Bill dates of service correctly to boost accuracy of claims processing

Blue Cross Blue Shield of Michigan frequently receives medical claims with an incorrect date of service. To help ensure that the correct dates are used, we want to let you know that Blue Cross defines “date of service” as the actual date the service was rendered to the patient.

For example, the date of service is the date when a patient receives an X-ray or the date a lab or pathology sample is taken.

Even when the tests are analyzed on a different day, use the date of service as it’s described in this article to bill the charge. Following this direction will help us process your claims with greater accuracy.

Members can get medications synchronized through Express Scripts, starting March 15

Blue Cross Blue Shield of Michigan and Blue Care Network will launch their medication synchronization program with Express Scripts for all commercial (non-Medicare) lines of business, starting March 15, 2017.

This program will allow medications for a patient to be refilled on the same day. Not only does the member get the convenience of fewer trips to the pharmacy, but the program may also increase medication adherence.

We’re adding this program in response to Michigan Public Act 38 of 2016, which requires that insurers allow members to synchronize multiple maintenance drug prescriptions for chronic long-term care conditions. The medication synchronization legislation takes effect March 15, 2017.

Which drug claims apply to the medication synchronization program?
The program allows:

• Medication synchronization of maintenance drugs for chronic long-term care conditions, with the exception of:
• Most Schedule 2-5 controlled substances (anti-epileptic prescriptions allowed)
• Select prescription drugs that are limited to certain fill requirements
• Medication synchronization on prescriptions that have authorized refills remaining

How will we synchronize prescription drugs?

• When a participating pharmacy submits a claim for a member that meets the criteria, our claims processer (Express Scripts) will apply a prorated, daily cost-sharing rate to the maintenance prescription drugs. The claims processing system will allow a pharmacist to dispense up to 29 days of acceptable drugs.
• Participating pharmacies will collect from the member the applicable cost share and receive a dispensing fee for each synchronized prescription claim submitted.

Blue Cross and Blue Care Network no longer cover EpiPen^® brand drugs, starting March 1

To provide the best value for our members, Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans no longer cover EpiPen^® 0.3 mg and EpiPen Jr^® 0.15 mg auto-injector drugs, effective March 1, 2017.

EpiPen injectors are used to treat allergic reactions.

Blue Cross and BCN will provide coverage for the authorized generic epinephrine auto-injectors. These generics are considered brand products and are available to the member at the preferred brand copay amount.

Both the epinephrine auto-injectors and the EpiPen products are manufactured by Mylan and have the same drug formulation and device functionality. Prescriptions written for EpiPen and EpiPen Jr are interchangeable with the ephinephrine auto-injector products when filled at the pharmacy.

Note: These changes don’t apply to MESSA groups.

Here’s a look at the alternatives for excluded drugs and the average cost:

**Approximate cost per package, based on the average wholesale price

If you’ve been prescribing EpiPen or EpiPen Jr, discuss the covered alternatives with your patients.

Online prescription drug lists updated

Blue Cross Blue Shield of Michigan updated its 2017 online prescription drug lists, or formularies.

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 at bcbsm.com/rxinfo. You can also see other pharmacy-related information at this link.

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

InterQual^® Criteria books going digital in 2017

Starting this year, McKesson Health Solutions’ InterQual Criteria books will only be available online. Any new or updated criteria will also be available only online. You won’t receive a printed InterQual book in 2017 or beyond. Instead, every user will have online access within the InterQual View application.

Blue Cross Blue Shield of Michigan will begin using the 2017 criteria in early August 2017.

Coming soon
To prepare for the online criteria release, your organization will receive registration information in April 2017 with detailed instructions. These instructions will include how to set up and use the InterQual View software. You’ll also receive instructions on how to register for online access to McKesson’s Download Central and Customer Hub. If you’re licensed with McKesson directly, you may have already registered.

Submit ‘void’ claim request, not refund request

Provider Inquiry will no longer accept refund requests through the mail. If you mail a refund request, it will be returned to you. We ask that you submit refund requests as a void claim.

For refund request instructions, see the January 2016 Record article.

HCPCS update: Codes added, deleted

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

The deleted codes are listed below.

We’re updating ClaimsXten™ for second quarter of 2017

Blue Cross Blue Shield of Michigan is updating ClaimsXten for the second quarter of 2017.

This helps ensure that we're using the most current CPT^® code updates, Centers for Medicare & Medicaid Services guidelines and specialty society guidelines. We also reference information from industry seminars and publications, as well as Blue Cross payment policy revisions, when performing our quarterly ClaimsXten updates.

