Policy Review & News
Important information about Highmark Blue Shield June 2006 www.highmarkblueshield.comPRN MA In This Issue Look for this symbol for all Medicare Blue Shield seeks new members for Medical Review Advantage related Committee ...... 1 information Verifying eligibility and benefits now easier for out-of-area Blue members ...... 5 B RotaTeq vaccine eligible for coverage ...... 7 Look for this symbol for all BlueCard® Supervision guidelines outlined ...... 17 related information News
Blue Shield seeks new members for Medical Review Committee
Highmark Blue Shield is searching for members to serve on its Medical Review Committee. The Medical Review Committee resolves disputes between participating providers and Highmark Blue Shield. These disputes may involve utilization and quality of care issues, as well as other alleged violations of the participating provider agreement and appeals regarding network terminations.
Eleven doctors of medicine, two doctors of osteopathy, one doctor of chiropractic medicine, and two consumer representatives now serve on the Committee. The Review Committee Selection Committee appoints the members to a two-year term. Members may be re-appointed.
The Medical Review Committee generally meets four times a year at the Highmark Blue Shield office in Camp Hill, Pennsylvania. Blue Shield does reimburse committee members for their expenses. Members also receive an honorarium from Blue Shield.
Highmark is a registered mark of Highmark Inc. Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. PRN
Committee member requirements and how to apply All potential candidates must be a Pennsylvania licensed health care provider who participates in a Highmark Blue Shield network.
If you are interested in being considered for membership by the Selection Committee, please send a copy of your current resume or curriculum vitae, by Aug. 31, 2006, to:
Raymond J. DiBello Secretary, Medical Review Committee Highmark Blue Shield 1800 Center Street Camp Hill, Pa. 17089
PremierBlue Shield credentialing not required for facility-based practitioners
Highmark Blue Shield does not require facility-based pathologists, anesthesiologists, radiologists, or emergency medicine specialists who practice exclusively in an acute care hospital setting to complete the standard Highmark Blue Shield credentialing or recredentialing process for the PremierBlueSM Shield network. However, these providers must complete the appropriate provider agreements to participate with Highmark Blue Shield’s Participating Provider and PremierBlue Shield networks.
Highmark Blue Shield does not require credentialing or recredentialing for the PremierBlue Shield network when these requirements are met:
The practitioner must:
• provide 100 percent of his or her services to members exclusively in the acute care or general hospital setting
• possess a current Pennsylvania medical license in good standing
• have current active malpractice insurance that meets or exceeds Pennsylvania state requirements
• actively participate with Medicare or Medicaid and have never been debarred from or excluded from participation in, any Medicare or Medicaid government programs
• sign an Affirmation of Medical Practice Statement (form No. 282)
If a provider begins to provide medical services to members outside of a Blue Shield network participating acute care hospital, the practitioner will be required to complete a Provider Application and go through the credentialing process. 2 6/2006
Blue Shield no longer produces Procedure Terminology Manual
Highmark Blue Shield stopped producing and distributing the Procedure Terminology Manual (PTM) in 2004. This was, in part, because local codes were eliminated with the implementation of the HIPAA national coding standards. Also, the procedure codes published in the PTM could be found in the American Medical Association’s (AMA) Current Procedural Terminology manual.
Another reason for discontinuing the PTM was Blue Shield’s move toward electronic communications. Blue Shield provides access to procedure codes and their complete terminology through NaviNetSM by using the procedure code inquiry function. Blue Shield also continues to make national alpha-numeric codes readily available on its online Provider Resource Center. You can find the Resource Center through NaviNet or at www.highmarkblueshield.com.
So that you report your professional services correctly and avoid claim denials, Blue Shield provides you with information about procedure code changes through its annual HCPCS Update. Every year Blue Shield mails the HCPCS Update to you by December first. This annual update outlines all new, deleted, and revised procedure codes effective for January 1 of the following year. Throughout the year, Blue Shield announces coding updates in PRN.
Reminder: be sure to report accurate membership information on claims
Submission of accurate member information is a necessary and essential requirement for timely and accurate claims processing and payment. Highmark Blue Shield will reject and return claim submissions that contain erroneous membership information, such as an invalid unique member identifier (UMI), an incorrect name, etc.
Background Your patients with health insurance coverage are either the subscriber or insured, or the dependent. Both are members. It’s important to understand the difference.
The subscriber or insured is the person specifically named in the Highmark Blue Shield agreement or policy through whom coverage is provided.
The dependent has coverage through a relationship to the subscriber or insured, such as spouse or child.
The term “member” applies to either. A member is anyone who has Highmark Blue Shield coverage.
Members are identified in Blue Shield’s membership system by a combination of data elements, including the UMI number, as well as first and last names, relationship to the subscriber or insured, sex, and date of birth.
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The identification card Highmark Blue Shield’s identification cards are issued at the member level, so they will also display the name of the individual member, along with the UMI. The card does not, however, display the relationship (self, spouse, child, or other) to the subscriber or insured. That’s why it’s very important that, for each office visit, you request to see the identification card, and ask if the patient is the subscriber or insured. If he or she is not, make note of his or her relationship to the subscriber or insured.
