 Provider News NevadaFebruary 1, 2020 February 2020 Anthem Provider News and Important Updates - NevadaAnthem Blue Cross and Blue Shield (Anthem) announced in July that the AIM Rehabilitative Program was delayed. This message is sent to announce that the AIM Rehabilitative program for Anthem’s Commercial Membership will relaunch April 1, 2020. AIM Specialty Health® (AIM), a separate company, will perform prior authorization review of physical, occupational and speech therapy services. Requests may be submitted beginning March 16, 2020 via the AIM ProviderPortal for dates of service April 1st and after. The OrthoNet program is no longer active in applicable markets. Processes have been put in place to allow providers to continue to provide treatment and allow claims to process. Claims that were denied for no authorization in error after 7/1 will reprocess.
The AIM Rehab Program follows the Anthem Clinical Guidelines that state the services must be delivered by a qualified provider of therapy services acting within the scope of their licensure. Qualified providers acting within the scope of their license, including chiropractors, who intend to provide PT, OT or ST services should request prior authorization for those services through AIM.
Please note that if you are providing PT/OT/ST services to an Anthem Commercial member whose state of issuance is part of the AIM Rehab Program, you will be required to obtain an authorization.
NEW CHANGES TO AIM’S REHAB PROGRAM
This is to inform you that Anthem and AIM Specialty Health are working together to make improvements to the clinical review of PT/OT/ST Services when used to treat Autism Spectrum Disorder or Pervasive Developmental Delays as defined by the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. Currently, prior authorization is not required for PT, OT, or ST out-patient therapy services when receiving skilled treatment for Autism Spectrum Disorder or Pervasive Developmental Delays for members with Anthem commercial plan. You may file your claims without a prior authorization number if you are billing with one of the following ICD-10 codes: F84.0, F84.2, F84.3, F84.5, F84.8, or F84.9. Please note that benefit limits, if applicable, will still be applied. We will let you know when the AIM Rehab Program for Autism Spectrum Disorder or Pervasive Developmental Delay program is scheduled for implementation.
Anthem is also transitioning vendors for review of Rehabilitative Services for our *Medicare members to include out-patient PT, OT, and SLP, to AIM Specialty Health. The AIM Rehab program will now begin in April 2020. Prior authorization will not be required for the above mentioned services through March 2020. *This does not apply to members in the states of FL, NJ and NY for whom prior authorization will still be required. Please review the update in an upcoming notice for more information about the AIM Rehabilitative Program for Medicare members. Anthem Commercial Risk Adjustment (CRA) contracts with Inovalon -- an independent company that provides secure, clinical documentation services -- to help us comply with provisions of the Affordable Care Act (ACA) that require us to assess members’ relative health risk level and report to CMS on those conditions. Your offices have been receiving Inovalon SOAP ( Subjective; Objective; Assessment; and Plan – these are health assessments) packets all year long as part of our risk adjustment cycle, asking for the physicians’ help with completing health assessments for some of their patients who are our members.
Incentives for submitting SOAP Notes/Health Assessments
SOAP Notes/Health Assessments submitted as paper are eligible for a $50 incentive; SOAPs submitted electronically through Inovalon’s ePASS system are eligible for a $100 incentive.
Submission Deadline and Important Reminder
While the dates of service for the patient visits must have been within 2019, the SOAP Notes/Health Assessments can be submitted up until February 15, 2020. We will still pay the incentive payments for these submissions through February 15, 2020.
Questions or assistance with SOAP Notes/Health Assessments
Need help with ePASS or have questions? Simply email your inquiry to Inovalon at ePASSsupport@inovalon.com with your name, organization, contact information, and any questions that you might have. Trained representatives are available to assist you. If you prefer to reach Inovalon by phone, please call 1-877-448-8125, Monday - Friday, 8 am - 9 pm ET; Saturday - Sunday, 10 am - 6 pm ET.
