Blue Cross to implement 2016 InterQual^® criteria Aug. 1

Blue Cross Blue Shield of Michigan will implement 2016 InterQual acute care, rehabilitation, skilled nursing, long-term acute care and home health criteria, starting Aug. 1, 2016.

The criteria format for rehabilitation, skilled nursing and long-term acute care hasn’t changed, but there were some changes made to the home health care criteria format last year. For details, see article at right.

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 those 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 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 to InterQual criteria, also called local rules, were posted on web-DENIS in June. To access them:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources in the left column.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources.

Submitting InterQual comments

If you have questions, concerns or comments about InterQual^® criteria, email McKesson Health Solutions at CESupport@mckesson.com and include the following:

• The name and address of your facility
• A note indicating that this is a question related to InterQual and which criteria set you’re inquiring about

Or you can email your provider consultant if you have questions. Don’t know who that is? Visit the Contact Us section of bcbsm.com/providers to locate the provider consultant for your area. Click on their name to access their email address.

Note: Our InterQual Criteria Helpline is no longer active.

To help us respond to you quickly and accurately, provide the following information when emailing your provider consultant:

• Criteria book you're using
• Page number from that book
• Criteria you have a question about
• Your question, comment or concern

Here’s an example of how to format a question:

Under “Acute Criteria, Adult” on Page ADLT-15 Acute Coronary Syndrome, INTERMEDIATE, Intervention: Do newer oral anticoagulants alone meet this criterion?

 Be sure to include your name and your organization’s name.

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

Submit 2016 service dates for MA Diagnosis Closure Incentive program

The 2016 Medicare Advantage Diagnosis Closure Incentive program is effective for dates of service Jan. 1, 2016, or later. As part of the program, health care providers should complete patient diagnoses, supported by any necessary documentation in their medical records and following M.E.A.T. (manage, evaluate, assess or treat) guidelines.

You’re required to address 2016 diagnosis gaps with a face-to-face visit with your patients by Dec. 31. You then have until Jan. 31, 2017, to submit results of your 2016 patient visits on Health e-Blue. (See article at right for information on accessing Health e-Blue.)

Your patients’ 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 2016 diagnosis gap, the diagnosis gap will open with the next refresh and the gap closure won’t count toward your 2017 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 2017.

See the March Record for details.

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

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

Here are tips for searching the provider manuals

Have you ever been frustrated when you couldn’t find something in the Blue Cross Blue Shield of Michigan provider manuals? Here’s how to make your search easier and more productive.

If you know which provider manual chapter you want to search, first open the chapter. Then:

• Press Ctrl + F on your keyboard. (Press F while you hold down the Ctrl key.) This will open the Find dialog box.
• Enter a search term in the Find dialog box.
• Click Next.

• Keep clicking Next until you find what you’re looking for.

Each time you click Next, you’ll be taken to another location in the chapter where your search term appears.

The Ctrl + F method of searching can be used in any document, not just in a provider manual chapter. For instance, you can also use it on The Record Archive page to help you find a newsletter article headline.

When using Ctrl + F, the more words you use, the fewer results you’ll get. That’s because the more words that are in your search term, the fewer are the chances that all those words will appear together — and in the exact order in which you’ve arranged them — in the document you’re searching. For example, if you search for “claim” in the Claims chapter, you’ll find more than 100 results. However, if you search for “claim form,” you’ll find 13 matches.

If you don’t know which provider manual chapter you want to search, you can search the entire provider manual using the Keyword Search and the Virtual Document.

1. Keyword search
   
   After selecting your Provider Type, click on Keyword(s) in the Provider Manuals dashboard.
   
   This will open a Keyword Criteria panel that offers you two boxes in which to type keywords. You can only type one word in each of the boxes. If you type two words in one box, you will not get any results.
   
   When you click Finish and then click Search in the dashboard, the computer will take up to a minute to compile your list of manual chapters that contain the search words you’ve chosen. In some cases, there will be many chapters in the result. This is the case for the example shown above. The search terms “claim” and “appeal” exist in 12 chapters of the MD-DO provider manual. If you don’t want to click through each chapter to find what you’re looking for, you can use the Virtual Document.

