The National Accounts 2021 Pre-certification list has been published. Please note, providers should continue to verify member eligibility and benefits prior to rendering services.

 

 

660-1020-PN-CONV

As providers, you are committed to providing the best care for your patients – our members.  That care may now include telehealth visits.  Recognizing the continuing increased need for telephone and virtual services during the COVID-19 public health emergency, the U.S. Department of Health and Human Services (HHS) has given additional consideration to the treatment of telephone-only services in the HHS-operated Risk Adjustment Program.  HHS has clarified that telephone-only service CPT codes (98966-98968 and 99441-99443) are valid for the Risk Adjustment Program.  Telephone-only visits may benefit your patients who have not participated in, or felt comfortable using, a telehealth video visit.  Thank you for your continued commitment to assessing your patients’ health and closing possible gaps in care.

 

Please contact the Commercial Risk Adjustment Network Education Representative if you have any questions:

Socorro.Carrasco@anthem.com.

 

 

658-1020-PN-CONV

CMS average sales price (ASP) fourth quarter fee schedule with an effective date of October 1, 2020 will go into effect with Anthem Blue Cross and Blue Shield (Anthem) on November 1, 2020. To view the ASP fee schedule, please visit the CMS website at http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/.

 

 

648-1020-PN-CONV

Anthem Blue Cross and Blue Shield (Anthem) offers you the ability to have a copy of the member’s ID card without having to physically handle the member’s card. This easy, low-touch access to view a member’s ID card is available from the Availity Portal.

 

Accessing via the Availity Portal

 

When conducting an eligibility and benefits (E&B) inquiry for Anthem members via Availity, select Patient Registration | Eligibility and Benefits Inquiry and complete the required eligibility and benefits fields.  From the Eligibility and Benefits results page, simply select View Member ID Card. Note: the Availity Portal requires you to enter the member’s ID number as well as a date of birth, or the member’s first and last name into the search options in order to submit an E&B inquiry.

 

 

Images of both the front and back of the member ID card are available, allowing you to get all of the pertinent information without the need to make a phone call. The images can be saved directly to your practice management system as PDF files.

 

Accessing via the member’s mobile app

 

Another option available is to access the member’s digital version of their ID card as many members have transitioned to using a digital card instead of a paper card. Members are able to email or fax a copy of the electronic ID card from their phone/app.

 

We encourage you to integrate these options into your workflow now.

 

 

677-1020-PN-CONV

An online course for providers and office staff that addresses gaps in care and offers approaches to communication with patients.  This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians.

 

The What Matters Most training can be accessed at: www.patientexptraining.com.

 

 

653-1020-PN-CONV

Anthem Blue Cross and Blue Shield (Anthem) providers may now learn how to use Availity's attachment tools to submit and track supporting documentation electronically by attending one of the upcoming live webinars hosted by Availity. 

 

The attachments application is a multi-payer, multi-workflow feature. It allows inclusion of multiple records across a variety of workflows and request types to support different business processes for payers.

 

By attending one of the upcoming webinars, attendees will learn both the digital and electronic processes that include:

• How your organization gets set up
• Demonstrations of the tools used to submit attachments via Availity Portal
• Navigating the Attachments dashboard
• View electronic records of your submissions

 

As part of the session, we will answer questions and provide handouts and a job aid for you to reference later.

 

Register for an upcoming webinar session

1. In Availity Portal, select Help & Training > Get Trained.
2. The Availity Learning Center opens in a new browser tab.
3. Search for and enroll in a session using one of these options.
   • In the Catalog, search by webinar title or keyword (medattach).
   • Select the Sessions tab to scroll the live session calendar.
4. After you enroll, you will receive emails with instructions to join the session.

 

October/November Dates

 

Date	Day	Time
10/07/2020	Wednesday	4:00 p.m. – 5:00 p.m. ET
10/20/2020	Tuesday	11:00 a.m. – 12:00 p.m. ET
11/04/2020	Wednesday	4:00 p.m. – 5:00 p.m. ET
11/17/2020	Tuesday	2:00 p.m. – 3:00 noon ET

 

Where can you find more help?

Select Help & Training > Find Help to display Availity Help in a new browser window.

Use Contents to display topics.

 

Depending on your needs, consider exploring these topics:

 

• Claim Submission
• Attachments (new)
• Medical Attachments (legacy)

 

 

702-1020-PN-CONV

As employers across the country host open enrollment periods for their employees, many will offer a new option this fall: plans built around a Blue High Performance Network.

