Chances are that one out of every four patients you see in your office has low back pain. The Centers for Disease Control and Prevention (CDC) reports that in the last three months, 25% of U.S. adults report having low back pain, making it second only to the common cold as a cause for lost work time and a primary reason for a doctor’s visit.¹  Back pain will usually go away on its own. About 90 percent of patients with low back pain recover within six weeks.² For this reason, the National Committee for Quality Assurance (NCQA) recommends avoiding imaging for patients when there is no indication of an underlying condition. In a study published by the CDC, Early imaging for acute low back pain, the findings indicated not only was early imaging not associated with better outcomes, it also indicated that certain early imaging (MRI) was associate with an increased likelihood of disability and its duration.³

Watch this video to learn more

Take advantage of the Recommendation for Treating Acute Low Back Pain video located on the CDC website or use this link. The video also offers communications strategies to share with patients for effectively treating their low back pain.

HEDIS® measure: Use of imaging studies for low back pain (LBP)

Description:  The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. The higher compliance score indicates appropriate treatment of low back pain.

Exclusions include cancer, recent trauma, IV drug abuse, neurologic impairment, HIV, spinal infection, major organ transplant and prolonged use of corticosteroids.

Coding tips: This is a few of the approved codes for the diagnosis and services associated with the LBP measure. For a complete list, visit ncqa.org.

CPT	72010, 72020, 72052, 72100	Imaging study
ICD-10	M47.898	Other spondylosis, sacral and sacrococcygeal region
ICD-10	M48.08	Spinal stenosis, sacral and sacrococcygeal region
ICD-10	M53.2X8	Spinal instabilities, sacral and sacrococcygeal region
ICD-10	M54.40	Lumbago with sciatica, unspecified side
ICD-10	M51.26 – M51.27	Other intervertebral disc displacement, lumbar lumbosacral region
ICD-10	M54.30 – M54.32	Sciatica, unspecified, right side, left side
ICD-10	M51.16-M51.17	Intervertebral disc disorders with radiculopathy, lumbar region, lumbosacral region
ICD-10	M51.26-M51.27	Intervertebral disc displacement, lumbar region, lumbosacral region
ICD-10	M51.36-M51.37	Other intervertebral disc degeneration, lumbar region, lumbosacral region
ICD-10	M51.86-M51.87	Other intervertebral disc disorders, lumbar region, lumbosacral region
ICD-10	M99.53	Intervertebral disc stenosis of neural canal of lumbar region
ICD-10	S33.100A, S33.100D, S33.100S	Subluxation of unspecified lumbar vertebra; initial, subsequent, sequela encounter
ICD-10	S33.5XXA	Sprain of ligaments of lumbar spine; initial encounter
ICD-10	S33.6XXA	Sprain of sacroiliac joint; initial encounter
ICD-10	S33.8XXA	Sprain of other parts of lumbar spine and pelvis; initial encounter
ICD-10	S33.9XXA	Sprain of unspecified parts of lumbar spine and pelvis; initial encounter
ICD-10	S39.002A, S39.002D, S39.002S	Unspecified injury of muscle, fascia, and tendon of lower back; initial, subsequent, sequela encounter
ICD-10	S39.82XA, S39.82XD, S39.82XS	Other specified injuries of lower back; initial, subsequent, sequela encounter

 

1 https://www.cdc.gov/acute-pain/low-back-pain/index.html#:~:text=25%25%20of%20U.S.%20adults%20report,the%20most%20common%20pain%20reported.

2 https://abcnews.go.com/Health/CommonPainProblems/story?id=4047737#:~:text=Answer%3A%20Back%20pain%20usually %20goes,people%20recover%20faster%20than%20others

3 http://dx.doi.org/10.1097/BRS.0b013e318251887b

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

1180-0621-PN-GA

 

Nationally, seven percent of all claims are denied because they weren’t filed within the timely filing limits. At Anthem, we want your claims to be received on time, so they get paid on time. One way to ensure your claim isn’t denied because it wasn’t received within timely filing limits is to follow-up with your clearinghouse on a regular basis.

When you send claims electronically through a clearinghouse, if errors are identified on the claims, they won’t get submitted for payment. Checking in regularly with your clearinghouse is key to identifying claims errors. This gives you the opportunity to correct claims quickly, avoiding delays in filing and running the risk of a claim denial because it wasn’t filed within the timely filing limit.

Have you confirmed the patient is an Anthem member?

