provider news - highmark · advanced trauma life support (atls); and (3) pediatric advanced life...

PROVIDERNews

Spring 2008

NaviNet Update 2Benefits Under FEP 3CMS 1500 Claim Submitters 3Credentialing Criteria CHANGES 42008 Provider Workshops 6Meet Your External PPR Reps. 7Contracting/Reimbursement Update 8Blues On Call - Good Decisions 11

Inside This Edition:Shared Decision-Making Videos 14Quality Management Cards 16Hospital Based Providers:Credentialing/Contracting Update 17New Groups 19HealthPLACE on the Move 19Updated Medical Policies 20

Did You Miss the Deadline?

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Reminder About May 23, 2008, NPI Compliance DeadlineElectronic claims submitters are reminded that, effective May 23, 2008 — the date on which the CMS contingency guidelines for HIPAA-covered entities expired — Mountain State began rejecting electronic claim submissions that do not contain an NPI in the billing, rendering provider and service facility field (when applicable) and began returning the claims to the provider. Additionally, Mountain State is rejecting electronic inquiry transactions — such as eligibility, authorization and claims status inquiries — that do not contain NPIs. For more information, reference the “Provider EDI Reference Guide” on Mountain State’s Web site at www.msbcbs.com/msbc_trading.htm.

In the process of maintaining Mountain State Blue Cross Blue Shield’s information systems for compliance with the Centers for Medicare & Medicaid Services’ (CMS) HIPAA mandate and enforcement of the NPI Final Rule, Mountain State has found that some network providers’ tax identification (ID) numbers submitted on electronic claims do not match the tax IDs that are linked to the NPI on file with us.

In an effort to avoid paying claims to the wrong provider, effective Sept. 12, 2008, Mountain State will reject electronic claims that include tax ID numbers that do not match the providers’ tax ID-NPI combination that we have on file in our information systems. Additionally, when such a rejection is issued, the following rejection codes will be included on the 277 claim acknowledgment (277 CA) report:

Claim Status Category Code: A8 — Rejected for relational field in error

Claim Status Codes: 128 — Entity’s Tax ID562 — Entity’s National Provider Identifier (NPI)

Entity ID:85 — Billing Provider

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PROVIDERNews

NAVINET UPDATENaviNet enabled users are encouraged to access the various NaviNet transactions before calling Mountain State Customer Service or Provider Relations. Many of the phone calls and correspondence received could be answered by using the NaviNet Eligibility and Benefit transaction and the NaviNet Claim Inquiry transaction. Claim adjustment requests can also be sent electronically using NaviNet.

NaviNet will save you time and money. It is available to our providers hours beyond our servicing times. NaviNet can be accessed Monday through Saturday from 5:00 a.m. until 3:00 a.m. and on Sunday from 5:00 a.m. until 5:00 p.m.

Also, Security Officers should frequently review their ‘Users Able to Access NaviNet’ list located under the NaviNet Administration tool bar. Be sure all staff members who contact Mountain State are included as users and are trained.

Recent changes to NaviNet include:When searching for a claim’s status by Member • ID, you can now search by claim number.Security Officers can now select and manage • which transactions individual users have access to.Unread Action Items now appear in • bold print, allowing you to differentiate between read and unread action items.

Present on • Admission indicator fields have been added to the UB Claim Submission Footer screen for all diagnosis codes. The Present on Admission values indicate whether the patient had the diagnosis reported upon admission to the hospital. (See additional information on page 10)

Details on these changes are listed under NaviNet Customer Care/Mountain State New Features and New Features Archive.

Any network provider who has a computer and internet access can enroll in NaviNet by calling NaviNet Customer Care at 1-888-482-8057, accessing www.msbcbs.com/navinet and clicking on the ‘Request NaviNet’ link or by contacting their External Provider Relations Representative.

Did You Miss the Deadline?Continued From Page 1

In recent months, Mountain State has been proactively contacting practices when this issue has arisen regarding electronic claim submissions to assist providers in resolving the matter. Once the Sept. 12, 2008, deadline arrives, however, Mountain State will simply reject such electronic claims and return them to the submitter. For detailed instructions on including your NPI on your electronic claim submission, please consult the “Provider EDI Reference Guide,” which is available via Mountain State’s Web site at www.msbcbs.com/msbc_trading.htm. Or you may contact your Mountain State Provider Relations Representative. To check your tax ID number or numbers on file with Mountain State, please call 1-800-798-7768 or 304-424-7795.

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Spring 2008

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Attention CMS 1500 Claim SubmittersIn August 2007, Mountain State implemented a claims scanning system for paper claims (OCR- Optical Character Recognition). This technology is an automated alternative to manually entering claims data, ensuring a more accurate and timely claim turnaround for our members and providers.

Here are some general tips for submitting paper claims:

Use computer-printed forms, or type within the boundaries of �the boxes.

Avoid handwritten claims, rubbers stamps, use of highlighters �to emphasize information, excessive correction fluid, red ink, or post-it notes. Information becomes blackened out when imaged and is not legible.

Regularly change your print ribbon to ensure print readability. Light print cannot be read by the scanner. �

Do not fill in blank fields, or space, with unnecessary data. �

Avoid using special characters such as dollar signs, hyphens or slashes. �

Anytime you have a question regarding the requirements for completing a claim form, you may contact our Customer Service Department, or your External Provider Relations Representative.

Mental Health and Substance Abuse Benefits under FEPBasic Option members must use Preferred Providers and receive prior approval before seeking outpatient Mental Health and Substance Abuse (MHSA) treatment. Basic Option members are not required to submit written treatment plans. The member must call the MHSA number on the back of the ID card for prior approval before receiving outpatient care. If approval is not obtained prior to the first visit, then the claim will be denied. (Prior approval is not required for pharmacotherapy.) Under Basic Option there is no two-hour per visit limitation, regardless of the year of service. In addition, there is no annual visit limitation. Basic Option members pay one, single copayment per provider, per day for covered therapy.

For Preferred benefits under Standard Option, the provider (on behalf of the member) must submit a treatment plan for the Local Plan’s approval prior to the ninth outpatient visit. There is a maximum of 25 visits per year for office visits, partial hospitalization, intensive outpatient treatment, and other hospital outpatient treatment. The first 25 visits under Standard Option each calendar year by Preferred providers and Non-preferred providers count toward this maximum. This maximum may be waived for services received from Preferred Providers.

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PROVIDERNews

Credentialing Criteria Changes for 2008

Mountain State Blue Cross Blue Shield (Mountain State) endeavors to keep network practitioners and providers informed about network credentialing polices and procedures. Below are some of the changes that have been or will be taking place in 2008. A complete list of credentialing requirements may be obtained by visiting Mountain State’s website at www.msbcbs.com, selecting the Provider tab and then clicking on Credentialing.

Initial Credentialing Time FramesMountain State entered into a Settlement Agreement in the Love Class Action case. One of the terms of the Agreement is to ensure that Medical Doctors (MD) and Doctors of Osteopathy (DO) are initially credentialed within ninety (90) days of the Plan receiving a complete credentialing application. Therefore, the following time frames for initial credentialing will be applied for MDs and DOs starting in August of 2008.

MDs and DOs: 90 days turn around time

All other practitioners: The turn around time will remain 120 days, in compliance with West Virginia State Code §33-45-2.

Revision to CT Scan Credentialing RequirementsMountain State has revised a credentialing element for CT scan providers. State survey results will now be accepted, in lieu of accreditation, for hospitals only. Free standing or physician office based outpatient CT scan providers must be accredited by either the American College of Radiology (ACR) or the International Societal Commission for the Accreditation of CT Labs (ICACTL).

CT scan providers who are currently contracted with Mountain State have until December 31, 2008, to submit all required credentialing elements to the Office of Network Credentialing. Please call 888-475-2391 (Option 7) with any questions.

