Medicare Advantage members in crisis to get new options for behavioral health care treatment

Starting Jan. 1, 2024, our Medicare Advantage members (Medicare Plus Blue℠ and BCN Advantage℠) will have some new options for receiving help if they’re having a behavioral health crisis, as part of our crisis services program.

“These options can be used in place of going to an emergency room in an effort to hasten access to behavioral health-focused care,” said Dr. William Beecroft, medical director of behavioral health for Blue Cross Blue Shield of Michigan.

Blue Cross and Blue Care Network commercial plans began offering this program in October 2021.
Care options include:

• Psychiatric urgent care
• Mobile crisis services
• On-site crisis stabilization services
• Residential crisis treatment

Several facilities in Michigan currently offer these services as part of this program, with additional facilities expected to join the program in the future.

See our Help in times of crisis flyer for details on locations, phone numbers, service areas and care options available at these locations.

In a crisis, members or other individuals — including family members, friends, law enforcement personnel or emergency department staff — can call the number of a crisis location in their service area for guidance.

A mobile unit may be deployed to offer assessment and treatment. Walk-ins are also accepted at some locations.

“The goal of such services is to make sure our members get treated at the right place at the right time,” Dr. Beecroft said.

About our mobile crisis services

Mobile crisis services include:

• Professional mental health teams in the community who can evaluate the members wherever they are located — even in their homes, school, work or doctor’s office
• Face-to-face evaluations, telemedicine or phone evaluations to develop a treatment plan, initiate treatment and, if needed, referral to an appropriate placement for the member

The mobile crisis team may stay involved for two to four weeks after the initial encounter to ensure members are connected to the right level of care for mental health or substance use disorder treatment, and to provide treatment as necessary.

About our on-site crisis stabilization services

On-site crisis stabilization services include:

• Behavioral health evaluation to initiate appropriate treatment (similar to medical observation services)
• Physical site‑based services that are necessary to support the mobile crisis team
• Includes intake assessment, psychiatric evaluation, crisis intervention and initiation of treatment, such as psychotherapy, medication administration, therapeutic injection, observation and peer support
• Initiating coordinated linkages and “warm handoffs” to the appropriate level of care and community resources

Facilities used for physical site-based services are open 24/7. Members will have access to services from a multidisciplinary staff, including physicians, registered nurses, licensed master social workers, psychologists, clinical supervisors and additional support staff.

As part of the evaluation and treatment process at these facilities, some members may still need psychiatric hospitalization.

We’ll keep you informed as additional locations join this program.

Here’s some key information for Michigan providers who treat Medicare Plus Blue members

We’ve compiled some important information that we want to make sure health care providers who treat Medicare Plus Blue℠ members know about, including:

• Determining whether prior authorization is required for a Medicare Plus Blue member
• Submitting preservice and post-service appeals
• Submitting claims
• Changes resulting from the end of the COVID-19 public health emergency

Prior authorization

To determine whether prior authorization is required for a service for a Medicare Plus Blue member, see the document Determining prior authorization requirements for members, which you can find at ereferrals.bcbsm.com. The sections for Michigan providers include step-by-step instructions.
When submitting prior authorization requests, always include complete clinical documentation to support medical necessity.

Select elective medical and surgical procedures require prior authorization for members who reside in Michigan and use contracted Medicare Plus Blue providers. See the “Prior authorization of other medical/surgical services” section of the Medicare Plus Blue PPO Provider Manual for information about authorization criteria and medical policies.

Appeals

All Michigan providers should submit preservice and post-service appeals directly to Blue Cross Blue Shield of Michigan. Appeals should include the member’s most recent medical records. Noncontracted providers must submit a waiver of liability.

Claim submissions

Blue Cross follows the Centers for Medicare & Medicaid Services guidelines published in the Medicare Claims Processing Manual** and the Medicare National Coverage Determinations / Local Coverage Determinations.**

To reduce the chance of a claim denial:

• Refer to CMS guidelines to confirm services that require medical records and other criteria.
• Ensure that all appropriate diagnosis codes, procedure codes and modifiers (if applicable) are included on the initial claim.
• Reference CMS coding guidelines to prevent unbundling and other coding errors. Bill in the same manner as you would bill Medicare.
• Before submitting a duplicate claim, allow 30 to 45 days for the initial claim to be processed and a determination to be made.

Helpful resources

Review the following for more information on the topics addressed above:

• Services that require authorization for Michigan providers, available on ereferrals.bcbsm.com
• Provider preauthorization and precertification requirements
• Medicare Plus Blue PPO Provider Manual

Changes resulting from end of COVID-19 public health emergency

Many of the flexibilities and waivers that were put in place during the COVID-19 public health emergency, or PHE, ended when the PHE ended on May 11, 2023. The only changes that remain are those the U.S. government extended or made permanent — telehealth flexibilities, for example. For services provided to Blue Cross members on and after May 12, 2023, normal plan rules apply.

The following utilization management requirements resumed on July 1, 2023:

• Clinical review is required for acute medical inpatient admissions related to COVID-19, flu, pneumonia or respiratory syncytial virus.
• Standard time frames for submitting appeals of prior authorization determinations apply. Refer to the denial letter to determine the time frame.

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

Ruoff’s family practice: Team approach leads to high-quality care

Dr. Gary S. Ruoff, pictured with Teri Brady, family nurse practitioner, said of his practice in Traverse City: “We have a high-functioning team that operates much like a family.”

