Inside This Issue… · Eligibility line at 800-676-BLUE (2583). Northeast Kansas: BlueCard Billing...

Sent to: CAP CPT only © 2001 American Medical Association. All Rights Reserved

January 8, 2003 S-09-02

Questions: Contact your Professional Relations Representative, or the Professional Relations Hotline in Topeka at 785-291-4135 or 1-800-432-3587.

OUR WEB ADDRESS: http://www.bcbsks.com

The Blue Shield Report is

published by your Professional Relations

Department.

Communication Coordinator

Larry Callahan

Inside This Issue… Section 1: Reminders ..................................................................... Pg. 2 Routine Hearing and Vision Screening Content of Medical Visit ........Pg. 2 Neuromuscular/Interferential Stimulator ..............................................Pg. 2 Low-Level Laser Infrared Therapy .......................................................Pg. 2 Chemical Peels and Cryosurgery...........................................................Pg. 2 MRV vs. MRA ......................................................................................Pg. 2 Section 2: Updates ......................................................................... Pg. 3 Anesthesia Services ...............................................................................Pg. 3 OB Epidural Anesthesia ........................................................................Pg. 3 Via Christi Riverside and Wesley Renew for 2003...............................Pg. 5 Newborn Care........................................................................................Pg. 5 Cataract Surgery....................................................................................Pg. 5 Section 3: BlueCard .................................................. Pg. 6 Tyson Members Protected By The Blues ..............................................Pg. 6 Northeast Kansas: BlueCard Billing for Border Counties and Multiple Contract Providers ...........................................................Pg. 6 Section 4: www.bcbsks.com....................................... Pg. 7 Password Challenge...............................................................................Pg. 7 Searching For Past Articles ...................................................................Pg. 7 Internet Tip: Multiple Profiles..............................................................Pg. 7 Section 5: Pharmaceuticals ........................................ Pg. 8 Radiological Pharmaceuticals................................................................Pg. 8 Prescription Drugs Move To Three-Tier Copay Benefit.......................Pg. 8 Prime Therapeutics National Formulary Update ...................................Pg. 9 Miscellaneous.........................................................Pg. 11 Provider Change Form.........................................................................Pg. 11 Acknowledgement: CPT codes, descriptions, and material only are copyright 2001 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS Restrictions Apply to Government Use.

Blue Shield Report S-09-02 January 8, 2003


Section 1: Reminders

Routine Hearing and Vision Screening Content of Medical Visit If routine hearing and vision screenings are done during an evaluation and management (E&M) visit or consultation, the screening is considered content of the visit. This has been effective since July 1, 2001, following the Medical Advisory Committee meeting. E&M visits or consultations supported by pathological diagnoses, which are performed on the same day as a routine hearing and vision screening are allowed separately.

Neuromuscular/Interferential Stimulator Neuromuscular/interferential stimulator rentals are covered for one month when used to treat disuse atrophy or muscle weakness in which muscle mass and strength can be regained. If the stimulator is prescribed as treatment for chronic pain, such as chronic low back pain, then the claim must be reviewed to determine that the treatment is medically necessary before reimbursement will be made.

Low-Level Laser Infrared Therapy The Food and Drug Administration (FDA) has approved low-level laser infrared therapy for treating carpal tunnel syndrome. BCBSKS will allow the therapy and it is suggested to bill the treatment using CPT code 97026.

Chemical Peels and Cryosurgery Chemical peels and cryosurgery treatment for actinic keratosis is reimbursed if the evaluation, diagnostic tests, and pretreatment photos establish medical necessity through a consultant review. Authorization for subsequent treatment requires current photos. Claims not accompanied by the required photos and records will be denied as cosmetic treatment.

MRV vs. MRA Bill NOC (not otherwise classified) code 76498 for magnetic resonance venography (MRV) services. Do not use a magnetic resonance angiography (MRA) code.



Section 2: Updates

Anesthesia Services Effective January 1, 2003, anesthesia services should be billed with the appropriate CPT code, which is the same as the American Society of Anesthesiologists (ASA) anesthesia code. The time of the anesthesia procedure must be reported in minutes (using three digits) in the “units” field on the claim form. The reimbursement methodology is outlined in 2003 Policy Memo No. 12. BCBSKS will accept current billing process for surgical anesthesia until March 31, 2003; however providers are encouraged to commence billing anesthesia codes immediately. NOTE: OB epidural anesthesia billing must follow anesthesia coding (01967, 01968, 01969) as of January 1, 2003, for correct payment calculation. See the following article “OB Epidural Anesthesia” for details.