2. Virtual Document
   
   The first item listed in the search results is the Virtual Document. When you click on it, you’ll get the following message in green: The requested virtual document has been created. Click the Jobs tab to view it.
   
   When you click on the Jobs tab, you’ll see a document listed. Click on it and it will open one long document that contains every chapter that was in your Keyword search results.

3. Use Ctrl + F
   
   Now you can use Ctrl + F to open the Find dialog box and click on Next to quickly review all instances of your search terms in the manual.

If you need assistance, Provider Inquiry or your provider consultant can help. You can also send an email to ProviderManuals@bcbsm.com for concerns related to the Blue Cross provider manuals.

Use Medical Record Routing Form as cover sheet when sending medical records to Blue Cross

When sending records to us, it’s important to fill out the Medical Record Routing Form and use it as your cover sheet. This applies to:

• Medical records we’ve requested from you
• Supporting medical records you’re sending to us as part of a request to review a rejected claim

Instructions for filling out the form online are included with it on web-DENIS. Once we receive the completed form with the records, all of the documents are scanned into our repository. Then the department responsible for reviewing the claim and documentation is notified that the records have been received.

Allow 30 days for medical record reviews.

For BlueCard^® claims, the completed form and medical records should only be submitted if you received a BlueCard claim rejection requesting the records.

Below are some tips to ensure your records are reviewed promptly:

Follow these guidelines

• Fill out the Medical Record Routing Form on web-DENIS, print it and use it as your cover sheet.
• Fax the routing form and medical records totaling 100 pages or fewer to 1-866-617-9917.  Medical record documentation more than 100 pages should be mailed to us at the address on the bottom of the form.
• Contact our Provider Inquiry staff if you have questions on a medical record request or to find out the status of your records review if you haven’t received a response to the claim after 30 days.

Avoid these missteps

• Don’t attach a paper claim form to the Medical Record Routing Form with your records.
• Don’t attach multiple records for different claims or patients to a single routing form.
• Don’t copy the form and complete it by manually writing in the required information.

The Medical Record Routing Form can be found under the Frequently Used Forms section of web-DENIS. Follow these steps:

1. Go to bcbsm.com.
2. Log in as a provider.
3. Click on web-DENIS.
4. Click on BCBSM Provider Publications and Resources.
5. Click on Newsletters and Resources.
6. Click on the Frequency Used Forms section in the upper right corner of the page.
7. Choose Medical Records Routing Form.

HCPCS codes added, deleted

The Centers for Medicare & Medicaid Services has added 12 new HCPCS codes, deleted three codes and added one modifier as part of its quarterly HCPCS updates.
The new codes are listed below.

The deleted codes are listed below.

Following is the added modifier.

For UAW retirees, report condition dates on ER professional claims to comply with new policy

We’d like to clarify a policy that took effect Jan. 1 for members of our UAW Retiree Medical Benefits Trust. URMBT members must receive emergency room services within 72 hours of the onset of the condition for which they are seeking treatment. If they receive services after 72 hours, we won’t cover those services.

This applies to professional and facility claims.

To ensure your claim is processed correctly, begin reporting the patient’s condition date on the ER professional claim. Failure to report the condition date could result in delays or a rejected claim. The condition code date is also required on the hospital’s emergency room claim.

If you have any questions on a rejected claim, contact our Provider Inquiry department for assistance.

Look for online updates to our prescription drug lists

Blue Cross Blue Shield of Michigan recently updated its online prescription drug lists, or formularies.

We regularly update these lists to help ensure patient safety and assist prescribers in selecting the most effective and affordable drug therapy for their patients.

You can view the most recent prescription drug list updates, including updates to the custom select drug list, at bcbsm.com/rxinfo. You can also see other pharmacy-related information at this link.

Our prescription drug lists can help prescribers make better-informed prescribing decisions that can lead to increased medication adherence. They can also help health care providers explain prescription drug coverage to our members.

BlueCard^® connection: Why does my claim on web-DENIS have a 17-digit number in the ICN field?