This is the fifth article in a series highlighting some top performers in the Patient-Centered Medical Home Designation Program.

Gary S. Ruoff, D.O., a family practitioner in Traverse City, firmly believes that a team approach is the best way to achieve high-quality care.

“We have a high-functioning team that operates much like a family,” he said. “As a result, we experienced very little turnover during the pandemic, which is a testament to our shared commitment to providing the best possible care to patients.”

Dr. Ruoff’s team-based approach is rooted in the Patient-Centered Medical Home model of care. The practice has been part of Blue Cross Blue Shield of Michigan’s  Patient-Centered Medical Home designation program for more than 10 years.

“The PCMH Interpretive Guidelines provide a great outline for delivering high-quality care and holding the practice accountable to ensure they have a standardized and documented process to catch any patients who might otherwise fall through the cracks,” he said.

To further help patients, the practice has added care management to the array of services they provide, which has been helpful in engaging patients who need additional support and closing gaps in care. “The use of care management, registries and other PCMH tools has helped us to not only manage individual patients, but better manage the entire patient population,” he said.

Advice for other practices

The first step in implementing PCMH capabilities, Dr. Ruoff said, is to assess which capabilities are most relevant to the practice, with an end goal of improving patient outcomes, enhancing the patient experience and reducing costs. “It’s crucial to create processes and procedures with this framework in mind,” he said.

He added that building a strong team of committed staff members who work well together is crucial for success. And he recommends that practices engage with their physician organization early on to learn from others who have gone through the same journey.

Other articles in this series

Check out the following four articles, which appeared in previous issues of The Record:

• “The Pediatric Place: Creating a centralized hub to facilitate information exchange”
• “MyMichigan Family Practice Center: Building a high-functioning team”
• “Bronson Internal Medicine: Embracing team-based care to support patients”
• "Forest Hills Pediatric Associates: Using PCMH and Collaborative Care to better serve patients”

If you’d like to learn more about becoming a PCMH-designated practice, talk with your physician organization or send an email to valuepartnerships@bcbsm.com.

Questionnaire updates in e-referral system

In June, we updated questionnaires in the e-referral system. We also updated the corresponding preview questionnaires on the ereferrals.bcbsm.com website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Updated questionnaires

We updated the following questionnaires on the date specified below:

Preview questionnaires

Preview questionnaires show the questions in the e-referral system so you can prepare your answers ahead of time. To access them, go to ereferrals.bcbsm.com and:

• For BCN: Click on BCN and then click on Authorization Requirements & Criteria. Scroll down and look under the Authorization criteria and preview questionnaires heading.
• For Medicare Plus Blue: Click on Blue Cross and then click on Authorization Requirements & Criteria. Scroll down and look under the Authorization criteria and preview questionnaires – Medicare Plus Blue heading.

Authorization criteria and medical policies

The Authorization Requirements & Criteria pages explain how to access the pertinent authorization criteria and medical policies.

Changes for in-lab sleep studies start Oct. 9

Prior authorization requirements for in-lab sleep studies will change for dates of service on or after Oct. 9, 2023.

For dates of service on or after Oct. 9

• For Medicare Plus Blue℠ members, prior authorization won’t be required for in‑lab sleep studies. However, if the provider is out of network for the member’s plan, then prior authorization will be required.
• For BCN Advantage℠ members, plan notification will be required to facilitate claims payment. Prior authorization won’t be required.

For dates of service before Oct. 9

Continue to submit prior authorization requests as you do now. Specifically:

• For Medicare Plus Blue members, submit prior authorization requests to Carelon Medical Benefits Management through the Carelon ProviderPortal.
  Additional options for submitting requests are outlined on the Blue Cross Carelon-Managed Procedures webpage at ereferrals.bcbsm.com.
• For BCN Advantage members, submit prior authorization requests to BCN Utilization Management through the e-referral system.
• You must complete the sleep study questionnaire in the e-referral system.

Additional information

Before Oct. 9, we’ll update several documents to reflect these changes, including:

• Procedures that require prior authorization by Carelon: Cardiology, radiation oncology, radiology (high technology) and sleep studies (in lab)
• BCN referral and authorization requirements for Michigan providers 

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.

It’s important to monitor the metabolic effects of psychiatric medications

A column from Dr. Beecroft on this topic appeared in the May-June issue of Hospital and Physician Update. We’re reprinting it here in case you missed it.

Antipsychotic medications, along with antidepressants and mood stabilizers, have significant weight gain associated with them.

The newer medications are better than the first-generation drugs but still have this side effect. Second-generation antipsychotic medications, such as Zyprexa^® and Risperdal, have the most weight gain associated with them. Seroquel, Latuda^®, Abilify^® and Invega^® tend to cause a medium amount of weight gain, while Geodon has the least effect. In fact, some people actually lose weight while on Geodon.

Antidepressants

Antidepressants in the SSRI** class and SNRI** class also can contribute to weight gain. Wellbutrin, an atypical agent, has the least amount of weight gain associated with it; some people lose weight on it. Depakote and lithium have long been associated with weight gain. This side effect contributes to glucose intolerance and may lead to diabetes if unmonitored.

There is some evidence that metformin prevents the weight gain. Likewise, more recent information suggests semaglutide is an effective agent to assist in the prevention of metabolic syndrome and, ultimately, diabetes. Before prescribing any of these medications, doctors should discuss possible side effects with the patient and the role that diet and exercise can play in treating prediabetes.

