, evaluate, assess or treat every patient and every condition, every year.

Visit the link above to learn more about best practices in documentation and coding and its advantages to you and your patients.

UAW Retiree Medical Benefits Trust members may elect separate health plans and carriers

Effective Jan. 1, 2016, URMBT members will be allowed to split their health care elections if they have both a Medicare enrolled and a non-Medicare enrolled member currently on the same contract, using the same contract ID. This split contract means that contract holders and spouses may have elected separate health plans or carriers.

If a contract holder chooses a separate health plan or carrier, the spouse or dependent will receive a new ID card with a new contract ID number. Both in-state and out-of-state providers will need to verify if the members have changed coverage and check plan eligibility for the affected contract holder, spouse or dependent.

If you have any questions about the new health plan election option, please contact Blue Cross Blue Shield of Michigan.

New NDC daily quantity maximum messaging begins in January

The daily quantity maximum is the number of units a National Drug Code can be billed on a single claim line for a particular date. Starting Jan. 1, 2016, when an NDC reaches or goes over its daily quantity maximum, you’ll receive a new message on your provider voucher:

We can pay for this service, but our payment policy has limits for this National Drug Code. This drug claim has a daily quantity maximum that’s more than we can pay. We’ve based our payment and the member’s liability on the eligible limit amount. (P610)

For example, if an NDC’s quantity maximum is five per date of service and 15 are coded, the message will also say that there’s been an adjustment in the reimbursement. Payment will be made for the first five units only.

A participating provider shouldn’t ask the member to pay more than the amount we allow.

BlueCard^® connection: Learn about coordination of benefits policy for BlueCard claims

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

Does Blue Cross Blue Shield of Michigan’s coordination of benefits policy apply to BlueCard claims?

No. The member’s home plan is responsible for determining the coordination of benefits method used for its members’ secondary or tertiary claims.

Members are responsible for:

• Notifying their home plan if they are covered under more than one health insurance contract
• Keeping their coordination of benefits information updated as required by their plan
• Notifying their home plan if one or more of the policies terminate

If you receive a claim rejection regarding a coordination of benefits discrepancy, please notify the member. Also notify the member if you receive a rejection advising you that the member has not responded to an open coordination of benefits inquiry with his or her plan. The member is responsible for resolving the issue with his or her plan.

For more information on the coordination of benefits program for BlueCard, refer to the BlueCard chapter of the online provider manuals. The BlueCard chapter includes other information about the program, such as links to and articles about online tools.

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: best practices for documenting pregnancy, childbirth and puerperium

The introduction of ICD-10-CM coding on Oct. 1, 2015, brought many changes to how we code pregnancies and the complications of pregnancies. ICD-10-CM coding captures a greater level of specificity for obstetric conditions, as it does for other conditions. Let’s explore some of these changes.

ICD-10-CM official guidelines for reporting and coding

“Pregnancy, Childbirth, and the Puerperium” is found in Chapter 15 of the ICD-10-CM coding manual. The majority of the codes in this chapter have a final character indicating the pregnancy trimester. Trimesters are counted from the first day of the last menstrual period and 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 until delivery

For example:

• O09.00 — Supervision of pregnancy with history of infertility, unspecified trimester
• O09.291 — Supervision of pregnancy with other poor reproductive or obstetric history, first trimester

Codes from category Z3A are for use only on the maternal record to indicate the pregnancy gestation weeks. Remember to first code complications of pregnancy, childbirth, puerperium (o00-o9A):

• O09.291 — Supervision of pregnancy with other poor reproductive or obstetric history, first trimester
• Z3A.09 — Nine weeks gestation of pregnancy

This is especially important as some providers are submitting Z3A codes as a reason for performing ultrasounds. These informational codes are not payable because they don’t code to an actual condition. These codes should only be reported as a secondary diagnosis.

If a trimester is not a component of a code, it’s because the condition always occurs in a specific trimester or the pregnancy trimester is not applicable. Certain codes have characters for only certain trimesters because the condition doesn’t occur in all trimesters. For example:

• O21.2 — Late vomiting during pregnancy (excessive vomiting that starts after 20 weeks of gestation)

The provider’s documentation of the number of weeks of pregnancy may be used to assign the appropriate code identifying the trimester.

