Provider Update May 2025

Medical: Commercial and FEP

Reminder: Updated TriWest information for BCBSNE providers

• April 29, 2025: The TRICARE West Region Referral Waiver has been extended through June 30, 2025.
• April 1, 2025: Behavioral health counselor claims were denied due to a supervisory requirement error. TriWest has corrected this issue and is working to reprocess the claims.

Providers should use the following TriWest resources:

• TRICARE West Region Referral Waiver Approval Letter 4-2-25
• Need quick tips? Access the How to Submit Referrals and Authorizations Quick Reference Guide. 
• Need training? Go to the TriWest Learning Center in Availity for referral and authorization webinars and on demand options. 
• Talk to a Customer Service Representative at 1-888-TRIWEST (874-9378)
• Click here for help navigating their Provider IVR
• Fax: 866-852-1893 (for same-day, urgent referrals, fax detailed information)

BCBSNE can assist with the following:

• Adding Individual Providers to the TRICARE Roster: Submit through the BCBSNE credentialing process on the credentialing page
• Adding New group Individual Providers to the TRICARE Roster: Submit through the BCBSNE credentialing process on the credentialing page
• Adding Existing group Individual Providers to the TRICARE Roster: Submit changes through CAQH Provider Data Portal to have the provider’s information updated
  

Credentialing Variances for TRICARE Network in Nebraska:

• Licensure Disciplinary Actions: Providers with actions on their state licenses cannot be offered participation in the TRICARE network
• Board Certification: PAs, CRNAs and CNMs must be board certified to be offered participation in the TRICARE network
• Provisional providers: Excluded from TRICARE network

Accreditation Requirements:

• Birthing Centers: Must be accredited by TJC, AAAJHC, CABC or AABC and licensed according to state and local laws
• Substance Use Disorder Rehab: Must be accredited by TJC, CARF or COA
• Intensive Outpatient Programs (IOP): Must be accredited by TJC, CARF or COA
• Psychiatric Residential Treatment Facilities: Must be accredited by TJC, CARF or COA
• Residential Treatment Centers (RTC): Must be accredited by TJC, CARF or COA

Note: These requirements differ from our regular requirements, as we only verify accreditation but do not require it. 

Medicare Advantage

The importance of kidney and eye health in diabetic patients

Diabetes is a leading cause of chronic kidney disease (CKD) and vision loss, making the management of kidney and eye health crucial for diabetic patients. This article outlines the guidelines from the Centers for Medicare and Medicaid Services (CMS) and the American Diabetes Association (ADA) on the importance of regular evaluations and the role of statins in managing these complications.

Kidney health
CKD is a significant concern for diabetic patients. According to CMS guidelines, regular kidney health evaluations are essential for early detection and management of CKD. The CMS recommends that patients aged 18-85 with diabetes undergo annual evaluations of their estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) to monitor kidney function.

The ADA also emphasizes the importance of assessing kidney function in diabetic patients. They recommend annual screening for albuminuria and eGFR in patients with type 1 diabetes with a duration of five years or more and in all patients with type 2 diabetes.

Monitoring these parameters helps in early identification and management of CKD, potentially delaying its progression and reducing the risk of cardiovascular complications.

Eye health
Diabetic retinopathy is a leading cause of blindness among adults. The ADA highlights the importance of annual comprehensive eye exams to detect early signs of diabetic retinopathy and other eye conditions.

Regular eye exams can help prevent or delay vision loss by enabling timely interventions.

Physicians should educate patients about the importance of maintaining good glycemic control and managing blood pressure to reduce the risk of diabetic retinopathy. Additionally, referring patients to an ophthalmologist for specialized care when necessary is crucial for preserving vision.

Prescribing statins
Statins play a vital role in managing cardiovascular risk in diabetic patients. The ADA recommends statin therapy for diabetic patients aged 40-75 years with LDL cholesterol levels of 70-189 mg/dL, regardless of their baseline cardiovascular risk.

For patients with higher cardiovascular risk, such as those with established atherosclerotic cardiovascular disease (ASCVD) or multiple risk factors, high-intensity statin therapy is advised.

Statins not only help in lowering LDL cholesterol but also provide a protective effect against cardiovascular events, which are common in patients with diabetes and CKD. Physicians should consider the patient's overall risk profile and potential drug interactions when prescribing statins.

