HCPCS Update: Coverage decisions on 2017 procedure codes now available on web-DENIS

Information about new or deleted HCPCS codes, including CPT codes, has been released. You may begin using the new codes starting Jan. 1, 2017.

We’ve posted the 2017 coverage decisions as a PDF on web-DENIS. You can access our annual HCPCS Update document as follows:

• From the home page of web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on News & Resources.
• Look under What’s New to find 2017 HCPCS Update.

Our claims processing systems use HCPCS codes to allow health care providers to report services they performed. HCPCS is a two-level coding system. Providers should use the following resources to find the code that best describes the service provided:

• Level I codes are published in the Physicians' Current Procedural Terminology, CPT 2017, maintained by the American Medical Association. For a comprehensive list of 2017 changes, refer to Appendix B.
• Level II codes are the Centers for Medicare & Medicaid Services codes and apply to professional services, procedures, items and supplies. For a comprehensive list of CMS Level II code changes, refer to the HCPCS Level II Code Book.

The 2017 CPT and HCPCS manuals may be purchased from various sources, including the following:
American Medical Association

To order by mail:

Order Department
American Medical Association
P.O. Box 930876
Atlanta, GA 31193-0876

To order online: amabookstore.com

To order by phone: 1-800-621-8335

Practice Management Information Corporation

To order by mail:

PMIC
200 W. 22nd St., Ste. 253
Lombard, IL 60148

To order online: pmiconline.com

To order by phone: 1-800-633-7467, ext. 2713

For more information about the 2017 HCPCS Update, send an email to ProvComm@bcbsm.com.

We’re enhancing PARS to give you even better service

The Provider Automated Response System, or PARS, currently gives you benefits and eligibility information for Blue Cross Blue Shield of Michigan members.

As you may have read in the December Record, PARS was enhanced to provide information about our members’ remaining number of visits or days in the benefit period for chiropractic spinal manipulation and cardiac rehabilitation services. Beginning in January 2017, PARS will provide remaining visit or day limits in the benefit period for physical therapy, occupational therapy and speech therapy for some groups.

Remaining day or visit limits for physical therapy, occupational therapy and speech therapy will not be available through PARS for Blue Care Network, the Federal Employee Program^®, MESSA and Medicare Advantage. To obtain the remaining days or visits for these policies, you may ask to speak to a Customer Service representative after obtaining benefit information through PARS. You must listen to at least one benefit or hear all benefits in PARS before a transfer to a Customer Service representative is offered.

Coming soon
In the near future, PARS will provide claim information, allowing you to get answers to your questions much faster. We'll provide more details as we update the system to provide this additional enhancement.

Reminder: Blue Cross expanding coverage of gender transition services, starting Jan. 1

In a November Record article, Blue Cross Blue Shield of Michigan announced that it will extend gender transition benefits to individuals and groups that currently have none or only some of them, starting on Jan. 1, 2017.

Blue Cross already provides gender transition benefits to many of its groups.

New benefits may include:

• Gender reassignment surgery
• Hormone therapy
• Psychotherapy and counseling
• Mastectomy for female to male transitions

Some surgical procedures will continue to require preauthorization. Always check a member’s eligibility and benefits.

Our benefits for gender transition are changing in response to this year’s final rule under Section 1557 of the Affordable Care Act. The rule prohibits discrimination on the basis of race, color, national origin, sex, age or disability in health care programs or activities that receive federal financial assistance. It requires that gender transition benefits be available in health care plans starting on or after Jan. 1.

Blue Cross MOS groups and individual customers will receive the benefit on Jan. 1, 2017. NASCO Classic groups, with the exception of MESSA, will receive the benefit at the start of their 2017 plan year. MESSA will receive the benefit beginning Jan. 1, 2017.

Here’s a look at Federal Employee Program^® Service Benefit Plan coverage changes for 2017

Autism spectrum disorder coverage

We now provide benefits for applied behavior analysis for the treatment of an autism spectrum disorder. Prior approval is required for applied behavior analysis and related services, including assessments, evaluations and treatment. Benefits aren’t available for applied behavior analysis for any other condition. Previously, benefits weren’t provided for applied behavior analysis services. For benefit questions, call FEP Customer Service at 1-800-482-3600. For prior authorization, call New Directions Behavioral Health Inc. at 1-800-342-5891.