Blue Cross Blue Shield of Michigan uses a 14-digit internal control number to identify all commercial claims in our system, including ones for the BlueCard^® program.

But you may see a “710” code at the end of the 14-digit ICN when viewing a claim on web-DENIS on the Claims Summary page. The numbers “710” represent our Michigan plan code.

Our plan code should never be included when you’re asked to report an ICN on a replacement or void claim, or when completing the Medical Records Routing Form.

For more information on the BlueCard program, including links and articles on online tools, reference the BlueCard chapter of the online provider manuals.

If you’re experiencing issues with the information provided in the BlueCard chapter of the online manual — or if you’d like more information on a particular topic — contact your provider consultant.

Want to suggest a topic to be covered in this series? Send an email to ProvComm@bcbsm.com and put “BlueCard series” in the subject line.

Coding corner: Proper coding for major depressive disorder

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

You should always document the symptoms of MDD in the patient’s medical record to substantiate the diagnosis. Be sure to provide details of the most recent episode the patient experienced.

According to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), at least five of the nine symptoms listed at right need to be present on a regular basis during the same two-week period for the patient to be diagnosed with MDD. At least one of the symptoms must either be a depressed mood or loss of interest.

MDD is assigned to ICD-10 subcategories, depending on whether the condition is a single episode (F32.–) or a recurrent episode (F33.–). A fourth character is always necessary when coding MDD. The fourth-digit subclassifications specify the severity of the condition and identify the presence of related psychotic features, if applicable. A fifth character is only necessary when using subcategory F33.4– (major depressive disorder, recurrent, in remission) to specify if the patient is in partial, complete or an unspecified level of remission.

The terms utilized for the fourth- and fifth-digit subclassifications of MDD are used in conjunction with the specific diagnostic criteria listed below. The list details the level of severity along with the requirements needed to diagnose the severity.

• Unspecified: This term is used when the information in the medical record is insufficient to assign a more specific code.
• Mild: The patient experiences at least five of the symptoms needed for a diagnosis of MDD, which also pose a mild overall functional impairment.
• Moderate: The patient experiences seven to eight symptoms, or the symptoms he or she suffers from pose a moderate overall functional impairment.
• Severe without psychotic features: The patient experiences most or all of the symptoms, or the symptoms he or she experiences pose a severe functional impairment, but the patient presents without any psychotic features.
• Severe with psychotic features: The patient experiences most or all of the symptoms, or the symptoms he or she experiences pose a severe functional impairment and the patient presents with psychotic features.
• In full remission: The patient previously had two or more episodes but has been free from symptoms for at least two months.
• In partial remission: Some symptoms may still be present but the full criteria are no longer met, or there are no longer any significant symptoms of an episode, but the patient hasn’t been in remission for two months or longer.

Caution should be taken when coding to a specific severity level without that level being stated in the medical record, even if documentation of the clinical requirements for that level of severity are noted in the medical record. Providers should clearly state the level of severity of the depression and correlate this with supporting documentation, such as current prescribed medications, a PHQ-9 or another standardized assessment.

The major difference between ICD-9 and ICD-10 coding for depression is that medical record documentation that simply states “depression” and has no further supporting documentation will now index to “major depression, single episode, unspecified (F32.9).” Following are all the code choices for MDD.

ICD-10 code choices

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

 None of the information included herein 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 all applicable state and federal laws and regulations.

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.

Here’s how newborn coverage was updated

When Blue Cross Blue Shield of Michigan became a mutual company in January 2014, its newborn coverage policy changed. We want to make sure you are aware of these updates.

Newborn coverage changes

• Newborns are covered for the first 31 days from the date of their birth whether or not the baby is listed on the subscriber’s contract. Coverage includes both well-baby care visits and claims for injury, sickness, congenital defects and birth abnormalities. If the baby is not enrolled on the subscriber’s contract on day 32, coverage under our 31-day newborn coverage policy terminates.

• The 31-day newborn coverage policy applies to either the mother’s or the father’s contract, whoever is the subscriber. The mother is not required to be listed on the father’s contract for the newborn to be covered.

