Our first group customer selects Reference Based Benefits feature for certain member segments

Last month, we told you about a new benefit feature that some of our large, national customers are looking at — Reference Based Benefits, or RBB. This new feature encourages members to use online tools to help compare the costs of certain services and also establishes a reference price for those services.

As of our publication date, there’s one customer that has selected this feature for some of its members — syncreon. The group number, segment, alpha prefix and other key information will be included in The Record’s billing chart next month. However, we wanted to take this opportunity to remind you about working with RBB for Blue Cross Blue Shield of Michigan members.

How do I identify a member with RBB?

For syncreon, members will be identified with group number 71316. Additionally, a special message will appear on web-DENIS when you look up a member’s benefits and eligibility. The message will tell you that the contract includes Reference Based Benefits.

Where can I get information about the member liability?

For more information about the member liability for a given service, go to web-DENIS and check your patient’s benefits and eligibility. Once you enter the member’s ZIP code and select a treatment category, you’ll see the associated RBB information, including the reference price. As we explained in last month’s Record, the member is responsible for their usual cost share plus any difference between the reference price and the allowed amount for the service if the allowed amount exceeds the reference price.

Note: Keep in mind that this feature affects member cost share, not what health care providers will charge for services. In-network providers can expect to receive contracted rates on all procedures.

What services does this apply to?

For syncreon, the customer has decided to apply Reference Based Benefits to services such as:

• Hip and knee replacement (inpatient)
• Shoulder arthroscopy, upper GI endoscopy, sigmoidoscopy (outpatient)
• MRIs, CT scans and ultrasounds (diagnostic radiology)

A full list of applicable services is posted on web-DENIS in the Benefits and Eligibility section.

How does RBB work?

For planned, non-emergent services, members will access an online cost transparency tool to search for providers and compare the estimated costs for those services. When they receive services from providers at costs below the reference price, reference pricing will not apply. Blue Cross will continue to pay the allowed amount, and the member will be responsible for their usual cost share. For services with a cost that exceeds the reference price, Blue Cross will pay up to the reference price, and the member is responsible for any difference between the reference price and the allowed amount of the service, plus their usual cost share.

For example: If a reference price is $500 for an MRI of the spine and the allowed amount is $700, then Blue Cross pays up to $500 for the procedure. The member is responsible for their standard cost share on the $500, plus the $200 difference between the allowed amount and the reference price.

For more information, see the presentation on web-DENIS, which will be available by Dec. 1:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletter and Resources.
• It will be in the “What’s New” section of the page.

Basic organ, bone marrow transplant donor services covered in 2017

Starting Jan.1, 2017, Blue Cross Blue Shield of Michigan will cover living donor-related services under the recipient’s medical policy when the donor isn't a listed member.

• Only bill the recipient’s medical policy for living donors who are donating to a member on the policy.
• These changes don't apply to self-donations or cadaveric donations.
• This change only applies to Blue Cross basic organ transplants (bone marrow, kidney, cornea and skin).

This change doesn’t apply to members enrolled in the following groups:

• UAW Retiree Medical Benefits Trust™
• General Motors
• Ford hourly
• Fiat Chrysler Automobiles

Basic organ transplant, living donor billing guidelines
When a Blue Cross member is the recipient of a basic organ:

• Continue to follow the usual billing guidelines.
• Submit the claim using the recipient’s name and member ID number with the applicable recipient procedure and diagnosis codes.

When a member is the donor of a basic organ:

• Submit the claim using the recipient’s name and the recipient’s member ID number.
• Use the applicable donor procedure and diagnosis codes.

When you have a non-plan, member-donor claim:

• Use the donor diagnosis codes in the Z52- code section in the ICD-10-CM code set.
• List the Z52- diagnosis codes as a principal diagnosis code.
• Providers may also submit an attachment that indicates the patient is a donor, but it isn't required.

If the donor and the recipient are family members with coverage under the same policy:

• Submit the claims using the respective donor and recipient names.
• Use the applicable procedure and diagnosis codes for recipient and donor.

This billing requirement is for basic organ transplants only and doesn't apply to specified organ transplants.

Continue following the usual billing processes for all other organ transplants.

This requirement doesn't change any group benefits, it places the medical necessity and financial responsibility with the recipient. The donor won’t be billed. Donor coverage for complications is included in the post-operative care period.

Check bcbsm.com for recent prescription drug lists

Blue Cross Blue Shield of Michigan recently updated its 2016 online prescription drug lists, also called formularies.

