Effective for all claims received on and after May 1, 2024, Anthem is updating its outpatient facility editing system to align with correct coding guidelines. As a result, claims billed with HCPCS/CPT^® codes 0373T, 0362T, 90853, 90887, 96121-96171, 97151-97158, 90785, 90791, 90792, 90832-90847, 90863, H0001-H2035, S0201, S9480, and an inappropriate revenue code(s) will be denied.

For assistance with coding guidelines, please refer to CPT Coding Guidelines or Encoder Pro. If you believe you have received a denial in error, please follow the standard claim payment dispute process outlined in the provider manual. To access, visit anthem.com/provider and select Change State, then select Providers, Guidelines & Manuals. Finally, select Download the Manual under the Provider Manuals ribbon.

As previously noticed in our March 2020 provider newsletter tinyurl.com/mr3n9nw2, providers must code their claims to the highest level of specificity in accordance with industry standard coding guidelines, such as ICD-10-CM coding guidelines and reporting. When an ICD-10-CM diagnosis code has a specified anatomical laterality within the code description, the anatomical modifier that is appended to a CPT^® or HCPCS code must correspond to the laterality within the ICD-10-CM description to identify different areas of the body that were treated. Proper application of the anatomical modifiers helps ensure the highest level of specificity on the claim and can help show that different anatomic sites received treatment.

Professional claims submitted on a CMS 1500 form, for claims processed on or after May 1, 2024, Anthem will apply these correct coding ICD-10-CM guidelines and deny claim lines that have a laterality diagnosis submitted with a CPT or HCPC modifier that does not correspond to the diagnosis. 

These are some improper coding examples:

• Reported diagnosis: E11.3593 (Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral)
  Billed CPT code: 67228-RT Treatment of extensive or progressive retinopathy (for example, diabetic retinopathy), photocoagulation.
  Determination: It is not appropriate to report an RT modifier when the laterality of bilateral is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied.
• Reported diagnosis: S91.011A (Laceration without foreign body, right ankle, initial encounter)
  Billed CPT code: 27786-LT (Closed treatment of distal fibular fracture: lateral malleolus; without manipulation)
  Determination: It is not appropriate to report an LT modifier when the laterality of right is identified in the ICD-10 diagnosis. Therefore, the claim line will be denied.

Additionally, the ICD-10-CM diagnosis code should correspond to the medical record, CPT,^® HCPCS code(s), and/or modifiers billed.

Anthem will continue to enhance its editing system to automate edits and simplify remittance messaging supported by correct coding guidelines. The enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines. If you have questions about this communication or need assistance, contact your provider relationship management representative.

EOB message — Diagnosis codes with a specified laterality description should be submitted with the appropriate modifier of specificity and procedure code. Ex code: 00W19

With your help, we can continually build towards a future of shared success.

Based on feedback from our care provider partners, we understand the majority prefer not to receive paper letters. We want to make our interactions easy through digital channels and ensure you receive authorization case notifications timely. Since notifications about authorization decisions are available today through Availity Essentials, we will soon eliminate sending paper notifications.

You now have 24/7 access to authorization case information in one location through Availity Essentials. The digital authorization case status notifications are available under the Authorizations and Referrals* application once you have logged in to Availity Essentials and selected Patient Registration. By eliminating the redundancy of receiving both a digital and paper letter, you’ll see fewer errors associated with manual processes in handling the paper letters while reducing cost and our carbon footprint.

* Note: Your Availity Essentials administrator must assign you the role of Authorization & Referral Inquiry or request to access this application.

Care providers will be able to choose different options to receive authorization decision notifications via the Provider Preference Center under Availity Payer Spaces. Look for details on the Provider Preference Center options and ways to access authorization case status in an upcoming communication.

We are focused on reducing administrative burdens, so you can do what you do best — care for our members.

Please review your online provider directory information on a regular basis to ensure it is correct. Access your online provider directory information by visiting anthem.com/provider, then at the top of the webpage, choose Find Care. Review your information and let us know if any of your information in our online directory has changed.

Updating your information

Anthem uses the provider data management (PDM) capability available on Availity Essentials to update your provider or facility data. Using the Availity PDM capability meets the quarterly attestation requirement to validate provider demographic data set by the Consolidated Appropriations Act (CAA).

PDM features include:

• Updating provider demographic information for all assigned payers in one location.
• Attesting to and managing current provider demographic information.
• Monitoring submitted demographic updates in real-time with a digital dashboard.
• Reviewing the history of previously verified data.

