CMA Practice Resources (CPR) is a free monthly e-bulletin from the California Medical Association’s practice management experts that focuses on critical payor and health care industry changes and how they directly impact the business of a physician practice. Each issue includes tips on reimbursement and contracting related issues along with information on the latest practice management news.
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In this issue:
- Anthem Blue Cross announces changes to reimbursement policies and claims software
- United Healthcare to alter Premium Designation criteria
- Survey: Is your practice ready for ICD-10?
- Ask the Expert: If Medicare pays for a procedure, does a Medicare Advantage plan also
have to pay?
- United Healthcare to deactivate inactive physician TINs as part of provider directory cleanup
- The Coding Corner: Joint aspiration/injection coding
Anthem Blue Cross recently notified physicians of upcoming changes to the insurer’s reimbursement policies and claims editing software, called ClaimsXten. The changes will go into effect on July 1, 2015. Because of these changes, physicians may notice a difference in how certain codes and code pairs are adjudicated.
Along with the notice, Anthem provided a comprehensive grid outlining the new, revised and existing reimbursement policies and claims editing rules as well as copies of Anthem’s reimbursement policies.
The changes include additions to the types of service Anthem will consider bundled with another procedure and thus will be ineligible for separate reimbursement (Policy CA – 0008). Anthem has also added to the list of CPT codes that will have a frequency edit (Policy CA – 0016), thus setting a limit on the number of units or number of times a code is eligible for reimbursement on a single date of service. A new frequency edit of note is a limit on the preparation of allergen immunotherapy of 120 doses per 365 days. Anthem has clarified to the California Medical Association (CMA) that it will consider payment for more than 120 doses per 365 days if there is a medical reason, and if the additional doses are actually received by the patient and not discarded as pharmaceutical waste.
There are also new policies on cancer treatment planning (Policy CA – 0043) and documentation guidelines on psychotherapy services (Policy CA – 0047).
While Anthem’s grid outlining policy changes indicates that the Multiple and Bilateral Surgery Processing policy (Policy CA – 0010) is existing, inferring there are no changes, CMA has identified that while the policy is not new, three new CPT codes (43233, 43266 and 43270) were added to the list of affected codes. These codes were newly added to the CPT manual in 2014. The policy states that when billing multiple esophagogastroduodenoscopy codes, practices will be paid 100 percent of the fee schedule for the primary procedure and 25 percent for subsequent procedures. At CMA’s suggestion, Anthem will update the policy grid to indicate this policy is “revised.”
The most significant change, however, is a modification to Anthem’s policy on evaluation and management (E/M) services billed on the same day as a preventive exam (Policy CA – 0026). Effective July 1, 2015, when physicians bill a preventive visit on the same day as a problem-oriented E/M visit, Anthem will only reimburse the problem-oriented E/M visit at 50 percent of the physician’s contracted rate. While some other payors have similar policies, this will reflect a change in reimbursement for affected Anthem claims.
To address this change, practices have the option of advising patients that a separate appointment is required to address the problem-focused issue. However, it will be important for practices to manage patient expectations.
When the preventive services appointments are scheduled, staff should inquire with patients about whether they wish to discuss any other health issues with the physician and, if so, advise that a separate appointment will be required due to the plan/insurer’s policy. The practice can then schedule the problem-oriented visit first and schedule the preventive service for a later date. Even if the patient indicates he/she has no other health issues to discuss with the physician, the scheduler should advise the patient that if other health issues arise, another visit may be required.
Physicians are encouraged to review all of the claims editing changes as well as the corresponding detailed payment policies to understand how the changes will affect their individual practices.
Physicians can also access this information via the Blue Cross ProviderAccess website (log in, then select “Reimbursement Policies and McKesson ClaimsXten Rules” under the “What’s New” section).
Questions about any of the claims editing rules or payment policies can be directed to the Blue Cross Provider Care Department at (800) 677-6669.
Contact: CMA reimbursement helpline, (888) 401-5911 or email@example.com.
The California Medical Association (CMA) has learned that United Healthcare (UHC) has altered the criteria for meeting the physician cost efficiency component of its Premium Designation program. UHC will now designate a physician as “Cost Efficient” when he or she has met the episodic cost benchmark, even if the physician did not achieve the population cost benchmark. The change only impacts those physician specialties that are evaluated on both population cost and episode cost, which include:
- Family medicine,
- Internal medicine
Surgical specialties are all excluded.
Previously, physicians who met episodic cost but failed to meet the population cost component did not receive the UHC Cost Efficiency designation in the Premium Designation assessment. The results of the modified criteria were communicated to affected physicians in a letter in March and are also available on the UHC website. This designation includes data from January 1, 2011, through February 28, 2014.
