We’re making some changes to our prior authorization processes

As you read in the April 2017 Record, there are three major changes coming to our prior authorization processes as follows:

• Beginning July 5, we’ll require prior authorization for our Medicare Advantage PPO patients for select specialty medications covered under the Medicare medical benefit. (These are medications that aren’t self-administered but must be administered via injection or infusion in a physician’s office by a doctor or health care professional.)
• Beginning July 31, 2017, prior authorization for Medicare Advantage patients will be required for select surgical procedures. Procedures will include the following:
• Arthroplasty (hip, knee, shoulder)
• Correction of hammertoe
• Nasal/sinus endoscopy
• Endovascular intervention, peripheral artery
• Radiofrequency ablation and transarterial embolization
• Vagus nerve stimulation
• Intrathecal catheter/pump placement
• Spinal cord stimulator insertion
• Gastric stimulation
• Beginning July 31, 2017, we’re moving from the prenotification system to e-referral. If you’ve been using the prenote system for services requiring prior authorization (also called authorization or preauthorization), you’ll be switching to e-referral.
  
  Note: If you’re not an e-referral user already, you can sign up on the Sign up for e-referral or change a user page on the ereferrals.bcbsm.com website. The page contains information providers need to sign up for access to the e-referral system.

The table below outlines all the prior authorization programs for Medicare Advantage PPO and commercial members, including the changes that are coming in July:

More information

• For information on a webinar on Blue Cross’ Medicare Plus Blue^SM PPO medical drug authorizations, see the article in this issue.

• We’ll provide details on how you can get trained on e-referral in the July issue of The Record.

• For more details on the upcoming changes, see the following two April Record articles:
• New prior authorization requirements begin this summer
• We’re moving from prenotification system to e-referral

2017 InterQual^® criteria delayed

Blue Cross Blue Shield of Michigan and Blue Care Network will delay the implementation of the 2017 InterQual criteria until October because of the Care Advance upgrade. Until the upgrade is complete, we’ll continue to follow the 2016 criteria for all levels of care.

PARS will provide claims information June 30

Beginning June 30, 2017, you can get claims information or benefits and eligibility when calling the Provider Automated Response System, or PARS.

Claims information is available through PARS 24 hours a day, seven days a week.

If you choose benefits and eligibility, you’ll continue to receive the current information for your patient.

If you choose claims, you’ll receive claims information, including:

• Status of a claim, payment and rejection details
• Check information
• Member liability

PARS will ask if you’re checking the status of your claim. If you have submitted a claim, but you haven’t received a remittance, answer “yes.” If you have received a remittance for your claim, but you need additional assistance, answer “no.”

You’ll need to provide the following information to obtain assistance with claims:

• Provider information billed on the claim
• Facility Code or Professional Provider ID, or National Provider Identification, or Tax Identification Number for ancillary services
  Note: You must authenticate with your provider information to obtain any claims information. We’re unable to provide protected health information without this verification.
• Patient contract number
• Patient name
• Patient date of birth
• Date of service billed
• Charged amount on the claim

Claims Status

If you’re checking on the status of a claim, PARS will find the claim in the system and provide applicable information.

For finalized claims, the following information is available:

• Paid claims
• Internal claim number, or ICN
• EFT Trace number (for electronically paid providers) or the check number
• EFT payment date or the check date and check posting date
• Total amount paid on the claim
• Member cost share applied
• Deductible
• Coinsurance
• Copay
• If the claim was processed to the subscriber, PARS will speak this in addition to providing the payment date (if a payment was made).
• Rejected claims
• ICN
• Denial reason
• Date the claim was finalized

Specific, detailed information is also available for each claim line. You'll be asked to provide the procedure code or revenue code. PARS will then provide the following at claim-line level:

• Charged amount
• Allowed amount
• Payment amount
• Rejection/denial reason
• Member liability (deductible, coinsurance, copay), if applicable

A hardcopy of this claims status information will also be available upon request. This hardcopy will include applicable payment or rejection/denial information, but it’s not intended as a replacement for provider vouchers. Hard copies won’t be available for the Federal Employee Program^® or Blue Care Network.

For pending claims, the following information is available:

• ICN
• Date claim was received
• Message indicating the claim is pending
• If the claim has been pending less than 30 days, allow additional time for the claim to finalize.
• If the claim has been pending for more than 30 days, you’ll have the option to transfer to a call center for assistance.

If there is no claim found, that means there is no claim on file. In that case, you'll need to resubmit.

Claims Inquiry

If a remittance has already been received, but more discussion is needed, PARS will offer the following options:

• Payment other than anticipated
• Clarify a rejection/denied claim
• Discuss account receivables/account payables
• Follow up on a previously submitted inquiry/dispute
• Obtain status on a previously submitted medical-surgical preauthorization request (only for Blue Cross Blue Shield of Michigan policies)
• Preauthorization requests aren’t handled through the call centers but, if a medical-surgical preauthorization request has already been submitted in writing, the status of this request will be available
• Initiate a recovery (for Blue Cross and Medicare Advantage policies only)
• Check status (only for BCN policies)
• Appeals (only for BCN policies)

PARS will provide claims information for the following lines of business:

• Professional
• Facility
• Vision
• Dental (FEP only)
• Hearing

The following products will be available for claims information on PARS:

• Blue Cross Commercial
• Blue Cross Medicare Advantage
• BCN Commercial
• BCNA
• FEP

The following claims information won’t be available on PARS:

• Pharmacy
• Dental (FEP Dental claims information will be available)
• Payments made via manual check writing
• MESSA paid claims

Beginning June 30, 2017, the current PARS benefit phone numbers should be used for both benefits and eligibility, and claims information.

PARS professional providers.....................................................................1-800-344-8525
PARS facility providers.................................................................................1-800-249-5103
PARS vision and hearing............................................................................1-800-482-4047
PARS Federal Employee Program...........................................................1-800-840-4505
PARS Medicare Advantage.........................................................................1-866-309-1719
PARS Medicare Advantage dental.............................................................1-888-826-8152

Tower International selects Reference Based Benefits feature for some member segments

Beginning July 1, 2017, Tower International has selected the Reference Based Benefits feature for some of its employees. This benefit feature sets a maximum (reference) price Tower International will pay for select services for its employees. And RBB encourages members to use online tools to help compare health care facilities based on costs.

We’ll include information for Tower International in the July billing chart.

How can I tell a member has RBB?
Tower International employees have group number 71379 on their member ID cards, with a prefix of TOV. Additionally, when you look up member benefits and eligibility, verbiage appears on web-DENIS that says the contract has Reference Based Benefits.

Where can I get information about the member’s liability?
For more information about the member’s liability after a given service, go to web-DENIS and check your patient’s benefits and eligibility to see the associated RBB information. This will include the reference price. The member pays for his or her standard cost share and any difference between the Blue Cross Blue Shield of Michigan allowed amount and the reference price.

Note: This feature affects member cost share, not what Blue Cross will pay health care providers for services. In-network providers can expect to receive contracted rates on all procedures.

What services does this apply to?
Tower International has selected to apply RBB to the following services:

• Inpatient surgeries — hip and knee replacement
• Outpatient surgeries — bariatric surgery, cataract removal, carpal tunnel repair, ACL repair, shoulder arthroscopy (and select others)

The benefits and eligibility section on web-DENIS has a full list of affected services.