Transgender benefit coverage

We now provide benefits for gender reassignment surgery, limited to once per lifetime, for adult members age 18 or older. Prior approval is required. Previously, benefits were not available for gender reassignment surgery.

Preventive care coverage

We’re expanding the eligibility criteria for BRCA-related testing for members with a first- or second-degree relative diagnosed with pancreatic or prostate cancer.

We now provide annual preventive care benefits for screening mammography using digital technology. Previously, digital technology was only covered for diagnostic mammograms.

Vision benefit change

We now provide benefits for the nonsurgical treatment of amblyopia and strabismus for children from birth through age 21. Previously, benefits were provided for children from birth through age 18.

Sleep study benefit change

We now require prior approval for sleep studies performed in a location other than the
member’s home.

Member incentive program changes

Members who qualify for the Diabetes Management Incentive Program will now receive a maximum incentive of up to $100 for their wellness account. We have also reduced the number of steps required to earn the incentive.

The WalkingWorks^® wellness program was eliminated due to changes in the tracking activities technology.

Prescription drug benefit changes

Certain FDA-approved drugs that have multiple generic equivalent or alternative medications may be excluded from the Standard Option and Basic Option formularies. If the member purchases a drug that is excluded from the formulary, he or she will be responsible for the full cost of that drug. Previously, all FDA-approved drugs were covered under prescription drug benefits, with the exception of some lifestyle drugs.

We now limit benefits for certain self-injectable drugs obtained from a source other than a pharmacy. Medical benefits are provided for a once-per-lifetime dose. Benefits for additional doses are available only when the drug is dispensed by a pharmacy under the pharmacy benefit. This limitation doesn’t apply to members with primary coverage under Medicare Part B. Previously, benefits were available for these drugs through medical benefits without limit. Basic Option members must use a preferred pharmacy.

Overseas admission changes

Member cost share for inpatient admissions to facilities overseas is waived when the Worldwide Assistance Center (provided by AXA Assistance) has arranged direct billing or acceptance of a guarantee of benefits with the facility. Previously, members were responsible for a copayment or coinsurance for these admissions.

Following are changes to our Standard Option only:

We now limit preventive dental care benefits for the topical application of fluoride or fluoride varnish to up to two services per person per calendar year. Previously, there was no benefit limit for these services.

We revised our dental benefits to provide a fee schedule for each extraoral diagnostic image. Previously, dental benefits included references to both “extraoral - first image” and “extraoral - each additional image.”

Following are changes to our Basic Option only:

We’ve reduced the member responsibility for sleep studies performed in the home and billed by preferred professional providers.

The enrollment codes for 2017 remain the same:

BlueCard^® connection: Do I report Medicare supplemental claims differently for members enrolled outside of Michigan?

No. All claims, including Medicare supplemental claims, must be reported the same way you report claims for Blue Cross Blue Shield of Michigan members.

Most Medicare primary claims automatically transfer, or cross over, to a member’s home plan. That’s why you shouldn’t send a Medicare supplemental BlueCard claim to us for at least 30 days from the date of Medicare’s payment to you. Billing sooner can result in a front-end edit for electronic submitters or a payment delay or claim denial for paper submitters.

The following Blue Cross edits will be returned to electronic submitters on 277CAP transactions and R277CAH and R277CAI edit reports:

• P951 A3 516 SUPPLEMENTAL CLM RECD WITHIN 30 DAYS OF MEDICARE PROC DATE
• F716 A3 516 SUPPLEMENTAL CLM RECD WITHIN 30 DAYS OF MEDICARE PROC DATE

Here are some other things you need to know about BlueCard supplemental claims:

• Report all of the prior payer information exactly as it was returned to you on Medicare’s 835 electronic remittance or the Medicare paper voucher.
• Medicare supplemental claims for BlueCard members who have notified Medicare of their supplemental contract will cross over directly to the member’s Blue Cross plan. The home plan will pay you directly.

