COVID-19

• Information from Anthem for Care Providers About COVID-19

 

New prior authorization requirements for providers may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.

• Anthem prior authorization updates for specialty pharmacy are available – April 2020*
• UPDATE: Notice of changes to the AIM Musculoskeletal Program prior authorization requirements*
• MCG Care Guidelines 24th Edition*

 

Other Important Updates

• Medicare and Medicaid News – COVID-19 Updates

 

For the most up-to-date information from Anthem Blue Cross and Blue Shield about COVID-19, please bookmark/add to favorites Provider News Home and check back often.

At Anthem Blue Cross and Blue Shield (Anthem), we continue to make changes to our public provider website to make it easier for you to find the information you need. The end of Q1 brings a few updates for the site at anthem.com:

• Information has been added to our website regarding Patient-Centered Specialty Care (PCSC) – Anthem’s value-based payment program for cardiology, endocrinology and obstetrics/gynecology providers. You can find this information online as an extension of our broader patient-centered, value-based care program – Enhanced Personal Health Care (EPHC).
• Documents listed on the Prior Authorization page can be conveniently accessed via online links.
• Medicare Advantage will be live in the coming days. You will be able to view updated Medicare Advantage pages on the commercial public sites.”
• Medical Policies (MP) and Clinical Utilization Management Guidelines (CUMG) now display on our newly designed Web pages.

If you have any questions, please contact Michelle Fraser at michelle.fraser@anthem.com or Nick Kizirnis at nick.kirzinis@anthem.com. 

A key goal of Anthem’s provider transparency initiatives is to improve quality while managing health care costs. One of the ways is through Anthem’s value-based programs such as Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, and so on – called the “Programs.” Certain providers (“Value-Based Program Providers” also known as “Payment Innovation Providers”) in Anthem’s various value-based programs receive quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value-Based Program Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in the provider getting more referrals from Value-Based Program Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

 

Providing this type of data, including comparative cost information, to Value Based Program Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Value Based Program Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Anthem will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers, including any opportunities for improvement. For questions or support, please refer to your local Network Representative or Care Consultant.

Anthem completed its acquisition of Beacon Health Options, a large behavioral health organization that serves more than 36 million people across the country. The company will operate as a wholly owned subsidiary of Anthem.

Bringing together our existing solid behavioral health business with Beacon’s successful model and support services creates one of the most comprehensive behavioral health networks in the country. It’s also an opportunity to offer best-in-class behavioral health capabilities and whole person care solutions in new and meaningful ways to help people live their best lives.

From the standpoint of our customers and providers at this time, it’s business as usual:

• Members should continue to call the customer service number on the back of their membership card or access their health plan’s website for online self-service.
• Providers should continue to use the provider service contact information, websites and online self-service portals as part of their agreement with either Anthem or Beacon.
• There will be no immediate changes to the way Anthem or Beacon manage their respective provider networks, contracts and fee arrangements. Anthem and Beacon provider networks, contracts and fee arrangements will remain separate at this time.

We know our providers continue to expect more of their healthcare partner, and at Anthem, we aim to deliver more in return.

For more details, please see the press release.

 

Click here for more information about the COVID-19 Virus Talking Points for Medicare Advantage.

 

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

 

• Coding tip for psychological and neuropsychological testing
• Medical Policies and Clinical Utilization Management Guidelines update
• New Medicare Advantage opioid treatment Program benefit
• Prior authorization requirements: new 2020 codes for coverage and precertification

 

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved 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.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting November 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

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On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved 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.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting December 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.*

 

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

 

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The Medicare Risk Adjustment Regulatory Compliance team at Anthem Blue Cross and Blue Shield (Anthem) offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

 

Medicare Risk Adjustment and Documentation Guidance (General)

• When: The trainings will be offered the first Wednesday of each month from 1 p.m. to 2 p.m. ET (from January 8, 2020, to December 2, 2020).
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity has been reviewed and is acceptable for up to 1 prescribed credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:

• Medicare Risk Adjustment and Documentation Guidance (General)

 

Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (Condition Specific)

• When: The trainings will be offered on the third Wednesday of every other month from noon to 1 p.m. ET (from January 15, 2020 to November 18, 2020).
• Learning objective: This is a collaborative learning event with Enhanced Personal Health Care (EPHC)* to provide in-depth disease information pertaining to specific conditions including an overview of their corresponding HCC, with guidance on documentation and coding.
• Credits: This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

