UpdateS E P T E M B E R 2 015

PA R T N E R I N G W I T H YO U F O R A H E A LT H I E R N E B R A S K Anebraskablue.com

The Update is a bimonthly provider newsletter that contains up-to-date information about Blue Cross and Blue Shield of Nebraska for health care providers. It is published by the Health Network Services Department (HNS) and Corporate Communications.

If you are a contracting BCBSNE health care provider, this newsletter serves as an amendment to your agreement and affects your contractual relationship with us. You are encouraged to file every issue of the Update within your BCBSNE Policies and Procedures manual and reference it often. You may also view the current manual in the Provider section at nebraskablue.com.

As a service for Blue Cross and Blue Shield members, we also send this newsletter to non-participating Nebraska providers.

We also publish each issue online in the Provider section at: nebraskablue.com

For permission to reprint mate-rial published in the Update or to receive a printed copy, e-mail the editor, Kimberly Vavra, at: kimberly.vavra@nebraskablue.com

If you would like to receive an e-mail each time a new issue of this newsletter is posted on the website, go to bit.ly/updatenewslettersignup. You can view the newsletter and request online notifications of special announcements about workshops, resources, and other information from BCBSNE.

Blue Cross and Blue Shield of Nebraska is an Independent Licensee of the

Blue Cross and Blue Shield Association.

Sometimes you have patients who have a Blues Plan – just not a Nebraska Blues Plan. In those cases, Blue Cross and Blue Shield of Nebraska (BCBSNE) can’t process or forward preauthorization requests for “BlueCard” members. If you have a BlueCard member with coverage from another state, you can avoid hassles and delays by following the guidelines and directions of the various Blues plans to preauthorize services for BlueCard members. Our local Nebraska preau-thorization requirements and medical policy apply only to our members, and each Blues plan has different criteria.

Every Blues member’s ID card should have a preauthorization phone number on the back of the card. You may also use the “Medical Policy and Pre-Cert List for all Blues Plans” router on our website at http://bit.ly/1LKLyoF.

Be Sure to Submit Preauthorizations to the Correct Blues Plan

Be Sure to Submit Preauthorizations to the Correct Blues Plan 1

BlueBoard: Fluoride Varnish for Children 2

BlueBoard: Provider Effective Date Reminder 2

Researching Claims Status with NaviNet – Effective Jan. 1 2

Single Sign on Available through NaviNet! 3

Timely Filing for Newborns 3

ICD-10 is Here! 4

For Your Information: Pharmacy Drug Price Increases 4

Determining the Correct Usage of Modifiers 25 and 59 5

Guidelines for Modifier 25 6

Guidelines for Modifier 59 7

In this issueClick on one of the headlines below to go directly to the article you wish to view.

When you enter the member’s three-digit ID prefix from his or her card, you will be directed to that member’s home plan for precertification and preauthorization requirements and/or contact information for that Blues plan.

While BlueCard members’ benefits information and preauthorization are determined by their home plans, you will still file claims to BCBSNE unless otherwise directed.

PPO Health - Select NetworkSelect BlueChoiceNEtwork BLUE Dental

Copays May Apply

PPO

Member NameJohn DoeIDXYZ123456789

Medical and Rx BenefitsRxBIN 610455RXPCN RxNEBPlan Code 263 763

NEtwork BLUE

nebraskablue.com

File all claims with local Blue Cross and/or Blue Shield Plan/Licensee in whose Service Area the member received services.

Admission Certification required prior to inpatient admission. Penalties may apply.

Dental GRID / GRID+

Blue Cross and Blue Shield of Nebraska PO Box 3248 Omaha, NE 68180-0001 An Independent Licensee of the Blue Cross and Blue Shild Association.

Member Services: 1-888-592-8960 Admission Certification: Omaha: 1-402-390-1870 Toll-free: 1-800-247-1103 Provider Locator: 1-800-810-2583 NE Provider Services: 1-800-635-0579 Providers Outside NE: 1-800-676-2583 Pharmacy Help Desk: 1-800-821-4795

2

BlueBoard

Fluoride Varnish for Children Good oral health starts young, so the Affordable Care Act (ACA) requires that fluoride varnish is a covered benefit for children from 6 months up to 6 years old. Medical providers must bill with CPT code 99188. Claims billed with a dental code will be denied.

