Blue Cross Notice 052110

May 21, 2010 <<Provider Business Name>> <<Address>> <<City>>, <<State>> <<ZIP>>
Re:
Amendment to Prudent Buyer Participating Physician Agreement, McKessons ClaimsXten Rule Updates, and Updated PPO Professional Reimbursement Policies
Dear Participating Prudent Buyer Physician: Thank you for participating in our network and for the care you provide to your patients who are our members. We are writing to inform you of changes to your current Prudent Buyer Participating Physician Agreement that we are putting into place on August 23, 2010, as well as McKessons ClaimsXten rule updates which support the updated PPO Professional Reimbursement policies that become effective later this year. We have enclosed: Prudent Buyer Participating Physician Agreement Amendment McKesson ClaimsXtenTM Rule Updates and Updated PPO Professional Reimbursement Policies
Prudent Buyer Participating Physician Agreement Amendment Enclosed is an Amendment to the Prudent Buyer Participating Physician Agreement which is effective August 23, 2010. This Amendment updates several aspects of the Agreement. I. Exhibit F (Medicare Advantage PPO Participation Attachment) has been added to the Agreement. This Medicare Advantage PPO Participation Attachment sets forth the rules and requirements to ensure compliance with Medicare Advantage PPO program, including Freedom Blue PPO Plan. This Exhibit F replaces the stand alone Freedom Blue PPO Plan Bulletin that was provided to you previously. Section 4.18 has been revised to clarify that when physicians opt out of the requirement to provide Medical Services for work-related injuries or illnesses to Members who are eligible for workers compensation benefits, that PHYSICIAN understands that any subsequent decision to seek to opt in may not enable the physician to be automatically reinstated to participate in certain workers compensation payors medical provider networks. Section 13.3 (Notices) of the Agreement has been revised so that notices shall be in writing and delivered by electronic mail, by facsimile, by hand or sent postage prepaid mail to an address that Anthem has on file for the Physician practice. Such notices will no longer be required to be sent via certified mail, return receipt requested to either Anthem Blue Cross or to the physician practice. The address to which notices to Blue Cross should be directed remains unchanged.
II.
III.
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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.
McKessons ClaimsXten Rule Updates We are taking this opportunity to notify you of upcoming changes to our claims editing rules, administered by ClaimsXtenTM later this year. Claims submitted in a CMS-1500 format will be subject to the editing rules that support the PPO Professional Reimbursement Policies listed below and described in the enclosed. Updates Effective 8/23/10 Global Surgery. The following services are also not eligible for separate reimbursement when performed during the global post operative period of the related surgical procedure: Incision and drainage of abscess, simple/single/complicated or multiple (10060-10061) Incision and drainage of hematoma, seroma, or fluid collection (10140) Puncture aspiration of abscess, hematoma, bulla, or cyst (10160) Incision and drainage, complex postoperative wound infection (10180)
Anesthesia. Revised to indicate that qualifying patient circumstances codes (99100, 99116, 99135, 99140) should not be reported with 01996. Updates Effective 8/29/10 Global Surgery. Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline (S2083) will not be eligible for separate reimbursement when performed during the global post operative period of the related surgical procedure: Modifier -59 (Distinct Procedural Service). Circumstances which are exempt from the modifier -59 override are described in detail in the section entitled Exceptions to Modifier -59 Override in the Modifier -59 (Distinct Procedural Service) policy and are applied based on the claim processing date, and in this case are applied to claims with dates of service prior to the 8/29/10 effective date of this rule. Exceptions to Modifier -59: NCCI (National Correct Coding Initiative) edit code pairs with a superscript of zero, or a modifier allowance indicator of zero do not allow the -59 override. Sleep Studies. Please refer to the Bundled Services and Supplies for Polysomnography and Other Sleep Studies in the reimbursement policies provided in the enclosed document. Updates Effective 11/21/10 Anesthesia and Global Surgery Postoperative E/M visits reported within a 10 day aftercare period for anesthesia services will be denied. Bundled Services and Supplies. Electroencephalogram (EEG) during non-intracranial surgery is not eligible for separate reimbursement. Modifier -59 Modifier -59 will not cause the override, and will not allow for separate reimbursement, for professional interpretation and reporting codes/components of an EKG and/or radiology when billed by the provider rendering emergency room services.
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Updates Effective 11/21/10 (cont.) Laboratory and Venipuncture. Collection of Blood Specimen. Anthem Blue Cross follows CPT coding guidelines which state that CPT 36591-36592 .should not be reported in conjunction with any other service. Therefore, these codes are not eligible for separate reimbursement when billed with any other service. Updated PPO Professional Reimbursement Policies Anthem Blue Cross is updating its PPO professional reimbursement policies by adopting the following policies as of August 29, 2010 (except when specifically indicated otherwise), some of which are revisions of existing policies and some of which are new. Revised policies: Anesthesia Bundled Services and Supplies Global Surgery Multiple Surgery New Policies: Documentation and Reporting Guidelines for Consultations Documentation and Reporting Guidelines for Evaluation and Management Services Modifier 59 (Distinct Procedures Service) Bundled Services and Supplies for Polysomnography and Other Sleep Studies Tests Comprehensive Laboratory and Venipuncture Services Complete versions of the PPO Professional Reimbursement Policies are included in the enclosure, and online via our secure ProviderAccess website. If you are registered for ProviderAccess, go to https://provider2.anthem.com/wps/portal/ebpmybcc and select the McKesson ClaimsXtenTM Rules and PPO Professional Reimbursement Policies link under the Whats New section. If your organization is not registered for ProviderAccess, contact your office administrator or click on the Register for ProviderAccess link. We value and appreciate you as our partner in providing quality care. If you have any questions about these changes, please contact our Provider Care Department at (800) 677-6669. Sincerely,
Mike Ramseier Vice President, Provider Engagement and Contracting Enclosures
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AMENDMENT TO ANTHEM BLUE CROSS PRUDENT BUYER PLAN PARTICIPATING PHYSICIAN AGREEMENT
This Amendment to the ANTHEM BLUE CROSS Prudent Buyer Plan Participating Physician Agreement between BLUE CROSS OF CALIFORNIA dba ANTHEM BLUE CROSS and its Affiliates ("BLUE CROSS") and PHYSICIAN is effective August 23, 2010.
RECITALS A. BLUE CROSS and PHYSICIAN have previously entered into an ANTHEM BLUE CROSS Prudent Buyer Plan Participating Physician Agreement, as may have been amended (the "Agreement") whereby PHYSICIAN is designated as a Participating Physician. BLUE CROSS desires to amend the Agreement by providing PHYSICIAN prior written notice in accordance with the Agreement.
B.
THEREFORE, the Agreement is amended to provide as follows: I. Table of Contents is hereby amended to add the following reference to Exhibit F, Medicare Advantage PPO Attachment, to the list of Exhibits: F. II. Medicare Advantage PPO Attachment
Section 4.18 of the Agreement is hereby deleted in its entirety and replaced with the following: 4.18 PHYSICIAN agrees that, in the event a Member who is covered for workers compensation benefits by a workers compensation carrier affiliated with BLUE CROSS or under a workers compensation arrangement administered by an Affiliate, seeks services for a work-related illness or injury, PHYSICIAN shall provide such Medical Services as are Medically Necessary to all Members, including existing and new workrelated injuries, and shall complete a Doctors First Report of Injury as defined in the California Labor Code. As payment for such Medical Services rendered, PHYSICIAN agrees to accept compensation in accordance with the schedule contained in Exhibit B hereof. PHYSICIAN further agrees that, in the event such MEMBER requires Medical Services in connection with such work-related injury or illness beyond the treatment provided at the initial visit and which is outside the scope of PHYSICIANs practice, PHYSICIAN shall refer MEMBER to a participating provider in the Prudent Buyer Comp Provider Network. If PHYSICIAN elects to opt-out of treating all Members with a work-related illness or injury, PHYSICIAN agrees to refer such MEMBER only to a participating provider in the Prudent Buyer Comp Provider Network. PHYSICIAN may elect to opt out of Section 4.18 by indicating his/her desire to do so on the signature page. If PHYSICIAN does not make such election, then the above provision shall remain in effect for the term of this Agreement. By opting out of the requirement to provide Medical Services for work-related injuries or illnesses to Members who are eligible for workers compensation benefits. PHYSICIAN understands that any subsequent decision to seek to opt in to Section 4.18 may not enable PHYSICIAN to be automatically reinstated to participate in certain workers compensation programs, portions of the Prudent Buyer Comp Provider Network and/or workers compensation payors medical provider networks.
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III.
Section 4.23 is hereby added to the Agreement: 4.23 PHYSICIAN will comply with all requirements set forth in Exhibit F, Medicare Advantage PPO Attachment, and all other applicable Centers for Medicare & Medicaid Services (CMS) requirements that may be promulgated hereafter.
IV.
Section 13.3 of the Agreement is hereby deleted in its entirety and replaced with the following: 13.3 Notices Any notice required to be given pursuant to the terms and provisions of this Agreement shall be in writing and shall be delivered by electronic mail, by facsimile, by hand, or sent postage prepaid by mail. Unless specified otherwise in writing by a party, BLUE CROSS shall send PHYSICIAN notice to an address that BLUE CROSS has on file for PHYSICIAN, and notice initiated by PHYSICIAN shall be sent to BLUE CROSSs address as set forth below. Notice shall be effective upon the marked date associated with the corresponding delivery method noted above. Notwithstanding the foregoing, BLUE CROSS may post updates to the Prudent Buyer Operations Manual and policies on its web site. Anthem Blue Cross Prudent Buyer Plan Contract Processing Mail Station 8A P.O. Box 4330 Woodland Hills, California 91365-4330
V.
Exhibit F, Medicare Advantage PPO Attachment, is hereby added and incorporated herein.
[THE REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK]
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EXHIBIT F MEDICARE ADVANTAGE PPO ATTACHMENT TO THE ANTHEM BLUE CROSS PRUDENT BUYER PLAN PARTICIPATING PHYSICIAN AGREEMENT This Attachment to the Anthem Blue Cross Prudent Buyer Plan Participating Physician Agreement ("Agreement"), entered into by and between BLUE CROSS and PHYSICIAN, is incorporated into the Agreement. ARTICLE I DEFINITIONS The following definitions shall apply to this Medicare Advantage PPO Participation Attachment: 1.1 "Clean Claim" means a Claim that has no defect or impropriety, including a lack of required substantiating documentation, or particular circumstances requiring special treatment that prevents timely payment from being made on the Claim. A Claim is clean even though BLUE CROSS refers it to a medical specialist within BLUE CROSS for examination. If additional documentation (e.g., a medical record) involves a source outside BLUE CROSS, then the Claim is not considered clean. "Covered Individual" means, for purposes of this Attachment, a Medicare beneficiary covered under a Medicare agreement between CMS and BLUE CROSS under Part C of Title XVIII of the Social Security Act ("Medicare Advantage Program"). "Emergency or Emergency Medical Condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (1) serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; (2) serious impairment to bodily functions; or (3) serious dysfunction of any bodily organ or part. "Emergency Services" means covered inpatient and outpatient Health Services that are: (1) furnished by a provider qualified to furnish emergency services; and (2) needed to evaluate or stabilize an Emergency Medical Condition. "CMS" means the Centers for Medicare and Medicaid Services. "Medicare" means the Health Insurance for the Aged Act, Title XVIII of the Social Security Act, as then constituted or later amended. "Urgently Needed Care" means Covered Services provided when a Covered Individual is either: 1.7.1 Temporarily absent from BLUE CROSS Medicare Advantage service area and such Covered Services are Medically Necessary and immediately required: (1) as a result of an unforeseen illness, injury, or condition; and (2) it was not reasonable, given the circumstances, to obtain the services through BLUE CROSS Medicare Advantage Network; or Under unusual and extraordinary circumstances, the Covered Individual is in the service area but BLUE CROSS provider Network is temporarily unavailable or inaccessible and such Covered Services are Medically Necessary and immediately required: (1) as a result of an unforeseen illness, injury, or condition; and (2) it was not reasonable, given the circumstances, to obtain the services through BLUE CROSS Medicare Advantage Network.
