Policy Review & News

PRNImportant information about Pennsylvania Blue Shield April 2001 In This Issue Avoid claim denials: report required information ...... 1 Blue Shield updates manual on Documentation of Services Provided in a Teaching Setting ...... 4 Blue Shield to provide electronic remittance advice for Independence Blue Cross and AmeriHealth claims ...... 5 Pennsylvania Blue Shield revises guidelines for oncologic PET imaging .10 PRN index for 2000 ...... insert Pages i - viii

News

Avoid claim If you do not report certain information or you report incorrect information on your denials: report claims, Pennsylvania Blue Shield either calls you or sends you a letter requesting the required missing or correct information. This procedure is changing. information Beginning July 1, 2001, Blue Shield will deny your claim if you do not report a diagnosis code, procedure code or performing provider’s identification number. Blue Shield will also deny your claim if you report an invalid diagnosis code or procedure code. Blue Shield’s new procedure of denying claims in these instances is similar to HGSAdministrators’ processing procedures for Medicare claims. Blue Shield is committed to processing your claims timely and accurately. To avoid delays and denials, please provide Blue Shield with the basic information it needs to process your claim. Here are some hints that will help you report correct information.

Diagnosis code ¥ Report a valid ICD-9-CM diagnosis code or description on all claims. Blue Shield will reject paper claims if you do not report a valid diagnosis code. The ICD-9-CM code is a required field on the claim form. PRN

¥ Enter the most appropriate three-, four-, or five-digit ICD-9-CM diagnosis code for the reported service. Be as specific as possible when reporting ICD-9-CM codes. For example, code 403.00 is a valid diagnosis code. If reported incorrectly as 403 or 403.0, it becomes invalid. ¥ List the primary diagnosis first. ¥ When reporting more than one ICD-9-CM diagnosis code, be sure to reference a diagnosis code to each service performed by reporting the reference number 1, 2, 3 or 4 from the diagnosis or nature of illness or injury block to the diagnosis code block on the line item. Please refer to Section 7, Claims Submission and Billing Information, in the Blue Shield Reference Guide, for more information about reporting diagnosis codes.

Procedure code ¥ You must report a valid procedure code on all claims—it is required information. If you do not report a procedure code on your claim, Blue Shield will no longer contact you for the missing code. Blue Shield will reject electronic and paper claims if you do not report valid procedure codes. ¥ Report the appropriate procedure code and any applicable modifiers on your claims. Refer to Blue Shield’s Procedure Terminology Manual for this information. ¥ If you cannot find a procedure code that accurately describes the procedure performed, use the appropriate “unlisted procedure” code. Always include a complete description of the service in the explanation field. If you have questions about how to report procedure codes on electronic claims, please contact your vendor. For questions about reporting procedure codes on paper claims, please refer to Section 7, Claims Submission and Billing Information, in the Blue Shield Reference Guide.

Performing provider identification number ¥ Report the Blue Shield identification number of the provider who performed the services on all claims. Blue Shield will reject electronic and paper claims if you do not report the performing provider’s identification number. ¥ For electronic claims: if you report services under a group practice’s (assignment account’s) Blue Shield identification number or one-person corporation’s Blue Shield identification number, you must also identify the individual provider who performed the services. Enter his or her individual Blue Shield identification number in the rendering provider indentification field. If you have any questions, please contact your vendor. ¥ For paper claims: if you report services under a group practice’s (assignment account’s) Blue Shield identification number or one-person corporation’s Blue Shield identification number, you must also identify the individual provider who performed the services. Enter his or her individual Blue Shield identification number, including the alphabetical prefix, in the appropriate block. 2 4/2001

This block is labeled “leave blank” on most claim forms. The 1500A claim form titles block No. 24.H, “performing provider.” On the HCFA 1500 claim form, block No. 24.K is titled, “reserved for local use.” You must provide this information for each service line listed on the claim. If you have questions about reporting the performing provider’s identification number, please refer to Section 7, Claims Submission and Billing Information, in the Blue Shield Reference Guide. If you submit your claims under an individual provider’s Blue Shield identification number, you do not have to report a performing provider identification number.

Call Blue Shield Now you can call Pennsylvania Blue Shield’s medical-surgical Customer Service toll free departments or your Provider Relations representative toll free. It’s easy to convert the telephone numbers you’ve been using to call Customer Service or your Provider Relations representative to toll free. Simply replace area code 717 or 610 with area code 866. For example, instead of dialing (717) 975-7290, use the toll-free number (866) 975-7290. Please make this change to the telephone numbers you have for Blue Shield’s Customer Service departments and its Provider Relations representatives.