• The 31-day newborn coverage does not apply to the newly born child of a dependent. If the mother is a dependent (not the subscriber or the spouse) on the contract, then claims for the newborn will be denied. Blue Cross does not provide coverage to the newborn of a dependent unless the subscriber has legal responsibility for the newborn. Coverage for the newborn may be available through other sources.

Note: The 31-day newborn coverage policy does not apply to Federal Employee Program^® members. For self-funded groups, newborn coverage is determined by the group’s plan.

For additional information about our newborn coverage policy, refer to the benefit section of our online provider manuals, which will be updated to include information on this policy July 1, 2016.

If you have questions regarding a denied claim or to status a claim that you reported, please contact Provider Inquiry.

Blue Cross not covering select high-cost drugs with comparable alternatives

To address the high cost of drugs and provide the best value for our members, Blue Cross Blue Shield of Michigan commercial plans will no longer cover select high-cost, U.S. Food and Drug Administration-approved drugs for which more cost-effective therapeutic alternatives are available. This doesn't apply to Michigan Education Special Services Association members.

The initial drugs targeted for this initiative are Jublia^®, Kerydin^® and Onmel^®, a group of medications used to treat onychomycosis, or toenail fungus. These drugs will no longer be covered beginning Aug. 1, 2016.

The following table includes the approximate cost of the brand-name drugs and associated therapeutic alternatives:

**Approximate cost for a 30-day supply based on the average wholesale price.

In some cases, members’ out-of-pocket costs for these brand-name drugs may be lower than their copay due to manufacturer savings cards. However, the high cost of these drugs is reflected in future premium rates and may affect the claims experience for both members and plans.

As part of this ongoing initiative, Blue Cross will continue to identify select high-cost drugs and will stop covering them when there are more cost-effective alternatives available for our commercial members.

Blue Cross adding 2 additional specialty drugs to Medical Drug Prior Authorization program Oct. 1

Beginning Oct. 1, 2016, two more specialty drugs will need prior authorization from Blue Cross Blue Shield of Michigan before they’ll be covered under a member's medical benefits.

Keep in mind that prior authorization is just a clinical review approval, not a guarantee of payment. Providers will still need to verify the necessary coverage for this medical benefit. Our office will accept the medical drug prior authorization request forms, with supporting documentation, for these newly added drugs as early as Aug. 1, 2016.

Starting Oct. 1, 2016, the following two drugs will need prior authorization:

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

1. Click on BCBSM Provider Publications and Resources.
2. Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
3. 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 faxed or mailed to Blue Cross, or a request uploaded onto NovoLogix, an online-based tool. Standard processing time for request review is 15 days. An urgent request can be reviewed within 72 hours.

The list** below shows all the medications that are part of the Medical Drug Prior Authorization Program.

Note: The prior authorization requirement doesn’t apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

**Blue Cross reserves the right to change this list at any time.

Confirm your provider directory information in CAQH ProView

It’s important that your contact information in the Blue Cross Blue Shield of Michigan and Blue Care Network health care provider directory is accurate, current and complete. Patients and referring physicians use this information to search for a health care practice that meets their needs.

New federal and state regulations require regularly updated, accurate information in provider directories. There are new rules by the Centers for Medicare & Medicaid Services for Medicare Advantage plans and Medicare and Medicaid insurance plans, requirements for qualified health care plans participating in the federally facilitated Marketplace and provider directory requirements in 26 states.

In the May 2016 Record, we informed you that Atlas Systems will help gather information for our provider directory.

Working with CAQH
Within in the next couple of months, Blue Cross and BCN will work with CAQH**, a nonprofit alliance, to ensure that the information in our provider directory is accurate and up to date. Our goal is to help you avoid frequent outreach for the same information by multiple health care plans, which could create a significant burden on your staff’s time and resources.

For many years, we’ve been a participant in CAQH ProView, which streamlined the credentialing process. Now we’re working together to use that same information to simplify the process of updating provider directories. We’ll be using CAQH ProView for our quarterly directory attestation.