Your submissions may be rejected if member data is wrong In the past, when claim information did not precisely match data in its membership files, Blue Shield would try to match the limited patient or member information on the claim submission with the existing data in its membership files to see if the claim could be processed. In some instances, this may cause a privacy breach when, given the quality of information submitted on the claim, Blue Shield may be prevented from correctly identifying the patient who received the care.
To maintain its commitment to member privacy and comply with HIPAA regulations and other federal and state laws, Blue Shield must change its approach to handling submissions that contain incomplete or incorrect membership information. Blue Shield will no longer attempt to identify members based on the limited information submitted. If an electronic or paper submission includes an incorrect first or last name, relationship, sex, or date of birth, Blue Shield may reject the submission and return it to the provider. It continues to be the provider’s responsibility to correct inaccurate information contained in their claims submissions, then resubmit them as new and corrected claims.
Tips to avoid rejections Many errors occur when membership information on the provider’s file from a previous visit is not updated at the time of the current service. At each visit, please be sure to check the member’s identification card and verify this information:
• subscriber’s or insured’s UMI number
• subscriber’s or insured’s last name
• subscriber’s or insured’s first name
• patient’s first name
• patient’s last name
• patient’s relationship to subscriber or insured
• patient’s sex
• patient’s date of birth 4 6/2006
Additionally, when referring members to other providers, such as radiologists, independent laboratories, durable medical equipment suppliers, etc., be sure that the member information you send is accurate.
If you have questions about reporting accurate member data, including the UMI, please contact your Provider Relations representative.
Verifying eligibility and benefits now easier for out-of-area Blue members B Highmark Blue Shield understands you need tools and resources to provide the best care to Blue members. So to help you obtain member eligibility and benefits quicker, Blue Shield has enhanced its electronic services for out- of-area Blue members.
You will now receive real-time responses to your eligibility and benefit requests for out-of-area Blue members. The service hours of all Plans have been extended, so now your out-of-area electronic eligibility requests can be processed from Monday through Saturday, 7 a.m. to 1 a.m. EST. Outside of these hours, real time answers may be available but are not guaranteed. If real time processing is not available, a real time response will be sent stating that processing is not available at this time.
There are two ways to submit out-of-area electronic eligibility and benefit requests for Blue members:
• submit a 270 Eligibility Inquiry transaction and receive a 271 Eligibility Response transaction
• enter an inquiry through the BlueExchange (Out-of-Area) transaction in NaviNetSM. NaviNet’s hours of operation remain Monday through Saturday from 5 a.m. to midnight, Sunday from 5 a.m. to 5 p.m.
Regardless of how you submit your out-of-area inquiry, it will be routed to the member’s Plan through BlueExchange, which acts as a gateway to direct these transactions to the member’s Plan.
All Blue Plans are now responding to out-of-area inquiries in real time, according to the hours of availability mentioned above. Blue Shield encourages you to try an electronic eligibility and benefit transaction for your out-of-area members if you haven’t already done so.
Here are some tips to assist you when initiating an electronic eligibility and benefits inquiry:
• Always enter the identification number shown on the identification card, including the alphabetical prefix. This prefix serves as the router to direct your inquiry to the member’s Blue Plan.
• It is most helpful to provide the name of the patient and his or her date of birth. And, if the patient is a dependent, include the name of the subscriber as well.
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Your satisfaction is very important to Blue Shield and it is committed to improving its service to you. This year, you will see several additional enhancements in the electronic services arena, including providing you with more detailed eligibility and benefit information for all out-of-area Blue members.
If you have questions, contact your Provider Relations representative.
Don’t maintain alphabetical prefix lists, check the patient’s identification card B Do not use alphabetical prefix listings that you maintain in your office to file claims for members from other Blue plans. Alphabetical prefixes constantly change and if you report an incorrect prefix, your claims may be routed to the wrong Blue plan and reject.
The member’s identification number will always include the alphabetical prefix in the first three positions. At each visit check your patient’s identification card to verify their alphabetical prefix. Report this prefix on each claim as it is critical for confirming membership and coverage and is the key to facilitating prompt payments.
For fast and efficient claims processing, file all of your BlueCard member claims electronically to Highmark Blue Shield.
Health care consumers want access to quality data
As higher deductible health plans grow in popularity, health care consumers have greater out-of-pocket expenses. In turn, they want access to credible quality and cost information to help in their decision making.
This marketplace demand for quality and cost information, also known as “transparency,” is increasing, and Highmark Blue Shield is working to meet this need in a manner that is beneficial to its members. Blue Shield’s goal is to give its members—your patients—the reliable hospital information they need to become more educated, active health care consumers.
There are a multitude of resources available to the consumer to obtain publicly available data on quality. The Internet alone offers hundreds of sites. “Highmark evaluated its member Web site—My Shield OnlineSM at www.highmarkblueshield.com—to determine what enhancements we could make to provide easy access to cost and quality information about our network providers,” says Kim Bellard, Highmark’s vice president of eMarketing. “We’d been giving our members access to a variety of sources of public quality measures over the past few years, but in March 2006, we consolidated several links, making it easier for them to find the information they need. We also expanded on the numbers and types of measures reported.”