Use OASIS or InfoFax for immediate answers to some questions You can still access Blue Shield’s toll-free automated inquiry mechanisms, OASIS and InfoFax. Because you can obtain immediate answers to your general benefits and eligibility questions, Blue Shield encourages you to use these options. Please continue to contact Blue Shield’s Customer Service department for questions about: ¥ claims processed by Blue Shield; or ¥ your reimbursement. Your Provider Relations representative can help you with your more complex questions or issues that are best resolved through personal contact. These include questions about applications of medical policy, credentialing, or claim issues that cannot be resolved over the telephone.

2001 PTM mailed In March, Pennsylvania Blue Shield mailed the 2001 edition of the Procedure in March Terminology Manual (PTM) to most health care professionals. If you are an out-of-state provider, you must have contracted with Blue Shield as a participating provider to receive a 2001 PTM. Blue Shield designs the PTM to assist your staff in submitting claims to Blue Shield. When reporting services, always use the appropriate procedure code number. Remember, reporting deleted codes will delay payment and may result in the denial of your claim. The listing of a procedure in this manual does not necessarily indicate that it is eligible for payment under Blue Shield’s programs. 3 PRN

The 2001 Health Care Financing Administration Common Procedure Coding System (HCPCS) and the American Medical Association’s Current Procedure Terminology (CPT) changes are included in the PTM. If you have not received your copy of the 2001 PTM, please contact: Pennsylvania Blue Shield Shipping Control Department PO Box 890089 Camp Hill, Pa. 17089-0089 (717) 763-3256

Blue Shield The 2000 edition of the Documentation of Services Provided in a Teaching Setting updates manual on manual is now available. This version replaces the 1996 edition. Documentation of The updated manual clarifies Pennsylvania Blue Shield’s requirements for documenting Services Provided services that are provided in a teaching setting. These requirements became effective July in a Teaching 1, 1996 for Blue Shield’s traditional fee-for-service programs. Highmark Inc.’s wholly- Setting owned managed care programs began to adhere to these requirements in April 1999. Blue Shield has eliminated all references to Xact Medicare Services, now known as HGSAdministrators, in the manual. The manual defines the criteria you will use to distinguish physician services furnished in a teaching setting that you may bill Blue Shield on a 1500A or HCFA 1500 claim form. Services provided by residents, or services provided by teaching physicians for the general benefit of patients are considered administrative services. These services cannot be billed separately by either the physician or the hospital. Blue Shield’s Benefits Cost Management department will conduct audits to ensure compliance with the requirements published in the manual. If you have questions about the documentation requirements, please call Mary Miller at (717) 975-7473. For additional copies of the manual, call Janet George at (717) 975-7287.

Report HCPCS Please remember to only report HCPCS procedure codes on your electronic or paper codes that are claims that are valid at the time a service is performed. valid at the time of The Transaction Rule of the Health Insurance Portability and Accountability Act service (HIPAA) requires all health care payers to process a claim based on the medical code sets valid at the time of service. This is a change to the way Pennsylvania Blue Shield currently processes your claims. Blue Shield now processes claims based on the medical code sets valid on the processing date. Blue Shield will begin to process your claims according to HIPAA’s new requirements on May 12, 2001. Please see, “HIPAA requires new reporting method for HCPCS procedure codes,” in the 4 February 2001 PRN for instructions on what to do if your service is rejected. 4/2001 EMC News

NAIC assigned to The National Association of Insurance Commissioners has assigned NAIC code 54704 to Independence Blue Independence Blue Cross’ Personal Choice product. Cross’ Personal Pennsylvania Blue Shield’s EDI Services will begin to accept NAIC code 54704 on May Choice product 11, 2001. The new code is part of EDI Services’ DataStream TIER 1 service. Blue Shield has notified its vendor and clearinghouse community of the new code. Please contact your vendor or clearinghouse to update your system with NAIC code 54704.

Blue Shield to Pennsylvania Blue Shield will begin to produce electronic remittance advice (ERA) for provide electronic these DataStream Tier 1 professional claims beginning May 11, 2001: remittance advice ¥ Independence Blue Cross (Personal Choice)—NAIC code 54704 for Independence ¥ AmeriHealth (Delaware) (non HMO)—NAIC code 93688 Blue Cross and ¥ AmeriHealth (New Jersey) (non HMO)—NAIC code 60061 AmeriHealth claims How to obtain ERA If you are an electronic provider that does not receive ERA, you can request access by completing a DataStream subscription application. To request the application: ¥ visit www.highmark.com; or, ¥ call Highmark EDI Services at (800) 992-0246, select fax-back option No. 1 and request document No. 102. Electronic providers already receiving ERA for Pennsylvania Blue Shield NAIC code 54771 do not need to complete another application to receive ERA for Personal Choice or AmeriHealth claims.