How does this work?
When you charge eligible services below the reference price, Blue Cross will pay the allowed amount minus any member liability. For those charges that may exceed the reference price, the member pays his or her standard cost share, plus any difference between the Blue Cross allowed amount and the reference price.

For example: If the reference price is $500 for a bunionectomy and the Blue Cross allowed amount is $700, then Blue Cross pays up to $500, less the member’s standard cost share, for the procedure. The member pays for his or her standard cost share on the part up to $500, plus the $200 difference between the Blue Cross allowed amount and the reference price.

For more information, see the Reference Based Benefits article published in the November 2016 issue of The Record.

None of the information included herein is intended to be legal advice and as such it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Waiving nursing requirement for home infusion therapy

Often during an audit, we see that a patient is performing home infusion therapy on their own — without nursing care — but the required Certificate of Medical Necessity documentation doesn’t follow the necessary guidelines. To waive the nursing requirement, the following must apply and be documented:

• The patient considers himself or herself independent and no longer wants or requires nursing visits.
• Documentation on the CMN states:
• The nursing visit requirement was explained to the family or caregiver.
• The patient or caregiver is capable and willing to provide the infusion-related care.
• The patient or caregiver is aware that nursing is available on an as-needed basis.
• The patient’s physician signs the CMN within the required 90 days, as stated in the guidelines, of the criteria above, acknowledging his or her agreement.

All future CMNs will require the same components, and CMNs must be renewed every 120 days. If a CMN doesn’t have all the necessary components, a sanction equivalent to the cost of one nursing visit will be applied to the S code every seven days that nursing wasn’t provided.

None of the information included herein is intended to be legal advice and as such it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Physicians must sign orders for infusion therapy

Physician signatures are required on orders for infusion therapy before providing care or services.
Each order must include:

• The date the order was written. The order must be in place within 48 hours of administering the medication
• Physician signature, which must be legible so it can be easily authenticated

Verbal orders must be committed to writing, dated and signed by the person who receives the order and must be subsequently signed and dated by the ordering physician. Blue Cross Blue Shield of Michigan documentation guidelines state, “The request for the physician’s signature must be initiated within 10 days of receipt of the verbal order and received within 30 days of receipt of the verbal order.”

Blue Cross accepts written or electronic signatures. Stamped signatures aren’t acceptable.

For more information about physician signature requirements, refer to the medical record entry and physician documentation-related obligation sections of the BCBSM Documentation Guidelines for Physicians and other Professional Providers.

None of the information included herein is intended to be legal advice and as such it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Coding corner: What to know when coding for vascular disease

Vascular disease is any abnormal condition of the blood vessels and includes conditions that affect the circulatory system. There are many risk factors for vascular diseases, including aging, a family history of vascular or heart disease, diabetes, high cholesterol, hypertension, smoking and obesity.

Here are some important things to keep in mind when coding for vascular disease:

• Is the condition considered part of a patient’s past medical history that no longer requires any form of treatment?
• Does the patient have a chronic condition? State the acuity and note the current treatment.
• Is the current condition a manifestation of a chronic condition? (e.g., diabetic angiopathy)

Peripheral vascular disease
One disease of the vascular system is peripheral vascular disease, or PVD. Sometimes referred to as peripheral arterial disease or peripheral angiopathy, PVD is a circulatory condition resulting in reduced blood flow to the extremities, typically occurring in the legs. The American Heart Association defines PVD as diseases of blood vessels outside the heart and brain. It’s often a narrowing of vessels that carry blood to the legs, arms, stomach or kidneys.

The most common symptom of PVD is intermittent claudication, which is pain while walking that resolves after a few minutes of rest. The location of the pain depends on the site of the narrowed or clogged artery.

To code PVD to the highest specificity, look for these key components:

• Location of vein or artery affected
• Complications such as intermittent claudication, ulceration or pain at rest
• Laterality — left, right or bilateral
• The cause, if known
• Whether gangrene is present

If PVD is noted without further specificity, use ICD-10 code I73.9, Peripheral vascular disease, unspecified. This code also includes intermittent claudication, peripheral angiopathy NOS and spasm of artery.

Peripheral vascular disease and diabetic complications
Documentation is extremely important when PVD is a manifestation associated with a specific condition. Peripheral vascular disease codes require a fourth – and sometimes – a fifth digit.

Examples below show coding with the required fifth digit:

• E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
• E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene

According to the AHA Coding Clinic (Fourth Quarter, 2016), considered an official resource by the Centers for Medicare & Medicaid Services, new instructions were released on the assumed cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves and circulatory system. These instructions are in accordance with the updates to the 2017, ICD-10-CM Official Guidelines for Coding and Reporting. Following is a look at the ICD-10-CM alphabetic index format for certain conditions linked to diabetes Type 2 using the subterm “with”:

Diabetes, diabetic (mellitus)(sugar) Type 2 E11.9 With
Amyotrophy E11.44 Chronic kidney disease E11.22 Circulatory complications E11.59 Peripheral angiopathy E11.51		Relationship assumed

If a provider has documented diabetes and peripheral angiopathy in a medical record, the conditions are assumed to be related even if the doctor doesn’t specifically document the relationship. However, if the doctor documents that the Type 2 diabetes mellitus isn’t the underlying cause of the peripheral angiopathy, the condition shouldn’t be coded as a diabetic complication. If the coder isn’t able to determine whether the Type 2 diabetes mellitus and peripheral angiopathy are related or the ICD-10-CM classification doesn’t provide coding instruction, it’s appropriate to query the doctor for clarification so that appropriate codes may be reported.

None of the information included herein is intended to be legal advice and as such it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

3 Medicare star rating measures support importance of statin therapy for patients with cardiovascular disease and diabetes

The Centers for Medicare & Medicaid Services has issued two new star rating measures to support the importance of statin therapy for patients with cardiovascular disease and diabetes. There’s also an existing medication adherence measure that plays a key role in the effectiveness of statin treatment.

Here’s an overview of the three measures:

Statin therapy for patients with cardiovascular disease
This new measure assesses the percentage of men ages 21 to 75 and women ages 40 to 75 who were identified as having clinical atherosclerotic cardiovascular disease and met the following criteria:

• Received statin therapy: Patients were dispensed at least one high or moderate-intensity statin medication in the measurement year.

Statin use in persons with diabetes
This new measure assesses the percentage of people ages 40-75 with diabetes who met the following criteria:

• Received statin therapy: Patients were dispensed at least one statin medication of any intensity during the measurement year.

Medication adherence for cholesterol (statins)
This measure assesses the percentage of people age 18 and older who met the following criteria:

• Were dispensed at least two fills of a statin medication and filled the medication for at least 80 percent of the treatment period.

Following is a look at why statin therapy is beneficial for people with cardiovascular disease and diabetes.

Cardiovascular disease
Cardiovascular disease is the leading cause of death in the United States. More than 85 million American adults have one or more types of cardiovascular disease. It’s estimated that by 2030, more than 43 percent of Americans will have a form of cardiovascular disease.

According to the American College of Cardiology and the American Heart Association, statins of moderate or high intensity are recommended for adults with established clinical atherosclerotic cardiovascular disease. Many studies support the use of statins to reduce atherosclerotic cardiovascular disease events in primary or secondary prevention.

Diabetes
Prevention of cardiovascular disease is an important aspect of diabetes management. The risk of an adult with diabetes developing cardiovascular disease is two to four times higher than for adults without diabetes.