We reserve the right to make changes or corrections when required or new information becomes available. In some instances, we may apply changes to ClaimsXten retroactively.

BlueCard^® connection: How does a BlueCard member’s filing limitations affect adjustment claims I bill to Blue Cross?

In addition to Blue Cross Blue Shield of Michigan’s timely filing policy, some BlueCard members have specific filing limitations as part of their contracted group benefits. Both policies apply to claims you report for BlueCard members. To avoid claim rejections, promptly report all BlueCard original and replacement claims.

For more information on the BlueCard program, including links and articles on online tools, refer to 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: When is it appropriate to use a ‘history of’ code when reporting cancer?

As you’ve read in “Coding corner” before, selecting the code that best captures a patient’s condition at the time of his or her visit can be a challenge, but keeping some basic guidelines in mind can help. Here’s what you need to know about coding for cancer.

Your documentation should always specify one of the following:

• The cancer is active and still being treated.
• The cancer is no longer active or there’s no recurrence and no further treatment is necessary.

When coding for active malignancy versus coding for a person with a history of malignancy, ICD-10-CM coding guidelines are specific. Section I.C.2.m. states:

“When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

“When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.”

Scenario one:
A patient with a history of breast cancer and mastectomy of the right breast — but who has no evidence of cancer or isn’t currently receiving treatment — comes in for an office visit. The provider documents that there are no presenting problems that may affect the overall plan of care and that the patient isn’t receiving active adjuvant therapy. In this scenario, a personal history code should be used. Example: Z85.3 Personal history of malignant neoplasm of breast

Patients who currently have cancer
In the scenarios below, the cancer is still being actively managed, so a current malignancy code should be used. Example: C50.111 Malignant neoplasm of central portion of right female breast

Scenario two:
A patient diagnosed with breast cancer returns to the office for a visit after a mastectomy and is currently receiving radiation therapy.

Scenario three:
A patient, diagnosed with breast cancer last year, had a mastectomy followed by radiation and chemotherapy. She was hormone receptive positive and is currently taking Arimidex^®.

In summary
To ensure best documentation practices, refer to the ICD-10-CM guidelines to assist with the code selection that clearly supports the documentation. Clinical evidence needs to be documented to support an active diagnosis of cancer.

The documentation must clearly state that the cancer is currently and actively being treated and managed. If the cancer has been excised or eradicated and there’s no evidence of recurrence and no further treatment is needed, then it’s appropriate to use a “personal history” code.

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 all applicable state and federal laws and regulations.

Correction: Grede Holdings LLC’s drug plan applies to Brillion retirees (Wisconsin)

An article in the "Group Benefit Changes" section of the January billing chart contained incorrect information about the Grede Holdings LLC’s drug plan. For “drug plan,” it should have specified that it relates to only Brillion retirees (Wisconsin). To see all the information on Grede Holdings, go to the “Group Benefit Changes” section of the March billing chart.

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.

Professional providers will soon be required to submit claims electronically

In 2009, Blue Cross Blue Shield of Michigan began looking for ways to transition some of the 5 million paper claims received annually to electronic claims. We’ve made tremendous strides since then, reducing the number of paper claims by nearly 80 percent to the 1.1 million paper claims we receive today. We’re committed to working closely with health care providers to continue to reduce the number of costly, inefficient paper claims and resubmissions.

Starting June 30, 2017, participating providers will be required to submit the following types of claims electronically:

• Original claims
• Replacement claims
• Void or cancel claims
• Any claim that includes services for which you will submit medical records

Claims excluded from the electronic submission requirement are:

• Coordination of benefits tertiary claims
• COB secondary claims
• Claims for specified human organ and bone marrow transplants
• Medicaid claims
• Medicare Advantage claims
• Blue Care Network claims

Have questions?

• If you have any electronic claims questions, contact the Electronic Data Interchange help desk at 1-800-542-0945.
• For assistance with reporting this information using your practice management system, contact your software vendor or clearinghouse.
• If you need information on the status of a claim you submitted or have any other questions, contact Provider Inquiry.
• If you have additional concerns that can’t be addressed by Provider Inquiry, contact your provider consultant.

Here’s what you need to know about providing up-to- date demographic data

At Blue Cross Blue Shield of Michigan, we’re continually working to improve the quality of information in our provider directories.

Members need to know how to get in contact with physicians who participate with their insurance plan and where practices are located. All insurance plans are tasked with providing accurate, up-to-date physician information to members.