 

Blue High Performance Network® plans offer access to providers with a record of delivering high-quality, efficient care. These networks will go live January 1, 2021 in more than 50 cities across the country, including Las Vegas. 

 

The Blue High Performance Network is a national network designed from our local market expertise, deep data and strong provider relationships, and aligned with local networks across the country. These local networks are then connected to the national chassis to form a national Blue High Performance Network. In Nevada, the Pathway HMO network is our Blue High Performance Network. Providers participating in the Pathway HMO will be in-network for any members with High Performance Network plans.

 

If you are not sure whether your practice is part of the Pathway HMO network and therefore the Blue High Performance Network, ask your office manager or business office, or contact your Anthem network representative. Blue High Performance Network participation will be displayed in provider profiles in our provider directory January 1, 2021.

 

Beginning January 1, you may see patients accessing this network through either a national employer plan, Blue High Performance Network, or large group employer plans with access to the Pathway HMO network. Under these plans, out of network benefits are limited to emergency or urgent care. Members must select a primary care provider, but PCP referrals are not required for specialty care.

 

Below is a sample ID card for a member from Nevada enrolled in the national employer Blue High Performance Network plan. Note the new “HPN” indicator in the suitcase icon.

 

Note: The High Performance Network acronym HPN is not used in conjunction or affiliated with any other local organizations known by the same acronym.

 

 

685-1020-PN-NV

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

 

• Evaluation and management services correct coding
• May 2020 Medical Policies and Clinical Utilization Management Guidelines Update

 

 

ABSCRNU-0165-20

ABSCRNU-0167-20

 

 

Effective October 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will integrate community health workers (CHWs) used by GroundGame Health (GGH)* into our current care management program. Referrals into the program are completed via provider direct referrals or ad hoc referrals from the Anthem Case Management team. Provider direct referrals will include members with the following situations:

• Identified social determinants of health needs including, but not limited to:
  • Living environment
  • Transportation
  • Food insecurity issues
  • Financial issues
  • Social isolation, etc.
• Hospital readmissions
• A readmission risk score of more than 24

 

GGH provides an extra layer of support by using CHWs as an extension of care management to help members navigate the complex health care system. PCHP makes an initial outreach to identified members to determine the appropriate level of services a member may need, but they do not provide any clinical services, replace case management from Anthem, or replace the care and care management provided by PCPs and specialists. Note: There is no requirement that members participate in this program, and members have the opportunity to opt out of the program as they choose.

 

A GGH CHW may reach out to your practice to introduce themselves and establish a relationship with the physician(s) at your practice based on referrals received. CHWs may also discuss developing a mechanism by which to share information regarding patients who have been identified for complex care services.

 

The CHW may also broaden the impact of case management by focusing on action plan developments in various ways, such as helping members fill prescriptions, scheduling appointments and arranging rides to the doctor. CHWs can even accompany members to appointments when appropriate and provide connections to meal delivery services that may be available to them.

 

To learn more about GGH, please visit https://groundgamehealth.org. If you have questions regarding GGH, CHWs and complex care services, please call 1-866-739-6323 or email physicianreferral@preferredchp.com.

 

 

ABSCARE-0564-20

On January 1, 2021, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements will change for codes below. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

Prior authorization requirements will be added for the following codes:

• C1764 Event recorder, cardiac (implantable)
• E0720 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, TWO LEAD, LOCALIZED
• E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS,
• E0731 Conductive Garment For Tens
• G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy, centrifugation, and all other preparatory procedures, administration and dressings, per treatment
• L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each
• L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength
• L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each
• L3224 Woman's Shoe Oxford Brace
• L3225 Man's Shoe Oxford Brace
• L3300 Shoe Lift Taper To Metatarsal
• L3310 Lift, elevation, heel and sole, neoprene, per in
• L3332 Lift, elevation, inside shoe, tapered, up to one-half in
• L3334 Lift, elevation, heel, per in
• L3340 Heel wedge, SACH
• L3350 Shoe Heel Wedge
• L3370 Shoe Sole Wedge Between Sole
• L3390 Shoe Outflare Wedge
• L3400 Shoe Metatarsal Bar Wedge Ro
• L3450 Shoe Heel Sach Cushion Type
• L3485 Shoe Heel Pad Removable For
• L3540 Ortho Shoe Add Full Sole
• L3580 O Shoe Add Instep Velcro Clo
• L3610 Transfer of an orthosis from one shoe to another, caliper plate, new
• L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing
• L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new
• L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified
• L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
• L3710 Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf
• L3761 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf
• L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf
• L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
• L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type
• L3912 Hand-finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-the-shelf
• L3913 HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
• L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
• L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated,