Monitoring patients who are on antipsychotics or antidepressants

Monitoring for metabolic syndrome as outlined below is the standard of care when patients start on these medications. The American Diabetes Association suggests monitoring the following:

• Personal history (at baseline and annually)
• Weight (at baseline, 4 weeks, 8 weeks, 12 weeks, quarterly and annually)
• Waist circumference (at baseline, 12 weeks and annually)
• Blood pressure (at baseline, 12 weeks and annually)
• Fasting plasma glucose/A1c (at baseline, 12 weeks and annually)
• Fasting lipid profile (LDL, HDL, total cholesterol; at baseline, 12 weeks and annually)

If significant issues develop while the patient is on any of these medications, changing medications may be the best solution. Or if the medication (or medication combination) the patient is on is the only one that works, then treating the resulting metabolic issues aggressively may help enhance the patient’s quality of life and decrease adverse events in the future.

We encourage you to monitor the key areas outlined above, making them part of your follow-up routine with patients who are on these medications. It’s also important to help patients understand the importance of these measures and the role they play in keeping them well. 

**SSRI stands for selective serotonin reuptake inhibitors while SNRI stands for serotonin and norepinephrine reuptake inhibitors.

This content is for informational purposes only and is not intended to be medical advice. This information does not substitute for professional medical advice or a consultation with a healthcare professional.

Requirements and codes changed for some medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain comprehensive lists of requirements for our members.

In April, May and June 2023, we added requirements for some medical benefit drugs. In addition, some drugs were assigned new HCPCS codes.

Changes in requirements

For Blue Cross commercial and BCN commercial members: We added prior authorization requirements, site-of-care requirements or both as follows:

For Medicare Plus Blue℠ and BCN Advantage℠ members: We added prior authorization requirements as follows:

Code changes

The table below shows HCPCS code changes that were effective April 1, 2023, for the medical benefit drugs we manage.

Drug lists

For additional details, see the following drug lists:

• For commercial members: Blue Cross and BCN utilization management medical drug list
• For Medicare Advantage members: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members

These lists are also available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Additional information about these requirements

We communicated these changes previously through provider alerts that contain additional details.

You can view the provider alerts on ereferrals.bcbsm.com and on our Provider Resources site, which is accessible through our provider portal, availity.com.***

Additional information about Blue Cross commercial groups

For Blue Cross commercial groups, authorization requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

Reminder

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

**May be assigned a unique code in the future.

***Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

How Blue Cross and BCN are handling prior authorizations for Makena following FDA announcement

In an April 6 news release,** the U.S. Food and Drug Administration announced it has withdrawn its approval of Makena^® (hydroxyprogesterone caproate), HCPCS codes J1726 and J1729. The decision also applies to generic Makena products.

This means Makena and its generic products are now unapproved and can’t lawfully be distributed in interstate commerce.

For Blue Cross Blue Shield of Michigan and Blue Care Network commercial members, here’s how we’re handling prior authorizations for Makena:

• We’re honoring prior authorization requests that have already been approved for this medical benefit drug through their end dates.
• We’re denying prior authorization requests submitted for dates of service on or after April 6, 2023.

These changes apply to:

• All Blue Cross and BCN commercial members
• All versions of Makena, including compounded and generic versions

We’ve updated the pertinent drug lists to reflect this change.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

We’re changing prior authorization requirements for some weight loss drugs

Beginning Sept. 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network will amend prior authorization coverage criteria for the brand-name weight loss medications listed below for commercial members.

• Contrave^®
• Qsymia^®
• Saxenda^®
• Wegovy^®
• Xenical^®

For certain members, weight loss drugs are excluded under the pharmacy benefit.

Prior authorization and renewal criteria changes

Starting Sept. 1, we’ll shorten the initial prior authorization approval duration to four months from 12 months for commercial Blue Cross and BCN members who initiate one of these drug therapies for the first time. The duration of subsequent prior authorization renewals following initial prior authorization approval will remain unchanged and valid for 12 months for members who meet renewal requirements. 

We’ll also amend the renewal criteria for these weight loss drugs. Health care providers will be required to attest that the member is actively engaged in appropriate lifestyle modifications in conjunction with weight loss therapy for continuation of coverage after the initial prior authorization expires, and for each renewal request thereafter.
 
For a list of prior authorization and renewal requirements for pharmacy benefit drugs, refer to our prior authorization and step therapy document at bcbsm.com/rxinfo.

Reasons for these changes

Weight loss drug therapy is highly effective when used in conjunction with appropriate lifestyle interventions, including a balanced healthy diet and exercise. Providers should follow up with patients at regular intervals after initiating weight loss pharmacotherapy to make sure they’re continuing to engage in appropriate lifestyle modifications for optimal weight loss results.

Documentation of appropriate lifestyle modifications

Providers must attest through electronic prior authorization, or ePA, that the patient has provided them with documentation to show that they’re participating in appropriate lifestyle modifications. Here are some examples of documentation and lifestyle modifications:

• Patient documentation of lifestyle modifications may include recent food logs, exercise logs or receipts to show engagement in a formal weight loss modification program.
• Appropriate lifestyle modifications may include member participation in a formal lifestyle modification program or participation in an appropriate lifestyle modification treatment plan (healthy diet and exercise) under the supervision of their provider.

Member eligibility

Not all members have weight loss drugs covered under their pharmacy benefit. Providers should determine if members are eligible before prescribing weight loss drug therapy.