1.2
1.3
1.4
1.5 1.6
1.7
1.7.2
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ARTICLE II SERVICES/OBLIGATIONS 2.1 Participation-Medicare Advantage. As a participant in BLUE CROSS Medicare Advantage Program, PHYSICIAN will render Covered Services to Covered Individuals enrolled in BLUE CROSS Medicare Advantage Program in accordance with the terms and conditions of the Agreement and this Attachment. Except as set forth in this Attachment or Exhibit B attached to the Agreement, all terms and conditions of the Agreement will apply to PHYSICIAN's participation in BLUE CROSS Medicare Advantage PPO Program(s). This Agreement does not apply to any of the BLUE CROSS Medicare Advantage Private Fee for Service or Medical Savings Account Programs. Participation-Out of Area Programs. Pursuant to the Blue Cross and Blue Shield Out of Area Program provision of the Agreement, PHYSICIAN hereby acknowledges and agrees that PHYSICIAN shall provide Covered Services to any person who is covered under another Blue Cross and Blue Shield BLUE CROSS under the Blue Cross and Blue Shield Association Out of Area Program, including, but not limited to, a network sharing PPO developed to support Medicare Advantage Programs. Participation-Medicare Advantage Program. By virtue of the fact that PHYSICIAN is a Medicare Advantage Network/Participating Provider, PHYSICIAN hereby acknowledges and agrees that PHYSICIAN shall provide services to any Medicare Advantage PPO Covered Individual enrolled in a BLUE CROSS insured product that utilizes the Medicare Advantage Network. Covered Individual/Covered Service-Defined. The parties agree that all references in the Agreement to Covered Individual(s) include Covered Individuals of BLUE CROSS Medicare Advantage Program and all references to Covered Services include services offered pursuant to BLUE CROSS PPO Medicare Advantage Program. Medical Necessity. Medical Necessity decisions regarding Covered Individuals will be made in compliance with CMS guidelines. Accountability/Oversight. BLUE CROSS delegates to PHYSICIAN its responsibility under its Medicare Advantage contract with CMS to provide the services as set forth in this Attachment to Covered Individuals. BLUE CROSS may revoke this delegation, including, if applicable, the delegated responsibility to meet CMS reporting requirements, and thereby terminate the Attachment if CMS or BLUE CROSS determines that PHYSICIAN has not performed satisfactorily. Such revocation shall be consistent with the termination provisions of this Attachment. Performance of the PHYSICIAN shall be monitored by BLUE CROSS on an ongoing basis as provided for in this Attachment. PHYSICIAN further acknowledges that BLUE CROSS is accountable to CMS for the functions and responsibilities described in the Medicare Advantage regulatory standards and ultimately responsible to CMS for the performance of all services. PHYSICIAN acknowledges that BLUE CROSS shall oversee and is accountable to CMS for the functions and responsibilities described in the Medicare Advantage regulatory standards. Further, PHYSICIAN acknowledges that BLUE CROSS may only delegate such functions and responsibilities in a manner consistent with the standards as set forth under 42 CFR 422.504(i)(4). Accountability/Credentialing. Both parties acknowledge that accountability shall be in a manner consistent with the requirements as set forth in 42 CFR 422.504(i)(4). Therefore the following are acceptable for purposes of meeting these requirements: 2.7.1 The credentials of medical professionals affiliated with the BLUE CROSS or the PHYSICIAN will be either reviewed by the BLUE CROSS if applicable; or
2.2
2.3
2.4
2.5
2.6
2.7
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2.7.2
The credentialing process will be reviewed and approved by the BLUE CROSS and the BLUE CROSS must audit the BLUE CROSS credentialing process and/or delegate's credentialing process on an ongoing basis.
2.8
Medicare Physician. PHYSICIAN must have a provider and/or supplier agreement, whichever is applicable, with CMS that permits them to provide services under original Medicare. ARTICLE III ACCESS: RECORDS/FACILITIES
3.1
Inspection of Books/Records. PHYSICIAN acknowledges that Plan, Health and Human Services department (HHS), the Comptroller General, or their designees have the right to inspect, evaluate and audit any books, contracts, medical records, patient care documentation, and other records of PHYSICIAN, or its subcontractors or transferees involving transactions related to BLUE CROSS Medicare Advantage contract through ten (10) years from the final date of the contract period or from the date of the completion of any audit, or for such longer period provided for in 42 CFR 422.504(e)(4) or other applicable law, whichever is later. For the purposes specified in this provision, PHYSICIAN agrees to make available PHYSICIAN's premises, physical facilities and equipment, records relating to BLUE CROSS Covered Individuals, and any additional relevant information that CMS may require. Confidentiality. Each party agrees to abide by all federal and state laws applicable to that party regarding confidentiality and disclosure for mental health records, medical records, other health information, and enrollee information. PHYSICIAN agrees to maintain records and other information with respect to Covered Individuals in an accurate and timely manner; to ensure timely access by enrollees to the records and information that pertain to them; and to safeguard the privacy of any information that identifies a particular enrollee. Information from, or copies of, records may be released only to authorized individuals. PHYSICIAN must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released only in accordance with federal or state laws, court orders or subpoenas. ARTICLE IV ACCESS: BENEFITS AND COVERAGE
3.2
4.1
Non-Discrimination. PHYSICIAN shall not deny, limit, or condition the furnishing of Health Services to Covered Individuals of BLUE CROSS on the basis of any factor that is related to health status, including, but not limited to medical condition; claims experience; receipt of health care; medical history; genetic information; evidence of insurability, including conditions arising out of acts of domestic violence; or disability. This provision was intentionally left blank. Direct Access. PHYSICIAN acknowledges that Covered Individuals may obtain covered mammography screening services and influenza vaccinations from a participating provider without a referral and that Covered Individuals who are women may obtain women's routine and preventive Health Services from a participating women's health specialist without a referral. No Cost Sharing. PHYSICIAN acknowledges that covered influenza vaccines and pneumococcal vaccines are not subject to Covered Individual Cost Share obligations. Timely Access to Care. PHYSICIAN agrees to provide Covered Services consistent with BLUE CROSS: (1) standards for timely access to care and member services; (2) policies and procedures that allow for individual Medical Necessity determinations; and (3) policies and procedures for the PHYSICIAN's consideration of Covered Individual input in the establishment of treatment plans.
4.2 4.3
4.4
4.5
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4.6
Continuity of Care. PHYSICIAN shall provide Health Services on a twenty-four (24) hour per day, seven (7) day a week basis or at such times as Health Services are typically provided by similar providers to assure availability, adequacy and continuity of care to Covered Individuals. If a physician is not a PCP or gynecologist, then health services shall be provided to members on a 24 hour per day, 7 day a week basis or at such times as health services are typically provided by similar providers. To assure availability, adequacy, and continuity of care to members. If a physician is unable to provide health services as described, the physician must arrange for another network provider to cover physicians members during the period of absence. ARTICLE V BENEFICIARY PROTECTIONS
5.1
Cultural Competency. PHYSICIAN shall ensure that Covered Services rendered to Covered Individuals, both clinical and non-clinical, are accessible to all Covered Individuals, including those with limited English proficiency or reading skills, with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical and mental disabilities. PHYSICIAN must provide information regarding treatment options in a cultural-competent manner, including the option of no treatment. PHYSICIAN must ensure that individuals with disabilities have effective communications with participants throughout the health system in making decisions regarding treatment options. Identifying Complex and Serious Medical Condition. PHYSICIAN acknowledges that BLUE CROSS has procedures to identify Covered Individuals with complex or serious medical conditions for chronic care improvement initiatives; and to assess those conditions, including medical procedures to diagnose and monitor them on an ongoing basis; and establish and implement a treatment BLUE CROSS appropriate to those conditions, with an adequate number of direct access visits to specialists to accommodate the treatment plan. To the extent applicable, PHYSICIAN agrees to assist in the development and implementation of the treatment plans and/or chronic care improvement initiatives. Advance Directives. PHYSICIAN shall establish and maintain written policies and procedures to implement Covered Individuals' rights to make decisions concerning their health care, including the provision of written information to all adult Covered Individuals regarding their rights under state and federal law to make decisions regarding their right to accept or refuse medical treatment and the right to execute an advance medical directive. PHYSICIAN further agrees to document or oversee the documentation in the Covered Individuals' medical records whether or not the Covered Individual has an advance directive, that PHYSICIAN will follow state and federal requirements for advance directives and that PHYSICIAN will provide for education of its staff and the community on advance directives. Standards of Care. PHYSICIAN agrees to provide Covered Services in a manner consistent with professionally recognized standards of health care. Hold Harmless. PHYSICIAN agrees that in no event, including but not limited to non-payment by BLUE CROSS, insolvency of BLUE CROSS or breach of the Agreement, shall the PHYSICIAN bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a Covered Individual or persons other than BLUE CROSS acting on their behalf for Covered Services provided pursuant to the Agreement. This provision does not prohibit the collection of supplemental charges or Cost Shares on BLUE CROSS behalf made in accordance with the terms of the Covered Individual's Health Benefit Plan or amounts due for services that have been correctly identified in advance as a non-Covered Service, subject to medical coverage criteria, with appropriate disclosure to the Covered Individual of their financial obligation. This advance notice does not apply to services not covered due to a statutory exclusion from the Medicare Advantage Program.
5.2
5.3
5.4
5.5
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5.5.1
PHYSICIAN further agrees that for Covered Individuals who are dual eligible enrollees for Medicare and Medicaid, that PHYSICIAN will ensure they will not bill the Covered Individual for Cost Sharing that is not the Covered Individual's responsibility and such Covered Individuals will not be held liable for Medicare Parts A and B Cost Sharing when the State is liable for the Cost Sharing. In addition, PHYSICIAN agrees to accept the BLUE CROSS payment as payment in full or by billing the appropriate state source.
5.6
Continuation of Care-Insolvency. PHYSICIAN agrees that in the event of BLUE CROSS insolvency, termination of the CMS contract or other cessation of operations, Covered Services to Covered Individuals will continue through the period for which the premium has been paid to BLUE CROSS, and services to Covered Individuals confined in an inpatient hospital on the date of termination of the CMS contract or on the date of insolvency or other cessation of operations will continue until their discharge. Survival of Attachment. PHYSICIAN further agrees that: (1) the hold harmless and continuation of care provisions shall survive the termination of the Covered Individual; (2) these provisions supersede any oral or written contrary agreement now existing or hereafter entered into between PHYSICIAN and a Covered Individual or persons acting on their behalf that relates to liability for payment for, or continuation of, Covered Services provided under the terms and conditions of these clauses; and (3) any modifications, addition or deletion to these provisions shall become effective on a date no earlier than fifteen (15) days after the Administrator of CMS has received written notice of such proposed changes. Health Assessment. Physician acknowledges that BLUE CROSS has procedures approved by CMS to conduct a health assessment of all new Covered Individuals within ninety (90) days of the effective date of their enrollment. Physician agrees to cooperate with BLUE CROSS as necessary in performing this initial health assessment. ARTICLE VI COMPENSATION AND FEDERAL FUNDS
5.7
5.8
6.1
Compensation-Medicare Advantage. For Covered Services provided to Covered Individuals, PHYSICIAN shall be compensated in accordance with the Medicare Advantage rate in effect at the time the Covered Service is rendered, and as set forth in Exhibit B attached to the Agreement. Such Exhibit B may be amended from time to time as provided for in the Agreement. Prompt Payment. BLUE CROSS agrees to make best efforts to pay a majority of Clean Claims for Covered Services submitted by or on behalf of Covered Individuals, within forty-five (45) days of receipt by BLUE CROSS. BLUE CROSS agrees to make best efforts to pay all remaining Clean Claims for Covered Services submitted by or on behalf of Covered Individuals, within sixty (60) days of receipt by BLUE CROSS. BLUE CROSS agrees to make best efforts to pay all nonClean Claims for Covered Services submitted by or on behalf of Covered Individuals within sixty (60) days of receipt by BLUE CROSS of the necessary documentation to adjudicate the Claim. Federal Funds. PHYSICIAN acknowledges that payments PHYSICIAN receives from BLUE CROSS to provide Covered Services to Covered Individuals are, in whole or part, from Federal funds. Therefore, PHYSICIAN and any of its subcontractors are subject to certain laws that are applicable to individuals and entities receiving Federal funds, which may include but is not limited to, Title VI of the Civil Rights Act of 1964 as implemented by 45 CFR Part 84; the Age Discrimination Act of 1975 as implemented by 45 CFR Part 91; the Americans with Disabilities Act; the Rehabilitation Act of 1973 and any other regulations applicable to recipients of Federal Funds.
6.2
6.3
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ARTICLE VII REPORTING AND DISCLOSURE REQUIREMENTS 7.1 Data Reporting Submissions. PHYSICIAN agrees to provide to BLUE CROSS all information necessary for BLUE CROSS to meet its data reporting and submission obligations to CMS, including but not limited to, data necessary to characterize the context and purpose of each encounter between a Covered Individual and the PHYSICIAN ("Risk Adjustment Data"), and data necessary for BLUE CROSS to meet its reporting obligations under 42 CFR 422.516 and 422.310. Risk Adjustment Data. PHYSICIAN's Risk Adjustment Data shall include all information necessary for BLUE CROSS to submit such data to CMS as set forth in 42 CFR 422.310 or any subsequent or additional regulatory provisions. If PHYSICIAN fails to submit its Risk Adjustment Data accurately, completely and truthfully, in the format described in the 42 CFR 422.310 or any subsequent or additional regulatory provisions, then this will result in denials and/or delays in payment of PHYSICIAN's Claims. Accuracy of Risk Adjustment Data. PHYSICIAN further agrees to certify the accuracy, completeness, and truthfulness of PHYSICIAN generated Risk Adjustment Data that BLUE CROSS is obligated to submit to CMS. Within thirty (30) days after the beginning of every Fiscal Year or as required by CMS while the Medicare Advantage Participation Attachment is in effect, PHYSICIAN agrees to give BLUE CROSS a certification in writing, in a format that BLUE CROSS specifies, that certifies to the accuracy, completeness, and truthfulness of PHYSICIAN's Risk Adjustment Data submitted to BLUE CROSS during the specified period. ARTICLE VIII QUALITY ASSURANCE/QUALITY IMPROVEMENT REQUIREMENTS 8.1 Independent Quality Review Organization. PHYSICIAN agrees to comply and cooperate with an independent quality review and improvement organization's activities pertaining to the provision of Covered Services for Covered Individuals. Compliance with BLUE CROSS Medical Management Programs. PHYSICIAN agrees to comply with BLUE CROSS medical policies, quality improvement and performance improvement programs, and medical management programs to the extent provided to or otherwise made available to PHYSICIAN in advance. Consulting with Network/Participating Providers. BLUE CROSS agrees to consult with Network/Participating Providers regarding its medical policies, quality improvement program and medical management programs and ensure that practice guidelines and utilization management guidelines: (1) are based on reasonable medical evidence or a consensus of health care professionals in the particular field; (2) consider the needs of the enrolled population; (3) are developed in consultation with participating physicians; (4) are reviewed and updated periodically; and (5) are communicated to providers and, as appropriate, to Covered Individuals. BLUE CROSS also agrees to ensure that decisions with respect to utilization management, Covered Individual education, coverage of Health Services, and other areas in which the guidelines apply are consistent with the guidelines. ARTICLE IX COMPLIANCE Compliance-Medicare Laws/Regulations. PHYSICIAN agrees to comply, and to require any of its subcontractors to comply, with all applicable Medicare laws, regulations, and CMS instructions. Further, PHYSICIAN agrees that any Covered Services provided by the PHYSICIAN or its subcontractors to BLUE CROSS Covered Individuals will be consistent with and will comply with BLUE CROSS Medicare Advantage contractual obligations.