Blue Cross and BCN worked with CAQH to begin a multi-plan initiative to encourage physicians and other health care professionals with existing CAQH ProView^®** profiles to:

• Review their current information in a new “Provider Directory Snapshot” as part of their regular re-attestation process
• Make updates to their information and affiliations, as appropriate
• Re-attest that this information is current, accurate and complete and may be published in the provider directories for the participating health care plans that they designate

After Blue Cross and BCN receive this information, we’ll incorporate it into our provider files. To meet CMS and other requirements, CAQH will reach out to you once each quarter to review and update your directory information. We also encourage other health care plans you contract with to participate in this initiative as well.

If you have questions about your provider file information or about CAQH ProView**, contact your provider consultant. To learn more about the CAQH Provider Directory initiative**, go to caqh.org**.

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

Here’s what you need to know about surgical debridement and routine foot care coding

Debridement is the surgical removal of infected, weakened or pathological tissue, as well as foreign material. Postoperative complications, such as a deep wound gap or wound infection, may require surgical debridement.

The patient’s medical records must document both the need for and performance of these services. You can use the following procedure codes to report the appropriate description and level of wound debridement:

*11000
*11001
*11042
*11043
*11044
*97597

Note: Codes *11040 and *11041 have been discontinued.

Don't use the codes above when reporting:

• Postoperative debridement of incisions, which involve normal exfoliation of the superficial layers of the skin
• Procedures using chemical, cryotherapy, laser or other destruction where there's expected exfoliation or drainage secondary to the procedure performed

Routine foot care guidelines

Debridement for routine foot growths — corns, calluses — refers to the paring, curettement, shaving, cutting or sharp dissection of nonpathological tissue, which isn't associated with a wound, ulceration or infected tissue.
Routine foot care is the routine treatment and cutting of corns, calluses and nail treatment. It includes paring, cutting, debridement and curettement of:

• Corns
• Calluses
• Nails
• Benign lesions or other thickened skin
• Toenails infected with a fungus

Blue Cross Blue Shield of Michigan doesn't cover routine foot care, except for the following groups:

• Kmart
• Michigan Education Special Services Association, or MESSA
• State of Michigan

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.

Documenting and coding arthrocentesis procedures

Taber’s Cyclopedic Medical Dictionary defines arthrocentesis as “Puncture of a joint space by using a needle; usually done in order to remove accumulated fluid from the joint.”

Arthrocentesis is a widely used and relatively uncomplicated procedure to perform. It's an effective diagnostic and therapeutic method that introduces a corticosteroid or a local anesthetic agent into a joint when medically necessary and appropriate.

Complications, side effects and contraindications for this procedure may include:

• Exacerbation of infection
• Damage to joint tissues
• Tendon rupture
• Ligament rupture
• Masking of advancing disease activity
• Septic arthritis
• Neuropathic arthropathy
• Muscle atrophy
• Local osteoporosis
• Avascular necrosis
• Fatty atrophy
• Delayed healing

Documentation requirements
Medical records must chronologically document the patient’s medical history and physical exam in sufficient detail to ensure that he or she receives high-quality care. This will also allow a fair and accurate review of a physician’s services by payers.

The patient's chart should include:

• Symptoms and physical findings
• Diagnosis
• Specific procedure performed
• Exact site of injection
• Amount and dose of the anesthetic agent or the anti-inflammatory agent used in the injection
• Physician’s rationale for each injection and treatment plan
• Patient’s condition and response to the procedures

Also, be sure to document the following in the patient's chart:

• Clearly stated and specific rationale for extending treatment beyond three to five injections for one joint or area
• Patient response to previous treatments
• A proposed plan for the resolution of the problem
• A proposal for alternative therapy if there's inadequate patient response

Coding guidelines
Intra-articular steroid injections are included as part of arthrocentesis surgical procedures. There's no separate reimbursement for the medication.

Beacon Health offers behavioral health consultation services to physicians regarding URMBT members

Beacon Health offers Blue Cross Blue Shield of Michigan participating primary care physicians the opportunity to consult with a psychiatrist regarding patients who are members of the UAW Retiree Medical Benefits Trust.

Beacon Health is the behavioral health manager for the URMBT.