That same procedure code 99188 for fluoride varnish submitted by the primary care clinician covers children from newborn through age five. Currently the correct diagnosis code for the claim is V20.2. As of Oct. 1, the ICD-10 code for this service will be Z00.129.

If this claim is submitted by a dentist or other health care provider, it will be denied. It will also be denied if a primary care clinician bills dental code D1206 and D1208.

Reminder: Provider Effective Date

BCBSNE cannot assign an effective date prior to the provider’s license date. If you’re not sure of the license date, you can verify it at http://1.usa.gov/1iFO6sq.

Researching Claims Status with NaviNet – Effective Jan. 1 BCBSNE is always looking for ways to better serve providers and customers in a timely manner. That’s why BCBSNE is switching to NaviNet for providers to research claims. As part of this process, we will direct providers to use NaviNet whenever possible and/or if the claim was submitted within the past 30 days. This will free up personnel to support more complex benefit and claims calls.

The program is already available for use, but as of Jan. 1, 2016, we will require it as a first line of answers. On that date, you must use NaviNet for your claim inquiries within the first 30 days of the claims submission. Up until that date, Customer Service will assist you in using NaviNet to find your answers when you call to inquire about assistance on a claim. You can get also get assistance on navigating NaviNet via www.navinet.net.

To find out more, you can view a description of NaviNet, a guide and FAQs at https://bit.ly/1hbmg6f.

3

Single Sign on Available through NaviNet!As part of an update to our NaviNet provider portal, we are happy to introduce a single sign-on enhancement that will provide direct, more convenient access to the following vendor program websites:

• Radiology Quality Initiative through American Imaging Management (AIM)

• Spine Pain Management Program through NIA Magellan/RadMD

As part of this new feature, providers can simply log into NaviNet and click on “Spine Pain Management Prior Authorization” and “AIM Diagnostic Imaging Request,” and they will automatically be logged in – no additional user names or passwords needed!

Note: AIM users may have to recreate their favorites within NaviNet’s single sign on account.

Log in to NaviNet today to try the single sign on feature!

Timely Filing for NewbornsAll providers submitting newborn claims, please note that our system will always accept these claims initially. As a result, resubmitting the exact same claim after the baby is added will process as a duplicate regardless if the claim didn’t pay due to the member not being identified as our insured. If the baby is not loaded in our system, then the claim will be returned. After verifying the baby has been added to the policy, please resubmit as a corrected claim. Place a value of “7’” (replacement of prior claim) in the 2300 CLM 05-3 element in the 837P file. Enter the original claim number assigned by BCBSNE in the 2300 REF*8 segment of the 2300 loop. Currently, the timely filing for newborn claims is 180 days. Please follow up with the parent and review NaviNet to confirm membership changes. (Please note: This is an exception to the return claim rule, which requires a new claim submission.)

A reconsideration and/or appeal for newborn claims returned because the baby is not loaded cannot be submitted because the claim was not adjudicated and a remit issued.

• A reconsideration is a request from a provider for BCBSNE to review a claim with additional information not previously provided.

• An appeal is a request from a provider for BCBSNE to review a claim with a disposition that the member or provider disagrees with based on the information presented.

Not on NaviNet? Learn more and sign up today at www.nebraskablue.com/navinet!

The advantages of using NaviNet include:

• Check current member claim status – no need to pick up the phone!

• Quickly access member eligibility and benefits information

• Access pre-service review information for out-of-area members.

We understand the workloads you encounter every day and recognize the need for administrative efficiencies. If you have any questions about this new feature or about NaviNet in general, please contact NaviNet at (617) 715-6000.

180 DAYS is the current timely filing for newborn claims

4

ICD-10 is Here!No doubt you’ve worked hard and put in some long days leading up to Oct. 1! ICD-10 is going to be around for a long time, so make sure your entire team has the tools they need. If you need additional information, check out the WHO program at http://bit.ly/1KGnkKd.

Also, we want to clarify a couple of items from our recent ICD-10 newsletter, available online at http://bit.ly/1OCNRfg:

• For inpatient claims, use the code in effect on the date of the patient’s discharge.