Accessing the PDM application

Log on to Availity.com and select My Providers > Provider Data Management to begin using PDM. Administrators will automatically be granted access to PDM. Additional staff may be given access to PDM by an administrator. To find your administrator, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

PDM training

PDM training is available:

• Learn about and attend one of our training opportunities by visiting here.
• View the Availity PDM quick start guide here.
• Roster automation standard template and roster automation rules of engagement specific training:
  • Listen to our recorded webinar here.

Not registered for Availity Essentials yet?

If you aren’t registered to use Availity Essentials, signing up is easy and 100% secure. There is no cost for providers to register or to use any of our digital applications. Start by going to Availity.com and selecting New to Availity? Get Started at the top of the home screen to access the registration page. If you have more than one tax ID number (TIN), please ensure you have registered all TINs associated with your account.

If you have questions regarding registration, reach out to Availity Client Services at 800‑AVAILITY.

We are excited for genuine collaboration with you, our care provider partners.

Anthem uses post-pay and prepayment review in certain circumstances to validate the appropriate level for facility emergency department (ED) claims. This process identifies the level of ED E&M code by intensity and/or complexity of resources or interventions a facility uses to furnish all services indicated on the claim. Providers must use appropriate HIPAA-compliant codes for all services rendered during the ED encounter. The highest intervention/resource used will determine the final facility ED level.

Anthem defines:

• Interventions: the staff the facility uses and their work performed
• Resources: facility building, equipment, and/or supplies used
• Note: Professional provider services are not considered facility interventions or resources.
• Intensity and/or complexity: quantity, type, or specialization of interventions and/or resources used and the nature of the presenting problem, member age, acuity, and diagnostic services performed, as indicated on the claim
• Emergency services: a medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care, could result in (a) placing the health of an individual in serious jeopardy, (b) serious impairment to bodily function, (c) serious dysfunction of any bodily organ or part, (d) serious disfigurement, or (e) in the case of a pregnant woman, serious jeopardy to the health of the woman or her unborn child

** In the event a determination cannot be made based on the guidance in this document, a referral to a medical director for a determination will be made.

For specific administrative policy details, visit anthem.com/provider/forms and select your state. Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.

We strive to advance health equity so everyone has a fair opportunity to be at their healthiest. As we reduce barriers to whole health — physical, behavioral, and social — and personalize the healthcare journey, we can more effectively advance health equity. While focusing on understanding member needs, we actively develop educational tools for care providers.

In recognition of the American Heart Association designating April as National Minority Health Month and Stress Awareness Month, we are featuring two Continuing Medical Education (CME) courses offered in a comprehensive repository of resources on My Diverse Patients. The site is designed to help care providers support the needs of diverse patients and address healthcare disparities.

For the month of April, our featured eLearning experiences are:

• Reducing Health Care Stereotype Threat — course benefits:
  • Understand Health Care Stereotype Threat (HCST) and its implications for multicultural patient groups.
  • Learn to recognize when patients may be experiencing HCST.
  • Explore shifts that you can make to reduce the likelihood that patients from diverse groups will experience HCST.
  • Identify the benefits of reducing HCST to both your patients and your practice.
• Medication Adherence — course benefits:
  • Recognize potential barriers to medication adherence and what influences your patients’ thoughts and emotions.
  • Understand the importance of meeting your patients where they are, and not where you want them to be.
  • Learn how to navigate and break through barriers with C.A.R.E.

These courses are designed for: doctors (CME credit provided); nurses; health professionals; and medical office staff.

Providers can view these courses on their smartphone, tablet, or computer.

Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

Blue High Performance Network^SM (BlueHPN^SM) plans offer access to providers with a record of delivering high-quality, efficient care. Since January 2021, we’ve been collaborating with select healthcare providers across the U.S. to make BlueHPN available to members. Anthem’s mission is to provide affordable, quality healthcare benefits to its members. This in-network only plan helps keep members’ healthcare costs more predictable and manageable.

It is important to know that only in-network care is covered in the BlueHPN. Members in the BlueHPN cannot go to out-of-network doctors or hospitals, except in an urgent and/or emergent situation. If they see a provider for routine or non-urgent care outside the BlueHPN, they will not have coverage.

If you are not participating in the Blue Connection network, you are also not participating in the BlueHPN.

Recognizing BlueHPN members

You and your staff can identify patients enrolled in BlueHPN plans by their member ID card. The BlueHPN name will be prominently displayed on the front of the member ID card, along with the BlueHPN suitcase logo, as shown below:

Eligibility and benefits

BlueHPN does not offer coverage for out-of-network care with the exception of urgent and/or emergent services. This means that BlueHPN patients will receive full benefits from in-network BlueHPN providers.