Reapplying after being out of the NetworkNetwork providers who leave any of the contracted networks for more than thirty days will need to reapply to become a participating provider. Initial credentialing will be required.

Hospital Based PractitionersHospital based practitioners will no longer be required to undergo full credentialing with Mountain State. Practitioners who work full time in an inpatient setting will be given the opportunity to be reviewed under an abbreviated process. Please see page 17 for more details.

Emergency Medicine Certification RequirementsMedical Doctors and Doctors of Osteopathy who work in an Emergency Room setting part time and are not board certified in Emergency Medicine, must submit proof of the following required certifications: (1) Advanced Cardiac Life Support (ACLS); (2)

Advanced Trauma Life Support (ATLS); and (3) Pediatric Advanced Life Support (PALS).

Practitioners who are currently contracted with Mountain State have until the end of 2008 to obtain the required certifications. New applicants must have already obtained the required certifications to pass initial credentialing.

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Spring 2008

Submission of Continuing Education CreditsMedical Doctors and Doctors of Osteopathy who are not board certified in their specialty will be asked to submit proof of continuing education credits for initial credentialing as well as recredentialing. Mountain State requires the same number of credits as the state licensing boards.

24/7 Availability RequirementsPractitioners are required to be available to their patients 24/7. Acceptable means of coverage include an answering service that can get in touch with the provider or an answering machine that gives patients a number to call to be able to reach the practitioner on call.

24/7 coverage is not required for the following provider types: Audiologists, Diabetic Educators, Pathologists, Preventive Medicine, Massage Therapists, Occupational Therapists, Physical Therapists, Registered Dieticians and Speech Pathologists.

DEA Certificates Applicable practitioners who provide services in multiple states will need to maintain an active DEA certificate for each state in which he/she practices.

Primary Care Physician AvailabilityPrimary Care Physicians are required to be available to provide services to members at least twenty (20) hours a week. Group coverage by a provider of same or like specialty is acceptable.

Onsite Office Reviews for New PCP’s, OB/Gyn Providers and Behavioral Health ProvidersFor Highmark’s Medicare Advantage network, Mountain State will conduct onsite office reviews for initial applicants. Providers who do not pass the onsite review will be given six months to correct any identified deficiencies. Contact Mountain State’s Office of Network Credentialing at 888-475-2391 with any questions.

Sleep Lab/Center Credentialing-New Mountain State InitiativeMountain State’s Office of Network Credentialing has developed credentialing criteria for sleep labs/centers. The requirements are listed below and pertain to facility based/supervised services only. Home/portable sleep services are still considered investigational. Existing sleep lab providers will be given one year, until May of 2009, to submit the required documentation. New applicants must submit all required credentialing documents, prior to being contracted.

Credentialing Criteria WV OH KY VA PA MDState License/Registration/Certificate of Need (CON)

State CON/ Business

Registration

N/A State Business License

State Business License

State BusinessLicense

State BusinessLicense

Accreditation from the American Academy of Sleep Medicine (AASM)

Required Required Required Required Required Required

Professional Liability Insurance $1/$3 million

Required Required Required Required Required Required

Medicare Eligible Required Required Required Required Required Required

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Credentialing and Recredentialing of OrthodontistsMountain State’s Office of Network Credentialing has developed credentialing criteria for Orthodontist who provide services related to cleft palate repair.

The requirements are:Active state license in the state in which he/she practices;1. Completion of a Cleft Craniofacial Orthodontic Fellowship accredited by the Commission on 2. Dental Accreditation(CODA);Professional liability insurance in the amounts of $1.0 million per occurrence and $3.0 3. aggregate;Ability to provide 24/7 coverage to members;4. Individually eligible to participate with Medicare for the Medicare Advantage network;5. Five years of work history for initial credentialing. 6.

Credentialing Criteria Continued...

PROVIDERNews

6

2008Provider

Workshops

Save The Date

You are invited to attend one of the following 2008 Provider Workshops covering a variety of topics relating to Mountain State Blue Cross Blue Shield. All workshops are free of charge and will be conducted from 9:00 a.m. until 12:00 p.m. Mark your calendars now and plan to attend the workshop in your area. More details to follow.

August 18, 2008Grand Point Conference Center

ParkersburgFacilitated by Michelle Caldwell

August 27, 2008Holiday InnMartinsburg

Facilitated by Michelle Haley

August 28, 2008Bridgeport Conference Center

Bridgeport Facilitated by Michelle Haley

September 18, 2008Holdiay Inn

Bluefield Facilitated by Mary DeLaRosa

September 19, 2008TamarackBeckley

Facilitated by Mary DeLaRosa

September 23, 2008Charleston Civic Center

Charleston Facilitated by Tifaney Rader

September 25, 2008Ramada Inn - Hal Greer Blvd.

Huntington Facilitated by Tifaney Rader

September 30, 2008McLure Hotel

Wheeling Facilitated by Melanie Clyde

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Spring 2008

Meet Your External Provider Relations RepresentativesThe PPR Representatives conduct training, orientations and daily routine visits to both physicians and hospital staff employees. Each representative is assigned a geographical area for professional and selected ancillary contracting providers. They are also responsible for maintaining the provider networks within the state and contiguous counties. The representatives and the counties they cover are as follows:

Melanie Clyde

Michelle Caldwell

Michelle Haley

Mary DeLaRosa

Tifaney Rader

(304) [email protected]





Brooke• Hancock• Marshall• Ohio• Tyler• Wetzel• Belmont, OH•

Columbiana, OH• Jefferson, OH• Monroe, OH• Beaver, PA• Fayette, PA• Greene, PA• Washington, PA•

Barbour• Calhoun• Doddridge• Gilmer• Jackson• Lewis• Pleasants• Randolph•

Ritchie• Tucker• Upshur• Wirt• Wood• Athens, OH• Washington, OH•

Berkeley• Grant• Hampshire• Hardy• Harrison•

Jefferson• Marion• Mineral• Monongalia• Morgan• Pendleton• Preston• Taylor• Allegany, MD•

Frederick, MD• Garrett, MD• Washington, MD• Augusta, VA• Clarke, VA• Frederick, VA• Loudoun, VA• Rockingham, VA• Shanandoah, VA•

Fayette*• Greenbrier• McDowell• Mercer•

Monroe• Nicholas• Pocahontas• Raleigh• Summers• Webster• Wyoming•

Alleghany, VA• Bath, VA• Bland, VA• Buchanan,VA• Craig, VA• Giles, VA• Highland, VA• Tazewell, VA•

Boone• Braxton• Cabell• Clay•

Kanawha• Lincoln• Logan• Mason• Mingo• Putnam• Roane•

Wayne• Boyd, KY• Lawrence, KY• Martin, KY• Pike, KY• Gallia, OH• Lawrence, OH• Meigs, OH•

*Montgomery, WV to be serviced by Tifaney Rader

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PROVIDERNews

Contracting & Reimbursement Update...

Mountain State Blue Cross Blue Shield

WVSBP Update – Using PEIA pricing and RVUs from the Centers for Medicare and Medicaid Services (CMS) for the West Virginia Small Business Plan, Mountain State updated the RBRVS reimbursable services with an effective date of May 1, 2008.

2008 RBRVS Reimbursement Updates – In the Winter edition of this newsletter, Providers were advised that in 2007, Mountain State implemented the Resource Based Relative Value Scale (RBRVS) annual update with an effective date of July 1, 2007 for our commercial products. This approach provided Mountain State the time to effectively review and analyze the comprehensive changes made by CMS. The RBRVS 2008 annual update for Traditional, PPO, POS and Steel will be effective July 1, 2008. The new codes were added effective 1-1-2008 utilizing the CMS Work RVU Budget Neutral Factor of 0.8806.