7.2
7.3
8.2
8.3
9.1
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9.2
Compliance-Exclusion from Federal Health Care Program. PHYSICIAN may not employ, or subcontract with an individual, or have persons with ownership or control interests, who have been convicted of criminal offenses related to their involvement in Medicaid, Medicare, or social services programs under Title XX of the Social Security Act, and thus have been excluded from participation in any Federal health care program under 1128 or 1128A of the Act (or with an entity that employs or contracts with such an individual) for the provision of any of the following: 9.2.1 9.2.2 9.2.3 9.2.4 healthcare; utilization review; medical social work; or administrative services.
9.3
Compliance-Appeals/Grievances. PHYSICIAN agrees to comply with BLUE CROSS policies and procedures in performing its responsibilities under the Agreement. PHYSICIAN specifically agrees to comply with Medicare requirements regarding Covered Individual appeals and grievances and to cooperate with BLUE CROSS in meeting its obligations regarding Covered Individual appeals, grievances and expedited appeals, including the gathering and forwarding of information in a timely manner and compliance with appeals decisions. Compliance-Policy and Procedures. PHYSICIAN agrees to comply with BLUE CROSS policy and procedures in performing its responsibilities under the Agreement and this Attachment including any supplementary documents that pertain to BLUE CROSS Medicare Advantage Program such as the Product Guide. Compliance-CMS Notice of Discharge and Appeal Rights. PHYSICIAN agrees to comply with all CMS regulations in their issuance of any and all notices required to be provided to Medicare enrollees to inform them of their rights as a hospital patient, including their discharge and appeal rights. Illegal Remunerations. Both parties specifically represents and warrants that activities to be performed under this Agreement are not considered illegal remunerations (including kickbacks, bribes or rebates) as defined in 42 USCA 1320(a)-7b. Compliance-Training, Education and Communications. In accordance with, but not limited to 42 CFR 422.503(b)(4)(vi)(C)&(D), PHYSICIAN agrees and certifies that it, as well as its employees, subcontractors, downstream entities, related entities and agents who provide services to or for BLUE CROSS Medicare Advantage Covered Individuals or to or for the BLUE CROSS itself shall participate in applicable compliance training, education and/or communications as reasonably requested by the BLUE CROSS or its designee annually or as otherwise required by applicable law or mutually agreed to by both parties in writing. Both parties agree that the BLUE CROSS or its designee may make such compliance training, education and lines of communication available to PHYSICIAN in either electronic, paper or other reasonable medium. To the extent that BLUE CROSS does not indicate that it will be documenting attendance and completion of the compliance training, education and/or lines of communication, PHYSICIAN shall be responsible for documenting applicable employee's, subcontractor's, downstream entity's, related entity's and/or agent's attendance and completion of such training. Upon notice, PHYSICIAN shall provide such documentation to BLUE CROSS unless otherwise not required by CMS regulation.
9.4
9.5
9.6
9.7.1
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10.1
ARTICLE X MARKETING Approval of Materials. Both parties agree to comply, and to require any of its subcontractors to comply, with all applicable federal and state laws, regulations, CMS instructions, and marketing activities under this Agreement, including but not limited to, the National Marketing Guide and any requirements for CMS prior approval of materials. Any printed materials, including but not limited to letters to BLUE CROSS Covered Individuals, brochures, advertisements, telemarketing scripts, packaging prepared or produced by PHYSICIAN or any of its subcontractors pursuant to this Agreement must be submitted to BLUE CROSS for review and approval at each planning stage (i.e., creative, copy, mechanicals, blue lines, etc.) to assure compliance with federal, state, and Blue Cross/Blue Shield Association guidelines. BLUE CROSS agrees its approval will not be unreasonably withheld or delayed. ARTICLE XI TERM AND TERMINATION Notice Upon Termination. If BLUE CROSS decides to terminate this Attachment, BLUE CROSS shall give PHYSICIAN written notice, to the extent required under CMS regulations, of the reasons for the action, including, if relevant, the standards and the profiling data the organization used to evaluate PHYSICIAN and the numbers and mix of Network/Participating Providers BLUE CROSS needs. Such written notice shall also set forth PHYSICIAN's right to appeal the action and the process and timing for requesting a hearing. Termination for Medicare Exclusion. PHYSICIAN acknowledges that this Attachment shall be terminated if PHYSICIAN, or a person or entity with ownership or control interest in PHYSICIAN, is excluded from participation in Medicare under 1128A of the Social Security Act or from participation in any other Federal health care program. Termination Without Cause. Either party may terminate PHYSICIAN's participation in BLUE CROSS Medicare Advantage Network without cause by giving at least one hundred eighty (180) days prior written notice of termination to the other party. Upon your notice of Termination Without Cause, Provider is required to notify Covered Individual(s) sixty (60) days prior to your effective date of termination with Anthem.
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Term/Termination. This Attachment shall continue in effect unless otherwise terminated as provided for in this Attachment or in the Agreement. ARTICLE XII GENERAL PROVISIONS
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Inconsistencies. In the event of an inconsistency between terms of this Attachment and the terms and conditions as set forth in the Agreement, the terms and conditions of this Attachment shall govern. Except as set forth herein, all other terms and conditions of the Agreement remain in full force and effect. Interpret According to Medicare Laws. PHYSICIAN and BLUE CROSS intend that the terms of the Agreement and this Attachment as they relate to the provision of Covered Services under the Medicare Advantage Program shall be interpreted in a manner consistent with applicable requirements under Medicare law. Subcontractors. PHYSICIAN agrees that if PHYSICIAN enters into subcontracts to perform services under the terms of this Attachment, PHYSICIAN's subcontracts shall include: (1) an agreement by the subcontractor to comply with all of the PHYSICIAN's obligations in the Agreement and this Attachment; (2) a prompt payment provision as negotiated by the PHYSICIAN and the subcontractor; (3) a provision setting forth the term of the subcontract (preferably one (1) year or longer); and (4) dated signatures of all the parties to the subcontract.
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Delegated Activities. If BLUE CROSS has delegated activities to PHYSICIAN, then the BLUE CROSS will provide the following information to PHYSICIAN and PHYSICIAN shall provide such information to any of its subcontracted entities: 12.4.1 12.4.2 12.4.3 12.4.4 12.4.5 A list of delegated activities and reporting responsibilities; Arrangements for the revocation of delegated activities; Notification that the performance of the contracted and subcontracted entities will be monitored by the BLUE CROSS; Notification that the credentialing process must be approved and monitored by the BLUE CROSS; and Notification that all contracted and subcontracted entities must comply with all applicable Medicare laws, regulations and CMS instructions.
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Delegation of PHYSICIAN Selection. In addition to the responsibilities as set forth in section 12.4 above, to the extent that BLUE CROSS has delegated selection of the providers, contractors, or subcontractor to PHYSICIAN, the BLUE CROSS retains the right to approve, suspend, or terminate any such arrangement.
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McKESSON CLAIMSXTEN RULE UPDATES Overview We are taking this opportunity to notify you of upcoming changes to our claims editing rules, administered by ClaimsXtenTM later this year. Claims submitted in a CMS-1500 format will be subject to the editing rules that support the PPO Professional Reimbursement Policies listed below. Anthem Blue Cross will apply certain updates to the claims editing software product from McKesson, Inc. called ClaimsXten that is used Anthem Blue Cross PPO professional reimbursement policies as indicated in the following pages. Claims must be in accordance with the reporting guidelines and instructions contained in the American Medical Association (AMA) CPT Manual, CPT Assistant, and HCPCS publications. Providers are responsible for accurately reporting the medical, surgical, diagnostic, and therapeutic services rendered to a member with the correct CPT and/or HCPCS codes, and for appending the applicable modifiers, when appropriate. Upgrades may be implemented from time to time to reflect the addition of new/revised CPT/HCPCS codes and their associated edits, Correct Coding Initiative (CCI) revisions, and changes identified through regular review or inquiry. In addition to upgrades that are implemented quarterly to reflect the addition of new/revised CPT/HCPCS codes and their associated edits, Correct Coding Initiative (CCI) revisions, and changes identified through regular review or inquiry, we will be updating the rules outlined below.
Third Party Administrators (TPAs) Please note that some Third Party Administrators (TPAs) that process claims for our clients have not transitioned to this claims editing tool yet. Efforts are under way to transition all TPAs to this claims editing tool. Services rendered to patients whose claims are processed by TPAs not transitioned yet do not have ClaimsXten editing applied.
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McKESSON CLAIMSXTEN RULE UPDATES (cont.) Updates Effective 8/23/10 Global Surgery. The following services are also not eligible for separate reimbursement when performed during the global post operative period of the related surgical procedure: Incision and drainage of abscess, simple/single/complicated or multiple (10060-10061) Incision and drainage of hematoma, seroma, or fluid collection (10140) Puncture aspiration of abscess, hematoma, bulla, or cyst (10160) Incision and drainage, complex postoperative wound infection (10180) Anesthesia. Revised to indicate that qualifying patient circumstances codes (99100, 99116, 99135, 99140) should not be reported with 01996. Updates Effective 8/29/10 Global Surgery. Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline (S2083) will not be eligible for separate reimbursement when performed during the global post operative period of the related surgical procedure. Modifier -59 (Distinct Procedural Service). Circumstances which are exempt from the modifier -59 override are described in detail in the section entitled Exceptions to Modifier -59 Override in the Modifier -59 (Distinct Procedural Service) policy below and are applied based on the claim processing date, which means that it could apply to claims with dates of service prior to the effective date of this rule (8/29/10). Exceptions to modifier -59: NCCI (National Correct Coding Initiative) edit code pairs with a superscript of zero, or a modifier allowance indicator of zero do not allow the -59 override. Sleep Studies. Please refer to the Bundled Services and Supplies for Polysomnography and Other Sleep Studies in the reimbursement policies provided below. Updates Effective 11/21/10 Anesthesia and Global Surgery Postoperative E/M visits reported within a 10 day after care period for anesthesia services will be denied. Bundled Services and Supplies Electroencephalogram (EEG) during non-intracranial surgery is not eligible for separate reimbursement. Modifier -59 Adding modifier 59 to a CPT/HCPCS code will not cause the override, and will not allow for separate reimbursement, for professional interpretation and reporting codes/components of an EKG and/or radiology when billed by the provider rendering emergency room services.