Each quarter, we update these lists to help ensure patient safety and to help prescribers select the most effective and affordable drug therapy for patients.

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

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

Streamlined EFT process starts in December

In the November Record, we announced that as of 9 p.m. Dec. 8, Blue Cross Blue Shield of Michigan will only require your National Provider Identifier, or NPI, and its corresponding tax ID number to register for electronic funds transfer, update existing EFT bank information or cancel an EFT.

With this change, Blue Cross will only be able to support EFT to one bank account per NPI and tax ID. Practices or hospitals with multiple accounts for EFT have been notified and were asked to update their banking information to a single account before Dec. 8.

With this streamlined EFT process:

• You’ll only need to enter banking information for EFT once, even if your NPI and tax ID number are associated with multiple internal PINs.
  Note: If your internal PIN is affiliated with more than one NPI and tax ID, you’ll need to use every NPI and tax ID affiliated with your PIN to make EFT changes.

• Once you enter your NPI and tax ID to make an EFT change, Blue Cross will systematically update all internal PINs and banking information affiliated with your NPI and tax ID, including:
• PINs that were not registered for EFT before Dec. 8
• PINs with an expiration date less than two years from the submission date
• When a new internal PIN is created for an NPI and tax ID already registered for EFT, Blue Cross will systematically register the new PIN for EFT using the banking information already on file.
  
  
• Blue Cross will continue to share EFT banking information entered in the Provider Secured Services portal with Blue Care Network and Medicare Advantage.

Please contact Provider Inquiry or your provider consultant if you have any questions.

In February 2017, we’re discontinuing VBR for J-code oncology subset

Providers taking part in the Physician Group Incentive Program’s Michigan Oncology Clinical Treatment Pathways Collaborative were eligible to receive value-based reimbursement for a subset of J-codes for oncology drugs.

The Pathways program was retired June 30, 2016. Therefore, starting Feb. 28, 2017, Blue Cross Blue Shield of Michigan will discontinue providing value-based reimbursement for the subset of J-codes. Blue Cross will continue to pay value-based reimbursement for these subset J-codes to all former Pathways participants until Feb. 28.

These are the J-codes that will no longer be eligible for value-based reimbursement.

We remain committed to the development of an incentive model for oncologists for their efforts in improving cancer care for patients. Over the next year, Blue Cross will be working with our partners in the Michigan Oncology Quality Consortium collaborative to design and implement a modernized oncology value-based reimbursement that takes into account participation in quality initiatives and patient outcome measures. Our goal is to have a new oncology value-based reimbursement model in place by March 1, 2018.

We value the importance of our oncology community and strive to provide quality oncology care for all Michigan residents. We appreciate your patience and continued support as we work with together with our provider partners to develop an oncology program that brings value to the provider community and its patients.

If you have questions, email Marc Cohen, manager, Value Partnerships, at CQIprograms@bcbsm.com.

Online visits and telemedicine claims reporting clarified

On July 1, 2016, Blue Cross began extending services under telemedicine to include all codes specific to range of practice.

Submitted codes must have a GT modifier added. Modifier GT defines services given through interactive audio and video telecommunication systems.

However, certain codes don’t need the GT modifier. For example, online (98969 and 99444) and telephone (99443, 98966, 98967 and 98968) evaluation and management visits don’t need the GT modifier.

How to report in an office location

When the patient is initiating an online (98969 and 99444) or telephone (99443, 98966, 98967 and 98968) E&M service, providers should report an office location of service code (11-office) with the applicable online visit or telephone E&M procedure code. When a telemedicine E&M visit is submitted with a GT modifier, (e.g., 99212 – GT) also report the office location of service code.

How to report in a facility setting

If the patient is located in a facility setting, the applicable location of service code should be reported for telemedicine services. Refer to the Blue Cross telemedicine medical policy for more details.

PARS to provide members’ remaining visits or days in December 2016

The Provider Automated Response System, or PARS, currently provides you with the remaining amounts of member services in terms of cost-share dollars after you authenticate.

Beginning in mid-December 2016, PARS will be enhanced to provide members’ remaining number of visits or days in the benefit period for chiropractic spinal manipulation and cardiac rehabilitation services. Cardiac rehabilitation service limits won’t be available for MESSA members.

Remaining visit limits for physical therapy will be available starting in January 2017. We’ll provide more details in future communications.

