 Provider News New YorkJuly 2020 Empire Provider NewsBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As a provider, we understand you are committed to providing the best care for our members, which now involves telehealth visits. Telehealth visits are an acceptable format for seeing your patients and assessing if they have risk adjustable conditions. As we reported in the May and June newsletters, we are completing our prospective and retrospective reviews for 2020 for Empire BlueCross BlueShield’s (“Empire”) Commercial Risk Adjustment (CRA) program. The retrospective program focuses on medical chart collection. The prospective program focuses on member health assessments for patients with undocumented Hierarchical Condition Categories (HCC’s), in order to help close patients’ gaps in care.
What’s in it for you?
First, monthly you will receive a list of your patients who are Empire members enrolled in Affordable Care Act (ACA) compliant coverage who may have gaps in care to help you reach out to them, so they can come in for office visits earlier.
Second, we’ve heard resoundingly from providers that participation in these programs helps them better evaluate their patients and, as a result, perform more strongly in population health management and gain sharing programs. Many cite that they ask different questions today that allow them to better manage their patients end to end.
Finally, when you see Empire ACA members and submit health assessments, we pay incentives of $50 for a paper submission and $150 for an electronic submission. For additional details on how to earn these incentives and the options available, please contact the CRA Network Education Representative listed below.
What’s in it for your patients
Empire is completing monthly postcard campaigns to members with ACA compliant coverage when we suspect a high-risk condition with messaging to encourage the member to call his or her Primary Care Provider (PCP) and schedule an annual checkup. The goal is to get the members to have a visit with their PCPs, so the PCPs have an overall picture of their patients’ health and schedule any screenings that may be needed. Telehealth visits have become very flexible formats for patients and doctors to meet, so we encourage telehealth visits to be scheduled if that is what the patient is most comfortable with at this time.
We will continue these monthly postcard mailings throughout the remainder of 2020 to encourage the members to schedule an annual checkup, which supplements any patient outreach you may be doing.
If you have any questions regarding our reporting processes, please contact the CRA Network Education Representative: Alicia.Estrada@anthem.com.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Custom Learning Center in the Availity portal offers an array of learning opportunities where you can access required training, recommended/elective trainings and view additional learning resources. Access to the Custom Learning Center is via Payer Spaces in the Availity Portal.
Highlights of the Custom Learning Center
- All the learning is in one place
- You can filter topics of interest
- View all your completed training
- Course resources may include links to a job aid
Your required courses are easily accessible and the available content is specific to your region. You may track your accomplishments, and view or download your training history via the Custom Learning Center Dashboard.
Select Access Your Custom Learning Center from the Applications tab in Payer Spaces.
Examples of trainings offered in the Custom Learning Center:
- Authorizations
- Coding and Documentation
- Claims and Payments
- Recommended administrative support courses
In addition, illustrated reference guides are located on Custom Learning Center - Resources. Select Resources from the menu located on the upper left corner of the screen. Usually, you may download or print reference guide materials.
Current Reference Guide topics include:
- Interactive Care Reviewer – Request Appeals Reference Guide
- Interactive Care Reviewer – Inquiries Reference Guide
- Patient 360 Navigation
- Remittance Inquiry Tips
Be sure to visit the Custom Learning Center in the Availity Portal often. New content is regularly added to the site.
For questions regarding the Availity Portal, please contact Availity Client Services at 1-800-282-4548.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Atypical providers may now utilize the Claims Status Listing and Remittance Inquiry tools on www.Availity.com, Payer Spaces using a State Medicaid ID.
The Remittance Inquiry tool has been updated to allow atypical providers to search for remittances using the date range search option. Enhancements to the claims status-listing tool, allows atypical providers to view a list of claims. Both tools now have a State Medicaid ID search capability.