In fact, last year, the Centers for Medicare & Medicaid Services mandated that Medicare Advantage health plans provide complete and accurate information regarding physicians to members. If a plan fails to provide accurate provider directories, it’s subject to compliance or enforcement actions, including civil monetary penalties and Medicare star ratings or enrollment sanctions.

Here are answers to some frequently asked questions:

What are Blue Cross and Blue Care Network doing to make it easier for providers to attest to their demographic data?
Currently, we’re using Atlas System’s PRIME-Hub online tool to collect practitioner attestations. However, we’ll be transitioning to DirectAssure™, a CAQH Solution^® in mid-2017. DirectAssure will work in concert with CAQH’s ProView^® program to improve provider directory data. 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.

Through DirectAssure^®, Blue Cross and BCN providers can confirm their directory information in one place, where it can be shared with participating health plans and will meet our quarterly directory attestation requirement. We’ll incorporate the DirectAssure^® information into our provider files to give our members the most up-to-date, accurate information.

What do Blue Cross and BCN providers need to do this year?

For the first half of 2017 (until we transition to DirectAssure), all providers will need to attest to their current demographic data through Atlas System’s PRIME-Hub tool. For details, see the June 2016 Record article.

What do I do if my demographic information is incorrect in PRIME-Hub?
To update your demographic information, go to the Enrollment and Changes section of bcbsm.com/providers.

How should I prepare for the move to CAQH’s DirectAssure?
We strongly recommend you continue to update your directory information in CAQH ProView (see July 2016 Record article) to help ensure a smooth transition when we adopt DirectAssure mid-year.

What happens if I fail to comply?
Consistent attestation noncompliance by individual physicians will result in such actions by Blue Cross Blue Shield of Michigan as suppression from our provider directories and suppression of value-based reimbursement for physicians who participate in the Physician Group Incentive Program. If non-compliance continues, you could be terminated from Blue Cross and BCN networks.

For PGIP participants only:

Is there any additional information that providers who participate in the Physician Group Incentive Program need to know about?
Yes. To help ensure compliance, Value Partnerships recently launched an incentive opportunity known as the Provider Directory Data Quality Compliance Program. PGIP physician organizations can elect to submit physician demographic data electronically, thereby bringing their affiliated physicians into compliance. An electronic submission from the physician organization would serve as the attestation on behalf of the practitioner.

For the first half of 2017, PGIP participants will want to confirm with their PO whether it is participating in the Provider Directory Data Quality Compliance Program and will be submitting physician demographic data electronically on your behalf. If your PO isn’t participating in the electronic file submission, you must attest to your current demographic data by using the PRIME-Hub online tool and then DirectAssure later in the year.

For more information, PGIP participating physicians can contact their PO. Non-PGIP physicians, contact your provider consultant.

Provider forums coming to a town near you

Blue Cross Blue Shield of Michigan and Blue Care Network provider forums are coming to you. While we don’t have all the details yet, we’re announcing the dates and locations so you can save the date. Look for registration information and details on the covered topics in a future issue of The Record.

We look forward to seeing you.

Here’s what you need to know about Blue Distinction Total Care

In previous articles and other communications, we’ve told you about Blue Distinction Total Care, a Blue Cross and Blue Shield Association program. We’d like to provide a brief refresher, highlighting what you need to know.

• Blue Distinction Total Care is a national program that connects members of out-of-state Blue plans with health care providers in our Patient-Centered Medical Home and Organized Systems of Care programs. Also, Blue Cross Blue Shield of Michigan members who reside outside of Michigan are connected to high-quality health care providers in other states.
• Michigan physicians who have PCMH designation or who participate in our OSC program are considered Blue Distinction Total Care providers.
• We help steer members to BDTC doctors through our Find a Doctor search tool on bcbsm.com.

What do Patient-Centered Medical Homes and Organized Systems of Care need to know?

How does Blue Distinction Total Care work for different provider types?

**Note: Some specialty types will be eligible to bill for PDCM services as part of the PDCM specialty program, starting July 1, 2017. Send an email to valuepartnerships@bcbsm.com for more information.

Future Blue Cross plans include products that will steer members to BDTC providers through new products for national PPO customer groups. We expect these products to be available in 2018 and 2019.

For more information
For more information, physicians can contact their physician organization administrators. If you have a specific question and don’t have access to the Physician Group Incentive Program Collaboration site, email your questions to valuepartnerships@bcbsm.com.