Inpatient substance abuse day limits won’t be available through PARS. For this service, you’ll hear the following message, “Due to HIPAA regulations, we cannot provide remaining amounts on member sensitive benefits. If you require further assistance, please contact Provider Inquiry.”

Remaining day or visit limits for Blue Care Network, Federal Employee Program^® and Medicare Advantage policies won’t be available through PARS. To obtain the remaining days or visits for these policies, you should request to speak to a Customer Service representative after obtaining benefit information through PARS.

Note: You must listen to at least one benefit in PARS before a transfer to a Customer Service representative is offered.

Skilled Nursing Facility Pay-for-Performance program offers opportunities to earn incentive rewards

Blue Cross Blue Shield of Michigan freestanding and hospital-based skilled nursing providers can earn incentive rewards in 2017 by participating in the health information exchange through the Michigan Health Information Network notification service.

The goal of the Skilled Nursing Facility Pay-for-Performance program is to:

• Enhance the population-based model of health.
• Promote a team-based approach.
• Engage a strong commitment to the care continuum.
• Ensure that a patient’s caregivers receive timely notification of an admission, discharge, transfer or emergency room visit.
• Improve coordination of care and outcomes.
• Reduce the likelihood of an unplanned readmission.

Program details and rewards
Blue Cross will recognize skilled nursing facilities that fully implement the MiHIN admission, discharge and transfer use case. We’ll also recognize participants who implemented the use case in 2016 and continue to meet participation expectations.

Providers who meet expectations and deadlines will be eligible to receive an additional 1 percent reward for either six or 12 months following the incentive’s effective date.

Skilled nursing facilities that don’t meeting the program requirements or choose not to participate will forfeit the incentive opportunity.

Important dates

Additional information

• Program guides will be published online in the skilled nursing facility provider manual during December, before the beginning of the program year.

If you have questions, please contact your provider consultant.

HCPCS codes added, deleted; a code effective date changed

The Centers for Medicare & Medicaid Services has added nine new HCPCS codes and deleted two codes as part of its regular quarterly HCPCS updates. One code has a new effective date.

The new codes are listed below.

The deleted codes are listed below.

Clarification: Requirements for sleep testing

In a recent publication of the medical policy for sleep testing, we omitted some essential requirements. To clarify, the requirements are as follows:

• To perform and get reimbursed for in-center or out-of-center sleep testing, a doctor must be board-certified in sleep medicine by the American Board of Medical Specialties or the American Board of Sleep Medicine.
• Any M.D. or D.O. may order a sleep test as long as it’s performed and interpreted by a doctor who is board-certified in sleep medicine.
• Follow our pre-authorization program for in-lab sleep testing.

Correction: Use J9310 for rituximab to treat patients with Devic disease

The benefit and medical policy for procedure code J9310 identified the wrong drug in the November billing chart. It should have read:

Blue Cross Blue Shield of Michigan has approved rituximab, 100 mg for off- label use to treat patients with neuromyelitis optica, also known as Devic disease, when reported with procedure code J9310 and ICD 10 diagnosis G36.0.

The physician who prescribes this drug for off-label use must determine the appropriate dose when used other than that approved by the FDA.

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.

Participants in urological surgery collaborative get additional reimbursement opportunity

Value Partnerships continues to identify new and innovative models to reward physicians for improving the quality of care for our members and all Michigan residents. The most recent example of the program’s ongoing efforts is the new value-based reimbursement project for urologists participating in the Michigan Urology Surgery Improvement Collaborative Quality Initiative, part of Value Partnerships’ Physician Group Incentive Program.

The project combines Blue Cross Blue Shield of Michigan claims data with robust clinical data from the MUSIC CQI registry to identify specific quality targets for our Blue Cross Commercial PPO members who are treated by MUSIC urologists. Blue Cross and MUSIC Coordinating Center leadership collaborated to develop a set of quality measures and performance goals for prostate biopsy-related infections and imaging for patients who’ve been diagnosed with prostate cancer. The goals are to achieve a rate of 26.6 percent or lower for imaging and 6.6 percent or lower for infection.

Additional value-based reimbursement
MUSIC participants have the potential to achieve an additional 3 percent VBR, starting March 1, 2017, for collectively meeting or exceeding specific quality targets. This is in addition to their opportunity to receive 105 percent or 110 percent of the Standard Fee Schedule for performance on population-level measures of cost and quality.