If you have any questions regarding our risk adjustment process, please contact our CRA Network Education Representative who supports your area: Socorro.Carrasco@anthem.com.Anthem is collaborating with leading organizations on a new school-based initiative called Shine Light on Depression to help tackle the issue of teen depression and suicide in middle and high school youth nationwide. The Shine Light on Depression e-toolkit (e.g., website) will provide school communities with free, ready-to-use tools designed to raise awareness of depression and suicide prevention in a positive, fact-based, and inclusive manner. This approach will help build a community in which there is open discussion and appropriate vocabulary about the subject of depression and places it in the broader context of good mental health. The e-toolkit features customizable classroom lessons to empower educators to lead effective depression awareness programs, family-community workshop materials to help adults and families talk about how to support teens, and teen club resources that empower students to lead activities and help each other by talking and listening. With 24,053 secondary schools in the U.S., the Shine Light on Depression e-toolkit has the potential to impact large numbers of individuals who are at risk of depression and suicide and support schools in meeting state teaching mandates.
Visit Shine Light on Depression to learn more.
Shine Light on Depression is a unique collaboration of organizations committed to raising awareness of depression and suicide prevention among young people: American School Health Association, Anthem, Inc., Erika’s Lighthouse, JetBlue Airways Corporation, and the National Parent Teachers Association.
Effective with dates of service on and after April 1, 2020, and in accordance with the IngenioRx Pharmacy and Therapeutic (P&T) process, Anthem Blue Cross and Blue Shield (Anthem) will update its drug lists that support commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes here.
IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem.Category: Medicare
Effective May 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) has updated the Modifier 62: Co‑Surgeons reimbursement policy to expand the current policy’s language, adding that Anthem does not consider surgeons performing different procedures during the same surgical session as co-surgeons, and Modifier 62 is not required.
Assistant surgeon and/or multiple procedures rules and fee reductions apply if a co-surgeon acts as an assistant in performing additional procedure(s) during the same surgical session.
Please note that assistant surgeon rules do not apply to procedures appropriately billed with Modifier 62.
Please visit www.anthem.com/medicareprovider to view the Modifier 62: Co-Surgeons reimbursement policy for additional information regarding percentages and reimbursement criteria.
Category: Medicare
CMS requires that all hospitals and critical access hospitals (CAHs) provide written notification and an oral explanation to individuals receiving observation services as outpatients for more than 24 hours.
Hospitals should use the OMB-approved standardized Medicare Outpatient Observation Notice (MOON), form CMS-10611. All hospitals and CAHs are still required to provide this statutorily required notification. The notice and accompanying instructions are available at https://go.cms.gov/391jZH9.
The MOON was developed to inform all Medicare beneficiaries, including Anthem Blue Cross and Blue Shield members, when they are an outpatient receiving observation services, and are not an inpatient of the hospital or CAH. The notice must include the reasons the individual is an outpatient receiving observation services and the implications of receiving outpatient services, such as required Medicare cost-sharing and post-hospitalization eligibility for Medicare coverage of skilled nursing facility services.
Hospitals and CAHs must deliver the notice no later than 36 hours after observation services are initiated or sooner if the individual is transferred, discharged or admitted.
Category: Medicare
Maintaining accurate provider information is critically important to ensure that our members have timely and accurate access to care.
Additionally, Anthem Blue Cross and Blue Shield Healthcare Solutions is required by Centers for Medicare & Medicaid Services (CMS) to include accurate information in provider directories for certain key provider data elements. To remain compliant with federal and state requirements, changes must be communicated within 30 days in advance of a change or as soon as possible.
Key data elements include physician name, address, phone number, accepting new patient status, hospital affiliations and medical group affiliations.
Please notify us by emailing demographic changes to nv1-providerservices@anthem.com or contacting your provider relations representative. Thank you for your help and continued efforts in keeping our records up to date.
Category: Medicaid
Maintaining accurate provider information is critically important to ensure that our members have timely and accurate access to care.
Additionally, Anthem Blue Cross and Blue Shield Healthcare Solutions is required by Centers for Medicare & Medicaid Services (CMS) to include accurate information in provider directories for certain key provider data elements. To remain compliant with federal and state requirements, changes must be communicated within 30 days in advance of a change or as soon as possible.