Providers can call the Provider Inquiry automated response system at 1-800-344-8525 to verify eligibility for members with Blue Cross or BCN commercial coverage.

Do you know about our ‘Practice Up’ podcast series?

We wanted to remind you about our podcast series, “Practice Up,” which gives health care providers quick, easy tips for improving the patient experience.

Podcasts include the following:

• Episode 1: A Minute to Win It
• Episode 2: What Matters Most
• Episode 3: Finding Room for Feelings
• Episode 4: Rock the Wrap-up

“These podcasts give providers concrete tools they can implement that will improve the patient experience,” said Martha Walsh, M.D., senior medical director and associate chief medical officer for Provider Engagement.

They can be accessed through our provider training site by following these steps:

1. Open the registration page.
2. Complete the registration, which takes less than a minute. (We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for provider-related needs. This will become your login ID.)
3. Follow the link to log in.
4. Scroll down and click on the link that says Click here to locate the podcasts.

Note: If you already have access to the site, you can go directly to Step 3 to log in.

Listening to all four of the episodes — and scoring 100% on the quiz questions — will also allow you to apply for continuing medical education credit.

If you need assistance creating your login ID or navigating the site, contact ProviderTraining@bcbsm.com.

Lunch and learn webinars for physicians and coders focus on risk adjustment, coding

As a reminder, we’re offering live, 30-minute educational webinars that provide updated information on documentation and coding for common challenging diagnoses. Webinars include an opportunity to ask questions. 

Here’s our upcoming schedule and tentative topics for the webinars. Each session starts at noon Eastern time. Log in to the provider training website to register for sessions that work with your schedule.

If you haven’t already registered for the provider training website, follow these steps:

1. Click here to register.
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for other needs. This will become your login ID.

Locating a session

Click here if you’re already registered for the provider training website. On the provider training website, look in the Event Calendar or use the search feature using the keyword “lunch” to quickly locate all 2023 sessions.

See the screenshots below for more details.

Previous sessions

You can also listen to previously recorded sessions. Check out the following:

                                       
For more information

If you have any questions about the sessions, contact April Boyce at aboyce@bcbsm.com. If you have questions regarding a session or website registration, email ProviderTraining@bcbsm.com.

New on-demand training available

Provider Experience continues to offer helpful training resources for health care providers and staff. Our on-demand courses can help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

We recently added the following new learning opportunity to our training site:

Prior authorization basic tools — This course offers an introduction to tools and references used for submitting prior authorization requests for services, inpatient admissions and medications. Primarily designed for providers new to Blue Cross and BCN, it covers submission of prior authorization requests and a review of available tools. Search “authorization” to quickly locate the course.

Announcements and new courses, including those with CME offerings, are posted for health care providers and staff on the provider training site dashboard. Follow these steps to request access to the training site:

1. Open the registration page
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross for provider-related needs. This will become your login ID.
3. Follow the link to log in.

If you need assistance creating your login ID or navigating the site, contact ProviderTraining@bcbsm.com.

Here are some patient resources and HEDIS tip sheets on flu vaccines and antibiotic use

This is part of an ongoing series of articles focusing on the tools and resources available to help FEP members manage their health.

To help patients understand the importance of getting the flu vaccine and why antibiotics usually don’t help for acute bronchitis, this article offers some resources for health care providers and patients.

To encourage patients to get a flu shot every year and educate them on why not taking antibiotics for acute bronchitis may be a good idea, share the following two flyers with patients:

• Arm Yourself Against the Flu (for Blue Cross and Blue Shield Federal Employee Program^® members)
• Preventing and Treating Bronchitis**

For information on the 2023 HEDIS^® measures about these topics, Blue Cross Blue Shield of Michigan developed these tip sheets for providers:

• Flu Vaccinations for Adults Ages 18-64
• Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis

For benefit information, providers and FEP members can call Customer Service at 1-800-482-3600 or go to fepblue.org.

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

HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance, or NCQA.

Submit prior authorization requests for non-emergency air ambulance flights through the Alacura PreAuth Portal

Prior to each flight, Michigan and non-Michigan health care providers must submit a prior authorization request for non-emergency air ambulance services. This requirement applies to Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members.

Michigan’s prior authorization law requires providers to submit these requests electronically to Alacura Medical Transport Management.

Submit requests using the web form on the Alacura PreAuth Portal. To learn how to access the web form and for detailed information about completing the form, see the document titled Non-emergency air ambulance prior authorization program: Overview for Michigan and non-Michigan providers.

If you can’t access the Alacura PreAuth Portal, call Alacura or fax the Air ambulance flight information (non-emergency) form to Alacura. You can find information about these alternate submission methods in the document linked above.

You can access the overview document and the form discussed above from the Blue Cross Authorization Requirements & Criteria page or the BCN Authorization Requirements & Criteria page on the ereferrals.bcbsm.com website.

Alacura Medical Transport Management is an independent company that manages the authorization of non-emergency flights for Blue Cross Blue Shield of Michigan and Blue Care Network members who have commercial plans.

Medicare Advantage members in crisis to get new options for behavioral health care treatment

Starting Jan. 1, 2024, our Medicare Advantage members (Medicare Plus Blue℠ and BCN Advantage℠) will have some new options for receiving help if they’re having a behavioral health crisis, as part of our crisis services program.

