The Record - All Articles (2024)

September 2017

The Record - All Articles (1)

The Centers for Medicare & Medicaid Services is taking steps to remove Social Security numbers from Medicare cards. This initiative will help CMS prevent fraud, fight identity theft and protect essential program funding, as well as the private health care and financial information of Medicare beneficiaries.

CMS will issue new Medicare cards with a new unique, randomly assigned number called a Medicare Beneficiary Identifier to replace the existing Social Security-based Health Insurance Claim Number — both on the cards and in various CMS systems. CMS will start mailing cards to people with Medicare benefits in April 2018. All Medicare cards will be replaced by April 2019.

CMS is committed to helping providers by giving them the tools they need. CMS wants to make this process as easy as possible for you, your patients and your staff. Based on feedback from health care providers, practice managers and other stakeholders, CMS is developing capabilities where doctors and other providers will be able to look up the new MBI through a secure tool at the point of service.

To make this change easier, there will be a 21-month transition period, running April 2018 through December 2019, when all providers will be able to use either the MBI or the HICN for billing purposes. Even though your systems will need to be able to accept the new MBI format by April 2018, you can continue to bill and file claims using a patient’s HICN during the transition period. We encourage you to work with your billing vendor to make sure your system will be updated to reflect these changes as well.

5 steps to help you get ready

Beginning in April 2018, Medicare patients will come to your office with new cards in hand. Here are five steps you can take today to help your office or facility get ready:

  1. Go to the CMS provider website** and sign up for the weekly MLN Connects® newsletter.
  2. Attend CMS’s quarterly calls, also called Open Door Forums, to get more information. They’ll let you know when calls are scheduled in the MLN Connects newsletter.
  3. Verify all of your Medicare patients’ addresses. If the addresses you have on file are different than the Medicare address you get on electronic eligibility transactions, ask your patients to contact Social Security** and update their Medicare records.
  4. Work with CMS to help your Medicare patients adjust to their new Medicare card. When it’s available later this fall, you can display helpful information about the new Medicare cards.
  5. Test your system changes and work with your billing staff to be sure your office is ready to use the new MBI format.

To learn more, visit CMS.gov.**

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

As you’re probably aware, Blue Cross Blue Shield of Michigan-branded ID cards display a three-digit alpha prefix in the first three positions of the member’s ID number. However, with the ongoing development of new products and networks, the need for new prefixes for member ID cards is growing.

To accommodate this need, a combination of three-digit alpha-numeric prefixes will be issued as early as April 15, 2018. The numeric value may be assigned in any of the three positions of the prefix, but the prefix will never consist of all numbers. Members who currently have a three-digit alpha prefix on their member ID card will retain that three-digit alpha prefix and won’t be affected by this change.

In the future, you’ll see either a three-digit alpha prefix or a three-digit alpha numeric combination prefix on a member ID card. As a result, all health care providers and billers must ensure that their systems are able to accept both alpha and numeric characters in the prefix field before April 15, 2018.

As you know, the member’s alpha prefix should always precede the member’s ID number on claims or correspondence you report to Blue Cross. The member’s alpha prefix and contract ID number are used to identify members and the plan they’re enrolled in. With the exception of dental or pharmacy, failure to include the prefix on your claim submission could result in misrouted claims and claim denials. Keep in mind that a member’s ID card isn’t a guarantee that their coverage is active or that a service is a benefit or a guarantee of payment for a claim.

If you have any questions or concerns, contact Provider Inquiry or talk with your provider consultant.

Over the past two months, we’ve received several authorization requests through the e-referral system for procedures for Blue Cross Blue Shield of Michigan PPO (commercial) members that didn’t require authorization.

Keep in mind that the list of Services That Require Authorization for procedures that require authorization, as of July 31, 2017, applies only to Blue Cross Medicare Plus BlueSM members.

Here’s a summary of what’s required for both sets of members:

For procedures

  • For Blue Cross Medicare Plus Blue members: Professional providers must submit authorization requests through the e-referral system for the procedures listed on the Services That Require Authorization document. Authorization criteria related to these procedures are now available on the Blue Cross on ereferrals.bcbsm.com.
  • For Blue Cross PPO (commercial) members: Professional providers should continue to request authorization only for procedures that currently require it, such as the radiology procedures submitted through AIM and a few others. Joint replacements and similar procedures that require authorization for Blue Cross Medicare Plus Blue members, starting July 31, 2017, don’t require authorization for Blue Cross commercial members.

For inpatient admissions

  • Facility providers should submit authorization requests for inpatient admissions through the e-referral system for dates of service on or after July 31, 2017, instead of using the prenotification system that's been used for these requests in the past.
  • For issues related to Blue Cross commercial member authorizations, call 1-800-572-3413.
  • For issues related to Blue Cross Medicare Plus Blue member authorizations, call 1-866-309-1719.
  • To add a temporary member to Blue Cross commercial, such as a newborn admitted to a neonatal intensive care unit, fax requests to 1-866-411-2585.

Effective Dec. 1, 2017, the participating provider agreements for the following types of providers will have updated reimbursem*nt language:

  • Hospice
  • Long term acute care hospital
  • Freestanding and hospital-based substance abuse facility
  • Skilled nursing facility
  • Vision specialist
  • Ambulance
  • Ambulatory infusion center
  • Ambulatory surgery facility
  • Home infusion therapy
  • Home health care facility
  • Retail health center
  • Freestanding radiology center
  • Certified registered nurse anesthetist
  • Mental health and substance abuse facility managed care program
  • Mental health and substance abuse managed care program professional provider

The reimbursem*nt sections of the above-mentioned agreements will reference Blue Cross Blue Shield of Michigan PPO programs. The following language will be incorporated into the agreements:

Accept Blue Cross payment as payment in full. Except for copayments and deductibles
specified in members’ certificates, provider will accept Blue Cross’ approved amount as full payment for covered services and agrees not to collect any further payment from any member, except as set forth in Addendum “D.” Provider also agrees to accept as payment in full for covered services, except for applicable copayments and deductibles, Blue Cross-approved amount for members covered under any Blue Cross PPO program, or Blue Cross DME or P&O programs, or any Blue Cross DME or P&O program if provider covers services to such member. Provider won’t collect deposits from members. “Deposit” is defined as an amount in excess of a copayment or deductible, which is collected on or prior to the date of service.

This uniformity will eliminate confusion and streamline your PPO experience in accordance with Blue Cross Blue Shield Association requirements.

In the July billing chart, the item on “Therapeutic massage,” procedure code *97124, contained some incorrect terminology. To see the revised entry, access the billing chart in this issue.

Blue Cross Blue Shield of Michigan aims to achieve the most favorable outcomes for our members who receive total and partial knee arthroplasty. As more services become available in the ambulatory setting, we’re learning more about which care processes are associated with the best clinical outcomes.

To that end, Blue Cross has implemented a program to enhance payment to surgeons who perform total or partial knee arthroplasty when they:

  1. Participate in the Michigan Arthroplasty Registry Collaborative for Quality Improvement.
    Sites may decide to participate in advance or join at the time of recruitment. Each site identifies a physician champion and that surgeon actively participates and follows MARCQI’s data submission processes. Although no additional payment will be made for completing the MARCQI data abstraction process, our professional reimbursem*nt policy has been adjusted to defray the MARCQI data submission costs.
  2. Implement a Blue Cross-approved prehabilitation program, such as a program employing the X-10 Knee Recovery System. (For more information about the system, visit x10herapy.com.**)

Effective immediately, for both ambulatory and inpatient locations, when the above conditions are met, the surgeon should apply modifier 22 to the surgical code and Blue Cross will increase the allowed amount by 35 percent. At a future time, the policy will be adjusted to focus on ambulatory settings. However, inpatient locations are included during this initial implementation period as we gain knowledge about clinical outcomes.

Physicians who haven’t previously participated in MARCQI but committed to joining at the time of recruitment are eligible. In the future, we’ll add other criteria to qualify for the enhanced fee in support of continued improvements in care and outcomes.

In conjunction with this policy, Blue Cross also has approved a prehabilitation process using the X-10 device and encourages physicians who participate with MARCQI to evaluate whether their patients would benefit from such a program.

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

When a provider reports more than one E&M service for the same patient on the same date of service, with or without modifiers appended, Blue Cross Blue Shield of Michigan policy allows payment for only one.

Would you like to feel more confident and comfortable in culturally sensitive situations? Join William Beecroft, M.D., BCN medical director, as he discusses how cultural differences can affect health care practices. This online program shares:

  • Why cultural sensitivity is important
  • Examples of culturally sensitive situations
  • Government standards
  • How to exhibit your knowledge and awareness of cultural sensitivity to the community
  • Additional resources

The need for cultural sensitivity awareness and training is increasingly important as the U.S. Census Bureau estimates non-Caucasian people will comprise more than 50 percent of the total U.S. population by 2044.

We encourage you to learn tips for handling culturally sensitive situations by viewing this short training program from your office, home computer, smartphone or tablet.