The VBR fee schedule for urologists is applied only to commercial PPO claims for most procedure codes typically billed by urologists.

The two tables below show how the MUSIC VBR will be applied and define the measurement and reimbursement period.

To receive the MUSIC VBR, urologists must fully participate in the collaborative. Participation includes contribution of data to the MUSIC registry.

For more information

• For more details on the value-based reimbursement criteria, see the following two April Record articles:
• Here's what you need to know about participating in Value Partnerships quality programs
• We’re making some changes to the Value-Based Reimbursement Fee Schedule, effective July 1, 2016
• For more information on MUSIC, go to musicurology.com.
  
  
• If you have questions about the information in this article, email Marc Cohen of Value Partnerships at CQIprograms@bcbsm.com.

Requirements for 2 Blue Cross wellness products change

In response to recent federal regulations, Blue Cross Blue Shield of Michigan is making some changes to its workplace wellness products. Beginning with plan years on or after Jan. 1, 2017, requirements for the following products will apply to subscribers only:

• Healthy Blue Achieve^SM PPO
• Healthy Blue Incentives^SM

What’s changed?

You won’t be required to complete a qualification form for spouses and domestic partners, beginning with the contract’s 2017 plan year.

Note: Always remember to check a member’s eligibility and benefits.

Here’s what you need to know about the plan all-cause readmissions measure

We want to help you better understand the plan all-cause readmissions measure that is a HEDIS measure as well as a star ratings measure.

About the measure
Plan all-cause readmissions measures the number of acute inpatient hospital stays for patients during the measurement year that were followed by an acute readmission for any diagnosis within 30 days, as well as the predicted probability of an acute readmission.

• The commercial measure looks at patients ages 18 to 64.
• The star measure applies to patients 18 and older.

Patients must be members of their plan for one year before being identified for the measure.

HEDIS defines potentially preventable readmissions as those that are directly tied to conditions that could have been avoided in the inpatient setting.

Why the measure is important
Understanding readmission rates is important because discharge from a hospital is a crucial transition point in a patient’s care. According to the Centers for Medicare & Medicaid Services, about one in five Medicare patients is readmitted within 30 days. Poor care coordination at discharge can lead to adverse events for patients and potentially preventable readmissions.

While not all readmissions are avoidable, many potentially preventable readmissions can be avoided when hospitals and providers actively manage the complexities of transitioning care to another setting after hospitalization. The Mayo Clinic found that only 42 percent of discharged patients knew their diagnoses and only 37 percent could explain the purpose of their medications.

Readmissions also cost Medicare about $15 billion annually. To bring readmission rates down, CMS implemented its Hospital Readmissions Reduction Program. It will withhold $528 million in payments under this program in 2017.

According to a study by the University of California San Francisco, there are steps to reduce the need for readmissions. They include:

• Improving communication between patients and clinicians as well as between primary care and hospital doctors
• Assessing patients’ readiness for discharge
• Offering better post-discharge resources to patients

How can doctors help prevent unnecessary hospital readmissions?
Encourage your patients to schedule visits with you after they have been discharged from a hospital or other facility, preferably within seven days of discharge. If you learn that a patient was discharged, have your office staff reach out to schedule a visit.

Before the post-discharge visit:

• Review the patient's hospital discharge summary and get any test results that weren’t available when the patient was discharged.
• See if the inpatient facility’s doctors discontinued medications that you think the patient needs.

As part of the visit:

• Make sure the patient understands:
• His or her diagnosis
• Why he or she was admitted
• Signs and symptoms of when he or she should call you (during and after office hours) or when he or she should go to the emergency room
• Conduct post-discharge medication reconciliation by:
• Comparing the hospital discharge medications to the patient’s office medications
• Documenting it in the patient’s medical record
• As part of medication reconciliation, help your patient understand:
• Newly prescribed medications
• Which medications he or she should stop taking
• Talk about conditions and events (e.g., medication adherence) that contributed to the patient’s hospitalization and discuss the plan of care with the patient.
  
  
• Ask if the patient has completed or scheduled prescribed outpatient work-ups or other services, such as physical therapy and home health care visits, and ordered durable medical equipment.

For Medicare Advantage PPO members, bill $10 for CPT^® II category code *1111F for medication reconciliation. The *1111F description reads, “Discharge medications reconciled with the current medication list in the outpatient medical record.” MA PPO members can be identified by the XYL prefix on the member ID number.