How to access the tool:
From the Availity home page, select Payer Spaces > Empire BlueCross BlueShield > payer tile > Applications. Choose the tool you want to proceed with, Claims Status Listing or Remittance Inquiry, followed by the organization name > TIN
Claim Status Listing:
- Choose your provider from the Express Entry drop down box. *If the selected provider has been designated as atypical, the NPI field will gray out and the Payer Assigned Provider Identifier (State Medicaid ID) field will be populated
- Enter Dates of Service (DOS) to search (a 30 day date span can be searched at one time) > select Search
- View a list of your claims that fall within the search criteria entered
Remittance Inquiry
- Choose your provider from the Express Entry drop down box. *If the selected provider has been designated as atypical, the NPI field will gray out and the Payer Assigned Provider Identifier (State Medicaid ID) field will be populated
- Enter Dates of Service (DOS) to search (a 7 day date span can be searched at one time) > Select Search
- View a list of your remittances that fall within the search criteria entered
*Note: A provider must first be designated as atypical through the Express Entry process.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective July 1, 2020, we will begin using the new acute viral illness guidelines that have been added to the 24th edition of MCG. Based on the presenting symptoms or required interventions driving the need for treatment or hospitalization, these guidelines are not a substantive or material change to existing MCG guidelines we use now, such as systemic or infectious condition, pulmonary disease, or adult or pediatric pneumonia guidelines.
Inpatient & Surgical Care (ISC)
- Viral Illness, Acute – Inpatient Adult (M-280)
- Viral Illness, Acute – Inpatient Pediatric (P-280)
- Viral Illness, Acute – Observation Care (OC-064)
Recovery Facility Care (RFC)
- Viral Illness, Acute – Recovery Facility Care (M-5280)
For questions, please contact the provider service number on the back of the member's ID card.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The County of Suffolk (EMHP of Suffolk County) has limited their lab networks to non-hospital based participating laboratories such as LabCorp and Quest for all of their membership.
Any lab claim being sent from an office setting or an Urgent Care Facility should be sent to LabCorp or Quest when the Suffolk County prefix of “CDK” or “SUF” is present. The exception to this is when a patient is in an Outpatient or Inpatient at a hospital facility.
If you have any questions, please call 1-800-939-7515.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (“Empire”) is required by the State of New York to ensure that we are publishing accurate directory information for our members in both our on-line and paper provider directories. However, this information is only as good as what you, our physicians and practitioners provide.
In the past Empire conducted an annual verification of your demographic and participation information by either fax or roster via email and we asked that you reply confirming the information was correct or needs correction. In order to lessen the administrative burden, Empire has changed the process.
We will continue to send your office the demographic and participation information we have on file for each location. However, effective July 1st, 2020 this information will be sent to you quarterly, but if there are no changes, you do not have to reply. You need only respond with changes.
If you received a fax and need to add a new office location(s) and/or any other additional demographic changes that are not on this form, complete the Provider Maintenance Form, which can be located by navigating to www.availity.com> Payer Spaces > Empire BlueCross BlueShield > Resources > Empire BCBS Provider Maintenance Form
If your office received a roster, there is a separate tab where any additional offices can be added.
Again, please note that even though you will receive the data quarterly, no response will constitute no changes and we will continue to display the current information in our system in the online Provider Directory.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield’s (“Empire”) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health (AIM), a separate company.
The following Clinical Criteria documents were endorsed at the May 15, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.
Revised Clinical Criteria effective May 28, 2020
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0031 Intravitreal Corticosteroid Implants
Revised Clinical Criteria effective June 15, 2020
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0042 Monoclonal Antibodies to Interleukin-17
- ING-CC-0092 Adcetris (brentuximab)
- ING-CC-0098 Doxorubicin Hydrochloride Liposome
- ING-CC-0099 Abraxane (paclitaxel, protein bound)
- ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
- ING-CC-0111 Nplate (romiplostim)
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0127 Darzalex (daratumumab)
- ING-CC-0128 Tecentriq (atezolizumab)
Revised Clinical Criteria effective June 15, 2020
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0045 Increlex (mecasermin)
- ING-CC-0069 Egrifta (tesamorelin)
- ING-CC-0114 Jevtana (cabazitaxel)
- ING-CC-0116 Bendamustine agents
- ING-CC-0119 Yervoy (ipilimumab)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0137 Cablivi (caplacizumab-yhdp)
- ING-CC-0142 Somatuline Depot (lanreotide)
- ING-CC-0143 Polivy (polatuzumab vedotin-piiq)
- ING-CC-0145 Libtayo (cemiplimab-rwlc)
- ING-CC-0151 Yescarta (axicabtagene ciloleucel)
Revised Clinical Criteria effective July 1, 2020
The following clinical criteria were updated with CPT/HCPCS procedure code updates.