New place-of-service code for telemedicine

Starting Jan. 1, 2017, Blue Cross Blue Shield of Michigan adopted the Center for Medicare & Medicaid Services' new place-of-service code, 02-Telehealth.

The POS code indicates the location where services were rendered through telecommunication technology. Always report POS code 02 with the GT modifier. This new billing requirement applies to all telemedicine claims submitted on or after Jan. 1, 2017, regardless of the date of service.

As a reminder, you should report online visit procedure codes (*98969 and *99444) and telephone evaluation and management visits (*98966, *98967, *98968, *99441, *99442 and *99443) in an office location (11). The new place of service code 02 doesn’t apply to online visits and telephone evaluation and management visits. Also, these eight codes don't require the GT modifier.

These billing guidelines are consistent with the National Correct Coding Initiative and Blue Cross payment policy guidelines and are subject to audit review.

Are you using Clear Claim Connection?

If you’re using Clear Claim Connection, you’ll need to follow a somewhat different process until we’re able to update the Clear Claim Connection tool to accommodate the new place-of-service code. For telehealth place of service (02), select office location (11).

Orthopedic footwear, therapeutic shoes will have quantity, frequency limitations, starting April 2017

Beginning with dates of service on or after April 1, 2017, therapeutic shoes and orthopedic footwear will have quantity and frequency limitations.

Keep the following in mind:

• A-HCPCS and L-HCPCS codes below require LT or RT modifiers or both.
• The KX modifier is required for the A-HCPCS codes below ("Therapeutic shoes for persons with diabetes").
• Claims will reject if you don’t bill the modifiers.
• If the member requires a shoe or insert because of a diabetes-related condition, submit your claim using the appropriate A-HCPCS code for therapeutic shoes for persons with diabetes.

Reminder: Supporting documentation required for billing procedure codes reported with modifier 62

“Co-surgery” refers to a single surgical procedure that requires the skill of two surgeons. The two surgeons, who are from the same specialty or different ones, perform parts of the same procedure.

Procedure codes reported with “modifier 62 – co-surgery” must be submitted with the operative report. If no additional documentation is submitted, the service will be rejected, with a message indicating that supporting documentation is required before payment can be considered.

Note: Co-surgeons should coordinate their claim submissions within the same time frame, and both providers should use modifier 62. If the claims aren’t coordinated or modifier 62 isn’t used, the second surgeon’s claim may be rejected.

For additional information about reporting services that always require medical records, refer to the Claims chapter of the online provider manual.

Payable diagnosis codes for procedure codes *98940, *98941 and *98942 have changed

Blue Cross Blue Shield of Michigan is aligning its policy for spinal manipulation with Medicare’s payable diagnostic codes. We’re adding all diagnostic codes payable by Medicare. This will affect procedure codes *98940, *98941 and *98942. Click here to see the list of affected codes.

Payable diagnosis codes for procedure codes J0882, J0887 and Q4081 have changed

Blue Cross Blue Shield of Michigan is aligning its policy for procedure codes J0882, J0887 and Q4081 with Medicare’s payable diagnostic codes. We’re adding all diagnostic codes payable by Medicare. Click here to see the list of affected codes.

Provider forums coming to a town near you

Blue Cross Blue Shield of Michigan and Blue Care Network provider forums are coming to you. While we don’t have all the details yet, we’re announcing the dates and locations so you can save the date. Look for registration information and details on the covered topics in a future issue of The Record.

We look forward to seeing you.

Reminder: Supporting documentation required for billing procedure codes reported with modifier 62

“Co-surgery” refers to a single surgical procedure that requires the skill of two surgeons. The two surgeons, who are from the same specialty or different ones, perform parts of the same procedure.

Procedure codes reported with “modifier 62 – co-surgery” must be submitted with the operative report. If no additional documentation is submitted, the service will be rejected, with a message indicating that supporting documentation is required before payment can be considered.

Note: Co-surgeons should coordinate their claim submissions within the same time frame, and both providers should use modifier 62. If the claims aren’t coordinated or modifier 62 isn’t used, the second surgeon’s claim may be rejected.

For additional information about reporting services that always require medical records, refer to the Claims chapter of the online provider manual.

All hospitals must give Medicare Outpatient Observation Notice to patient

Blue Cross Blue Shield of Michigan adheres to guidance from the Centers for Medicare & Medicaid Services for the Medicare Outpatient Observation Notice, commonly referred to as MOON.