 

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

 

1. Red Flag HCCs Part 1 (January 15, 2020) — register for a recording of the session: Training will cover HCCs most commonly reported in error as identified by CMS (Chronic Kidney Disease Stage 5, Ischemic or Unspecified Stroke, Cerebral Hemorrhage, Aspiration and Specified Bacterial Pneumonias, Unstable Angina and Other Acute Ischemic Heart Disease, End-Stage Liver Disease).
   - Link: Red Flag Hierarchical Condition Categories (HCCs), part one

 

2. Red Flag HCCs Part 2 (March 18, 2020): Training will cover HCCs most commonly reported in error as identified by CMS (Atherosclerosis of the Extremities with Ulceration or Gangrene, Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome, Drug/Alcohol Psychosis, Lung and Other Severe Cancers, Diabetes with Ophthalmologic or Unspecified Manifestation)
   - Link: Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 2

 

3. Neoplasms (May 20, 2020)
   - Link: Neoplasms
   

 

4. Acute, Chronic and Status Conditions (July 15, 2020)
   - Link: Acute, Chronic and Status Conditions

 

5. Diabetes Mellitus and Other Metabolic Disorders (September 16, 2020)
   - Link: Diabetes Mellitus and Other Metabolic Disorders

 

6. TBD - This Medicare risk adjustment webinar will cover the critical topics and updates that surface during the year (November 18, 2020)
   - Link: Topic TBD

 

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Click here for more information about the COVID-19 information from Anthem Blue Cross and Blue Shield.

Please continue to check Provider Communications & Updates on the provider webpage for the latest information, including:

 

• False Claims Act awareness
• Coding tip for psychological and neuropsychological testing

 

Overuse of antibiotics is directly linked to the prevalence of antibiotic resistance. Promoting judicious use of antibiotics is important for reducing the emergence of harmful bacteria that is unresponsive to treatment. The following HEDIS® measures assess appropriate antibiotic prescribing for pharyngitis, upper respiratory infection and bronchitis/bronchiolitis. Changes for HEDIS 2020 include expanded age range and additional stratifications.

 

Appropriate Testing for Pharyngitis (CWP)

Pediatric Clinical Practice Guidelines recommend only children with lab‑confirmed group A strep or other bacteria-related ailments be treated with appropriate antibiotics. This measure reports the percentage of episodes for members 3 years of age and older where the member was diagnosed with pharyngitis, prescribed an antibiotic at an outpatient visit and received a group A strep test. A higher rate indicates better performance (in other words, appropriate testing).

 

Appropriate Treatment for Upper Respiratory Infection (URI)

This measure calculates the percentage of episodes for members 3 months of age and older with a diagnosis of upper respiratory infection that did not result in an antibiotic dispensing event. Reducing unnecessary use of antibiotics is the goal of this measure. It is reported as an inverted rate. A higher rate indicates appropriate upper respiratory infection treatment (in other words, the proportion of episodes that did not result in an antibiotic dispensing event).

 

Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)

There is considerable evidence that prescribing antibiotics for uncomplicated acute bronchitis is not indicated unless it is associated with a comorbid diagnosis. This measure assesses the percentage of episodes for members ages 3 months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event. It is reported as an inverted rate. A higher rate indicates appropriate acute bronchitis/bronchiolitis treatment (in other words, the proportion of episodes that did not result in an antibiotic dispensing event).

 

Helpful tips:

• When patients present with symptoms of pharyngitis, ensure proper testing (for strep) is performed to avoid the unnecessary prescribing of antibiotics. Record the results of the strep test.
• If prescribing an antibiotic to members with acute bronchitis, be sure to use the diagnosis code for the bacterial infection and/or comorbid condition.
• Educate members on the difference between bacterial and viral infections. Refer to the illness as a common cold, sore throat or chest cold. Parents and caregivers tend to associate these labels with a less frequent need for antibiotics.
• Write a prescription for symptom relief, such as rest, fluids, cool mist vaporizers and over‑the‑counter medicine.
• If a patient insists on an antibiotic, consider using delayed prescribing. Refer to the CDC handout for patients titled What is Delayed Prescribing? available at the link below.