Physicians can schedule a telephone consultation with a board-certified psychiatrist to discuss behavioral health conditions typically seen in a primary care setting, such as depression, anxiety, bipolar disorder and substance abuse. They can seek advice on the diagnosis, treatment and medication for these conditions.

Call the Beacon Health PCP hotline at 1-877-241-5575 to schedule a consultation Monday through Friday from 7 a.m. to 3:30 p.m. Eastern time. There is no cost for this service for either the physician or the patient.

Did you know? Appropriate and early treatment of behavioral health issues can improve a patient’s overall medical care and reduce medical complications down the road.

Reminder: Blue Cross expanding 24/7 online health care coverage

On July 1, Blue Cross Blue Shield of Michigan will expand 24/7 online health care services with American Well^® to all underwritten Blue Cross groups and individuals.

Blue Cross has contracted with American Well, an independent company, to provide online health care for our members.

As you read in The Record previously, this service has been available since Jan. 1, 2016, to Blue Cross and Blue Care Network self-funded groups that choose to participate, as well as to all BCN underwritten groups and individuals.

Physicians who already provide — or who wish to provide — their own telemedicine services should review Blue Cross’ updated telemedicine policy in the billing chart in the February Record. The policy, effective Jan. 1, 2016, is detailed in the “Updates to payable procedures” section of the chart.

To review BCN’s telemedicine policy, see the March – April issue of BCN Provider News.

If you choose not to provide telemedicine services, your patients may have covered services through our arrangement with American Well.

Reminder: Reporting insertion and removal of bone fixation devices

Insertion of fixation devices
Use procedure code *20650 for skeletal traction or for the percutaneous fixation of a fracture or dislocation. Bill either closed reduction or percutaneous fixation — not both.

Removal of fixation devices
Reimbursement for removing the external bone fixation devices is included in the reimbursement for the original surgical procedure in which the devices were inserted. Procedures would not be billed separately from the initial surgical procedure.

However, you may bill procedure code *20670 as a separate code if you’re not an associate of or a member of the same group as the original operating physician.

Superficial pin removal refers to K-wires, or to buried wire or rods within the skin layer that may be removed with or without local anesthesia, but don't require incision or dissection of muscle, tendon or fascia. Pins located distal to the metacarpal or metatarsal joints are all considered superficial pin removal whether or not the pins are located below the dermis.

Deep pin removal refers to removal of a wire, pin, screw, metal band, nail, rod or plate that’s buried so that the ends or surface are located beneath the dermal layer.

Note: Do not use procedure code *20680 to report the removal of temporary K-wires.

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: Coverage for physical therapy procedure codes when supervised by a chiropractor

In the August 2015 Record, we published an article announcing that additional physical therapy procedure codes are payable to chiropractors. The article also should have stated that for Michigan Education Special Services Association members, additional physical therapy procedure codes are payable when supervised by a chiropractor.

This means that chiropractors can delegate physical medicine services, including massage therapy, to another person. The chiropractor isn't required to provide them directly.

A member doesn’t need a prescription to receive covered physical medicine services from a chiropractor. But for these services to be reimbursed, the chiropractor must develop a physical medicine treatment plan after the member’s first physical medicine service.

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. Blue Cross Blue Shield of Michigan maintains the current payment structure for these treatments.

Keep in mind that no physician agreement or signature is required on a treatment plan for MESSA members.

Check the billing chart under Updates to Payable Procedures in the August 2015 Record for a list of procedure codes that were newly reimbursable to chiropractors.

Reminder: When billing chiropractic claims, include all required documentation

When chiropractors bill for procedure code *97012 and other physical therapy codes, they must include the following information in their documentation:

• The device used to apply the therapy
• The anatomic location of the therapy (for example, cervical, thoracic or lumbar region of the spine)
• The time of treatment
• The medical justification (for example, to reduce a disc bulge or reduce scarring)

This information is required for reimbursement. Also, remember that you're subject to all Blue Cross Blue Shield of Michigan documentation guidelines located on the following sites:

• Our online Chiropractor provider manual on web-DENIS
• The Record newsletter articles
• Web-DENIS broadcast messages
• The ChiroCode DeskBook for chiropractic coding, reimbursement and compliance

To locate our online Chiropractor provider manual and find billing guidelines, log in to web-DENIS and follow these steps:

• Click on BCBSM Provider Publication and Resources.
• Click on Provider Manual.
• Enter the provider type and click on Search.
• Click on Chiropractic Services.
• Click on Billing Guidelines.