- ING-CC-0006 Hyaluronan Injections
- ING-CC-0062 Tumor Necrosis Factor Antagonists
- ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease
- ING-CC-0075 Rituximab Agents for Non-Oncology Indications
- ING-CC-0154 Givlaari (givosiran)
Revised Clinical Criteria effective October 1, 2020
The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0002 Colony Stimulating Factor Agents
- ING-CC-0003 Immunoglobulins
- ING-CC-0032 Botulinum Toxin
- ING-CC-0044 Exondys 51 (eteplirsen)
- ING-CC-0057 Krystexxa (pegloticase)
- ING-CC-0068 Growth hormone
- ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
- ING-CC-0098 Doxorubicin Hydrochloride Liposome
- ING-CC-0099 Abraxane (paclitaxel, protein bound)
- ING-CC-0105 Vectibix (panitumumab)
- ING-CC-0106 Erbitux (cetuximab)
- ING-CC-0107 Bevacizumab for Non-Ophthalmologic Indications
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0128 Tecentriq (atezolizumab)
- ING-CC-0134 Provenge (sipuleucel-T)
- ING-CC-0152 Vyondys 53 (golodirsen)
- ING-CC-0153 Adakveo (crizanlizumab)
New Clinical Criteria effective October 1, 2020
The following clinical criteria are new.
- ING-CC-0162 Tepezza (teprotumumab-trbw)
- ING-CC-0163 Durysta (bimatoprost implant)
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. These updates list the new and/or revised Empire BlueCross BlueShield (“Empire”) medical policies, clinical guidelines and reimbursement policies*. The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised medical policy, clinical guideline or reimbursement policy is effective for all claims processed on and after the specified implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the changes. If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.
Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates that may have been issued by Empire. Please include this update with your Provider Manual for future reference.
Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Empire’s medical policies and clinical guidelines can be found at empireblue.com.
*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.
Medical Policy Updates
Revised Medical Policies Effective 06-13-2020
(The following policies were revised to expand medical necessity indications or criteria.)
- DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting
- DME.00034 - Standing Frames
- SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
- SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
Revised Medical Policies Effective 07-01-2020
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- GENE.00010 - Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
- MED.00129 - Gene Therapy for Spinal Muscular Atrophy
- SURG.00010 - Treatments for Urinary Incontinence
- SURG.00126 - Irreversible Electroporation
Revised Medical Policies Effective 07-01-2020
(The following policies were updated with CPT/HCPCS procedure code updates.)
- GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
- LAB.00011 - Analysis of Proteomic Patterns
- SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
- SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
Archived Medical Policy Effective 07-08-2020
(The following policy has been archived and its content has been transferred to an existing Medical Policy.)
- TRANS.00036 - Stem Cell Therapy for Peripheral Vascular Disease [Note: Content transferred to TRANS.00035 Other Stem Cell Therapy]
Revised Medical Policy Effective 07-08-2020
(The following policy was revised to expand medical necessity indications or criteria.)
- MED.00004 - Technologies for the Evaluation of Skin Lesions (Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
Revised Medical Policies Effective 07-08-2020
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ADMIN.00002 - Preventive Health Guidelines
- ADMIN.00004 - Medical Necessity Criteria
- ADMIN.00005 - Investigational Criteria
- ADMIN.00007 - Immunizations
- ANC.00006 - Biomagnetic Therapy
- DME.00024 – Transtympanic Micropressure for Treatment of Ménière’s Disease
- DME.00030 – Altered Auditory Feedback Devices for the Treatment of Stuttering
- DME.00037 – Cooling Devices and Combined Cooling/Heating Devices
- DME.00038 – Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
- DME.00039 – Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
- GENE.00041 – Genetic Testing to Confirm the Identity of Laboratory Specimens
- GENE.00051 – Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer
- LAB.00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
- LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
- LAB.00031 - Advanced Lipoprotein Testing
- LAB.00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
- LAB.00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
- MED.00004 - Technologies for the Evaluation of Skin Lesions (Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
- MED.00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
- MED.00098 - Hyperoxemic Reperfusion Therapy
- MED.00127 - Chelation Therapy
- OR-PR.00005 - Upper Extremity Myoelectric Orthoses
- OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
- RAD.00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy)
- RAD.00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
- SURG.00005 - Partial Left Ventriculectomy
- SURG.00045 - Extracorporeal Shock Wave Therapy
- SURG.00071 - Percutaneous and Endoscopic Spinal Surgery
- SURG.00076 - Nerve Graft after Prostatectomy
- SURG.00077 - Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
- SURG.00084 - Implantable Middle Ear Hearing Aids
- SURG.00105 - Bicompartmental Knee Arthroplasty
- SURG.00111 - Axial Lumbar Interbody Fusion
- SURG.00116 - High Resolution Anoscopy Screening for Anal Intrathelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
- SURG.00118 - Bronchial Thermoplasty
- SURG.00120 - Internal Rib Fixation Systems
- SURG.00121 - Transcatheter Heart Valve Procedures
- SURG.00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
- SURG.00134 - Interspinous Process Fixation Devices
- SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
- SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
- SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
- TRANS.00035 - Other Stem Cell Therapy [Note: Content of TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease has been moved to this Medical Policy.]
