Many members have both primary and secondary insurance policies, and it’s important to know which policy is primary. We want to make it as easy as possible for you to find out so you can avoid claim denials for not filing the secondary claim within the timely filing guidelines.

Before the member arrives for their appointment, check the primary insurance carrier using the Eligibility and Benefits app in Availity. Log onto Availity.com, go to payer spaces, select us as the payer and use the Patient Registration tab to run an Eligibility and Benefits Inquiry. If you find that we are the primary payer, confirm that when the member arrives for their appointment. After providing services, submit the member’s claim as usual – you can use Availity for that, too, through the Claims & Payments app.

If we are the secondary payer, we will need the explanation of benefits (EOB) from the primary carrier along with the claim submission to determine our payment amount. You can submit the EOB and the claim through Availity using the Claims & Payments app.

When a claim is submitted to us as the primary payer, and we are the secondary payer, our claim system will deny the claim because we don’t have the EOB. This can cause a delay in receipt of your payment and can even cause you to miss the timely filing guideline.

We want you to have of the information you need to know the very best way to file your claims. For more information about filing claims, visit Anthem.com/provider/claims-submissions. For help using Availity, log onto Availity.com and select the Help & Training tab.

1234-0721-PN-CA

It wasn’t too long ago when patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. Thanks to a small, portable device, patients on warfarin can now self-test with a finger prick drop of blood. There is more to self-testing than the ease and convenience, though. Patients are happier! Their quality of life improved because they can keep up with their activities – even travel, without the stress of making and keeping testing appointments.

Self-testing: Measurable difference when correct coding is reflected

This type of quality care and improved outcomes are making a measurable difference in the lives of our members. We want this success accounted for in the INR clinical quality measure and with your help, we can do it.  Use these codes to reflect INR In-home monitoring when noting the INR results for your patients.

INR clinical quality measure:

The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.

1231-0721-PN-CA

Do you utilize nurse practitioners or physician assistants in your practice?  These provider types are underutilized resources that benefit the practices and communities they serve. 

If your medical practice includes nurse practitioners and physician assistants, we want to know about them. 

• Initiate the Digital Enrollment Process to add nurse practitioners and physician assistants to your Anthem Blue Cross Tax ID.
• Once added, they can treat and bill for services rendered to Anthem members.
• Submit claims under the rendering practitioner’s own name and NPI.
• These providers will not display in our online provider directory, Find Care.

Note: Nurse practitioners and physician assistants can treat Anthem members under a contracted physician practice.  They cannot practice independently under their own Anthem contract (agreement) at this time.

Learn more about the Digital Enrollment Application.  Select the link to get started today!

1213-0721-PN-CA

In a recent study published by Pediatrics¹, economic hardship, school closing and shutdowns led to sedentary lifestyles and increases in childhood obesity. The research analyzed doctor visits pre-pandemic then during the pandemic period and the increases were dramatic. Overall obesity increased from 13.7% to 15.4%. Increases observed ranged from 1% in children aged 13 to 17 years to 2.6% for those aged 5 to 9 years.

The study recommended new approaches to Weight Assessment and Counseling. These include recommending virtual activities that promote increased physical activity. Focusing on ways to remain safe and active with outside activities, such as park visits, walks and bike riding were also suggested.

The Centers for Disease Control and Prevention has a great resource, “Ways to promote health with preschoolers.” This fun flyer shows how we can all work together to support a healthy lifestyle. You can download a copy here.

The HEDIS® measure Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) requires a nutritional evaluation and pro-active guidance as part of a routine health visit.

• When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.
• When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.
• Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.

HEDIS® measure WCC looks at the percentage of members, 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:

• Body mass index (BMI) percentile (percentage, not value)
• Counseling for nutrition
• Counseling for physical activity

Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.

Code services correctly to measure success

These diagnosis and procedure codes are used to document BMI percentile, weight assessment, and counseling for nutrition and physical activity:

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

American Academy of Pediatrics. American Academy of Pediatrics raises concern about children’s nutrition and physical activity during pandemic. Available at: http://services.aap.org/en/news-room/news-releases/aap/2020/american-academy-of-pediatrics-raises-concern-about-childrens-nutrition-and-physical-activity-during-pandemic/. Accessed December 10, 2020

¹ https://pediatrics.aappublications.org/content/147/5/e2021050123?cct=2287#F1

1232-0721-PN-CA

Overview:

Join us throughout the year in a new Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving Star ratings.