Specifications Professional and institutional electronic remittance advice (ERA) specifications changed change for on March 9, 2001. professional and Here are the new specifications: institutional ERA ANSI X12 Ð 835 Version 3051 Claim payment ¥ Claim level data, Table 2, claim payment loop, position 010 (CLP segment). When CLP02 qualifier is = 22 do not map zeros to CLP05. Note: CLP05 (member liability) will not contain any liability for reversal claims (CLP02=22). ¥ Claim filing indicator, Table 2, claim payment loop, position 010 (CLP segment). The code “MC”—Medicaid (Clarity Gateway Vision)—is being added as a valid value. 5 PRN

¥ Rendering provider name, Table 2, claim payment loop, position 030 (NM1 (3) segment). When NM101 = “82” and NM108 = “UP” (Unique Physician Identification Number [UPIN]). This segment is present only when the rendering provider for the claim is different from the billing provider for the 835 transaction. ¥ Medicare inpatient adjudication, Table 2, claim payment loop, position 033 (MIA segment). This segment is present when an informational message applies to the claim. ¥ Medicare outpatient adjudication, Table 2, claim payment loop, position 035 (MOA segment). This segment is present when an informational message applies to the claim. Service payment ¥ Medical remark code, Table 3, service payment loop, position 130 (LQ segment). This segment is present when an informational message is applicable to a line level service. National Standard Format, Version 2.0 Claim data record (patient) ¥ Medicare inpatient and outpatient adjudication codes, Record 400, fields 23-27, claim message code positions 234-258. If you receive an informational claim message, an applicable code will be supplied. Required field status is changed from “O” optional to “C” conditional. Service data-2 ¥ Auto offset line remark codes (LQ-CODE), Record 451, fields 16-20, remark code positions 133-157. If you receive an informational line level message, an applicable code will be supplied. Required field status is changed from “O” optional to “C” conditional.

Policy

Morphometric Pennsylvania Blue Shield does not consider morphometric analysis of tumors to be analysis of tumors generally accepted within the medical community as clinically useful in diagnosis or not covered treatment. Therefore, Blue Shield will not pay for this test. A participating, preferred or network provider cannot bill the member for this service. Use code 88358 to report morphometric analysis of tumors. Morphometric analysis of tumors is a test that identifies the assessment of nuclear DNA for aneuploid clones and estimation of percentage of cells in the S-phase. Assessment of ploidy may be helpful to estimate the prognosis and to plan therapy for patients from whom tumors have been sampled or excised. 6 4/2001

In vitro Pennsylvania Blue Shield considers in vitro chemoresistance and chemosensitivity assays chemoresistance as investigational tests. Therefore, they are not eligible for payment. and Chemoresistance and chemosensitivity assays are intended to aid in choosing chemosensitivity chemotherapy drugs. They can either rule out or aid in selecting a drug for use in assays considered treatment. The various assays differ in their processing and in the technique used to investigational measure sensitivity or resistance. However, there are four basic steps common to all: 1. Isolation of cells. 2. Incubation of cells with drugs. 3. Assessment of cell survival. 4. Interpretation of results. A tumor’s response to the drug is classified as sensitive or resistant, although sometimes tumors are described as intermediate. The assay results may be used in making a treatment decision. A drug with a “sensitive” result on assay is thought to be potentially effective in vivo chemotherapy. Drugs identified as “resistant” are thought to be potentially ineffective chemotherapies. Use code 89399 to report chemoresistance assays, including but not limited to, extreme drug resistance assays, for example, ChemoFx assay or cell culture drug resistance testing (CCDRT). Use code 89399 to report chemosensitivity assays, including but not limited to, the histoculture drug response assay or a fluorescent cytoprint assay. When you report code 89399, please include a complete description of the service performed.

Correction of Pennsylvania Blue Shield considers the correction of inverted nipples (procedure code inverted nipples 19355) performed in an attempt to restore the ability to breast feed to be reconstructive considered surgery. In this instance, the procedure is eligible for payment. cosmetic in most Reconstructive surgery is performed to improve or restore bodily function. It is generally cases eligible for payment under standard Blue Shield medical-surgical contracts. Blue Shield considers correction of inverted nipples for any other condition as cosmetic. Thus it is not eligible for payment.