• If institutional (outpatient) and professional (inpatient and outpatient) services are provided on Sept. 30 and Oct. 1, the claims should be split.

For Your Information: Pharmacy Drug Price IncreasesRecent drug price increases taken by pharmaceutical organizations have been all over the news. This has members and patients concerned about the potential impact on health care costs and their pocketbooks.

In an effort to provide information on cost of medications, the following chart provides pricing information on specific drugs, including the price increase and the estimated monthly cost difference.

Brand Name (active ingredients)

Drug Manufacturer

Price Increases

(%)

Estimated Monthly Cost

Difference

Price Increases Timeframe

Duexis (ibuprofen/famotidine) Horizon 119% $823 1/1/14-

9/30/15

Glumetza (metformin ER) Valeant 800% $6,050 6/1/15-

9/30/15

Vimovo (naproxen/esomeprazole) Horizon 86% $700 1/1/14-

9/30/15

Zegerid (omeprazole/sodium bicarbonate) Valeant 691% $2,703 6/1/15-

9/30/15

Here are a few more excellent resources to guide you as we kick off ICD-10 – and of course you can always reach out to ICD10@nebraskablue.com.

• roadto10.org

• CMS.gov/ICD10

• medilexicon.com

• medicalbillingandcoding.org

• http://bit.ly/1KGnkKd

• ahima.org

• himss.org/library/icd-10/playbook

Now let’s hit the road!

* Many medications have had price increases. This is not a complete list of all drugs with price increases. The brand names are trademarks of their respective organizations.

5

Determining the Correct Usage of Modifiers 25 and 59BCBSNE has contracted with Verisk Health, Inc., to evaluate claims with modifiers 25 or 59. Per NCCI, modifier 25 refers to significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service, whereas the primary purpose of modifier 59 is to indicate that two or more procedures are performed at different anatomic sites, during different patient encounters, by different providers, or in unusual but not overlapping procedures. Verisk will begin reviewing the claims for appropriateness of the 25 and 59 in modifier early 2016.

If Verisk determines the claim was coded incorrectly they will advise BCBSNE to deny the claim, but the provider will have the opportunity to submit for reconsideration with medical records. When BCBSNE receives the reconsideration and records, we will send them on to Verisk for their nurses to review. They will then advise us whether to approve or deny the claim(s). If the denial is upheld, providers have the option for a second level review with BCBSNE.

For more detailed descriptions of the appropriate use of modifiers 25 and 59, please see the following guidelines, provided by Verisk.

6

References• National Correct Coding Initiative Policy Manual, Revision

Effective Date: January 1, 2012.

• Current Procedural Terminology 2012, Published by the American Medical Association, 2012

• Coding With Modifiers, Published by the American Medical Association, 2007

Guidelines for Modifier 25Provided by Verisk Health, Inc.

CPT specifies that on modifier 25, the provider indicates that a “significant, separately identifiable evaluation and management service (was provided) by the same physician on the same day of the procedure or other service.”

Additional CPT guidelines state that this significant and sepa-rable service must be “above and beyond” the other service provided or beyond the usual pre-operative and postoperative care associated with the procedure that was performed. For minor procedures, routine pre-operative services also include instances in which the decision to perform the procedure is made immediately before the service (e.g., sutures are needed to close a wound, or needing to remove a mole or wart). Minor surgeries and endoscopies are defined as those surgeries with a 0- to 10-day global period. For major surgeries, the decision for surgery should be identified by the application of modifier 57, not modifier 25.

The AMA Guidelines in Coding with Modifiers state the following: “The E/M service must meet the key components (e.g., history, examination, medical decision-making) of that E/M service including medical record documentation. To use modifier 25 correctly, the chosen level of E/M service needs to be supported by adequate documentation for the appropriate level of service, as well as referenced by a diagnosis code. The CPT codes for procedures do include the evaluation services necessary before the performance of the procedure (e.g., assessing the site and condition of the problem area, explaining the procedure, obtaining informed consent); however, when significant and identifiable (e.g., medical decision-making and another key component) E/M services are performed, these services are not included in the descriptor for the procedure or service performed.”