Program objectives:

• Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas including telehealth, pharmacy measures, chronic disease monitoring, cancer screenings, documentation and more.
• Apply the knowledge you gain from the webinars to improve your organization’s quality.

Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.

REGISTER HERE for our upcoming clinical quality webinars!      

1230-0721-PN-CA

You should always submit claims to Anthem Blue Cross. Be sure to include the member’s complete identification number when you submit the claim. The complete identification number includes the three-character alpha/numeric prefix. Do not make up alpha prefixes. Claims with incorrect or missing alpha prefixes and/or member identification numbers cannot be processed.

1237-0721-PN-CA

Submission of claims in overlapping Blue Plan service areas is dependent on what plan(s) the provider contracts with in that state, the type of contract the provider has for example, PPO, Traditional, etc., and the type of contract the member has with their Home Plan.

In other states, a company may carry the Blue Cross and Blue Shield name together, as a single entity. In California, there are two separate and independent Blue Cross Blue Shield companies. One is Anthem Blue Cross, and the other is Blue Shield of California.

• If you contract with both Plans in California, you may file an out-of-area Blue Plan member’s claim with either Plan.
• If you contract with one Plan but not the other, file all out-of-area claims with your contracted Plan.

Use the Anthem Blue Cross Payer ID number that was assigned to you, not the Blue Shield of California Payer ID number. If you submit an Anthem Blue Cross member claim with the Blue Shield of California Payer ID number instead of the Anthem Blue Cross Payer ID number, the claim will process as out-of-network.

1236-0721-PN-CA

The BlueCard® Program provides a valuable service that lets you file all claims for members from other Blue Plans with Anthem Blue Cross. Here are some key points to remember:

• Make a copy of the front and back of the member’s ID card.
• Look for the three-character prefix that precedes the member’s ID number on the ID card.
• Call BlueCard Eligibility at 1-800-676-BLUE (2583) to verify the patient’s membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to Anthem Blue Cross.
• Submit the claim to Anthem Blue Cross. Always include the patient’s complete identification number, which includes the three-character prefix.
• For claims inquiries, contact Anthem Blue Cross.

Prompt written notice of a closed practice prevents member servicing delays. Are you accepting new patients? Your practice status - open or closed must be reflected accurately in our provider directories. California law requires that participating health care providers notify health plans within five days when their “Accepting New Patients” status changes.

1239-0721-PN-CA

Anthem Blue Cross does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at www.anthem.com/ca/medicareprovider.

ABCCRUN-0165-21

517554MUPENMUB

Read the full Infusion Step Therapy Retraction Notice.

ACA-NU-0344-21

Read the full Specialty Pharmacy Prior Authorization Retraction Notice.

ACA-NU-0345-21

ACA-NU-0349-21

Effective September 1, 2021, prior authorization (PA) requirements will change for 0205U, 0209U, and 0218U. The medical codes listed below will require PA from Anthem Blue Cross for our members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• 0205U — ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negative for neovascular age-related macular-degeneration risk associated with zinc supplements
• 0209U — cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities
• 0218U — neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or saliva, identification and characterization of genetic variants

To request PA, you may use one of the following methods:

• Web: https://providers.anthem.com/ca
• Fax: 800-754-4708
• Phone:
  • 888-831-2246 Medi-Cal Managed Care (Medi-Cal)
  • 877-273-4193 Major Risk Medical Insurance Program/Medi-Cal Access Program

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool through the Availity* Portal at https://www.availity.com or by going to the provider website at https://providers.anthem.com/ca > Login. Contracted and noncontracted providers who are unable to access Availity can call one of our Medi-Cal Customer Care Centers for assistance with PA requirements:

• 800-407-4627 (outside L.A. County)
• 888-285-7801 (inside L.A. County).

ACA-NU-0353-21

As part of our ongoing quality improvement efforts, Anthem Blue Cross is updating our precertification processes for certain specialty medications. Effective August 1, 2021, we may request additional documentation for impacted medications to determine medical necessity.