 

Resources:

• CDC’s Be Antibiotics Aware campaign: https://www.cdc.gov/antibiotic-use/index.html
• CDC handouts for patients: https://www.cdc.gov/antibiotic-use/community/materials-references/index.html

Code only confirmed cases

According to ICD-10-CM coding guidelines for Chapter One, code, only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H. In this context, “confirmation” does not require documentation of positive serology or culture for HIV. The provider’s diagnostic statement that the patient is HIV positive or has an HIV-related illness is sufficient.

 

Status	ICD-10-CM code
Asymptomatic HIV	Assign code Z21 – Asymptomatic human immunodeficiency virus [HIV] infection status when the patient without any documentation of symptoms is listed as being ‘HIV positive’, ‘known HIV’, ‘HIV test positive’ or similar terminology.   Assign code B20 – Human immunodeficiency virus [HIV] disease on the claim when the term AIDS is used, when the patient is being treated for HIV-related illness or when the patient is described as having any active HIV-related condition.
Patients with inconclusive HIV serology	Assign code R75 – Inconclusive laboratory evidence of human immunodeficiency virus [HIV] when the patient’s record is documented with inconclusive HIV serology, but there is no definitive diagnosis or manifestations of the illness.
Previously diagnosed HIV-related illness	Code B20 if you document a patient as having had any known prior diagnosis of an HIV-related illness – Z21 is no longer reported. If the patient develops an HIV-related illness, they should be assigned code B20 on every subsequent admission/encounter.
HIV infection in pregnancy, childbirth and the puerperium	Assign code O98.7 – Human immunodeficiency virus [HIV] disease complicating pregnancy, childbirth and the puerperium first when a patient presents for treatment of an HIV-related illness during pregnancy, childbirth or the puerperium followed by code B20.   Also assign additional code(s) for HIV-related illness(es). Keep in mind that codes from Chapter 16 take priority when sequencing codes on the claim.   If a patient with asymptomatic HIV infection status presents for a routine visit during pregnancy, childbirth or the puerperium, the correct code assignment would be O98.7 followed by code Z21.

 

Assign code B20 for all types of HIV infections, which may be described by a variety of terms including:

• AIDS.
• Acquired immune deficiency syndrome.
• Acquired immunodeficiency syndrome.
• AIDS-related complex (ARC).
• AIDS-related conditions.
• HIV infection, symptomatic.

 

Testing for HIV:

• Assign code Z11.4 – Encounter for screening for human immunodeficiency virus [HIV] when seeing a patient with no prior diagnosis of HIV infection or positive HIV-status to determine their HIV-status.
• Code the signs and symptoms when seeing a patient with signs or symptoms for HIV testing. If you provide counseling during the encounter, assign additional code

Z71.7 – Human immunodeficiency virus [HIV] counseling.

• Assign code Z71.7 if a patient’s test results are negative for HIV.
• Assign code Z72.8 if a patient is known to be in a high-risk group for HIV infection. Other problems related to lifestyle can be assigned as an additional code.

 

Major HIV-related conditions

 

HIV-related condition	ICD-10-CM code
Pneumonia, unspecified organism	J18.9
Tuberculosis of other sites	A18.89
Sepsis, unspecified organism	A41.9
Candida stomatitis (thrush)	B37.0
Herpes zoster (any site)	B02.9
Encephalopathy, unspecified	G93.40

 

Other HIV-related conditions	ICD-10-CM code
Tinea cruris	B35.6
Anemia, unspecified	D64.9
Underweight	R63.6
Acute lymphadenitis	L04.9
Arthropathy, unspecified	M12.9
Splenomegaly, not elsewhere classified	R16.1
Weakness	R53.1

 

HIV/AIDS prevention

The CDC works with other federal agencies, state and local health departments, national organizations, and other entities to reduce the spread of HIV in the United States. This work covers several components:

• Behavioral interventions – These interventions ensure people have the information, motivation and skills necessary to reduce the risk of infection.
• HIV testing – Testing is critical to prevent the spread of HIV.
• Treatment and care – Treatment and care enable individuals with HIV to live longer, healthier lives.

 

The CDC remains on the forefront of pursuing high-impact prevention. This approach is designed to maximize the impact of prevention efforts for all Americans at risk for HIV infections and the CDC is aligning its efforts with the first National HIV/AIDS Strategy for the United States (NHAS). The Division of HIV/AIDS Prevention has developed a strategic three-year plan for 2017-2020 with the goal of one day achieving a future free of HIV.

 

Resources:

• ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2019.
• http://www.cdc.gov: HIV/AIDS.