For commercial and BCN members, we don’t currently reimburse for *1111F. However, we’ll begin reimbursement for commercial members in 2017. Please watch The Record for more information.

Steps to reduce the need for readmissions include improving communications between patients and clinicians as well as between primary care and hospital doctors, assessing patients’ readiness for discharge and providing better post-discharge resources.

For more information on medication reconciliation and reimbursement, please read the following articles from The Record:

“New Medicare star ratings measure: Medication reconciliation post-discharge"

“Providers receive reimbursement for conducting medication reconciliation post-discharge for MA PPO members"

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

Select multiple diagnostic imaging procedures performed on same day pay more in 2017

Effective Jan. 1, 2017, when select multiple diagnostic imaging procedures are performed on the same date of service, the professional component of the highest paid service will continue to be paid at 100 percent. Professional reimbursement for the subsequent services performed that day will increase from 75 percent to 95 percent.

Bill all ambulance services by pickup ZIP code

Effective Oct. 15, 2016, all ambulance claims — ground, air or boat — must be reported with a point of pickup ZIP code. Claims reported without the required ZIP code will be denied.

This ZIP code reporting policy doesn’t alter the current policy for air ambulance reporting. Air ambulance must be billed to the Blue plan based on the point of pickup.  Please see the May 2015 air ambulance Record article for additional information.

When reporting ambulance services on electronic facility institutional claim 837I:

• Report value code A0 in Loop 2300, HI Segment with a BE qualifier.

When reporting ambulance services on electronic professional claim 837P:

• Report entire Loop 2310E for pickup location.
• Report entire Loop 2310F for drop-off location.

If you have questions about a claim, contact Provider Inquiry.

Bill all ambulance services by pickup ZIP code

Effective Oct. 15, 2016, all ambulance claims — ground, air or boat — must be reported with a point of pickup ZIP code. Claims reported without the required ZIP code will be denied.

This ZIP code reporting policy doesn’t alter the current policy for air ambulance reporting. Air ambulance must be billed to the Blue plan based on the point of pickup.  Please see the May 2015 air ambulance Record article for additional information.

When reporting ambulance services on electronic facility institutional claim 837I:

• Report value code A0 in Loop 2300, HI Segment with a BE qualifier.

When reporting ambulance services on electronic professional claim 837P:

• Report entire Loop 2310E for pickup location.
• Report entire Loop 2310F for drop-off location.

If you have questions about a claim, contact Provider Inquiry.

We’re changing our reimbursement policy for hospice services

For dates of service on or after March 1, 2017, Blue Cross Blue Shield of Michigan is launching a statewide rate for each billable hospice revenue code. For 2017, Blue Cross will apply the 2016 highest Core-Based Statistical Area rate as the new statewide rate schedule. The new pre-hospice and hospice reimbursement amounts were published on web-DENIS on Nov. 21, 2016.

Revenue code 0659 replaced with 0658

In addition, Blue Cross is modifying its reimbursement policy for members with the nursing home plus hospice support benefit. Today, hospices providing this benefit bill revenue code 0659, and the payment rate covers both the room and board as well as support services. For dates of service on or after March 1, 2017, providers will no longer bill revenue code 0659 but instead use revenue code 0658.

The statewide rate for 0658 will cover only room and board. Providers will bill revenue code 0651 in conjunction with 0658 for the provision of the routine home care portion. This change applies to Blue Cross members with the hospice plus nursing home support benefit.

To determine if a member has hospice plus nursing home support coverage, refer to the Provider Automated Response System, or PARS, and the web-DENIS subscriber information screens.

Follow these guidelines for an audit of catastrophic case outlier

Please use this as a guide of what to expect and do for your hospital's next catastrophic case outlier utilization review:

Blue Cross Blue Shield of Michigan sends appointment letters to the hospital at least 30 days in advance of the audit, listing the cases to be audited and the items required to conduct the audit.

Catastrophic case outlier audits require the complete medical record, progress notes and medication administration sheets organized by date order. The file needs to include emergency room records, outpatient procedures, the utilization review worksheets and a copy of the most current itemized bill.

Blue Cross will only consider adjustments, late charge claims reported with frequency code 5 and or replacement claims reported with frequency code 7 if billed to the catastrophic claim within 30 days of the scheduled audit. This allows Blue Cross to finalize the late charge or replacement claim adjustments and post the new claim information to our financial systems before the scheduled audit. Late charge or replacement adjustment claims reported after 30 days of the scheduled audit won’t be considered in the catastrophic outlier audit.