New Medical Policy Effective 10-01-2020
(The policy below was created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- MED.00133 - Ingestion Event Monitors
Revised Medical Policies Effective 10-01-2020
(The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- GENE.00007 - Cardiac Ion Channel Genetic Testing
- GENE.00017 - Genetic Testing for Diagnosis of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
- GENE.00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome
- GENE.00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
- SURG.00007 – Vagus Nerve Stimulation
New Medical Policies Effective 10-03-2020
(The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- DME.00042 - Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
- MED.00131 – Electronic Home Visual Field Monitoring
Revised Medical Policies Effective 10-03-2020
(The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
- MED.00004 - Technologies for the Evaluation of Skin Lesions (Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
Revised Medical Policies Effective 10-17-2020
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ANC.00007 - Cosmetic and Reconstructive Services: Skin Related [Note: Moved information addressing dermal fillers, collagen injections and hyaluronic acid gel products to new policy MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures]
- MED.00110 - Silver-based Products and Autologous Skin-, Blood- or Bone Marrow-derived Products for Wound and Soft Tissue Applications [Note: Moved information addressing autologous adipose-derived regenerative cell therapy to new policy MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures]
- SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting [Note: Moved HCPCS codes C1878 and L8607 for soft tissue fillers to new policy MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures]
New Medical Policies Effective 10-17-2020
(The policies below were created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- MED.00132 - Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures [Note: Content related to dermal fillers, collagen injections and hyaluronic acid gel products moved from ANC.00007 Cosmetic and Reconstructive Services: Skin Related; content for autologous adipose-derived regenerative cell therapy (for example, Lipogems) moved from MED.00110; and HCPCS codes C1878 and L8607 for soft tissue fillers moved from SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting]
- THER-RAD.00012 - Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
Clinical Guideline Updates
Revised Clinical Guidelines Effective 06-13-2020
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
- CG-MED-77 - SPECT/CT Fusion Imaging
Revised Clinical Guideline Effective 07-01-2020
(The following adopted guideline was reviewed and had no significant changes to the policy position or criteria.)
- CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome
Revised Clinical Guideline Effective 07-01-2020
(The following adopted clinical guideline was updated with CPT/HCPCS procedure code updates.)
- CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions
Revised Clinical Guidelines Effective 07-08-2020
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-DME-45 - Ultrasound Bone Growth Stimulation
- CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
- CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
- CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults
- CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
- CG-MED-76 - Magnetic Source Imaging and Magnetoencephalography
- CG-MED-83 - Level of Care: Specialty Pharmaceuticals
- CG-REHAB-11 - Cognitive Rehabilitation
- CG-SURG-05 - Maze Procedure
- CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
- CG-SURG-12 - Penile Prosthesis Implantation
- CG-SURG-34 - Diagnostic Infertility Surgery
- CG-SURG-35 - Intracytoplasmic Sperm Injection (ICSI)
- CG-SURG-50 - Assistant Surgeons
- CG-SURG-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
- CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants
- CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
- CG-SURG-84 - Mandibular/Maxillary (Orthognathic) Surgery
- CG-SURG-85 - Hip Resurfacing
- CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
- CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
- CG-SURG-88 - Mastectomy for Gynecomastia
- CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
- CG-SURG-101 - Ablative Techniques as a Treatment for Barrett’s Esophagus
- CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation
Revised Clinical Guidelines Effective 10-01-2020
(The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary.)