Note: To avoid claim rejection after a patient receives an ultrasound, consider the following:

Example A: A member who is 16 weeks pregnant with twins (monochorionic monoamniotic) arrives for an ultrasound. Apply the complication code, the appropriate gestation code and the appropriate CPT code:

• O30.012 — Twin pregnancy (monochorionic monoamniotic), second trimester
• Z3A.16 — 16 weeks of gestation of pregnancy
• Appropriate CPT code

Example B: A member who is nine weeks pregnant arrives for a routine fetal ultrasound. Apply normal screening code first (uncomplicated pregnancy), followed by the appropriate CPT code:

• Z36 — Encounter for antenatal screening of mother
• Appropriate CPT code

Maternal record

Chapter 15 codes are to be used only on the maternal record, never on the newborn’s record. Codes from this chapter should be used for conditions related to or aggravated by the pregnancy, childbirth or by the puerperium (maternal causes or obstetric cases). For example:

• O00.1 — Tubal pregnancy

For the category O00, use any additional code from category O08 to identify any associated complications:

• O00.1 — Tubal pregnancy
• O08.1 — Delayed or excessive hemorrhage following ectopic and molar pregnancy

Status codes used only on the maternal record are from category Z37. For example, outcome of delivery category Z37.

Outcome of delivery codes should be included on every maternal record when a delivery has occurred. These codes shouldn’t be used on subsequent records or on the newborn record. Here are a few examples from category Z37:

• Z37.0 — Single live birth
• Z37.50 — Multiple births, unspecified, all live born
• Z37.9 — Outcome of delivery, unspecified

Note:  These codes shouldn’t be reported as a primary diagnosis on professional claims because they are informational in nature and don’t code to a reason for the service. They should only be used on the mother’s claim as a secondary diagnosis.

There are codes exclusively for the newborn record, such as category Z38. For example, Z38 “live born infants according to place of birth and type of delivery.” Here are a few examples from category Z38:

• Z38.0 — Single live born infant, born in hospital
• Z38.63 — Quadruplet live born infant, delivered vaginally
• Z38.8 — Other multiple live born infants, unspecified as to place of birth

HIV infection in pregnancy, childbirth and puerperium

During pregnancy, childbirth or the puerperium, a patient admitted because of an HIV-related illness should receive a principal diagnosis from subcategory O98.7-, “human immunodeficiency disease complicating pregnancy, childbirth and the puerperium,” followed by the code(s) for the HIV-related illness(es). For example:

• A patient presenting for an HIV-related illness should receive a principal diagnosis code O98.7 — followed by category B20 and the code(s) for the HIV illness(es) such as
• Pneumonia
• Herpes zoster
• HIV wasting syndrome, etc.
• Remember, codes from Chapter 15, “Pregnancy, Childbirth and the Puerperium,” always take sequencing priority
• O98.713 — HIV disease complicating pregnancy, third trimester
• B20 — HIV disease
• J15.4 — Pneumonia due to other streptococci
• Z3A.30 — 30 weeks gestation of pregnancy
• Patients with asymptomatic HIV infection status admitted (or presenting for a health care encounter) during pregnancy, childbirth or the puerperium should receive codes O98.7- and Z21.

Diabetes mellitus in pregnancy

Diabetes mellitus is a significant complicating factor in pregnancy. Pregnant women who are diabetic should be assigned a code from category O24, first followed by the appropriate diabetes code(s) (E08-E13) from Chapter 4.

Codes for gestational diabetes are in subcategory O24.4, gestational diabetes mellitus. Other codes from category O24, diabetes mellitus in pregnancy, childbirth and the puerperium, shouldn’t be assigned. For example:

• O24.011 — Pre-existing diabetes, type 1, in pregnancy, first trimester
• E10.9 — Type 1 diabetes mellitus, without complications
• Z79.4 — Long term use of insulin
• Z3A.09 — Nine weeks gestation of pregnancy

Consider the codes for gestational (pregnancy-induced) diabetes:

• O24.420 — Gestational diabetes mellitus in childbirth, diet controlled
• Z3A.37 — 37 weeks gestation of pregnancy
• Z37.0 — Single live birth
• Remember: Subcategory O24.4 includes diet and insulin-controlled codes. The use of code Z79.4 for long-term use of insulin is not needed

To ensure complete and accurate documentation and correct coding, be sure to code all pregnancy and pregnancy-related complications to the highest level of specificity.