If the audit is conducted at your site and you have electronic medical records, please provide one computer for each auditor along with an individual access or login permission for each auditor. The auditor will need someone from your staff to help the auditor access and navigate your electronic medical record.

Each auditor will also need an electrical outlet for his or her Blue Cross computer and a telephone in the designated audit room.

If the audit is conducted at our offices and you grant us web access, we require an individual login for each auditor and a contact person who can help access the electronic record.

The Blue Cross auditor usually makes a courtesy call to the hospital contact person before beginning the audit to answer questions that may occur during the preparation.

We’ll provide you with daily deletion sheets during the audit so you have the opportunity to gather additional supporting documentation. While on-site, the auditor will identify the itemized bills to be mailed to Blue Cross.

We’ll need the name, title and email address of the person who should receive the reporting letter. The hospital staff has the responsibility to share audit findings with other individuals or departments in the hospital.

After you receive the reporting letter, you have the opportunity to provide clarification or missing documentation during the appeal process. Hospitals are allowed 50 calendar days from receipt of the audit reporting letter to submit a written request for internal review.

Reminder: Coverage criteria for TENS unit

As a reminder, since March 1, 2013, Blue Cross Blue Shield of Michigan has aligned with the Centers for Medicare & Medicaid Services’ medical necessity criteria for the transcutaneous electrical nerves stimulation unit. A TENS unit is covered for the treatment of patients who meet the coverage criteria with chronic intractable pain or acute post-operative pain.

For acute post-operative pain:

• The medical necessity is usually limited to 30 days from the day of surgery.
• Payment for more than one month is determined by individual consideration based upon supportive documentation provided by the attending doctor.
• Payment will be made only as a rental.
• A refund request will be made for a TENS unit on post audit as not reasonable and necessary for acute pain (less than three months duration) other than post-operative pain.

For chronic pain:

• The medical record must document the location of the pain, the duration of time the patient has had the pain and the presumed etiology of the pain.
• The pain must have been present for at least three months.
• Other appropriate treatment modalities must have been tried and failed.
• The medical record must document what treatment modalities have been used.
• The presumed etiology of the pain must be a type that's accepted as responding to TENS therapy.

When used for the treatment of chronic, intractable pain:

• The TENS unit must be used by the patient on a trial basis for a minimum of one month (30 days), but not to exceed two months.
• The trial period will be paid as a rental.
• The trial period must be monitored by the doctor to determine the effectiveness of the TENS unit in modulating the pain.

For coverage of a purchase:

• The physician must determine that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time.
• The doctor’s records must document a re-evaluation of the patient at the end of the trial period, must indicate how often the patient used the TENS unit, the typical duration of use each time and the results.

Examples of conditions for which a TENS unit aren’t considered medically necessary (not all-inclusive):

• Headache
• Visceral abdominal pain
• Pelvic pain
• Temporomandibular joint pain

Reminder: Submit 2016 service dates for Medicare Advantage 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, 2016. You then have until Jan. 31, 2017, to submit results of your 2016 patient visits on Health e-Blue. (See side panel at right for information on accessing Health e-Blue.)

You’ll find diagnosis gaps for your patients on Health e-Blue’s Diagnosis Evaluation panel. Health care providers can 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.

Have questions about dates of service, diagnosis gap submissions or the Diagnosis Closure Incentive program? Contact our provider consultants on the HEDIS^® and risk adjustment provider outreach team:

• Sue Brinich at 313-225-8981
• Tom Rybarczyk at 313-225-0445
• Corinne Vignali at 313-225-7782

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

Reminder: Dose limits for Medicare members’ opioid prescriptions to take effect Jan. 1

As you read in the November Record, Blue Cross Blue Shield of Michigan and Blue Care Network will be required by the Centers for Medicare & Medicaid Services to establish a dose limitation for opioid drugs prescribed to our Medicare members. This change, part of an effort by CMS to combat the epidemic of prescription opioid abuse in the U.S., takes effect Jan. 1, 2017.

All Medicare prescription drug claims that include opioids and exceed a daily morphine equivalent dose of 250 mg will require a prior authorization and clinical review by Blue Cross before they may be dispensed at a pharmacy. If a claim is stopped at the pharmacy, clinical documentation may be required. This morphine equivalent dose will be calculated using the member’s opioid prescription claims history in our system.

For full details, see the November Record article.