OB Epidural Anesthesia OB Epidural Guidelines as published in 2003 Policy Memo No. 12 with notes and billing examples added for the purpose of this communication:

F. OB ANESTHESIA

1. OB Epidural Guidelines

a. Epidural placement, monitoring and delivery anesthesia will be reimbursed using the

appropriate CPT neuraxial labor analgesia/anesthesia codes for vaginal and cesarean deliveries.

b. Providers will need to include on the claim the type of service (7).

c. Anesthesia time should be reported as total minutes of documented direct care for

anesthesia administration.

d. BCBSKS will reimburse one unit for every hour of documented direct attendance monitoring.

NOTE: Additional units of monitoring are allowed per hour when the face to face patient monitoring exceeds 15 minutes. The provider will bill 15 minutes for each additional unit of epidural monitoring.

e. If the direct attendance exceeds 15 minutes in any given hour, then there must be

documentation on the patient’s medical record to support the medical necessity for the additional time.



NOTE: Records are not to be submitted with the claim when the provider is requesting additional 15 minute units of monitoring above the one allowed 15 minute unit per hour. Post pay audits will be conducted to validate the accuracy of billing.

f. The billing clerk will submit to BCBSKS the total minutes of documented direct

attendance.

g. Total time from placement to removal of epidural SHOULD NOT be billed, but rather bill the minutes that the anesthesia provider is in direct attendance with the patient.

h. When a vaginal delivery with epidural anesthesia is expected but results in a C-

section, you should bill 15 minutes per hour of documented direct care epidural anesthesia plus the general anesthesia time for the delivery. Use the normal process for reporting general anesthesia time.

i. BCBSKS will reimburse 20 units maximum without review for vaginal deliveries

and 25 units maximum for C-section.

Billing Example #1: Vaginal Delivery - 01967

• Epidural placement took 30 minutes Bill 30 minutes • Patient monitored every hour for 3 hours. Bill 45 minutes*

Total minutes/units on the claim: 075 minutes

*The policy states reimbursement for epidural monitoring will be based on one unit per hour of monitoring. Report 15 minutes per hour in order for proper claims payment calculation to occur.

Billing Example #2: Cesarean Delivery Following Planned Vaginal Delivery –01967 & 01968

• Epidural placement took 30 minutes • Patient monitored every hour for 4 hours • General anesthesia administered for cesarean 1:04 PM to 1:30 PM

Calculate and report total minutes for the scenario as:

Service Minutes Epidural Placement minutes: 30

Hour(s) of monitoring 4 x 15 minutes 60* Total minutes/units reported as 01967 090 General anesthesia reported as 01968 026

*The policy states reimbursement for epidural monitoring will be based on one unit per hour of monitoring. Report 15 minutes per hour in order for proper claims payment calculation to occur.



Via Christi Riverside and Wesley Renew for 2003 Via Christi Riverside Medical Center and Wesley Medical Center have renewed their contracts with Blue Cross and Blue Shield of Kansas (BCBSKS) for 2003.

Newborn Care Currently providers are instructed to bill 99431, which is intended to encompass all the care given to a newborn during a hospital stay. Effective January 1, 2003, newborn care billing will follow CPT guidelines. The CPT guidelines are:

1. 99431 is used for the initial history and exam. 2. 99433 is used for subsequent hospital care. 3. 99238 is used when the newborn is discharged on a day

subsequent to the admittance day. 4. 99435 is used when the newborn is admitted and discharged

on the same day.

Cataract Surgery Although not specifically listed in CPT, use of dye during complex cataract extraction is recognized. Cataract surgery reimbursement will not change for 2003 and providers must continue to bill appropriately for the service performed.



Section 3: BlueCard®

Tyson Members Protected by the Blues As a result of the Tyson-IBP merger, effective October 1, 2002, nearly 2,900 Tyson employees in Kansas have been covered by BlueCard® PPO benefits. You will recognize these members by their unique alpha prefix, TYS. Address questions concerning Tyson benefits to the BlueCard Eligibility line at 800-676-BLUE (2583).

Northeast Kansas: BlueCard Billing for Border Counties and Multiple Contract Providers Do you practice in an area that borders another state, or do you contract with multiple Blue Cross and Blue Shield Plans within a state? Below are guidelines for filing claims for Blue Plan members under these circumstances. Multiple Contract Providers If you practice in a state with more than one Blue Plan and you contract with more than one Blue Plan for the same product type (i.e., PPO or Traditional), then you may choose which Blue Plan to send an out-of-area Blue Plan member’s claim. If you have a PPO contract with one Blue Plan, but a Traditional contract with another Blue Plan, file the out-of-area Blue Plan member’s claim by product type. For example, if it’s a PPO member, file to the Plan with which you have a PPO contract. Border County Providers For providers that practice in border areas, the standard rule is to always file the claim to the Plan located in the state where you provided the service. Exception: when the member is from a bordering Blue Plan with which you have a contract, then file the claim directly to the bordering Blue Plan.