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.

Clarification: Provider Financial Responsibility mandate

In previous issues of The Record, we’ve written extensively about the Provider Financial Responsibility mandate. We want to make sure you know that all inpatient Case Management-approved services are excluded from the mandate. For other details about the Phase II implementation stage of the mandate, see the June Record article titled “Providers could be financially responsible for not obtaining preservice reviews for Blue Cross members prior to inpatient admissions.”

Billing chart
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.

Reminder: Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange PHI electronically with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures that information is routed to the appropriate destination. You don’t need to update the Provider Authorization if your submitter and Trading Partner IDs don’t change.

Keep the following in mind when changes occur. You should review your Provider Authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization if you will send claims using a different submitter ID or route your 835s to a different unique receiver/Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers.

• Click on Quick Links
• Click on Electronic Connectivity (EDI)
• Click on Update your Provider Authorization Form

If you have questions about EDI enrollment, call our help desk at 1-800-542-0945. For assistance with TPA and Provider Authorization form, select the TPA option.

Clarification: August Record article about additional procedure codes payable to chiropractors

In an August Record article, we used incorrect terminology when referring to certain physical rehabilitative services payable to chiropractors. We should have written that additional procedure codes are payable to chiropractors for physical medicine services, effective Aug. 1, 2015. This change applies to groups with standard chiropractic benefits.

Due to this change, medical physicians (M.D.s or D.O.s) may be asked to agree to and sign a physical medicine treatment plan developed by chiropractors. A prescription is not required for a member to receive covered physical medicine services from a chiropractor.

This provision means that Blue Cross Blue Shield of Michigan will pay for the first physical medicine service per patient and not per visit. After the first physical medicine service is provided, Blue Cross will not pay for additional physical medicine services to the patient without the development of a physical medicine treatment plan that is agreed to and signed by the member’s M.D. or D.O.

The only exception to this requirement is for mechanical traction (procedure code *97012), which may be performed at subsequent visits without a physical medicine treatment plan. For mechanical traction, Blue Cross will maintain the current payment structure. A physical medicine treatment plan is not required for this code.

Health care providers should document the use of procedure code *97012 in the physical medicine treatment plan if mechanical traction is performed in addition to other physical medicine services. That way, the M.D. or D.O. is aware of all of the treatment the patient is receiving to help ensure coordination and quality of care.

For a list of reimbursable procedure codes, refer to the August Record article.

Note: No physician (M.D. or D.O.) agreement or signature is required on a treatment plan for MESSA members.

Clarification: Preauthorization for abdomen and pelvis CT scans

It’s come to our attention that some facility providers aren’t sure how to handle preauthorization for abdomen and pelvis CT scans. We’ve clarified the rules below.

The preauthorization process for CT abdomen (*74150, *74160, *74170), CT pelvis (*72192-*72194), and CT abdomen pelvis combination tests (*74176-*74178) follows some specific rules:

• When the imaging service is performed and it’s determined that a different CPT procedure(s) is more appropriate than the preauthorized CPT, the imaging facility or the ordering physician must contact AIM Specialty Health to change the order. The office that changed the order (imaging facility or ordering physician) must withdraw the original request and obtain authorization for the new procedure.
• In these specific circumstances, we provide a post-procedure window of up to 60 days for the ordering or servicing providers to obtain the new authorization. AIM may perform a retrospective review either by phone or online.  Contact AIM at 1-800-728-8008 or aimspecialtyhealth.com.**
• To prevent retrospective reviews and comply with the preauthorization program, all imaging providers are required to obtain a valid authorization before performing these scans.

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

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

Blue Cross is changing its reimbursement policy for prehospice services

Blue Cross Blue Shield of Michigan created the prehospice benefit to improve quality of care for patients with advanced illnesses. The benefit provides increased access to hospice and palliative care services.

Blue Cross commercial members with the prehospice benefit may receive coverage for counseling, education and support services delivered by participating hospice providers.

Please note:

• Prehospice services are payable for members who may not be eligible for hospice care or do not wish to enroll in it.
• Members may continue receiving treatments directed toward curing their disease while using prehospice services.