“These options can be used in place of going to an emergency room in an effort to hasten access to behavioral health-focused care,” said Dr. William Beecroft, medical director of behavioral health for Blue Cross Blue Shield of Michigan.

Blue Cross and Blue Care Network commercial plans began offering this program in October 2021.
Care options include:

• Psychiatric urgent care
• Mobile crisis services
• On-site crisis stabilization services
• Residential crisis treatment

Several facilities in Michigan currently offer these services as part of this program, with additional facilities expected to join the program in the future.

See our Help in times of crisis flyer for details on locations, phone numbers, service areas and care options available at these locations.

In a crisis, members or other individuals — including family members, friends, law enforcement personnel or emergency department staff — can call the number of a crisis location in their service area for guidance.

A mobile unit may be deployed to offer assessment and treatment. Walk-ins are also accepted at some locations.

“The goal of such services is to make sure our members get treated at the right place at the right time,” Dr. Beecroft said.

About our mobile crisis services

Mobile crisis services include:

• Professional mental health teams in the community who can evaluate the members wherever they are located — even in their homes, school, work or doctor’s office
• Face-to-face evaluations, telemedicine or phone evaluations to develop a treatment plan, initiate treatment and, if needed, referral to an appropriate placement for the member

The mobile crisis team may stay involved for two to four weeks after the initial encounter to ensure members are connected to the right level of care for mental health or substance use disorder treatment, and to provide treatment as necessary.

About our on-site crisis stabilization services

On-site crisis stabilization services include:

• Behavioral health evaluation to initiate appropriate treatment (similar to medical observation services)
• Physical site‑based services that are necessary to support the mobile crisis team
• Includes intake assessment, psychiatric evaluation, crisis intervention and initiation of treatment, such as psychotherapy, medication administration, therapeutic injection, observation and peer support
• Initiating coordinated linkages and “warm handoffs” to the appropriate level of care and community resources

Facilities used for physical site-based services are open 24/7. Members will have access to services from a multidisciplinary staff, including physicians, registered nurses, licensed master social workers, psychologists, clinical supervisors and additional support staff.

As part of the evaluation and treatment process at these facilities, some members may still need psychiatric hospitalization.

We’ll keep you informed as additional locations join this program.

Changes for in-lab sleep studies start Oct. 9

Prior authorization requirements for in-lab sleep studies will change for dates of service on or after Oct. 9, 2023.

For dates of service on or after Oct. 9

• For Medicare Plus Blue℠ members, prior authorization won’t be required for in‑lab sleep studies. However, if the provider is out of network for the member’s plan, then prior authorization will be required.
• For BCN Advantage℠ members, plan notification will be required to facilitate claims payment. Prior authorization won’t be required.

For dates of service before Oct. 9

Continue to submit prior authorization requests as you do now. Specifically:

• For Medicare Plus Blue members, submit prior authorization requests to Carelon Medical Benefits Management through the Carelon ProviderPortal.
  Additional options for submitting requests are outlined on the Blue Cross Carelon-Managed Procedures webpage at ereferrals.bcbsm.com.
• For BCN Advantage members, submit prior authorization requests to BCN Utilization Management through the e-referral system.
• You must complete the sleep study questionnaire in the e-referral system.

Additional information

Before Oct. 9, we’ll update several documents to reflect these changes, including:

• Procedures that require prior authorization by Carelon: Cardiology, radiation oncology, radiology (high technology) and sleep studies (in lab)
• BCN referral and authorization requirements for Michigan providers 

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.

It’s important to monitor the metabolic effects of psychiatric medications

A column from Dr. Beecroft on this topic appeared in the May-June issue of Hospital and Physician Update. We’re reprinting it here in case you missed it.

Antipsychotic medications, along with antidepressants and mood stabilizers, have significant weight gain associated with them.

The newer medications are better than the first-generation drugs but still have this side effect. Second-generation antipsychotic medications, such as Zyprexa^® and Risperdal, have the most weight gain associated with them. Seroquel, Latuda^®, Abilify^® and Invega^® tend to cause a medium amount of weight gain, while Geodon has the least effect. In fact, some people actually lose weight while on Geodon.

Antidepressants

Antidepressants in the SSRI** class and SNRI** class also can contribute to weight gain. Wellbutrin, an atypical agent, has the least amount of weight gain associated with it; some people lose weight on it. Depakote and lithium have long been associated with weight gain. This side effect contributes to glucose intolerance and may lead to diabetes if unmonitored.

There is some evidence that metformin prevents the weight gain. Likewise, more recent information suggests semaglutide is an effective agent to assist in the prevention of metabolic syndrome and, ultimately, diabetes. Before prescribing any of these medications, doctors should discuss possible side effects with the patient and the role that diet and exercise can play in treating prediabetes.

Monitoring patients who are on antipsychotics or antidepressants

Monitoring for metabolic syndrome as outlined below is the standard of care when patients start on these medications. The American Diabetes Association suggests monitoring the following:

• Personal history (at baseline and annually)
• Weight (at baseline, 4 weeks, 8 weeks, 12 weeks, quarterly and annually)
• Waist circumference (at baseline, 12 weeks and annually)
• Blood pressure (at baseline, 12 weeks and annually)
• Fasting plasma glucose/A1c (at baseline, 12 weeks and annually)
• Fasting lipid profile (LDL, HDL, total cholesterol; at baseline, 12 weeks and annually)

If significant issues develop while the patient is on any of these medications, changing medications may be the best solution. Or if the medication (or medication combination) the patient is on is the only one that works, then treating the resulting metabolic issues aggressively may help enhance the patient’s quality of life and decrease adverse events in the future.