Key data elements include physician name, address, phone number, accepting new patient status, hospital affiliations, and medical group affiliations.
Please notify us by emailing demographic changes to nv1-providerservices@anthem.com or contacting your provider relations representative. Thank you for your help and continued efforts in keeping our records up to date.
Category: Medicaid
ICD-10-CM coding
Respiratory diseases are classified in categories J00 through J99 in Chapter 10, “Diseases of the Respiratory System” of the ICD-10-CM Official Guidelines for Coding and Reporting.
Pneumonia
Pneumonia is coded in several ways in ICD-10-CM. Combination codes that account for both pneumonia and the responsible organism are included in Chapter 1, “Certain Infectious And Parasitic Diseases” and Chapter 10, “Diseases of the Respiratory System.” Examples of appropriate codes for pneumonia include:
- J15.0 -- pneumonia due to Klebsiella
- J15.211 -- pneumonia due to Staphylococcus aureus
- J11.08 + J12.9 -- viral pneumonia with influenza.
Other types of pneumonia are coded as manifestations of underlying infections classified in chapter 1; two codes are required in such cases. Examples of this dual classification coding include I00 + J17 — pneumonia in rheumatic fever. When the diagnostic statement is pneumonia without any further specification and the organism is not identified, the assigned code is J18.9 -- pneumonia, unspecified organism.
Influenza
ICD-10-CM classifies influenza as the following categories:
- J09 -- due to certain identified influenza viruses
- J10 -- due to other identified influenza virus
- J11 -- due to unidentified influenza virus.
Codes from categories J09 and J10 should be assigned only for confirmed cases of avian flu and other novel influenza A, or for other identified influenza virus.
Chronic obstructive pulmonary disease (COPD) and asthma
COPD is a general term used to describe a variety of conditions that result in obstruction of the airway. ICD-10-CM classifies these conditions to category J44, other chronic obstructive pulmonary disease. Category J44 includes the following conditions:
- Asthma with chronic obstructive pulmonary disease
- Chronic asthmatic (obstructive) bronchitis
- Chronic bronchitis with airways obstruction
- Chronic bronchitis with emphysema
- Chronic emphysematous bronchitis
- Chronic obstructive asthma
- Chronic obstructive bronchitis
- Chronic obstructive tracheobronchitis
Category J44 is further subdivided to specify whether there is an acute lower respiratory infection (J44.0) and whether there is an exacerbation of the condition (J44.1). If applicable, a code from category J45 is assigned to specify the type of asthma. It is appropriate to code both the COPD with acute exacerbation and COPD with a lower respiratory infection. Be specific in the documentation, including the type of infection and the infective agent.
For COPD, document severity as either mild, moderate or severe. COPD can occur with or without acute or chronic respiratory failure, so any respiratory failure should be separately noted.
Asthma is classified into category J45; a fourth character indicates the severity as either mild intermittent, mild persistent, moderate persistent, severe persistent, other and unspecified; also, a final character indicates whether the condition is uncomplicated, or whether status asthmaticus or exacerbation is present.
Asthma characterized as obstructive or diagnosed in conjunction with COPD is classified to category J44 -- other chronic obstructive pulmonary disease. If the specific type of asthma is documented, also use code J45.
Signs and symptoms of COPD or asthma that are separately reported when they occur include hypercapnia, hypoxemia, polycythemia, and acute or chronic respiratory failure. Document any dependence on a ventilator or supplemental oxygen.
A diagnosis of asthmatic bronchitis without further specification is coded as J45.9 if the diagnosis is stated as exacerbated or acute chronic asthmatic bronchitis, code J44.1 is assigned. A diagnosis of asthmatic bronchitis with COPD or chronic asthmatic bronchitis is coded to J44.9.
Examples of coding for asthma include the following:
- J45.902 -- asthmatic bronchitis with status asthmaticus
- J44.9 + J45.40 -- moderate persistent asthma with COPD.
