Provider Update March 2024

Medical

Recent updates to Medical Policy:

III.57 – COSMETIC AND RECONSTRUCTIVE SURGERY

Effective Jan. 23, 2024 - Added: M. Mastopexy when performed as a staged procedure prior to nipple sparing mastectomy for individuals with a high risk of breast cancer OR when performed as a breast reconstruction procedure following or in conjunction with mastectomy or breast-conserving surgery due to a diagnosis of breast cancer.

 

I.200 – AMNIOTIC MEMBRANE AND AMNIOTIC FLUID

Effective Feb. 1, 2024 – Added: G. Difficult to heal chronic venous partial and full-thickness ulcers of the lower extremity that have failed standard wound therapy greater than four weeks duration.

 

I.214 – VIRTUAL REALITY-ASSISTED THERAPY & PRESCRIPTION DIGITAL THERAPIES

Effective Feb. 1, 2024 – Added: Prescription Digital Therapies as investigational.

 

III.238 – HIP LABRUM RECONSTRUCTION SURGERY

Effective Feb. 1, 2024 – Added: Labral augmentation was added to this policy as an investigational procedure.

 

III.170 – Lumbar Artificial Intervertebral Discs 

Effective March 22, 2024 - Will retire and CPT codes 0164T, 0165T, 22857, 22860, 22862 and 22865 will be reviewed with criteria under Medical Policy III.187 NIA (Interventional Pain Management and Cervical/Lumbar Spine Surgery).

Reminder: Submitting corrected claims

Corrected claims should only be submitted after the claim has been adjudicated and the status of the claim in NaviNet shows “Finalized.”

For more information on submitting corrected claims, please reference the Corrected Claims policy.

Reminder: Provider sanction for non-Nebraska claims

As communicated on Happening Now on Dec. 29, 2023, If a provider obtained a prior authorization or retro authorization from a non-Nebraska Blues Plan, but the claim has been denied as a Provider Sanction, please be advised:

• Provider must submit a reconsideration via NaviNet
• BCBSNE will send the reconsideration to the member’s Plan for review
• BCBSNE will notify you of the decision made by the member’s plan as they determine if the claim will be reprocessed or if the denial is upheld.

Reminder: Changing number of days auto-approved for inpatient admissions

As communicated last month via Happening Now and our Provider Bulletin, BCBSNE utilizes InterQual criteria for hospital inpatient admission reviews, and hospitals can submit precertification requests for admissions via our online portal by signing into NaviNet. Currently, acute inpatient admissions that meet InterQual criteria and do not pend for a BCBSNE nurse to review, receive an automatic approval of 4 days for the initial admission. 
 
Effective June 1, 2024, the initial length of stay automatically approved for acute inpatient admissions will be reduced from four to three days. If additional days are needed, a concurrent review request is submitted via the online portal as it is today. The number of days automatically approved for observation admissions or concurrent reviews that meet the appropriate InterQual criteria will not change.

Effective Jan. 1, 2024, BCBSNE made the business decision to not cover CPT 99459

CPT 99459 is direct practice expenses associated with performing a pelvic exam in the non-facility setting. Keep in mind that while you can bill this code, BCBSNE considers this service as inclusive; therefore, included in the allowance for the pelvic exam. It is not necessary to submit a reconsideration request as these denials will be upheld.

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Services

Effective Apr. 1, 2024, BCBSNE will apply a payment reduction when multiple eligible diagnostic imaging services are provided to the same patient on the same day by the same provider or different providers within the same group practice.

Aligning with the Centers for Medicare & Medicaid Services, MPPR on certain diagnostic imaging services applies to the professional component and technical component services. It applies to both professional component-only services, technical component-only services, professional component and technical component of global services, and to multiple units of the same technical component and professional component services.

Full payment is made for each professional component and technical component service with the highest payment under the Medicare Physician Fee Schedule for the procedures with a multiple surgery value of ‘4’ in the Medicare Fee Schedule database. Payment is made at 95 percent for subsequent professional component services. Payment is made at 50 percent for subsequent technical component services.

Professional claims with diagnostic imaging services should be submitted with a single date of service on each line. 

Unlisted codes for ambulatory surgical center facilities (ASC), effective July 1, 2024

Effective July 1, 2024, ASC Facilities will follow the same procedure as professional claims for Unlisted CPT/HCPC codes.  See policy number RP-X-008 for complete details. 