Blue Shield to Pennsylvania Blue Shield will not implement the coverage guidelines for the follow ACIP pneumococcal vaccine, 7-valent (Prevnar) that were published in the October 2000 PRN. guidelines for Blue Shield will continue to provide coverage for Prevnar according to the Advisory Prevnar Committee on Immunization Practices’ (ACIP) guidelines. Here are the ACIP’s coverage guidelines: ¥ All infants up to age 23 months. ¥ Children aged 24-59 months who are at high risk for invasive pneumococcal infection. This recommendation applies to these groups: 7 PRN

¥ children with SCD and other sickle cell hemoglobinopathies, children who are functionally or anatomically asplenic; ¥ children with HIV infection; ¥ children who have chronic disease, including chronic cardiac and pulmonary disease (excluding asthma), diabetes mellitus or CSF leak; and ¥ children with immunocompromising conditions. The ACIP recommends that health care professionals consider vaccination for all other children aged 24-59 months, with priority given to these populations: ¥ children aged 24-35 months; ¥ children of Alaska Native or American Indian descent; ¥ children of African-American descent; ¥ children who attend group day care centers; ¥ children who are socially or economically disadvantaged; and ¥ children with frequent or recurrent otitis media.

Blue Shield’s Pennsylvania Blue Shield will pay for externally-generated regional hyperthermia and coverage interstitial and intracavitary hyperthermia when used in conjunction with radiation guidelines of therapy for the treatment of malignant tumors. hyperthermia If hyperthermia is used alone or in connection with chemotherapy, Blue Shield will deny explained it as not medically necessary. A participating, preferred or network health care professional cannot bill the member for the denied service.

How to report hyperthermia Do not report separate charges for treatment planning for both radiation therapy and hyperthermia. When both modalities are included in the radiation therapy treatment prescription, report the treatment planning for both modalities with: 77261—Therapeutic radiology treatment planning; simple; 77262—Therapeutic radiology treatment planning; intermediate; or 77263—Therapeutic radiology treatment planning; complex Use these codes, as appropriate, to report hyperthermia: 77600—Hyperthermia, externally-generated; superficial (i.e., heating to a depth of 4 cm or less) 77605—Hyperthermia, externally-generated; deep (i.e., heating to depths greater than 4 cm) 77610—Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators 77615—Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators 77620—Hyperthermia generated by intracavitary probe(s) 8 4/2001

Hyperthermia for the treatment of cancer consists of the use of heat to make tumors more susceptible to cancer therapy measures. It may be induced by a variety of sources such as microwave, ultrasound, low energy radiofrequency conduction or by probes.

Coverage Pennsylvania Blue Shield will pay for intracoronary brachytherapy using gamma or beta guidelines for radioactive ribbons when used to treat or manage in-stent restenosis in native coronary intracoronary vessels. Coverage begins July 16, 2001. brachytherapy Blue Shield considers intracoronary brachytherapy investigational in these applications: explained ¥ When performed with beta or gamma radioactive ribbons as an adjunct to PTCA (with or without stenting) in the management of an initial lesion (de novo) to prevent restenosis. ¥ When performed using any other radioactive source, for example, an alpha energy source such as helium ions. ¥ When performed using radioactive stents or catheter balloons filled with radioactive material. The long-term efficacy of intracoronary brachytherapy in the management of initial (de novo) lesions (with or without stent) has not been established. In addition, the FDA has not approved radioactive stents or catheter balloons filled with radioactive material for any indication. Use procedure code 77799—unlisted procedure, clinical brachytherapy—to report intracoronary brachytherapy. Include a complete description of the procedure.

Guidelines for Pennsylvania Blue Shield applies specific coverage criteria to PET scans based on the reporting PET anatomic area imaged. These guidelines are the same whether the PET study is performed scans performed using a dedicated PET scanner or coincidence detection imaging system. on coincidence A coincidence detection imaging system uses a modified SPECT gamma camera adapted detection imaging to produce PET-like images. systems Use code S8085—FDG imaging using dual-head coincidence detection system (non- dedicated PET scan)—to report all PET scans performed using a coincidence detection imaging system, regardless of the anatomic area studied.