In 2014, CMA raised multiple concerns with the payor’s criteria for evaluating physician cost efficiency and urged the payor to make changes. To read more about the concerns, click here.
Physicians who have questions or concerns with their physician assessment reports or their Premium Designation can contact UHC at (866) 270-5588. Practices that are unable to obtain answers to their questions or resolve the issue with United Healthcare directly should contact CMA at (916) 551-2865.
For more information on the Premium Designation program, visit the United Healthcare website at www.unitedhealthcareonline.com.
With less than five months left until the October 1, 2015, implementation date of ICD-10, physician practices should be well into the preparation and planning process for the ICD-10 transition. Congress has reaffirmed that it intends on moving forward with no delays in the implementation date.
In an effort to gauge members’ preparedness, the California Medical Association (CMA) is surveying physicians on their readiness for ICD-10 implementation. The survey will take less than five minutes, and your participation will help in directing our advocacy efforts around additional ICD-10 training and educational resources for physician practices.
The survey can be completed online at www.surveymonkey.com/s/AreYouReadyForICD10. Please complete the survey by May 22.
To help physicians prepare for the transition, CMA has published the “ICD-10 Transition Guide – What physicians need to know,” which includes an ICD-10 transition preparation checklist.
CMA has also created an ICD-10 transition webpage, www.cmanet.org/icd10, which includes important news articles and other ICD-10 transition information.
CMA is also partnering with AAPC to offer two-day live ICD-10 boot camp classes throughout the state. The training is designed for coding staff and intended to provide a comprehensive understanding of guidelines and conventions of ICD-10, and how to decipher and accurately select ICD-10 codes. To register, visit www.cmanet.org/AAPC-ICD10 and select the course nearest you, or call (800) 786-4262. Space is limited and is on a first-come, first served basis. CMA members and their staff receive steep discounts to the live training events.
The California Medical Association (CMA) has received this question from physician practices many times over the past few years. The answer is – it depends.
Title XVIII of the Social Security Act established regulations for the Medicare program, which includes provisions affecting Medicare Advantage (MA) plans. The Centers for Medicare and Medicaid Services (CMS) has interpreted these provisions through the Medicare Managed Care Manual (Chapter 4 – Benefits and Beneficiary Protections). The Manual provides guidance for MA plans under Internet-only manual (IOM) 100-16. These guidelines reflect CMS’ current interpretation of the provisions of the MA statute and regulations (Chapter 42 of the Code of Federal Regulations, part 422) pertaining to benefits and beneficiary protections.
In general, the Act lists categories of items and services covered by Medicare. Congress occasionally adds specific services to be covered by Medicare. The MA plans are required to provide enrollees with all basic categories of benefits under Original Medicare. Some examples of services that are specifically defined in the Act and that MA plans would be required to cover are prostate cancer screening tests for a man over 50 years of age who has not been tested in the preceding year, as well as pneumococcal, influenza and hepatitis B vaccines and administration.
While MA plans are required to provide coverage for the same basic categories of benefits as Original Medicare would provide, MA plans are not necessarily required to pay for all of the same procedures that Medicare would have paid. So, how can you determine when an MA plan is required to pay?
According to the CMS Internet Only Manual 100-16, Chapter 1 (page 4), an item or service classified as an original Medicare benefit must be covered by an MA plan if:
- The specific service is specifically identified in the Act (section 1861) (unless superseded by written CMS instructions or regulations regarding Part C of the Medicare program);
- CMS has a National Coverage Determination specifically listing that CPT code as medically necessary/payable; or
- A local Medicare Administrative Contractor with jurisdiction for claims in your geographic region has a Local Coverage Determination that specifically lists that CPT code as medically necessary/payable.
In other words, if the service in question doesn’t fall into one of the above categories, the MA plan may have its own medical policy and deem a procedure experimental, investigational or not medically necessary and deny payment. For this reason, it’s important to be familiar with the medical policies of the plans for which you contract.
Beginning August 1, 2015, United Healthcare (UHC) will initiate a cleanup of its participating provider database and directory. Participating physicians who have not submitted a claim to UHC for a period of one year will be deemed to have voluntarily ceased participation in the UHC physician network; United will initiate a termination of the physician agreement. UHC will contact impacted providers to advise of the termination and to clarify any concerns from the physician. The California Medical Association has inquired about when and how physicians will be notified.
Additionally, if a participating physician has multiple tax identification numbers (TIN) and UHC shows that any one of the TINs has not submitted claims for a period of one year or greater, UHC will deactivate that TIN. The provider will retain his or her participation status under the active TIN and no notification of deactivation of the inactive TIN will be provided. Providers who wish to reactivate a TIN should contact UHC Network Management at (866) 574-6088 to update their information in its system.
