As a reminder, we previously communicated in the January 2021 and June 2021 editions of Provider News that Evaluation and Management (E/M) services should be reported in accordance with the American Medical Association (AMA) CPT® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. The coded service should reflect and not exceed the level needed to manage the member’s condition(s).

The maximum level of service for E/M codes will be based on the complexity of the medical decision-making or time and reimbursed at the supported E/M code level and fee schedule rate.

Providers who believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the dispute resolution process (including submission of such documentation with the dispute) as outlined in the Provider Manual.

If you have questions on this program, contact your Provider Experience representative.

706-0322-PN-CT

Patients say they are more likely to have a cancer screening when their physician recommends it. What else can you do to influence cancer screenings?¹

• Understand the power of the physician recommendation.
  • Your recommendation is the most influential factor in whether a person decides to get screened.
  • Patients are 90% more likely to get a screening when they reported a physician recommendation.
  • “My doctor did not recommend it,” is the primary reason for screening avoidance.
• Recognize cultural barriers that may impact your diverse patients.
• Culturally sensitive conversations with your patients can help with fear, embarrassment, anxiety, and misconceptions about screenings.
• Go to mydiversepatients.com for information and resources.
• Measure the screening rates in your practice; it may not be as high as you think.
  • Set goals to get screening rates up.
  • Follow the HEDIS® guidelines included in this article to help accurately track your care gap closures.
• More screening doesn’t have to mean more work for you.
  • Reach out to us about available member data – we may be able to help identify or supply access to data for those members who are due screenings.
  • Develop a reminder system, which has been demonstrated to be effective, to remind you and staff that patients have screenings due.
• Help members access benefit information about screenings to eliminate the cost barrier.
  • Log onto Availity.com and use the Patient Information tab to run an Eligibility and Benefits inquiry.
  • Members can access their benefit information by logging onto anthem.com, through Live Chat, or by downloading the Sydney Health App.
  • Blue Cross Blue Shield Service Benefit Plan members, also known as Federal Employee Program® members, can access their benefit information by logging onto fepblue.org, or by downloading the fepblue App from the Apple Store or on Google Play.

Measure Up: Cancer Screening for Women HEDIS® Measure Specifications

Organized and continuous screenings along with removal of precancerous lesions can lead to a 60% decrease in cervical cancer.²

Cervical Cancer Screening (CCS) is measured by the percentage of women 21 to 64 years of age who were screened for cervical cancer using either of the following criteria:

• Women 21–64 years of age who had cervical cytology performed within the last 3 years.
• Women 30–64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years.
• Women 30–64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) co-testing within the last 5 years.

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

1 http://thecanceryoucanprevent.org/wp-content/uploads/14893-80_2018-PROVIDER-PHYS-4-PAGER-11-10.pdf

2 National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/9253676/

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Colorectal cancer is the most common cause of cancer death among Asian Americans¹, while African Americans are 40% more likely to die from the disease than any other racial or ethnic group² in the United States. There are many possible reasons for the differences in survival rates among these racial and ethnic groups, but the common thread between them both is screening. For African Americans and Asian Americans, the reluctance could be cultural. They may not be as likely to ask about the screenings as their White counterparts.

Resources to help talk to patients about colorectal cancer screening

The Centers for Disease Control and Prevention website is an excellent resource for information about colorectal cancer that you can share with your patients. There is even a quiz to help your patients understand the importance of screening as a prevention.

We’ve also developed two videos for you to play in your patient waiting room, share with patients in the exam room, or share the link through your digital schedulers.

• Colorectal Screening for Asian Americans
• Colorectal cancer screening for African Americans

Measure up: HEDIS ® measures members ages 50–75 who receive the appropriate screening for colorectal cancer.

There are multiple test types that meet the requirement:

• Screening colonoscopy every 10 years
• Screening flexible sigmoidoscopy every 5 years
• Computed tomography (CT) colonography every 5 years
• Screening fecal occult blood test (FOBT) annually
• FIT DNA (i.e. Cologuard®) at home testing every 3 years

Coding tips

For screening, use the appropriate code:

For exclusions, use the appropriate ICD-10 code:

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

1 “Colorectal cancer in the United States and a review of its heterogeneity among Asian American subgroups”, https://onlinelibrary.wiley.com/doi/full/10.1111/ajco.13324#:~:text=Colorectal%20cancer%20is%20the%20second,common%20in%20the%20%20United%20States