When an E/M service is billed (either with or without modifier 25) Verisk Health uses the following guidelines to assist us in determining whether or not a separate E/M service was likely rendered:

• A diagnosis on the claim indicates that a separate medical condition was treated (e.g., a separate body system, a complicating co-morbid condition, or morbidity of the primary condition).

• Other diagnostic procedures or services (such as laboratory or radiology tests) billed by the provider indicate the provider was evaluating separate conditions.

• The provider billed for supplies or equipment unrelated to the procedure performed but required an E/M services to determine the patient’s need.

• Medical record documentation that supports the significant circumstances including medical decision-making plus one other key component of the E/M service.

Examples:• An established patient presents to the podiatrist

with complaints of an ingrown toenail. The foot was assessed, and the decision is made to remove the ingrown nail. An E/M service should not be reported.

• An established patient presents to the family physician with a new complaint of an uncontrolled bloody nose. An E/M service would be appropriate because the physician would have to do a significant and separate evaluation in addition to controlling the nasal hemorrhage (30901).

7

Guidelines for Modifier 59Provided by Verisk Health, Inc.

The NCCI (National Correct Coding Initiative) states the primary purpose of modifiers 59, XE, XS, XP, XU are to indicate that two or more procedures are performed at different anatomic sites, during different patient encounters, by different providers or in unusual, but not overlapping, procedures.

The CPT Manual defines modifier 59 as follows:

“Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”

The new X modifiers were implemented by CMS to replace modifier 59 and provide a more specific explanation of the circumstances normally coded with modifier 59:

• XE Separate Encounter – a service that is distinct because it occurred during a separate encounter

• XS Separate Structure – a service that is distinct because it was performed on a separate organ/structure

• XP Separate Practitioner – a service that is distinct because it was performed by a different practitioner

• XU Unusual Non-Overlapping Service – the use of a service that is distinct because it does not overlap usual components of the main service

Many providers are incorrectly assigning modifier 59 to any code that will result in a denial due to unbundling. Commonly we find misuse of modifier 59 related to the portion of the definition of modifier 59, allowing its use to describe “different procedure or surgery.” CMS has recently clarified that the provider should not use modifier 59 solely based on the two codes being different procedures/surgeries, which is often what is stated by the provider in an appeal letter justifying why they are requesting additional payment. Only if the two procedures/surgeries are performed at separate anatomic sites or at separate patient encounters on the same date of service would modifier 59 be appropriate.

NCCI defines different anatomic sites to include different organs, or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. NCCI examples of situations that would constitute a single anatomical site include:

• Treatment of the nail, nail bed, and adjacent soft tissue

• Treatments of posterior segment structures in the eye

Use of modifier 59 to indicate different procedures/surgeries do not require a different diagnosis for each procedure/surgery performed. However, this would clearly be an indicator on a claim to allow both procedures without having to review clinical documentation to determine that the procedures were performed at different anatomic sites.

References: • National Correct Coding Initiative Policy Manual, Revision

Effective Date: January 1, 2012.

• Current Procedural Terminology 2012, Published by the American Medical Association, 2012

• Coding With Modifiers, Published by the American Medical Association, 2007

The following are some examples of different situations and their outcomes: • NCCI denies CPT Code 11720 (debridement of nail(s)

by any method(s); one to five) when reported with 11055 (paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion).

• NCCI approves modifier 59 if the debridement is performed at a separate site or at separate patient encounters. It would be considered incorrect coding to report the debridement with codes 11055-11057 for removal of hyperkeratotic skin adjacent to nails needing debridement. The same is true when reporting CPT Code 11719 (trimming of non-dystrophic nails, any number) with CPT Code 11720 (debridement of nail(s) by any method(s); one to five). Modifier 59 is only appropriate if the trimming and the debridement of the nails are performed on different nails or if the two procedures are performed at separate patient encounters.

• CPT Codes 98942 (chiropractic manipulative treatment (CMT); spinal, five regions) and 97112 (therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities) are edited when reported together.

• Modifier 59 is only appropriate if the physical therapy service 97112 is performed in a different region than where the CMT is performed. Providers commonly submit their notes and only indicate that these are “different procedures” which would not support the use of modifier 59.