During the winter and spring Mountain State has been analyzing the changes CMS made in RVUs. Mountain State will continue the implementation of the transitional RVU for 2008, which will be effective for dates of service beginning July 1, 2008.

Mountain State would like to provide an example for providers regarding the RBRVS calculation for our commercial business using the budget neutrality (BN) factor (as of July 1, 2008) related to the RVU work component. This calculation applies only to services that have a value assigned to the work component. Mountain State does not utilize the GPCI component in the RVU calculation.

2008 Non-Facility Pricing Amount =[((Work RVU * Budget Neutrality Adjustor (0.8806)) +(Transitioned Non-Facility PE RVU) + (MP RVU)] * Conversion Factor

2008 Facility Pricing Amount =[((Work RVU * Budget Neutrality Adjustor (0.8806)) + (Transitioned Facility PE RVU) + (MP RVU)] * Conversion Factor

CPT/HCPCS

code

Description

90283 Immune globulin (IgIV), human, for intravenous use

90291 Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use

J1561 Injection, immune globulin, (Gamenex), intravenous, nonlyophilized (e.g. liquid), 500 mg

J1562 Injection, immune globulin (Vivaglobin), 100 mg

J1566 Injection, immune globulin, intravenous, lyophilized (e.g. powder), not otherwise specified, 500 mg

J1568 Injection, immune globulin, (Octagam), intravenous, nonlyophilized, (e.g., liquid), 500 mg

J1569 Injection, immune globulin, (Gammagard liquid), intravenous, nonlyophilized (e.g. liquid), 500 mg

J1572 Injection, immune globulin, (Flebogamma), intravenous, nonlyophilized (e.g. liquid), 500 mg

J2791 Injection, Rho (D) immune globulin (human), (Rhophylac), intramuscular of intravenous, 10 IU

Following is a sample calculation using 99213:(0.92 * 0.8806) + 0.73 + 0.03 = 1.57 (Total Non-Facility Transitional RVU) * 47.69 = 74.87

(0.92 * 0.8806) + 0.26 + 0.03 = 1.1 (Total Facility Transitional RVU) * 47.69 = 52.46

Medmark Update – Mountain State will be adding some of the intravenous immune globulins services to the mandatory Medmark Drug List effective September 1, 2008. Following is a list of services and CPT/HCPCS codes.


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Spring 2008


Contracting & Reimbursement Update Continued...



Laboratory and Pathology Update – Mountain State will be updating the laboratory and pathology services that do not have RVUs developed by CMS by using the Ingenix 2008 RVUs. The effective date is September 1, 2008.

Point of Origin For Admission or Visit Code ChangesMountain State Blue Cross Blue Shield (Mountain State) and Highmark Health Insurance Company (HHIC) began to accept Point of Origin Codes E and F and Special Source of Admission newborn codes 4 and 5 effective April 11, 2008. In addition,

Mountain State and HHIC began to reject claims submitted with Point of Origin Codes 3 and A, and Special Source of Admission newborn codes 1, 2, 3, or 4.

The National Uniform • Billing Committee (NUBC) added Point of Origin

codes E (Transfer from Ambulatory Surgery Center) and F (Transfer from Hospice).Code 3 (HMO referral) and Code A (Transfer • from a Critical Access Hospital) have been discontinued.Newborn Codes - It should be noted that there • are a special set of Source of Admission (Point of Origin) codes used for newborn when the Priority (Type of Visit (Type of Admission) is reported as a 4 - newborn. The NUBC agreed to simplify the newborn coding by eliminating codes 1 - 4 (Normal Delivery, Premature Delivery, Sick Baby, Extramural Birth respectively) and define two new codes. Code 5 will be Born in Hospital and Code 6 will be Born Outside the Hospital.

BILLING INSTRUCTIONSSource of Admission/Point of Origin codes are to be billed on a UB-04 form in form locator 15.

New Patient Discharge Status Code 7070 – Discharged/transferred to another Type of Health Care Institution not Defined Elsewhere in this Code List

New patient discharge status code 70, per NUBC and effective April 1, 2008, was created in order for providers to be able to indicate discharges/transfers to another type of health care institution not defined elsewhere in the code list. This code is effective for use by providers for MSBCBS claim submissions for discharges/to dates on or after April 1, 2008 for all Commercial products and HHIC Medicare Advantage products.

BILLING INSTRUCTIONSA patient discharge status code is a two-digit code that identifies where the patient is at the conclusion of a health care facility encounter. It belongs in Form Locator 17 on a UB-04 claim form or its electronic equivalent in the HIPAA compliant 837 format.

It is important to select the correct patient discharge status code, and in cases in which two or more patient discharge status codes apply, you should code the highest level of care known. Applying the correct code will help assure that you receive prompt and correct payment.

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PROVIDERNews

Contracting & Reimbursement Update Continued...Mountain State Blue Cross Blue Shield

Implementing Present on Admission (POA) for Acute-Care HospitalsIn October 2007, acute-care providers were required by the Centers for Medicare and Medicaid Services (CMS) to submit POA indicators on all primary and secondary diagnoses for Traditional Medicare beneficiaries. In January 2008, CMS began to process POA indicator data submitted on Medicare claims to provide feedback to providers not submitting the data. Currently, Highmark Health Insurance Company (HHIC) accepts the POA information on all principal (primary) and secondary (other) diagnoses for FreedomBlue product claims representing inpatient discharges from acute-care hospitals. HHIC will require POA information on FreedomBlue claims effective July 19, 2008. On and after that date, claims submitted without POA information will be rejected. Please visit the Mountain State Provider News and Bulletins website (http://www.msbcbs.com/msbc_provnews.htm) for more information.

Providers will utilize the same requirements for Mountain State commercial product claims beginning July 19, 2008.

New Medical Necessity Policy for All ProvidersMountain State Blue Cross Blue Shield Medical Policy Bulletin Z-11 (Definition of Medical Necessity) became effective March 3, 2008. This policy is applicable to all Provider types, including Hospitals, Ancillaries, and Professional Providers. This policy and others included in this newsletter are available on the web at www.msbcbs.com.

New Edit Requiring CPT and HCPCS Codes for All Hospital Inpatient and Outpatient ReimbursementMountain State Blue Cross Blue Shield will require the inclusion of CPT and HCPCS procedure codes for all inpatient and outpatient claims effective as of July 1, 2008. As with Original Medicare, accurate and complete coding of CPT and HCPCS procedure codes, procedure modifiers, revenue codes, and units will maximize your reimbursement and speed the processing of claims.

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Spring 2008

As the medical armamentarium grows, doctors and patients have more and more choices. Medical conditions that could once be treated in one or two ways can now be treated with a panoply of options, each with a different set of advantages and drawbacks. Having these choices is good. It paves the way for personalized care. Unfortunately, it also brings added complexity, and makes the “right” treatment more elusive. After all, how can you tell when a medical decision is a good one?

That is a question Al Mulley, MD, Chief of the General Medicine Division at Massachusetts General Hospital and co-founder of the Foundation for Informed Medical Decision Making, has been studying for years. According to him, a good decision is one that the doctor and patient make together—one made deliberately, with the necessary communication between doctor and patient to assure a thorough understanding of the available options, and after a lot of introspection by the patient.

“There’s understanding the relevant science, which tells you the probability of different outcomes,” says Mulley, “but then there’s understanding yourself well enough to know what really matters to you in life and making a choice that is consistent with what matters to you.”

The BPH ExampleTo get at what he means by that, imagine two men with urinary symptoms from benign prostatic hyperplasia (BPH). Both are equally bothered by their symptoms and both are candidates for the same treatment options, including watchful waiting, medical therapy, and surgery.

One of the men has an active sex life, while the other is widowed and has little interest in sex. For the first man, the idea of developing retrograde ejaculation, a common side effect of surgery, sounds intolerable. For the second, retrograde ejaculation would be a trivial price to pay in exchange for sleeping through the night.