In addition to being at a higher risk for developing cardiovascular disease, patients with diabetes tend to have a worse survival rate after the onset of cardiovascular disease. The Centers for Disease Control and Prevention estimates that adults with diabetes are 1.7 times more likely to die from cardiovascular disease than adults without diabetes.

Consider prescribing statins not only for your patients with hypercholesterolemia, but also for patients diagnosed with atherosclerotic cardiovascular disease or diabetes.

Here's what you should know about urinary incontinence in older adults

Bladder control is a widespread issue among older adults. According to the National Association for Continence, 1 in 5 individuals older than 40 suffers from urinary continence.

Urinary incontinence isn’t just a physical condition. It can also affect a patient’s quality of life. It causes many older people to avoid activities, limit social interactions, become depressed and even struggle to get a good night’s sleep. There’s also the risk of falling in patients who try to make it to the bathroom in time.

A challenge for sufferers

Even though it’s common and can cause problems, patients find the subject difficult to bring up with their doctors. According to the Agency for Healthcare Research and Quality, more than 50 percent of women never get treatment for their stress incontinence.

Not only do patients find it embarrassing, they assume incontinence or leakage is a natural part of the aging process. They may not realize it’s a treatable condition.

Starting the discussion about urinary incontinence with patients may be what helps them understand they no longer have to live with it.

Forms of urinary incontinence

To help you discuss the topic with patients, here’s a refresher on the ways urinary incontinence can occur.

• Urge incontinence: The most common diagnosis, this involves an urgent need to urinate resulting in the loss of urine before one arrives to a toilet.
• Stress incontinence: This occurs when an increase in abdominal pressure overcomes the closing pressure of the bladder. Abdominal pressure rises when you cough, sneeze, laugh, climb stairs or lift objects.
• Overflow incontinence: Rarely diagnosed, this happens when one’s bladder never completely empties causing leakage when the bladder becomes overly full.
• Functional incontinence: This is a form of urinary incontinence in which a person is usually aware of the need to urinate but for one or more physical or mental reasons, the person is unable to get to the bathroom.
• Mixed incontinence: Sometimes patients experience more than one type of incontinence, and usually it’s a combination of stress and urge incontinence, especially for women.

Treatment options

After a diagnosis is made, available courses of treatment include:

• Behavioral therapy: Usually the first line of treatment is behavioral therapy, which will often help improve the incontinence. Treatments can include bladder training, scheduled bathroom trips, pelvic floor muscle exercises and fluid and diet management.
• Medications: These are frequently used in combination with behavioral therapies and include anticholinergic or antispasmodic drugs, topical hormonal therapy for females or antibiotics when incontinence is caused by a urinary tract infection or an inflamed prostate gland.
• Medical devices: Women can be prescribed devices such as urethral inserts, which are placed usually before activities related to urinary incontinence episodes, and pessaries or intra-vaginal devices, which are similar to diaphragms and support the bladder.

With your help, urinary incontinence doesn’t have to take over the lives of your patients. Start the discussion and tell them about the variety of treatments that can help them enjoy life without the worry of leakage.

BlueCard^® connection: Why can’t I bill the patient when a claim rejects for timely filing?

As we mentioned in our March 2017 “BlueCard connection” article, providers should be aware of two filing limits with BlueCard claims:

1. There’s a timely filing limit imposed by Blue Cross Blue Shield of Michigan based on your contractual requirements.
   
   
2. The member’s home plan could have a timely filing limit related to his or her contracted group benefits.

When claims reject for timely filing, the charges are a provider’s liability and require provider write-off. We understand that sometime things occur that are outside of a provider’s control. So if you disagree with a timely filing rejection, you may contact Provider Inquiry for assistance. A representative will work with you to review the rejection and take corrective action when appropriate.

To ensure that your BlueCard claim is processed within the timely filing limits:

• Familiarize yourself with your timely filing requirements per your contract with Blue Cross.
• Verify whether a member’s contract has timely filing restrictions when verifying eligibility and benefits.
• File claims promptly.

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

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

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

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.

Register for training webinar on Medicare Plus Blue^SM PPO medical drug authorizations

Select specialty medications covered under the Medicare Part B medical benefit will require prior authorization, starting July 5, 2017.

Beginning on that date, health care providers should submit prior authorization requests electronically through NovoLogix^®, a secure online tool. NovoLogix allows providers to obtain real-time status checks on prior authorizations and to obtain immediate approvals for certain medications.

Use of the NovoLogix tool will save time and lessen your administrative burden by eliminating the process of filing forms manually. Blue Cross Blue Shield of Michigan has been using NovoLogix for the past two years so some providers may already be familiar with the tool.

To learn how to use the NovoLogix tool, you’ll want to sign up for a webinar training session, which will conclude with a question-and-answer session. You can choose from one of the following sessions:

Follow these steps to register:

1. Click here to access the webinar registration form.
2. Complete the registration form.
3. Submit the completed form in one of the following ways:
• Email it to ProviderInvitations@bcbsm.com.
• Fax it to 1-866-652-8983.
  

You’ll receive an email the Friday before the webinar session with a link to the webinar. The email will include:

• Name of webinar
• Time of webinar
• Session number
• Session password
• Teleconference number
• Contact name and phone number in case you need assistance

Beginning July 5, 2017, the NovoLogix online tool can be accessed through the Provider Secured Services home page. After signing in, select Medicare Advantage PPO Medical Benefit-Medication Prior Authorization to initiate a request.

For more details on the new prior authorization requirement for select specialty medications, see the article titled “We’re making some changes to our prior authorization processes.”

Physicians must sign orders for infusion therapy

Physician signatures are required on orders for infusion therapy before providing care or services.
Each order must include:

• The date the order was written. The order must be in place within 48 hours of administering the medication
• Physician signature, which must be legible so it can be easily authenticated

Verbal orders must be committed to writing, dated and signed by the person who receives the order and must be subsequently signed and dated by the ordering physician. Blue Cross Blue Shield of Michigan documentation guidelines state, “The request for the physician’s signature must be initiated within 10 days of receipt of the verbal order and received within 30 days of receipt of the verbal order.”

Blue Cross accepts written or electronic signatures. Stamped signatures aren’t acceptable.

For more information about physician signature requirements, refer to the medical record entry and physician documentation-related obligation sections of the BCBSM Documentation Guidelines for Physicians and other Professional Providers.

None of the information included herein is intended to be legal advice and as such it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Reminder: Professional providers required to submit claims electronically, starting June 30

Beginning June 30, 2017, participating providers will be required to submit the following types of claims electronically if they currently have the capability to submit electronic claims:

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

Although we encourage the following types of claims to be submitted electronically, they’re excluded from the electronic submission requirement:

• 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

If you have questions or need more information, see the March Record article.

Here’s updated information about MA PPO Physical Therapy Use Management Program

Blue Cross Blue Shield of Michigan continues to partner with eviCore for its Medicare Advantage PPO Physical and Occupational Therapy Program. In response to questions we’ve received from health care providers, we’d like to provide updated information about the program.

Thanks to all of you who notified us about issues you’ve experienced during the first quarter of the program. Your input helps us make improvements to the program, which will be especially beneficial as we move forward with preauthorization for our commercial product in 2018.