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To accomplish this in a user-friendly format, Highmark Blue Shield contracted with Subimo, LLC, a leader in Web-based health care decision support tools. Blue Shield now links to Subimo’s Healthcare AdvisorTM directly from its member Web page. The Healthcare Advisor is a tool that aggregates publicly reported information from the Centers for Medicare & Medicaid Services, Health Forum/AHA, National Research Corporation, Leapfrog Group, state data agencies, and other sources. “In doing this, our goal is to give our members clear, accurate information about hospitals in our service area and easy-to-understand guidance about treatment options,” says Mr. Bellard.
Subimo captures any available new or refreshed data on a quarterly basis from the primary sources. But the update cycles can vary greatly from primary source to primary source, as well as the age of the data. For example, Leapfrog updates its data multiple times per year and is relatively current; but the Pennsylvania Health Care Cost Containment Council (PHC4) clinical data is more than a year old, as are almost all hospital discharge sources in the country, for example, the current data from PHC4 is for calendar year 2004.
Blue Shield continues to explore additional opportunities to share quality and cost data with members and is looking to include physician data, as well. As plans progress, Blue Shield will share the details with you in advance of a public release.
Policy
Highmark Blue Shield’s medical policies are available online in the Provider Resource Center through NaviNetSM or at www.highmarkblueshield.com. An alphabetical, as well as a sectional index, is available on the Medical Policy page. You can search for a medical policy by entering a key word, policy number, or procedure code.
RotaTeq vaccine eligible for coverage
Highmark Blue Shield began providing coverage for the new vaccine RotaTeq® on Feb. 3, 2006.
Blue Shield will determine coverage for RotaTeq according to the member’s contract and the Childhood Immunization Act for dependent children as well as applicants or members and their spouses who are up to and including 20 years of age. For individuals outside this population, Blue Shield will base coverage for RotaTeq on the member’s contract.
Report RotaTeq with code 90680.
RotaTeq, a live, oral vaccine, is used to prevent rotavirus gastroenteritis in infants and children. It’s administered as a 3-dose series to infants between the ages of 6 to 32 weeks.
MA Does not apply to FreedomBlue.
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Autologous blood-derived growth factors not covered
Highmark Blue Shield considers autologous blood-derived preparations experimental or investigational when they’re used:
• to treat chronic non-healing wounds
• as a primary procedure for other miscellaneous conditions including, but not limited to, epicondylitis, plantar fasciitis, or Dupuytren’s contracture
Blue Shield will deny claims reporting this procedure. A participating, preferred, or network provider can bill the member for the denied procedure.
Report these services with the appropriate code:
• S9055 for autologous blood-derived preparations for chronic non-healing wounds
• 20999 for injection of autologous blood-derived preparations for miscellaneous conditions
When you report code 20999, please include a complete description of the procedure you performed in the narrative section of the electronic or paper claim.
Do not use code 20926 to report autologous blood-derived preparations.
MA Does not apply to FreedomBlue.
Blue Shield covers intraperitoneal chemotherapy for treating advanced ovarian cancer
Highmark Blue Shield will cover intravenous paclitaxel plus intraperitoneal cisplatin and paclitaxel for women with stage III, optimally debulked (residual tumor, less than or equal to 1.0 cm in diameter) epithelial ovarian cancer.
Blue Shield considers the use of intraperitoneal chemotherapy for any other diagnosis experimental or investigational. It is not covered. A participating, preferred, or network provider can bill the member for the denied therapy.
According to a study conducted by the Gynecologic Oncology Group, a National Cancer Institute supported research network, women with stage III ovarian cancer who received a combination of intravenous and intraperitoneal chemotherapy following surgical debulking of their tumor had a median survival nearly 16 months longer than women who received only IV chemotherapy. 8 6/2006
Because of the evidence from the study, the National Cancer Institute encourages the administration of a combination of intravenous and intraperitoneal chemotherapy to women with advanced ovarian cancer, who have undergone optimal surgical debulking.
Report procedure code 96445—chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis—when you perform this service.
Blue Shield will determine coverage for intraperitoneal chemotherapy according to the individual or group customer benefits.
MA Also applicable to FreedomBlue.
Goeckerman regimen eligible for lichen planus
Highmark Blue Shield will now pay for Goeckerman regimen for lichen planus.
When you submit claims for the Goeckerman regimen, please report ICD-9-CM diagnosis code 697.0.
MA Does not apply to FreedomBlue.
Manipulation services include evaluation and management service
Manipulation includes a pre-manipulation assessment. This means that Highmark Blue Shield will pay for a separate evaluation and management service only in these circumstances:
• initial examination of a new patient or condition,
• acute exacerbation of symptoms or a significant change in the patient’s condition, or,
• distinctly different indications, which are separately identifiable and unrelated to the manipulation.
When you report evaluation and management services, the level reported should be consistent with the complexity of the history, physical, and medical decision making involved in the patient encounter.