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
Four questions commonly arise when coding for joint aspiration or injection:
- When is it appropriate to report guidance in addition to joint aspiration/injection?
- When is it appropriate to report multiple code units for joint aspiration/injection?
- May I report an evaluation and management (E/M) service in addition to joint aspiration/injection?
- Should I report supplies separately with joint aspiration/injection?
Before answering these questions, let’s consider coding basics for these procedures.
During either joint aspiration or injection, imaging guidance may be employed to ensure accurate needle placement. For CPT® 2015, the American Medical Association revised the previous joint (or bursa) aspiration/injection codes to specify “without ultrasonic guidance,” while adding codes to describe the same procedures with ultrasonic (US) guidance:
- 20600 Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); without ultrasound guidance
- 20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting
- 20605 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance
- 20606 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting
- 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance
- 20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting
If the provider performs joint aspiration/injection with US guidance, select 20604, 20606 or 20611 (depending on the joint targeted). If the provider aspirates/injects the joint/bursa without guidance of any kind, select from among 20600, 20605 and 20610.
Some guidance may be separate
CPT® allows you to separately report fluoroscopic, CT or MRI guidance for needle placement during joint/bursa aspiration/injection, when performed. Claim the “without ultrasonic guidance” code for the aspiration/injection, plus 77002 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device); 77012 Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation; or 70021 Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation, as appropriate.
Reporting multiple units
Report a single unit of 20600-20611 for each joint treated, regardless of how many aspirations and/or injections occur in a single joint.
You may report multiple units of a single code for aspiration/injection of multiple joints of same size (e.g., two large joints, left knee and left shoulder). If aspirations and/or injections occur on opposite, paired joints (e.g., both knees), report one unit of 20610 with modifier 50 Bilateral procedure appended, per Centers for Medicare and Medicaid (CMS) instruction. Non-Medicare payers may specify different methods to indicate a bilateral procedure.
If the provider performs injections on separate, non-symmetrical joints (e.g., left shoulder and right knee), report two units of the aspiration/injection code and append modifier 59 Distinct procedural service to the second unit (e.g., 20610, 20610-59).
20610 and same-day E/M
Do not report an E/M service with a planned injection service if the patient presents without complications or a new problem. CPT Assistant (March 2012) offers the following example:
A patient complained of left knee pain. At a previous visit, the physician evaluated the knee, ordered a prescription of a nonsteroidal anti-inflammatory drug and scheduled a follow-up visit two weeks later for performance of an arthrocentesis if not improved. The patient returned, wherein the physician performed an arthrocentesis and injection of the left knee joint and scheduled a follow-up visit for one month later.
It would not be appropriate to report the E/M service at the two-week follow-up visit because the focus of the visit was related to the performance of an arthrocentesis. Only code 20610 for the arthrocentesis would be reported.
If an E/M service is separately identifiable from the typical pre-service work of an aspiration/injection, you may report the E/M service separately with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended. A separate E/M might also be appropriate if the physician performs the injection/aspiration and also evaluates the patient for a different or exacerbated condition.
Documentation must substantiate that the E/M service was significant; a best practice is to separate the documentation for the joint injection/aspiration and the E/M service. Only if the E/M service stands on its own may you report it separately with modifier 25.
For Medicare payers, the aspiration/injection codes do not include the drug supply (other than local anesthetic) for injection. If the provider paid for the drug, he or she may report the supply separately using the appropriate HCPCS supply code.
“The staff at CMA are invaluable. We are a small sole practitioner office who has greatly appreciated the assistance of CMA helping us navigate through the changes in health care including meaningful use, ICD-10 and PQRS. We really don't know what we would do without their support. Thank you, CMA.”
Bakhtiar Ahmad, M.D.
Member since 1993
ANTHEM BLUE CROSS
New codes added to specialty pharmacy prior authorization list
Blue Cross will be adding the following specialty pharmacy drug codes to its Specialty Pharmacy Prior Authorization list effective July 15, 2015. These changes will not apply to Blue Card out-of-area, HMO, Medicare, Medicare Advantage (MA), Federal Employee Program® (FEP®), State Sponsored Business (SSB) or selected National accounts. If the service is not prior authorized/pre-certified, records will be requested for post-service review based on the same criteria listed in the medical policy or clinical guideline.
|Medical Policy/Clinical Guideline||Drug Name||Drug Code|
|DRUG.00072||Alpha-1 Proteinase Inhibitor Therapy||Existing codes J0256 and J0257|
|DRUG.00073||Rionacept(Arcalyst)||Existing code J2793|
|DRUG.00074||Alemtuzumab (Lemtrada)||No specific code for Lemtrada. J3490 and J3590 NOC- will be reviewed for medical necessity when specified Lemtrada|
|CG-DRUG-42||Asparagine Specific Enzymes (Asparaginase)||J9019, J9020, J9266|
Precertification required on four new Part B injectables
Anthem has added four new injectable drugs to the 2015 Medicare Advantage list of Part B Injectables/Infusibles requiring precertification. As of March 1, 2015, providers must call for prior authorization of these drugs.