Preauthorization

• All cases are reviewed on an individual basis for medical necessity so the number of approved visits may vary.
• Providers may request additional visits for approval within the original 30-day period; additional visits will also be based on medical necessity.
• If you don’t use all the approved days for an original issue and want to begin therapy on a second issue, use the days that have already been approved. Notify eviCore of the new therapy if additional days are required for the secondary issue after the approved days have been exhausted.
• If treatment begins on the same day of the evaluation, you must have the treatment approved. The start date is always the first day treatment begins.
• Initial evaluations don’t require preauthorization. We’re making the appropriate edits to our system to accommodate this.
• Reevaluations for PT and OT do require authorization.
• Peer-to-peer reviews may be requested before a denial is made. This allows the provider to have full understanding of the medically necessary information eviCore is looking for to approve services.
• Once a denial is made by eviCore, eviCore can’t overturn it. The case must be appealed through Blue Cross.
• Providers may upload or fax specific information to eviCore if they’re unable to add it on the form that’s been posted on the portal. Doing this may result in a longer response time from eviCore.
• If additional visits are required, the provider may go back to eviCore seven days before the end of the approved period. Approval will be based on the most current documentation of medical necessity.
• Providers can log in to the portal to see the status of their request. Simply select auth lookup and it will display the approval date, expiration date, number of visits approved and number of units approved.
• All Centers for Medicare & Medicaid Services documentation requirements for reporting remain the same. However, it’s no longer necessary to report the level of functional improvement that a Medicare Advantage patient has achieved.

Provider categories

• Blue Cross will categorize providers in January and July. Providers should be receiving their categorization letters in early to mid-February and early to mid-August. The effective dates for the new categories will be April and October, depending on when the categorization occurred.
• Providers can check the portal for their current categorization information.

Upcoming upgrades

• eviCore and Blue Cross are working together to provide a job aid to assist our providers with identifying mandatory versus optional fields on the web portal. In addition, eviCore is working on ways to update the portal to expedite the authorization process.
• eviCore is working on new pathways that will expedite the overall authorization process and eliminate the redundancy of information requested after the original case has been entered.
• Blue Cross will set up training sessions when the upgrades have been completed.

New sites of care pilot program provides options for members to receive infusion services

In June, Blue Cross Blue Shield of Michigan members who are receiving select, specialty drugs in a hospital outpatient facility will start receiving phone calls from Option Care™, one of our home infusion providers. The purpose of these calls is to educate members about the safe options available for moving to home-infusion therapy. In 2017, this is a voluntary program for members. Members aren’t obligated to select Option Care as their provider.

In 2018, we’ll require that members receive infusions in a professional office setting, a professional infusion center or in the member’s home. Additional approval will be required for members to receive infusions in a hospital outpatient department.

This pilot program doesn’t affect the Blue Cross or BCN medical specialty drug prior-authorization program. And the pilot is independent of BCN’s sites of care optimization program requirements.

Specialty drugs targeted for the call program may include:**

**Targeted drugs are subject to change.

Provider forums will continue throughout June

Blue Cross Blue Shield of Michigan and Blue Care Network provider forums are coming to you. We’ve scheduled a series of provider forums across the state focusing on topics of interest to providers. A forum scheduled for hospitals is noted at the end of the list. All other forums are targeted to professional providers.

The forums will cover topics such as:

• 2017 coding and documentation updates for ICD-10 CM, CPT and HCPCS (morning)

• HEDIS^® updates (morning)

• Patient experience (morning)

• Blue Cross Complete update (afternoon)

• Review of Blue Cross and BCN authorizations (afternoon)

• Products at a glance (afternoon)

• Who to contact at Blue Cross and BCN (afternoon)

• Blue Card update (afternoon)

• Provider enrollment updates (afternoon)

Schedule of events:

• Registration begins at 7:30 a.m. The morning session starts at 8 a.m. and includes a continental breakfast. The afternoon session begins at noon and includes lunch.
• You can register for the full day, or you can choose to attend just the morning or afternoon session.

We look forward to seeing you.

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

Clarification of rules for supervision for nonphysician mental health practitioners

We’ve been asked to clarify Blue Cross Blue Shield of Michigan’s rules for supervision of nonphysician mental health practitioners in a non-outpatient psychiatric care facility setting.

Fully licensed

Generally, Blue Cross will cover the services of any fully licensed nonphysician mental health practitioner as long as the practitioner is supervised by an M.D., D.O., or fully licensed psychologist and billed by the supervising M.D., D.O., or fully licensed psychologist. When determining whether a service is a covered benefit, Blue Cross will apply any State of Michigan laws or regulations that specify requirements regarding supervision. Compliance with legal and regulatory provisions must be documented for the purposes of audit.

There are two areas where there are such requirements:

1. In the general provisions of the public health code, section 333.16109 defines supervision as having all of the following:
• The continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional.
• The availability of a licensed health professional on a regularly scheduled basis to review the practice of the supervised individual, to provide consultation to the supervised individual, to review records and to further educate the supervised individual in the performance of the individual's functions.
• The provision by the licensed supervising health professional of predetermined procedures and drug protocol.
2. Limited licensed psychologists must be supervised by fully licensed psychologists (or other such individuals as designated by law) in the manner prescribed in rules governing psychologists. (See MCLA 333.18223 and also see Regulation 338.2571 Supervision requirements; reporting of supervision.)

Supervision and billing responsibilities for nonphysician mental health practitioners

**The supervising M.D or D.O. must submit the bill using the supervising M.D. or D.O.’s NPI.

^The supervising FLP must submit the bill using the supervising FLP’s NPI.

#Either the supervising fully licensed nonphysician practitioner of the same provider type must bill using the supervisor’s NPI or the M.D./D.O./FLP supervisor of the fully licensed practitioner must bill.

State and Federal Definitions of Supervision

STATE

MCLA. 333.16109

(2) “Supervision”, except as otherwise provided in this article, means the overseeing of or participation in the work of another individual by a health professional licensed under this article in circumstances where at least all of the following conditions exist:

(a) The continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional.

(b) The availability of a licensed health professional on a regularly scheduled basis to review the practice of the supervised individual, to provide consultation to the supervised individual, to review records, and to further educate the supervised individual in the performance of the individual's functions.

(c) The provision by the licensed supervising health professional of predetermined procedures and drug protocol.

Note: For educational limited licenses, different supervision requirements are required, which vary by provider type.

FEDERAL

42CFR410.32(b)(3)

(i) General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

(ii) Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

(iii) Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

We’ve made changes to Ambulance Provider Participation Agreement

A new ground and air Ambulance Provider Participation Agreement — a combined Blue Cross Blue Shield of Michigan and Blue Care Network agreement — has been approved by the Michigan Department of Insurance and Financial Services.

It includes changes to the existing Medical Necessity Criteria and Confidentiality Policy. To view the agreement, which has been posted on bcbsm.com, click here.

Enrollment materials will be available electronically from bcbsm.com/providers by June 1, 2017. Follow these steps to enroll:

• Visit the Enrollment and Changes section.
• Click on Provider Enrollment Form.
• Select Physicians and Professional.
• Select Enroll a New Provider.
• Under “Allied Providers,” select Ambulance.
• Select BCBSM agreements and signature documents.
• Select BCBSM Ambulance Provider Participation Agreement.