The patient’s medical record should include documentation of the components of the separate and distinct evaluation and management service as well as the reasons for performing the separate evaluation and management service.
Report modifier 25 with the evaluation and management service to identify it as a separately identifiable service.
MA Does not apply to FreedomBlue. 9 PRN
Blue Shield denies chemical endarterectomy administration
Highmark Blue Shield considers the use of Edetate Disodium (J3520) in the treatment of atherosclerosis, arteriosclerosis, or any other condition experimental or investigational. It is not covered. A participating, preferred, or network provider can bill the member for the denied service.
Because Blue Shield does not cover chemical endarterectomy, it will not pay for any related services, for example, evaluation and management, laboratory work, infusion services, administration (M0300), etc.
When the administration code M0300 is reported with procedure code J3520, Blue Shield will deny it as experimental or investigational. A participating, preferred, or network provider can bill the member for the denied service.
MA Also applicable to FreedomBlue.
Patient selection criteria for bariatric surgery explained
For Highmark Blue Shield to consider payment for the surgical treatment of morbid obesity, all of these patient selection criteria must be met:
• The patient must be morbidly obese.
Blue Shield defines morbid obesity as a condition of consistent and uncontrollable weight gain that is characterized by:
• a weight that is at least 100 pounds or 100 percent over ideal weight, or
• a BMI of at least 40 (V85.4) or a BMI of 35 (V85.35-V85.39) with comorbidities, for example, hypertension, cardiovascular heart disease, dyslipidemia, diabetes mellitus type II, sleep apnea.
• The patient must be at least 18 years old.
• The patient must receive non-surgical treatment, for example, dietitian or nutritionist consultation, low calorie diet, exercise program, and behavior modification. The patient’s attempts at weight loss have failed.
• The patient must participate in and meet the criteria of a structured nutrition and exercise program. This includes dietician or nutritionist consultation, low calorie diet, increased physical activity, behavioral modification, and/or pharmacologic therapy. This information must be documented in the patient’s medical record.
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The structured nutrition and exercise program must meet all of these criteria:
a. The nutrition and exercise program must be supervised and monitored by a physician working in cooperation with dieticians and/or nutritionists.
b. The nutrition and exercise program(s) must be for a cumulative total of six months or longer.
c. The nutrition and exercise program must occur within two years before the surgery.
d. The patient’s participation in a structured nutrition and exercise program must be documented in their medical record by the attending physician that supervised the patient’s progress. A physician’s summary letter is not sufficient documentation.
Documentation should include medical records of the physician’s on-going assessments of the patient’s progress throughout the course of the nutrition and exercise program. For patients who participate in a structured nutrition and exercise program, medical records documenting the patient’s participation and progress must be available for Blue Shield’s review.
• The patient must complete a psychological evaluation that’s been performed by a licensed mental health care professional. The mental health care professional should provide a recommendation for the bariatric surgery. The patient’s medical record documentation should indicate that all psychosocial issues have been identified.
Patient selection is a critical process requiring psychiatric evaluation and a multidisciplinary team approach. The patient’s understanding of the procedure, and ability to participate and comply with life-long follow-up and the life-style changes, for example, changes in dietary habits, and beginning an exercise program, are necessary for the procedure to succeed.
MA Does not apply to FreedomBlue.
Computed tomographic angiography for coronary artery evaluation not covered
Highmark Blue Shield considers computed tomographic angiography (CTA) for coronary artery evaluation experimental or investigational because there is not enough scientific evidence to determine whether it improves patient health outcomes.
Blue Shield will deny claims reporting a CTA. A participating, preferred, or network provider can bill the member for a denied CTA.
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Report one of these procedure codes, as appropriate, for CTA of the heart and coronary arteries:
0144T—computed tomography, heart, without contrast material, including image post processing and quantitative evaluation of coronary calcium
0145T—computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology
0146T—computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium
0147T—computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium
0148T—computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology and computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium
0149T—computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology and computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium
0150T—computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology in congenital heart disease
0151T—computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; function evaluation (left and right ventricular function, ejection fraction and segmental wall motion)
S8092—electron beam computed tomography (also known as ultrafast CT, cine CT)
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CTA, a noninvasive imaging study, uses intravenously administered contrast material and high-resolution, rapid imaging CT equipment to obtain detailed volumetric images of blood vessels. CTA can image blood vessels throughout the body. However, imaging of the coronary vasculature requires shorter image acquisition times to avoid blurring from the motion of the beating heart.
MA Does not apply to FreedomBlue.
How to report paramagnetic contrast agents used with MRI
Magnetic resonance imaging (MRI) can be performed with and/or without contrast agents.
When you use a paramagnetic contrast material to perform an enhanced MRI study, report it with one of these codes:
Q9952—injection, gadolinium-based magnetic resonance contrast agent, per ml
Q9953—injection, iron-based magnetic resonance contrast agent, per ml
Q9954—oral magnetic resonance contrast agent, per ml
Highmark Blue Shield determines coverage for paramagnetic contrast agents used to perform an MRI according to the member’s individual or group benefits.