Upon request, providers shall submit documentation from the member’s medical record for each policy question flagged for documentation. A denial may result if documentation does not support medical necessity.

Should you have any questions, please refer to the Clinical Criteria policy website for specific medication criteria details.

ACA-NU-0354-21

Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

Let's Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

• Address disparities for vaccine-preventable diseases.
• Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
• Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.
• Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.

ACA-NU-0355-21

Effective October 1, 2021, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by Anthem Blue Cross for our members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added to the following:

• 0045U — oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score
• 0153U — oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s) with information on immune cell involvement
• 0244U — oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin-embedded tumor tissue
• 81414 — cardiac ion channelopathies (for example, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1
• 81439 — hereditary cardiomyopathy (for example, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy), genomic sequence analysis panel, must include sequencing of at least 5 cardiomyopathy-related genes (for example, DSG2, MYBPC3, MYH7, PKP2, TTN)
• 81518 — oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes
  (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy
• 81519 — oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score
• 81520 — oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score
• 81521 — oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis
• 81522 — oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and
  4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score

To request PA, you may use one of the following methods:

• Web: https://providers.anthem.com/ca
• Fax: 800-754-4708
• Phone:
  • 888-831-2246 (Medi-Cal Managed Care)
  • 877-273-4193 (Medi-Cal Access Program/Major Risk Medical Insurance Program)

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at https://www.availity.com or on the provider website at https://providers.anthem.com/ca > Login. Contracted and noncontracted providers who are unable to access Availity can call one of our Customer Care Centers for assistance with PA requirements:

• 800-407-4627 (outside L.A. County)
• 888-285-7801 (inside L.A. County).

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross.
ACA-NU-0356-21

On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other members of your practice and office staff.

Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

ACA-NU-0358-21

As patient panels grow more diverse and needs become more complex, providers and office staff need more support to help address patients’ needs. Anthem Blue Cross (Anthem) wants to help.

Cultural competency resources

Here is an overview of the cultural competency resources available on our provider website.

• Cultural Competency and Patient Engagement includes:
• The impact of culture and cultural competency on healthcare.
• A cultural competency continuum, which can help providers assess their level of cultural competency.
• Disability competency and information on the Americans with Disabilities Act (ADA).
• Caring for Diverse Populations Toolkit includes:
• Comprehensive information, tools and resources to support enhanced care for diverse patients and mitigate barriers.
• Materials that can be printed and made available for patients in provider offices.
  • Regulations and standards for cultural and linguistic services.
• My Diverse Patients offers:
• A comprehensive repository of resources to providers to help support the needs of diverse patients and address disparities.
• Courses with free continuing education credit through the American Academy of Family Physicians.
  • Free accessibility from any device (for example, desktop computer, laptop, phone or tablet), no account or login required.

To access these resources, go to https://providers.anthem.com/ca > Provider Training Academy > Cultural competency resources.

In addition, providers can access Stronger Together, which offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.

Prevalent non-English languages (based on population data)

Like you, Anthem wants to effectively serve the needs of diverse patients. It’s important for us all to be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the prevalent non-English languages spoken by 5% or 1,000 individuals in California .¹

Language support services

As a reminder, Anthem provides language assistance services for our members with limited English proficiency (LEP) or hearing, speech, or visual impairments. Please see the provider manual for details on what is available and how to access resources. In addition, the cultural competency resources shared above provide guidance on communicating and serving diverse populations effectively.

1 Source: American Community Survey, 2019 American Community Survey 1-Year Estimates, Table B16001, generated 10/04/2020.

ACA-NU-0343-21

Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

Let's Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

• Address disparities for vaccine-preventable diseases.
• Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
• Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.
• Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.

ABCCRNU-0176-21

518911MUPENMUB

On October 1, 2021, prior authorization (PA) requirements will change for A0426 and A0428 covered by Anthem Blue Cross. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

PA requirements will be added for the following codes:

• A0426 — ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)
• A0428 — ambulance service, basic life support, nonemergency transport (BLS)

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at https://www.availity.com or on the provider website at https://www.anthem.com/ca/medicareprovider > Login. Contracted and noncontracted providers unable to access Availity can call the Provider Services located on the back of their patient’s member ID card for PA requirements.