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Pennsylvania Blue Pennsylvania Blue Shield now considers positron emission tomography (PET) studies to Shield revises be medically necessary and eligible in the following oncologic applications. guidelines for PET brain imaging for malignancies (codes 78608, 78609) oncologic PET Blue Shield considers PET imaging for malignancies of the brain medically necessary imaging and eligible for payment. Blue Shield limits PET imaging of the brain for malignancies to one scan every 12 months from the date of the previous scan.

Colorectal PET imaging (code G0163) Blue Shield considers colorectal PET imaging as medically necessary in these situations: ¥ In the evaluation of patients suspected of having recurrent or metastatic colorectal cancer due to rising CEA levels with pain and/or weight loss, and in whom CT or MRI studies are inconclusive. ¥ In the evaluation of patients with a prior diagnosis of colorectal cancer who may be candidates for surgical re-excision. Blue Shield limits colorectal PET imaging to one scan every 12 months from the date of the previous PET scan. Use code G0163—Positron emission tomography (PET), whole body, for recurrence of colorectal or colorectal metastatic cancer—to report this procedure.

Esophageal PET imaging (code 78810) Blue Shield considers esophageal PET imaging as medically necessary in detecting esophageal cancer in patients who are suspected of having distant lymph node and/or organ metastasis (Stage IV) esophageal cancer. CT and/or endoscopic ultrasound studies are the standard imaging methods to assess patients with esophageal cancer. When CT and/or endoscopic ultrasound are inconclusive, PET imaging may be used as an adjunct to obtain additional information. When PET is used alone or in place of CT or endoscopic ultrasound for the detection and initial staging of local or regional esophageal cancer, Blue Shield considers it not medically necessary. Blue Shield limits payment for esophageal PET imaging to one scan every 12 months from the date of the previous PET scan. Use code 78810—Tumor imaging, positron emission tomography (PET), metabolic evaluation—to report this procedure.

PET imaging for lymphoma, including Hodgkin’s and non-Hodgkin’s disease (code G0164) Blue Shield considers PET imaging for lymphoma, including Hodgkin’s and non- Hodgkin’s disease, medically necessary in evaluating, staging and restaging lymphoma, monitoring the disease and the patient’s response to treatment. Blue Shield limits payment for PET imaging for lymphoma to one scan every 50 days from the date of the previous PET or Gallium scan. 10 4/2001

Use code G0164—Positron emission tomography (PET), whole body, for staging and characterization of lymphoma—to report this procedure.

PET imaging for melanoma (code G0165) Blue Shield considers PET imaging for melanoma medically necessary: ¥ to assess extranodal spread of malignant melanoma at initial staging; ¥ to evaluate suspected recurrent disease; ¥ to detect melanoma metastasis, for example, soft tissue, small bowel, lymph node metastasis; or ¥ during follow-up treatment. Blue Shield considers PET imaging not medically necessary when it’s used to detect regional lymph node metastases in patients with clinically localized melanoma who are candidates for sentinel lymph node biopsy. Blue Shield limits payment for PET imaging for melanoma to one scan every 12 months from the date of the previous scan. Use code G0165—Positron emission tomography (PET), whole body, for recurrence of melanoma or melanoma metastatic cancer—to report this procedure.

Pancreatic PET imaging (code 78810) Blue Shield considers pancreatic PET imaging medically necessary for patients with suspected pancreatic adenocarcinoma when the results of other imaging modalities, for example, CT, endoscopic retrograde cholangiopancreatography (ERCP), ultrasonography, are inconclusive. Blue Shield will not pay for pancreatic PET imaging for other diagnoses or conditions. It will deny the service as not medically necessary. Blue Shield limits payment for pancreatic PET imaging to one scan every 12 months from the date of the previous scan. Use code 78810—Tumor imaging, positron emission tomography (PET), metabolic evaluation—to report this procedure.

PET imaging of lung malignancies (codes G0125, G0126) Blue Shield will pay for PET imaging for lung malignancies in these situations: ¥ In patients who have a solitary pulmonary nodule and in whom chest x-ray and computed tomography have failed to distinguish benign from malignant disease, when the results of the test could change the management of the patient (code G0125). ¥ For the staging of lung cancer (including the assessment of the status of mediastinal lymph nodes) (code G0126). Blue Shield limits payment of PET imaging for lung malignancies to one scan every 12 months from the date of the previous scan. Use one of these codes, as appropriate, to report PET imaging for lung malignancies: ¥ G0125—PET lung imaging of solitary pulmonary nodules using 2-(fluorine-18) - fluoro-2-deoxy-D-glucose (FDG), following CT (71250/71260 or 71270); or 11 PRN

¥ G0126—PET lung imaging of solitary pulmonary nodules using 2-(fluorine-18) - fluoro-2-deoxy-D-glucose (FDG), following CT (71250/71260 or 71270); for initial staging of pathologically diagnosed non-small cell lung cancer.