off-the-shelf

• L3925 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf
• L3927 Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/spring, extension/flexion (for example, static or ring type), may include soft interface material, prefabricated,

off-the-shelf

• L3999 Upper Limb Orthosis Nos
• L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system
• L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee
• L5620 Test Socket Below Knee
• L5645 Addition to lower extremity, below knee (BK), flexible inner socket, external frame
• L5649 Addition to lower extremity, ischial containment/narrow M-L socket
• L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
• 0232T Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
• 0397T Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure.)
• 0421T Transurethral waterjet ablation of prostate, including control of post-operative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)
• 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure.)
• 0480T Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure.)
• 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation
• 33361 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous femoral artery approach
• 33362 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery approach
• 33363 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery approach
• 33365 Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach (eg, median sternotomy, mediastinotomy)
• 33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis
• 33419 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure)
• 33477 Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed
• 33979 Insertion, Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle
• 33990 Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only
• 36514 Therapeutic Apheresis; Plasma Pheresis
• 36522 Photopheresis, Extracorporeal
• 37215 Transcatheter Placement Of Intravascular Stent(S), Cervical Carotid Artery, Percutaneous; With Distal Embolic Protection
• 55874 Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed
• A4224 Supplies for maintenance of insulin infusion catheter, per week
• A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
• A5500 Diabetic Shoe For Density Insert
• A5501 Diabetic Custom Molded Shoe
• A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe
• A5504 Diabetic Shoe With Wedge
• A5505 Diabetic Shoe W/Metatarsal Bar
• A5507 Modification Diabetic Shoe
• A5512 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fah
• A5513 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each
• A9580 Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries
• C1722 Cardioverter-defibrillator, single chamber (implantable)
• L5671 Addition to lower extremity, below knee (BK)/above knee (AK) suspension locking mechanism (shuttle, lanyard, or equal), excludes socket insert
• L5673 Addition to lower extremity, below knee/above knee, custom fabricated
• L5679 Addition to lower extremity, below knee/above knee, custom fabricated
• L5700 Replace Socket Below Knee
• L5701 Replace Socket Above Knee
• L5940 Endo Bk Ultra-Light Material
• L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature
• L5981 All lower extremity prostheses, flex-walk system or equal
• L5987 All lower extremity prostheses, shank foot system with vertical loading pylon
• L8699 Prosthetic implant, not otherwise specified
• L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code

 

Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.anthem.com/medicareprovider > Login. Contracted and noncontracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.

 

 

ABSCRNU-0172-20

A key goal in our provider transparency initiative is to improve quality while managing health care costs. One of the ways we do that is by offering value-based programs including Freestanding Patient Centered Care (FPCC), Medicare Advantage Enhanced Personal Health Care Essentials and so on (known as the Programs).

 

Value-based program providers (also known as payment innovation providers) in our programs receive quality, utilization and/or cost data, reports, and information about the health care providers (referral providers) to whom the providers may refer their Anthem Blue Cross and Blue Shield (Anthem) patients. If a referral provider is higher quality and/or lower cost, this component of the Programs should result in the provider receiving 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 to value-based program providers (including comparative cost information) helps them make more informed decisions about managing health care costs, maintain/improve quality of care and succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representative/vendors) may also be given data about value-based program providers or referral providers to better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will 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.

 

Upon request, Anthem will share the data used to make these quality/cost/utilization evaluations and will discuss it with referral providers, including any opportunities for improvement.

 

If you have questions or need support, contact your local Market Representative or Care Consultant.

 

 

ABSCRNU-0171-20

On February 21, 2020, May 15, 2020, and June 18, 2020, 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 June 2020]. Visit Clinical Criteria to search for specific policies.

           

If you have questions or would like additional information, use this email.