Good DecisionsChoosing the Correct Medical Options

None of the treatment options the men are facing is obviously superior to the others. Studies show that surgery is more effective than the other treatments at symptom reduction, but it also involves more risks and side effects, including retrograde ejaculation. Hence, according to Mulley, “whether or not a BPH patient gets his prostate operated on should depend on who he is and what he cares about.”

The point is, although the men in the example are clinically identical, the “right” treatment for each of them is likely to be quite different. What’s more, the only way a doctor can determine the right treatment for each of these patients is to engage them, question them, and find out how they feel about each of the treatment options and their respective advantages and tradeoffs. Thus, medical decision-making becomes a shared process, and the quality of a decision is based not on its outcome but how the patient feels about the choice being made.

Improving Decision QualityGiven the number of options for men with BPH, it might take a doctor several standard-length visits just to explain the mechanics of and risks and benefits of each option. It might take even more time to elicit an individual patient’s preferences and how they relate to the different possible outcomes. The same would be true of any medical condition


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PROVIDERNews


This year, the Blues On Call provider satisfaction survey is available online. Doctors are invited to complete a brief questionnaire by accessing the Blues On Call link under the Provider Tab of our website, www.msbcbs.com, starting in August 2008.

At the start of the survey, you will be asked for your name and the name of your practice. This information will only be used by Guideline, the survey vendor, to make sure a paper survey is not mailed to your office later this fall. Your information will not be seen by Mountain State Blue Cross Blue Shield. All survey results will be seen by Mountain State in aggregate.

The Blues On Call program provides disease management and decision support to eligible Mountain State members. Health Coaches help members manage their condition, e.g. asthma, diabetes, heart failure, COPD, and heart disease. Health Coaches are also available to help members facing important medical decisions.

We value your feedback and appreciate the time you spend completing the survey.

with several treatment options. That kind of time commitment is obviously not tenable in modern practice, so doctors interested in improving decision quality have to call on the help of decision aids and Health Coaches.

Decision aids are high-quality educational tools that meet international standards for unbiased presentation of the treatment options for a given condition. Health coaches are healthcare professionals, usually nurses, who are specifically trained to support patients and help them communicate effectively with their physicians to make shared decisions.

“Physicians who take advantage of those resources cannot only provide better care that leads to more satisfied, and more importantly, healthier patients,” says Mulley, “but they can do that far more efficiently.”

Decision Support Available to You and Your PatientsMountain State Blue Cross Blue Shield’s Blues On CallSM program offers your patients access to Health Coaches trained in decision support, as well as to almost 30 high quality Shared Decision- Making® aids—including DVDs, printed booklets, and online content. To learn more about improving decision quality in your practice, contact the Blues On Call Provider Hotline at 1-888-777-9522.

Shared Decision-Making® is a registered trademark of the Foundation for Information Medical Decision Making. Used with permission.

SM

Provider Survey Now Available Online

Choosing the Correct Medical Options Continued...

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Spring 2008

(Editor’s Note: The following article was reprinted with permission and was originally published in Clinical Views, a Highmark physician journal distributed in Pennsylvania.)

For most of her adult life, Linda Caldwell knew there was a high probability that she could develop breast cancer. Her mother had died from the disease at a young age.

“I had been having regular mammograms since my early 40s and had already had one biopsy. It was benign,” Ms. Caldwell recalls. “But, I always felt it was more like when I was going to get breast cancer, not if.”

Still, when Ms. Caldwell, the office manager at Skytop Chiropractic Life Center in State College, PA, was diagnosed with ductal carcinoma in 2003, the news hit hard.

“I was reeling emotionally,” she says. All of the feelings she thought she prepared herself for were overwhelming.

“Once you get diagnosed, there are so many decisions you have to make,” Ms. Caldwell says. Decisions such as: mastectomy vs. lumpectomy; radiation and what types to undergo; chemotherapy or no chemotherapy.

Her doctor reassured her that the cancer hadn’t metastasized and was contained to the duct.

“The best thing my doctor did was say, ‘You are not going to die of breast cancer,’ ” she recalls.

But Ms. Caldwell was still in no condition to make decisions when she was first diagnosed, she notes. Her doctor realized this and gave her a full week to deal with the news before making any treatment decisions.

“He was very smart doing that,” Ms. Caldwell notes. “In that week, it gave me a chance to settle down, talk to friends and get the emotion out of the way.”

Blues On Call Videos HelpIt was also during this time that Ms. Caldwell remembered Blues On Call and the educational videos they offer.

“I had called Blues On Call once before and had a good experience with them,” Ms. Caldwell says.

The unique series of videos are produced by The Foundation for Informed Medical Decision-Making, led by John E. Wennberg, MD, and Albert G. Mulley, Jr., MD. The videos provide a complete overview of selected health topics, using the latest medical research and information available, and present an unbiased description of the benefits and risks of various treatment options. For more information on the Blues On Call videos, see “Shared Decision-Making Videos: Preparing Your Patients With Latest Information,” on the next page.

Ms. Caldwell obtained the Blues On Call video on breast cancer to help her decide what treatment method to use.

Her doctor had also given her informational pamphlets and brochures, but Ms. Caldwell found the Blues On Call video the most helpful.

“I think the video is better than reading,” she notes. “I’m a visual learner and it helps to visualize. That visual effect was so much better than just reading about it. When you’re emotional, it can be difficult to concentrate and grasp all that you’re reading. A visual learning tool that you can watch repeatedly, if necessary, is more helpful, I think.”

Blues On CallSM Videos Answer Questions for Breast Cancer Survivor


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PROVIDERNews

Ms. Caldwell found the video was quite comprehensive and covered all options in language that was easy to understand. “The thing I liked is that the video wasn’t telling you what choice to make, but it just explained all the options,” she notes.

The video helped Ms. Caldwell understand the options more completely.

“My first instinct was to just get a mastectomy,” she recalls. “But after watching the video I realized there were all these other options. I also learned that lumpectomy and radiation have an equal cure rate. That’s just all education.”

Ms. Caldwell ultimately decided to have a five-day radiation therapy targeted at the site of the cancer. The therapy involved using a catheter to insert a radioactive pellet at the cancer site, which keeps the heart and lung from radiation exposure – something that can be a side effect of full-radiation treatment.

“I was impressed that the Blues On Call video covered the procedure I was considering – even though it was new and still in clinical trials. So they obviously keep the videos updated.” Ms. Caldwell says.

The therapy worked and Ms. Caldwell has been in remission since December 2003.

“I’m still getting digital mammography every six months,” she notes. “I still have to keep an eye on this for the rest of my life.”21Survivor Highly Recommends Blues On Call VideoNow a cancer survivor, Ms. Caldwell would highly recommend the Blues On Call educational videos, she adds.

“I thought it was first class – very professionally done,” she notes. “The video didn’t tell you what to do, it just educated you. I have recommended the Blues On Call videos to friends, patients and even my family doctor.

“I’ve never seen anything like them. They were so well done. Even though there are doctors speaking on the video, they didn’t get into so much ‘doctor speak’ that it wasn’t understandable.”

In addition to the educational videos, Ms. Caldwell recommends Blues On Call in general. “It’s a great service. Anytime that a person has symptoms that come up and they don’t know what to do, they can call someone 24 hours a day,” she says. “It can even avoid a doctor or emergency room visit. It’s a great guidance tool.”

Shared Decision-Making Videos: Preparing Your Patients with Latest InformationPatients dealing with complex health conditions can greatly benefit from information and support. Studies show that the more patients are informed and involved in their care decisions, the more likely they are to adhere to the treatment plan and feel satisfied with the outcome.