Here are some tips and reminders for calling the Provider Automated Response System, known as PARS:

  • You can’t bypass PARS for claims or eligibility and benefits, even if you need to speak with a representative; calls will be transferred from PARS to the appropriate call center for assistance.
  • Pressing “0” at any point on PARS or saying “representative” won’t get you to a representative faster. Follow the prompts carefully when interacting with the interactive voice response system and listen for the prompts offering a transfer to a representative (played at the end of the options menus, where applicable). This applies to both claims and benefits and eligibility.
  • You can enter information on PARS with your touchtone keypad as long as the information is completely numeric. Spelling of the member’s first name isn’t numeric and must be spoken. This applies to both claims and benefits and eligibility.
  • PARS has changed. The first question you’ll be asked is if you’re calling for claims or benefits and eligibility. If you don’t answer this question, the call will be handled as if it were a benefits and eligibility call.
  • For claims, PARS will ask two questions to determine whether BlueCard is involved. Providers in Michigan who provided services for a non-Michigan member won’t be able to use the IVR for claims status and, if these questions are not answered correctly, there may not be an offer to speak with a representative.

    Question 1: Are you calling on behalf of a Michigan member?
    Answer: Say “yes” if it’s a Michigan policy; say “no” if the member doesn’t have Blue Cross Blue Shield of Michigan.

    Question 2: Were the services rendered in Michigan?
    Answer: Say “yes” if you’re a Michigan provider; say “no” if the services weren’t provided in Michigan.

    • For Michigan providers who saw non-Michigan members, the answers would be “no” and then “yes.” There will be an option to transfer to a representative.
  • Claims status on PARS
    • Claims status should only be selected if you’re inquiring on the initial outcome of your claim. It shouldn’t be selected if you already know the initial outcome of your claim but wish to discuss further.
    • PARS will ask, “Are you calling in for a status on your claim?”
      • If you’ve already submitted a claim, but you haven’t received a reply on web-DENIS or through your remittance/voucher, you should answer “yes.”
      • If you’ve submitted a claim and you already obtained the initial outcome via web-DENIS or through your remittance/voucher, but you would like additional assistance, you should say “no.”
    • After listening to claims status, PARS will ask: “Do you want to repeat that, hear the next claim, get details, get a hard copy, benefits and eligibility, or more options?”
      • If you say “get details,” you’ll be asked to provide the procedure code or revenue code for the claim lines you’re checking. PARS will provide the claims information at line-level and then will ask: “Do you want to repeat the information, check other claims, get benefits or speak to a representative?”
      • If you say “more options,” PARS will ask: “Would you like to inquire on another date of service, inquire on another member, inquire on another contract, request a hard copy or speak with a representative.”
  • Non-claims status inquiries on PARS
    • If you said “no” to claims status, PARS will ask if you’ve received a voucher for the claim you billed.
      • If you’ve already verified claims information on web-DENIS or through your remittance/voucher, and you need additional assistance, you should answer “yes
    • PARS will ask what you would like to discuss about your claim: Payment other than anticipated, rejection/denial, accounts receivable/payable, follow up on a previous inquiry, etc...
      • Regardless of your selection, PARS will be able to transfer the call to a representative. However, at this point, PARS will say, “If you are calling on a status of your claims say status, if you are calling for eligibility and benefits say eligibility and benefits, or if you would like to speak to a representative say representative.” This allows you to check other information through PARS before being transferred. Please listen to the end of this option menu to hear the offer to transfer to a representative.
  • Claims inquiry options on PARS
    • If you said “no” to claims status and “no” to receiving a voucher, PARS will ask if you’re calling about preauthorization or something else.
      • If you say “preauthorization,” you’ll hear a message detailing the Blue Cross Blue Shield of Michigan preauthorization process. If you’re checking on a previously submitted request for medical-surgical preauthorization, you'll be offered a transfer to the appropriate call center. Initial preauthorization requests can’t be handled over the phone (whether through PARS or speaking to a representative).
      • If you say “something else,” PARS will treat the call as though it’s for claims status and will ask for the member/claims information.
        • PARS will provide the claims information, if a claim is found.
        • After claims status is provided, PARS will offer the following options: “Do you want to repeat that, hear the next claim, get details, get a hardcopy, benefits and eligibility or more options?”
          • If you say “more options,” PARS will offer the following: “Would you like to inquire on another date of service, inquire on another member, inquire on another contract, request a hardcopy, or speak with a representative?”

Your previous feedback on the new PARS Claims Status IVR helped us make these improvements.

BlueCard claims should be reported the same way you’re required to report services for any in-state commercial Blue Cross Blue Shield of Michigan claim. Claims reported for both screening or preventative and diagnostic services can be reported on a single claim or billed separately on two claims.

Splitting the preventative or screening services from the diagnostic services on two separate claims results in each category of service being processed separately, based on a member’s contracted benefits.It doesn’t result in a duplicate rejection. Splitting the claims also doesn’t require you to contact our Provider Inquiry department to request assistance in getting dual diagnosis services processed on a single claim.

If you choose to report all services with dual diagnoses on a single claim form, please keep the following in mind:

  • Currently, the electronic 837 file doesn’t include diagnostic pointers that identify which diagnosis applies to each service reported on the claim. The claim will process based on the first diagnosis on the claim.
  • You should report the screening or preventative diagnosis code first on a dual diagnosis claim.
  • A replacement claim (frequency code 7) won’t reprocess the claim to reconsider the diagnostic services when the preventative services on the same claim were processed.
  • When the preventative or screening services have been processed, you should contact Provider Inquiry to determine which services on the claim should be processed with the diagnostic ICD-10 codes.The Provider Inquiry representative will initiate an adjustment on your behalf.

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.

Have a BlueCard question you’d like answered?

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.

We’ve made it easier for you to find our drug plan prior authorization criteria online. From bcbsm.com, type in either “PA criteria” or “Medicare PA criteria” in the search field.

To find:

Type:

Prior authorization criteria for a PPO pharmacy plan

PA criteria

Prior authorization criteria for a Blue Care Network HMO plan

PA criteria

Prior authorization criteria for a BCN Advantage Medicare plan

Medicare PA criteria

Following is a screen shot of what you’ll see when using the search feature:

The Record - All Articles (2)

Effective immediately, Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Services has discontinued publishing the following guides:

  • Custom Quick Guide
  • Custom Select Quick Guide

Instead, we’re merging the guides into monthly updates to give our customers timelier information. These drug lists are searchable, contain the most up-to-date information and are available on the Drug Lists page on bcbsm.com. They can be printed if necessary.

Fiscal year 2018 ICD-10-CM and ICD-10-PCS code updates, effective with dates of service on or after Oct. 1, 2017, are now available on the Centers for Medicare & Medicaid Services website. This year’s updates include:

  • 3,922 new CM/PCS diagnosis and inpatient procedure codes
  • 2,274 CM/PCS code revisions
  • 788 CM/PCS code deletions

You can see the code updates on the CMS website.**

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

“Once morbid obesity is diagnosed and coded as such, it’s important that the diagnosis be coded correctly during each visit. To provide the best quality of care for these patients, accurate and consistent coding plays a key role in helping identify appropriate disease and care management programs for morbidly obese patients.”

— Dr. Raymond Hobbs, Blue Cross medical consultant

With obesity on the rise, it’s crucial that doctors recognize the negative effect that obesity and accompanying complications can have on their patients’ health.

“Overweight,” “obesity” and “morbid obesity” are distinct diagnoses that should be properly documented.

The Centers for Medicare & Medicaid Services includes morbid obesity (ICD-10-CM code E66.01) and its associated body mass index values (40 and above: ICD-10-CM code range Z68.41-Z68.45) in its ICD-10 Hierarchical Condition Categories for calendar year 2017. This categorization affects how providers document the condition.

Coding issues occur when the condition isn’t noted in the medical record. For example, even when height and weight measurements alone might indicate that the patient is morbidly obese, the provider must document the BMI of 40 or more — as well as comorbid conditions such as diabetes and hypertension — in the notes.

Can a BMI value of 40 with comorbid conditions and no mention of morbid obesity in the medical record be used to code for morbid obesity? The answer is no. Documentation of “morbid obesity” must be noted in the medical record to assign code E66.01. It’s important to note that BMI is a secondary code assignment; a primary diagnosis of overweight, obesity or morbid obesity must be in the documentation to submit the BMI code.

In addition, health care providers might not document morbid obesity in its early stages as they evaluate the patient over time and recommend interventions that could help reverse the trend. These may include education about how the condition can affect overall health, exercise and diet counseling.

Here are some morbid obesity coding tips:

  • A coder can only code what is documented in the medical record.
  • The diagnosis must be documented to its highest specificity. The BMI or complications alone can’t determine the specificity and ICD-10 code selection.
  • It’s crucial to document the medical condition even after a patient has had weight loss surgery.
  • Documentation is the key to coding morbid obesity.
  • When the diagnosis of “overweight” or “obesity” is documented in the medical record and it’s noted the patient has a BMI of 40 or above — along with comorbid conditions affecting the patient’s overall health — the coder can only code the condition of overweight or obesity with the Z code for the BMI of 40 or above.

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.

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.
Code* BCBSM changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines
UPDATES TO PAYABLE PROCEDURES

19296, 19297, 19298, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77316, 77317, 77318, 77778

Basic benefit and medical policy

Accelerated breast irradiation after breast-conserving surgery for early stage breast cancer and breast brachytherapy as boost with whole-breast irradiation

Following breast-conserving surgery for early stage breast cancer:

  • Accelerated whole breast irradiation, and interstitial or balloon brachytherapy may be considered established for patients who meet inclusionary guidelines. These procedures are useful therapeutic options for patients meeting selection criteria.
  • Accelerated whole breast irradiation is considered experimental in all other situations involving treatment of early stage breast cancer after breast-conserving surgery.
  • Interstitial or balloon brachytherapy may be considered established for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in those who are also treated with breast-conserving surgery and whole-breast external-beam radiotherapy.
  • Accelerated partial breast irradiation, including interstitial accelerated partial breast irradiation, balloon accelerated partial breast irradiation, external beam accelerated partial breast irradiation, noninvasive brachytherapy using Accuboost®, and intra-operative accelerated partial breast irradiation, is considered experimental.
  • Noninvasive brachytherapy using Accuboost for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with breast-conserving surgery and whole breast external-beam radiotherapy is considered experimental.