- CG-GENE-02 - Analysis of RAS Status
- CG-GENE-13 - Genetic Testing for Inherited Diseases
- CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
- CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation)
Revised Clinical Guidelines Effective 10-17-2020
(The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary.)
- CG-DME-46 - Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
- CG-MED-68 - Therapeutic Apheresis
- CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
Coding Updates
As a result of coding updates in the claims system, the claim system edits for the clinical guideline listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary determination.
Effective October 17, 2020, we will be implementing coding updates in the claims system for the following clinical guideline listed below which may result in not medically necessary determinations for certain services.
- CG-SURG-106 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As you know, AIM Specialty Health ® (AIM) administers the musculoskeletal program, which includes the medical necessity review of certain surgeries of the spine and joints and interventional pain treatment. For certain surgeries, the review also includes a consideration of the level of care for Commercial fully insured Empire BlueCross BlueShield (“Empire”) members and some ASO groups.
According to the clinical criteria for level of care, which is based on clinical evidence as outlined in the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures, it is generally appropriate to perform joint codes (CPT codes 27130, 29871, 29892) and 4 spine codes (CPT codes 22633, 22634, 63265 and 63267) in an hospital outpatient setting. To avoid additional clinical review for these procedures, providers requesting prior authorization, should either choose “hospital observation” admission as the site of service or Hospital Outpatient Department (HOPD). If the provider determines that an inpatient stay is necessary due to post-operative care requirements, they can initiate a concurrent review request for inpatient admission with the health plan by contacting the number on the back of the member ID card.
Total hip arthroplasty (CPT code 27130) is currently reviewed for medical necessity and level of care. Effective October 1, 2020, 4 spine codes (CPT codes 22633, 22634, 63265 and 63267) and 2 joint codes (29871 and 29892) will be incorporated into the AIM Level of Care Guideline for Musculoskeletal Surgery and Procedures. We will review requests for inpatient admission and will require the provider to substantiate the medical necessity of the inpatient setting with proper medical documentation that demonstrates one of the following:
- Current postoperative care requirements are of such an intensity and/or duration that they cannot be met in an observation or outpatient surgical setting.
- Anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk.
Peer to peer conversations are available to a provider at any time to discuss the applicable clinical criteria and to provide information about the circumstances of a specific member.
Providers should continue to submit pre-service review requests to AIM using one of the following ways:
- Access AIM ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Portal at availity.com
- Call the AIM toll-free number at 1-877-430-2288, Monday through Friday 8:00 am – 6:00 pm ET.
For questions, please contact the provider number on the back of the member ID card.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. We all want to reduce unnecessary contacts and coordinate excellent quality of care for your patients, our members. To help expedite claims payment, all FEP member days of care will need to be certified. We will also assist you in discharge planning/case management services in order to help provide optimal patient outcomes.
How do we accomplish those activities while minimizing your time involvement?
Initial admission review process
Contact us by phone at 1-800-860-2156 or electronically through Empire’s online inpatient review system for providers.
Whether you call us or electronically submit information to Empire’s FEP Medical Management Department to report an inpatient admission, once we certify the admission we’ll provide an initial length of stay determination.. At that time, we will also request the discharge planner’s name and phone number to help facilitate discharge planning/case management,
Next steps after initial admission approval
After you receive initial admission approval, you will need to call:
- With a discharge date if it falls within initial length of stay period OR
- If the patient stays one or more days or longer than the initial length of stay approved – we require updated clinical information for review and for approval of any subsequent length of stay decisions.
- We will also need an update on any discharge plans.
Working together
The Empire FEP Medical Management Department is committed to working with you and look for opportunities to coordinate the patient’s benefits and discharge plans. Please feel free to contact the Empire FEP UM team members for assistance at 1-800-860-2156.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Prior authorization updates
Effective for dates of service on and after October 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Please note, inclusion of NDC code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
To access the Clinical Criteria information please click here.
Empire BlueCross BlueShield’s (“Empire”) prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
ING-CC-0038
|
J3110
|
Bonsity
|
|
ING-CC-0162
|
J3490
J3590
|
Tepezza
|
|
ING-CC-0163
|
J3490
C9399
|
Durysta
|
Step therapy updates
Effective for dates of service on and after October 1, 2020, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
To access the Clinical Criteria information with step therapy(ies), please click here.