Among the various shared decision-making tools available to Mountain State members through Blues On CallSM is a unique series of videos. Produced by The Foundation for Informed Medical Decision-Making, the videos work in tandem with the personalized health coach services, so that your Mountain State patient maintains a relationship with his/her health coach throughout the education process.

The coach mails the video directly to the patient, so he/she can view it with family in the comfort of home. Once your patient has had the opportunity to view the video, the coach calls him/her to discuss

Breast Cancer Survivor Continued...


15

Spring 2008

Shared Decision-Making Videos Continued:

any issues or concerns and helps the patient prepare for the next office visit with you. Mountain State members can receive any of the following videos, listed below, free-of-charge through the Blues On Call program.

We want our network physicians to be comfortable in referring their Mountain State patients for this support service. You are welcome to view any videos of interest to you and your area of specialty. Call the Blues On Call Provider Hotline at 1-888-777-9522, for more information.

Low Back Pain/Herniated Disc: For people who have had low back and leg pain for more than four weeks with a diagnosis or suspicion of herniated disc; covers non-surgical treatment options as well as surgery

Low Back Pain/Spinal Stenosis: For people who have had low back pain for more than four weeks with a diagnosis or suspicion of spinal stenosis; covers non-surgical treatment options as well as surgery

Chronic Low Back Pain/Managing Your Pain and Your Life: For people with low back pain that has lasted for more than three months and is severe enough to limit activities; includes staying active, managing stress and depression, getting support and using treatments wisely

Benign Prostatic Hyperplasia: Generally for men 50 and older; reviews treatment choices for symptoms of prostate enlargement (benign prostatic hyperplasia), including watchful waiting (watching symptoms, but no immediate intervention), medical therapies and surgical options

Early Breast Cancer/Hormone Therapy and Chemotherapy — Are They Right for You? For women who have already had surgery for early stage breast cancer; covers whether or not to elect follow-up programs such as chemotherapy and hormone therapy

Early Stage Breast Cancer/Choosing Your Surgery: For women with early-stage breast cancer; covers important treatment options for the primary breast tumor and compares mastectomy versus breast-sparing surgery with radiation

Breast Reconstruction/Is it Right for You? For women with breast cancer who would

like to learn more about breast reconstruction choices

after mastectomy: no reconstruction, prosthesis and implant and flap procedures

DCIS/Choosing Your Treatment:

For women with ductal carcinoma in situ (DCIS),

also known as intraductal carcinoma, noninfiltrating breast cancer, noninvasive breast cancer, and Stage 0 breast cancer; covers treatment options including lumpectomy, radiation, tamoxifen and mastectomy

Treatment Choices for Abnormal Uterine Bleeding: For women who are considering treatment for abnormal uterine bleeding, determined not to be caused by a cancerous condition or by fibroids; covers a range of treatment options, including watchful waiting, medical therapy, limited surgery and hysterectomy

Treatment Choice for Uterine Fibroids: For pre-menopausal women considering treatment choices for fibroids; covers a range of options, including watchful waiting, medical therapy, limited surgery and hysterectomy

Continued On Next PageContinued On Next Page

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PROVIDERNews

Coronary Artery Disease: For people with stable angina; covers treatment options, including medical therapy, bypass surgery and angioplasty

Living with Coronary Artery Disease/Doing Your Part: For people with coronary artery disease to learn more about lifestyle changes

Informed Health Care Consumer: Introduces the concepts and methodology of shared decision-making — the uncertainty in medicine, the importance of patient preference in selecting among various treatment options and the benefits of sharing treatment decision-making with your doctor

Ovarian Cancer/Reducing Your Risks: For women who want to understand and reduce their risks of developing ovarian cancer; includes strategies for assessing and reducing those risks

Peace of Mind: For patients and family members facing the difficult topic of end-of-life decisions with a focus on how to achieve a meaningful peace of mind about health matters; covers documenting requests and wishes about medical care for family members

PSA Decision: For men 50 or older in good health; covers the decision of whether or not to have a prostate specific antigen (PSA) blood test to detect possible prostate cancer

Knee Osteoarthritis: For people with osteoarthritis of the knee who have pain, stiffness or other symptoms; covers treatment options, including lifestyle changes, medications, injections, complementary therapy and surgery

Coping with Symptoms of Depression: For people who are wondering if they have depression or have been diagnosed with depression and are considering treatment options

Living Better with Chronic Pain: For patients who have pain that has lasted for 6 months or longer under the care of a doctor, may not have a cure, and makes some daily activities difficult or impossible.

Living with Diabetes – Making Lifestyle Changes to Last a Lifetime: For adults with type 2 diabetes who are newly diagnosed or have been living with the condition for some time.

Through quality management efforts established by Mountain State, we have identified low utilization of breast and colorectal cancer screenings. Therefore, in an effort to encourage members to talk with their doctors about these or other appropriate screenings, the Quality Management Program is now sending birthday cards to female members turning age 40 and to all members turning age 50. Since the cards encourage the member to talk with their doctor about preventive health services, your patient may come to you with one of the following cards in hand.

If you would like to see these cards in greater detail, or need further information, please access the Blues On Call link under the Provider Tab of our website, www.msbcbs.com.

Birthday Card to Female Members

Turning Age 50

Birthday Card to Male Members Turning Age 50to Your Mountain State Blue

Cross Blue Shield Patients

Happy Birthday

Birthday Card to Female Members Turning Age 40

Shared Decision-Making Videos Continued:

17

Spring 2008

Update on Credentialing and Contracting Requirements for Hospital Based Providers

Mountain State Blue Cross Blue Shied (Mountain State) and Highmark have evaluated their respective credentialing processes for Mountain State networks and Highmark Health Insurance Company (HHIC) Medicare Advantage PPO networks. A change has been made that we believe will positively affect pathologists, radiologists, anesthesiologists, emergency room providers, hospitalists and hospital based allied health providers.

Currently, these providers must successfully complete our full credentialing and recredentialing process to obtain and maintain status as a participating provider. We recognize that these practitioner specialties/types employed in or contracted directly with an inpatient facility are held to many hospital board accreditations and credentialing standards.

If you are a hospital based provider, and practice exclusively in an acute care setting (inpatient facility), you will be exempt from the full credentialing process. However, if you also practice anywhere other than an inpatient setting, you will be required to undergo full credentialing and recredentialing.

To be exempt from the full credentialing process, we must obtain a signed Affirmation of Medical Practice Statement Form (Affirmation) for our records indicating, among other things, that you practice exclusively in an acute care setting. The Affirmation is maintained at the practice level.

We previously announced in our Winter 2008 Provider News that Hospital Based Providers must complete Mountain State’s full credentialing and recredentialing process to obtain and maintain their status as a participating provider. The following guidelines have been implemented to allow hospital based providers to exempt from the full credential process providing the following criteria is met by the provider:

Therefore, should you join another practice we will require that you complete another Affirmation. Mountain State also requires a copy of your current medical license with each Affirmation.

Please send all Affirmations to:Mountain State Blue Cross Blue ShieldOffice of Provider RelationsP.O. Box 1948Parkersburg, WV 26102

If you have any questions concerning this process, please contact Provider Relations at1-800-798-7768 or you may access this information via Mountain State’ website at www.msbcbs.com under the “Provider” dropdown menu then select News & Bulletins.


18

PROVIDERNewsAffirmation of Medical Practice Statement

By signing this affirmation, I declare my desire to join or remain a provider of Mountain State Blue Cross Blue Shield’s (MSBCBS) commercial PPO/POS network and/or Highmark Health Insurance Company (HHIC) Medicare Advantage PPO Network.

I understand that the information herein will be used by MSBCBS and/or HHIC in making decisions about my participation in the networks.