MA Also applicable to FreedomBlue.
New indication added for Herceptin coverage
Highmark Blue Shield will provide coverage for Herceptin® (Trastuzumab) when it is:
• indicated as a single agent for patients with metastatic breast cancer whose breast tumors have HER2 protein overexpression and who have received one or more chemotherapy regimens for their metastatic disease
• indicated in combination with other FDA-approved chemotherapeutic agents for the treatment of metastatic breast cancer in patients whose tumors overexpress the HER2 protein and who have not previously received chemotherapy for metastatic disease
• used as an adjuvant in combination with other chemotherapeutic agents for patients with early-stage breast cancer who overexpress the HER2 protein
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Report this drug with code J9355—Trastuzumab, 10 mg.
Blue Shield considers the use of Herceptin to treat a diagnosis other than breast cancer with the indications on Page 13 experimental or investigational. It is not covered. A participating, preferred, or network provider can bill the member for the denied drug.
Blue Shield determines coverage for Herceptin according to the individual or group customer benefits.
MA Also applicable to FreedomBlue.
Coverage expanded for bladder cancer tumor markers
Highmark Blue Shield has expanded coverage for tumor markers BTA and NMP-22 as an adjunct to cystoscopy for diagnosing patients that present with signs and symptoms suspicious of bladder cancer.
Blue Shield also covers BTA and NMP-22 for monitoring patients for the eradication of cancer, or recurrence after eradication.
Use procedure code 86294—immunoassay for tumor antigen, qualitative or semiquantitative—to report BTA and NMP-22.
Blue Shield covers the use of fluorescence in situ hybridization (FISH) testing when it’s reported as an adjunct to cystoscopy for diagnosing and monitoring patients with hematuria suspected of having bladder cancer.
You can use procedure code 88365—in situ hybridization, each probe—to report FISH testing.
MA Also applicable to FreedomBlue.
Palatal stiffening procedures to treat obstructive sleep apnea considered investigational
Highmark Blue Shield considers palatal stiffening procedures, including but not limited to, the cautery-assisted palatal stiffening operation (CAPSO) experimental or investigational. A participating, preferred, or network provider can bill the member for the denied procedure.
Blue Shield will not pay for these procedures because there are minimal published data about the CAPSO and palatal implants.
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Use code 42299—unlisted procedure, palate, uvula—to report palatal stiffening procedures. When reporting code 42299, please provide a complete description of the service you performed in the narrative field of the electronic or paper claim.
Palatal stiffening procedures include the CAPSO and insertion of palatal implants. The CAPSO procedure uses cautery to induce a midline palatal scar designed to stiffen the soft palate to eliminate excessive snoring. The implanted device is a cylindrical-shaped segment of braided polyester filaments that is permanently implanted submucosally in the soft palate.
MA Also applicable to FreedomBlue.
Reporting guidelines for electronystagmography and videonystagmography clarified
Highmark Blue Shield considers each of these components of electronystagmography (ENG) and videonystagmography (VNG) eligible for payment as a distinct and separate service:
• spontaneous nystagmus test, including gaze fixation nystagmus, with recording (92541)
• positional nystagmus test, with recording (92542)
• caloric vestibular test, each irrigation, with recording (92543)
• optokinetic nystagmus test, bidirectional, foveal, or peripheral stimulation, with recording (92544)
• oscillating tracking test, with recording (92545)
• sinusoidal vertical axis rotational testing (92546)
• saccades testing (92700)
Report each individual service using the procedure codes indicated.
Blue Shield considers placement of vertical electrodes (92547) an inherent part of ENG. When placement of vertical electrodes is reported with any of the above services, Blue Shield will combine the services and will pay for only the ENG service. If placement of vertical electrodes is reported alone, Blue Shield will deny it as not covered. A participating, preferred, or network provider cannot bill the member separately for the placement of the vertical electrodes.
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ENG involves the electrical recording of movements of the eyes. VNG is a non-invasive evaluation of eye movements that is performed using video imaging technology rather than the use of electrodes. These services are used to evaluate dizziness, vertigo, or balance dysfunction.
MA Also applicable to FreedomBlue.
Abatacept covered for active rheumatoid arthritis
As of Dec. 23, 2005, Highmark Blue Shield covers Abatacept (Orencia®) for the treatment of adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate or tumor necrosis factor (TNF) antagonists such as adalimumab, etanercept, or infliximab.
If Orencia is reported for any other diagnosis, Blue Shield considers it experimental or investigational. It is not covered. A participating, preferred, or network provider can bill the member for the denied drug.
Report Orencia with procedure code J3590. When you report unlisted code J3590, please provide the name of the drug and the dosage in the narrative field of the electronic or paper claim.
Orencia may be used as monotherapy or concomitantly with DMARDs, but should not be administered with TNF antagonists. It is not recommended for use with anikinra.
Orencia is administered as a 30-minute intravenous infusion at a fixed dose based on weight range approximately 10mg/kg at day 0, 2 weeks, 4 weeks, and every 4 weeks thereafter.