If you need assistance on a BlueCard Medicare crossover claim, contact Blue Cross Provider Inquiry. We’ll contact the out-of-area Blue Cross plan for you.

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

If you have questions about the information 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 with “BlueCard series” in the subject line.

Correction: Coding for morbid obesity with comorbid conditions

The “Coding corner” article on morbid obesity in the October 2016 Record contained a misleading example of how to code for a patient with a BMI over 40 and a comorbid condition.

It should have read:

“In circumstances where the medical record shows a final assessment of obesity with a BMI of 40 or more and comorbid conditions, such as uncontrolled diabetes and hypertension with a plan of care, the BMI value can be coded along with a code for obesity.”

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 a refresher on our new Blue Cross^® Personal Choice PPO product; new webinars scheduled

More than 1,000 members have enrolled in Blue Cross^® Personal Choice PPO, which we wrote about in the September Record. Members who enrolled have coverage that began as early as Oct. 1, 2016.

The product gives members the opportunity to lower their out-of-pocket costs when they coordinate their health care with their primary care physician through our Organized Systems of Care program. It also offers access to the broader PPO network.

Here’s a recap of how it works:

• Members who select a primary care doctor who affiliates with a Level 1 OSC and who use other health care providers associated with that OSC receive high-quality, coordinated care at the lowest out-of-pocket cost.
• Members who have selected a primary care doctor in a Level 1 OSC but who seek services from other doctors and hospitals outside of that OSC will need to seek a referral from their primary care doctor to stay at the Level 1 cost share.

Managing referrals electronically
An e-referral process has been developed to help manage your referrals electronically. If you currently use the e-referral system for your Blue Care Network patients, you already have access to the new Blue Cross Blue Shield of Michigan e-referral system. If e-referral is new to you, here’s what you do:

Requesting access to e-referral process

• Go to the Sign Up or Change a User page at ereferrals.bcbsm.com.

Submitting referrals

• Go to ereferrals.bcbsm.com and click on Login.
• Click on BCBSM e-referral.
• Choose Submit Referral from the Referrals/Authorization drop-down menu at the top.
• Fill in all required fields.
• Click Submit.

Additional webinars, other training
We continue to offer health care providers training opportunities to learn or to refresh their understanding of Blue Cross Personal Choice PPO:

• Watch a one-hour webinar in January 2017. If you haven’t already seen the webinar, click here to access the invitation.
• Access an online training presentation, called Brainshark, by clicking here.

For more information

• Go to ereferrals.bcbsm.com, click on Blue Cross and then on Blue Cross Personal Choice PPO.
• Download an e-referral user guide.
• Check out the new flier.
• Visit PersonalChoicePPO.com.

If you have any additional questions after reviewing these resources, reach out to your provider consultant or other Blue Cross contact.

New drugs added to Medical Drug Prior Authorization Program

Starting April 1, 2017, Exondys 51™ (eteplirsen), Remicade^® (infliximab) and Inflectra™ (infliximab-dyyb) will be added to the list of drugs that require a medical drug prior authorization. The Medical Drug Prior Authorization Program does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

The list below includes the three newly added drugs, along with all other medications that are part of the Medical Drug Prior Authorization Program.

Let's clarify nursing documentation needs for home infusion therapy providers

This overview can help clarify nursing documentation for home infusion therapy providers. Documentation should include the following components.

• An evaluation of the patient, including:
• The diagnosis and reason for therapy with each visit
• A basic assessment of the patient, including orientation, breathing, color, complaints or anything related to diagnosis. For example, if a patient needs home infusion for an infected wound, there should be information about the wound and the dressing. If the nurse doesn’t change the dressing, he or she should not simply state that the wound has a nonremovable dressing or the wound clinic is performing wound care. If there is no dressing change, documentation, at a minimum, should include a detailed assessment of the dressing and surrounding area
• Questions about any side effects to the drug or how they were feeling after the last dose
• The visit’s start and end time
• The infusion’s start and end time
• The therapy the registered nurse administered during the visit
• Notes about teaching the patient or caregiver, assessment of patient’s or caregiver’s technique for self administration
• The patient’s response to infusion given
• Any changes in treatment
• Date, signature and credentials of the registered nurse

Tier changes for some hepatitis C drugs start Jan. 1

Blue Cross Blue Shield of Michigan and Blue Care Network are changing how they manage certain hepatitis C drugs starting Jan. 1, 2017.

