As you know, AIM Specialty Health® (AIM)* administers the musculoskeletal program for Medicare Advantage members, which includes the medical necessity review of certain surgeries of the spine, joints and interventional pain treatment. For certain surgeries, the review also includes a consideration of the level of care.

                                                                                                                                             

Effective December 1, 2020, two joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM guideline, it is generally appropriate to perform these two procedures in a hospital outpatient setting. To avoid additional clinical review for these surgeries, providers requesting prior authorization should either choose hospital observation admission as the site of service or Hospital Outpatient Department (HOPD).


We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:

  • Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
  • Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.


On January 1, 2020, CMS removed total hip arthroplasty as well as six spine codes from the inpatient only (IPO) list making these procedures eligible for payment by Medicare in the hospital outpatient setting in addition to the hospital inpatient setting. The two-midnight rule should guide providers on the expected reimbursement. The codes that were removed from the inpatient only list and are also in the AIM Musculoskeletal program are 27130, 22633, 22634, 63265 and 63267. CMS has established a two year grace period (ending December 31, 2021) for site of service reviews of these codes in order to facilitate provider transition to compliance with the two-midnight rule. To this end, it is recommended that providers choose hospital observation or Hospital Outpatient Department (HOPD) during the prior authorization process when clinically appropriate to the respective patient. Choosing hospital observation still allows for the surgery to be performed and recovered in the main hospital, so long as discharge is planned for less than two midnights. Alternatively, the provider may choose to perform the procedure in the Hospital Outpatient Department (HOPD). However, the inpatient setting will still be approved should the provider decide it is the optimal setting for the member.

 

Providers should continue to submit prior authorization requests to AIM using one of the following ways:

  • Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • Access AIM via the Availity Portal* at availity.com.
  • Call the AIM toll-free number at 800-714-0400, Monday through Friday 8:00 a.m. to 8:00 p.m. ET.

 

If you have questions, please contact the provider number on the back of the member’s ID card.


 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. Availity, LLC is and independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.


ABSCRNU-0163-20



Featured In:
October 2020 Anthem Provider News - Georgia