Blue Shield determines coverage for Orencia according to the individual or group customer benefits. Blue Shield does not provide reimbursement for Orencia under the member’s prescription drug benefit.
Orencia to be reimbursed at 95 percent of AWP Blue Shield has set its UCR and PremierBlueSM Shield reimbursement at 95 percent of the average wholesale price for all new therapeutic injections and chemotherapy drugs approved by the Food and Drug Administration (FDA) on or after Jan. 1, 2005.
These reimbursement rates will remain in effect for one year from the date the drug is first approved by the FDA. After the one-year introductory period expires, Blue Shield will price the drug or biological at 85 percent of the AWP.
Because of this, Blue Shield will price Orencia at 95 percent of the AWP until Dec. 23, 2006. After that date, Blue Shield will price Orencia at 85 percent of the AWP. The FDA approved Orencia on Dec. 23, 2005.
MA Also applicable to FreedomBlue. 16 6/2006
Blue Shield denies services provided for immediate relatives or household members
Highmark Blue Shield will not pay for charges imposed by a physician on his or her immediate relatives or members of his or her household or for services rendered by a physician to himself or herself. Blue Shield’s reason for this exclusion is to bar payment for physicians’ personal services that would ordinarily be furnished gratuitously.
These relatives of the provider are included in Blue Shield’s definition of “immediate relative”:
• husband or wife
• natural parent or child
• adopted child or adoptive parent
• stepparent or stepchild
• father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law
• grandparent or grandchild
• sibling, stepbrother, or stepsister
Blue Shield will pay for a provider’s services to his or her spouse’s stepparents.
Blue Shield will pay for charges imposed on immediate relatives or household members by a provider to recover expenses incurred in furnishing covered items or supplies, such as drugs and biologicals, prosthetic devices, etc.
Members of a patient’s household are persons sharing a common abode with the patient as part of a single family unit, including those related by blood, marriage, or adoption.
MA Also applicable to FreedomBlue. For FreedomBlue, Blue Shield also considers the spouses of a grandparent and grandchild as well as adopted siblings as immediate relatives.
Supervision guidelines outlined
Highmark Blue Shield only pays for covered services when they’re personally performed by an eligible professional provider or under that provider’s direct personal supervision, in accordance with the following licensure and employment criteria:
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Eligible professional providers are those providers defined by Blue Shield’s Regulatory Act, that is, enabling legislation, duly licensed and acting within their scope of license. They include:
• Audiologists
• Certified registered nurses
• Certified registered nurse anesthetists
• Certified registered nurse practitioners
• Certified enterostomal therapy nurses
• Certified community health nurses
• Certified psychiatric mental health nurses
• Certified clinical nurse specialists
• Clinical laboratories
• Dentists
• Doctors of chiropractic
• Doctors of medicine
• Doctors of osteopathy
• Nurse midwives
• Optometrists
• Physical therapists
• Podiatrists
• Psychologists
• Speech pathologists
• Teachers of the hearing impaired
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Blue Shield will also reimburse covered services when they’re performed by licensed health care practitioners, who are employed and personally supervised by eligible professional providers.
For purposes of this guideline, Blue Shield defines “health care practitioner” as a person who is licensed to perform health-related services, but is not eligible for direct reimbursement from Blue Shield. Examples of health care practitioners include a registered nurse (RN), licensed practical nurse (LPN), physician assistant (PA), and licensed clinical social workers.
“Personal supervision” means that the professional provider must be present in the immediate vicinity, in the event his or her personal assistance is required for the procedure or to assume care of the patient.
For its supervision guidelines, Blue Shield defines “immediate vicinity” as within the same office or suite of offices, so that the professional provider can respond promptly to a request for assistance. Availability of the supervising professional provider by telephone does not constitute direct personal supervision.
Blue Shield recognizes services performed by a PA when they’re employed by and acting under the direct supervision of a physician. Indirect supervision, that is, the supervising physician is not on the premises but is available by phone or radio contact, is recognized for PAs practicing in medically underserved areas where physician access is limited.
When providing care to his or her patient, the professional provider has medical and legal responsibility for the services provided, whether performed personally or by a licensed employee. This includes the ability to take over the procedure or to care for the patient in the event it becomes necessary. For example, patients may experience an acute medical problem, for example, syncopal episode, cardiac arrest, even during non-invasive diagnostic procedures. It is also possible for equipment failure to result in circumstances that require patient management by a physician.
For reimbursement purposes, Blue Shield requires that services reported for its members are either personally performed by the eligible professional provider or under that provider’s direct supervision.
Certain diagnostic tests have been identified that have extended technical components wherein the patient goes about normal daily activities while being monitored. These tests include holter monitoring (93224, 93230, and 93235), cardiac event monitoring (93268), and sleep studies (95807-95811). These procedures are performed under the physician’s overall management and control, but the physician is not present for the duration of the test.
There may be exceptions to these guidelines depending on the individual member’s contract, and provider network rules.