Currently, hospice providers performing prehospice care can bill revenue code 0691 regardless of the nature of the visit performed. But effective March 1, 2016, there will be two billable levels of prehospice care:

1. Consultation and education for prehospice and palliative care services (revenue code 0694) should be billed if the nature of the visit is purely educational or consultative. This includes:
• Promoting an understanding of palliative care
• Informing the patient about the availability of hospice care services
• Answering questions and discussing options
2. A charge for a prehospice or palliative care visit (revenue code 0691) should be billed if the visit involves additional aspects of patient care. This includes:
• Clinical decision-making
• Symptom management
• Delivery of other tangible support or skilled care services

Blue Cross members with prehospice coverage have a lifetime limit of up to 28 prehospice visits. The 28-visit limit includes a combination of both revenue codes 0691 and 0694. These visits are not charged against the patient’s hospice day or dollar benefit maximums. To determine if a member has prehospice coverage, please refer to PARS and the web-DENIS Subscriber Information screens.

The new prehospice reimbursement amounts will be included with the hospice rate schedule. The schedule will be available on web-DENIS on or before Dec. 1, 2015. As a reminder, prehospice and hospice rate updates will take effect March 1, 2016.

Clarification about maximum coverage amount

Updates to the maximum coverage amount for 2016 will be effective Jan. 1. But as of Oct. 1, 2016, Blue Cross will be updating its annual adjustments to the hospice maximum coverage amount in accordance with the Centers for Medicare & Medicaid Services’ published hospice cap. You can access information about CMS’ annual hospice cap and effective date through the CMS website by clicking here.**

**Blue Cross Blue Shield of Michigan doesn’t own or control the content of this website.

ClaimsXten™ coming to outpatient facilities next year: Let us help you make the transition

As you’ve read in The Record previously, McKesson ClaimsXten is coming to outpatient facility claims in early 2016. Below we’ve outlined how ClaimsXten will further align Blue Cross Blue Shield of Michigan’s outpatient and professional payment policy as it relates to quantity, bundling and same-day medical services. Also included is additional detail regarding appropriate reimbursement for multiple surgical and multiple radiology services.

 Modifiers may be used as appropriate

Modifiers are used to indicate that a service or procedure has been altered by some specific circumstance, or to provide more information regarding the service performed. Most modifiers apply to a group of procedure codes and may only be reported with those specified codes.

Per billing guidelines, outpatient facilities should report, as required, modifiers for the appropriate procedure code. Modifiers can affect the payment policy recommendation given by ClaimsXten, but doesn’t guarantee payment. Use of the following modifiers where appropriate will ensure payment accuracy and coding consistency.

Billing identical procedures multiple times

The clinically recommended daily allowance determines the number of times identical procedures can be billed on a single date of service for the same patient. The total number of times that a specific procedure code may be allowed reflects the number of times that it is clinically appropriate to perform the service on a single date of service across all anatomic sites.

ClaimsXten quantity editing determines when the use of multiple units is appropriate. Factors included in this determination are derived from the nomenclature for a particular procedure code or the ability to clinically perform a particular service more than one time on a single date of service.

All or any of the following factors below will determine the number of times a code is eligible for reimbursement on a single date of service:

• The nomenclature of a procedure code includes the word “bilateral.”

• The nomenclature of a procedure code includes the phrase “unilateral/bilateral.”

• A procedure code description specifies “unilateral” and there is another code for the bilateral service or another add-on code for additional services. (The unilateral procure code cannot be submitted more than once on a single date of service.)

• The total number of times it is clinically possible to perform a given procedure on a single date of service might be limited. In some circumstances, a site specific modifier will allow a code to process when used more than once. These modifiers will identify the specific side or finger digit when more than one site is being treated or evaluated.

• When a procedure code is submitted with multiple units — and only a single unit is allowed — reimbursement will be based on only one unit unless an appropriate modifier is appended.

• Surgical services are not subject to quantity reimbursement; they are subject to multiple surgical bundling logic.

New reporting and payment policy guidelines

Blue Cross continues to demonstrate its commitment to the development of a fair and consistent payment policy by working collaboratively with its participating outpatient facility providers. If you have questions about a Blue Cross payment decision, contact your provider consultant or continue to follow the same appeals process that you do today.