We encourage you to monitor the key areas outlined above, making them part of your follow-up routine with patients who are on these medications. It’s also important to help patients understand the importance of these measures and the role they play in keeping them well. 

**SSRI stands for selective serotonin reuptake inhibitors while SNRI stands for serotonin and norepinephrine reuptake inhibitors.

This content is for informational purposes only and is not intended to be medical advice. This information does not substitute for professional medical advice or a consultation with a healthcare professional.

Requirements and codes changed for some medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain comprehensive lists of requirements for our members.

In April, May and June 2023, we added requirements for some medical benefit drugs. In addition, some drugs were assigned new HCPCS codes.

Changes in requirements

For Blue Cross commercial and BCN commercial members: We added prior authorization requirements, site-of-care requirements or both as follows:

For Medicare Plus Blue℠ and BCN Advantage℠ members: We added prior authorization requirements as follows:

Code changes

The table below shows HCPCS code changes that were effective April 1, 2023, for the medical benefit drugs we manage.

Drug lists

For additional details, see the following drug lists:

• For commercial members: Blue Cross and BCN utilization management medical drug list
• For Medicare Advantage members: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members

These lists are also available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Additional information about these requirements

We communicated these changes previously through provider alerts that contain additional details.

You can view the provider alerts on ereferrals.bcbsm.com and on our Provider Resources site, which is accessible through our provider portal, availity.com.***

Additional information about Blue Cross commercial groups

For Blue Cross commercial groups, authorization requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

Reminder

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

**May be assigned a unique code in the future.

***Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

How Blue Cross and BCN are handling prior authorizations for Makena following FDA announcement

In an April 6 news release,** the U.S. Food and Drug Administration announced it has withdrawn its approval of Makena^® (hydroxyprogesterone caproate), HCPCS codes J1726 and J1729. The decision also applies to generic Makena products.

This means Makena and its generic products are now unapproved and can’t lawfully be distributed in interstate commerce.

For Blue Cross Blue Shield of Michigan and Blue Care Network commercial members, here’s how we’re handling prior authorizations for Makena:

• We’re honoring prior authorization requests that have already been approved for this medical benefit drug through their end dates.
• We’re denying prior authorization requests submitted for dates of service on or after April 6, 2023.

These changes apply to:

• All Blue Cross and BCN commercial members
• All versions of Makena, including compounded and generic versions

We’ve updated the pertinent drug lists to reflect this change.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

We’re changing prior authorization requirements for some weight loss drugs

Beginning Sept. 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network will amend prior authorization coverage criteria for the brand-name weight loss medications listed below for commercial members.

• Contrave^®
• Qsymia^®
• Saxenda^®
• Wegovy^®
• Xenical^®

For certain members, weight loss drugs are excluded under the pharmacy benefit.

Prior authorization and renewal criteria changes

Starting Sept. 1, we’ll shorten the initial prior authorization approval duration to four months from 12 months for commercial Blue Cross and BCN members who initiate one of these drug therapies for the first time. The duration of subsequent prior authorization renewals following initial prior authorization approval will remain unchanged and valid for 12 months for members who meet renewal requirements. 

We’ll also amend the renewal criteria for these weight loss drugs. Health care providers will be required to attest that the member is actively engaged in appropriate lifestyle modifications in conjunction with weight loss therapy for continuation of coverage after the initial prior authorization expires, and for each renewal request thereafter.
 
For a list of prior authorization and renewal requirements for pharmacy benefit drugs, refer to our prior authorization and step therapy document at bcbsm.com/rxinfo.

Reasons for these changes

Weight loss drug therapy is highly effective when used in conjunction with appropriate lifestyle interventions, including a balanced healthy diet and exercise. Providers should follow up with patients at regular intervals after initiating weight loss pharmacotherapy to make sure they’re continuing to engage in appropriate lifestyle modifications for optimal weight loss results.

Documentation of appropriate lifestyle modifications

Providers must attest through electronic prior authorization, or ePA, that the patient has provided them with documentation to show that they’re participating in appropriate lifestyle modifications. Here are some examples of documentation and lifestyle modifications:

• Patient documentation of lifestyle modifications may include recent food logs, exercise logs or receipts to show engagement in a formal weight loss modification program.
• Appropriate lifestyle modifications may include member participation in a formal lifestyle modification program or participation in an appropriate lifestyle modification treatment plan (healthy diet and exercise) under the supervision of their provider.

Member eligibility

Not all members have weight loss drugs covered under their pharmacy benefit. Providers should determine if members are eligible before prescribing weight loss drug therapy.

Providers can call the Provider Inquiry automated response system at 1-800-344-8525 to verify eligibility for members with Blue Cross or BCN commercial coverage.

Lunch and learn webinars for physicians and coders focus on risk adjustment, coding

As a reminder, we’re offering live, 30-minute educational webinars that provide updated information on documentation and coding for common challenging diagnoses. Webinars include an opportunity to ask questions. 

Here’s our upcoming schedule and tentative topics for the webinars. Each session starts at noon Eastern time. Log in to the provider training website to register for sessions that work with your schedule.

If you haven’t already registered for the provider training website, follow these steps:

1. Click here to register.
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for other needs. This will become your login ID.