Another reason claims are delayed is because the claim was filed with Anthem, but it should have been filed with another insurance company first. To make sure your claim is received on time, double check the member’s insurance information with each visit to your office confirming their primary insurance. To check the member’s eligibility or to get a digital copy of the member’s ID card, log onto Availity.com. From the Patient Registration tab use the Eligibility and Benefits Inquiry tool for a quick and easy search.

Checking your claims status.

It is easy to check your claim online to confirm we’ve received it. Log onto Availity.com and use the Claims & Payment tab for the Claims Status tool. You may also be able to check the claim to verify no adjustments are needed through the Claims Status Listing application located on the Payer Spaces home page.

The sooner you file the faster your claim is paid.

Filing your claim within the timely filing limits can eliminate claim denials. If your claim denies because it was filed late, Anthem will deny the claim as outlined in your contract with us. It is important to note that the member cannot be billed for denied claims that were not filed timely.

Use these helpful tips when filing your claims because Anthem understands that timely payments are as important as timely filing.

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Easily update demographic changes and much more, by simply submitting your updates through Anthem Blue Cross and Blue Shield (Anthem) online Provider Maintenance Form. Online update options include: add an address location, name change, tax ID changes, providers leaving a group or a single location, phone/fax numbers, closing a practice location. Visit the Provider Maintenance Form landing page to review more.

 

Important information about updating your practice profile:

• Change request should be submitted using the online Provider Maintenance Form
• Submit the change request online. No need to print, complete and mail, fax or email demographic updates
• You will receive an auto-reply e-mail acknowledging receipt of your request and another email when your submission has been processed
• For change(s) that require submission of an updated IRS Form w-9 or other documentation, attach them to the form prior to submitting

 

You can check your directory listing on the Anthem “Find Care”. The Find Care tool at Anthem is used by consumers, members, brokers, and providers to identify in-network physicians and other health care providers supporting member health plans. To ensure Anthem has the most current and accurate information, please take a moment to access Find Care. Go to anthem.com, select Providers, under Provider Overview, choose Find Care. You can log in as a guest to view how you and your practice are being displayed.

 

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Healthcare providers are often 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; and
• 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.

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Effective July 19, 2021, Anthem Blue Cross and Blue Shield (Anthem), and AIM Specialty Health_® (AIM), a separate specialty benefits management company, will launch a new back pain management program for Anthem fully insured members to help educate and support members navigate through their back pain journey to reduce risk of chronicity, minimize recurrences, and minimize complications.

The program will be utilizing predictive analytic models to identify members that are experiencing back pain or are at risk for complications related to back pain conditions. This early identification allows our program to target members who could experience an increase in back pain without the right education and support.

 

Our targeting management process includes:

• Predictive models for members likely to be referred for back surgery based on several risk factors
• Risk stratification to ensure the appropriate level of support is provided
• Targeted outreach to members through our digital engagement platform, email and calls
• Customized education and support of provider treatments based on member’s specific needs
• Education and support of services such as behavioral health as appropriate

 

 

Members included in the new program

All fully insured members currently participating in AIM and Anthem programs are included. The following groups are excluded:  self-funded (ASO) groups, Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA EGR, Federal Employee Program® (FEP®). 

 

The AIM back pain management program microsite helps you learn more and access helpful information and tools such as program information and FAQs.

 

AIM back pain program Informational webinars                                                                    

Anthem Blue Cross and Blue Shield invites you to take advantage of a free informational webinar that will introduce you to the program_.  Go to the AIM back pain management program microsite to register for an upcoming webinar.

 

We value your participation in our network and look forward to working with you to help improve the health of our members.

 

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Medicare Advantage

Please continue to check Important Medicare Advantage Updates at anthem.com/medicareprovider for the latest Medicare Advantage information, including:

• Anthem Blue Cross and Blue Shield working with Optum to collect medical records for risk adjustment
• Medical drug benefit clinical criteria updates
• Updates to the AIM advanced imaging clinical appropriateness guidelines

 

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ABSCRNU-0223-21

ABSCRNU-0216-21

Medicare Advantage

As a reminder, Anthem Blue Cross and Blue Shield (Anthem) Medicare Advantage does not allow separate reimbursement for claims that have been identified as a readmission to the same hospital for the same, similar or related condition unless provider, federal or CMS contracts and/or requirements indicate otherwise, as further described in the existing reimbursement policy located at anthem.com/medicareprovider.

 

If Anthem Medicare Advantage determines that this reimbursement policy has not been followed, Anthem Medicare Advantage may deny the claim prior to payment or recover any paid claim. Providers may dispute any claim denied under this policy consistent with applicable law, your agreement with Anthem Medicare Advantage and Anthem Medicare Advantage policies.