 

 

ABSCRNU-0173-20

On January 1, 2021, Anthem Blue Cross and Blue Shield prior authorization (PA) requirements changed for codes below. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

Prior authorization requirements will be added for the following codes:

• 15771 - Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
• 15772 - Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
• 15773 - Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
• 15774 - Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
• 31574 - Laryngoscopy, flexible; with injection(s) for augmentation (for example, percutaneous, transoral), unilateral
• 0378T - Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional
• 0379T - Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional
• C9122 - Mometasone furoate sinus implant, 10 mcg (Sinuva)
• 11950 - Subcutaneous injection of filling material (for example, collagen); 1 cc or less
• 11951 - Subcutaneous injection of filling material (for example, collagen); 1.1 to 5.0 cc
• 11952 - Subcutaneous injection of filling material (for example, collagen); 5.1 to 10.0 cc
• 11954 - Subcutaneous injection of filling material (for example, collagen); over 10.0 cc
• 0565T - Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation
• 0566T - Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral
• C1878 - Material for vocal cord medialization, synthetic (implantable)
• G0429 - Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (for example, as a result of highly active antiretroviral therapy)
• L8607 - Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies
• Q2026 - Injection, Radiesse, 0.1 ml
• Q2028 - Injection, sculptra, 0.5 mg
• 0489T - Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells
• 0490T - Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands
• 0202U - Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected
• 17999 - Unlisted procedure, skin, mucous membrane and subcutaneous tissue
• 46999 - Unlisted procedure, anus

Not all prior authorization requirements are listed here. Prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at www.availity.com at https://www.anthem.com/provider/medicare-advantage > Login. Contracted and noncontracted providers who are unable to access Availity* may call the number on the back of the member’s ID card.

 

 

ABSCRNU-0170-20

Please continue to check Medicaid Provider Communications & Updates at anthem.com/mediproviders for the latest Medicaid information.

 

• May 2020 Medical Policies and Clinical Utilization Management Guidelines Update
• Provider Chat -- A fast, easy way to have your questions answered

 

 

ANV-NU-0150-20

ANVPEC-1371-20

This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).

 

Effective October 1, 2020, Anthem will integrate community health workers (CHWs) used by GroundGame Health (GGH)* into our current care management program. Referrals into the program are completed via provider direct referrals or ad hoc referrals from the Anthem Case Management team. Provider direct referrals will include members with the following situations:

 

• Identified social determinants of health needs including, but not limited to:
  • Living environment
  • Transportation
  • Food insecurity issues
  • Financial issues
  • Social isolation, etc.
• Hospital readmissions
• A readmission risk score of more than 24

 

GGH provides an extra layer of support by using CHWs as an extension of care management to help members navigate the complex health care system. PCHP makes an initial outreach to identified members to determine the appropriate level of services a member may need, but they do not provide any clinical services, replace case management from Anthem, or replace the care and care management provided by PCPs and specialists. Note: There is no requirement that members participate in this program, and members have the opportunity to opt out of the program as they choose.

 

A GGH CHW may reach out to your practice to introduce themselves and establish a relationship with the physician(s) at your practice based on referrals received. CHWs may also discuss developing a mechanism by which to share information regarding patients who have been identified for complex care services.

 

The CHW may also broaden the impact of case management by focusing on action plan developments in various ways, such as helping members fill prescriptions, scheduling appointments and arranging rides to the doctor. CHWs can even accompany members to appointments when appropriate and provide connections to meal delivery services that may be available to them.

 

To learn more about GGH, please visit https://groundgamehealth.org. If you have questions regarding GGH, CHWs and complex care services, please call 1-866-739-6323 or email physicianreferral@preferredchp.com.

 

 

ANVPEC-1280-20

The What Matters Most online training course for providers and office staff addresses gaps in care and offers approaches to communication with patients. The course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. The What Matters Most online training course can be accessed at: www.patientexptraining.com.

 

 

ANV-NU-0145-20

Behavioral health disorders are classified in Chapter 5 of the ICD-10-CM

Behavioral health disorders are commonly underreported on claims. Many Anthem Blue Cross and Blue Shield Healthcare Solutions members may have behavioral health disorders that are not properly managed. Health care providers can assist by taking detailed histories and coding behavioral health issues properly on claims. Below are the ICD-10-CM coding guidelines for behavioral health conditions.

 

When documenting behavioral disorders, the following descriptors apply:

• Type: Depressive, manic, or bipolar disorder
• Episode: Single or recurrent
• Status: Partial or full remission; identify most recent episode as manic, depressed, or mixed
• Severity: Mild, moderate, severe, or with psychotic elements.

 

Schizophrenic related disorders

Schizophrenic related disorders are classified in category F20, with a forth character indicating the type of schizophrenia as follows:

 

Code	Description
F20.0	Paranoid schizophrenia
F20.1	Disorganized schizophrenia
F20.2	Catatonic schizophrenia
F20.3	Undifferentiated schizophrenia
F20.5	Residual schizophrenia
F20.8	Other schizophrenia This subcategory is further subdivided as follows: F20.81 Schizophreniform disorder F20.89 Other schizophrenia
F20.9	Schizophrenia, unspecified

 

Major depressive disorder (MDD)

Major depressive disorder (MDD) is classified in ICD-10-CM to categories:

• F32.- Major depressive disorder, single episode
• F33.- Major depressive disorder, recurrent.