Locating a session

Click here if you’re already registered for the provider training website. On the provider training website, look in the Event Calendar or use the search feature using the keyword “lunch” to quickly locate all 2023 sessions.

See the screenshots below for more details.

Previous sessions

You can also listen to previously recorded sessions. Check out the following:

                                       
For more information

If you have any questions about the sessions, contact April Boyce at aboyce@bcbsm.com. If you have questions regarding a session or website registration, email ProviderTraining@bcbsm.com.

HCPCS 2nd-quarter update: New and deleted codes

The Centers for Medicare & Medicaid Services has added several new codes as part of its quarterly Health Care Procedure Coding System updates. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Injections

Injection/chemotherapy

Outpatient prospective payment system/injections

Outpatient prospective payment system/radiology

Outpatient prospective payment system/surgery

Outpatient prospective payment system/other medical services

Outpatient prospective payment system/injections/chemotherapy

Skin substitutes

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.

HCPCS replacement codes, effective July 1, 2023, established

C9151 replaces C9399, J3490, J3590 and J9999 when billing for Syfovre (pegcetacoplan) for facility only

The Centers for Medicare & Medicaid Services has established a permanent procedure code for the specialty medical drug Syfovre (pegcetacoplan).

All facility services through June 30, 2023, will continue to be reported with code C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with C9151.

All professional services will continue to be reported with C9399, J3490, J3590 and J9999.

Prior authorization is still required for all groups opted into the Medical Benefit Drug program.

For groups that have opted out of the Medical Benefit Drug program, this service requires manual review.

J0457 replaces S0073 when billing for Aztreonam

CMS has established a permanent procedure code for the specialty medical drug Aztreonam.

All services through June 30, 2023, will continue to be reported with code S0073. All services performed on and after July 1, 2023, must be reported with J0457.

J0665 replaces S0020 when billing for Bupivicaine

CMS has established a permanent procedure code for the specialty medical drug Bupivicaine.

All services through June 30, 2023, will continue to be reported with code S0020.  All services performed on and after July 1, 2023, must be reported with J0665.                         

J0736 and J0737 replace S0077 when billing for clindamycin phosphate

CMS has established a permanent procedure code for the specialty medical drug clindamycin phosphate.

All services through June 30, 2023, will continue to be reported with code S0077. All services performed on and after July 1, 2023, must be reported with J0736 or J0737.

J1836 replaces S0030 when billing for Metronidazole

CMS has established a permanent procedure code for the specialty medical drug Metronidazole.

All services through June 30, 2023, will continue to be reported with code S0030. All services performed on and after July 1, 2023, must be reported with J1836.

J1440 replaces C9399, J3490, J3590 and J9999 when billing for fecal microbiota, live – jslm

CMS has established a permanent procedure code for the specialty medical drug fecal microbiota, live – jslm.

All services through June 30, 2023, will continue to be reported with code C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J1440.

Prior authorization is required through the Medical Benefit Drug program for J1440 for all groups unless they are opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

J1961 replaces C9399, J3490, J3590 and J9999 when billing for lenacapavir

CMS has established a permanent procedure code for the specialty medical drug lenacapavir.

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J1961.

J2249 replaces C9399, J3490, J3590 and J9999 when billing for reminazolam

CMS has established a permanent procedure code for the specialty medical drug reminazolam.

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J2249.

J2329 replaces C9399, J3490, J3590, J9999 when billing for ublituximab-xiiy

CMS has established a permanent procedure code for the specialty medical drug ublituximab-xiiy.

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J2329.

J2371 replaces J2370 when billing for phenylephrine hydrochloride

CMS has established a permanent procedure code for the specialty medical drug phenylephrine hydrochloride.

All services through June 30, 2023, will continue to be reported with code J2370. All services performed on and after July 1, 2023, must be reported with J2371.

J2372 replaces J2370 when billing for phenylephrine hydrochloride (Biorphen)

CMS has established a permanent procedure code for the specialty medical drug phenylephrine hydrochloride (Biorphen).

All services through June 30, 2023, will continue to be reported with code J2370. All services performed on and after July 1, 2023, must be reported with J2372.

J2427 replaces C9399, J3490, J3590 and J9999 when billing for paliperidone palmitate extended release (invega hafyera or invega trinza)

CMS has established a permanent procedure code for the specialty medical drug paliperidone palmitate extended release (invega hafyera or invega trinza).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J2427.

J2561 replaces C9399, J3490, J3590 and J9999 when billing for phenobarbital sodium (Sezaby)

CMS has established a permanent procedure code for the specialty medical drug phenobarbital sodium (Sezaby).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J2561.

J7213 replaces C9399, J3490, J3590, J9999 and J7199 when billing for IXINITY

CMS has established a permanent procedure code for the specialty medical drug IXINITY.

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and J7199. All services performed on and after July 1, 2023, must be reported with J7213.

J9029 replaces C9399, J3490, J3590 and J9999 when billing Adstiladrin (nadofaragene firadenovec-vncg)

CMS has established a permanent procedure code for the specialty medical drug Adstiladrin (nadofaragene firadenovec-vncg), a gene/cellular therapy drug.

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J9029.

J9063 replaces C9399, J3490, J3590, J9999 and C9146 when billing for ELAHERE (mirvetuximab soravtansine-gynx)

CMS has established a permanent procedure code for the specialty medical drug ELAHERE (mirvetuximab soravtansine-gynx).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and C9146. All services performed on and after July 1, 2023, must be reported with J9063.