In addition to codes in categories J44 and J45, codes may also be assigned to identify exposure to environmental tobacco smoke (Z77.22), history of tobacco dependence (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17. or tobacco use (Z72.0)
HEDIS® quality measures for respiratory conditions:
Medication Management for People with Asthma (MMA)
This HEDIS measure looks at patients who have been identified as having persistent asthma and have been dispensed appropriate medication on which they remained during the treatment period.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Two rates are reported:
- The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period
- The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period
For patients with asthma, you should:
Prescribe controller medication.
- Educate them on identifying asthma triggers and taking controller medications.
- Create an asthma action plan (document in the medical record).
- Remind them to get their controller medication filled regularly.
- Remind them to continue taking the controller medications even if they are feeling better and free of symptoms.
Exclusions:
Acute respiratory failure
- Chronic respiratory conditions due to fumes/vapors
- COPD
- Cystic fibrosis
- Emphysema
- Other emphysema
Asthma Medication Ratio (AMR)
This HEDIS measure looks at patients who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.5 or greater during the measurement year.
Helpful tips:
- For each member, count the units of asthma controller medications dispensed during the measurement year.
- For each member, count the units of asthma reliever medications dispensed during the measurement year.
- For each member, sum the units calculated in step 1 and step 2 to determine units of total asthma medications.
- For each member, calculate the ratio of controller medications to total asthma medications (units of controller medications divided by units of total asthma).
Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)
This HEDIS measure looks at members 40 years of age and older with a new diagnosis of COPD or newly active COPD who received appropriate spirometry testing to confirm the diagnosis.
Helpful tips:
- Managing chronic conditions takes planning. A pre-visit chart review is a good place to start.
- Proper diagnosis is needed to ensure members receive appropriate short- and long-term treatment.
- Both symptomatic and asymptomatic patients suspected of COPD should have spirometry performed to establish airway limitation and severity.
Resources:
- ICD-10-CM Expert for Physicians: the complete official code set. Optum360, LLC. 2019.
- ICD-10-CM/PCS Coding: theory and practice. 2019/2020 Edition. Elsevier
- NCQA: HEDIS & performance management: https://www.ncqa.org/hedis/measures
Category: Medicaid
As patient panels grow more diverse and needs become more complex, providers and office staff need more support to help address patients’ needs. Anthem Blue Cross and Blue Shield Healthcare Solutions (Anthem) wants to help.
Cultural competency resources
We have cultural competency resources available on our provider website. Leveraging content created by the Industry Collaboration Effort (ICE) Cultural and Linguistic Workgroup, the Cultural Competency Training and the Caring for Diverse Populations Toolkit have enhanced content.
- Cultural Competency Training includes:
- Enhanced content regarding culture including language and the impact on health care.
- A cultural competency continuum that can help providers assess their level of cultural competency.
- Guidance on working effectively with interpreters.
- Comprehensive content on serving patients with disabilities.
- Caring for Diverse Populations Toolkit includes:
- Comprehensive information on working with diverse patients and effectively supporting culture, language and disabilities in health care delivery.
- Tools and resources to help mitigate barriers including materials that can be printed and made available for patients in your office.
- Guidance on regulations and standards for cultural and linguistic services.
In addition, providers can access https://mydiversepatients.com for tools and resources that are accessible from any smartphone, tablet or desktop. Providers will find free continuing medical education courses that cover topics relevant to providing culturally competent care and services for diverse individuals.
Prevalent non-English languages (based on population data)
Like you, Anthem wants to effectively serve the needs of diverse patients. It’s important for us all to be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the prevalent non-English languages spoken by 5 percent or 1,000 individuals in Nevada. (Source: American Community Survey, 2016 American Community Survey 5-Year Estimates, Table B16001, generated 10/03/2018)
| Prevalent non-English languages in NV |
| Spanish |
Thai, Lao or other Tai-Kadai |
Language support services
As a reminder, Anthem provides language support services for our members with limited English proficiency (LEP) or hearing, speech or visual impairments. Please see the provider manual at https://mediproviders.anthem.com/nv for details on the available services and how to access them.
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