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McKESSON CLAIMSXTEN RULE UPDATES (cont.) Updates Effective 11/21/10 (cont.) Laboratory and Venipuncture. Collection of Blood Specimen: Anthem Blue Cross follows CPT coding guidelines which state that CPT 36591-36592 .should not be reported in conjunction with any other service. Therefore, these codes are not eligible for separate reimbursement when billed with any other service.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES Overview Anthem Blue Cross is updating its PPO professional reimbursement policies by adopting the following policies as of August 29, 2010 (except when specifically indicated otherwise), some of which are revisions of existing policies and some of which are new. Revised policies: Anesthesia -Expanded descriptions of some existing sections and added separate sections related to Time, Modifiers, Field Avoidance and Unusual Positioning, Anesthesia for Oral Surgery, and Services Included/Excluded in the Global Reimbursement for Anesthesia. -Deleted reference to modifier -47 as an informational modifier; it is and has been nonpayable in accordance with Modifier Rules policy communicated in 2009. -Revised to indicate that as of August 23, 2010 qualifying patient circumstances codes (99100, 99116, 99135, 99140) should not be reported with 01996 -Effective November 21, 2010, postoperative E/M visits reported within a 10 day aftercare period for anesthesia services will be denied. Bundled Services and Supplies -Effective November 21, 2010, added: Electroencephalogram (EEG) during non-intracranial surgery is not eligible for separate reimbursement. -Clarifies that the following codes not eligible for separate reimbursement when billed with any other service: 36591, 36592, 96523. Global Surgery -Expanded descriptions of some existing sections. -The following procedures were added to the list not eligible for separate reimbursement when performed during the global post operative period: Effective 8/23/10: Effective 8/29/10: 10060, 10061, 10140, 10160, 10180. S2083
-Added section regarding Coding with Modifiers to indicate a Transfer of Care -Effective November 21, 2010, postoperative E/M visits reported within a 10 day aftercare period for anesthesia services will be denied. Multiple Surgery -Clarified that the designation of the primary surgery designation for all multiple surgery reimbursement will be based on the highest relative value based on the CMS National Physician Fee Schedule Relative Value File.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) New Policies: Documentation and Reporting Guidelines for Consultations Documentation and Reporting Guidelines for Evaluation and Management Services Modifier 59 (Distinct Procedures Service) Bundled Services and Supplies for Polysomnography and Other Sleep Studies Tests Laboratory and Venipuncture Services -This is a new policy which combines and replaces the previously separate policies: Lab Panel Codes, and Routine Venipuncture and Lab Handling. -Clarifies that the following codes not eligible for separate reimbursement when billed with any other service: 36591, 36592.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) ANESTHESIA Effective 8/29/10 (except as specifically indicated otherwise) Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. Description Anesthesia describes the loss of sensation resulting from the administration of a pharmacologic agent that blocks the passage of pain impulses along nerve pathways to the brain. There are many types of anesthesia, but the three major types are: General----anesthesia affecting the entire body and accompanied by a loss of consciousness. Regional---loss of all forms of sensation of a particular region of the body. Local-------loss of sensation in a limited and superficial (i.e. surface) area of the body. Services involving the administration of anesthesia are reported by using the anesthesia five digit Current Procedural Terminology (CPT1) procedure code (00100-01999) and, if applicable, a physical status modifier and/or a servicing modifier. Anthem Blue Cross uses a number of factors in determining the reimbursement amount for a particular anesthesia service. Some of the factors that Anthem Blue Cross uses, in combination or separately, are: Base Units (BU)-----------are assigned to a specific anesthesia CPT code and are derived from the Medicare Anesthesia Relative Guide Time Units (TU)----------- a time unit is equal to 15 minutes Conversion Factors (CF)--is a single unit rate used in the calculation for anesthesia reimbursement Modifiers--------------------are to identify servicing and physical status Additional Factors---------such as qualifying circumstances, field avoidance, or unusual positioning Policy 1. TIME Anesthesia time begins when the individual who administers the anesthesia begins to prepare the patient for anesthesia care in the operating room or in the equivalent area, and ends when such individual is no longer in personal attendance and is no longer providing anesthesia services. Anesthesia time can be counted in blocks of time if there is an interruption in anesthesia, as long as the time counted is that in which continuous anesthesia services are provided. Based on American Society of Anesthesiologists (ASA) billing guidelines, when anesthesia services are provided for multiple surgical procedures, only the anesthesia procedure code for the most complex service should be reported. Base units are only used for the primary procedure and not for any secondary procedures. If two separate anesthesia codes are reported, the procedure with the lesser charge will be denied.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) ANESTHESIA (continued) If Anthem Blue Cross can determine, based on its review of the anesthesia record, that a separate subsequent operative session took place with more than an hour separation from the initial anesthesia, the second subsequent anesthesia service may be considered eligible for separate reimbursement. This unique situation may occur due to a complication creating an emergency situation necessitating a return to the operating room; or, when two distinct conditions are treated and services are rendered in separate service sites.
2. MODIFIERS a. Servicing Modifiers A claim for anesthesia should identify whether anesthesia services were provided by a physician or non physician. Therefore, a servicing modifier should be appended to the reported anesthesia code. When a non physician bills for anesthesia administration, and a physician/anesthesiologist (MD) bills for supervising the non physician, payment is made to the supervising MD and the administering non MD according to the appropriate modifier and rate listed below. Total reimbursement for anesthesia services provided by an MD and a non MD will not exceed the reimbursement that would have been allowed had anesthesia been provided by one MD. The following table identifies servicing modifiers and indicates the applicable reimbursement percentage of the maximum allowance for such servicing modifier. Modifier AA QK Description Anesthesia services personally performed by anesthesiologist Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals CRNA with medical direction by a physician Medical direction of one CRNA or AA by an anesthesiologist CRNA without medical direction by physician Monitored Anesthesia Care (MAC) Services Reimbursement Percentage of maximum allowance 100% 50%
QX QY QZ QS, G8-G9
50% 50% 100% 100%
b. Physical Status Modifiers Physical Status Modifiers identify a specific physical condition which indicates an added level of complexity to the anesthesia service provided. Anthem Blue Cross follows the ASA recommendation that unit values be assigned to the following physical status modifiers for additional reimbursement when appended to the base anesthesia code.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) ANESTHESIA (continued) Modifier P3 = 1 unit (A patient with severe systemic disease) Modifier P4 = 2 units (A patient with severe systemic disease that is a constant threat to life) Modifier P5 = 3 units (A moribund patient who is not expected to survive without the operation)
Anthem Blue Cross does not recognize unit values for the following physical status modifiers, and no additional reimbursement is made. Modifier P1 = A normal, healthy patient Modifier P2 = A patient with mild systemic disease Modifier P6 = A declared brain-dead patient whose organs are being removed for donor purposes
c. Informational Modifier: Modifier 23-- Unusual Anesthesia: Occasionally a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This modifier does not affect the reimbursement for the reported anesthesia code. 3. Field Avoidance and Unusual Positioning Field Avoidance: Anthem Blue Cross has designated a minimum Base Unit of 5 for any procedure performed around the head, neck or shoulder girdle, requiring field avoidance to administer anesthesia, regardless of any lesser Base Unit assigned to such procedure. Unusual Positioning: Anthem Blue Cross will reimburse the maximum allowance for any anesthesia procedure regardless of unusual positioning which may be required. Unusual positioning is not eligible for additional reimbursement. 4. Qualifying Circumstances for Anesthesia Sometimes anesthesia services are provided under difficult circumstances which may affect the condition of the patient, or present unusual operative conditions and/or risk factors. The following codes are used to identify these circumstances and are reported in addition to the anesthesia procedure or service provided. 99100 Anesthesia for patient of extreme age, younger than 1 year and older than 70 99116 Anesthesia complicated by utilization of the total body hypothermia 99135 Anesthesia complicated by utilization of controlled hypotension 99140 Anesthesia complicated by emergency conditions
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) ANESTHESIA (continued) These codes are eligible for separate reimbursement at the maximum allowance. We follow ClaimsXtenTM editing logic to determine when there may be a mutually exclusive relationship with the reported base anesthesia code.* * Note: Based on the ASA RVG3 comment which states that qualifying circumstances codes (+99100 through +99140) should not be reported with 01996. Effective August 23, 2010 Anthem Blue Cross will deny the qualifying circumstances code(s) 99100, 99116, 99135, or 99140 as mutually exclusive if billed with 01996 (daily hospital management of epidural or subarachnoid continuous drug administration). CPT 99140 is eligible for separate reimbursement for emergency services. However, if 99140 is reported for an unscheduled routine obstetrical delivery with the one of the diagnosis codes listed below, 99140 will not be eligible for separate reimbursement. DX Code V22.0 V22.1 650 654.20 654.21 669.70 669.71 V23.81 V23.82 V23.83 V23.84
Description Supervision of normal 1st pregnancy Supervision of other normal pregnancy Normal Delivery Previous cesarean delivery complicating pregnancy unspecified episode care or not applicable Previous cesarean delivery complicating pregnancy delivered with/without mention antepartum condition cesarean delivery without mention of indication unspecified episode care or not applicable cesarean delivery without mention of indication delivered with/without mention antepartum condition Elderly primigravida (1st pregnancy for woman who will be 35 yrs or older at delivery 2nd or more pregnancy for woman who will be 35 yrs or older at delivery First pregnancy in female less than 16 at time of delivery 2nd or more pregnancy in female less than 16 at time of delivery
5. Obstetric Anesthesia Using a time accounting method listed in the ASA RVG4, Anthem Blue Cross reimburses at a single maximum allowance for obstetric anesthesia. This allowance incorporates the reimbursement for providing labor analgesia as well as the intensity and time involved in performing and monitoring any neuraxial labor analgesic. Obstetric anesthesia includes the following codes and code ranges: 01958, 01960-01963, 0196501967. Add-on codes 01968-01969 are also eligible for separate reimbursement at the maximum allowance.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) ANESTHESIA (continued) 6. Anesthesia for Oral Surgery When an oral surgeon is reporting anesthesia services for a CPT-based surgical procedure, modifier 47 should be appended to the CPT code. This appropriately indicates that the same provider performing the service provided the anesthesia. A covered oral surgery procedure is eligible for reimbursement at the maximum allowance. There is no additional reimbursement when modifier 47 is appended to the CPT code. Procedures billed with modifier 47 will be denied. CPT anesthesia codes (00100 01999) and CDT anesthesia codes (D9210 D9248) are not eligible for separate reimbursement when the operating surgeon performs both the CPT-based surgical procedure and the anesthesia. When an oral surgeon renders a surgical procedure that is reported with a Current Dental Terminology (CDT) based procedure code (i.e. D codes), and also provides the anesthesia service, the appropriate CDT-based anesthesia code (D9210-D9248) should be reported for the anesthesia service. Covered anesthesia services in this scenario are reimbursed at the maximum allowance. 7. Services Included/Excluded in the Global Reimbursement for Anesthesia Global reimbursement for the anesthesia service provided includes all procedures integral to the successful administration of anesthesia from the initial pre-anesthesia evaluation through the time when the anesthesiologist is no longer in personal attendance. We follow ClaimsXten editing logic to determine when a service is included or excluded from global anesthesia reimbursement. a. Examples of services and corresponding codes that are included in global reimbursement and are not eligible for separate reimbursement are, but are not limited to: Pre and postoperative visits (E/M services performed one day prior to and one day after surgery). Effective November 21, 2010, postoperative E/M visits will be denied when reported within a 10 day aftercare period. Placement of endotracheal and naso-gastric tubes (31500, 91000, 91055, 91105) Laryngoscopy and bronchoscopy procedures (31505, 31515, 31527, 31622, 31645 Placement and interpretation of any non-invasive monitoring, which may include ECG testing (93000-93010, 93015-93018,93040-93042), monitoring of temperature/blood pressure/, pulse oximetry (CPT 94760-94761), capnography (CPT 94770) and mass spectrometry, and vital capacity. Venipuncture and transfusion (36400-36440) Inhalation treatments (94640) Placement of peripheral intravenous lines and administration of fluids, anesthetic or other medications through a needle or tube inserted into a vein (36000, 96360-96361, 9636596372) Echocardiography (93303, 93304, 93307, 93308) EEG: electroencephalogram (95812, 95813, and 95955) Daily hospital management of patient controlled analgesia (when a patient controls the amount of analgesia he or she receives)
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) ANESTHESIA (continued) b. Examples of services and corresponding codes that are excluded from global reimbursement and are eligible for separate reimbursement are, but are not limited to: The placement of catheters in arterial, central venous or pulmonary arteries (e.g. 36620, 36625, 36555-36556, 93503) The use of transesophageal echocardiography or TEE, (93312-93318) 8. Pain Management Pain management services by an anesthesiologist, such as an injection or catheter insertion into the epidural space or major nerve, are eligible for separate reimbursement. Pain management services are reimbursed at a maximum allowance and time units are not applicable. This applies to the following codes and ranges: 62310- 62319, 64412- 64425 and 64445 64450. An epidural or major nerve injection or catheter insertion performed by an anesthesiologist before, during, or following the surgical procedure for postoperative pain management is eligible for separate reimbursement in addition to the primary anesthesia code. Modifier 59 must be appended to the appropriate procedure code to indicate a district procedural service was performed. The daily management of epidural drug administration (CPT 01996) performed by the anesthesiologist is eligible for reimbursement one time per date of service subsequent to the surgery date. However, if the daily management code is billed with an anesthetic injection code (CPT codes 62310, 62311, 62318 & 62319), only the injection code is eligible for reimbursement.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) BUNDLED SERVICES AND SUPPLIES EFFECTIVE 11/21/10 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. Description Anthem Blue Cross considers certain services and supplies to be ineligible for separate reimbursement when reported by a professional provider. These services and /or supplies may be reported with a primary service or as a stand alone service. This policy is divided into 2 sections: The first section provides a description and coding grid for services and/or supplies not eligible for separate reimbursement. These services and/or supplies may be reported with another service or as a stand alone service. The second section provides a description and the code relationship for those procedures that are not eligible for separate reimbursement when performed with another specific service.