MA Does not apply to FreedomBlue. 19 PRN
Application of a vasopneumatic device eligible for specific indications
Highmark Blue Shield covers the application of a vasopneumatic device as a physical medicine modality for these conditions:
• edema of the extremities
• hematoma of the leg
• lymphedema of the arm
• lymphedema of the leg
• venous insufficiency or venous stasis disorder
Blue Shield considers the application of a vasopneumatic device for any other conditions, or for those with an active infection, not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.
When preparing documentation to support the application of a vasopneumatic compression device, remember to include the type, amount, and location of the edema as well as the circumferential measurements of the treated extremity, before and after treatment.
Blue Shield determines coverage for this service according to individual or group customer benefits.
Use code 97016 to report the application of a vasopneumatic device.
MA Does not apply to FreedomBlue.
Vitrectomy coverage expanded
Highmark Blue Shield now pays for a vitrectomy (65810, 67005, 67010, 67036, 67038, 67039, 67040) for these new indications:
• anomalies of lens shape (743.36)
• bullous keratopathy (371.23)
• central retinal vein occlusion (362.35) and venous tributary (branch) occlusion (362.36)
• corneal edema, unspecified (371.20) and secondary corneal edema (371.22) 20 6/2006
• disruption of internal operation wound (998.31)
• foreign body in anterior chamber (360.61)
• foreign body in lens (360.63)
• foreign body in other or multiple sites (360.69)
• foreign body in posterior wall (360.65)
• Harada’s disease (363.22)
• macular degeneration (senile), unspecified (362.50) and exudative senile macular degeneration (362.52)
• non-healing surgical wound (998.83)
• organ or tissue replaced by other means, lens (V43.1)
• Pars planitis (363.21)
• retinal defect, unspecified (361.30)
• retinal edema (362.83)
• vitreous degeneration (379.21) and other disorders of vitreous (379.29)
MA Does not apply to FreedomBlue.
Report anesthesia time during conscious sedation to avoid claim delays
Because Highmark Blue Shield uses the anesthesia conversion factor to calculate its reimbursement for moderate (conscious) sedation services (99143-99150), you must report anesthesia time incurred during “face-time” with the patient. If you do not, your claims may be delayed or may not be paid correctly.
To avoid delays or incorrect payments, always report total anesthesia time in minutes.
Blue Shield will pay for conscious sedation when it’s performed for any covered surgical procedure by a provider other than the operating surgeon, or attending health care professional.
MA Also applicable to FreedomBlue.
21 PRN
Fees for not otherwise classified drugs and biologicals available through NaviNet
Highmark Blue Shield has developed fee information for drugs and biologicals that do not have a specific HCPCS code assigned to them. This information is available through NaviNetSM on the “Not Otherwise Classified Drug and Biological Bulletin.” This bulletin includes potentially covered unlisted drugs and biologicals that are frequently reported for which Blue Shield has established allowances.
Blue Shield is making these fees available to you so that you have as much reimbursement information as possible.
Remember, when you report a not otherwise classified (NOC) drug and biological code, be sure to include the drug and/or biological name and dosage in the narrative section of the electronic or paper claim.
MA Also applicable to FreedomBlue.
Correction
In our article “Coverage guidelines for intra-articular hyaluronan injections for osteoarthritis of the knee apply to Synvisc, Hyalgan, Supartz, and Orthovisc” (Pages 13-14 in the April 2006 PRN), we incorrectly told you that the information does not apply to FreedomBlue.
The policy guidelines in the article do apply to Highmark Blue Shield’s Medicare Advantage product, FreedomBlueSM.
Here is the correct statement:
MA Also applicable to FreedomBlue.
Questions or comments on these new medical policies?
We want to know what you think about our new medical policy changes. Send us an e-mail with any questions or comments that you may have on the new medical policies in this edition of PRN.
Write to us at [email protected].
22 6/2006
Codes
New codes available July 1
These new procedure codes became available July 1, 2006:
Code Terminology K0733 Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (eg, gel cell, absorbed glassmat)
K0734 Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth
K0735 Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
K0736 Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth
K0737 Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
0155T Laparoscopy, surgical, implantation or replacement of gastric stimulation electrodes, lesser curvature (ie, morbid obesity)
0156T Laparoscopy, surgical, revision or removal of gastric stimulation electrodes, lesser curvature (ie, morbid obesity)
0157T Laparotomy, implantation or replacement of gastric stimulation electrodes, lesser curvature (ie, morbid obesity)
0158T Laparotomy, revision or removal of gastric stimulation electrodes, lesser curvature (ie, morbid obesity)
0159T Computer aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure)
0160T Therapeutic repetitive transcranial magnetic stimulation treatment planning
0161T Therapeutic repetitive transcranial magnetic stimulation treatment delivery and management, per session
23
PRN
CMS reinstates deleted code G0252
Code G0252—PET imaging, full and partial-ring PET scanners only, for initial diagnosis of breast cancer and/or surgical planning for breast cancer (e.g., initial staging of axillary lymph nodes)—was deleted on Jan. 1, 2006.
The Centers for Medicare & Medicaid Services (CMS) has reinstated the code so it is again available for you to report this service.