Blue Cross not covering select high-cost drugs with comparable alternatives

To address the high cost of drugs and provide the best value for our members, Blue Cross Blue Shield of Michigan commercial plans will no longer cover select high-cost, U.S. Food and Drug Administration-approved drugs for which more cost-effective therapeutic alternatives are available. This doesn't apply to Michigan Education Special Services Association members.

The initial drugs targeted for this initiative are Jublia^®, Kerydin^® and Onmel^®, a group of medications used to treat onychomycosis, or toenail fungus. These drugs will no longer be covered beginning Aug. 1, 2016.

The following table includes the approximate cost of the brand-name drugs and associated therapeutic alternatives:

**Approximate cost for a 30-day supply based on the average wholesale price.

In some cases, members’ out-of-pocket costs for these brand-name drugs may be lower than their copay due to manufacturer savings cards. However, the high cost of these drugs is reflected in future premium rates and may affect the claims experience for both members and plans.

As part of this ongoing initiative, Blue Cross will continue to identify select high-cost drugs and will stop covering them when there are more cost-effective alternatives available for our commercial members.

Blue Cross adding 2 additional specialty drugs to Medical Drug Prior Authorization program Oct. 1

Beginning Oct. 1, 2016, two more specialty drugs will need prior authorization from Blue Cross Blue Shield of Michigan before they’ll be covered under a member's medical benefits.

Keep in mind that prior authorization is just a clinical review approval, not a guarantee of payment. Providers will still need to verify the necessary coverage for this medical benefit. Our office will accept the medical drug prior authorization request forms, with supporting documentation, for these newly added drugs as early as Aug. 1, 2016.

Starting Oct. 1, 2016, the following two drugs will need prior authorization:

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

1. Click on BCBSM Provider Publications and Resources.
2. Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
3. 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 faxed or mailed to Blue Cross, or a request uploaded onto NovoLogix, an online-based tool. Standard processing time for request review is 15 days. An urgent request can be reviewed within 72 hours.

The list** below shows all the medications that are part of the Medical Drug Prior Authorization Program.

Note: The prior authorization requirement doesn’t apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

**Blue Cross reserves the right to change this list at any time.

Here’s how newborn coverage was updated

When Blue Cross Blue Shield of Michigan became a mutual company in January 2014, its newborn coverage policy changed. We want to make sure you are aware of these updates.

Newborn coverage changes

• Newborns are covered for the first 31 days from the date of their birth whether or not the baby is listed on the subscriber’s contract. Coverage includes both well-baby care visits and claims for injury, sickness, congenital defects and birth abnormalities. If the baby is not enrolled on the subscriber’s contract on day 32, coverage under our 31-day newborn coverage policy terminates.

• The 31-day newborn coverage policy applies to either the mother’s or the father’s contract, whoever is the subscriber. The mother is not required to be listed on the father’s contract for the newborn to be covered.

• The 31-day newborn coverage does not apply to the newly born child of a dependent. If the mother is a dependent (not the subscriber or the spouse) on the contract, then claims for the newborn will be denied. Blue Cross does not provide coverage to the newborn of a dependent unless the subscriber has legal responsibility for the newborn. Coverage for the newborn may be available through other sources.

Note: The 31-day newborn coverage policy does not apply to Federal Employee Program^® members. For self-funded groups, newborn coverage is determined by the group’s plan.

For additional information about our newborn coverage policy, refer to the benefit section of our online provider manuals, which will be updated to include information on this policy July 1, 2016.

If you have questions regarding a denied claim or to status a claim that you reported, please contact Provider Inquiry.

Reminder: Follow billing guidelines when purchasing, administering medical drugs to outpatients

When a hospital purchases and administers a medical drug for a Blue Cross Blue Shield of Michigan member who is an outpatient, the hospital should bill the revenue code and corresponding procedure code for both the drug and its administration, using separate revenue lines.