Local boost irradiation when combined with whole-breast radiotherapy but without surgical excision is considered experimental. There is a lack of published data to validate the efficacy of brachytherapy without surgical excision of the tumor.

The coverage criteria has been updated, effective Sept. 1, 2017.

Inclusions:
Following breast-conserving surgery for early stage breast cancer:

  • Accelerated whole breast irradiation for patients who meet the following conditions:
    • Invasive carcinoma of the breast
    • Tumors >5 centimeters in diameter
    • Negative lymph nodes
    • Technically clear surgical margins, for example, no ink on tumor on invasive carcinoma or ductal carcinoma in situ
    • Age at least 50 years old
  • Interstitial or balloon brachytherapy may be considered established for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with breast-conserving surgery and whole-breast external-beam radiotherapy.

Exclusions:

  • Accelerated whole breast irradiation for patients not meeting the above inclusions.
  • Accelerated partial breast irradiation, including interstitial accelerated partial breast irradiation, balloon accelerated partial breast irradiation, external beam accelerated partial breast irradiation, noninvasive brachytherapy using Accuboost, and intra-operative accelerated partial breast irradiation.
  • Interstitial or balloon brachytherapy in all other situations not specified under the inclusions.
  • Noninvasive brachytherapy using Accuboost for patients undergoing initial treatment for stage 1 or 2 breast cancer when used as local boost irradiation in patients who are also treated with breast-conserving surgery and whole breast external-beam radiotherapy.
  • Local boost irradiation when combined with whole-breast radiotherapy but without surgical excision.

38204-38215, 38220, 38221, 38230, 38232, 38240 - 38243, 81265 - 81268, 81370 - 81383, 86812, 86813, 86816, 86817, 86821, 86822, S2140, S2142, S2150

Basic benefit and medical policy

BMT-HCT for Hodgkin lymphoma

The safety and effectiveness of autologous or myeloablative allogeneic hematopoietic cell transplantation, reduced-intensity allogeneic hematopoietic cell transplantation and tandem autologous hematopoietic cell transplantation have been established. They can be useful therapeutic options for patients with primary refractory or relapsed Hodgkin lymphoma who meet patient selection criteria. Other uses for hematopoietic cell transplantation are experimental.

The coverage criteria has been updated, effective Sept. 1, 2017.

Inclusions:
Allogeneic hematopoietic cell transplantation, using either myeloablative or reduced intensity conditioning hematopoietic cell transplantation:

  • Patients with primary refractory Hodgkin lymphoma
  • Patients with relapsed Hodgkin lymphoma

Autologous hematopoietic cell transplantation:

  • Patients with primary refractory Hodgkin lymphoma
  • Patients with relapsed Hodgkin lymphoma

Tandem autologous hematopoietic cell transplantation in patients with either of the following:

  • With primary refractory Hodgkin lymphoma
  • With relapsed disease with poor risk features who don’t attain a complete remission to cytoreductive chemotherapy prior to transplantation

Exclusions:

  • A second autologous cell transplant for relapsed lymphoma after a prior autologous hematopoietic cell transplantation.
  • Other uses of hematopoietic cell transplantation in patients with Hodgkin lymphoma including, but not limited to, initial therapy for newly diagnosed disease to consolidate a first complete remission.

Potential contraindications for transplant:
Note: Final patient eligibility for transplant is subject to the judgment and discretion of the requesting transplant center.

The selection process for approved tissue transplants is designed to obtain the best result for each patient. Therefore, potential contraindications to hematopoietic cell transplantation may include, but are not limited to:

  • Poor cardiac function: Ejection fraction should be greater than 45 percent with no overt symptoms of congestive heart failure.
  • Poor pulmonary function: Pulmonary function tests must be greater than or equal to 50 percent of predicted value.
  • Poor renal function: Renal creatinine clearance should be greater than 40 ml/min or creatinine must be less than or equal to 2mg/dl.
  • Poor liver function: There should be no history of severe chronic liver disease.
  • Presence of HIV or an active form of hepatitis B, hepatitis C or human T-cell lymphotropic virus.

97124

Basic benefit and medical policy

Therapeutic massage

The criteria has been updated for the therapeutic massage policy. This policy was effective May 1, 2017.

The safety and effectiveness of manual therapeutic massage, code *97124, as part of an overall physical therapy/medicine treatment plan has been established. It may be considered established and medically necessary when the following criteria are met:

  • It’s provided as part of a formal course of physical therapy/medicine in addition to other therapeutic interventions on the same date of service.
  • Massage therapy is provided in the early, acute phase of therapy of a musculoskeletal problem and is generally limited to two weeks of treatment.
  • Massage therapy alone, either as a one-time service or as a series of massages over time, isn’t a covered benefit.
  • All Blue Cross Blue Shield of Michigan requirements related to the identification and qualifications of approved providers of physical therapy or physical medicine, apply to the providers of massage therapy.
  • Blue Cross rules regarding orders and documentation of rehabilitation services apply to the provision of massage therapy.
  • All Blue Cross rules and requirements related to “incident to” billing for physical therapy or physical medicine apply.

Blue Cross reimburses providers for physical medicine services “incident to” physician or nonphysician practitioner services in the outpatient setting when such services are performed by the physician, nurse practitioner or a licensed physical therapist.

Physicians, nurse practitioners, independent physical therapists, OPT facilities and outpatient hospitals can bill for the services of physical therapist assistants and athletic trainers when such services are directly supervised by a licensed physical therapist.

As of August 1, 2015, chiropractors may perform therapeutic massage therapy when provided as part of a complete physical medicine service plan. They’re not allowed to supervise other provider types in the performance of therapeutic massage.

No provider type can supervise therapeutic massage (procedure code *97124) or delegate therapeutic massage to any individual not eligible to perform therapeutic massage including, but not limited to, massage therapists, therapy aides, exercise physiologists or kinesiotherapists. Medically necessary therapeutic massage may be delivered by participating providers, when such massage is within their scope of practice. This rule applies to all provider types. Self-insured groups may elect a different benefit design that isn’t consistent with these rules.

POLICY CLARIFICATIONS

33361, 33362, 33363, 33364, 33365, 33366, 33367, 33368, and 33369

Basic benefit and medical policy

Transcathreter aortic valve implantation aortic stenosis

The criteria have been updated for the transcatheter aortic valve implantation for aortic stenosis policy. This policy is effective, Sept. 1, 2017.

Inclusions:
Transcatheter aortic valve replacement with a device approved by the U.S. Food and Drug Administration and performed via an approach consistent with the device’s FDA-approved labeling is established for patients with aortic stenosis when all of the following conditions are present:

  • One of the following:
    • Severe aortic stenosis with a calcified aortic annulus
    • Failed (stenosed, insufficient or combined) of a surgical bioprosthetic aortic valve
  • New York Heart Association heart failure class II, III or IV symptoms
    • Left ventricular ejection fraction greater than 20 percent
  • One of the following:
    • Patient isn’t an operable candidate for open surgery, as judged by at least two cardiovascular specialists including a cardiac surgeon
    • Patient is an operable candidate but is at high risk for open surgery (for example, Society of Thoracic Surgeons operative risk score > 8 percent or at a > 15 percent risk of mortality at 30 days).
    • Patient is at intermediate or greater surgical risk for open aortic valve replacement (only when used in concordance with FDA regulations for Sapien XT transcatheter heart valve, see below)

Edwards SAPIEN XT Transcatheter Heart Valve:

  1. Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
  • An aortic valve area of > 1.0 cm² or aortic valve area index < 0.6 cm2/m2
  • A mean aortic valve gradient > 40 mmHg
  • A peak aortic-jet velocity > 4.0 m/sec
  • Native anatomy appropriate for the 23, 26, or 29 mm valve system (between 18 and 28 mm)
  • New York Heart Association heart failure Class II, III or IV symptoms
  • Patient isn’t a candidate for open surgery, as judged by a heart team, including a cardiac surgeon, or to be at high or greater risk for open surgical therapy (for example, Society of Thoracic Surgeons operative risk score > 8 percent or at a > 15 percent risk of mortality at 30 days).
  • Patient is at intermediate surgical risk for open aortic valve replacement (for example, predicted risk of surgical mortality > 3 percent at 30 days based on the Society of Thoracic Surgeons Risk Score and other clinical comorbidities unmeasured by the STS Risk Calculator).
  • Medtronic CoreValve™ (Evolut) system:

    1. Severe aortic stenosis with a calcified aortic annulus and one or more of the following:
    • An aortic valve area of < 1.0 cm² or aortic valve area index < 0.6 cm2/m2
    • A mean aortic valve gradient > 40 mmHg
    • A peak aortic-jet velocity > 4.0 m/sec
    • Native aortic annulus diameters between 23 and 31 mm
  • New York Heart Association heart failure Class II, III or IV symptoms
  • Patient is judged by a heart team, including a cardiac surgeon, to be at extreme risk or inoperable for open surgical therapy (predicted risk of operative mortality and/or serious irreversible morbidity > 15 percent at 30 days).
  • Exclusions:
    Transcatheter aortic valve replacement is considered experimental for all other indications, including but not limited to:

    • The individual is an appropriate candidate for the standard, open surgical approach but has refused
    • Hypersensitivity or contraindication to an anticoagulation/antiplatelet regimen
    • Presence of active bacterial endocarditis or other active infections
    • Non-FDA approved systems

    Relative contraindications:
    In some cases, the benefits of transcatheter aortic valve implantation may exceed potential risks. In such instances, the cardiologist should provide an attestation indicating that a relative contraindication exists and that the patient fully understands all risks. While the items below aren’t absolute exclusions, the safety and effectiveness of transcatheter aortic valve implantation haven’t been evaluated in patients with the following characteristics or co-morbidities:

    • Patients without aortic stenosis
    • Untreated, clinically significant coronary artery disease requiring revascularization
    • Cardiogenic shock manifested by low cardiac output, vasopressor dependence or mechanical hemodynamic support
    • Transarterial access not able to accommodate an 18-Fr sheath
    • Sinus of valsalva anatomy that would prevent adequate coronary perfusion
    • End-stage renal disease requiring chronic dialysis or creatinine clearance <20 cc/min
    • Symptomatic carotid or vertebral artery disease
      • Safety, effectiveness and durability haven’t been established for valve-in-valve procedures
    • Non-calcified aortic annulus
    • Severe ventricular dysfunction with ejection fraction < 20 percent
    • Congenital unicuspid or congenital bicuspid aortic valve
    • Mixed aortic valve disease (aortic stenosis and aortic regurgitation with predominant aortic regurgitation > 3+)
    • Prosthetic ring in any position
    • Severe mitral annular calcification, severe mitral insufficiency, moderate to severe mitral or tricuspid regurgitation or Gorlin syndrome
    • Moderate to severe mitral stenosis
      • Blood dyscrasias defined as: leukopenia, acute anemia (Hb < 9 g/dL), thrombocytopenia, history of bleeding diathesis or coagulopathy, or hypercoagulable states
    • Hypertrophic cardiomyopathy with or without obstruction
    • Echocardiographic evidence of intracardiac mass, thrombus or vegetation
    • Excessive calcification of vessel at access site
    • Bulky calcified aortic valve leaflets in close proximity to coronary ostia
    • The safety and effectiveness of the Medtronic CoreValve™ system haven’t been evaluated in the pediatric population

    Established
    61850, 61863, 61864, 61867, 61868, 61880 61885, 61886, 61888, 95970, 95978. And 95979

    Experimental/investigational
    64999

    Basic benefit and medical policy

    Deep brain stimulation

    The safety and effectiveness of unilateral deep brain stimulation of the thalamus is established. It may be considered a useful therapeutic option in patients with disabling, medically unresponsive tremor due to essential tremor or Parkinson’s disease.

    The safety and effectiveness of bilateral deep brain stimulation of the thalamus have been established. It may be considered a useful therapeutic option in patients with disabling, medically unresponsive tremor in both limbs due to essential tremor or Parkinson disease.

    The safety and effectiveness of unilateral or bilateral deep brain stimulation of the globus pallidus or subthalamic nucleus have been established. It may be considered a useful therapeutic option in patients with medically refractory Parkinson’s disease, essential tremor or primary dystonia.

    Deep brain stimulation for other movement disorders including, but not limited to, tremors associated with multiple sclerosis, post-traumatic dyskinesia and tardive dyskinesia, is considered experimental. The safety and effectiveness of this treatment for these conditions haven’t been established.

    Deep brain stimulation for the treatment of other psychiatric or neurologic disorders including, but not limited to, Tourette syndrome, depression, obsessive-compulsive disorder, Alzheimer disease, anorexia nervosa, alcohol addiction, chronic pain, epilepsy and chronic cluster headaches, is considered experimental. The safety and effectiveness of this treatment for these conditions haven’t been established.

    This policy is effective Sept. 1, 2017.

    Inclusions:
    Unilateral deep brain stimulation of the thalamus may be indicated in patients with disabling, medically unresponsive tremor due to essential tremor or Parkinson disease.

    Bilateral deep brain stimulation of the thalamus may be indicated in patients with disabling, medically unresponsive tremor in both upper limbs due to essential tremor or Parkinson disease.

    Unilateral or bilateral deep brain stimulation of the globus pallidus or subthalamic nucleus may be indicated in the following patients:

    • Those with Parkinson disease with all of the following:
      • A good response to levodopa
      • Motor complications not controlled by pharmacologic therapy
      • One of the following:
        • A minimal score of 30 points on the motor portion of the Unified Parkinson Disease Rating Scale when the patient has been without medication for approximately 12 hours
        • Parkinson disease for at least four years
    • Patients older than age 7 with chronic, intractable (drug refractory) primary dystoria, including generalized or segmental dystonia, hemidystoria and cervical dystoria (torticollis)
    • Essential tremors

    Disabling, medically unresponsive tremor is defined as all of the following:

    • Tremor causing significant limitation in daily activities
    • Inadequate control by maximal dosage of medication for at least three months before implant

    Exclusions:

    • Deep brain stimulation for other movement disorders including, but not limited to, multiple sclerosis, post-traumatic dyskinesia, and tardive dyskinesia
    • Deep brain stimulation for the treatment of chronic cluster headaches
    • Deep brain stimulation for the treatment of other psychiatric or neurologic disorders including, but not limited to, Tourette syndrome, depression, obsessive-compulsive disorder, Alzheimer disease, anorexia nervosa, alcohol addiction, chronic pain and epilepsy
    • Movement disorders from other causes not noted above
    • Patients who have cognitive impairments, such as those who have dementia that may interfere with the ability to cooperate
    • Such as patients who have dementia that may interfere with the ability to cooperate
    • Patients who are unable to comply and participate with the treatment plan
    • Patients who aren’t good surgical risks because of unstable medical problems or because of the presence of a cardiac pacemaker
    • Patients who have medical conditions that require repeated magnetic resonance imaging
    • Patients who have had botulinum toxin injections within the last six months

    81161 and 81408

    Basic benefit and medical policy

    Genetic testing for duch*enne and Becker muscular dystrophy

    The criteria have been updated for the genetic testing for duch*enne and Becker muscular dystrophy policy. This policy is effective Sept. 1, 2017.

    Inclusions:

    • For a male or female with signs and symptoms of a dystrophinopathy in order to confirm the diagnosis and direct treatment (See testing strategy of a male suspected of dystrophinopathy below.)
    • For at-risk female relatives (See testing strategy for carrier testing in at-risk female relatives below.)
    • At-risk females include:
      • Sisters, daughters, mother and maternal female relatives of an affected male
      • First–degree relatives of a known carrier female
    • For at-risk male offspring (see definition of at-risk male offspring below)
    • To confirm or exclude the need for medical and cardiac surveillance

    Testing strategy of a male or female suspected of dystrophinopathy

    To establish the diagnosis of a male with clinical findings that suggests duch*enne muscular dystrophy or Becker muscular dystrophy:

    • Perform duch*enne muscular dystrophy genetic testing for deletion/duplication analysis first.
    • If a mutation isn’t identified, perform sequence analysis for a point mutation.
    • If a disease-causing duch*enne muscular dystrophy mutation is identified, the diagnosis of a dystrophinopathy is established.
    • In cases where a distinction between duch*enne muscular dystrophy and Becker muscular dystrophy is difficult, the reading frame rule states that the type of deletion/duplication (those that alter the reading frame [out of frame], which correlates with the more severe phenotype of duch*enne muscular dystrophy versus those that don’t alter the reading frame [in-frame] that correlate with the milder Becker muscular dystrophy phenotype) can distinguish the duch*enne muscular dystrophy and Becker muscular dystrophy phenotypes with 91-92 percent accuracy.
    • If no disease-causing duch*enne muscular dystrophy mutation is identified, skeletal muscle biopsy is warranted for western blot and immunohistochemistry studies of dystrophin.

    Testing strategy for carrier testing in at-risk female relatives:

    • When there is a known duch*enne muscular dystrophy mutation, test for that deletion/duplication or point mutation using appropriate testing method.
    • When an affected male isn’t available for testing, perform testing by deletion/duplication first and if no mutation is identified, by sequence analysis.

    At-risk male
    An at-risk male is defined as an asymptomatic male offspring of a female carrier or an asymptomatic male sibling of a patient with a duch*enne muscular dystrophy-associated dystrophinopathy.

    Exclusions:
    All other indications

    Established
    81519 and 84999

    Experimental
    S3854 and 0008M

    Basic benefit and medical policy

    Genetic testing – assays of genetic expression in tumor tissue as a technique to determine prognosis in patients with breast cancer

    The criteria has been updated for the genetic testing – assays of genetic expression in tumor tissue as a technique to determine prognosis in patients with breast cancer policy. This policy is effective Sept. 1, 2017.