 

For more detailed information on the inpatient readmissions reimbursement policy, please visit anthem.com/provider/policies/reimbursement.

 

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Medicare Advantage

The Group Retiree Medicare Advantage membership is experiencing a high volume of enrollment, and as we continue to grow, we wanted to send these reminders for our PPO plans for Anthem Blue Cross and Blue Shield (Anthem). Group Retiree Medicare Advantage memberships may include the National Access Plus benefit, which allows retirees to receive services from any provider, as long as the provider is eligible to receive payments from Medicare and accepts the member’s PPO plan. These PPO plans also offer benefits that original Medicare doesn’t cover, including an annual routine physical exam, hearing, vision, chiropractic care, acupuncture, LiveHealth Online^* and SilverSneakers^®.^*

 

If you are already part of our Medicare Advantage PPO network, thank you. The FAQ below will be helpful as you grow your practice and serve members who may be new to our Group Retiree PPO plans.

 

Out-of-network providers are paid Medicare allowable rates for covered services, less the member’s copay, coinsurance, and/or deductible. No contract is required.

With the National Access Plus benefit, the member’s cost share doesn’t change — whether local or nationwide, doctor or hospital, in- or out-of-network.

 

To view the Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ’s open the attached PDF titled “Medicare Advantage Group Retiree PPO plans and National Access Plus FAQ.pdf.”

 

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield. LiveHealth Online is the trade name of Health Management Corporation, an independent company, providing telehealth services on behalf of Anthem Blue Cross and Blue Shield. Tivity Health, Inc. is an independent company providing the SilverSneakers fitness program on behalf of Anthem Blue Cross and Blue Shield. Aspire Health is an independent company providing palliative care services on behalf of Anthem Blue Cross and Blue Shield. CoverMyMeds is an independent company providing electronic prior authorization services on behalf of Anthem Blue Cross and Blue Shield. Surescripts is an independent company providing electronic prior authorization services on behalf of Anthem Blue Cross and Blue Shield. myNEXUS is an independent company providing claims processing and network management for providers providing home health services on behalf of Anthem Blue Cross and Blue Shield. Specialty Condition Management Powered by IngenioRx is an independent company providing targeted disease management services on behalf of Anthem Blue Cross and Blue Shield.

ABSCRNU-0226-21

 

Medicare Advantage

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. Please note: The Medical Policies and Clinical UM Guidelines below are followed in the absence of Medicare guidance.

 

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

 

To view a guideline, visit anthem.com/provider/policies/clinical-guidelines/search.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• *CG-LAB-17 – Molecular gastrointestinal pathogen panel (GIPP) testing for infectious diarrhea in the outpatient setting
  • Outlines the medical necessity and not medically necessary criteria for multiplex PCR-based panel testing of gastrointestinal pathogens for infectious diarrhea in the outpatient setting
• *ANC.00008 – Cosmetic and reconstructive services of the head and neck
  • Added otoplasty using a custom-fabricated device, including but not limited to a custom fabricated alloplastic implant, as cosmetic and not medically necessary
• *CG-OR-PR-04 – Cranial remodeling bands and helmets (cranial orthotics)
  • Removed condition requirement from reconstructive criteria and replaced current diagnostic reconstructive criteria with criteria based on one of the following cephalometric measurements: the cephalic index, the cephalic vault asymmetry index, the oblique diameter difference index, or the cranioproportional index of plagiocephelometry
• *CG-SURG-78 – Locoregional and surgical techniques for treating primary and metastatic liver malignancies
  • Added TACE using immunoembolization (for example, using granulocyte-macrophage colony-stimulating factor [GM-CSF]) as not medically necessary for all liver-related indications

• *CG-SURG-82 – Bone-anchored and bone conduction hearing aids
  • Revised audiologic pure tone average bone conduction threshold criteria for unilateral implant for bilateral hearing loss
  • Added not medically necessary statement for when medical necessity criteria have not been met and clarified not medically necessary statement regarding replacement parts or upgrades
  • Added bone conduction hearing aids using an adhesive adapter behind the ear as not medically necessary for all indications
• CG-GENE-22 – Gene expression profiling for managing breast cancer treatment
  • A new clinical guideline was created from the content contained in GENE.00011. There are no changes to the guideline content and the publish date is April 7, 2021.
• CG-GENE-23 – Genetic testing for heritable cardiac conditions
  • A new clinical guideline was created from the content contained in GENE.00007 and GENE.00017. There are no changes to the guideline content and the publish date is April 7, 2021
• CG-SURG-110 – Lung volume reduction surgery
  • A new Clinical Guideline was created from the content contained in SURG.00022. There are no changes to the guideline content and the publish date is June 25, 2021

 

AIM Specialty Health_®* (AIM) clinical appropriateness guideline updates.