Empire’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team.
|
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS Codes
|
|
ING-CC-0072
|
Preferred
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Avastin
|
J9035, C9257
|
|
ING-CC-0072
|
Preferred
|
Mvasi
|
Q5107
|
|
ING-CC-0072
|
Preferred
|
Zirabev
|
Q5118
|
|
ING-CC-0072
|
Preferred
|
Eylea
|
J0178
|
|
ING-CC-0072
|
Non-preferred
|
Lucentis
|
J2778
|
|
ING-CC-0072
|
Non-preferred
|
Macugen
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J2503
|
|
ING-CC-0072
|
Non-preferred
|
Beovu
|
J0179
|
CORRECTION: June 2020 step therapy update on clinical criteria ING-CC-0003:
Panzyga has been non-preferred for ING-CC 0003 since 2018. In the June 2020 Provider News edition, we published information regarding Panzyga to be effective 9/1/2020. This was published in error.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning July 1, 2020, most of Empire BlueCross BlueShield’s (“Empire”) ACA-complaint non-grandfathered health plans will cover pre-exposure prophylaxis (PrEP) medication at 100% with no member cost share, when used for prevention of HIV and dispensed at an in-network pharmacy with a prescription.
Since medications used for PrEP can also be used to treat HIV, Empire will review medical and pharmacy claims data to determine if a member has been diagnosed and prescribed treatment for HIV or prescribed PrEP for preventive purposes. When prescribed for prevention of HIV, this drug is covered with no member cost share. When prescribed for treatment of HIV, member cost shares apply based on the member’s benefit plan. Coverage includes Truvada (200- 300 mg), and its generic components, Emtriva 200mg and tenofovir 300mg. When medically necessary, a prior authorization process is available for Descovy to be covered with no member cost share when used for prevention of HIV.
Providers can contact the provider service number on the back of the member ID card to determine if a member’s plan includes this benefit.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On March 30, 2020, we introduced the Interactive Care Reviewer (ICR) — a self-service prior authorization (PA) tool that will improve the efficiency of your authorization process for Empire BlueCross BlueShield HealthPlus members. ICR offers a streamlined process to request and check the status of medical and behavioral health inpatient and outpatient procedures. You can easily access ICR through the Availity Portal.*
What benefits/efficiencies does the ICR provide?
- You can determine if PA is needed. For most requests, when you enter patient, service and provider details, you will receive a message indicating whether review is required.
- You receive a comprehensive view of all your PA requests. You have a complete view of all the utilization management requests you submitted online, including the status of your requests and specific views that provide case updates and a copy of associated letters.
- You will have inquiry capability. Ordering and servicing physicians and facilities can locate information on PA requests for those with which they are affiliated; this includes requests previously submitted via phone, fax and ICR.
- You have the ability to request and check the status of clinical appeals. You can use ICR to request a clinical appeal for denied authorizations and access letters associated with the appeal.
- ICR reduces the need to fax. ICR allows text detail as well as images to be submitted along with the request.
- There is no additional cost to you. ICR is a no-cost solution that’s easy to learn and even easier to use.
Follow these instructions to access ICR through the Availity Portal
First, ask your Availity administrator to grant you the appropriate role assignment.
Do you create and submit PA requests?
Required role assignment: Authorization and Referral Request
Do you check the status of the case or results of the authorization request?
Required role assignment: Authorization and Referral Inquiry
Once you have the authorization role assignment, log in to Availity with your unique user ID and password and follow these steps:
- Select Patient Registration from Availity’s home page.
- Select Authorizations & Referrals.
- Select either Authorizations for requests or Auth/Referral Inquiry for inquiries.
Monthly ICR training
Register for one of our free webinars created to familiarize new users with ICR features and navigation. Registration link: https://anthemincub.webex.com/anthemincub/onstage/
g.php?PRID=aa5396352099172976c26a64eacbad6f
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (Empire) is offering Special Needs Plans (SNPs) to people eligible for both Medicare and Medicaid benefits or who are qualified Medicare Advantage beneficiaries. SNPs provide enhanced benefits to people eligible for both Medicare and Medicaid. These include supplemental benefits such as hearing, dental, vision and transportation to medical appointments. Some SNP plans include a card or catalog for purchasing over-the-counter items. SNPs do not charge premiums.