Policy Section 1: Services and supplies that are not eligible for separate reimbursement In most cases, services rendered without direct (face-to-face) patient contact are considered to be an integral component of the overall medical management service and are not eligible for separate reimbursement. In addition, modifier 59 will not override the denial for the bundled services and/or supplies listed below. These bundled services and supplies may include, but are not limited to: 1. administrative services requiring physician documentation (e.g. recertification, release forms, physical/camp/school/daycare forms, etc.) 2. all practice overhead costs, such as heat, light, safe access, regulatory compliance including CDC and OSHA compliance, general supplies (paper, gauze, band aids, etc.), insurance (including malpractice insurance), collections 3. application of a modality to one or more areas; hot or cold packs 4. collection/analysis of digitally/computer stored data 5. copies of test results for patient 6. costs to perform participating provider agreement requirements, such as prior authorizations, appeals, notices of non coverage 7. determination of venous pressure 8. DME delivery and/or set up fees 9. electroencephalogram (EEG) during non-intracranial surgery 10. handling and/or conveyance fees 11. heparin lock flush solution or kit for non therapeutic use 12. hospitalist services (additional unspecified) 13. hospital mandated on-call service 14. insertion of a pain pump by the operating physician during a surgical procedure 15. peak expiratory flow rate 16. photography 17. pharmacy dispensing services and/or supply fees, etc. 18. physician care plan oversight 19. Physician Quality Reporting Indicator Codes (G8006-G9140)
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) BUNDLED SERVICES AND SUPPLIES (continued) 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. physician standby service post op follow up visit during the global period for reasons related to the original surgery prescriptions, electronic, fax or hard copy, new and renewal, including early renewal prolonged physician in-patient service prolonged E/M service before and after direct patient care pulse oximetry recording or generation of automated data review of medical records robotic surgical system routine post surgical services such as dressing changes and suture removal stat laboratory request supplemental tracking codes for performance measurement (Category II CPT Codes) surgical/procedural supplies and materials supplied by the provider rendering the primary service (e.g. surgical trays, syringes, needles, sterile water etc.) 33. telephone consultations with the patient, family members, or other health care professionals 34. team conferences to coordinate patient care
Coding Section 1: Services and supplies that are not eligible for separate reimbursement The following table identifies by code some of the procedures and supplies that are described above. The inclusion or exclusion of a specific code does not indicate eligibility for coverage under all circumstances. This table is provided as an informational tool only, to help identify some of the procedures described above. 0185T 15850 78890 78891 90889 93770 94005 A9900 94760 94761 95955 97010 98966 98967 98968 99000 99001 99002 99024 99027 99053 99056 99058 99060 99070 99090 99091 99339 99340 99356 99357 99358 99359 99360 99361 99362 99366 99367 99368 99374 99375 99376 99377 99378 99379 99380 99441 99442 99443 A4262 A4263 A4270 A4300 A4550 A9901 G0269 H0048 J1642 S0221 S0310 S2900 S3600 S3601 S8110
Policy Section 2: Services that are not eligible for separate reimbursement when billed with another specific procedure or service. These bundled services may include, but are not limited to: 1. demonstration and/or evaluation of the use of an inhaler/nebulizer when performed with an evaluation and management service 2. digital rectal exam for prostate cancer screening when performed with a preventive or E/M service 3. electrodes when billed with other services (e.g., EKG; EEG; stress test; sleep study; electric stimulation modalities) 4. interpretation and report of a routine EKG when performed with an E/M 5. obtaining, preparing, and conveyance of cervical or vaginal PAP smear 6. cervical or vaginal cytopathology when performed with a preventive or E/M service 7. preventive medicine counseling when performed with a routine comprehensive preventive medical examination 8. removal of impacted cerumen when performed with audiologic function testing 9. vital capacity when performed with an E/M service
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) BUNDLED SERVICES AND SUPPLIES (continued) Coding Section 2: Services that not eligible for separate reimbursement when reported with another specific procedure or service. The following list identifies by code some of the procedures that are described above. The inclusion or exclusion of a specific code does not indicate eligibility for coverage under all circumstances. These code relationships are provided as an informational tool only, to help identify some of the procedures described above. They include but are not limited to: 1. 94664 with E/M codes such as 99201-99215 2. G0102 with Preventive and E/M codes such as 99381-99397 and 99201-99215 3. A4556 with services such as 93000, 93015, 95805, 95812, 97014, and 97033 4. 93010 with E/M codes such as 99201-99215, 99281-99285, and 99221-99223 5. Q0091 with Preventive and E/M codes such as 99381-99397 and 99201-99215 6. 88141-88155 with Preventive and E/M codes such as 99381-99397 and 99201-99215 7. 99401-99404 & 99411-99412 with Preventive E/M codes such as 99381-99397 8. 69210 with audiologic function tests such as 92551-92557 9. 94150 with E/M codes such as 99201-99215 10. 96523 is not eligible for separate reimbursement when billed with any other service 11. 36591-36592 are not eligible for separate reimbursement when billed with any other service.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) GLOBAL SURGERY Effective 8/29/10 (except as specifically indicated otherwise) Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. Description The Global Surgery Concept is based on the understanding that reimbursement for a surgical procedure includes the work value of an established Evaluation and Management service (E/M) and other services as defined in the policy section. The global period is derived from The Centers for Medicare & Medicaid Services (CMS) designations. A surgical procedure is usually assigned one of three global periods depending on whether the procedure performed is classified as major or minor. Major procedures have a 90-day global surgical period. Minor procedures have either a 0-day global or a 10-day global surgical period based on complexity. CMS does not list all Current Procedural Terminology (CPT1) codes in one of these three categories. (There is a separate 45 day global period assigned to certain maternity delivery codes.) Procedures that are not placed in these major categories are listed in supplemental categories of MMM, XXX, YYY, and ZZZ. Please refer to the coding section for clarification.
Policy Surgical procedures are subject to preoperative, same day and postoperative care edits. E/M services rendered within the applicable global period will not be eligible for separate or additional compensation. However, there are times when the global surgical package may not apply. Refer to the exception section of this policy for more information. Services included in the global surgical package may be furnished in any setting, (e.g. Hospital, Ambulatory Surgical Center, or Physicians Office.) Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon. However, critical care services (99291-99292) are payable separately in some situations (see Exceptions to global surgery). Surgical Procedures The allowance for a surgical procedure includes the following services related to that surgery when performed by the same operating physician or same physician group based on tax identification number. Evaluation and management visits beginning the day before a major surgical service. E/M visits occurring on the same day as a surgical procedure or substantial diagnostic or therapeutic procedure or service (such as dialysis, chemotherapy and osteopathic manipulative treatment). Intraoperative services (such as monitoring) that are a usual and necessary part of a surgical procedure. Follow-up E/M visits during the postoperative period that relate to recovery from the surgery. Note: The postoperative period begins on the next day following the surgical service. Any additional medical or surgical services by the surgeon during the postoperative period because of complications that do not require a return trip to the operating room. Intraoperative pain management by the surgeon, including moderate sedation and intraoperative pain management devices.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) GLOBAL SURGERY (Continued) Postoperative pain management by the surgeon, including patient controlled analgesia. Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline (S2083) Miscellaneous services Anthem Blue Cross considers to be routine post surgical care, including but not limited to: dressing changes; local incision care; removal of sutures, staples, lines, wires, tubes, drains, catheters, and/or casts Effective August 23, 2010 in addition to the list above, the following services are also not eligible for separate reimbursement when performed during the global post operative period of the related surgical procedure: o Incision and drainage of abscess, simple/single/complicated or multiple (1006010061) o Incision and drainage of hematoma, seroma, or fluid collection (10140) o Puncture aspiration of abscess, hematoma, bulla, or cyst (10160) o Incision and drainage, complex postoperative wound infection (10180)
Exceptions: There are times when the global surgical package may not apply. 1. The following E/M services are described by CPT guidelines as applying to a new or established patient and are excluded from the global surgical package when billed on the same day as a procedure with a zero (0) day postoperative follow-up period. These E/M services include but are not limited to: a. Initial observation care 99218-99220 b. Observation care 99234-99236 c. Initial hospital care 99221-99223 d. Office or other outpatient consultations 99241-99245 e. Initial inpatient consultations 99251-99255 f. Confirmatory consultations 99271-99275 g. Critical Care 99291-99292 2. Critical care services provided by the surgeon for a seriously injured or burned patient are eligible for reimbursement during the global period when the critical care is above and beyond, and in most cases unrelated to, the specific anatomic injury or general surgical procedure performed. (Modifier 24 and/or 25 is required.) 3. An E/M visit code reported with a one day pre-op date of service and a different ICD-9 diagnosis than the surgical procedure is excluded from global surgery editing and is eligible for reimbursement. Anthem Blue Cross considers a different diagnosis one in which the first three digits of the diagnosis code for the E/M service differs from the first three digits of the of the diagnosis code for the surgical/procedural service. 4. E/M services billed with the following modifiers are excluded from global surgery editing and are eligible for reimbursement in addition to the surgical fee: a. Modifier 24 unrelated E/M service by the same physician during the postoperative period. In addition to reporting modifier 24, the diagnosis code should be different than the diagnosis for the surgical period. A different diagnosis
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) GLOBAL SURGERY (Continued) b. is defined when the first three digits differ from the first three digits of the surgical procedure. c. Modifier 25 significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. d. Modifier 57 decision for surgery 5. Related surgical services performed during a postoperative surgical period are eligible for separate reimbursement at 70% of the applicable surgical reimbursement maximum allowance. A surgical service reported with modifier 78 will not start a new global surgery period. a. Modifier 78 return to the operating room for a related procedure during the postoperative period. 6. Post surgical procedures and services, unrelated to the prior surgery, are eligible for separate reimbursement in the assigned post operative period. However, it is recommended to append the 79 modifier to indicate that these services are unrelated to the prior surgery. a. Modifier 79 unrelated procedure or service by the same physician during the postoperative period. Note: Documentation to support the use of the modifiers listed above is not required with claim submission, but may be requested.
Coding The following tables show applicable postoperative days assigned by Anthem Blue Cross: MMM 0 postoperative days except the following: XXX 45 days for codes: 59400, 59410, 59510, 59515, 59610, 59614, 59618, and 59622. 10 days for codes: 59409, 59514, 59612, 59620 (These are delivery only codes.), anesthesia codes
0 postoperative days for surgical procedures 10 postoperative days for anesthesia procedures (effective 11/21/2010-refer to anesthesia policy for details)
YYY
We reserve the right to apply a global period for aftercare based on the postoperative days designated for a similar procedure. Please see the new table below for YYY designations. ** Same postoperative days as the parent procedure. For example: CPT 22585 will be assigned the same 90 day period as the parent code 22554
ZZZ
* XXX postoperative days: Note This applies to surgical procedures **YYY postoperative days: See table below
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) GLOBAL SURGERY (Continued) Applicable Postoperative Days: 10 45
90
17999, 38589, 40899, 41899, 68899 59898 15999, 19499, 20999, 21089, 21299, 21499, 21899, 22899, 22999, 23929, 24999, 25999, 26989, 27299, 27599, 27899, 28899, 29999, 30999, 31299, 32999, 33999, 36299, 37501, 37799, 38129, 38999, 39499, 39599, 40799, 41599, 42299, 42699, 42999, 43656, 43999, 44238, 44799, 44899, 44979, 45499, 46999, 47379, 47399, 47579, 47999, 48999, 49329, 49659, 49999, 50549, 50949, 51999, 53899, 55559, 55899, 58578, 58679, 58999, 59899, 60659, 60699, 64999, 66999, 67299, 67599, 67999, 68399, 69399, 69799, 69949, 69979
Coding with Modifiers to indicate a Transfer of Care: Per CPT, the following modifiers should be used to reflect the appropriate services. Modifier 54---surgical care only. Reimbursement will be calculated at 70% of the applicable surgical reimbursement maximum allowance. Modifier 55---postoperative management only. Reimbursement will be calculated at 20% of the applicable surgical reimbursement maximum allowance. Modifier 56---preoperative management only. Reimbursement will be calculated at 10% of the applicable surgical reimbursement maximum allowance.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) MULTIPLE SURGERY Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. Description Multiple surgeries are distinct surgical procedures performed by a provider on the same patient during the same operative session. These secondary surgical procedures are eligible for reimbursement, but at a lower allowance, and can be distinguished from other procedures that might be components of, or incidental to, the primary service performed. This policy applies to all professional providers billing Current Procedural Terminology (CPT) or HCPCS codes on a CMS-1500 that are considered to be surgical procedures. Policy 1. Standard multiple surgery reimbursement: Standard multiple surgery reimbursement is 100% of the maximum allowance for the procedure with the highest RVU, and 50% of the maximum allowance for the second and each subsequent procedure. Exception: Some members may continue to apply a 100%, 50%, 25% multiple surgical reimbursement for all surgeries including multi-Endoscopy until the member benefits are modified. The designation of the primary surgery designation for all multiple surgery reimbursement will be based on the highest relative value based on the CMS National Physician Fee Schedule Relative Value File. 2. Multiple endoscopic surgical procedure reimbursement: Endoscopic surgical reimbursement in the same base family is 100% of the maximum allowance for the procedure with the highest RVU, and at a lower percentage for each subsequent procedure when performed at the same operative session, with the same endoscopic base code as defined by The Centers for Medicare & Medicaid Services (CMS). Multiple endoscopic surgical procedures performed on the same day, not within the same base family, will continue to be subject to the standard multiple surgery reimbursement methodology.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) MULTIPLE SURGERY (continued The following table lists many of the code ranges subject to multiple surgical endoscopic reimbursement rules and the percentage the maximum allowance will be lowered for subsequent procedures: Base Family Shoulder arthroscopy Elbow arthroscopy Wrist arthroscopy Hip arthroscopy Knee arthroscopy Bronchoscopy Upper GI endoscopy Colonoscopy Retrograde Cholangiopancreatography (ERCP) Codes 29805 29826, 29827-29828 29830 29838 29840 29847 29860 29863 29870 29887 31622 - 31631, 31635 31636, 31638, 31640 31641, 31645 43231, 43232, 43235 - 43259 45378 45392 43260 43265, 43267 43269, 43271 - 43272 Percentages 100% primary; 30% subsequent 100% primary; 25% subsequent 100% primary; 25% subsequent 100% primary; 25% subsequent 100% primary; 35% subsequent 100% primary; 25% subsequent 100% primary; 25% subsequent 100% primary; 25% subsequent 100% primary; 25% subsequent