PET imaging of other anatomic areas (code 78810) investigational Blue Shield considers PET tumor imaging of malignancies in other anatomic areas investigational for all other uses. Examples include, but are not limited to, the detection, staging or monitoring of treatment for other diseases and malignancies such as breast, head and neck, musculoskeletal, thyroid, cervix or ovaries, prostate, or germ-cell cancers, and thymoma.

Blue Shield revises Pennsylvania Blue Shield has revised its reporting guidelines for follow-up inpatient reporting consultations, codes (99261-99263). guidelines for Currently, Blue Shield instructs you to report follow-up inpatient consultations using the follow-up inpatient codes for the appropriate level of medical care, for example, 99211-99215, 99231-99233, consultations etc. Beginning July 16, 2001, report codes 99261-99263 for follow-up inpatient consultations. It is no longer necessary to report the medical care codes. Use codes 99261-99263 to report follow-up consultations on electronic and paper claims.

Streptomycin now Pennsylvania Blue Shield will begin to pay for injections of Streptomycin. Coverage eligible for becomes effective for Streptomycin administered on or after July 2, 2001. payment Use procedure code J3000—Streptomycin, up to 1 gm—to report injections of the drug. Report J3000 per gram of Streptomycin administered.

Integral services Pennsylvania Blue Shield considers these services to be an integral part of a health care professional’s medical or surgical care: ¥ macroscopic examination of arthropod or parasite (87168, 87169); ¥ medical nutrition therapy (97802-97804); ¥ naso- or oro-gastric tube placement, necessitating physician skill (43752); ¥ physician certification services for Medicare-covered services provided by a participating home health agency (patient not present) (G0180); ¥ physician recertification services for Medicare-covered services provided by a participating home health agency (patient not present) (G0179); ¥ physician supervision of a patient receiving Medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities (G0182); ¥ physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency (patient not present) requiring complex and multidisciplinary care modalities (G0181); and 12 4/2001

¥ visual function screening, automated or semi-automated bilateral quantitative determination of visual acuity, ocular alignment, color vision by pseudoisochromatic plates, and field of vision (may include all or some screening determination(s) for contrast sensitivity, vision under glare) (99172).* Blue Shield will not pay for these as separate and distinct services when performed with medical or surgical care.

*These services are also integral to a routine eye examination and refraction covered under Blue Shield’s routine vision programs administered by Clarity Vision, Inc. The routine vision programs include, but are not limited to, OptiChoice, VueFlex and PennVision.

Blue Shield allows Pennsylvania Blue Shield no longer considers payment for consultations prior to surgery payment for or obstetrical delivery as part of the global surgery or delivery allowance. consultations prior Effective immediately, Blue Shield will pay for consultations separately when they’re to surgery and performed prior to surgery or obstetrical delivery, if they are a benefit of the member’s obstetrical delivery contract.

Ultrasonic Pennsylvania Blue Shield considers low-intensity pulsed ultrasound to be medically osteogenic necessary as a treatment of nonunion of fractures (733.82), excluding the skull and stimulator eligible vertebra.* Low intensity ultrasound is delivered non-invasively with the use of an for treatment of ultrasonic osteogenic stimulator. nonunion fractures Blue Shield will begin to pay for in-home low-intensity ultrasound treatment of nonunion fractures effective April 30, 2001. Blue Shield will only pay for an FDA-approved ultrasonic osteogenic stimulator. Use code E0760 to report the ultrasound device. Although the patient applies ultrasound treatment in the home, there is physician involvement with the device. Blue Shield will pay the physician for assisting the patient in positioning the device over an existing cast and instructing the patient in the use of the device. Report these services with procedure code 20979. Blue Shield will deny low-intensity ultrasound treatment when it’s used in addition to conventional management, that is, closed reduction and cast immobilization, for the treatment of fresh, closed fractures. In these instances, Blue Shield will deny the treatment as not medically necessary. A participating, preferred or network health care professional cannot bill the member for the denied service. Blue Shield considers other applications of low-intensity ultrasound treatment, including but not limited to treatment of delayed unions or congenital pseudarthroses, as investigational.** *A nonunion fracture is a fracture that has not united within a minimum of three months of the original fracture.