Section 4: www.bcbsks.com

Password Challenge

Forgetting a password becomes tremendously inconvenient when you have to apply for a new password and wait a few days for it to arrive in the mail. To address this inconvenience, a new system was implemented November 18, 2002, which will assist you in retrieving a forgotten password. The new “challenge response” process allows you to save responses to two questions, such as “what is your favorite dessert,” or “who was your favorite teacher?” If you forget your password, you will be asked to give the answers to the two questions that you chose. Answering correctly will allow you to change your password and gain immediate access. To maintain security, answering incorrectly will lock the account and a new password will be sent to the mailing address on file.

Searching For Past Articles Finding past professional relations publications at www.bcbsks.com is easier with a new search engine. At the top of the Professional Provider Publications page is a link called “search the publications.” Clicking this option takes you to the search form. The search result displays all publications containing your keywords, along with a link to view those publications. Things to keep in mind:

1. Searches are case sensitive and letter specific, meaning different results will be displayed using capital letters and/or spaces. For example, a search for “E&M” yields different results than “E & M” or “e&m.”

2. If searching for a specific CPT or procedure code, the code

may have been reported in the newsletter within a range of codes. Another option is to search by the topic.

Publications dated 1999 to current are available online.

Multiple Profiles Internet Tip!

Establish multiple provider profiles if you need several people to access the BCBSKS Web site. Allowing multiple users access

permits them to have individual passwords. By doing this, employees can change their individual passwords without affecting

fellow employees’ ability to access our Web site. wwwwww..bbccbbsskkss..ccoomm



Section 5: Pharmaceuticals

Radiological Pharmaceuticals Currently, BCBSKS allows up to two units of A9500 – A9505 when billed with the radiology procedure code 78465, 78472, or 78473. Based on claims history, BCBSKS has elected to adjust reimbursement to accommodate the way these codes are actually billed. For service dates after December 31, 2002, BCBSKS will allow up to four units of A9505. The maximum allowable payment (MAP) for one unit of A9505 will be reduced to one fourth of its current amount to account for the increased number of units allowed. If A9505 is billed, only one unit of A9500, A9502, A9503, or A9504 will be allowed. If A9505 is not billed, then up to two units of A9500, A9502, A9503, or A9504 is allowed.

Prescription Drugs Move to Three-Tier Copay Benefit Costs for prescription drugs continue to rise at double-digit rates. BCBSKS is working to find ways to keep drug coverage affordable for members, including educating members on the safety of using generic medications. Effective January 1, 2003, a number of Blue Cross Blue Shield of Kansas members will begin using a three-tier copay benefit. This plan design was added as a way to help manage costs while allowing a choice for members and physicians to select the most appropriate medications for each individual. Members will be responsible for the lowest level of copay when utilizing generics, a higher copay for formulary brand-name drugs and the highest level of copay for non-formulary drugs. BCBSKS will utilize the Prime Therapeutics National formulary, which will be printed and distributed to physicians and members. The formulary may also be accessed on the Prime Therapeutics Web site, www.primetherapeutics.com. Members are encouraged to take their Preferred Medication List (formulary) to each office visit to assist you in prescribing a formulary medication, when appropriate. Additions to the formulary will occur quarterly. Deletions from the formulary will occur annually, except as new generic drugs become available. When a generic becomes available for a formulary brand-name drug, the brand-name drug may immediately move to

non-formulary status at the highest level of copayment. This plan design still allows for member choice, as no drug is excluded from payment based on formulary status. The following table illustrates the prescription benefits available from Blue Cross and Blue Shield of Kansas. There are four different plans available with varying levels of copayment. The coinsurance option utilizes “the greater of” logic in determining member copay.

Tier 1: Generic Copay Option 1 $5 Option 2 $10 Option 3 $15

Option 4 $10 or 20% coinsurance

Tier 2: Formulary Brand Copay Option 1 $15 Option 2 $20 Option 3 $30


Tier 3: Non-formulary Brand Copay Option 1 $30 Option 2 $40 Option 3 $45




BCBSKS uses the Prime Therapeutics National Pharmacy and Therapeutics (P & T) Committee to make formulary decisions. A Kansas physician, along with other practicing physicians and pharmacists, reviews scientific literature and reports, consults with other healthcare professionals and uses their expertise to determine which medications should be added to and deleted from the formulary. Prescription drugs are selected for inclusion on the formulary based on safety, clinical effectiveness, uniqueness and cost factors. The goal of the formulary is to assist in maintaining the quality of patient care and containing the cost of prescription drugs. We understand a formulary drug may not always be the appropriate therapy for your patient. No drug will be denied based on formulary status, but the patient will be responsible for the highest level of copay when a non-formulary brand is used. There will not be a formulary exceptions process. We appreciate your cooperation in our effort to provide a quality, cost-effective prescription drug program to our members and your patients. Please contact us if you have questions regarding the formulary or the three-tier benefit.