3. Bilateral surgical procedure reimbursement: A bilateral surgical service using a unilateral code should be reported once with modifier 50, using one unit of service. This line item will be considered as one surgical service and will be eligible for reimbursement equal to 150% of the maximum allowance for the code. When a bilateral surgical procedure is reported with other surgical procedures, the multiple surgical reimbursement policy (standard and/or multiple endoscopic) shall apply to determine reimbursement. The bilateral surgery reimbursement rate (150% of allowance) is applied prior to the multiple surgery reimbursement rules, and that total rate of 150% determines which is the primary service and which is the secondary/subsequent service(s). The bilateral surgery reimbursement rate (150% of allowance) is applied after the primary and subsequent procedures are ranked according to highest RVU. With surgical procedure codes containing the terminology bilateral or unilateral or bilateral modifier 50 should not be used, as the description of the code already defines the procedure as a bilateral code. 4. The standard multiple surgery reimbursement is NOT applicable for the following: Procedure codes reported with modifiers 26 or 66. Add-on codes as defined by CPT Appendix D, and HCPCS code G0289 Modifier 51 exempt codes as defined by CPT Appendix E. Procedures listed in the Surgery section of CPT (10000-60000 series) that Anthem Blue Cross does not consider to be a surgical procedure (e.g. 36415-36416; 36593; 5942559426)
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) MULTIPLE SURGERY (continued 5. Other Considerations In order for the multiple surgery reimbursement policy to apply, at least 2 or more codes must be eligible for the standard multiple surgical calculations when reported as performed during the same operative session For all other surgical procedure codes, Anthem Blue Cross will determine whether the standard multiple surgery policy is applicable 6. Focused Claim Review As part of our continued efforts to help ensure that claims are properly coded, we will begin administering a focused claim review for coding accuracy of multiple surgical services. This review will be focused on professional claims containing eight or more surgical services performed on the same date of service, by the same physician. In order to review these claims, an operative report is required. If a claim involving more than seven surgical services is submitted without the operative report, the claim will be denied requesting the operative report.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR CONSULTATIONS EFFECTIVE 8/29/10 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. Description Consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and management (E/M) of a specific clinical problem is requested by another physician or other appropriate professional. This policy addresses Anthem Blue Cross's requirements for the documentation of a reported E/M consultation service, the reporting guidelines, and the eligibility for consultation reimbursement based on the fulfillment of the required criteria. Please note that consultation codes are not reimbursed by The Centers for Medicare & Medicaid Services (CMS). This policy is applicable only for lines of business that do not use the CMS fee schedule for reimbursement purposes for either primary or secondary claims. Policy Anthem Blue Cross recognizes consultation services when a physician or other Appropriate Source is seeking advice, opinion, a recommendation, suggestion, direction, or counsel, etc. from another physician (usually a specialist) in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professionals knowledge. For purposes of this policy and consistent with the 1995 and 1997 editions of CMS E/M Services Guidelines and the Current Procedural Terminology (CPT) Manual, the following professionals are Appropriate Sources who are eligible to request consultations: physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer and insurance company. I. Types of Consultations CPT consultation codes are divided into two sections based on place of service: A. Office or Other Outpatient Consultations: Office or other outpatient consultations are reported with CPT codes 99241-99245 with no distinction between new and established patients. Consultation is appropriate in any outpatient setting including the office, emergency department, home, or domiciliary setting. B. Inpatient Consultations Inpatient consultations are reported with CPT codes 99251-99255. The codes are used to report physician consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting. II. Consultation Coding and Documentation Guidelines Please refer to Anthem Blue Crosss Reimbursement Policy entitled Documentation and Reporting Guidelines for Evaluation and Management Services. This policy contains: definitions of terms related to E/M services; information on the 1995 and 1997 editions of CMS E/M Services Guidelines; and documentation required for medical decision making.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR CONSULTATIONS (continued) Anthem Blue Cross requires that providers document and report both outpatient and inpatient consultation services using the same methodology described in the Documentation and Reporting Guidelines for Evaluation and Management Services Reimbursement Policy that is used for office or other E/M visits. Key components, along with contributory factors (counseling and coordination of care, nature of the present problem, and time) are used to determine the level of consultation to report. A. Anthem Blue Cross requires that the three components listed below be documented and used to determine the level of the consultation E/M visit: history of present illness examination medical decision making. B. Anthem Blue Cross follows CPT criteria in determining whether a visit will be considered a consult. In order for a service to be properly reported as a consult, there must be documentation of: 1. A written or verbal request for opinion or advice from another physician or Appropriate Source to either recommend care for a specific condition or problem OR to determine whether the consulting physician should accept responsibility for (a) patients entire care or (b) the care of a specific condition or problem. Standing orders in the medical record for consultation do not constitute such a request. 2. A clear explanation as to the reason for the consult by either the requesting physician or Appropriate Source; or the consulting physician. 3. A written report to the requesting physician or Appropriate Source of the consultants finding, opinions, recommendation, and any services that were ordered or performed. a. The report should not be a thank you note to the requesting physician or Appropriate Source for referring the patient, nor should it be a courtesy copy of the history/ physical. b. The report should provide instruction(s) to the requesting physician or Appropriate Source to assist in treating the patient; or should inform the requesting physician or Appropriate Source that the consulting physician is taking over the partial or total care of the patient. c. In the hospital or any setting where a shared chart is used, the consulting physician is not required to send a written report to the requesting physician or Appropriate Source because it is expected that the requesting physician or Appropriate Source will review the consultants assessment and recommendations for treatment. C. During an inpatient admission, after an initial consult, any additional E/M services rendered during the same admission should be reported using subsequent hospital care codes (99231-99233) or subsequent nursing facility care codes (99307-99310). Such subsequent services include visits performed to complete the initial consultation, monitor progress, revise recommendations, or address a new problem.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR CONSULTATIONS (continued) D. Anthem Blue Cross follows the CPT coding guideline that a consultation initiated by a patient and/or family, and not requested by a physician or other Appropriate Source, should not be reported using the consultation codes, but may be reported using the office visit, home service, or domiciliary/rest home care codes as appropriate. III. Transfer of Care Health Plan has adopted the following definition of transfer of care from the CPT Manual: Transfer of care is the process whereby a physician who is providing management for some/all of a patients problems relinquishes this responsibility to another physician who explicitly agrees to accept the responsibility, and who, from the initial encounter, is not providing consultative services. After a transfer of care, the requesting physician or Appropriate Source will no longer provide care for the specific condition for which care was transferred, but may continue providing care for other conditions when appropriate. A physician who has agreed to accept transfer of care prior to an initial evaluation should not report consultation codes to Health Plan. In such cases, the receiving physician should report the appropriate new or established patient visit code according to the place of service. If the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of site of service, then it would be appropriate to bill a consult.
IV. Initial and Follow-Up Consultation Services A. Initial Consultation 1. In the hospital and nursing facility setting, the consulting physician shall use the appropriate inpatient consultation CPT codes 99251-99255 for the initial consultation service. The initial inpatient consultation may be reported only once per consultant per patient per facility admission. 2. In the office or outpatient setting, the consultant should use the appropriate office or outpatient consultation CPT codes 99241-99245 for the initial consultation service. 3. A consulting physician may initiate diagnostic services and treatment at the initial consultation service or may even take over the patients care after the initial consultation.
B. Follow-up Services 1. Ongoing management, following the initial consultation service by the consulting physician, should not be reported with consultation service codes. These services need to be reported as subsequent visits with the appropriate place of service and level of service. 2. In the hospital setting, following the initial consultation service, the subsequent hospital care CPT codes 99231-99233 should be reported for additional follow-up visits. In the nursing facility setting, following the initial consultation service, the subsequent nursing facility care CPT codes 99307-99310 should be reported for additional follow-up visits.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR CONSULTATIONS (continued) 3. In the outpatient setting, following the initial consultation service, the office or outpatient established patient CPT codes 99212-99215 should be reported for additional follow-up visits. 4. If an additional request for an opinion regarding the same or new problem with the same patient is received from the same or another physician or Appropriate Source and documented in the medical record, the office or outpatient consultation CPT codes 9924199245 may be used again. However, if after any consultation service, the consultant then continues to care for the patient for the original condition, such follow-up services should not be reported with consultation service codes.
V. Second Opinion A second opinion E/M service initiated by a patient and/or family and performed in the office or other outpatient setting should not be reported using the consultation codes. Such services should be reported using the office or other outpatient new or established patient codes. In both the inpatient hospital setting and nursing facility setting, a request for a second opinion is made through the attending physician and may be reported using consultation service CPT codes. VI. Consultations Requested by Members of Same Group Practice In the event that one physician requests a consultation from another physician in the same group practice, consultation codes may be reported when that other physician has expertise in a specific medical area beyond the requesting physicians knowledge. Consultations should not be reported on every patient as a routine practice when physicians refer patients to each other within a group practice setting. VII. Consultation for Preoperative Clearance and Postoperative Evaluation A. Preoperative consultations for new and established patients performed by any physician at the request of a surgeon may be reported with consultation codes, as long as all the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not a routine screening. B. A physician (primary care or specialist) who performs a postoperative evaluation of a new or established patient at the request of the surgeon may report a consultation code for the E/M service furnished during the postoperative period when all the criteria for the use of the consultation codes are met, and the consulting physician has not already performed a preoperative consultation. C. In the hospital setting, a physician who has performed a preoperative consultation and assumes responsibility for the management of a portion or all of the patients condition(s) during the postoperative period should use the appropriate subsequent hospital care codes that he/she is providing. In the office setting, the appropriate established patient visit codes should be used during the postoperative period.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES EFFECTIVE 8/29/10 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. Description The Evaluation and Management (E/M) Service Code Section of the Current Procedural Terminology (CPT) Manual is divided into different types of E/M services. There are broad categories, such as office/outpatient visits, inpatient hospital visits, consultations, etc. Many of these categories are further divided into two or more subcategories appropriate for that service type such as: -Office visits have new and established patients, -Hospital E/M services are based on the health status of the patient (e.g., critical care or observation), -Other E/M services may be based on location alone (e.g. emergency department services). For E/M services, the nature and amount of provider work and documentation required varies by type of service, place of service, the patients medical status or other code criteria. This policy addresses Anthem Blue Cross's requirements for the documentation of a reported E/M service, the reporting guidelines, and the eligibility for E/M reimbursement based on the fulfillment of the required criteria. The Centers for Medicare & Medicaid Services (CMS) published E/M documentation guidelines in 1995 and 1997. Anthem Blue Cross follows CMS in allowing providers to use either the 1995 or 1997 CMS E/M documentation guidelines. Within a single encounter/claim, the two sets of guidelines cannot be mixed. In other words, the provider must follow either the 1995 or the 1997 guidelines for the single encounter/claim. The following information describes Anthem Blue Crosss interpretation of those CMS guidelines. Definitions Anthem Blue Cross uses the following definitions from the 1995 and 1997 editions of CMS E/M Services Guidelines: Chief Complaint (CC): A concise statement describing the symptoms, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patients words and documented in the medical record. Comprehensive Exam: A general multi-system examination or complete examination of a single organ system and other symptomatic or related body areas or organ system(s). Detailed Exam: An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s). Expanded Problem Focused Exam: A limited examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s). Family History: A review of medical events in the patients family, including diseases which may be hereditary or place the patient at risk.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES (CONTINUED) Medical Decision Making (MDM): The complexity of establishing a diagnosis and/or selecting a management option, as measured by the following documentation: 1. The number of possible diagnoses and/or the number of management options that must be considered 2. The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed. 3. The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patients presenting problem(s), diagnostic procedures(s), and /or the possible management options. Past History: A review of the patients past experiences with illnesses, operations, injuries and treatments. Problem Focused Exam: A limited examination of the affected body area or organ system. Review of Systems (ROS): An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. For the purpose of ROS, the following systems are recognized: eyes, ear nose, mouth, throat, respiratory, genitourinary, integumentary (skin and/or breast), psychiatric, hematologic/lympathic, constitutional (e.g. fever, weight loss) cardiovascular, gastrointestinal, musculoskeletal, neurological, endocrine, and allergic/immunologic. Social History: An age appropriate review of past and present activities.