Managing kidney and eye health in diabetic patients is critical for preventing severe complications. Adhering to CMS and ADA guidelines for regular evaluations and appropriate use of statins can significantly improve patient outcomes. Physicians play a key role in educating patients and ensuring adherence to these guidelines to enhance the quality of care for diabetic patients.

Quality and Risk

Ensuring accuracy: BCBSNE's upcoming Risk Adjustment Data Validation audit

CMS conducts an annual Risk Adjustment Data Validation (RADV) audit. The RADV audit verifies diagnosis codes submitted for payment, along with the corresponding medical records. BCBSNE will begin the process to retrieve medical records in June. Under the terms of your contract with us, health care professionals and facilities agree to submit medical records requested by BCBSNE in a timely manner at no cost to the patient or BCBSNE. Patients have consented to release medical records to us. An additional release is not required for this audit. All information resulting from the review is confidential.

Stroke: Documentation essentials for providers

Stroke is a leading cause of long-term disability and a significant contributor to morbidity and mortality in the U.S. As providers, accurate diagnosis, timely intervention and thorough documentation are critical for optimal patient outcomes. From a risk adjustment perspective, precise coding ensures appropriate resource allocation and reflects the true complexity of patient care. This article outlines key documentation elements and best practices to support accurate coding and risk adjustment for stroke patients.

Key Documentation Elements for Risk Adjustment^{1, 2, 3}:

1. Specify the type of stroke – clearly differentiate between:
   • Ischemic Stroke (ICD-10: I63.-)
   • Hemorrhagic Stroke (ICD-10: I60.-, I61.-)
   • Transient Ischemic Attack (TIA) (ICD-10: G45.9)
2. Acute vs. history of stroke
   • A stroke diagnosis should only be coded as acute if the event is ongoing and actively treated (i.e., during the admission or immediate post-event period).
   • If the stroke is a past event without ongoing deficits, use Z86.73 (personal history of TIA and cerebral infarction without residual deficits).
3. Residual deficits/post-Stroke sequelae (ICD-10: I69.-)
   • If a patient has lasting deficits, document the specific condition (e.g., hemiparesis, aphasia, dysphagia) and laterality.
   • Common sequelae include:
     • I69.35- Hemiplegia/hemiparesis
     • I69.32- Dysphasia
     • I69.81- Dysphagia
4. Document complications or manifestations such as:
   • Hypertension (I10)
   • Atrial Fibrillation (I48.-)
   • Diabetes Mellitus (E11.-)
   • Hyperlipidemia (E78.5)
   • Smoking History (Z87.891)
5. Include treatment details
   • Document medication use (e.g., insulin or oral agents), lifestyle interventions or other management strategies.

Documentation tips for stroke^{1, 2, 3}

Following best practices, include the following for accurate and complete risk adjustment documentation:

• Specify stroke type: Avoid vague terms like “stroke” without further clarification.
• Clearly identify sequelae: Always link deficits to the stroke using language such as “due to previous cerebrovascular accident.”
• Avoid contradictions: Do not document "history of stroke" if the patient still has active residual deficits. Instead, use I69.- codes for sequelae.
• Support risk adjustment documentation: Ensure that chronic conditions contributing to stroke risk (e.g., hypertension, diabetes, atrial fibrillation) are thoroughly documented and updated at each visit.
• Consistency across notes: Diagnosis should be consistent across problem lists, progress notes and assessments to avoid discrepancies in coding.

Accurate stroke documentation not only improves patient care but also ensures proper risk adjustment, impacting quality scores and reimbursement. By following these best practices, providers can enhance documentation integrity while ensuring patients receive the care they need.

Providers are responsible for documenting and coding all conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management.

For any questions or requests for additional documentation and coding education, please contact us at RiskAdjustment@NebraskaBlue.com.

 
References: 
¹American Stroke Association. (2019). Types of Stroke. www.stroke.org. www.stroke.org/en/about-stroke/types-of-stroke
²Centers for Disease Control and Prevention. (2024, April 25). About Stroke. Stroke. www.cdc.gov/stroke/about/index.html
³Optum360 EncoderPro.com - Login. (n.d.). www.encoderpro.com. www.encoderpro.com/epro/index.jsp

Security Corner

Have a plan

In the event of a cyberattack or data breach, you have three immediate priorities:

• Secure your operations
• Fix vulnerabilities
• Notify appropriate parties

Have a plan in-place for saving data, running the business and notifying patients in the event of a breach or cyberattack. Get started on your plan with help from the Federal Trade Commission here.