Prime Therapeutics National Formulary Update Additions to the Prime Therapeutics National Formulary effective 10/1/02 Chapter 1 – Anti-Infective Agents amoxicillin & potassium clavulanate tablets AVELOX/moxifloxacin GRIFULVIN V/griseofulvin, microsize VIREAD/tenofovir Chapter 4 – Endocrine and Metabolic Drugs NUTROPIN AQ PEN/somatropin prednisolone liquid 6.7 mg/5 mL Chapter 5 – Cardiovascular Agents COZAAR/losartan enalapril & hydrochlorothiazide fenofibrate flecainide HYZAAR/losartan & hydrochlorothiazide lisinopril lisinopril & hydrochlorothiazide ZOCOR/simvastatin Chapter 7 – Gastrointestinal Agents RENAGEL/sevelamer Chapter 8 – Genitourinary Products amino acid-urea cervical cream MACRODANTIN/nitrofurantoin macrocrystalline Chapter 11 – Neuromuscular Drugs bromocriptine tizanidine Chapter 14 – Topical Products azelaic acid clindamycin lotion desonide lotion FINEVIN cream/azelaic acid tretinon gel 0.01% Chapter 15 – Miscellaneous Products cyclosporine capsules

KEY BRAND Name drugs are

in upper case

generic drugs are in lower case



Deletions from the Prime Therapeutics National Formulary effective 10/1/02 Chapter 1 – Anti-Infective Agents CEFTIN tablets, generic tablets and CEFTIN suspension remain FLUMADINE tablets, generic tablets and FLUMADINE syrup remain FUROXONE/furazolidone Chapter 4 – Endocrine and Metabolic Drugs PEDIAPRED liquid, generic remains Chapter 5 – Cardiovascular Agents ATACAND/candesartan ATACAND HCT/candesartan & hydrochlorothiazide PRAVACHOL/pravastatin PRINIVIL, generic remains PRINZIDE, generic remains TAMBOCOR, generic remains ZESTORETIC, generic remains ZESTRIL, generic remains Chapter 7 – Gastrointestinal Agents COMPAZINE suppositories, generic remains GOLYTELY, generic solution remains METOCLOPRAMIDE INTENSOL, generic tablets and syrup remain NULYTELY/PEG(HIGH)-electrolyte powder for solution Chapter 8 – Genitourinary Products HIPREX/methenamine hippurate ORACIT/citric acid and sodium citrate URECHOLINE/bethanechol UREX/methenamine hippurate Chapter 9 – Central Nervous System Drugs REMINYL/galantamine Chapter 11 – Neuromuscular Drugs ZANAFLEX, generic remains Chapter 14 – Topical Products AZELEX CREAM, generic remains

You can access the latest formulary on

the Internet at www.bcbsks.com

Select

“Providers” from the homepage, then “Drug Formulary.”

KEY BRAND Name drugs are in

upper case

generic drugs are in lower case



Provider Information Change Form

Every month BCBSKS has reimbursement checks and essential communications returned due to outdated addresses and phone numbers. Help us help you by keeping your records current with BCBSKS. If you relocate or change any of the following information, you may use this form, sending it to the address below, or fax it to us directly. You may also call the Professional Relations Hotline in Topeka at 785-291-4135 (1-800-432-3587 outside of Topeka) or speak with your Professional Relations Representative to update your records. Provider Name Provider Billing Number Please make the following changes to my provider records: Practice Name Practice Address Mailing Address Telephone Number Fax Number Tax ID Number Specialty Completed By Authorizing Signature Date Please mail this form to: Blue Cross and Blue Shield of Kansas Attn: Cost Center 443 1133 SW Topeka Boulevard Topeka, KS. 66629-0001 or fax to: 785-290-0734 Attn: CC 443

Inside This Issue… · Eligibility line at 800-676-BLUE (2583). Northeast Kansas: BlueCard Billing...

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Transcript of Inside This Issue… · Eligibility line at 800-676-BLUE (2583). Northeast Kansas: BlueCard Billing...