Anthem Blue Cross uses the following definitions which are based on the 1995 and 1997 editions of CMS E/M Services Guidelines: Consult: A type of service provided by a physician, or other appropriate source, whose opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician or other qualified non-physician practitioners. The intent of the requesting provider is not to have the consulting physician treat the patients condition, but rather to render an opinion and/or working diagnosis to aid the referring provider in formulating a treatment plan. Counseling: A conversation with the patient and/or the family/patients guardian concerning test results, treatment, education, etc. History Present Illness (HPI): A chronological description of the development of the patients present illness from the first sign and/or symptom to the present. Usually this information is derived from the patients own words and obtained by the provider. Time: Face-to-face duration for office and other outpatient visits and unit/floor time for hospital and other inpatient services. Policy Anthem Blue Cross recognizes the seven components identified by both CPT and CMS that are used in defining the levels of E/M services. These components are: o History o Examination o Medical decision making o Counseling
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES (CONTINUED) o o o Coordination of care Nature of presenting problem Time
For the majority of E/M services, depending on the category, either two or three of the first three components listed above provide the sole basis for selecting the level of E/M service. For E/M services in which counseling and coordination of care constitute more than 50% of the total face-to face patient encounter, the level of E/M service may be based on the time component. See the E/M Service Guidelines Section of the CPT manual for more detailed information. I. History Component: Anthem Blue Cross requires that the medical record include documentation of the history component which is comprised of the following elements: Chief complaint or reason for the encounter (CC). History of Present Illness (HPI). Review of systems (ROS). Past, family, and/or social history (PFSH). A. Chief complaint (CC): The chief complaint is required for every E/M encounter. This is separate from the HPI. It is the first step in establishing the medical necessity for the presenting problem(s) for that specific encounter. It is used to determine to what extent HPI, ROS, and the nature of the physical exam is medically necessary. B. History of Present Illness (HPI): There are two levels of HPI (brief and extended) for both the 1995 and 1997 CMS documentation guidelines. Brief and extended HPI are differentiated by the amount of detail documented on the basis of the patients clinical and/or presenting problem(s). A brief history is taken for problem focused and extended problem focused level of E/M visit codes. A detailed or comprehensive history is required for the middle to upper level E/M visit codes. For the CMS 1995 and 1997 guidelines, at least one of eight elements must be documented as part of the brief HPI. Detailed and comprehensive HPI require at least four of the eight to be documented as part of the HPI. Alternatively, the 1997 guidelines permit documentation of the status of three or more chronic or inactive conditions in lieu of any elements. The chronic or inactive conditions stated in the 1997 HPI need to reflect the medical necessity pertaining to the specific encounter throughout the chief complaint, exam and medical decision making. The eight elements included in the HPI are: Location - where problem, pain or symptom occurs (e.g., leg, chest, back). Quality - description of problem, symptoms or pain (e.g., dull, itching, constant). Severity - description of severity of symptoms or pain (e.g., 1-10 rating, mild, moderate, severe). Duration - description of when the problem, symptom or pain started (e.g., one week, since last night, months) Timing - description of when the problem, symptom or pain occurred (e.g., morning, after eating, when lying down, on exacerbation).
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES (CONTINUED) Context - instances that can be associated with the problem, symptom or pain (e.g., while standing for long periods of time, when sitting). Modifying Factors - actions taken to make the problem, symptom or pain better or worse (e.g., pain relievers help dull pain, nausea after eating). Associated Signs or Symptoms - other problems, symptoms or facts that occur when primary problem, symptom or pain occurs (e.g., stress causes headache, dizziness with exercising). C. Review of Systems (ROS):.The level of the ROS needs to be relative to the medical necessity of the presenting problem(s). For example: It may be medically necessary to obtain a complete ROS when a patient presents as a new patient. It may not be considered medically necessary to repeat a complete ROS on a follow-up visit. If a provider uses a patient questionnaire to obtain information on the patients current signs and symptoms, the provider needs to acknowledge the review of the questionnaire as the source of the information, in the office note, along with the providers signature and date on the questionnaire. For new patient and consultation visits, the patients signs and symptom information (ROS) must be completely documented, including a description of each system that was reviewed during the encounter. Established visits may use reference to a patient questionnaire. The ROS must be supported in the CC and HPI. Documenting ROS negative or ROS noncontributory is not acceptable. The following documentation is required, at a minimum: Brief ROS documentation of positive/negative responses to problem pertinent systems directly related to the chief complaint. Extended ROS documentation of positive/negative responses for at least two to nine systems. Complete ROS documentation of positive/negative responses for ten or more systems. D. Past, Family and/or Social History (PFSH): Documentation needs to support the medical necessity for the encounter. For example: It may be medically necessary to obtain past medical, family and social history for a new or consult patient. It may not be medically necessary for a repeat past medical, family and social history for an established patient encounter. Anthem Blue Cross follows the CMS 1995 and 1997 documentation guidelines which both require that the CC, HPI, and ROS support the medical necessity of obtaining PFSH during an established visit for a patient that has been seen within the last three months for the same clinical condition(s).
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES (CONTINUED) Past history - Describes the patients past experiences or lack thereof with illnesses, operations, injuries and treatments. Family history A review of medical events in the patients family, including diseases which may be hereditary or place the patient at risk. Social history - Describes age-appropriate past and current activities. Some examples are e.g., marital status, education, tobacco, alcohol or drug abuse. II. Physical Examination: o Anthem Blue Cross requires that the medical record include documentation of the physical examination component. o The extent of the physical examination should correspond to the medical necessity of the presenting problem(s) stated in the chief complaint and history of present illness documentation. o The nature of the problem and severity of illness defines the intensity of the medical examination required. Anthem Blue Cross uses the following guidelines for documentation of the physical examination which are based on the CMS 1995 and 1997 guidelines. They are: A. 1995 GuidelinesProblem Focused examination requires a limited examination of the affected body area or organ system. Expanded Problem Focused examination requires a limited examination of between 2 to 7 body areas or organ systems. Detailed examination requires an extended examination of between 2 to 7 body areas or organ systems. Comprehensive examination requires a general multi-system examination of at least 8 organ systems or a complete examination of a single organ system. B. 1997 Guidelines-Single Organ System Examinations Complete information on the 1997 CMS guidelines for single organ examinations can be accessed at pages 14 through 44 of the following document: http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf Anthem Blue Cross requires the performance and documentation of the indicated elements of the 1997 guidelines for problem focused, expanded problem focused, detailed and comprehensive examinations. Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) must be documented. A notation of abnormal without elaboration is insufficient. Documenting No change in physical examination or no change in condition from last examination or similar non specific reference is not acceptable.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES (CONTINUED)
III. Medical Decision Making (MDM) Medical decision making is based on the patients clinical condition at the time of the specific visit. Anthem Blue Cross follows the requirements for documentation recorded in Medical Record Auditor, Grider, Deborah, 2nd edition, 2008. The patients medical record must include the following: For each encounter, an assessment, clinical impression, and/or diagnosis must be documented. The assessment, clinical impression, and/or diagnosis may be explicitly stated or implied in the documented decisions regarding management plans and/or further evaluation. The presenting problems need to be addressed in the history, physical examination, and MDM components. For a presenting problem with an established diagnosis, the record should reflect whether: a. the problem (s) is improved, well controlled, resolving, or resolved; or b. inadequately controlled, worsening, or failing to change as expected. For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of a differential diagnosis or as a possible, probable, or rule out diagnosis. The initiation of/or change in treatment must be documented. If referrals are made, consultations requested, or advice sought, the record must indicate to whom or where the referral or consultation is made, or from whom advice is requested. If diagnostic services (tests or procedures) are ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service (e.g., lab; x-ray) must be documented. The review of lab, radiology, and/or diagnostic tests must be documented. A simple notation such as WBC elevated or chest x-ray unremarkable is acceptable; or the review may be documented by the provider initialing and dating the report containing the test results. Relevant findings from the review of old records and/or receipt of additional history from the family, caretaker, or other source to supplement the information obtained from the patient must be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of old records reviewed or additional history obtained from family without elaboration is insufficient.
Anthem Blue Cross follows CPT coding guidelines for a new patient office visit or consultation and requires that all of the key components, i.e., history, examination, and medical decision making, must meet or exceed the stated requirements to qualify for reporting a particular level of E/M. For an established patient visit, Anthem Blue Cross requires that medical decision making be one of the two components used to determine the E/M code level selected. The other component can be either patient history or physical examination. Selecting a Level of Medical Decision Making for Coding an E/M Service: Anthem Blue Cross uses a point system described in a tool developed by the Marshfield Clinic in conjunction with CMS to quantify the presenting problem and the amount of comprehensive data that must be reviewed by the examining provider. This point system is used in conjunction with the CMS Documentation Guidelines Table from 1995 and/or 1997 for determining the appropriate level of E/M service to select. (See the table in Section C. shown below)
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES (CONTINUED) A. Number of Diagnoses/Management Options___________________________
Self-limited or minor (stable, improve, or worsened (maximum of 2 points in this category) Established problem (to examining MD); stable or improved Established problem (to examining MD); worsening New problem (to examining MD), no additional work-up planned (maximum of 3 points in this category) 3 point New problem (to examining MD); additional workup (diagnostic test)
Points
1 point 1 point 2 point 4 point
B. Amount and/or Complexity of Data Reviewed Points

Lab tests ordered and/or reviewed (regardless of number ordered) X-rays ordered and/or reviewed (regardless of number ordered) Procedures found in the Medicine section of CPT (90701-99199) ordered and/or reviewed Discussion of test results with performing physician Decision to obtain old record and/or obtain history from someone other than patient Review and summary of old records and/or obtaining history from someone other than patient and/or discussion with other health care provider Independent visualization of image, tracing, or specimen (not simply review of report) 1 point 1 point 1 point 1 point 1 point 2 points 2 points
Sections A and B (above), and C on the following page describe specific point value information. In order for an E/M service to be assigned a particular medical decision making level, the service must score at or above that level in two out of the three categories.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES (CONTINUED) C. Risk Level of Complication and /or Morbidity or Mortality Anthem Blue Cross uses the following risk table, which appears in both the 1995 and 1997 CMS published guidelines, as a tool for determining the appropriate risk level for a reported E/M visit. The procedures listed below appearing in bolded text within the Low and Moderate Risk Level rows were added by Anthem Blue Cross for further clarification of these two risk levels.
Risk Level
Minimal (straight forward)
Presenting Problem(s)
> One self-limited or minor problem (e.g. cold, insect bite, tinea corporis)
Diagnostic Procedure(s) Ordered

> Lab test requiring: Venipuncture Chest x-ray EKG/EEG Urinalysis Ultrasound/Echo KOH prep >Physiological test not under stress (PFT) >Non-cardiovascular imaging studies with contrast (barium enema, CT) > Sleep studies >Superficial needle biopsy arterial puncture >Skin biopsy >Physiological tests under stress (ex cardiac stress test, fetal contraction stress test) >Diagnostic endoscopies with no identified risk factors > Deep needle or incisional biopsy >Cardiovascular imaging studies with contrast and no identified risk factors (ex arteriogram, cardiac catheterization) >Obtain fluids from body cavity (ex L.P), thorancentesis
Management Options Selected

> Rest > Gargles >Elastic Bandages > Superficial dressings
Low
> Two or more self limited or minor problems > One stable chronic condition illness (e.g. HTN, DM, Cataracts, BPH ) > Acute uncomplicated illness or injury (e.g. sprain, cystitis, rhinitis) >One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment >Two or more stable chronic conditions >Undiagnosed new problem with uncertain prognosis (e.g. lump in breast) >Acute illness with systemic symptoms (e.g. pneumonitis, colitis, pyelonephritis) >Acute complicated injury (e.g. head injury with brief loss of consciousness) >One or more chronic illnesses with severe exacerbation, progression or side effects of treatment >Acute or chronic illnesses or injuries that pose a threat to life or bodily function (e.g. multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, suicidal with potential threat to self or other, peritonitis or acute renal failure) >Abrupt change in neurological status (e.g. seizure, TIA, weakness, sensory loss)
Moderate
High
>Cardiovascular imaging studies with contrast with identified risk factors >Cardiac electrophysiological tests >Diagnostic endoscopies with risk factors >Discography
>Over the counter drugs >Minor surgery with identified risk factor (0-10 days global period) >PT/OT,ST >IV fluids without additives >Prescription drug management maintenance phase >Minor surgery with identified risk factors >Elective major surgery (open, percutaneous, or endoscopic, davinci) with no risk identified risk factors >Prescription drug management (new medication for patient) >Therapeutic nuclear medicine >IV fluids with additives >Closed treatment of fracture or dislocation without manipulation >Elective major surgery (open, percutaneous or endoscopic) with identified risk factors >Emergency major surgery (open, percutaneous or endoscopic) >Parenteral controlled substances >Drug therapy requiring intensive monitoring for toxicity >Decision not to resuscitate or to de-escalate care because of poor prognosis
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) DOCUMENTATION AND REPORTING GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES (CONTINUED) Coding All E/M codes requiring at least either two or three components (history; examination; medical decision making) for providing the sole basis for selecting the level of E/M service are subject to this policy. These codes are: 99201-99205 Office or other outpatient visit; new patient 99211-99215 Office or other outpatient visit; established patient 99218-99220 Initial observation care 99221-99223 Initial hospital care 99231-99233 Subsequent hospital care 99234-99236 Observation or inpatient hospital care 99241-99245 Office/other outpatient consultation; new or established patient 99251-99255 Inpatient consultation; new or established patient 99281-99285 Emergency department visit 99304-99306 Initial nursing facility care 99307-99310 Subsequent nursing facility care 99318- E/M annual nursing facility assessment 99324-99328 Domiciliary or rest home visit; new patient 99334-99337 Domiciliary or rest home visit; established patient 99341-99345 Home visit; new patient 99347-99350 Home visit; established patient G0380-G0384 Hospital emergency department visit