ABCCRNU-0177-21

518884MUPENMUB

On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other members of your practice and office staff.

Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

ABCCRNU-0178-21518315MUPENMUB

This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7^® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

The Clinical Data Acquisition Group for Anthem integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:

• Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings.

Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.

Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started today.

ACA-NU-0326-21518933MUPENMUB

Anthem Blue Cross does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at https://providers.anthem.com/ca.

ACAD-NU-0154-21

517621CAPENABC

Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

• Address disparities for vaccine-preventable diseases.
• Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
• Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.
• Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer., and Vaccinate Your Family.

ACAD-NU-0160-21518911MUPENMUB

On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Anthem Blue Cross. These policies were developed, revised, or reviewed to support clinical coding edits.

Visit Clinical Criteria]to search for specific policies. If you have questions or would like additional information, use this email.

Please see the explanation/definition for each category of Clinical Criteria below:

• New: newly published criteria
• Revised: addition or removal of medical necessity requirements, new document number
• Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

Please share this notice with other members of your practice and office staff.

Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

ACAD-NU-0161-21

This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7^® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

The Clinical Data Acquisition Group for Anthem integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:

• Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings.

Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.

Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started today.

ACA-NU-0326-21

518933MUPENMUB

Anthem Blue Cross does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at https://providers.anthem.com/ca.

ACA-NU-0322-21

This communication applies to the Medicaid, Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7^® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

The Clinical Data Acquisition Group for Anthem integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Anthem:

• Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
• Proactively manage care transitions to avoid waste.
• Close care gaps and educate members about appropriate care settings.

Anthem would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Anthem through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Anthem to most effectively manage care transitions.

Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started today.

ACA-NU-0326-21518933MUPENMUB

Mental disorders among children may cause serious changes in the way children typically learn, behave or handle their emotions, which cause distress and problems getting through the day. Healthcare professionals use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5),¹ to help diagnose mental health disorders in children.

The most common mental disorders of childhood and adolescence fall into the following categories:

• Anxiety disorders (generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobic disorder)
• Depression
• Posttraumatic stress disorder (PTSD)
• Separation anxiety disorder
• Social anxiety disorder
• Obsessive-compulsive disorder
• Bipolar disorder
• Disruptive behavioral disorders (attention-deficit/hyperactivity disorder ADHD, conduct disorder, and oppositional defiant disorder)
• Eating disorders
• Schizophrenia (less common).

Other conditions and concerns that affect children’s learning, behavior and emotions include learning and developmental disabilities, autism, and risk factors like substance use and self-harm.

ICD-10-CM coding:

• Chapter 5 of the ICD-10-CM code set categorizes mental disorders.
• Codes from chapter 5 are assigned based on the express documentation of the provider’s clinical judgment regarding the patient’s mental or behavioral disorder(s). The codes are not assigned based on symptoms, signs, or abnormal clinical laboratory findings.

Affective disorders

Major depressive disorder (MDD) is classified in ICD-10-CM as:

• F32: Major depressive disorder, single episode
• F33: Major depressive disorder, recurrent

When documenting major depressive disorder, keep in mind that proper and specific coding requires clear documentation of the:

• Episode: single versus recurrent.
• Severity: mild, moderate, or severe.
• Psychotic features, when present.
• Status of remission as either partial or full.

Remember to document any established causality between multiple mental health conditions. For example:

• Suppose the patient has a diagnosis of depression and a diagnosis of anxiety with a causal relationship between the two conditions. In such cases, documentation must establish the relationship by stating depression with, due to, or related to anxiety

ICD-10-CM classifies bipolar disorders under the following categories:

• F30: Manic episode (bipolar disorder, single manic episode, and mixed affective episode)
• F31: Bipolar disorder (manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction)
• F34: Persistent mood affective disorders (cyclothymic disorder and dysthymic disorder)
• F39: Unspecified mood affective disorder (affective psychosis not otherwise specified).

Nonpsychotic mental disorders

Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders are classified in categories F40 to F48.

Anxiety disorders are classified in ICD-10-CM under the following categories:

• F40: Phobic anxiety disorders
• F41: Other anxiety disorders
• F42: Obsessive-compulsive disorder.