See the example below:

When a hospital administers a drug in an outpatient setting that isn’t purchased by the hospital, the hospital should bill for the administration. However, the hospital should include the revenue code and corresponding procedure code for the medical drug with total charges of $.01.

See the example below:

System updated to process DME/P&O and medical supply claims with office location

Blue Cross and Blue Shield of Michigan’s claims processing system has been updated to process all durable medical equipment, prosthetic, orthotics and medical supply claims with an office location.

Reminder: Procedure code E0485 not covered beginning Aug. 1

In alignment with Medicare’s policy, we’ll no longer pay for procedure code E0485 beginning Aug. 1, 2016. The code relates to a seldom-prescribed, pre-fabricated oral appliance.

We’ve been posting messages on web-DENIS about this coverage change since April.

Note: Federal Employee Program^® and Michigan Public School Employees Retirement System members are excluded from this change.

A custom oral appliance may still be covered. We’ll provide more details in The Record in the near future.

New webinar series on Prospective Provider Engagement Program now available

Blue Cross Blue Shield of Michigan and Blue Care Network have teamed with Data Driven Delivery Systems to provide an updated webinar on the Prospective Provider Engagement Program. The program is targeted to health care providers who treat Medicare Advantage patients.

This five-part educational program includes:

• A refresher course on how to accurately document patient conditions in a manner that’s compliant with the Centers for Medicare & Medicaid Services
• Program overview
• Clinical scenarios highlighting real-world examples to improve documentation accuracy
• Clinical expertise and support from Osamah El-Aroud, M.D., DDS medical director for Michigan

You can click on the links below to access the following modules:

1. Introduction to Risk Adjustment
2. DDS Program Overview
3. DDDS Clinical Documentation
4. Documentation Improvement Scenario — Diabetes with Complications, Morbid Obesity and Major Depression
5. Documentation Improvement Scenario — Angina, Pulmonary Hypertension and Secondary Hyperparathyroidism.

Each module lasts about 15 minutes. You can fast-forward, rewind or pause the recordings at any time and view as many times as you like.

How to print the presentation

You can print the presentation by clicking on the question mark icon in the lower right-hand corner of the viewing window. Select the Print Slides option.

About the presenter

Dr. El-Aroud has extensive experience in risk adjustment, Medicare Risk Adjustment Factor scores and Hierarchical Condition Category coding as they apply to the clinical world. He was instrumental in developing and implementing the Prospective Provider Engagement Program.

FAQs

You can access some of the most frequently asked questions by physicians by clicking on the attachments tab in the left-hand navigation menu and downloading the FAQs attachment.

Medicare Plus Blue^SM PPO prior authorization program to continue its expansion

Blue Cross Blue Shield of Michigan will expand its prior authorization program later this year to include three additional types of services for our Medicare Plus Blue^SM PPO members who reside in Michigan and use Michigan providers.

The expansion is intended to eliminate the unnecessary use of certain procedures to improve patient care and manage health care costs. Following are the three additional types of services that will require prior authorization:

• Lumbar spinal fusion surgery — Manage the utilization of spinal fusion surgeries to ensure clinical appropriateness.
• Interventional pain management — Manage the use of interventional pain procedures, including epidural injections, facet block and radiofrequency ablations, to help eliminate inappropriate delivery of such procedures.
• Radiation oncology — Manage the use of radiation therapy inclusive of modalities, dosing, coding and treatment goals, while reducing expenditures and the patient’s exposure to radiation therapy.

Prior authorization for these services will be administered by eviCore healthcare. EviCore is a national specialty benefit management company that focuses on managing quality and use for individual patients.

Providers will need to contact eviCore to request prior authorization for these services. If a prior authorization isn’t obtained for the above-mentioned services, claims will be denied as provider-liable.

For more information on changes to the post-acute care prior authorization process, read Reminder: Medicare Plus Blue^SM post-acute care prior authorization process changing June 1 in the June Record.

We’ll provide more details about these changes in future issues of The Record. We’ll also announce opportunities for training on the prior authorization expansion through web-DENIS broadcast messages.