    Inclusions (must meet all):
    The use of Oncotype DX® to determine recurrence risk for deciding whether or not to undergo adjuvant chemotherapy may be considered established in women with breast cancer meeting all of the following characteristics:

    • Unilateral tumor
    • Hormone receptor positive (that is, estrogen-receptor, or ER, positive or progesterone-receptor, or PR, positive)
    • Human epidermal growth factor receptor2, or HER2, negative
    • Tumor size 0.6-1 cm with moderate/poor differentiation or unfavorable features or tumor size larger than 1 cm
    • Node negative (lymph nodes with micrometastases [less than 2 mm in size] are considered node negative for this policy)
    • Who will be treated with adjuvant endocrine therapy, for example, tamoxifen or aromatase inhibitors
    • When the test result will aid the patient in making the decision regarding chemotherapy (for example, when chemotherapy is a therapeutic option)
    • When ordered within six months after diagnosis, since the value of the test for making decisions regarding delayed chemotherapy is unknown

    Note: The 21-gene RT-PCR assay Oncotype DX should only be ordered on a tissue specimen obtained during surgical removal of the tumor and after subsequent pathology examination of the tumor has been completed and determined to meet the above criteria (in other words, the test shouldn’t be ordered on a preliminary core biopsy). The test should be ordered in the context of a physician-patient discussion regarding risk preferences when the test result will aid in making decisions regarding chemotherapy.

    For patients who otherwise meet the above characteristics but who have multiple ipsilateral primary tumors, a specimen from the tumor with the most aggressive histological characteristics should be submitted for testing. It’s not necessary to conduct testing on each tumor; treatment is based on the most aggressive lesion.

    Exclusions:

    • All other indications for the 21-gene RT-PCR assay (for example, Oncotype DX), including determination of recurrence risk in invasive breast cancer patients with positive lymph nodes or patients with bilateral disease, are considered investigational.
    • Use of a subset of genes from the 21-gene RT-PCR assay for predicting recurrence risk in patients with noninvasive ductal carcinoma in situ, or DCIS, (for example, Oncotype DX DCIS) to inform treatment planning following excisional surgery is considered experimental.
    • The use of other gene expression assays (for example, MammaPrint 70-gene signature, Mammostrat® breast cancer test, the Breast Cancer IndexSM, the BreastOncPx™, NexCourse® Breast IHC4, Prosigna™, BreastPRS™, EndoPredict™, etc.) for any indication is experimental.
    • The use of gene expression assays in men with breast cancer is considered experimental.
    • The use of gene expression assays to molecularly subclassify breast cancer (for example, BluePrint®) is considered experimental.
    • The use of gene expression assays for quantitative assessment of ER, PR and HER2 overexpression (for example, TargetPrint®) is considered experimental.

    Established
    92537, 92538, 92540, 92541, 92542
    92544, 92545, 92546 and 92547

    Experimental
    92700

    Basic benefit and medical policy

    Vestibular function testing

    Vestibular function testing has been established. It’s a useful diagnostic option in specified situations. This policy is effective Sept. 1, 2017.

    Inclusions:
    Vestibular function testing using an electronystagmography and videonystagmography testing batteries, caloric testing or rotational chair testing may be considered medically necessary when the following conditions have been met:

    • The patient has symptoms of vestibular disorder (for example, dizziness, vertigo, imbalance).
    • A clinical evaluation, including maneuvers such as the Dix-Hallpike test if indicated, has failed to identify the cause of the symptoms.

    The ENG/VNG testing batteries may include caloric testing, positional tests and oculomotor evaluation (in other words, spontaneous nystagmus including gaze-evoked nystagmus, positional nystagmus, optokinetic nystagmus, smooth pursuit tracking, saccade test).

    Exclusions:
    Vestibular function testing for:

    • Assessment of typical benign paroxysmal positional vertigo that can be diagnosed clinically
    • Repeat testing when treatment resolves symptoms
    • In all other situations not listed in inclusions

    Vestibular evoked myogenic potential tests

    All other laboratory-based vestibular function tests not described above.

    EXPERIMENTAL PROCEDURES

    0423T

    Basic benefit and medical policy

    Secretory Type II Phospholipase A2, or sPLA2-IIA, testing to predict susceptibility to coronary artery disease

    Measurement of sPLA2-IIA biomarker levels is experimental. While measurement of sPLA2-IIA biomarker levels may be used to assess the patient’s potential risk for further cardiovascular disease, there is currently no pharmacological treatment for reducing sPLA2-IIA biomarker levels. Additional well-designed clinical trials are necessary to establish the clinical utility of sPLA2-IIA testing for cardiovascular risk assessment.

    This policy is effective Sept. 1, 2017.

    69799**

    **unlisted code used to report service

    Basic benefit and medical policy

    Balloon dilation of the eustachian tube

    Balloon dilation of the eustachian tube for the treatment of eustachian tube dysfunction is experimental. It hasn’t been scientifically demonstrated in well-controlled, randomized clinical trials to improve patient clinical outcomes. This policy is effective Sept. 1, 2017.

    J2504

    Basic benefit and medical policy

    Additional code added as payable to ambulatory infusion center

    The following code is now payable to an ambulatory infusion center:

    J2504, Injection, pegademase bovine, 25 IU

    GROUP BENEFIT CHANGES

    Letica Corporation

    Letica Corporation, group number 75412, added the following plans, effective July 1, 2017.

    Group number: 75412
    Alpha prefix: NLA (PPO)
    NKK (CMM)
    NLC (CMM/MED)
    Platform: NASCO

    Plans offered:
    Two PPO plans
    HSA
    Three prescription drug plans

    Plymouth-Canton Community Schools

    Plymouth-Canton Community Schools, group number 71711, is adding the following dental plans, effective Sept. 1, 2017.

    Dental group number: 71757
    Alpha prefix: JXP (PPO)
    Platform: NASCO

    Plans offered:
    Adding 17 dental plans

    The Record - All Articles (3)

    Blue Cross Blue Shield of Michigan continues to partner with eviCore healthcare for its physical and occupational therapy program for Medicare Plus Blue PPO members. Based on your input and comments about the preauthorization process, we’ve asked eviCore to help streamline the process and lessen the administrative burden.

    Some providers raised questions about which fields of the authorization form on the eviCore web portal were mandatory and which ones were optional. As promised in the June Record article, we've created a sample form to help you identify the mandatory fields and provide some explanation of the field contents when necessary.

    Click here to access the sample form. While it will help address some issues in the short term, eviCore continues to work on new ways to expedite the overall authorization process.

    For more information, go to ereferrals.bcbsm.com, select Blue Cross in the left-hand navigation and, under the Authorization/Referrals section, click on this link for eviCore-Managed Procedures. You can also go directly to the site by clicking on this link.

    We’ve created an FAQ about using the e-referral system as well.

    Your input helps us make improvements to the program, which will be especially beneficial as we move forward with preauthorization for other groups in 2018.

    Editor’s note: An August Record article detailed enhancements to our process for handling high-cost claims. This article looks specifically at high-cost claims for members with Blue Cross Blue Shield of Michigan Medicare Advantage PPO and Private Fee-for-Service plans.

    Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO and PFFS plans are implementing an enhancement to their handling of high-cost inpatient claims that result in a DRG outlier payment.

    On behalf of our group and individual Medicare Advantage PPO and PFFS customers, we’re seeking prepay solutions as a way to improve payment accuracy, avoid overpayment recoveries and control unnecessary costs.

    To help us address this, we have established a strategic relationship with Equian, an industry leader in prepay solutions. In December 2017, Equian will begin reviewing certain types of high-cost inpatient claims to detect and resolve errors before payment. Equian’s advanced analytics and service delivery model helps ensure its reviews are completed timely, using only an itemized bill for input.

    The result we hope to achieve by this change is that all claims will be paid right the first time.

    More details of this program will be published in the October Medicare Advantage PPO and PFFS manual updates.

    HMS (formerly Health Data Insights), an independent company working for Blue Cross Blue Shield of Michigan, will start auditing Medicare Plus Blue PPO inpatient rehabilitation facility claims on Oct. 1, 2017. The audit will:

    • Include a two-year look-back at claims.
    • Check patient-met criteria for admission to an inpatient rehabilitation facility.
    • Confirm billed case mix group codes.
    • Detect, prevent and correct waste and abuse.
    • Facilitate correct claim payment.

    Be ready to share medical charts. After an audit, HMS will send you a letter with the findings and information on how you can ask for an appeal, if necessary.

    Medical criteria information
    Inpatient rehabilitation facility level of care is reasonable and necessary if the patient meets all requirements (see Medicare Benefit Policy Manual, Chapter 1, Section 110 and Prospective Payment System rule 42 CFR 412.622(a)(3), (4) and (5)).

    HMS will confirm that you’ve properly documented requirements for inpatient rehabilitation facility level of care, such as:

    • The physician order
    • Patient supervision by a rehabilitation physician
    • Physician visits
    • The patient needed active and ongoing therapeutic intervention of multiple therapy disciplines

    Questions?

    • Call your Blue Cross provider consultant.
    • During the audit, if you need to speak to an HMS representative, call 1-866-875-1749.

    SCIO Health Analytics®, an independent company working for Blue Cross and Blue Shield of Michigan, started auditing Medicare Plus BlueSM PPO outpatient, observation and ambulatory payment classification claims on Aug. 1. These audits will:

    • Include a two-year look-back at claims.
    • Confirm medical necessity and compliance.
    • Detect, prevent and correct waste and abuse.
    • Facilitate correct claim payment.

    Be ready to share medical charts for review. After an audit, SCIO will send you a letter with findings and information on how you can request an appeal, if necessary.

    Outpatient hospital and facility audits
    These audits will confirm correct billing of revenue, CPT and HCPCS codes, as well as modifiers and units.