To view AIM guidelines, visit the AIM website.

• The Small Joint Surgery guideline has been revised and will be effective on March 14, 2021.
• The following guidelines have been revised and will be effective on June 4, 2021:
• * Imaging of the spine
• * Imaging of the extremities
• * Vascular imaging
• * Joint surgery
• * Spine surgery

 

Medical policies

On February 11, 2021, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following medical policies applicable to Anthem Blue Cross and Blue Shield (Anthem). These guidelines take effect June 4, 2021.

 

Publish date	Medical policy number	Medical policy title	New or revised
4/7/2021	*ANC.00008	Cosmetic and reconstructive services of the head and neck	Revised
2/18/2021	SURG.00121	Transcatheter heart valve procedures	Revised
2/18/2021	SURG.00145	Mechanical circulatory assist devices (ventricular assist devices, percutaneous ventricular assist devices and artificial hearts)	Revised

 

Clinical UM guidelines

On February 11, 2021, the MPTAC approved the following clinical UM guidelines applicable to Anthem. These guidelines were adopted by the medical operations committee for Anthem members on February 25, 2021. These guidelines take effect June 4, 2021.

 

Publish date	Clinical UM guideline number	Clinical UM guideline title	New or revised
4/7/2021	*CG-LAB-17	Molecular gastrointestinal pathogen panel (GIPP) testing for infectious diarrhea in the outpatient setting	New
2/18/2021	CG-GENE-21	Cell-free fetal DNA-based prenatal testing	Revised
4/7/2021	CG-MED-26	Neonatal Levels of Care	Revised
2/18/2021	CG-MED-87	Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications	Revised
4/7/2021	*CG-OR-PR-04	Cranial Remodeling Bands and Helmets (Cranial Orthotics)	Revised
2/18/2021	CG-SURG-55	Intracardiac Electrophysiological Studies (EPS) and Catheter Ablation	Revised
4/7/2021	CG-SURG-71	Reduction Mammaplasty	Revised
4/7/2021	*CG-SURG-78	Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies	Revised
4/7/2021	*CG-SURG-82	Bone-Anchored and Bone Conduction Hearing Aids	Revised
4/7/2021	CG-SURG-97	Cardioverter Defibrillators	Revised

 

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

ABSCRNU-0225-21

 

 

Medicare Advantage

Effective September 1, 2021, Anthem Blue Cross and Blue Shield will upgrade to the 25th edition of MCG* care guidelines for the following modules: inpatient and surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

 

Goal length of stay (GLOS) for inpatient and surgical care (ISC)

Guideline	MCG code	24th edition GLOS	25th edition GLOS
Aortic coarctation, angioplasty	S-152	Ambulatory or 1 day postoperative	Ambulatory
Cardiac septal defect: atrial, transcatheter closure	W0016	Ambulatory or 1 day postoperative	Ambulatory
Esophageal diverticulectomy, endoscopic	S-445	Ambulatory or 1 day postoperative	Ambulatory
Gastrectomy, partial - billroth I or II	S-510	4 or 6 days postoperative	5 days postoperative
Hernia repair (non-hiatal)	S-1305	Ambulatory or 1 day postoperative	Ambulatory
Pancreatectomy	S-1200	5 or 7 days postoperative	6 days postoperative
Pyloroplasty and vagotomy	S-990	4 or 6 days postoperative	4 days postoperative
Cervical laminectomy	W0097	2 days postoperative	Ambulatory or 2 days postoperative
Lumbar diskectomy, foraminotomy, or laminotomy	W0091	Ambulatory or 1 day postoperative	Ambulatory
Removal of posterior spinal instrumentation	S-530	1 day postoperative	Ambulatory or 1 day postoperative
Shoulder hemiarthroplasty	W0138	1 day postoperative	Ambulatory or 1 day postoperative
Spine, scoliosis, posterior instrumentation, pediatric	W0156	4 days postoperative	3 days postoperative
Bladder resection: cystectomy with urinary diversion, conduit or continent	S-190	5 or 6 days postoperative	5 days postoperative
Prostatectomy, transurethral resection (TURP)	S-970	Ambulatory or 1 day postoperative	Ambulatory
Urethroplasty	S-1172	Ambulatory or 1 day postoperative	Ambulatory