Effective Feb. 21, 2017, hospitals and critical access hospitals are required to furnish the MOON to any Medicare beneficiary who has been receiving observation services as an outpatient for more than 24 hours. This is a mandatory requirement for all hospitals.

The MOON is a standardized notice that informs beneficiaries (including Medicare health plan enrollees) that they are an outpatient receiving observation services and are not an inpatient of the hospital or a critical access hospital. The notice must be provided no later than 36 hours after observation services are initiated or, if sooner, upon release.

The notice informs beneficiaries of the reasons they’re an outpatient receiving observation services and how this may affect their Medicare cost sharing and coverage for post-hospitalization skilled nursing facility services.

You can find the standard language for the MOON and instructions on the CMS website by clicking here.**

**Blue Cross doesn’t own or control this website.

Orthopedic footwear, therapeutic shoes will have quantity, frequency limitations, starting April 2017

Beginning with dates of service on or after April 1, 2017, therapeutic shoes and orthopedic footwear will have quantity and frequency limitations.

Keep the following in mind:

• A-HCPCS and L-HCPCS codes below require LT or RT modifiers or both.
• The KX modifier is required for the A-HCPCS codes below ("Therapeutic shoes for persons with diabetes").
• Claims will reject if you don’t bill the modifiers.
• If the member requires a shoe or insert because of a diabetes-related condition, submit your claim using the appropriate A-HCPCS code for therapeutic shoes for persons with diabetes.

Here’s what you need to know about providing up-to- date demographic data

At Blue Cross Blue Shield of Michigan, we’re continually working to improve the quality of information in our provider directories.

Members need to know how to get in contact with physicians who participate with their insurance plan and where practices are located. All insurance plans are tasked with providing accurate, up-to-date physician information to members.

In fact, last year, the Centers for Medicare & Medicaid Services mandated that Medicare Advantage health plans provide complete and accurate information regarding physicians to members. If a plan fails to provide accurate provider directories, it’s subject to compliance or enforcement actions, including civil monetary penalties and Medicare star ratings or enrollment sanctions.

Here are answers to some frequently asked questions:

What are Blue Cross and Blue Care Network doing to make it easier for providers to attest to their demographic data?
Currently, we’re using Atlas System’s PRIME-Hub online tool to collect practitioner attestations. However, we’ll be transitioning to DirectAssure™, a CAQH Solution^® in mid-2017. DirectAssure will work in concert with CAQH’s ProView^® program to improve provider directory data. 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.

Through DirectAssure^®, Blue Cross and BCN providers can confirm their directory information in one place, where it can be shared with participating health plans and will meet our quarterly directory attestation requirement. We’ll incorporate the DirectAssure^® information into our provider files to give our members the most up-to-date, accurate information.

What do Blue Cross and BCN providers need to do this year?

For the first half of 2017 (until we transition to DirectAssure), all providers will need to attest to their current demographic data through Atlas System’s PRIME-Hub tool. For details, see the June 2016 Record article.

What do I do if my demographic information is incorrect in PRIME-Hub?
To update your demographic information, go to the Enrollment and Changes section of bcbsm.com/providers.

How should I prepare for the move to CAQH’s DirectAssure?
We strongly recommend you continue to update your directory information in CAQH ProView (see July 2016 Record article) to help ensure a smooth transition when we adopt DirectAssure mid-year.

What happens if I fail to comply?
Consistent attestation noncompliance by individual physicians will result in such actions by Blue Cross Blue Shield of Michigan as suppression from our provider directories and suppression of value-based reimbursement for physicians who participate in the Physician Group Incentive Program. If non-compliance continues, you could be terminated from Blue Cross and BCN networks.

For PGIP participants only:

Is there any additional information that providers who participate in the Physician Group Incentive Program need to know about?
Yes. To help ensure compliance, Value Partnerships recently launched an incentive opportunity known as the Provider Directory Data Quality Compliance Program. PGIP physician organizations can elect to submit physician demographic data electronically, thereby bringing their affiliated physicians into compliance. An electronic submission from the physician organization would serve as the attestation on behalf of the practitioner.

For the first half of 2017, PGIP participants will want to confirm with their PO whether it is participating in the Provider Directory Data Quality Compliance Program and will be submitting physician demographic data electronically on your behalf. If your PO isn’t participating in the electronic file submission, you must attest to your current demographic data by using the PRIME-Hub online tool and then DirectAssure later in the year.

For more information, PGIP participating physicians can contact their PO. Non-PGIP physicians, contact your provider consultant.