Dental

Submitting corrected claims 

When needing to correct services or charges previously submitted, please use our Reconsideration Request form. Resubmitting a new claim with changes written on the claim form have a high chance of being denied as a duplicate due to auto adjudication.

Reminder: Orthodontics/Invisalign

The initial banding charge should be up to one-third of the total charge. After the initial banding, the provider may bill monthly or quarterly (three-month increments) for the remainder of treatment, until the benefit is exhausted. Please see policy number DP-X-004 for complete details. 

Medicare Advantage

Reminder: Updates to Carelon Clinical Appropriateness Guidelines

Effective for dates of service on and after April 14, 2024, the following updates will apply to the Carelon Clinical Appropriateness Guidelines (formerly AIM Specialty Health guidelines). As part of the Carelon guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.

Updated Guidelines

Radiology

• Cardiac imaging / Imaging of the Heart
• Oncologic Imaging
• Brain Imaging 
• Head and Neck Imaging 
• Chest Imaging
• Abdomen-Pelvis Imaging

Musculoskeletal 

• Interventional Pain Management

Radiation Oncology 

• Radiation Therapy
      *  All other Radiation Oncology guidelines are reaffirmed without changes

For questions related to guidelines, please contact Carelon via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Advanced illness and frailty exclusions allowed for HEDIS^® star measures

The National Committee for Quality Assurance (NCQA) allows patients to be excluded from select HEDIS^® star quality measures due to advanced illness and frailty. They acknowledge that measured services most likely would not benefit patients who are in declining health.

You can submit claims with advanced illness and frailty codes to exclude patients from select measures. Using these codes also reduces medical record requests for HEDIS data collection purposes. 

Read the Advanced Illness and Frailty Exclusions for HEDIS Star Measures Guide for a description of the advanced illness and frailty exclusion criteria and a list with some of the appropriate HEDIS-approved billing codes.

_{Source: http://blog.ncqa.org/improving-care-advanced-illness-frailty/}

Encourage eligible Medicare Advantage patients to get screened for colorectal cancer

According to the American Cancer Society, colorectal cancer (CRC) is the second most common cause of cancer death for both men and women combined in the United States. However, more than one-half of all cases and deaths are attributable to modifiable risk factors, such as smoking, an unhealthy diet, high alcohol consumption, physical inactivity, and excess body weight,¹ and thus potentially preventable. In addition, a large proportion of CRC incidence and mortality can also be mitigated through appropriate screening, surveillance, and high-quality treatment.²

The Colorectal Cancer Screening (COL) HEDIS^® star measure assesses patients ages 45–75 who had appropriate screenings for colorectal cancer.
Colonoscopy is the gold standard for colorectal cancer screening. There are alternative options for patients who are hesitant to have one.
Read the Colorectal Cancer Screening tip sheet to learn about this measure including what information to include in medical records, codes for patient claims and tips for talking with patients.

_{Source: Colorectal cancer statistics, 2023 - Siegel - 2023 - CA: A Cancer Journal for Clinicians - Wiley Online Library 
¹Islami F, Goding Sauer A, Miller KD, et al. Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States. CA Cancer J Clin. 2018; 68:31-54.
²Winawer SJ, Zauber AG. The advanced adenoma as the primary target of screening. Gastrointest Endosc Clin N Am. 2002; 12:1-9, v.}

HEDIS measure: Follow-up after an emergency department visit is important patient care

Many patients discharged from the emergency department (ED) require urgent follow-up care with their providers due to their high-risk chronic conditions. Often, an ED discharge is based on the presumption of continued care.

The Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC) focuses on the percentage of members aged 18 and older who have multiple high-risk chronic conditions and who had a follow-up visit within seven days of an emergency department visit.

There are many ways to conduct a follow-up visit, including outpatient, telephone, Transitional Care Management (TCM), case management, complex care management, outpatient or telehealth behavioral health, intensive outpatient encounter or partial hospitalization, community mental health center, electroconvulsive therapy, telehealth, observation, e-visit, virtual check-in, or domiciliary/rest home visits.

Read the tip sheet to learn more about this measure, including information about eligible chronic conditions, exclusions, best practices, documentation requirements and more.

Transitions of Care HEDIS measure focuses on medication management & care coordination for Medicare beneficiaries

According to the American Journal of Managed Care, the ineffective transferring of a patient from one care setting (e.g., a hospital, nursing facility, primary care physician, long-term care, home health care, specialist care) to another often leads to confusion about treatment plans, missed follow-up appointments, patient dissatisfaction, medication nonadherence and, most importantly, unnecessary readmissions.