SNP members under Empire benefit from a model of care that is used to assess needs and coordinate care. Within 90 days of enrollment and annually thereafter, each member receives a comprehensive health risk assessment (HRA) that covers physical, behavioral and functional needs, and a comprehensive medication review. The HRA is used to create a member Care Plan. Members with multiple or complex conditions are assigned a health plan case manager.
SNP HRAs, Care Plans and case managers support members and their providers by helping to identify and escalate potential problems for early intervention, ensuring appropriate and timely follow-up appointments, and providing navigation and coordination of services across Medicare and Medicaid programs.
Provider training required
Providers contracted for SNP plans are required to complete an annual training to stay up-to-date with plan benefits and requirements, including details on coordination of care and model of care elements. Every provider contracted for SNP is required to complete an attestation, which states they have completed their annual training. These attestations are located at the end of the self-paced training document.
To take the self-paced training, go to the Model of Care Provider Training link on the Availity Portal.*
How to access the Custom Learning Center on the Availity Portal
- Log in to the Availity Portal.
- At the top of Availity Portal, select Payer Spaces and select the appropriate payer.
- On the Payer Spaces landing page, select Access Your Custom Learning Center from Applications.
- In the Custom Learning Center, select Required Training.
- Select Special Needs Plan and Model of Care Overview.
- Select Enroll.
- Select Start.
- Once the course is completed, select Attestation and complete.
Not registered for Availity?
Have your organization’s designated administrator register your organization for Availity.
- Visit https://www.availity.com to register.
- Select Register.
- Select your organization type.
- In the Registration wizard, follow the prompts to complete the registration for your organization.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (Empire) is proud to offer the 2020 Optum* In-Office Assessment (IOA) Program, formerly known as the Healthcare Quality Patient Assessment Form/Patient Assessment Form (HQPAF/PAF) program. The name change reflects significant advancements in technology over the past few years, evolving from a paper form-based program to a program that securely exchanges clinical information digitally through multiple digital modalities.
If you are interested in learning about the electronic modalities available, please contact your Optum representative or the Optum Provider Support Center at 1-877-751-9207 from 8 a.m. to 7 p.m. Eastern time, Monday through Friday.
The IOA Program is designed to help participating providers ensure chronic conditions are addressed and documented to the highest level of specificity at least once per calendar year for all of our participating Medicare Advantage plan members. The IOA Program is designed to help overall patient quality of care (preventive medicine screening, chronic illness management and trifurcation of prescriptions for monitoring of high-risk medications and medication adherence) and care for older adults when generated for a Special Needs Plan (SNP) member.
Success stories
Below are some achievements Optum has accomplished with provider groups through the IOA Program:
- As a result of incorporating technology and/or different types of resources offered under the IOA Program, numerous provider offices demonstrated an increase in productivity, documentation and coding accuracy.
- Providers have taken advantage of the IOA Program resources to help alleviate some of the burden for their staff and office resources.
COVID-19 update
Empire knows this is a difficult time for everyone. We will continue to adapt and evolve our practices to fully address the changing dynamics of these unprecedented events. Empire is following the CDC guidelines on social distancing; thus, all nonessential IOA Program personal are to work telephonically/electronically with the provider groups until further notice.
Dates and tips to remember:
- Empire strongly encourages participating providers to review their patient population as soon as possible. This will help get patients scheduled for an appointment if they have not already scheduled an in-office visit. This will also help the provider manage chronic conditions, which impact the health status of the patient.
- At the conclusion of each office visit with a patient, providers participating in the IOA Program are asked to complete and return an In-Office Assessment The form should be completed based on information regarding the patient’s health collected during the office visit. Participating providers may continue to use the 2020 version of the In-Office Assessment form for encounters that take place on or before December 31, 2020. Empire will accept the 2020 version of the form for 2020 encounters until midnight January 31, 2021.
- Participating providers are required to submit an Account Setup Form, W9 and completed direct deposit enrollment by March 31, 2021. Participating providers should call 1-877-751-9207 if they have any questions regarding this requirement. Participating providers who fail to comply with this requirement will result in forfeiture of the provider payment for submitted 2020 In-Office Assessment forms if applicable.
If you have any questions regarding the IOA Program, please call Optum at 1-877-751-9207, Monday through Friday from 9:30 a.m. to 7:30 p.m. Eastern time.