** Delayed unions are a decelerating healing process as determined by serial X-rays.

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Ultraviolet light Pennsylvania Blue Shield will pay for ultraviolet light therapy when it’s used to treat therapy now patients with dyshidrotic eczema. Payment for ultraviolet light therapy for this indication eligible for becomes effective May 14, 2001. dyshidrotic Remember to report ICD-9-CM code 705.81 when submitting ultraviolet light therapy eczema services for dyshidrotic eczema.

Corrections to The Health Care Financing Administration has made changes to certain vision codes that 2001 HCPCS were included in the 2001 HCPCS Update Publication: update ¥ G0183 has been deleted. Do not report code G0183. ¥ The terminology for code G0184 has been changed to, “Ocular photodynamic therapy treatment, second eye; destruction of localized lesion of choroid (includes infusion.).” When you report ocular photodynamic therapy, please use code 67221 for the first eye treated. Report code G0184 if treatment is performed on the patient’s other eye. Pennsylvania Blue Shield’s 2001 Procedure Terminology Manual (PTM) does not include code G0183. The 2001 PTM includes the correct terminology for G0184.

Codes

Changes to 2001 Please make these changes to your 2001 Procedure Terminology Manual for Ancillary Procedure Providers: Terminology Page Code Terminology Action Manual for 3 A0368 Ambulance service, ALS, emergency Delete. To report, Ancillary Providers transport, no specialized ALS services use A0429. rendered, mileage and disposable supplies separately billed 3 A0380 BLS mileage (per mile) Add 3 A0390 ALS mileage (per mile) Add 16 K0549 Hospital bed, heavy duty, extra wide, Add, with weight capacity greater than effective 4/1/01. 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress 16 K0550 Hospital bed, extra heavy duty, Add, extra wide, with weight capacity effective 4/1/01. greater than 600 pounds, with any type side rails, with mattress

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2001 PTM changes Please make these changes to your 2001 PTM:

Page Code Terminology Action 118 X3649 Subcutaneous intravascular catheter Delete, effective maintenance 5/7/01. To report, use code 37799. 129 42150 Remove exostosis bony palate Delete, effective 7/20/01. 243 G0202 Screening mammography, producing direct Add digital image, bilateral, all views 243 G0203 Screening mammography, film processed Add to produce digital images analyzed for potential abnormalities, bilateral, all views 243 G0204 Diagnostic mammography, producing Add direct digital image, bilateral, all views 243 G0205 Diagnostic mammography, film processed Add to produce digital image analyzed for potential abnormalities, bilateral, all views 243 G0206 Diagnostic mammography, producing direct Add digital image, unilateral, all views 243 G0207 Diagnostic mammography, film processed Add to produce digital image analyzed for potential abnormalities, unilateral, all views 381 99261- Follow-up inpatient consultations Delete note above 99263 code 99261. 410 90471 Immunization administration (includes Change terminology percutaneous, intradermal, subcutaneous, intramuscular and jet injections); one vaccine (single or combination vaccine/toxoid) 410 90472 Immunization administration (includes Change terminology percutaneous, intradermal, subcutaneous, intramuscular and jet injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) 410 90473 Immunization administration by intranasal Add or oral route; one vaccine (single or combination vaccine/toxoid) 410 90474 Immunization administration by intranasal or Add oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) 15 PRN

Page Code Terminology Action 417 K0548 Injection, Insulin Lispro, up to 50 units Add 419 J2993 Injection, Reteplase, 18.1 mg Change terminology

Patient News - Information about your patients who are Pennsylvania Blue Shield customers Central Region

Home health care When home health care is a benefit of a member’s contract, the services provided must guidelines meet certain criteria to be eligible for reimbursement. explained Members with Capital Blue Cross traditional coverage and those with Capital Blue Cross and Pennsylvania Blue Shield comprehensive major medical or CustomBlue coverage may be eligible for home health care services benefits. Capital Blue Cross and Pennsylvania Blue Shield will pay for home health care services only when they are provided by a home health care agency that is appropriately licensed. Skilled nursing or other services must be provided on an intermittent basis in the member’s home under a plan of care prescribed by the attending physician. While home health care coverage is available, it is limited to services used in place of or an extension of inpatient care. The services must be provided to a homebound patient.