 

Categories F32 and F33 are further subdivided with fourth characters, and sometimes fifth characters, to provide information about the current severity of the disorders, as follows:

• 0 Mild
• 1 Moderate
• 2 Severe, without psychotic features
• 3 Severe with psychotic features
• 4 In remission
• 5 In full remission
• 8 Other
• 9 Unspecified.

 

Fourth characters 1 through 8 are assigned only when provider documentation of severity is included in the medical record.

 

Manic episodes and bipolar disorders

The table below outlines the ICD-10-CM classification for bipolar disorders. Manic/mania also falls within this code category. The codes in these categories require fourth and/or fifth digits to identify the severity of the current episode and whether or not psychotic symptoms are involved.

 

Category	Description
F30.-	Manic episode (includes bipolar disorder, single manic episode, and mixed affective episode)	Select appropriate fourth and fifth digits to identify the severity of the current episode to indicate whether psychotic symptoms are involved
F31.-	Bipolar disorder (includes manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction)	Select appropriate fourth and fifth digits to specify the severity of the current episode and whether the current episode is hypomanic, manic, depressed or mixed, and with or without psychotic features.
F34.-	Persistent mood [affective] disorders (includes cyclothymic disorder and dysthymic disorder)	Includes, cyclothymic, dysthymic, and other specified mood disorders.
F39	Unspecified mood [affective] disorder (includes affective psychosis not otherwise specified)	Include affective psychosis when not otherwise specified

 

Anxiety disorders

Anxiety disorders are classified in ICD-10-CM under the following categories:

• F40 Phobic anxiety disorders
• F41 Other anxiety disorders
• F42 Obsessive-compulsive disorder.

 

Dissociative and conversion disorders

ICD-10-CM classifies dissociative and conversion disorders to category F44.

 

Dissociative disorders:

Code	Description
F44.0	Dissociative amnesia
F44.1	Dissociative fugue
F44.2	Dissociative stupor
F44.81	Dissociative identity disorder

 

Conversion disorders:

Code	Description
F44.4	Conversion disorder with motor symptom or deficit
F44.5	Conversion disorder with seizures or convulsions
F44.6	Conversion disorder with sensory symptom or deficit
F44.7	Conversion disorder with mixed symptom presentation

 

Behavioral syndromes associated with physiological disturbances and physical factors

Categories F50 through F59 grouping includes the following conditions:

 

Category/ code	Description
F50.0-	Eating disorders (such as anorexia nervosa and bulimia nervosa)
F51.-	Sleep disorders not due to a substance or known physiological condition
F52.-	Sexual dysfunction not due to a substance or known physiological condition
F53.-	Mental and behavioral disorders associated with the puerperium, not elsewhere classified
F54	Psychological and behavioral factors associated with disorders or diseases classified elsewhere
F55.-	Abuse of non-psychoactive substances
F59	Unspecified behavioral syndromes associated with physiological disturbances and physical factors

 

Disorders of adult personality and behavior

Categories F60 through F69 include disorders of adult personality and behavior:

 

Category code	Description
F60.0-	Specific personality disorders
F63.-	Impulse disorders
F64.-	Gender identity disorders
F65.-	Paraphilias
F66.-	Other sexual disorders
F68.-	Other disorders of adult personality and behavior

 

Psychosocial circumstances and encounters

ICD-10-CM provides codes for behaviors that have not yet been classified to behavioral disorders, but that may contribute to the need for further treatment or study. The table below shows some examples:

 

Code	Description
R41.0	Disorientation, unspecified
R41.82	Altered mental status, unspecified
R41.840	Attention and concentration deficit
R44.3	Hallucinations, unspecified
R45.83	Excessive crying of child, adolescent or adult
R45.84	Anhedonia
R45.86	Emotional liability
R45.87	Impulsiveness
R46.0	Very low level of personal hygiene
R46.2	Strange and inexplicable behavior
R46.81	Obsessive-compulsive behavior

 

For behavioral health disorders that resolve and do not require continued treatment, it is appropriate to report code Z86.59, Personal history of other mental and behavioral disorders.

 

Resources:

1. ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2019.
2. ICD-10-CM/PCS Coding. Theory and practice. 2019/2020 Edition. Elsevier.

 

 

ANV-NU-0148-20