    Observation audits
    These audits will confirm that claims include the following, as appropriate:

    • Medical necessity of an observation room
    • Patient discharge from emergency room, and not placed in observation status
    • Patient admission as an inpatient, and not placed in observation status
    • No other service needed with active monitoring
    • Time spent in observation, greater than eight hours
    • Time spent performing services

    Also, the Centers for Medicare & Medicaid Services requires that hospitals and critical- access hospitals give the Medicare Outpatient Observation Notice form to beneficiaries receiving outpatient observation services for more than 24 hours. SCIO will look for:

    • Proper MOON form usage
    • Accurate completion of the form
    • A copy of the form in the member’s medical record

    Ambulatory payment classification
    These audits will review medical records to:

    • Evaluate coding accuracy
    • Ensure proper documentation of services


    Questions?

    • Contact your Blue Cross provider consultant.
    • During an audit, if you need to speak to a SCIO vendor representative, call 1-866-628-3488.

    HMS (formerly Health Data Insights), an independent company working for Blue Cross Blue Shield of Michigan, started auditing Medicare Plus BlueSM PPO automatic implantable cardiac defibrillator claims on Aug. 1, 2017. These audits will:

    • Include a two-year look-back at claims.
    • Check patient-met criteria for automatic implantable cardiac defibrillator insertion.
    • Detect, prevent and correct waste and abuse.
    • Facilitate correct claim payment.

    Be prepared to share medical charts for review. After an audit, HMS will send you a letter with findings and information on how to request an appeal, if necessary.

    Medical criteria information
    To meet Centers for Medicare & Medicaid Services criteria for an implantable automatic defibrillator, a patient must not have had:

    • An enzyme-positive myocardial within the past 40 days
    • A coronary artery bypass graft or percutaneous transluminal coronary angioplasty within the past three months

    HMS reviews inpatient and outpatient-reimbursed claims for procedures involving insertion of these devices within the waiting periods, or time frames, indicated above. If a review of the medical record confirms that the procedure occurred within those time frames, HMS will tag all costs associated with the procedure as an overpayment.

    Questions?

    • Contact your Blue Cross provider consultant.
    • During an audit, if you need to speak to an HMS vendor representative, call 1-866-875-1749.

    On Aug. 1, 2017, SCIO Health Analytics®, an independent company working for Blue Cross Blue Shield of Michigan, began auditing Medicare Plus BlueSM PPO claims for durable medical equipment.

    The scope of the audit will be either claim-specific or project-based, and will ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract, according to Centers for Medicare & Medicaid Services guidelines. It applies to all providers who bill DME codes.

    The audits will look back two years and confirm that you’ve properly documented requirements for:

    • Equipment billed with inappropriate diagnosis code
    • Purchase versus rental
    • Multiple providers billing for same services
    • Multiple purchases of same items
    • Capitation arrangement with additional fee-for-service items
    • Capped rental items

    Be ready to share medical charts for review. After an audit, SCIO will send you a letter with the findings and information on how you can ask for an appeal, if necessary.

    The purpose of provider audits is to:

    • Confirm compliance with ICD-10 guidelines and diagnostic codes that are in effect on the date of service.
    • Confirm compliance with CPT guidelines and codes.
    • Confirm proper use of HCPCS codes.
    • Detect, prevent and correct waste and abuse.
    • Facilitate accurate claim payment.

    Questions?

    • Contact your Blue Cross provider consultant.
    • During an audit, if you need to speak to a SCIO representative, call 1-866-628-3488.

    Blue Cross Blue Shield of Michigan wants to make sure you’re aware of our reimbursem*nt policy for medication from multiple-use vials.

    Facilities that use a single dose of medication from a multiple-dose vial and then discard the rest won’t be reimbursed for the discarded portion. If we discover during a provider audit that we reimbursed you for the entire medication, we may recover the payment.

    To ensure claims are processed correctly, home health care agencies should bill Blue Cross Blue Shield of Michigan for services using the number of visits, rather than hours or increments of hours, as a unit of service. Also, when billing on a UB-04 claim section, keep in mind that 46 request units and one unit of service equal one visit.

    For more information about billing, see the provider manual on web-DENIS.

    The Record - All Articles (4)

    Blue Cross Blue Shield of Michigan continues to partner with eviCore healthcare for its physical and occupational therapy program for Medicare Plus Blue PPO members. Based on your input and comments about the preauthorization process, we’ve asked eviCore to help streamline the process and lessen the administrative burden.

    Some providers raised questions about which fields of the authorization form on the eviCore web portal were mandatory and which ones were optional. As promised in the June Record article, we've created a sample form to help you identify the mandatory fields and provide some explanation of the field contents when necessary.

    Click here to access the sample form. While it will help address some issues in the short term, eviCore continues to work on new ways to expedite the overall authorization process.

    For more information, go to ereferrals.bcbsm.com, select Blue Cross in the left-hand navigation and, under the Authorization/Referrals section, click on this link for eviCore-Managed Procedures. You can also go directly to the site by clicking on this link.

    We’ve created an FAQ about using the e-referral system as well.

    Your input helps us make improvements to the program, which will be especially beneficial as we move forward with preauthorization for other groups in 2018.

    On Aug. 1, 2017, SCIO Health Analytics®, an independent company working for Blue Cross Blue Shield of Michigan, began auditing Medicare Plus BlueSM PPO claims for durable medical equipment.

    The scope of the audit will be either claim-specific or project-based, and will ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract, according to Centers for Medicare & Medicaid Services guidelines. It applies to all providers who bill DME codes.

    The audits will look back two years and confirm that you’ve properly documented requirements for:

    • Equipment billed with inappropriate diagnosis code
    • Purchase versus rental
    • Multiple providers billing for same services
    • Multiple purchases of same items
    • Capitation arrangement with additional fee-for-service items
    • Capped rental items

    Be ready to share medical charts for review. After an audit, SCIO will send you a letter with the findings and information on how you can ask for an appeal, if necessary.

    The purpose of provider audits is to:

    • Confirm compliance with ICD-10 guidelines and diagnostic codes that are in effect on the date of service.
    • Confirm compliance with CPT guidelines and codes.
    • Confirm proper use of HCPCS codes.
    • Detect, prevent and correct waste and abuse.
    • Facilitate accurate claim payment.

    Questions?

    • Contact your Blue Cross provider consultant.
    • During an audit, if you need to speak to a SCIO representative, call 1-866-628-3488.

    When billing for laboratory tests, you must include your Clinical Laboratory Improvements Amendments certification number for any services that aren’t CLIA-waived. You should use the QW modifier for CLIA-waived tests and submit it in the first modifier field.

    Clinical Laboratory Improvements Amendments regulate laboratory testing. They require that clinical labs be certified by the state, as well as the Centers for Medicare & Medicaid Services, before they can accept samples for diagnostic testing.

    A certificate of waiver under CLIA is only granted to a lab that has performed a simple test like the glucose meter test. These are tests that the Food and Drug Administration and the Centers for Disease Control and Prevention have determined are at little risk for error.

    For more details, see the Clinical Laboratory Improvement Amendments page** of the CMS.gov** website.

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

    “Comprehensive diabetes care” — a HEDIS® and Centers for Medicare & Medicaid Services star rating measure — is a composite measure meant to provide a comprehensive picture of the clinical management of patients with diabetes. All comprehensive diabetes care measures are used for HEDIS reporting.

    Diabetes requires consistent medical care and monitoring to reduce risk of severe complications and improve outcomes. Interventions to improve diabetes outcomes go beyond glycemic control as diabetes affects the entire body.

    The guide below provides:

    • Brief descriptions about the HEDIS and Medicare star rating measures
    • Ways you can close gaps in care for patients with diabetes
    • Common chart deficiencies to help you keep on top of proper documentation

    Note: The descriptions include CPT II codes that can facilitate data collection for HEDIS. This reduces the need for you to provide medical records to Blue Cross for review.

    Star rating measure

    Measure description

    Comprehensive diabetes care

    Exclusion criteria apply to all comprehensive diabetes care measures

    Definition: Patients 18 to 75 years of age with diagnosis of diabetes (Type 1 and Type 2) who have had each of the following:

    • Retinal eye exam (Medicare stars reporting)
    • Medical attention for nephropathy (Medicare stars reporting)
    • Hemoglobin A1c (HbA1c) testing
    • Hemoglobin A1c (HbA1c) control
    • HbA1c <9% (Medicare stars reporting)
    • HbA1c <8%
    • HbA1c <7%
    • Blood pressure control (<140/90 mm Hg)

    Exclusion criteria (applies to all comprehensive diabetes care measures):

    If any of the following occurred any time during the member’s history on or before Dec. 31 of the measurement year

    • Gestational diabetes or steroid-induced diabetes during the measurement year or the year prior
    • Patients in hospice any time in the measurement year

    Comprehensive diabetes care:
    HbA1c control

    Definition: Patients 18 to 75 years of age with diagnosis of diabetes and an HbA1c test performed during the measurement year:

    • Control: <9% (Medicare stars reporting)
    • Control: <8%

    How to close gaps:

    • Perform or order HbA1c testing two to four times each year (optimal).
      • The last HbA1c of the year determines compliance.
      • Submit HbA1c claims with CPT II result codes:

    CPT II code

    Narrative

    Compliance

    *3044F

    HbA1C level <7%

    Compliant for:
    <9% (Medicare stars reporting)
    <8%

    *3045F

    HbA1C level 7.0% - 9.0%

    Compliant for <9% (Medicare stars reporting)

    *3046F

    HbA1C level >9%

    Non-compliant

    • When the patient’s A1c is out of control, adjust treatment, address medication compliance and continue to bring patient in for recheck until the A1c is controlled.
    • The medical record may be requested to obtain the HbA1c lab report, result and date when an A1c claim isn’t received with the CPT II result code.