Effective dates

• For newly enrolled providers, the agreement will be effective immediately upon enrollment.
• For providers who signed a Letter of Agreement prior to the Michigan Department of Insurance and Financial Services granting their approval, the effective date was Jan. 1, 2017.
• For providers who agreed to the terms of the previous Ambulance Provider Participation Agreement, the effective date is Sept. 1, 2017.

Blue Cross wellness programs help your patients improve their health

Blue Cross^® Health & Wellness programs are making a difference in your patients’ lives. Our wellness programs include the Blue Cross Health & Wellness website, powered by WebMD^®, along with additional programs to address tobacco use, weight, nutrition, physical activity and much more.

Website provides members with a variety of online health resources
The Blue Cross Health & Wellness site features a variety of health and wellness resources designed to help your patients learn their health risks and discover ways to live a healthier lifestyle. It also provides a centralized location for them to keep track of health measures and wellness program requirements. Blue Cross Blue Shield of Michigan members can reach the site by logging in to their member account at bcbsm.com.

These site features and online tools and resources can help your patients better monitor their health and get healthy, stay healthy or manage a chronic condition:

• Device and App Connection Center – Allows your patients to sync more than 200 fitness and medical devices, along with health-specific mobile apps
• Personal Health Record – Combines lab data imported from Blue Cross and Blue Care Network qualification forms with self-reported data, medical test results, conditions, medications, doctor visits, allergies and more. Your patients can even upload and store medical documents.
• Interactive online health assessment – Provides your patients with information about their health risks and what they can do to improve their health
• Digital Health Assistant programs – Help patients make small behavior changes and meet their health goals
• Health Trackers – Help your patients track their exercise, steps, diet, mood, pain, tobacco use and more
• Pregnancy Assistant – Tool for expectant mothers and their supporters that features a dashboard of quizzes, checklists, articles, videos, activities and more
• WebMD Health Topics^SM – Allows patients to search for specific health information
• Professionally monitored Message Board Exchanges – Allow patients to interact with others and find credible answers to their health questions
• Quizzes, slide shows, videos, recipes, calculators and more

Coaching programs help members see positive results
Our Lifestyle Coaching and Tobacco Cessation Coaching programs provide eligible members with the tools and resources they need to make healthy changes. Specially trained health coaches work with members using the Motivational Interviewing behavioral change technique.

Blue Cross members are usually stratified into these coaching programs based on data from their online health assessment or the Blue Cross Qualification Form. Lifestyle and Tobacco Cessation health coaches then use imported and self-reported data, along with programs goals, to help patients achieve health improvement targets.

Our coaching programs are working:

• More than 73 percent of eligible members have engaged in the moderate-risk Lifestyle Coaching program.
• More than 41 percent of those who have completed the Tobacco Cessation Coaching program remain tobacco-free.

One member said that the Tobacco Cessation Coaching program saved her life. When she first received a call from a health coach, she had no desire to quit smoking. But as she talked to him during a series of phone calls, she realized the bad choices she was making with continuing to smoke.

“I have been smoke-free for three months and 20 days. If it wasn’t for Vince (her health coach), I would probably not see my grandbabies for as long as I hope to,” she said. “You gave me some years back to my life, so I can’t thank you enough.”

Lifestyle Coaching and Tobacco Cessation Coaching are available only to members whose employer has purchased those programs. However, all members can access the Digital Health Assistant coaching programs on the Blue Cross Health & Wellness website. These online programs emulate the telephone coaching program. Programs are available for weight, exercise, nutrition, tobacco cessation, stress and mood.

Physician Health Screening program enhances patient interaction

You’ve probably been asked by some of your patients to complete a Blue Cross qualification form. This is part of the Physician Health Screening program designed to help our members establish relationships with their doctors and identify emerging health issues as early as possible. Again, qualification form data is uploaded into members’ online Personal Health Record and online health assessment, which is used to help stratify members into coaching programs.

Want to learn more?
Contact Susan Okonkowski at sokonkowski@bcbsm.com or call 313-448-7503 to schedule a webinar for your office.

WebMD Health Services is an independent company supporting Blue Cross Blue Shield of Michigan by providing health and wellness services.

Awards salute Medicare Advantage providers for their star-ratings support

We recently honored more than 200 Medicare Advantage providers with Provider Distinction Awards. These awards recognize the outstanding contributions providers have made to the BCN Advantage^SM and Blue Cross Medicare Plus Blue^SM PPO plans’ 2016 star ratings.

This is the fourth year we’ve recognized Medicare Advantage providers for their contributions to our star quality measures. Our relationship with providers is crucial to our star ratings success.

The Centers for Medicare & Medicaid Services measures the quality to drive improvements in accountability with the health care plans, doctors and hospitals. This rating system applies to all Medicare Advantage lines of business. The star rating includes 44 metrics that span five broad categories:

• Outcomes
• Intermediate outcomes
• Patient experience
• Access
• Process

The award criteria include the following measures that support the star ratings for BCN Advantage^SM and Blue Cross Medicare Plus Blue^SM:

• Achieving 83 percent or higher for joint contracts on the measures below
• Or 85 percent or higher for single contracts on the measures below

The measures are:

• Outcomes (Staying healthy)
• Breast cancer screening
• Colorectal cancer screening
• Intermediate outcomes (managing long-term conditions)
• Diabetes measurements
• Eye
• Kidney
• Blood sugar control

Providers must have a minimum of five services that count toward the star rating (for example, a diabetes test or colorectal screening). The number of services completed divided by the number of eligible services equals the quality score.

Please note:

• Providers must be currently credentialed and contracted with Blue Cross Medicare Plus Blue PPO or BCN Advantage, and in good standing.
• Providers may not be in the low quality score rating program. (Providers with low quality scores will be eligible for future awards once they’ve completed the Quality Rating System program.)

The Provider Distinction Awards plaque is perpetual; we add stars to it as the physician groups continue to achieve impressive scores. The providers who received plaques also receive gifts for their office staff who handled the administrative work. We appreciate their support.

Here’s updated information about MA PPO Physical Therapy Use Management Program

Blue Cross Blue Shield of Michigan continues to partner with eviCore for its Medicare Advantage PPO Physical and Occupational Therapy Program. In response to questions we’ve received from health care providers, we’d like to provide updated information about the program.

Thanks to all of you who notified us about issues you’ve experienced during the first quarter of the program. Your input helps us make improvements to the program, which will be especially beneficial as we move forward with preauthorization for our commercial product in 2018.

Preauthorization

• All cases are reviewed on an individual basis for medical necessity so the number of approved visits may vary.
• Providers may request additional visits for approval within the original 30-day period; additional visits will also be based on medical necessity.
• If you don’t use all the approved days for an original issue and want to begin therapy on a second issue, use the days that have already been approved. Notify eviCore of the new therapy if additional days are required for the secondary issue after the approved days have been exhausted.
• If treatment begins on the same day of the evaluation, you must have the treatment approved. The start date is always the first day treatment begins.
• Initial evaluations don’t require preauthorization. We’re making the appropriate edits to our system to accommodate this.
• Reevaluations for PT and OT do require authorization.
• Peer-to-peer reviews may be requested before a denial is made. This allows the provider to have full understanding of the medically necessary information eviCore is looking for to approve services.
• Once a denial is made by eviCore, eviCore can’t overturn it. The case must be appealed through Blue Cross.
• Providers may upload or fax specific information to eviCore if they’re unable to add it on the form that’s been posted on the portal. Doing this may result in a longer response time from eviCore.
• If additional visits are required, the provider may go back to eviCore seven days before the end of the approved period. Approval will be based on the most current documentation of medical necessity.
• Providers can log in to the portal to see the status of their request. Simply select auth lookup and it will display the approval date, expiration date, number of visits approved and number of units approved.
• All Centers for Medicare & Medicaid Services documentation requirements for reporting remain the same. However, it’s no longer necessary to report the level of functional improvement that a Medicare Advantage patient has achieved.