2 “Colorectal Cancer Rates Higher in African Americans, Rising in Younger People”, https://www.cancer.org/latest-news/colorectal-cancer-rates-higher-in-african-americans-rising-in-younger-people.html

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On January 10, 2022, updated Preventive Care Guidance was released by the Departments of Labor, Health and Human Services (HHS), and the Treasury. This new guidance (referenced on page 11 of the Preventive Care Guidance document) applies to most of Anthem’s ACA-complaint non-grandfathered health plans when services are provided in-network. This new guidance indicates:

On May 18, 2021, the USPSTF updated its recommendation for colorectal cancer screening. The USPSTF continues to recommend with an “A” rating screening for colorectal cancer in all adults aged 50 to 75 years and extended its recommendation with a “B” rating to adults aged 45 to 49 years. In its “Practice Considerations” section detailing screening strategies, the Final Recommendation Statement provides: “When stool-based tests reveal abnormal results, followup with colonoscopy is needed for further evaluation…. Positive results on stool-based screening tests require follow-up with colonoscopy for the screening benefits to be achieved.” Additionally, the Final Recommendation Statement provides with respect to direct visualization tests: “Abnormal findings identified by flexible sigmoidoscopy or CT colonography screening require follow-up colonoscopy for screening benefits to be achieved.”

For a follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization screening test for colorectal cancer, in-network providers should code the claim as a screening colonoscopy rather than as a diagnostic colonoscopy.

Providers can contact the provider service number on the back of the member ID card to determine if a member’s plan includes this benefit.

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We are asking you to review your online provider directory information on a regular basis to ensure it is correct. Access your information by visiting anthem.com, select Providers, then under Provider Overview, choose Find Care.

Submit updates and corrections to your directory information using our online Provider Maintenance Form. Online update options include:

• add/change an address location
• name change
• tax ID changes
• provider leaving a group or a single location
• phone/fax number changes
• closing a practice location

Once you submit the form, we will send you an email acknowledging receipt of your request.

The CAA contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. By reviewing your information regularly, you can help us ensure your online provider directory information is current.

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Consumer surveys show that doctors are the most persuasive and influential source of information around vaccines. Anthem is working to make it easier for physicians to offer their strong recommendations for vaccinations – especially vaccines for COVID-19 and influenza.

Anthem recently launched a single page to host resources for health care professionals related to vaccination, including a guide to talking with reluctant patients to respond to common concerns, and one comparing flu and COVID-19 vaccines.

We will continue to refresh and add to available content on the new vaccination resource page. 

Visit our website for the most up to date COVID-19 information from Anthem. 

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Please continue to check Important Medicare Advantage Updates for the latest Medicare Advantage information, including:

• Phone number change for AIM in Connecticut and New Hampshire
• Medical step therapy updates

Medication adherence improves overall member health and reduces hospitalizations. According to the World Health Organization, “Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.”¹

Did you know?

• Most medication-related ER visits and hospitalizations in the U.S. (up to 70%) are caused by nonadherence to medication.²
• Studies show that 50 to 60% of patients are not taking their prescribed medications correctly or at all.³
• Improved adherence can drive positive health and economic outcomes.
  • Patients’ adherence to statin medications at 12 months had improved LDL, reduced hospitalizations, and lower healthcare costs.⁴

Best practices for improving adherence

Support the implementation of medication nonadherence prevention strategies at each step of the medication use process:

• Prescribe maintenance medications for diabetes, cholesterol, and hypertension from the Anthem Medicare Advantage $0 copay list.
• Encourage IngenioRx* Home Delivery to improve medication adherence, prevent refill gaps, avoid long waits at the pharmacy, and to reduce costs.
  • IngenioRx Home Delivery members have 2 to 3% higher adherence rates
  • E-prescribe, fax 800-378-0323, or phone-in prescriptions 833-203-1742
• Enrolled nonadherent patients may benefit from a multi-dose packaging of medications. CVS pharmacy® SimpleDose™ and PillPack are preferred pharmacies that offer multi-dose packaging with free home delivery. To enroll, go to:
  • CVS.com/multidose or call 800-753-0596. Members may also enroll at their local CVS pharmacy. Members residing in the District of Columbia, Georgia, or South Carolina should call 844-650-1637.
  • Pillpack.com/blue or call 866-282-9462.
• Offer members the opportunity to use ZipDrug, which offers free access to high performing pharmacies that provide customized medication services, hand-delivered prescriptions, and increase medication adherence rates. Go to anthem.com/zipdrug or call 844-947-3748.
  • Patients who take medications for diabetes, cholesterol, and hypertension and enrolled in ZipDrug had a 4 to 10% increase in medication adherence rates.
• Encourage digital solutions: Sydney app can help Anthem members manage their medications through:
  • Enrollment in ZipDrug
  • Home delivery set-up
  • Manage auto-refill and renew
  • Text message reminders on prescriptions

Want more information regarding all the recommended best practices?