    Common chart deficiencies:

    • An HbA1c result is noted in the medical record without a lab report or without a date the test was drawn.
    • The patient has an HbA1c >9% but isn’t brought back in to have the HbA1c rechecked.

    Comprehensive diabetes care:
    Eye exam

    Definition: Patients 18 to 75 years of age with diagnosis of diabetes. Screening or monitoring for diabetic retinal disease by an eye care professional (optometrist or ophthalmologist) where at least one of the following conditions is satisfied:

    • A retinal or dilated eye exam by an eye care professional during the measurement year.
    • A negative retinal or dilated eye exam by an eye care professional in the year prior to the measurement year (a negative exam indicates no diabetic retinopathy is present).
    • Bilateral eye enucleation anytime during the member’s history through December 31 of the measurement year.

    Note: Eye exams are covered as part of essential benefits under medical. Not having vision coverage shouldn’t be a deterrent.

    How to close gaps:

    • Educate diabetic patients regarding the importance of an annual diabetic eye exam.
    • Be sure patient has their eyes examined yearly (or every other year if negative retinopathy).
    • Refer to eye care professional for eye exam if patient is overdue.
    • When you receive an eye exam report for your diabetic patients from an eye care professional, review the report, place it in the patient’s medical record and, for all appropriate codes, submit a $0.01 claim:
      • *2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed.
      • *2024F: Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist, documented and reviewed.
      • *2026F: Eye imaging validated to match diagnosis from seven standard field stereoscopic photo results documented and reviewed.
      • *3072F: Low risk for retinopathy (no evidence of retinopathy in the prior year).

    These CPT II codes may be billed alone or with other services.

    Common deficiencies:

    • Office receives eye exam report for a diabetic patient but doesn’t submit a claim with CPT II code *2022F, *2024F, *2026F or *3072F.
    • Eye exam screenings aren’t consistently documented in the patient’s history. Document that a retinal eye exam was performed, as well as the date of service, result and eye care professional’s name.
    • Eye exam screening is outdated but without documentation that screening was discussed or encouraged during the patient’s office visit.
    • Medical record may be requested to obtain an eye exam report if CPT II code isn’t billed.

    Comprehensive diabetes care:
    Medical attention for nephropathy

    Definition: Patients 18 to 75 years of age with diagnosis of diabetes. Screening for nephropathy or evidence of medical attention for nephropathy during the measurement year. Documentation needs to include at least one of the following, reported yearly.

    How to close gaps (one or more of the below):

    • Urine microalbumin or protein screening
      Include CPT code for urine protein screening (*81000, *81001, *81002, *81003, *81005, *82042, *82043, *82044 or *84156)
    • Treatment with an ACE/ARB
      Submit an office visit claim with *4010F: Angiotensin Converting Enzyme, Inhibitor or Angiotensin Receptor Blocker, therapy prescribed or currently being taken.
    • Evidence of CKD stage 4, ESRD, kidney transplant or a nephrology visit
      Submit an office visit claim with *3066F: Documentation of treatment for nephropathy (includes visit to nephrologist, receiving dialysis, treatment for end stage renal disease, chronic renal failure, acute renal failure or renal insufficiency)

    Common deficiencies:

    Urine microalbumin/protein screenings aren’t done or documented in the medical record and there is no evidence of medical attention for nephropathy.

    Comprehensive diabetes care:
    Blood pressure control

    Definition: Patients who are 18 to 75 years of age with diagnosis of diabetes. Diabetics who had their blood pressure taken during the measurement year. Documentation in the medical record must meet the following requirements:

    • Blood pressure must be the last reading of the measurement year from an outpatient visit.
    • For the blood pressure to be considered controlled, it must be less than 140/90 (no rounding of blood pressure numbers; document exact reading).

    How to close gaps:

    Include the appropriate blood pressure CPT II codes on your office visit claims:

    CPT II code

    Narrative

    Compliance

    *3074F

    Most recent systolic blood pressure <130 mm Hg

    Yes

    *3075F

    Most recent systolic blood pressure 130-139 mm Hg

    Yes

    *3077F

    Most recent systolic blood pressure >140 mm Hg

    No

    *3078F

    Most recent diastolic blood pressure <80 mm Hg

    Yes

    *3079F

    Most recent diastolic blood pressure 80-89 mm Hg

    Yes

    *3080F

    Most recent diastolic blood pressure >90 mm Hg

    No

    Common chart deficiencies:

    • High blood pressure readings aren’t retaken.
    • The patient doesn’t have a follow-up visit after an out-of-control blood pressure is documented.

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

    Breast cancer is the leading cause of cancer in women. One in eight women will be diagnosed at some point in her lifetime. Yet 20 percent of our female Medicare Plus BlueSM PPO members age 50-74 haven’t had a mammogram in two years.

    Breast cancer screening measure
    The HEDIS® measure for breast cancer screening is also used by the Centers for Medicare & Medicaid Services as a star rating measure to drive improvements in patient health.

    We recommend that you order routine mammograms at least once every 24 months for women ages 50 to 74 to ensure everyone who needs this screening gets it. This can also help to improve HEDIS scores.

    Women who had a bilateral mastectomy are excluded from the breast cancer screening measure.

    Risk factors may increase screening frequency
    Depending on risk factors, more frequent mammograms may be indicated. The biggest risk factor is age. Modifiable risk factors include alcohol use, physical inactivity and excess weight or obesity.

    Another risk factor is use of combined estrogen progestin hormone therapy for more than five years after menopause.

    Quick tips

    • Provide patients with an order for a mammogram and phone number to a local imaging center.
    • Follow up with patients after their screenings.
    • Document completed mammogram date and exclusion criteria in the medical record.
    • When you submit a claim for members with exclusions, please include the following ICD–10–CM diagnosis codes as appropriate:
      • Z90.13 — Acquired absence of bilateral breasts and nipples
      • Z90.12 — Acquired absence of left breast and nipple
      • Z90.11 — Acquired absence of right breast and nipple
    • Send all eligible women a reminder card with information about the importance of routine mammograms and stress that it’s a covered preventive screening.

    There’s a new Clinical Quality Corner page on web-DENIS. The site houses the 26 Clinical Quality Corner Tip Sheets that we’ve created for 2017 to help health care providers focus on key HEDIS® measures.

    You can access the tip sheets by following these steps:

    • From the home page of web-DENIS, click on BCBSM Provider Publications and Resources.
    • Click on Newsletters & Resources.
    • Click on Clinical Quality Corner on the left under Operations and Training.

    We also provided access to the tip sheets through an article in Hospital and Physician Update.

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

    Blue Cross Blue Shield of Michigan and Blue Care Network members rely on our online provider directory to make appointments with our physicians. Therefore, we’re requesting that you update the information for your non-appointing practitioners (i.e., providers who don’t see patients for appointments) and locations.

    Information about providers who don’t see patients for appointments, as well as locations that aren’t used for patient appointments, should be suppressed so that it isn’t displayed on the online directory. Emergency room physicians and administrative addresses are examples of information that shouldn’t be displayed in the directory.

    To ensure that these providers and locations are suppressed, go to the Enrollment and Changes page on bcbsm.com. For information on using the Provider Enrollment and Change Self-Service online application, click here.

    If you have questions or need support with updating your data, call Provider Enrollment at 1-800-822 2761 or contact your provider consultant.

    On Jan. 1, 2018, we’re removing the Group Change Form from bcbsm.com/providers. Authorized individuals will need to make any necessary group changes by using the Provider Enrollment and Change Self-Service online application.

    If you aren’t currently registered for online enrollment and change processing, here’s how you can register:

    1. Go to bcbsm.com/providers.
    2. Hover your mouse over Join Our Network, and click on Enrollment and Changes.
    3. Click on self-service FAQ.
    4. Click on How do I sign up?

    If you don’t have access to Provider Secured Services, you’ll need to register. You’ll find instructions under the How do I sign up? link found in Step 4 above. This only applies to professional group providers and professional group providers’ billing services. And it doesn’t matter what Blue Cross Blue Shield of Michigan or Blue Care Network coverage your patients may have.

    Note: All authorized individuals in your office need to request their own individual user ID for Provider Secured Services.

    Once you receive Provider Enrollment and Change Self-Service access, you can sign in to the application to submit group changes electronically.

    For more information, contact Provider Enrollment and Data Management at 1-800-822-2761.

    According to the U.S. surgeon general, more than 27 million people used illicit drugs or misused prescription drugs in 2015.1 Among those who met diagnostic criteria for substance use disorder, 12.5 million people reported misuse of prescription opioid pain relievers.1

    In Michigan alone, 1,275 opioid overdoses occurred during 2015, accounting for 67 percent of all drug overdose deaths in the state. The number of opioid overdose deaths exceeded that of gun and traffic fatalities.2 Opioid abuse continues to increase despite prevention efforts, such as state-run prescription drug monitoring programs and evidence-based prescribing guidelines.