J9259 replaces C9399, J3490, J3590 and J9999 when billing for American Regent (paclitaxel protein-bound particles)

CMS has established a permanent procedure code for the specialty medical drug American Regent (paclitaxel protein-bound particles).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J9259.

Prior authorization through Carelon (formerly AIM) is required for all groups opted into the Carelon prior authorization program.

For groups that aren’t in the prior authorization program, this code is covered for its FDA-approved indications.

J9322 replaces C9399, J3490, J3590 and J9999 when billing for pemetrexed (Bluepoint)

CMS has established a permanent procedure code for the specialty medical drug pemetrexed (Bluepoint).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J9322.

Prior authorization through Carelon is required for all groups opted into the Carelon prior authorization program.

For groups that aren’t in the prior authorization program, this code is covered for its FDA-approved indications.

J9323 replaces C9399, J3490, J3590 and J9999 when billing for pemetrexed ditromethamine, 10 mg

CMS has established a permanent procedure code for the specialty medical drug pemetrexed ditromethamine, 10 mg.

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J9323.

Prior authorization through Carelon is required for all groups opted into the Carelon prior authorization program.

For groups that aren’t in the prior authorization program, this code is covered for its FDA-approved indications.

J9347 replaces C9399, J3490, J3590, J9999 and C9147 when billing for Imjudo (tremelimumab-actl)

CMS has established a permanent procedure code for the specialty medical drug Imjudo (tremelimumab-actl).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and C9147. All services performed on and after July 1, 2023, must be reported with J9347.

J9350 replaces C9399, J3490, J3590 and J9999 when billing for Lunsumio (mosunetuzumab-axgb)

CMS has established a permanent procedure code for the specialty medical drug Lunsumio (mosunetuzumab-axgb).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J9350.

J9380 replaces C9399, J3490, J3590, J9999 and C9148 when billing for Tecvayli (teclistamab-cqyv)

CMS has established a permanent procedure code for the specialty medical drug Tecvayli (teclistamab-cqyv).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and C9148. All services performed on and after July 1, 2023, must be reported with J9380.

J9381 replaces C9399, J3490, J3590, J9999 and C9149 when billing for Tzield (teplizumab-mzwv)

CMS has established a permanent procedure code for the specialty medical drug Tzield (teplizumab-mzwv). 

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and C9149. All services performed on and after July 1, 2023, must be reported with J9381.

Prior authorization is required through the Medical Benefit Drug program for J9381 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

J1576 replaces C9399, J3490, J3590 and J9999 when billing for immune globulin (Panzyga)

CMS has established a permanent procedure code for the specialty medical drug immune globulin (Panzyga).

All services through June 30, 2023, will continue to be reported with code C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2023, must be reported with J1576.

Prior authorization is required through the Medical Benefit Drug program for J1576 for all groups unless they are opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

J1920 replaces C9399, J3490, J3590, J9999 and C9147 when billing for labetalol hydrochloride

CMS has established a permanent procedure code for the specialty medical drug labetalol hydrochloride.
All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and C9147. All services performed on and after July 1, 2023, must be reported with J1920.

J1921 replaces C9399, J3490, J3590, J9999 and C9147 when billing for labetalol hydrochloride (Hikma)

CMS has established a permanent procedure code for the specialty medical drug labetalol hydrochloride (Hikma).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and C9147. All services performed on and after July 1, 2023, must be reported with J1921.

J1805 replaces C9399, J3490, J3590, J9999 and C9147 when billing for esmolol hydrochloride

CMS has established a permanent procedure code for the specialty medical drug esmolol hydrochloride.

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and C9147. All services performed on and after July 1, 2023, must be reported with J1805.

J1806 replaces C9399, J3490, J3590, J9999 and C9147 when billing for esmolol hydrochloride (WG Critical Care)

CMS has established a permanent procedure code for the specialty medical drug esmolol hydrochloride (WG Critical Care).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and C9147. All services performed on and after July 1, 2023, must be reported with J1806.

J1813 replaces C9399, J3490, J3590, J9999 and C9148 when billing for insulin (Lyumjev) for administration through DME (i.e., insulin pump)

CMS has established a permanent procedure code for the specialty medical drug insulin (Lyumjev) for administration through durable medical equipment (i.e., insulin pump).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and C9148. All services performed on and after July 1, 2023, must be reported with J1813.

J1814 replaces C9399, J3490, J3590, J9999 and C9148 when billing for insulin (Lyumjev)
CMS has established a permanent procedure code for the specialty medical drug insulin (Lyumjev).

All services through June 30, 2023, will continue to be reported with codes C9399, J3490, J3590, J9999 and C9148. All services performed on and after July 1, 2023, must be reported with J1814.

Carelon Medical Benefits Management (formerly AIM Specialty Health) is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services.

Billing chart: Blue Cross highlights 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.

We'll publish information about new Blue Cross groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the Blue Cross' policies for these procedures, check under the Commercial Policy tab in Benefit Explainer on Availity^®. To access this online information:

1. Log in to availity.com.
2 .Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Benefit Explainer on the Applications tab.
5. Click on the Commercial Policy tab.
6. Click on Topic.
7. Under Topic Criteria, click on the circle for Unique Identifier and click the drop-down arrow next to Choose Identifier Type, then click on HCPCS Code.
8. Enter the procedure code.
9. Click on Finish.
10. Click on Search.

None of the information included in this billing chart 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.