Best practices for medication adherence are reviewed in this brief video.

Resources:

1 World Health Organization. Adherence to long-term therapies: evidence for action. Geneva:

   World Health Organization; 2003. http://apps.who.int/medicinedocs/pdf/s4883e/s4883e.pdf.

   Accessed Dec.22, 2021.

2 Cutler, Rachelle Louise et al. “Economic impact of medication non-adherence by disease groups: systematic

   review.” BMJ open vol. 8,1 e016982. 21 Jan. 2018, doi:10.1136/bmjopen-2017-016982

3 Journal of Managed Care & Specialty Pharmacy 2020 26:12, 1529-1537

4 JAMA.2018;320(23):2461-2473. https://pubmed.ncbi.nlm.nih.gov/30561486

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross and Blue Shield.

ABSCRNU-0045-22

Annual wellness visits (AWVs) are an important yet underutilized vehicle for ensuring successful value-based payment (VBP) arrangements. In 2022, there is an opportunity to increase your AWVs and, by extension, the health of your patients and your success in VBPs. 

Per the American Academy of Family Practitioners (AAFP), “90 percent of patients who had received an AWV said they did so at the recommendation of their physician.” AWVs are a yearly exam (usually with a physician) to develop or update a personalized prevention plan and assess health status and any social, psychological, and behavioral health risks. An AWV can be a useful tool for improving quality of care, providing proactive care management, facilitating care coordination, and positively impacting up to 20 Medicare Advantage Star measure ratings for health plans.

There is often confusion between an AWV and an annual routine physical (ARP). The ARP is more comprehensive than an AWV. It consists of a physical exam by a physician and includes bloodwork, screenings, and other tests. The AWV involves checking standard measurements such as blood pressure, height, and weight. AWVs are free for Medicare Advantage members and, in many instances, can be conducted remotely via telehealth.

Note: CMS does allow both visit types to occur on the same date/time and providers can submit one claim encompassing each type.

There are many provider benefits for completing an AWV, including:

• Opportunity to develop a complete medical history for members
• Strengthened relationship with member
• Ability to provide proactive care to member
• Increased performance on quality metrics
• An ongoing, sustainable revenue stream for practice
• Vehicle for providers to obtain caregiver demographics

There are also many member benefits for completing an AWV, including:

• No copay
• Strengthened relationship with healthcare providers

• Annual comprehensive preventive evaluation
• Reduced risk of chronic conditions
• Keeps members out of the hospital
• Prevents accidents at home

In the ever-increasing emphasis on value-based care that focuses on shared savings, it is urgent for providers to complete an AWV for each of their assigned members. Doing so keeps members healthy, reduces healthcare costs, and can increase practice revenues.

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On September 22, 2021, and November 19, 2021, the Pharmacy and Therapeutics (P&T) committee approved the following clinical criteria applicable to the medical drug benefit for Anthem Blue Cross and Blue Shield. 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 need additional information, use this email.

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

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

Please 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.

ABSCRNU-0311-22

As a reminder, and as previously communicated in Provider News, providers should report evaluation and management (E/M) services in accordance with the American Medical Association (AMA) CPT^® manual and CMS guidelines for billing E/M service codes: Documentation Guidelines for Evaluation and Management. The coded service should reflect and not exceed the level needed to manage the member’s condition(s).

The maximum level of service for E/M codes will be based on the complexity of the medical decision-making or time and reimbursed at the supported E/M code level and fee schedule rate.

Providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the dispute resolution process (including submission of such documentation with the dispute).

If you have questions on this program, contact your contract manager or Provider Experience representative.

Past notifications related to the E/M services correct coding — professional program may be found on our provider website.

ABSCRNU-0303-21

On June 1, 2022, prior authorization (PA) requirements will change for a code covered by Anthem. 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.

Prior authorization requirements will be added for the following codes:

• K1022 — Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type

Not all PA requirements are listed here. PA requirements are available to contracted providers on the provider website at https://www.anthem.com/medicareprovider > Login or by accessing Availity.* Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the member’s ID card.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

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