Here are guidelines for genetic testing reimbursement

The following requirements are for laboratories seeking reimbursement for genetic testing from Blue Cross Blue Shield of Michigan:

• All genetic testing must be performed according to the criteria in Blue Cross’ medical policy, provider manual or other Blue Cross provider communications.
  
  
• Algorithms** driving secondary testing must be:
• Approved by Blue Cross
• Ordered by an attending physician
• Supported by documentation in the medical record, or preauthorized by Blue Cross
  
  
• Panels for genetic testing must be:
• Approved by Blue Cross
• Ordered by an attending physician
• Supported by documentation in the medical record or preauthorized by Blue Cross

Note: For the purposes of this article, “approved by Blue Cross” refers to those algorithms** and panels listed on web-DENIS, in The Record or in any other Blue Cross publication.

**An algorithm is an evidence-based set of rules that allows clinicians and other medical professionals to make standardized decisions about testing, based on a given set of clinical circumstances and prior test results.

Reminder: Changes in billing and reimbursement for partial hospitalization program and electroconvulsive therapy

Blue Cross Blue Shield of Michigan will change the requirements for hospitals billing for the partial hospitalization program and electroconvulsive therapy services, starting Jan. 1, 2016.

The partial hospitalization program will be billed as an outpatient service only and electroconvulsive therapy can be billed as an inpatient or outpatient service. These changes will help to simplify billing and standardize reimbursement for these services across the state.

For more details about the billing changes, refer to the October Record article on this topic or contact your provider consultant.

Reminder: Get signature as proof of receipt

All Blue Cross Blue Shield of Michigan and Blue Care Network prescription drug programs require a signature as proof of receipt when a medication is dispensed. A signature from the member or his or her caregiver or representative is acceptable. Here are examples of proper proofs of receipt:

• A member’s signature on the pharmacy’s electronic or manual signature log
• A signature of a caretaker or other person who signs for delivered medication on behalf of the patient at his or her home
• The signature of the person in charge of receiving medications at a nursing home or other facility.

For prescriptions that pharmacies mail to members, we request that the pharmacy provide a dated “proof of receipt and delivery” — the medication can’t be left on the porch. Whether the pharmacy uses its own courier or an external courier, it must provide the receipt signed by the member, representative or caregiver showing the member received the medication.

Part of the pharmacy audit process is to verify patient receipt of medications. If we can’t verify signatures during an audit, we’ll seek a refund of those prescriptions. If you disagree with an audit finding, you can appeal by submitting a signed customer statement that has the:

• Prescription number
• Medication
• Quantity
• Date of receipt
• Patient’s full name, address and telephone number

Medicare Advantage Private Fee-For-Service plan to offer members an additional choice

To provide more choices for our Medicare-eligible members, we’re developing a Medicare Advantage Private Fee-For-Service plan. Eligible members will be offered the MA PFFS plan during the 2016 annual enrollment period, with coverage starting Jan. 1, 2017.

We’re building the Centers for Medicare & Medicaid Services-required PFFS network for 2017 using our existing statewide MA PPO network of providers. Your participation in the network is essential to ensuring that your patients have greater product choice, along with the ability to retain their current providers. We’ve changed the MA PPO Provider Contract to include this new product.

If you choose to participate in the MA PFFS plan, you don’t need to do anything. If you don’t want to participate in the plan, you’ll need to opt out of the MA PFFS network by Feb. 11, 2016, as the new contract will take effect on Feb. 12, 2016. However, we believe that you‘ll find this product easy to work with and also will give your patients who are transitioning to Medicare an additional option to consider.

The new contract is available for review on bcbsm.com/providers, along with the form to opt out. Here are the steps to follow:

• From the Provider Enrollment section of bcbsm.com/providers, follow the prompts.
• On the Forms and Documents page, click on the light blue box to expand the section on BCBSM agreements and signature documents.
• The provider who agrees to the agreement and information in the attachment must complete the signature document.
• Follow the directions on the document to submit the form to Blue Cross.

Opting out of the MA PFFS plan will not affect your MA PPO affiliation.

Here are some key facts about the new plan:

• Reimbursement will be the same as it is with your MA PPO Agreement.
• It pays on a fee-for-service basis.
• There are no preauthorization requirements.
• There is minimal member cost-sharing for services covered under the plan. Most services will have no copays or coinsurance.
• There is no drug component

If you have questions, contact your provider consultant.