You can check BlueHPN plan member eligibility and benefits the same way you do today for Blue Connection members — Either submit a HIPAA 270 eligibility and benefit request transaction or contact Provider Services at the number on the back of the member’s ID card.

Referrals to BlueHPN providers

BlueHPN is a comprehensive network that includes a full range of providers, from primary care doctors and specialists to hospitals. Not all healthcare providers are included. To ensure your BlueHPN patients will have full benefits when they need to see a specialist or another healthcare provider, it’s important that you only recommend other BlueHPN healthcare providers. You can use the Find a Doctor/Find Care tool at https://anthem.com/find-care to identify BlueHPN healthcare providers by searching by the member’s ID or alpha prefix. This will help ensure your patients will be receiving care from healthcare providers who are also committed to providing high quality, cost-efficient care. Please make sure you and your office staff are checking network status when referring members to new providers.

Formal physician-to-physician referrals are not required under BlueHPN plans, but out-of-network benefits are limited to urgent and/or emergent services only. That means referrals for non-emergency care to providers outside the BlueHPN network, including durable medical equipment and laboratory services, may be costly for your patients.

Additional network information

More than 60 large metropolitan areas have their own high-performance networks sponsored by local Anthem plans across the country, which gives national employers access to high quality, cost-efficient providers in these geographic areas. The Georgia BlueHPN uses the existing Blue Connection network; therefore, you may see both local patients who have access to Blue Connection through the Anthem plan and patients traveling from other cities where BlueHPN products are offered. Georgia-based employer-sponsored health plans with access to our Georgia High Performance Network refer to the BlueHPN as Blue Connection.

If you are not sure whether your practice is part of the Georgia BlueHPN or Blue Connection, ask your office manager or business office or contact your provider relationship account manager.

When we receive a corrected claim and it doesn’t have the original claim number, or the original claim number is not correctly entered, we are not able to process it because we’re not able to connect it to the original claim.

1. For providers and their vendors (clearinghouses or billing services) submitting a corrected claim through EDI, we will send you a 277CA EDI Response Report acknowledging that we’ve received the submission, but are not able to process it:

1. In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
2. It is important that you submit proof of timely filing when resubmitting the correction or the original claim so we can ensure the claim is processed according to the timely filing guidelines.
   

2. For providers using Claims Status application on Availity.com, you will not be able to access the corrected claim if it was rejected on the 277CA EDI Response Report:

1. In this instance, you can either submit a new corrected claim with the original claim ID number or submit the corrected claim as an original claim if you do not have the original claim ID number.
2. It is important that you submit proof of timely filing when resubmitting the correction or the original claim so we can ensure the claim is processed according to the timely filing guidelines.

We’ve also developed a training video that can help you reduce duplicate claims along with a training guide called Making the Claims Process Work for You to help you properly submit a corrected claim. Access the video and download the guide here. Provider information is required to view this training; however, you will only be prompted to enter this information the first time viewing this training.

If you have questions about submitting a corrected claim, reach out to your provider representative or work with your EDI vendor to ensure you are receiving the 277CA Response Report.

Only Electronic Clinical Data Systems (ECDS) reporting will be used for this measure.

Measure description

The percentage of members 45 to 75 years of age who had appropriate screening for colorectal cancer (revised the age range from 50 to 75 years of age to 45 to 75 years of age).

What we are looking for in provider records

Documentation in the medical record indicating the date when the colorectal cancer screening was performed and result or finding of one or more of the following:

• A pathology report that indicates the type of screening (for example, colonoscopy, flexible sigmoidoscopy) and the date the screening was performed
• Documentation of a Fecal Occult Blood Test (FOBT) during the measurement year (2024)
• Documentation of a flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year (January 1, 2020, to December 31, 2024)
• Documentation of a colonoscopy during the measurement year or the nine years prior to the measurement year (January 1, 2015, to December 31, 2024)
• Documentation of a CT colonography during the measurement year or the four years prior to the measurement year (January 1, 2020, to December 31, 2024)
• Documentation of Stool DNA (sDNA) with FIT test during the measurement year or two years prior to the measurement year (January 1, 2022, to December 31, 2024)
• Documentation of members who are diagnosed with colorectal cancer on or before December 31, 2024
• Documentation of a total colectomy on or before December 31, 2024 (documentation must state total, not partial)
• Evidence of hospice services in 2024
• Evidence patient expired prior to January 1, 2025

Helpful hints:

• Recommend colorectal cancer screening to all patients 45 to 75 years of age.
• If a patient is hesitant, discuss different screening options.
• Educate that screening is recommended, even if there is no family history of colon cancer.