Reactions to stress

ICD-10-CM provides category F43 for coding reactions to severe stress and adjustment disorders. Code F43.0, Acute stress reaction, classifies acute reaction to stress, including acute crisis reaction, crisis state, and psychic shock.

Posttraumatic stress disorder (PTSD) is classified in ICD-10-CM to subcategory F43.1, with fifth-characters for unspecified, acute, or chronic.

Adjustment disorders are classified to subcategory F43.2, with the fifth-character axis being the nature of the reaction, such as anxiety, depression, or other symptoms. For example:

• F43.24: Child adopted from a foreign country, suffering from culture shock with conduct disturbance.

Behavioral syndromes associated with physiological disturbances and physical factors

Categories F50 to F59 are devoted to behavioral syndromes associated with physiological disturbances and physical factors. These codes are not assigned when the conditions are present due to mental disorders classified elsewhere or organic in origin. This grouping includes, for example:

• F50.: Eating disorders (such as anorexia nervosa and bulimia nervosa)
• F51.: Sleep disorders, not due to a substance or known physiological condition
• F54*: Psychological and behavioral factors associated with disorders or diseases classified elsewhere
• F59: Unspecified behavioral syndromes associated with physiological disturbances and physical factors

* Code F54 classifies psychological and behavioral factors associated with diseases classified elsewhere. Typical conditions that are often associated with code F54 include asthma and dermatitis.

Schizophrenic disorders:

• Those types of disorders are classified in category F20, with a fourth character indicating the type of schizophrenia.
• The codes from category F20 are followed by an excludes one note indicating they should not be reported with codes classifying a brief psychotic disorder (F23) , cyclic schizophrenia (F25.0), schizoaffective disorder (F25-F25.9) and schizophrenic reaction not otherwise specified (NOS) (F23).
• Assign code F20.9, Schizophrenia, unspecified, for chronic schizophrenia with acute exacerbation. The existing ICD-10-CM codes for schizophrenia do not differentiate severity or an acute exacerbation (AHA Coding Clinic, Second Quarter 2019, p.32).

Attention deficit hyperactivity disorder (ADHD)

ICD-10-CM codes for ADHD include:

• F90.0: Attention-deficit hyperactivity disorder, predominantly inattentive type.
• F90.1: Attention-deficit hyperactivity disorder, predominantly hyperactive type.
• F90.2: Attention-deficit hyperactivity disorder, combined type.
• F90.8: Attention-deficit hyperactivity disorder, other types.
• F90.9: Attention-deficit hyperactivity disorder, unspecified type.

The ADHD diagnosis may not be established at the time of the initial physician office visit. Therefore, it may take two or more visits before the diagnosis is confirmed or ruled out.

ICD-10-CM outpatient coding guidelines specify not to assign a diagnosis code when documented as rule out, working diagnosis or other similar terms indicating uncertainty.

Instead, the outpatient coding guidelines instruct to code the condition(s) to the highest degree of certainty for that encounter/visit, requiring the use of codes that describe symptoms, signs or another reason for the visit.

History codes (categories Z80 to Z87) may be used as secondary codes if the historical condition or family history impacts current care or influences treatment. Personal and family history of ADHD has an impact on the clinical assessment of an individual for this disorder; the ICD-10-CM codes to report the history of ADHD in an individual include:

• Z86.59: Personal history of other mental and behavioral disorders.
• Z81.8: Family history of other mental and behavioral disorders.

Psychosocial circumstances

ICD-10-CM provides codes for behaviors that are not classified as behavioral disorders, such as:

• R41.840: Attention and concentration deficit
• R45.83: Excessive crying of child, adolescent, or adult
• R45.87: Impulsiveness
• R46.81: Obsessive-compulsive behavior.

Resources:

¹ American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5)

• ICD-10-CM Expert, 2021. Optum
• Coding Clinic. Optum
• Mental illness in children. https://www.webmd.com/anxiety-panic/mental-health-illness-in-children
• Children’s Mental Health https://www.cdc.gov/childrensmentalhealth/symptoms.html

ACA-NU-0328-21

What Matters Most: Improving the Patient Experience is an online course for providers and office staff that addresses gaps in care and offers approaches to communication with patients. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians.

The What Matters Most training can be accessed at www.patientexptraining.com.

ACA-NU-0339-21