Zepatier™ and Epclusa^® will:

• Move to a preferred tier on drug lists.
• Have a lower copayment than drugs on the nonpreferred tier.
• Require approval prior to coverage.

Zepatier will be the preferred drug for patients with hepatitis C, genotype 1 and 4, viral infections. And Epclusa will be the preferred drug for patients with hepatitis C viral infections when Zepatier isn't indicated.

Sovaldi^®, Harvoni^® and Viekira Pak™ will:

• Move to a nonpreferred tier on drug lists.
• Require member use of a preferred drug before nonpreferred drug approval.
• Require approval prior to coverage.

Patients currently taking Sovaldi, Harvoni and Viekira Pak will be allowed to continue treatment and pay their current copay.

Reminder: We’ll accept either 2016 InterQual Criteria or 2016.3 Clinical Revisions

In a Dec. 2 web-DENIS message, we reminded you that InterQual^® made some revisions to its 2016 criteria in September 2016. The 2016.3 Clinical Revisions relate to the Stroke/TIA section of Acute Adult Criteria and the Pancreatitis, DKA and Infection sections of Acute Pediatric Criteria.

We want to be sure you know that Blue Cross Blue Shield of Michigan will accept either the 2016.3 revisions or the 2016 InterQual Criteria that was distributed in book form to providers last summer.

InterQual also issued 2016.2 Clinical Revisions for skilled nursing facilities, but the changes don’t affect our participating providers because the changes are subject to Blue Cross Blue Shield of Michigan Modifications of InterQual criteria (local rules).

We expect that 2017 InterQual Criteria will be released in the spring.

Coming in March: KX modifier required for over-quantity maximum diabetic supplies

Beginning with dates of service on or after March 1, 2017, if your patients need more diabetic supplies than our quantity maximums allow, you'll be required to report the KX modifier with the diabetic supply procedure code.

If you don't report the KX modifier, your claims will reject. Reporting the KX modifier confirms that your patients meet our medical policy criteria for additional testing supplies.

Certificates of medical necessity, which include the reason for an over-quantity maximum order, are still required. We recommend that you keep the certificates in your patients’ files.

Here’s a refresher on our new Blue Cross^® Personal Choice PPO product; new webinars scheduled

More than 1,000 members have enrolled in Blue Cross^® Personal Choice PPO, which we wrote about in the September Record. Members who enrolled have coverage that began as early as Oct. 1, 2016.

The product gives members the opportunity to lower their out-of-pocket costs when they coordinate their health care with their primary care physician through our Organized Systems of Care program. It also offers access to the broader PPO network.

Here’s a recap of how it works:

• Members who select a primary care doctor who affiliates with a Level 1 OSC and who use other health care providers associated with that OSC receive high-quality, coordinated care at the lowest out-of-pocket cost.
• Members who have selected a primary care doctor in a Level 1 OSC but who seek services from other doctors and hospitals outside of that OSC will need to seek a referral from their primary care doctor to stay at the Level 1 cost share.

Managing referrals electronically
An e-referral process has been developed to help manage your referrals electronically. If you currently use the e-referral system for your Blue Care Network patients, you already have access to the new Blue Cross Blue Shield of Michigan e-referral system. If e-referral is new to you, here’s what you do:

Requesting access to e-referral process

• Go to the Sign Up or Change a User page at ereferrals.bcbsm.com.

Submitting referrals

• Go to ereferrals.bcbsm.com and click on Login.
• Click on BCBSM e-referral.
• Choose Submit Referral from the Referrals/Authorization drop-down menu at the top.
• Fill in all required fields.
• Click Submit.