Provider categories

• Blue Cross will categorize providers in January and July. Providers should be receiving their categorization letters in early to mid-February and early to mid-August. The effective dates for the new categories will be April and October, depending on when the categorization occurred.
• Providers can check the portal for their current categorization information.

Upcoming upgrades

• eviCore and Blue Cross are working together to provide a job aid to assist our providers with identifying mandatory versus optional fields on the web portal. In addition, eviCore is working on ways to update the portal to expedite the authorization process.
• eviCore is working on new pathways that will expedite the overall authorization process and eliminate the redundancy of information requested after the original case has been entered.
• Blue Cross will set up training sessions when the upgrades have been completed.

New sites of care pilot program provides options for members to receive infusion services

In June, Blue Cross Blue Shield of Michigan members who are receiving select, specialty drugs in a hospital outpatient facility will start receiving phone calls from Option Care™, one of our home infusion providers. The purpose of these calls is to educate members about the safe options available for moving to home-infusion therapy. In 2017, this is a voluntary program for members. Members aren’t obligated to select Option Care as their provider.

In 2018, we’ll require that members receive infusions in a professional office setting, a professional infusion center or in the member’s home. Additional approval will be required for members to receive infusions in a hospital outpatient department.

This pilot program doesn’t affect the Blue Cross or BCN medical specialty drug prior-authorization program. And the pilot is independent of BCN’s sites of care optimization program requirements.

Specialty drugs targeted for the call program may include:**

**Targeted drugs are subject to change.

Provider forums will continue throughout June

Blue Cross Blue Shield of Michigan and Blue Care Network provider forums are coming to you. We’ve scheduled a series of provider forums across the state focusing on topics of interest to providers. A forum scheduled for hospitals is noted at the end of the list. All other forums are targeted to professional providers.

The forums will cover topics such as:

• 2017 coding and documentation updates for ICD-10 CM, CPT and HCPCS (morning)

• HEDIS^® updates (morning)

• Patient experience (morning)

• Blue Cross Complete update (afternoon)

• Review of Blue Cross and BCN authorizations (afternoon)

• Products at a glance (afternoon)

• Who to contact at Blue Cross and BCN (afternoon)

• Blue Card update (afternoon)

• Provider enrollment updates (afternoon)

Schedule of events:

• Registration begins at 7:30 a.m. The morning session starts at 8 a.m. and includes a continental breakfast. The afternoon session begins at noon and includes lunch.
• You can register for the full day, or you can choose to attend just the morning or afternoon session.

We look forward to seeing you.

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

Clarification of rules for supervision for nonphysician mental health practitioners

We’ve been asked to clarify Blue Cross Blue Shield of Michigan’s rules for supervision of nonphysician mental health practitioners in a non-outpatient psychiatric care facility setting.

Fully licensed

Generally, Blue Cross will cover the services of any fully licensed nonphysician mental health practitioner as long as the practitioner is supervised by an M.D., D.O., or fully licensed psychologist and billed by the supervising M.D., D.O., or fully licensed psychologist. When determining whether a service is a covered benefit, Blue Cross will apply any State of Michigan laws or regulations that specify requirements regarding supervision. Compliance with legal and regulatory provisions must be documented for the purposes of audit.

There are two areas where there are such requirements:

1. In the general provisions of the public health code, section 333.16109 defines supervision as having all of the following:
• The continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional.
• The availability of a licensed health professional on a regularly scheduled basis to review the practice of the supervised individual, to provide consultation to the supervised individual, to review records and to further educate the supervised individual in the performance of the individual's functions.
• The provision by the licensed supervising health professional of predetermined procedures and drug protocol.
2. Limited licensed psychologists must be supervised by fully licensed psychologists (or other such individuals as designated by law) in the manner prescribed in rules governing psychologists. (See MCLA 333.18223 and also see Regulation 338.2571 Supervision requirements; reporting of supervision.)

Supervision and billing responsibilities for nonphysician mental health practitioners

**The supervising M.D or D.O. must submit the bill using the supervising M.D. or D.O.’s NPI.

^The supervising FLP must submit the bill using the supervising FLP’s NPI.

#Either the supervising fully licensed nonphysician practitioner of the same provider type must bill using the supervisor’s NPI or the M.D./D.O./FLP supervisor of the fully licensed practitioner must bill.

State and Federal Definitions of Supervision

STATE

MCLA. 333.16109

(2) “Supervision”, except as otherwise provided in this article, means the overseeing of or participation in the work of another individual by a health professional licensed under this article in circumstances where at least all of the following conditions exist:

(a) The continuous availability of direct communication in person or by radio, telephone, or telecommunication between the supervised individual and a licensed health professional.

(b) The availability of a licensed health professional on a regularly scheduled basis to review the practice of the supervised individual, to provide consultation to the supervised individual, to review records, and to further educate the supervised individual in the performance of the individual's functions.

(c) The provision by the licensed supervising health professional of predetermined procedures and drug protocol.

Note: For educational limited licenses, different supervision requirements are required, which vary by provider type.

FEDERAL

42CFR410.32(b)(3)

(i) General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

(ii) Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

(iii) Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

Notify Medicare Plus Blue^SM PPO members about their rights if post-acute care services will be terminated

Post-acute care facility providers, whether contracted or non-contracted, must notify Medicare Plus Blue^SM PPO members about their rights to appeal a decision regarding termination of post-acute care services. They must do this by complying with the requirements for the delivery of a valid Notice of Medicare Non-coverage (Form CMS 10123-NOMNC). Generally, this notice must be delivered to the member no later than two days before the termination of services.

Post-acute care facility providers include skilled nursing facilities, comprehensive outpatient rehabilitation facilities and home health agencies.

Upon receipt of a Notice of Medicare Non-Coverage, or NOMNC, members or their authorized representative have the right to an expedited appeal to a Centers for Medicare & Medicaid Services-delegated Quality Improvement Organization. In Michigan, KEPRO^® is the delegated QIO.

When a member appeals

If the member or the authorized representative appeals to the QIO, the provider will receive an Expedited Appeal Documentation Request from the QIO. The provider must:

• Deliver a valid Detailed Explanation of Non-Coverage to the member.
• Respond to the QIO’s Expedited Appeal Documentation Request.
• Submit supporting documentation within the timeframe set by the QIO.

Per CMS 100-04, Medicare Claims Processing Manual, Chapter 30, §260.3.6: “If a Qualified Independent Contractor (QIO) determines that a provider did not deliver a valid NOMNC to a beneficiary, the provider is financially liable for continued services until two days after the beneficiary receives valid notice, or until the effective date of the valid notice, whichever is later.” Providers may not bill members for the balance of these services.

CMS forms and instructions
To access NOMNC and DENC forms and instructions, click here.