Criteria for home health care services ¥ Services must be provided to a homebound patient. Capital Blue Cross and Pennsylvania Blue Shield define homebound as the patient’s medical condition is such that leaving the home is medically contraindicated or the patient’s illness or injury would not allow them to leave the home. Individuals who are able to leave the home for employment or schooling do not meet the criteria for home health care. The services are not covered. Regardless of the homebound status of the patient, home health care visits to draw blood such as bilirubin levels, protime, do not meet the criteria for home health care. They are not covered. ¥ Services provided must be skilled and medically appropriate in the home setting. Capital Blue Cross and Pennsylvania Blue Shield will not pay for nursing visits for: ¥ observation of a medically stable patient; ¥ patient or family education when a patient has been discharged from an acute care hospital; or ¥ routine postoperative incision care, such as observing the non-complicated incision, removal of staples, sutures, drains, or non-sterile dressing changes. ¥ Services provided must be in place of or an extension of inpatient hospital care. Coverage for home health care services are limited to those provided in the home that must reduce the length of stay or eliminate the need for an otherwise medically necessary inpatient admission. 16 4/2001

¥ Services must be provided in the patient’s permanent or temporary place of residence. Home health care services are not covered when provided to residents in other facilities such as skilled nursing facilities, when Capital Blue Cross is reimbursing the facility for the patient’s care. Note: Refer patients requiring infusion therapy without additional skilled nursing needs to a home infusion company, not a home health agency. ¥ Psychiatric home care guidelines For home care agencies providing psychiatric home care, these additional criteria must be met: ¥ A psychiatrist must be involved in directing the patient’s care. ¥ A certified psychiatric nurse must be available within the agency to directly provide or supervise the patient’s care. Note: Home health care is not eligible for reimbursement if the patient is involved in other types of outpatient psychiatric programs such as a group home, outpatient or partial psychiatric programs. ¥ Maternity home care guidelines Home health care for a maternity patient may be eligible for reimbursement. Capital Blue Cross and Pennsylvania Blue Shield will pay for one combined visit for the mother and baby for routine observation only if an early discharge such as these has occurred: ¥ Vaginal delivery if the discharge occurs less than 48 hours after delivery. ¥ Cesarean section delivery if the discharge occurs less than 96 hours after delivery.

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Notes

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Acknowledgement The five-digit numeric codes that appear in PRN were obtained from the Physician's Current Procedural Terminology, as contained in CPT-2001, Copyright 2000, by the American Medical Association. PRN includes CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials that are copyrighted by the American Medical Association.

Need to change Fax the information to us! your provider You can fax us changes about your practice information, such as the information listed on information? the coupon below. The fax number is (866) 731-2896. 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: Pennsylvania Blue Shield Provider Data Services PO Box 898842 Camp Hill, Pa. 17089-8842

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 19 PRN Contents Vol. 2001, No. 2

News Guidelines for reporting PET scans performed on coincidence detection imaging systems ...... 9 Avoid claim denials: report required information ...... 1 Pennsylvania Blue Shield revises guidelines for oncologic PET Call Blue Shield toll free ...... 3 imaging ...... 10 2001 PTM mailed in March ...... 3 Blue Shield revises reporting guidelines for follow-up inpatient Blue Shield updates manual on Documentation of Services consultations ...... 12 Provided in a Teaching Setting ...... 4 Streptomycin now eligible for payment ...... 12 Report HCPCS codes that are valid at the time of service ...... 4 Integral services ...... 12 Blue Shield allows payment for consultations prior to surgery EMC News and obstetrical delivery...... 13 NAIC assigned to Independence Blue Cross’ Personal Choice Ultrasonic osteogenic stimulator eligible for treatment of product ...... 5 nonunion fractures ...... 13 Blue Shield to provide electronic remittance advice for Ultraviolet light therapy now eligible for dyshidrotic eczema ... 14 Independence Blue Cross and AmeriHealth claims ...... 5 Corrections to 2001 HCPCS update ...... 14 Specifications change for professional and institutional ERA ..... 5 Codes Policy Changes to 2001 Procedure Terminology Manual for Ancillary Morphometric analysis of tumors not covered ...... 6 Providers ...... 14 In vitro chemoresistance and chemosensitivity assays considered 2000 PTM changes ...... 15 investigational ...... 7 Correction of inverted nipples considered cosmetic in most Patient News cases ...... 7 Home health care guidelines explained ...... 16 Blue Shield to follow ACIP guidelines for Prevnar ...... 7 Blue Shield’s coverage guidelines of hyperthermia explained .... 8 Need to change your provider information? ...... 19 Coverage guidelines for intracoronary brachytherapy explained ...... 9

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PRSRT STD U.S. POSTAGE PAID PRNPolicy Review & News HARRISBURG, PA Permit No. 320 Pennsylvania Blue Shield Camp Hill, Pennsylvania 17089

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