- Benlysta (belimumab) for treatment of lupus (SLE) (J0490) and drugs billed with NOC HCPCS J code (J3490)
- Iluvien (fluocinolone acetonide injection) for treatment of diabetic macular edema (DME) (unlisted, no J code established at this time)
- Lemtrada (alemtuzumab injection) for treatment of relapsing forms of multiple sclerosis (MS) (unlisted, no J code established at this time)
- Opdivo (nivolumab) for treatment of unresectable or metastatic melanoma (unlisted, no J code established at this time)
To obtain a prior authorization, providers can contact Anthem by phone at (866) 797-9884, by fax at (866) 959-1537 or by email at firstname.lastname@example.org.
HUMANA: Humana has announced updates to its claim payment policy and code-editing guidelines effective June 22, 2015. Physicians can view all payment policies online by visiting the Humana website at www.humana.com/provider/medical-providers/education/claims/processing-edits.
MEDI-CAL: Medi-Cal has announced that effective July 1, 2015, it will no longer accept the ZS modifier. Currently, this modifier is used for services that include both professional and technical components. After July 1, this modifier is no longer needed or required when billing for both technical and professional services.
Except for MRI, MRA or PET procedures, providers will be instructed to use one of the following methods when submitting a claim for both the professional and technical components of split-billable procedures:
- Physician billing: The physician bills for both the professional and technical components and then reimburses the facility for the technical component, according to their mutual agreements. The physician submits a CMS-1500 claim form with the procedure code on one claim line without a modifier in the Procedures, Services or Supplies/Modifier field (Box 24D).
- Facility billing: The facility bills for both the technical and professional components and then reimburses the physician for the professional component, according to their mutual agreements. The facility submits a UB-04 claim form with the procedure code on one claim line without a modifier in the HCPCS/Rate/HIPPS Code field (Box 44).
Except for MRI, MRA or PET procedures, when submitting a treatment authorization request (TAR) for both the professional and technical components of split-billable procedures, providers should submit the TAR with the procedure code on one service line without a modifier. See the relevant sections of the provider manual for details pertaining to the use of modifiers for MRI, MRA and PET procedures.
The California Medical Association’s Center for Economic Services provides direct reimbursement assistance to CMA physician members and their office staff.
Reimbursement Help Line (888/401-5911)
- One-on-one educational and reimbursement assistance to physician members and their staff
- Tools and resources to empower physician practices
- Seminars and toolkits for physicians and their staff
- Staffed by practice management experts with a combined experience of over 125 years in medical practice operations
Need help? Contact CMA’s reimbursement experts at (888) 401-5911 or email@example.com.
To make sure that you are aware of important news from your contracting health plans, we encourage you to regularly read plans' provider newsletters and bulletins. Follow the links below to access the current issues.
AETNA: www.aetna.com. Click on "Health Care Professionals" in the main menu, then on "News for Providers" in the left sidebar.
CIGNA: www.cigna.com. Click on "Health Professionals" under "Customer Care" in the main menu. Then, scroll down and click on "Newsletters."
ANTHEM BLUE CROSS: www.anthem.com/ca. Click on "Providers" in the main menu, then on "Professional Network Update" under "Spotlight."
BLUE SHIELD: www.blueshieldca.com. Click on "I'm a Provider," then on "Announcements" under "News and Features."
HEALTH NET: www.healthnet.com. Click on "I'm a Provider" and then "California." Enter username and password, and then click "Online News."
MEDI-CAL: www.medi-cal.ca.gov. Click on "Publications" in the main menu, then on "Provider Bulletins."
MEDICARE/NORIDIAN: https://med.noridianmedicare.com/web/jeb/fees-news. Noridian publishes individual articles through the Latest Updates section in the left sidebar. The articles are condensed approximately every six-to-eight weeks into a Bulletin.
UNITED HEALTHCARE: www.unitedhealthcareonline.com. Click on "Tools & Resources" in the main menu, then on "Network Bulletin."
CMA RESOURCE: Find up-to-date profiles on each of the major payors in California.
If you have questions related to any of the articles in this issue, please contact CMA's reimbursement help line, (888) 401-5911 or firstname.lastname@example.org. Questions about membership, including technical website issues, should be directed to CMA's member help center, (800) 786-4CMA or email@example.com.
Let us know which topics you would like to see addressed in future issues. Contact CMA's Center for Economic Services at (916) 551-2061 or firstname.lastname@example.org.