 

New guidelines for behavioral health care (BHC) and recovery facility care (RFC)

Body system	Guideline title	MCG code
Withdrawal management	Withdrawal management, adult: inpatient care	B-031-IP
Withdrawal management	Withdrawal management, adult: intensive outpatient program	B-031-IOP
Withdrawal management	Withdrawal management, adult: outpatient care	B-031-AOP
Withdrawal management	Withdrawal management, adult: partial hospital program	B-031-PHP
Withdrawal management	Withdrawal management, adult: residential care	B-031-RES
Cardiology	Hypertension	M-5197
Cardiology	Peripheral vascular disease (PVD)	M-7087
Nephrology	Rhabdomyolysis	M-7095
Nephrology	Encephalopathy	M-7100
Thoracic surgery	Rib fracture	M-5545

 

Customizations to MCG care guidelines 25th edition

Effective September 1, 2021, the following MCG care guideline 25th edition customization will be implemented:

• Transcranial magnetic stimulation (TMS), W0174 (previously ORG: B-801-T) - revised clinical indications for procedure and added the following:
• Need for acute TMS treatment, up to six weeks
• Acute treatment course needed as indicated by (a) initial course of treatment for major depressive disorder (severe), or (b) relapse of symptoms after remission
• Continuation of acute treatment, up to six months
• TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
• Maintenance TMS treatment
• Continuation of acute TMS treatment for longer than six months
• TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, anxiety disorders, bipolar depression, neurodevelopmental disorders, obsessive-compulsive disorder, peripartum depression, post-traumatic stress disorder, substance use disorders, Tourette's syndrome.      

To view a detailed summary of customizations, visit this link, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.

 

For questions, please contact the provider services at the number on the back of the member’s ID card.

 

* MCG Health is an independent company providing care guidelines on behalf of Anthem Blue Cross and Blue Shield.

ABSCRNU-0219-21

Osteoporosis affects more than 50 million Americans. Treatment options are better and bone fractures are more preventable the sooner it is detected.  Does your patient meet the criteria for a DEXA bone scan? Initial or repeat bone mineral density (BMD) measurement is not indicated unless the results will influence treatment decisions.

To assist providers in administrative requirements for bone mineral density (BMD) studies, the Federal Employee Program (FEP®) medical policy and utilization guidelines can be found on fepblue.org.  The medical policy is titled, Medical Policy MPM 6.01.01, Bone Mineral Density Studies.  Below is an outline of this policy.   

Policy Statement:

An initial measurement of central (hip/spine) BMD using dual x-ray absorptiometry (DXA) may be considered medically necessary to assess future fracture risk and the need for pharmacologic therapy in both women and men who are considered at risk for osteoporosis.

BMD testing may be indicated under the following conditions:

• Women age 65 and older, independent of other risk factors
• Men age 70 and older, independent of other risk factors
• Younger postmenopausal women with an elevated risk factor assessment (see policy guidelines)
• Men age 50 to 70 with an elevated risk factor assessment (see policy guidelines)
• Adults with a pathologic condition associated with low bone mass or increased bone loss
• Adults taking a medication associated with increased bone loss

 

Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry for individuals who previously tested normal may be considered medically necessary at an interval not more frequent than every 3 to 5 years; the interval depends on an updated patient fracture risk assessment.

Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-2 years as follows:

• Individuals with a baseline evaluation of osteopenia (BMD T- score -1.0 to -2.5)
• Adults with a pathologic condition associated with low bone mass or increased bone loss
• Adults taking a medication associated with increased bone loss

 

Repeat measurement of central (hip/spine) BMD using dual x-ray absorptiometry may be considered medically necessary at an interval not more frequent than every 1-3 years in individuals who are receiving pharmacologic treatment for osteoporosis when the information will affect treatment decisions (continuation, change in drug therapy, cessation or resumption of drug therapy).

Peripheral (lower arm, wrist, finger or heel) BMD testing may be considered medically necessary when conventional central (hip/spine) DXA screening is not feasible or in the management of hyperparathyroidism, where peripheral DXA at the forearm (i.e., radius) is essential for evaluation.

Dual x-ray absorptiometry of peripheral sites is considered investigational except as noted above.

BMD measurement using ultrasound densitometry is considered not medically necessary.

BMD measurement using quantitative computed tomography is considered investigational.

If you have any questions about Federal Employee benefits or medical policy information, please contact Customer Service at 800-282-2473.

 

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