I understand that credentialing will not be required as a condition of my becoming a party to the Network Provider Agreements, provided that (1) the services I provide to members serviced by the networks are delivered exclusively in the acute care hospital setting; (2) I provide medical care for such members only when they receive services in a Blue Cross Blue Shield Network Participating hospital; (3) I possess a current license in good standing in the state in which services are provided; (4) I have current active malpractice insurance that meets or exceeds the MSBCBS and/or HHIC requirements; (5) I actively participate with Medicare/Medicaid and have never been debarred from, or excluded from participation in, any Medicare/Medicaid government program; and (6) I am a member of the practice listed below.

By signing below, I am confirming that conditions (1) through (6) in the above paragraph are true and accurate statements.

I will be providing services to members serviced by the Networks in the following acute care hospitals:

____________________________________________________________________________________________

____________________________________________________________________________________________

Please indicate your specialty (required) ___________________________________________________________

I understand that if I begin to provide service to members outside of a Network Participating acute care hospital, I will have to be credentialed by MSBCBS and/or HHIC as a condition of administrative and regulatory compliance with MSBCBS Network Provider Agreements and participation in the applicable Networks.

Group Type2/Group National Practice Name:____________________________ Provider Identifier (NPI) _______________________________ MSBCBS Group ____________________________ Provider Number: _______________________________

Group Type2/Group National Practice Name: ____________________________ Provider Identifier (NPI) _______________________________ MSBCBS Group ____________________________ Provider Number: _______________________________

Group Type2/Group National Practice Name:____________________________ Provider Identifier (NPI) _______________________________ MSBCBS Group ____________________________ Provider Number: _______________________________

Individual Type1/Individual National Practice Name:____________________________ Provider Identifier (NPI) _______________________________ MSBCBS Group ____________________________ Provider Number: _______________________________

Physician Signature: __________________________________________ Date: __________________________

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Spring 2008

WELCOMEWV Mine Power

Effective Date: 4/1/08Number of employees: 359Group location: Rupert, WV

Product Type: PPOClaims processing location: Parkersburg

Account Representative: Cathy Cain

To Our New Groups:Carpenters Health Fund

Of West VirginiaEffective Date: 7/1/08

Number of employees: 2,278Group location: Charleston, WV

Product Type: PPOClaims processing location: Wheeling

Account Representative: Thomas Alderson

Is your office receiving “mystery” lab results for some patients?Are these lab results being processed by Lab Corp?

Are they being sent to your office by “HealthPLACE on the Move”?

Here’s Why: These patients have recently

participated in a HealthPLACE on the Move corporate health

screening.Mountain State Blue Cross Blue Shield’s HealthPLACE on the Move is a mobile health screening unit that travels West Virginia screening Mountain State members and participants of various community events.

The blood screening conducted by HealthPLACE on the Move includes a fasting lipid panel, complete metabolic panel and a PSA for males over 50 years of age. Participants are asked to fast 10 - 12 hours to ensure quality results. The specimens are drawn by a certified phlebotomist and meet Lab Corp’s specimen quality processing standards.

Each participant of this screening receives a complete report of their results. Staff from HealthPLACE on the Move encourages participants to discuss the blood screening results, especially “out of the norm”

values, during their next physician appointment.

For more information regarding the services offered by HealthPLACE on the Move, please contact Pam Stover-Jones at 304-347-7664.

20

PROVIDERNewsMEDICAL POLICYUPDATES

As an added enhancement to our Provider News, Mountain State Blue Cross Blue Shield communicates Medical Policy updates in each issue.

Our medical policies are also available online through NaviNet® or at www.msbcbs.com. An alphabetical, as well as a sectional index, is available on the Medical Policy page. You can search for a medical policy by entering a key word, policy number or procedure code.

Recent updates or changes are as follows:


Correction to Effective Date for Implementation of New Medical Policy X-69

Medical Policy Bulletin X-69 (Multiple Procedure Payment Reduction for the Technical Component of Certain Diagnostic Imaging Procedures)Effective: September 1, 2008

Mountain State Blue Cross Blue Shield plans to reduce its payment of the technical component of certain diagnostic imaging services when more than one service is performed for the same patient, during the same session, on the same service date. Mountain State Blue Cross Blue Shield implemented this policy for its Medicare Advantage products in April 2007.

Payment reduction to affect claims processed on or after Sept. 1, 2008.Mountain State Blue Cross Blue Shield’s payment reduction for diagnostic imaging services will mirror the Centers for Medicare & Medicaid Services (CMS) Multiple Procedure Reduction of the Technical Component of Certain Diagnostic Imaging Procedures implemented in January 2006. Mountain State Blue Cross Blue Shield’s payment reduction applies to only the technical component of diagnostic studies performed within 11 families of imaging codes relating to contiguous body areas. The 11 families of imaging procedures were designated by CMS.

Mountain State Blue Cross Blue Shield will make full payment for the highest priced procedure and will make payment at 75 percent of the technical component for each additional procedure when performed for the same patient during the same session on the same day.

This payment reduction will become effective for claims for the specific diagnostic imaging procedures that are processed on or after September 1, 2008.

Multiple Procedure Reduction of the Technical Component (TC) of Certain Diagnostic Imaging Procedures

Table of 11 Imaging FamiliesHCPCS Description

Family 01 Ultrasound (Chest/Abdomen/Pelvis-Non-Obstetrical) 76604 US exam, chest 76700 US exam, abdom, complete 76705 Echo exam of abdomen 76770 US exam abdo back wall, comp 76775 US exam abdo back wall, lim 76831 Echo exam, uterus 76856 US exam, pelvic, complete 76857 US exam, pelvic, limited

Family 02 CT and CTA (Chest/Thorax/Abd/Pelvis) 71250 CT thorax w/o dye 71260 CT thorax w/dye 71270 CT thorax w/o & w/dye 71275 CT angiography, chest 72191 CT angiograph pelv w/o&w/dye 72192 CT pelvis w/o dye 72193 CT pelvis w/dye 72194 CT pelvis w/o & w/dye 74150 CT abdomen w/o dye 74160 CT abdomen w/dye 74170 CT abdomen w/o & w/dye 74175 CT angio abdom w/o & w/dye 75635 CT angio abdominal arteries 0067T CT colonography;dx Family 03 CT and CTA (Head/Brain/Orbit/Maxillofacial/Neck)

70450 CT head/brain w/o dye 70460 CT head/brain w/dye 70470 CT head/brain w/o & w/dye 70480 CT orbit/ear/fossa w/o dye 70481 CT orbit/ear/fossa w/dye 70482 CT orbit/ear/fossa w/o&w/dye 70486 CT maxillofacial w/o dye 70487 CT maxillofacial w/dye

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Spring 2008

UPDATES

Continued On Next Page Continued On Next Page

70488 CT maxillofacial w/o & w/dye 70490 CT soft tissue neck w/o dye 70491 CT soft tissue neck w/dye 70492 CT sft tsue nck w/o & w/dye 70496 CT angiography, head

70498 CT angiography, neck Family 04 MRI and MRA (Chest/Abd/Pelvis)

71550 MRI chest w/o dye 71551 MRI chest w/dye 71552 MRI chest w/o & w/dye 71555 MRI angio chest w or w/o dye 72195 MRI pelvis w/o dye 72196 MRI pelvis w/dye 72197 MRI pelvis w/o & w/dye 72198 MR angio pelvis w/o & w/dye 74181 MRI abdomen w/o dye 74182 MRI abdomen w/dye 74183 MRI abdomen w/o & w/dye 74185 MRI angio, abdom w orw/o dye HCPCS Description

Family 05 MRI and MRA (Head/Brain/Neck)70540 MRI orbit/face/neck w/o dye 70542 MRI orbit/face/neck w/dye 70543 MRI orbt/fac/nck w/o & w/dye 70544 MR angiography head w/o dye 70545 MR angiography head w/dye 70546 MR angiograph head w/o&w/dye 70547 MR angiography neck w/o dye 70548 MR angiography neck w/dye 70549 MR angiograph neck w/o&w/dye 70551 MRI brain w/o dye 70552 MRI brain w/dye 70553 MRI brain w/o & w/dye