    The medical community can address this abuse by limiting prescriptions, yet opioids remain the mainstay of pain management. Restricting access may preclude patients from receiving necessary treatment. Insurers use utilization management, such as prior authorization, to help providers deliver effective therapy to patients while ensuring safe and appropriate use. However, opioid requests from providers often lack key information.

    To prevent delays in processing these claims, submit all opioid requests with the following:

    • Recent chart notes
    • Diagnosis
    • Documentation of trial and failure of alternatives
    • Treatment plan

    Chart notes are useful to verify dosing regimens and patient usage. Hospital chart notes are essential to review opioids prescribed during transition of care. If a patient continues therapy that was initiated in a hospital setting, hospital chart notes are required. This is especially important for cancer patients on opioid therapy or chemotherapy, because claims will be denied for both if chart notes aren’t included.

    A diagnosis helps the insurer differentiate between opioids prescribed for pain and opioids prescribed for substance abuse disorder.

    Documentation of a treatment plan, along with documentation of trial and failure of alternatives, ensures that the most up-to-date opioid prescribing guidelines are followed.

    The opioid epidemic is a public health crisis that must be addressed through a collaborative effort at multiple levels of the health care system. Prior authorization programs reduce prescriptions for high-risk doses and decrease rates of opioid overdose.3-5 With your help, we can continue to share in the responsibility to both curb prescription opioid misuse and connect more of our patients to safe and effective treatment.

    For more information on the Blue Care Network utilization management criteria for opioids, please see our prior authorization and step therapy guidelines.

    References

    1Mental, H. S. A. U. Office of the Surgeon General (US. (2016). Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health: 1-294.
    2http://www.mlive.com/news/index.ssf/2017/06/michigan_opioid_heroin.html**
    3Clark RE, Baxter JD, Barton BA, Aweh G, O’Connell E, Fisher WH. The impact of prior authorization on buprenorphine dose, relapse rates, and cost for Massachusetts Medicaid beneficiaries with opioid dependence. Health Serv Res 2014; 49(6):1964-79.
    4Garcia MM, Angelini MC, Thomas T, Lenz K, Jeffrey P. Implementation of an opioid management initiative by a state Medicaid program. J Managed Care Spec Pharm 2014; 20(5):447-54.
    5Faul M, Bohm M, Alexander C. Methadone Prescribing and Overdose and the Association with Medicaid Preferred Drug List Policies — United States, 2007-2014. MMWR Morb Mortal Wkly Rep 2017; 66(12):320-323.

    **Blue Cross Blue Shield of Michigan doesn’t control this website or endorse its general content.

    Blue Cross Blue Shield of Michigan understands that submitting prior authorization forms takes time, and we want to help improve the process by working more closely with our health care providers. As we work toward a more efficient prior authorization process, we’ve identified three medication classes that are often missing key lab values and patient-specific data that are required for coverage.

    Medications that are most commonly denied due to missing patient data on drug request forms include weight loss drugs and testosterone.

    Remember to submit the required lab values or measurements for the following:

    Drug category

    Required lab values or measurements

    Weight loss
    (e.g., Saxenda®, Contrave®, Belviq®, Qsymia®)

    Current weight (within 30 days) and body mass index
    Also required: Documentation of lifestyle modifications

    Testosterone
    (e.g., Androgel®, Axiron®, Fortesta®, Testim®)

    Two morning testosterone levels in the past year included in the lab report
    Also required: At least two documented signs or symptoms of testosterone deficiency

    Note: The table above doesn’t include all requirements for drug coverage. For a complete list of criteria, see the BCBSM Prior Authorization and Step Therapy guidelines.

    Blue Cross-specific prior authorization forms, sorted by drug, can be submitted online through a web-based system. Use the Provider Secured Services electronic prior authorization portal to ensure your patients receive treatment in a timely manner.

    On Sept. 1, 2017, the following will become nonpreferred (Tier 3) drugs on our Blue Cross Blue Shield of Michigan and Blue Care Network commercial (non-Medicare) prescription drug plan drug lists:

    • Cipro® HC
    • Pancreaze®

    Instead of Cipro HC, you can help your patients save money by prescribing one of these lower-cost alternatives:

    Lower-cost alternatives

    Tier

    Copayment level

    Neomycin/Polymixin B/ Hydrocortisone (Cortisporin Otic)

    1

    Generic

    Otovel®

    2

    Preferred brand

    CiproDex®

    2

    Preferred brand

    Instead of Pancreaze, suggest these lower-cost alternatives:

    Lower-cost alternatives

    Tier

    Copayment level

    Creon®

    2

    Preferred

    Zenpep®

    2

    Preferred

    We’ve notified our affected prescription drug plan members of this change and encouraged them to speak with you about switching to a lower-cost drug. If they decide to continue filling their current prescription on or after Sept. 1, they’ll have a higher copayment.

    To help you bill claim units more easily, use the RC Claim Assist tool. It’s available to all Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers at no cost.

    RC Claim Assist can help you make quick and easy conversions from HCPCS/CPT units to NDC units. As electronic billing at the NDC unit level becomes more of an industry standard, this tool helps you to correctly submit medical pharmacy claims.

    To complete a units conversion, include the:

    • HCPCS or CPT code
    • NDC code
    • HCPCS or CPT units administered

    Steps to follow

    1. Select the drug reimbursem*nt code.
    2. Enter the number of HCPCS or CPT units administered.
    3. Scroll down to see the correct NDC billable units that appear in the dark blue box on the right side of your screen (see screen shot below).
    4. View the average wholesale price, or AWP, displayed below the NDC billable units.

    The Record - All Articles (5)
    Tips to help you use the RC Claim Assist tool

    • You can use any of these starting points to retrieve the NDC billable unit:
      • HCPCS or CPT code
      • NDC code
      • Drug name
    • Refer to the tool only as a general reference and in conjunction with other resources, such as applicable fee schedules.
    • Check for information at the exact time of day you need it to ensure it’s valid.

    Tips for submitting NDC codes on medical pharmacy claims

    To correctly submit claims electronically, using the ANSI 837P format, include:

    • The 11-digit NDC code along with the applicable HCPCS or CPT code.
    • All the information shown in the chart below, along with the correct NDC billable units found using the RC Claim Assist tool.

    The Record - All Articles (6)

    Electronic billing example:

    SV1˜HC*90647˜66˜UN˜1˜˜˜2:
    DTP˜472˜D8˜20160115:
    REF˜6R˜266403606:
    LIN˜˜N4˜00006489700:
    CTP˜˜˜˜.5˜ML:

    How to access RC Claim Assist instructions
    For RC Claim Assist access instructions, please refer to the April 2017 Record article. It will help you through the tool’s registration process and direct you to the login page.

    Questions about the RC Claim Assist tool?
    Email RJ Health Systems at info@rjhealthsystems.com if you have questions about RC Claim Assist. You may also review the About and FAQ sections at the top of the RC Claim Assist home page** for more information on how to use the tool.

    Questions about NDC billing?
    If you have any questions about finding the NDC code and unit of measure or submitting the NDC on paper claims, refer to the February 2015 Record article.

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

    The Record - All Articles (7)

    On Sept. 1, 2017, the following will become nonpreferred (Tier 3) drugs on our Blue Cross Blue Shield of Michigan and Blue Care Network commercial (non-Medicare) prescription drug plan drug lists:

    • Cipro® HC
    • Pancreaze®

    Instead of Cipro HC, you can help your patients save money by prescribing one of these lower-cost alternatives:

    Lower-cost alternatives

    Tier

    Copayment level

    Neomycin/Polymixin B/ Hydrocortisone (Cortisporin Otic)

    1

    Generic

    Otovel®

    2

    Preferred brand

    CiproDex®

    2

    Preferred brand

    Instead of Pancreaze, suggest these lower-cost alternatives:

    Lower-cost alternatives

    Tier

    Copayment level

    Creon®

    2

    Preferred

    Zenpep®

    2

    Preferred

    We’ve notified our affected prescription drug plan members of this change and encouraged them to speak with you about switching to a lower-cost drug. If they decide to continue filling their current prescription on or after Sept. 1, they’ll have a higher copayment.

    The Record - All Articles (8)

    On Aug. 1, 2017, SCIO Health Analytics®, an independent company working for Blue Cross Blue Shield of Michigan, began auditing Medicare Plus BlueSM PPO claims for durable medical equipment.

    The scope of the audit will be either claim-specific or project-based, and will ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract, according to Centers for Medicare & Medicaid Services guidelines. It applies to all providers who bill DME codes.

    The audits will look back two years and confirm that you’ve properly documented requirements for:

    • Equipment billed with inappropriate diagnosis code
    • Purchase versus rental
    • Multiple providers billing for same services
    • Multiple purchases of same items
    • Capitation arrangement with additional fee-for-service items
    • Capped rental items

    Be ready to share medical charts for review. After an audit, SCIO will send you a letter with the findings and information on how you can ask for an appeal, if necessary.

    The purpose of provider audits is to:

    • Confirm compliance with ICD-10 guidelines and diagnostic codes that are in effect on the date of service.
    • Confirm compliance with CPT guidelines and codes.
    • Confirm proper use of HCPCS codes.
    • Detect, prevent and correct waste and abuse.
    • Facilitate accurate claim payment.

    Questions?

    • Contact your Blue Cross provider consultant.
    • During an audit, if you need to speak to a SCIO representative, call 1-866-628-3488.
    The Record - All Articles (2024)
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