Additional webinars, other training
We continue to offer health care providers training opportunities to learn or to refresh their understanding of Blue Cross Personal Choice PPO:

• Watch a one-hour webinar in January 2017. If you haven’t already seen the webinar, click here to access the invitation.
• Access an online training presentation, called Brainshark, by clicking here.

For more information

• Go to ereferrals.bcbsm.com, click on Blue Cross and then on Blue Cross Personal Choice PPO.
• Download an e-referral user guide.
• Check out the new flier.
• Visit PersonalChoicePPO.com.

If you have any additional questions after reviewing these resources, reach out to your provider consultant or other Blue Cross contact.

Reminder: We’ll accept either 2016 InterQual Criteria or 2016.3 Clinical Revisions

In a Dec. 2 web-DENIS message, we reminded you that InterQual^® made some revisions to its 2016 criteria in September 2016. The 2016.3 Clinical Revisions relate to the Stroke/TIA section of Acute Adult Criteria and the Pancreatitis, DKA and Infection sections of Acute Pediatric Criteria.

We want to be sure you know that Blue Cross Blue Shield of Michigan will accept either the 2016.3 revisions or the 2016 InterQual Criteria that was distributed in book form to providers last summer.

InterQual also issued 2016.2 Clinical Revisions for skilled nursing facilities, but the changes don’t affect our participating providers because the changes are subject to Blue Cross Blue Shield of Michigan Modifications of InterQual criteria (local rules).

We expect that 2017 InterQual Criteria will be released in the spring.

New drugs added to Medical Drug Prior Authorization Program

Starting April 1, 2017, Exondys 51™ (eteplirsen), Remicade^® (infliximab) and Inflectra™ (infliximab-dyyb) will be added to the list of drugs that require a medical drug prior authorization. The Medical Drug Prior Authorization Program does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

The list below includes the three newly added drugs, along with all other medications that are part of the Medical Drug Prior Authorization Program.

We’re changing how we process drugs with gender edits, starting Jan. 1

To meet federal guidelines, gender-specific coverage edits on the following drugs and drug categories will be modified, starting Jan. 1, 2017:

Drugs

• Testosterone
• Folic acid
• Tamoxifen
• Raloxifene

Drug categories

• Contraceptives
• Erectile dysfunction

In addition, starting Jan. 1, drugs used to treat erectile dysfunction will be coded to remove gender-specific coverage references.

Why are we making these changes?
We’re making these changes to meet the requirements of Section 1557 of the Affordable Care Act. The final rule, which was issued this year, prohibits discrimination on the basis of race, color, national origin, sex, age or disability in health care programs or activities that receive federal financial assistance.

For more information, call claims processor Express Scripts at 1-800-922-1557 from 8 a.m. to 5:30 p.m. Monday through Friday. For additional support, call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.

Tier changes for some hepatitis C drugs start Jan. 1

Blue Cross Blue Shield of Michigan and Blue Care Network are changing how they manage certain hepatitis C drugs starting Jan. 1, 2017.

Zepatier™ and Epclusa^® will:

• Move to a preferred tier on drug lists.
• Have a lower copayment than drugs on the nonpreferred tier.
• Require approval prior to coverage.

Zepatier will be the preferred drug for patients with hepatitis C, genotype 1 and 4, viral infections. And Epclusa will be the preferred drug for patients with hepatitis C viral infections when Zepatier isn't indicated.

Sovaldi^®, Harvoni^® and Viekira Pak™ will:

• Move to a nonpreferred tier on drug lists.
• Require member use of a preferred drug before nonpreferred drug approval.
• Require approval prior to coverage.

Patients currently taking Sovaldi, Harvoni and Viekira Pak will be allowed to continue treatment and pay their current copay.

What you should know about Blue Cross^® Medicare Private Fee for Service and Medicare Plus Blue^SM PPO

This chart contains important information about Blue Cross Medicare Private Fee for Service, also known as PFFS, and our Medicare Plus Blue products.