Family 06 MRI and MRA (Spine)72141 MRI neck spine w/o dye 72142 MRI neck spine w/dye 72146 MRI chest spine w/o dye 72147 MRI chest spine w/dye 72148 MRI lumbar spine w/o dye 72149 MRI lumbar spine w/dye 72156 MRI neck spine w/o & w/dye 72157 MRI chest spine w/o & w/dye 72158 MRI lumbar spine w/o & w/dye

Family 07 CT (Spine)72125 CT neck spine w/o dye 72126 CT neck spine w/dye 72127 CT neck spine w/o & w/dye 72128 CT chest spine w/o dye 72129 CT chest spine w/dye 72130 CT chest spine w/o & w/dye 72131 CT lumbar spine w/o dye 72132 CT lumbar spine w/dye 72133 CT lumbar spine w/o & w/dye

Family 08 MRI and MRA (Lower Extremities)73718 MRI lower extremity w/o dye 73719 MRI lower extremity w/dye 73720 MRI lwr extremity w/o&w/dye

73721 MRI jnt of lwr extre w/o dye 73722 MRI joint of lwr extr w/dye 73723 MRI joint lwr extr w/o&w/dye 73725 MR ang lwr ext w or w/o dye

Family 09 CT and CTA (Lower Extremities)73700 CT lower extremity w/o dye 73701 CT lower extremity w/dye 73702 CT lwr extremity w/o&w/dye 73706 CT angio lwr extr w/o&w/dye

Family 10 MR and MRI (Upper Extremities and Joints)73218 MRI upper extremity w/o dye 73219 MRI upper extremity w/dye 73220 MRI uppr extremity w/o&w/dye 73221 MRI joint upr extrem w/o dye 73222 MRI joint upr extrem w/dye 73223 MRI joint upr extr w/o&w/dye

HCPCS Description Family 11 CT and CTA (Upper Extremities)73200 CT upper extremity w/o dye 73201 CT upper extremity w/dye 73202 CT uppr extremity w/o&w/dye 73206 CT angio upr extrm w/o&w/dye

Medical Policy Bulletin I-95 (Ibandronate Sodium {Boniva®} Injection)Boniva® coverage guidelines clarified. Effective: February 11, 2008

Mountain State Blue Cross Blue Shield covers ibandronate sodium (Boniva®) injection for the treatment of osteoporosis in postmenopausal women (ICD-9-CM diagnosis code 733.01) who have failed oral bisphosphonate therapy.

Osteoporosis may be confirmed by the presence or history of osteoporotic fracture or by a finding of low bone mass (bone mineral density more than 2.5 standard deviations below the normal adult reference population, that is, T-score).

Mountain State Blue Cross Blue Shield considers a 6-12 month trial of oral bisphosphonates adequate to determine treatment failure. Mountain State Blue Cross Blue Shield defines failure as:

new fracture despite bisphosphonate therapy of • six months or more, or

a T-score of less than or equal to -3.0 despite • bisphosphonate therapy of 12 months or more.

22

PROVIDERNewsMountain State Blue Cross Blue Shield may give individual consideration to claims for Boniva® injections when the patient has difficulty with oral bisphosphonate dosing requirements, which include an inability to sit upright 30 to 60 minutes and/or swallow a pill. Individual consideration may also be given for claims for Boniva® injections when the patient has esophagitis, gastritis, or esophageal or gastric ulcers prohibiting the use of oral bisphosphonates.

The recommended dose of Boniva® injection for the treatment of postmenopausal osteoporosis is 3 mg every three months administered over a period of 15 to 30 seconds. Boniva® injection must be administered intravenously only by a health care professional.

If the patient can tolerate oral bisphosphonates, then Mountain State Blue Cross Blue Shield considers the injectable form not medically necessary; therefore, it is not covered. A participating, preferred, or network provider may not bill the member for the denied medication.

If Boniva® is used for any other indication, Mountain State Blue Cross Blue Shield considers it experimental or investigational. It is not covered. A participating, preferred, or network provider may bill the member for the denied medication.

Report code J1740 for Boniva® injection.

Mountain State Blue Cross Blue Shield determines coverage for Boniva® injection according to the individual or group customer benefits. Boniva® injection is not covered under the prescription drug benefit.

MA Does not apply to Medicare Advantage.

Medical Policy Bulletin C-2 (Consultations)Consultations defined.Effective: February 18, 2008

Mountain State Blue Cross Blue Shield defines consultation as a professional service furnished to a patient by a second physician at the written or verbal request of the attending physician. The written or verbal request for a consultation must be documented in the patient’s medical record.

A consultation includes a history, examination of the patient, and evaluation of tests, when applicable. The consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated by written report to the requesting physician.

Mountain State Blue Cross Blue Shield determines coverage for consultations according to individual or group customer benefits.

Use the appropriate procedure code within the 99241-99255 range to report consultations.

MA For Medicare Advantage, see Medicare Advantage Medical Policy Bulletin C-2.

Medical Policy Bulletin I-42 (Zoledronic Acid Reclast®Zometa®)Reclast® guidelines for postmenopausal osteoporosis explained.Effective: February 11, 2008

Mountain State Blue Cross Blue Shield covers Zoledronic acid (Reclast®) injection, a bisphosphonic acid and inhibitor of osteoclastic bone resorption, for the treatment of:

Paget’s disease of bone (ICD-9-CM diagnosis • code 731.0) in men and women

osteoporosis in postmenopausal women (ICD-9-• CM diagnosis code 733.01) who have documented failure of oral bisphosphonate therapy

Osteoporosis may be confirmed by the presence or history of osteoporotic fracture or by a finding of low bone mass (bone mineral density more than 2.5 standard deviations below the normal adult reference population, that is, T-score).

Mountain State Blue Cross Blue Shield considers a 6-12 month trial of oral bisphosphonates adequate to determine treatment failure. Failure will be defined as:


23

Spring 2008

new fracture despite bisphosphonate therapy of • six months or more, or

a T-score less than or equal to 3.0 despite • bisphosphonate therapy of 12 months or more.

Mountain State Blue Cross Blue Shield may give individual consideration to claims for Reclast in documented cases for patients who have difficulty with oral bisphosphonate dosing requirements, which include an inability to sit upright for 30 to 60 minutes and/or swallow a pill. Individual consideration may also be given for patients who have esophagitis, gastritis, or esophageal or gastric ulcers prohibiting the use of oral bisphosphonates.

Reclast® injection contains the same active ingredient found in Zometa®, which is used for oncology indications. A patient already being treated with Zometa® should not be treated with Reclast®.

If the patient can tolerate oral bisphosphonates then Mountain State Blue Cross Blue Shield considers the injectable form not medically necessary; therefore, it is not covered. A participating, preferred, or network provider may not bill the member for the denied injection.

Mountain State Blue Cross Blue Shield considers the use of Reclast® for any other indication as experimental or investigational. It is not covered. A participating, preferred, or network provider may bill the member for the denied injection.

Use code J3488 to report zoledronic acid (Reclast®).

Mountain State Blue Cross Blue Shield determines coverage for Reclast® according to individual or group customer benefits. Reclast® is not reimbursable under the prescription drug benefit.

MA Does not apply to Medicare Advantage.

Correction to number of regions identified for codes 98925-98929

Medical Policy Bulletin Y-9 (Manipulation Services)Manipulation services require specific medical record documentation.Effective: March 17, 2008In the Winter 2008 Provider News, we incorrectly told you that eleven regions are identified for codes 98925-98929.

This information should have read, “Ten regions are identified for codes 98925-98929. These include: head, cervical, thoracic, lumbar, sacral, pelvic, lower extremities, upper extremities, rib cage, and abdomen/visceral.