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) MODIFIER 59 - DISTINCT PROCEDURAL SERVICE EFFECTIVE 8/29/10 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. Description A modifier is made up of two alpha and/or numeric characters that are appended to a Current Procedural Terminology (CPT1) or HCPCS code. A modifier is used as a means of reporting a specific circumstance that further defines or alters the code but it does not change the definition of the procedure performed or item procured. Modifier 59 is described by CPT as identifying a distinct procedural service. Appendix A of the CPT Manual states that Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services that are not normally reported together, but are appropriate under the circumstances. Policy Anthem Blue Cross accepts modifier 59 for claims processing, but not always to determine compensation. Modifier 59 is important to the adjudication of the claim because it may result in the override of edits within the Procedure Unbundling ClaimsXten2 Rule. I. Procedure Unbundling: occurs when two or more procedure codes are used to describe a service when a single, more comprehensive procedure code exists that more accurately describes the complete service performed. Procedure unbundling edits include three components: Incidental, Mutually Exclusive, and Re-bundling. When modifier 59 is appended to a reported procedure code, our claims editing system will override most incidental, mutually exclusive, and re-bundling denials, and allow separate reimbursement for that procedure. The incidental, mutually exclusive, and re-bundling edits are not overridden when a different diagnosis is submitted, with a line item procedure code, without modifier 59. However, a different diagnosis alone does not justify the use of modifier 59. Unlisted procedures are not affected by modifier 59. II. Reporting and Documentation Rules and Criteria for Modifier 59: The reporting of modifier 59 by a provider must follow Health Plans requirements for correct coding. We follow The Center for Medicare & Medicaid Services (CMS) requirement that Modifier 59 should be attached to the secondary, additional, or lesser service in the code pair. It should not be appended to the code describing the primary procedure performed. We follow CPT coding guidelines requiring that modifier 59 only be used when there is no other appropriate established modifier, and only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) MODIFIER 59 - DISTINCT PROCEDURAL SERVICE (CONTINUED) Documentation is not required for a claim to be processed when modifier 59 is appended to a CPT/HCPCS code. However, if requested, the patient's medical records must legibly and accurately reflect the distinct procedural services that warranted the use of the modifier. Anthem Blue Cross follows CPT in requiring that documentation must support:
a different session or patient encounter a different procedure or surgery a different anatomical site or organ system a separate incision/excision a separate lesion a separate injury
The following example indicates the appropriate use of modifier 59 when two procedures codes that are not ordinarily performed together on the same day by the same provider, are reported. A single view chest x-ray (71010) is part of the more comprehensive radiologic exam described by 74022 (radiologic examination abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest). If these two procedures are reported together, 71010 will be denied separate reimbursement. When a single view chest x-ray is performed on the same day but at a different time and patient encounter, appending modifier 59 to CPT 71010 is warranted to signify that a separate and distinct service was performed. (Modifier 59 should follow modifier 26, if services are done in a facility setting.) Modifier 59 will override the procedure unbundling edit and 71010 will be eligible for separate reimbursement. III. Exceptions to Modifier 59 Override: Anthem Blue Cross has determined that there are certain circumstances which are exempt from modifier 59 overriding an unbundling edit, or that there are circumstances in which appending modifier 59 to a code is inappropriate. The following is a list of some, but not all of the circumstances, in which appending modifier 59 to a CPT/HCPCS code will not cause the override of the applicable edit, and will not allow for separate reimbursement: Duplicate coding Services and supplies specified in the Bundled Services and Supplies Policy E/M or DME item codes The following exception applies based on the claim processing date, which means that it could apply to claims with dates of service prior to the effective date of this rule (8/29/10). NCCI (National Correct Coding Initiative) edit code pairs with a superscript of zero, or a modifier allowance indicator of zero. Effective November 21, 2010 professional interpretation and reporting codes/components of an EKG and/or radiology when billed by the provider rendering emergency room services. In addition, modifier 59 will not override an edit, and will not allow for separate reimbursement for the first code(s) listed in the following code to code relationships:
1. 2. 3. 4. 5. 6. 7. 8. J2001 reported with 20526-20615, 27096, 64470-64484 E1820 reported with E0935-E0936 01996 reported with 62310-62319 12031-12032 reported with 11400-11401, 11420-11421 12041-12042 reported with 11420-11421 59620-59622 reported with 59618 59514-59515 reported with 59510 76872 reported with 76965
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) BUNDLED SERVICES AND SUPPLIES FOR POLYSOMNOGRAPHY AND OTHER SLEEP STUDIES/TESTS EFFECTIVE 8/29/10 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. Description Polysomnography is indicated for the diagnosis of certain sleep-related disorders. Standard polysomnogram (PSG) sleep studies are routinely performed at sleep study centers, either at a hospital or at a stand-alone facility. Current Procedural Terminology (CPT) codes 95808 and 95810 describe a technologist attended polysomnography with sleep staging. CPT code 95811 describes a technologist attended polysomnography with sleep staging, and the initiation of continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) ventilation. Home and portable sleep studies can be an alternative to standard polysomnography in certain situations. CPT codes 95806-95807 describe portable sleep studies, and HCPCS codes G0398G0399 describe home sleep tests. Please refer to Medical Policy MED.00002 Diagnosis of Sleep Disorders for medical necessity information. This policy addresses the services and supplies that Anthem Blue Cross considers to be included in polysomnography and other sleep studies/tests for providers who render these services and submit claims on a CMS 1500 form. Policy The CPT Manual indicates that polysomnography includes sleep staging which is an additional component not included in other sleep study services. Anthem Blue Cross requires that for a sleep study to be properly classified as polysomnography, sleep must be recorded and staged. All polysomnography services must include the first three sleep staging parameters listed below. The appropriate CPT code for the polysomnography service then should be determined based on how many of the additional sleep parameters listed below are measured. Sleep staging includes: 1-4 lead electroencephalogram (EEG) electroculogram (EOG) submental electromyogram (EMG) Additional parameters of sleep include: electrocardiography (EKG) measurement of O2 saturation (pulse oximetry) airflow respiratory effort measurements snoring extremity muscle activity, motor activity-movement
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) BUNDLED SERVICES AND SUPPLIES FOR POLYSOMNOGRAPHY AND OTHER SLEEP STUDIES/TESTS (CONTINUED) In a split-night study, when enough information is gathered for a positive diagnosis of obstructive sleep apnea (OSA), a nasal mask is applied to the patient and the CPAP machine is titrated to determine the most appropriate setting for relief of symptoms. Anthem Blue Cross does not separately reimburse for services and supplies integral to the performance of polysomnography and other diagnostic sleep studies/tests. In addition to those services listed above, other bundled services and supplies include, but are not limited to: tubing and filters for CPAP or BiPAP electrodes oral/nasal mask and cushions face mask, head gear, chin strap, etc. rental of CPAP or BiPAP humidifier initiation and management of CPAP or BiPAP education and training for self management. Coding The following table identifies by HCPCS and CPT code some, but not all, of the procedures and supplies considered inclusive to the performance of polysomnography and other sleep studies/tests. The inclusion or exclusion of a specific code does not indicate eligibility for coverage under all circumstances. Please note modifier 59 will not override the denial for the bundled services and/or supplies listed below. A4604 A4556 A4557 A4558 A7027 A7028 A7029 A7030 A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7044 A7045 A7046 E0470 E0471 E0561 E0562 E0601 94660 94760 94761 94762 98960
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) LABORATORY AND VENIPUNCTURE SERVICES EFFECTIVE 8/29/10 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. Description Multiple Component Blood Tests The first entry in the Pathology and Laboratory Section of the Current Procedural Terminology (CPT1) Manual is labeled Organ or Disease Oriented Panels. Under the code for each blood panel is an inclusive list of each component code which when grouped together comprise the entire blood panel. CPT indicates that these panels were developed for coding purposes only. The blood panels are: 80047: Basic metabolic panel (calcium, ionized) 80048: Basic metabolic panel (calcium, total) 80050: General health panel 80051: Electrolyte panel 80053: Comprehensive metabolic panel 80055: Obstetrical panel 80061: Lipid panel 80069: Renal function panel 80074: Acute hepatitis panel 80076: Hepatic function panel In addition to the blood panels listed above, the global codes for a complete blood count (85025 and 85027) also have multiple code components: 85025: Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count 85027: Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) Venipuncture Venipuncture is the process of withdrawing a sample of blood for the purpose of analysis or testing. There are several different methods for the collection of a blood sample. The most common method and site of venipuncture is the insertion of a needle into the cubital vein of the anterior forearm at the elbow fold. Please refer to the coding section of this policy for the CPT code most applicable to the method of blood withdrawal. This policy addresses Anthem Blue Crosss reimbursement policies pertaining to clinical laboratory and related laboratory services (e.g., venipuncture and the handling and conveyance of the specimen to the laboratory) for providers claims submitted on a CMS-1500 claim form, whether performed in a physicians office, a hospital laboratory, or an independent laboratory.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) LABORATORY AND VENIPUNCTURE SERVICES (CONTINUED) Policy I. Laboratory Combination Editing for Component Codes A. If Anthem Blue Cross receives a claim for all of the individual laboratory procedures codes that are part of a blood panel grouping (or other multiple component laboratory tests) ClaimsXten2 will bundle those separate tests together into the appropriate comprehensive CPT code listed above (i.e. organ or disease oriented panel codes; CBC codes). This claim editing is based on CPT reporting guidelines. B. Anthem Blue Cross follows CPT reporting guidelines which state: Do not report two or more panel codes that include any of the constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes C. Anthem Blue Crosss total reimbursement for individual laboratory codes that are part of a comprehensive blood panel/CBC code will not exceed the allowance for such comprehensive blood panel/CBC code. If Anthem Blue Cross receives a claim for two or more of the individual laboratory procedures codes that are part of a comprehensive blood panel/CBC code. ClaimsXten will bundle those separate tests together into the appropriate comprehensive blood panel/CBC code. The comprehensive blood panel/CBC code will be added to the claim regardless of whether or not the provider bills all of the individual codes that make up the comprehensive blood panel/CBC code. The laboratory comprehensive blood panel/CBC code will be eligible for reimbursement, and the individually reported codes will be denied. II. Modifiers A. Technical/Professional Modifiers TC/26 1. Technical/Professional Component Billing identifies proper coding of professional, technical and global procedures. Modifier 26 signifies the professional component of a procedure, and Modifier TC signifies the technical component. 2. When CMS National Physician Fee Schedule Relative Value File (NPFSRVF) designates that modifier 26 is applicable to a procedure code (PC/TC indicator of 1 or 6), and the procedure (e.g. radiology, laboratory, or diagnostic) has been reported by a professional provider with a facility place of service, the procedure code must be reported with modifier 26 or it will be denied. 3. If CMS NPFSRVF designates that the concept of a separate professional and technical component does not apply to a laboratory procedure (PC/TC indicator of 3 or 9), and a professional provider has reported the laboratory procedure code with a modifier 26, the laboratory procedure code will be denied. If a laboratory procedure with a PC/TC indicator of 3 or 9 is reported by a professional provider with a facility place of service, the laboratory procedure code will be denied; since in this case, the facility will bill for performing the laboratory procedure.
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) LABORATORY AND VENIPUNCTURE SERVICES (CONTINUED) 4. A global procedure code includes reimbursement for both the professional and technical components. If both of these components are performed by the same provider, the appropriate code must be reported without the 26/TC modifiers. If a provider has reported a global procedure and also reported the same procedure with a professional (26) or technical (TC) component modifier on a different line or claim, the procedure reported with the 26 or TC component modifier will be denied. If a professional provider bills the global code (no modifiers) with a facility place of service, the code will be denied. B. Informational Modifiers Anthem Blue Cross considers modifiers 90, 91 and 92 to be informational only and they do not affect the reimbursement of the laboratory code. III. Routine Venipuncture and the Collection of Blood Specimen A. Routine Venipuncture In addition to reimbursement for a covered laboratory blood test, routine venipuncture CPT codes 36415, 36416, or S9529 are eligible for reimbursement once per member per date of service. If more than one of these codes is reported for the same member on the same date of service, the second code will be denied as not eligible for separate reimbursement. B. Collection of Blood Specimen Anthem Blue Cross follows CPT coding guidelines which state that CPT 36591-36592 .should not be reported in conjunction with any other service. Therefore, these codes are not eligible for separate reimbursement when billed with any other service. Effective 11/21/10, ClaimsXtenTM editing software will apply this policy. IV. Handling and/or Conveyance of Specimen Anthem Blue Cross considers the handling and conveyance of a laboratory specimen, to be included in a providers management of a patient. Therefore codes 99000 and 99001 are not eligible for separate reimbursement. Coding Codes eligible for separate reimbursement when billed with another laboratory service 36415: collection of venous blood by venipuncture 36416: collection of capillary blood specimen (e.g., finger, heel, ear stick) S9529: routine venipuncture for collection of specimen (s), single home bound, nursing home, or skilled nursing facility patient Informational Modifiers -90: reference (outside) laboratory -91: repeat clinical diagnostic laboratory test -92: alternative laboratory platform testing
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UPDATED PPO PROFESSIONAL REIMBURSEMENT POLICIES (cont.) LABORATORY AND VENIPUNCTURE SERVICES (CONTINUED) Codes eligible for separate reimbursement when billed with any other service 36591: collection of blood specimen from a completely implantable venous access device 36592: collection of blood specimen using established central or peripheral venous catheter Codes not eligible for separate reimbursement 99000: handling and/or conveyance of specimen for transfer from the physician's office to a laboratory 99001: handling and/or conveyance of specimen for transfer from the patient in other than a physician's office to a laboratory
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May 21, 2010 <<Provider Business Name>> <<Address>> <<City>>, <<State>> <<ZIP>>

Mike Ramseier Vice President, Provider Engagement and Contracting Enclosures

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B. Amount and/or Complexity of Data Reviewed Points

Diagnostic Procedure(s) Ordered

Management Options Selected

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