The Transitions of Care (TRC) HEDIS measure for star ratings focuses on the percentage of members who had an acute or non-acute inpatient discharge during the measurement year and who had each of the following:

• Notification of inpatient admission
• Receipt of discharge information
• Patient engagement after inpatient discharge
• Medication reconciliation post-discharge 

Documentation of all four components must be in any outpatient record, as well as accessible by the PCP or ongoing care provider.

We encourage you to establish an office practice that explains to patients why it is critical they inform your office about their hospital admissions and discharges. Let them know this is important because it can improve their care coordination and maintain their safety. 

Read the tip sheet to learn more about the measure, including exclusions, best practices and documentation requirements.

_{Source: American Journal of Managed Care
Contributor: Why Medicare Advantage Plans Must Transform Post Discharge to Medication-Focused Transitions of Care (ajmc.com)}

Measurement Year 2023 HEDIS Medical Record Review

Each year from February through May, BCBSNE performs medical record reviews to collect HEDIS measurement quality data for Medicare Advantage and Commercial members. BCBSNE uses Reveleer to collect data for commercial members and CIOX for Medicare Advantage members. Both Reveleer and CIOX look for clinical details that may not have been captured in claims data, such as blood pressure readings, HbA1c lab results and colorectal cancer screenings.

Your clinic may be contacted by either Reveleer or CIOX requesting you provide the necessary records. We appreciate your assistance with these important reviews. Your cooperation helps us meet our quality goals as we seek to improve the overall health of our members – your patients. HEDIS medical record reviews reflect the quality-of-care patients receive that cannot be captured via the claims process.

As a reminder, your contract as a participating provider contains language around the provision of providing requested records to BCBSNE or third-party vendors, at no charge, to capture the content of clinical encounters with our members. We do not want to disrupt your office workflow more than necessary, so the faster we obtain the requested records, the fewer follow-up contacts will be needed. Thank you in advance for your prompt response to our requests and for helping us successfully complete our HEDIS reporting. 

For more information on HEDIS visit NCQA.org.

Medicare Advantage Access Standards

Blue Cross Blue Shield of Nebraska (BCBSNE) establishes provider access standards in accordance with CMS regulations for BCBSNE Medicare Advantage members. The following standards apply to BCBSNE Medicare Advantage Primary Care and Behavioral Health in-network providers for BCBSNE Medicare Advantage. Providers who do not meet the standards may be required to complete a Corrective Action Plan (CAP).

CMS requires the hours of operation of practitioners are convenient for and do not discriminate against members. Practitioners must provide coverage for their practice 24 hours a day, seven days a week with a published after-hours service, or recorded message directing members to a physician for after-hours care instruction. Recorded messages instructing members to obtain treatment via an emergency room for conditions that are not life threatening is not acceptable.

Provider Type	Appointment Type
Primary Care Provider General Practice Family Practice   Internal Medicine Pediatric Medicine Obstetrics and Gynecology practitioners	Routine and Preventive care must be provided within 30 business days of patient request.   Non-Urgent care requiring medical attention must be provided within 7 business days of patient request.  Emergent Care for urgently needed services must be provided immediately.
Behavioral Health Provider Psychology Psychiatry  Mental Health and Substance Abuse practitioners	Routine and Preventive care must be provided within 30 business days of patient request.   Non-Urgent care requiring medical attention must be provided within 7 business days of patient request.  Emergent Care for urgently needed services must be provided immediately.

After-Hours Access to Care

CMS requires that the hours of operation of its practitioners are convenient for and do not discriminate against members. 
 
Practitioners must provide coverage for their practice 24 hours a day, seven days a week with a published after-hours telephone number (to a practitioner’s home or other relevant location), pager or answering service, or a recorded message directing members to a physician for after-hours care instruction. 
 
Note: Recorded messages instructing members to obtain treatment via emergency room for conditions that are not life threatening is not acceptable. In addition, primary care physicians must provide appropriate backup for absences

Security Corner

National Consumer Protection Week 2024

National Consumer Protection Week takes place each March. This annual event is a great opportunity for government agencies, consumer protection groups, and organizations like BCBSNE and your practice to work together to help people learn about, report and avoid scams.
 
We encourage you to visit ProtectTheGoodLife.Nebraska.gov for information that could help you, and your patients, avoid Healthcare Scams.