Medical Policy Bulletin Z-11 (Definition of Medical Necessity)Definition of Medical Necessity Clarified.Effective: March 3, 2008

Effective March 3, 2008, Mountain State Blue Cross Blue Shield adopted the following definition of “medical necessity”:

“Medically Necessary” or “Medical Necessity” shall mean health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury or disease; and (c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant


24

PROVIDERNews


medical community, Physician Specialty Society recommendations and the views of Physicians practicing in relevant clinical areas and any other relevant factors.MA Does Not Apply to Medicare Advantage

Medical Policy Bulletin X-17 (Obstetrical Ultrasound)Diagnosis Code 642.03 (Benign Essential Hypertension, Antepartum) will be Allowable when Billed for First Trimester Ultrasound Studies.Effective: April 28, 2008

First trimester ultrasound studies Obstetrical ultrasound studies performed in the first trimester (codes 76801, 76802) by either the attending obstetrician or another health care professional (e.g., ultrasonographer, radiologist) are considered medically necessary in the following situations.

• ectopic pregnancy (633.00-633.11, 633.20-633.21, 633.80-633.81, 633.90-633.91)

• molar pregnancy/hydatidiform mole (630-631)

• hemorrhage in early pregnancy (640.01-640.03, 640.81-640.83, 640.91-640.93)

• missed abortion (632)

• hyperemesis gravidarum with metabolic disturbance, antepartum (643.11-643.13)

• habitual aborter (646.31-646.33)

• other antepartum hemorrhage (antepartum or intrapartum, associated with trauma, uterine leiomyoma)(641.81-641.83)

• abnormal findings on previous ultrasound (796.5)

• absence of fetal heart tones (659.73)

• adnexal mass (654.43)

• advanced maternal age (659.53, 659.63)

• carcinoma of cervix uteri (233.1)

• early pregnancy with pain (646.80, 646.83)

• fever (780.6)

• hemoperitoneum (568.81)

• history of greater than 1 loss in 1st trimester (V23.49)

• history of previous cesarean section (654.20, 654.23)

• history of uterine abnormality (654.03, 752.3)

• incompetent cervix (654.50, 654.53)

• leukocytosis (288.8)

• pain, unilateral or generalized (789.00, 789.03, 789.09)

• pregnancy with hypertension (642.93)

• size less than due date (656.53)

• size greater than due date (656.63)

• spotting early in pregnancy (641.93)

• syncope (hypovolemic) (780.2)

• tenderness without rebound (789.67)

• twin pregnancy (651.03)

• triplet pregnancy (651.13)

• quadruplet pregnancy (651.23)

• twin pregnancy with one fetal loss (651.33)

• triplet pregnancy with one or two fetal loss (651.43)

• quadruplet pregnancy with fetal loss and retention of one or more fetus(es)(651.53)

• other multiple pregnancy with fetal loss and retention of one or more fetus(es)(651.63)

• other specified multiple pregnancy (651.83)

• unspecified multiple gestation (651.93)

• tumors of body of uterus (654.13)

25

Spring 2008


• other known or suspected fetal abnormality, not elsewhere classified (655.83)

• benign essential hypertension, antepartum (642.03)

The above criteria for first trimester ultrasound studies also applies to transvaginal obstetrical ultrasound studies (code 76817) when they are performed in the first trimester.

Obstetrical ultrasound studies performed in the first trimester for other diagnoses or conditions are considered not medically necessary. Participating, preferred or network providers cannot bill the member for the denied service.

MA Does Not Apply to Medicare Advantage

Triesence covered for FDA approved indications.On Nov. 30, 2007, the U.S. Food and Drug Administration (FDA) approved Triesence™ (triamcinolone acetonide injectable suspension) 40 mg/ml to promote visualization during vitrectomy and for treatment of sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory conditions unresponsive to topical corticosteroids. Mountain State Blue Cross Blue Shield will cover Triesence for the new FDA approved indications.

Use procedure code 67028—intravitreal injection of a pharmacologic agent (separate procedure)—to report the intravitreal injection. Procedure code J3301—injection triamcinolone acetonide, per 10 mg—should be used to report the pharmacologic agent.

Triesence is a preservative-free synthetic corticosteroid prepared as an injectable suspension specifically developed for use in the eye.

MA Also applicable to Medicare Advantage.

Medical Policy Bulletin I-77 (Intravitreal Triamcinolone Acetonide)Policy ArchivedEffective: April 28, 2008

Effective April 28, 2008, Medical Policy Bulletin I-77 was archived.

Certain Services to be included in critical care payment.Mountain State Blue Cross Blue Shield will begin to include certain services in its payment for critical care codes 99291 and 99292 as of August 18, 2008.

Mountain State Blue Cross Blue Shield considers the following services to be part of critical care codes 99291 and 99292 when they’re performed during the critical period by the physician providing critical care:

interpretation of cardiac output measurements • (93561, 93562)

chest X-rays (71010, 71015, 71020)•

pulse oximetry (94760, 94761, 94762)•

blood gases, and information data stored • in computers, for example, ECG’s, blood pressures, hematologic data (99090)

gastric intubation (43752, 91105)•

temporary transcutaneous pacing (92953)•

ventilatory management (94002-94004, 94660, • 94662)

vascular access procedures (36000, 36410, • 36415, 36591, 36600)

If you perform these services in addition to 99291 or 99292, Mountain State Blue Cross Blue Shield will not pay separately for the additional services – it will include those services in its payment for the critical care.

If you perform any services that are not listed in the above text during the critical period, please report those services separately.

MA For Medicare Advantage, see Medicare Advantage Medical Policy Bulletin V-20.

26

PROVIDERNewsCodes and modifier updates for April 2008 The information below consists of four reinstated codes, four new codes, and one new modifier for your reporting purposes.Code Terminology Effective date

J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg

Reinstated April 1, 2008

J7612 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 0.5 mg


J7613 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg

Reinstated April 1,2008

J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg


Q4096 Injection, von Willebrand factor complex, human, Ristocetin cofactor (not otherwise specified), per I.U. VWF:RCO

April 1, 2008

Q4097 Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg

April 1, 2008

Q4098 Injection, iron dextran, 50 mg

April 1, 2008

S3628 Placental alpha microglobulin-1 rapid immunoassay for detection of rupture of fetal membranes

April 1, 2008

Terminology Effective date

KT Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item

April 1, 2008

Modifier


27

Spring 2008

New codes and modifier

Here are 12 new procedure codes and one new modifier for your reporting purposes:

Code Terminology Effective date

G0398 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation

3/13/2008

G0399 Home sleep study test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG heart rate and 1 oxygen saturation

3/13/2008

G0400 Home sleep test (HST) with type IV portable monitor, unattended, minimum of 3 channels

3/13/2008

K0672 Addition to lower extremity orthosis, removable soft interface, all components, replacement only, each

4/1/2008

Q4099 Formoterol fumarate, inhalation solution, FDA approved final product, non-compounded, administered through DME, unit dose form, 20 micrograms (Perforomist)

4/1/2008

S3628 Placental alpha microglobulin-1 rapid immunoassay for detection of rupture of fetal membranes

4/1/2008

0188T Remote real-time interactive videoconferenced critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes

7/1/2008

0189T Remote real-time interactive videoconferenced critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service)

7/1/2008

0190T Placement of intraocular radiation source applicator (List separately in addition to primary procedure)

7/1/2008

0191T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach

7/1/2008

0192T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach

7/1/2008

90738 Japanese encephalitis virus vaccine, inactivated, for intramuscular use

7/1/2008

Modifier Terminology Effective date

CG Policy criteria applied 7/1/2008


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PROVIDERNewsSpring 2008

provider news - highmark · advanced trauma life support (atls); and (3) pediatric advanced life...

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