Deleted codes
Here are five codes that Highmark Blue Shield has deleted and their corresponding terminology and deletion date:
Deleted code Terminology Date deleted E0590 Dispensing fee covered drug administered through Jan. 1, 2006 DME nebulizer
S0116 Bevacizumab 100 mg July 1, 2006
S0198 Injection, pegaptanib sodium July 1, 2006
S8075 Computer analysis of full-field digital mammogram and further July 1, 2006 physician review for interpretation, mammography (List separately in addition to code for primary procedure)
S9022 Digital subtraction angiography (use in addition to CPT code July 1, 2006 for the procedure for further identification)
AMA revises terminology for code S5523
The American Medical Association (AMA) has revised the terminology for code S5523.
As of July 1, 2006, the new terminology for code S5523 is: home infusion therapy, insertion of midline venous catheter, nursing services only (no supplies or catheter included).
24 6/2006
PET codes' deletion date revised
The Centers for Medicare & Medicaid Services (CMS) deleted procedure codes G0210-G0218 and G0220- G0234 on March 31, 2005. The deleted codes were replaced on Jan. 1, 2005 with CPT codes 78811-78816.
Because of conflicting information from CMS about invalid versus deleted code status, Highmark Blue Shield's files previously listed a deletion date of Dec. 31, 2005 for procedure codes G0210-G0218 and G0220-G0234. Blue Shield has updated its files to reflect the correct deletion date of March 31, 2005.
25 PRN
Notes
22 6 6/2006
Need to change your provider information?
Fax the information to us! You can fax us changes about your practice information, such as the information listed on the coupon below. The fax number is (800) 236-8641. Blue Cross of Northeastern Pennsylvania (BCNEPA) providers should use fax number (570) 200-6880. You may also continue to send information by completing the coupon below.
Coupon for changes to provider information Please clip and mail this coupon, leaving the PRN mailing label attached to the reverse side, to: Highmark Blue Shield Provider Data Services PO Box 898842 Camp Hill, Pa. 17089-8842
For BCNEPA providers:
Blue Cross of Northeastern Pennsylvania Provider System Support 19 North Main Street Wilkes-Barre, Pa. 18711
Name Provider ID number Electronic media claims source number Please make the following changes to my provider records: Practice name Practice address Mailing address Telephone number ( ) Fax number ( ) E-mail address Tax ID number Specialty Provider’s signature Date signed 27 PRN Contents Vol. 2006, No. 3
News Reporting guidelines for electronystagmography and Blue Shield seeks new members for Medical Review Committee ..1 videonystagmography clarified...... 15 PremierBlue Shield credentialing not required for facility-based Abatacept covered for active rheumatoid arthritis ...... 16 practitioners...... 2 Blue Shield denies services provided for immediate relatives or household members ...... 17 Blue Shield no longer produces Procedure Terminology Manual ...... 3 Supervision guidelines outlined ...... 17 Reminder: be sure to report accurate membership information Application of a vasopneumatic device eligible for specific on claims ...... 3 indications...... 20 Verifying eligibility and benefits now easier for out-of-area Blue Vitrectomy coverage expanded...... 20 members ...... 5 Report anesthesia time during conscious sedation to Don’t maintain alphabetical prefix lists, check the patient’s avoid claim delays ...... 21 identification card ...... 6 Fees for not otherwise classified drugs and biologicals available Health care consumers want access to quality data ...... 6 through NaviNet ...... 22 Correction ...... 22 Questions or comments on these new medical policies? ...... 22 Policy RotaTeq vaccine eligible for coverage ...... 7 Codes Autologous blood-derived growth factors not covered ...... 8 Blue Shield covers intraperitoneal chemotherapy for treating New codes available July 1 ...... 23 advanced ovarian cancer...... 8 CMS reinstates deleted code G0252 ...... 24 Goeckerman regimen eligible for lichen planus...... 9 Deleted codes ...... 24 Manipulation services include evaluation and management AMA revises terminology for code S5523...... 24 service ...... 9 PET codes’ deletion date revised ...... 25 Blue Shield denies chemical endarterectomy administration...... 10 Patient selection criteria for bariatric surgery explained ...... 10 Need to change your provider information?...... 27 Computed tomographic angiography for coronary artery evaluation not covered ...... 11 Acknowledgement How to report paramagnetic contrast agents used with MRI...... 13 The five-digit numeric codes that appear in PRN were obtained New indication added for Herceptin coverage ...... 13 from the Current Procedural Terminology, as contained in CPT- Coverage expanded for bladder cancer tumor markers ...... 14 2006, Copyright 2005, by the American Medical Association. Palatal stiffening procedures to treat obstructive sleep apnea PRN includes CPT descriptive terms and numeric procedure considered investigational...... 14 codes and modifiers that are copyrighted by the American Medical Association. These procedure codes and modifiers are used for reporting medical services and procedures. Visit us at www.highmarkblueshield.com
PRSRT STD U.S. POSTAGE PAID PRN HARRISBURG, PA Policy Review & News Permit No. 320 Highmark Blue Shield Camp Hill, Pennsylvania 17089