We’re updating qualification standards for freestanding substance abuse facility agreement

Effective Sept. 1, 2017, Blue Cross Blue Shield of Michigan is updating the credentialing requirement for residential facilities performing medical detoxification. Currently, Addendum A of our Freestanding and Hospital-Based Substance Abuse Facility Traditional Participation Agreement requires a substance abuse facility to maintain certain minimums to participate with Blue Cross.

Specifically, all residential facilities are currently required to have registered nursing personnel on-site “on a 24-hour basis.”

Substance abuse facilities that perform medical detoxification will still need registered nursing personnel on-site 24 hours per day, seven days per week.

But effective Sept. 1, substance abuse facilities that don’t perform medical detoxification:

• Will still be credentialed as substance abuse facilities

• Won’t be required to have nursing personnel on-site on a 24-hour basis as long as there are registered nursing personnel on call and able to respond in 60 minutes or less. So they may have registered nursing personnel on-site or on call 24 hours per day, seven days per week.

This update will differentiate between residential facilities performing medical detoxification and those that don’t deliver those services. And it allows our requirements to keep pace with the evolution of treatment.

Currently, many facilities don’t deliver medical detoxification and instead focus primarily on behavioral treatment of the patients. These facilities do administer medication when appropriate. But the medications typically used to address depression or anxiety, or to reduce cravings, don’t require close medical supervision. These facilities continue to have nursing personnel on-site during the day and on call 24 hours per day. When not on-site, the nursing personnel’s response time to the facility must be 60 minutes or less.

How to report telemedicine services in an outpatient psychiatric care facility

If you’re providing telemedicine services from an outpatient psychiatric care facility, follow these guidelines to ensure your claims process correctly.

Electronic claims
Here’s the instructions for electronic claims:

• Report the individual National Provider Identification number of the provider who performed the service in Loop 2010AA NM109.
• Report place of service code 02 in Loop 2300 CLM05.
• Report modifier GT or 95 in Loop 2400 SV101-3.

Review our Blue Cross Blue Shield of Michigan provider manuals for 1500 claim form instructions. As a reminder, only providers with individual NPIs can bill for telemedicine services.

Call the EDI help desk at 1-800-542-0945 if you have questions about electronic claim submissions.

Paper claims

For paper claims, you must report telemedicine services with a place of service code 02 and the modifier GT or 95. If you’re a provider rendering telemedicine services from an outpatient psychiatric care facility, you must report your individual provider identification number.

All outpatient psychiatric care facilities reporting a provider identification numbers beginning with 091 must be reported with a place of service code 52 or 53. To avoid your claim from rejecting for invalid place of service, remember to bill with the appropriate place of service.

For billing questions, contact your provider consultant.

Here are answers to frequently asked questions about therapy services documentation

This article provides an update to information that was published in the May and June 2008 issues of The Record.

As part of Blue Cross Blue Shield of Michigan’s ongoing hospital outpatient auditing process, we often receive questions about our documentation guidelines for physical therapy, occupational therapy, and speech and language pathology services. Following are answers to some of these questions. The information below also applies to freestanding outpatient physical therapy facilities.

To access the provider manual chapter titled “Documentation Guidelines for Physicians and Other Professional Providers,” see the instructions at the end of this article.

Note: These responses are considered explanatory and aren’t intended to override any published Blue Cross guidelines.

Q: If a physician signs a therapy order but doesn’t include a signature date, does Blue Cross accept a “date received” (date received by the therapy provider) stamp?

A: Yes.

Q: If a signed physician order is faxed with no signature date, is the date the fax is received considered the order date?

A: Yes.

Q: Blue Cross policy states that the attending physician’s order must contain information on diagnosis and areas of the body to be treated. Would the written diagnosis on the therapy order — which, by definition, includes a body part — satisfy this requirement?

A: The diagnosis generally includes or implies the body part, so a separate statement of the affected area usually is not necessary. If the original diagnosis is very general, however, it might not be possible to identify the affected area. In this case, the therapy plan of care, completed at the initial evaluation, should be written to provide information about the part of the body being treated, specific interventions and the frequency and duration of treatments.

Q: How long are physicians’ orders for therapy services valid?

A: They expire after 90 days for physical therapy and occupational therapy services and after 120 days for speech and language pathology services unless a specific duration or certification period are specified. These limitations apply even if the order says “ongoing” or indicates a period of time longer than 90 or 120 days, respectively. After that, the physician must write a new order for continuation of PT and OT or speech and language therapy services.

Q: When a physician signs and dates a PT or OT order, does the order expire 90 days after the signature date or 90 days after the date of the first evaluation or treatment?

A: The date of the order may not be the same day the patient receives the initial therapy evaluation. Once the evaluation has been completed and the plan of care is sent to the physician for review and signature, the signed care plan is valid for 90 days from the first treatment date unless a specific duration or certification period are specified.

Q: What if the physician doesn’t sign the plan of care?

A: If the plan of care is not signed but includes all the documentation Blue Cross requires, we use the initial order to validate services for the first 90 days unless a specific duration or certification period is specified. The required documentation includes:

• Date of order
• Diagnosis
• Type and focus of treatment to be provided
• Body areas to be treated
• Frequency of treatment
• Specific duration of treatment
• Changes in treatment plan or orders to continue treatment (when applicable)
• Physician’s signature and signature date

Q: When is the renewal order for continuation of therapy services due?

A: The renewal order is due 90 days after the first treatment date — or sooner depending on whether duration or certification dates are specified.

Q: Suppose a physician signs and dates a therapy order on Nov. 1, 2016, indicating specific treatment duration of Nov. 5, 2016, to Dec. 5, 2016. If the patient’s therapy evaluation and treatment begins on Nov. 5, does the order expire on Nov. 30 or Dec. 5?

A: Use the dates specified for valid dates of service. The order expires on Dec. 5.

Q: Suppose therapy evaluation and treatment began on Nov. 5, 2016, with specific treatment dates of Nov. 5, 2016, to Dec. 5, 2016. The patient returns to the physician on Nov. 15, 2016, (before completing the therapy), and the physician signs and dates a renewal order specifying treatment dates of Dec. 6, 2016, to Jan. 5, 2017. When does the renewal order expire?

A: The most recent specified dates apply, so the order expires Jan. 5.

Q: Suppose a patient is currently authorized to receive treatment from Nov. 1, 2016, to Nov. 30, 2016, but a renewal order for continuation of therapy services is sent to the physician on Nov. 18, 2016. If the physician doesn’t sign it until Dec. 9, 2016, when are the new covered dates of service?

A: The renewed plan of care should include the dates of service for which the 90–day continuation is being requested. When treatment dates are specified, it doesn’t matter when the physician signs it, as long as it’s within the specified treatment period. If there is no specified date range, the date of the physician’s signature becomes the new starting date for the 90–day coverage period.

Q: Is it necessary to wait for a signed plan of care before initiating therapy?

A: If the initial referral order from the physician says “evaluate and treat,” the therapist has the option, based on the patient evaluation, to initiate treatment without waiting for the signed plan of care. Unless the initial order indicates “evaluate only,” the risk that the physician won’t sign the plan of care is relatively minor. Services shouldn’t be billed to Blue Cross, however, until the therapist receives the signed plan of care. In addition, if the therapist recommends an intervention that may be viewed as controversial by the physician, the therapist should communicate with him or her and obtain verbal approval before initiating treatment.

Q: Blue Cross requires that the therapist write a treatment note for each session billed for physical therapy, occupational therapy, and speech and language pathology patients. What should be included in the treatment note?

A: The treatment note, which may be documented in progress notes, a flow chart or grid system, must include the interventions that were provided and the patient’s response to care. Blue Cross recommends that indications of progress and ongoing functional status be included in the treatment notes more frequently than the summary progress note required every 30 days for PT and OT, and 60 days for speech and language pathology because auditors use these elements to determine continuing medical necessity.

Q: Blue Cross requires that the therapist write a treatment summary or progress note at least every 30 days for PT and OT, and 60 days for speech and language pathology patients. What should be included in the progress note?

A: The progress note should include all of the following:

• Date of the summary or progress note and the dates of service covered by the summary or progress note
• Specific and objective evaluation of the patient’s progress and response to treatment during the period
• Changes in medical status, which must be documented in clear, concise, objective statements
• Changes in mental status and level of cooperation, which must be documented in clear, concise, objective statements
• Changes in the treatment plan, including a rationale for the changes and information addressing the patient’s readiness for discharge from treatment
• The signature and credentials of the therapist assessing the patient’s progress

Q: Will this progress note also serve as the required communication between the therapist and the physician in charge?

A: Yes, but only if it includes all the elements listed above. Blue Cross requires that the therapist and physician communicate regularly — every 90 days for PT and OT, and every 16 visits or 90 days (whichever comes first) for speech and language pathology services.

Q: Does Blue Cross require the summary or progress note be written on the date the care was provided?

A: No. A summary or progress note may be a standalone document written on a date when treatment wasn’t provided.

Q: Is it permissible for the physical therapist assistant or occupational therapy assistant to help the physical therapist write the progress note?

A: Yes, but the physical therapist or occupational therapist must be the primary author. The PTA or OTA may contribute to the progress note through data collection or by providing information other than patient assessments.

Q: Suppose we have a patient with a 60-consecutive day Blue Cros rehab benefit plan, and a physician sees him during the 30 days from Nov. 1 to Dec. 1. We request a “continuation of therapy services” or renewal order for the patient. However, in the meantime, the physician goes out of town for two weeks. As a result, the patient doesn’t receive services and is placed on hold for 14 days due to lack of a signed renewal order. Is it possible to recapture the “on hold” days, which would exceed the 60-day limit?

A: No. According to “Physical Therapy, Occupational Therapy, and Speech and Language Pathology Benefit”, a chapter in the Hospital — outpatient provider manual (see directions at the end of this article), when counting 60 consecutive calendar days per condition, “days are counted starting with the first date of treatment and ending 60 days later, regardless of how many services are provided during the 60-day period.” Coverage may vary under different contracts and for different groups but, in general, extensions aren’t allowed. From a clinical perspective, however, interruptions in care or delays in service continuity may be constructive and reasonable for the overall rehabilitation of the patient.

Q: Suppose we have a patient with a spinal cord injury who is stable, doing well in rehab and progressing toward independence at the time of both the required 30- and 60-day therapy reassessments. If the therapist determines that patient needs an additional 60 days of treatment to reach functional independence but the patient is unable to schedule a follow-up visit with the physician until 60 days later (120 days after the initial evaluation), will the patient’s services be covered?

A: The online provider manual states that “for physical therapy beyond 60 days, the physician must personally evaluate the patient every 90 days to determine whether continued therapy is needed and document the medical necessity for continuing the treatment.” Based on this scenario, without the personal evaluation by the physician at the 90-day and 120-day mark, services would be denied.

Q: How does Blue Cross make a final audit determination? Is there any way to appeal denied services?

A: Blue Cross makes an audit determination based on a review of the medical record documentation and an itemized bill. Providers who receive a service denial may appeal the audit findings. In such cases, clinicians would need to provide additional documentation that supports the medical necessity for continuing therapy services.

Hospital outpatient program and free standing outpatient physical therapy facility’s staff can direct their questions by sending an email to Utilizationreviewdept@bcbsm.com.

For more information on typical physical therapy, occupational therapy, and speech and language pathology therapy benefits, please consult the electronic provider manual.

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Under View a Provider Manual, select Hospital — outpatient.
• Click on Get Info.
• Scroll down; click on Physical Therapy, Occupational Therapy, and Speech and Language Pathology Benefit.

Follow these tips when billing vision claims

We’re providing you with updated tips for billing vision claims. These guidelines don’t apply to Blue Cross Blue Shield of Michigan products that use VSP.

Eligibility

• Remember to check the patient’s vision care benefit. Coverage may vary under different contracts and for different groups. If there’s a difference between what’s described in our provider manual and the patient’s Blue Cross contract, the contract applies.

Claims submission

• You can submit your vision claims electronically.

Progressive lenses

• Verify whether your patient has the progressive lens benefit before providing services. Call PARS, our automated benefits and eligibility information system, at 1-800-482-4047 to verify the benefit.

• If progressive lenses are covered under the patient’s vision benefit, use code V2781 and report the total lens charge. Submit your total charge for both lenses on a single service line. If billing one lens, adjust your charge accordingly.

• Blue Cross doesn’t reimburse for the progressive lens charge in addition to the spectacle lens fee. Please bill either the progressive lens or the spectacle lens, but not both.

• If progressive lenses aren’t covered under the patient’s vision benefit, use the appropriate code for the bifocal or trifocal lens. In addition, use procedure code S1001 to bill the difference in charges between the progressive lenses and the bifocal or trifocal lenses.

Miscellaneous or NOC procedure codes

• When billing a miscellaneous vision service for which there is no HCPCS code, use procedure code V2799. Remember to submit supporting documentation. Claims for this service will be rejected without supporting documentation. Note: Submitting documentation with this procedure code doesn’t guarantee payment.

Routine vision

• Use the following codes when billing routine vision (nonmedical) examinations and comprehensive contact lens evaluations:
• S0592
• S0620
• S0621
• *92015

Since vision exam codes S0620 and S0621 include refraction, procedure code *92015 isn’t payable as a separate benefit.

Medical diagnoses

When billing claims with the diagnosis codes below, vision care services (except S0620, S0621 and *92015) will be processed under the medical program.

H52.31 Anisometropia
H52.32 Aniseikonia
H18.601 Keratoconus, unspecified, right eye
H18.602 Keratoconus, unspecified, left eye
H18.603 Keratoconus, unspecified, bilateral
H18.609 Keratoconus, unspecified, unspecified eye
H18.611 Keratoconus, stable, right eye
H18.612 Keratoconus, stable, left eye
H18.613 Keratoconus, stable, bilateral eye
H18.619 Keratoconus, stable, unspecified eye
H18.621 Keratoconus, unstable, right eye
H18.622 Keratoconus, unstable, left eye
H18.623 Keratoconus, unstable, bilateral
H18.629 Keratoconus, unstable, unspecified eye
H27.00 Aphakia, unspecified eye
H27.01 Aphakia, right eye
H27.02 Aphakia, left eye
H27.03 Aphakia, bilateral
Q12.3 Congenital aphakia
Z96.1 Presence of intraocular lens
Z98.41 Cataract extraction status, right eye (Use additional code to identify intraocular lens implant status Z96.1.)
Z98.42 Cataract extraction status, left eye (Use additional code to identify intraocular lens implant status Z96.1.)
Z98.49 Cataract extraction status, unspecified eye (Use additional code to identify intraocular lens implant status Z96.1.)