* Optum is an independent company providing medical chart review services on behalf of Empire BlueCross BlueShield.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On November 15, 2019, and February 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield (Empire). These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the Empire provider website, and the effective dates will be reflected in the Clinical Criteria Web Posting February 2020. Visit Clinical Criteria to search for specific policies.
For questions or additional information, use this email.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. AIM Specialty Health ® (AIM) currently performs utilization management review for bilevel positive airway pressure (BiPAP) equipment and all associated supplies. Beginning July 1, 2020, the following codes will require prior authorization with Empire rather than with AIM.
Line of business: Individual Medicare Advantage, Group Retiree Solutions, and Medicare-Medicaid Plans
|
E0470
|
Respiratory assist device, bilevel pressure capability, without back-up rate feature, used with noninvasive interface, such as a nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
|
|
E0471
|
Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, such as a nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
|
AIM will continue to manage the supply codes for automatic positive airway pressure (APAP) and continuous positive airway pressure (CPAP) requests.
Empire will continue to follow the COVID-19 Public Health Emergency orders from CMS until the waivers no longer apply. If the Public Health Emergency Orders are no longer in place beginning July 1, 2020, the following codes will require prior authorization with Empire rather than with AIM when used in combination with the BiPAP codes above.
Precertification requests
Submit precertification requests via:
- Fax: 1-866-959-1537
- Phone: Please dial the customer service number on the back of the member’s card, identify yourself as a provider and follow the prompts to reach the correct precertification team. There are multiple prompts. Select the prompt that fits the description for the authorization you plan to request
- Web: Use the Availity Web Tool by following this link: https://apps.availity.com/availity/web/public.elegant.login
|
A4604
|
Tubing with heating element
|
|
A7046
|
Water chamber for humidifier, replacement, each
|
|
A7027
|
Combination Oral/Nasal Mask used with positive airway pressure device, each
|
|
A7030
|
Full Face Mask used with positive airway pressure device, each
|
|
A7031
|
Face Mask Cushion, Replacement for Full Face Mask
|
|
A7034
|
Nasal Interface (mask or cannula type), used with positive airway pressure device, with/without head strap
|
|
A7035
|
Headgear
|
|
A7036
|
Chinstrap
|
|
A7037
|
Tubing
|
|
A7039
|
Filter, non-disposable
|
|
A7044
|
Oral Interface for Positive Airway Pressure Therapy
|
|
A7045
|
Replacement Exhalation Port for PAP Therapy
|
|
A7028
|
Oral Cushion, Replacement for Combination Oral/Nasal Mask, each
|
|
A7029
|
Nasal Pillows, Replacement for Combination Oral/Nasal Mask, pair
|
|
A7032
|
Replacement Cushion for Nasal Application Device
|
|
A7033
|
Replacement Pillows for Nasal Application Device, pair
|
|
A7038
|
Filter, disposable
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In this coding spotlight, we will focus on several cardiovascular conditions; codes from Chapter 9 of the
ICD-10-CM are listed in the table below.
|
Diseases of the circulatory system
|
Category codes
|
|
Acute rheumatic fever
|
I00-I02
|
|
Chronic rheumatic heart diseases
|
I05-I09
|
|
Hypertensive diseases
|
I10-I16
|
|
Ischemic heart diseases
|
I20-I25
|
|
Pulmonary heart disease and diseases of pulmonary circulation
|
I26-I28
|
|
Other forms of heart disease
|
I30-I52
|
|
Cerebrovascular diseases
|
I60-I69
|
|
Diseases of arteries, arterioles and capillaries
|
I70-I79
|
|
Diseases of veins, lymphatic vessels and lymph nodes, not elsewhere classified
|
I80-I89
|
|
Other and unspecified disorders of the circulatory system
|
I95-I99
|
Hypertension
ICD-10-CM classifies hypertension by type as essential or primary (categories I10 to I13) and secondary (category I15).
Categories I10 to I13 classify primary hypertension according to a hierarchy of the disease from its vascular origin (I10) to the involvement of the heart (I11), chronic kidney disease (I12), or heart and chronic kidney disease combined (I13).1
Elevated blood pressure versus hypertension
A diagnosis of elevated blood pressure reading, without a diagnosis of hypertension, is assigned code R03.0. This code is never assigned on the basis of a blood pressure reading documented in the medical record; the physician must have specifically documented a diagnosis of elevated blood pressure.
The postoperative hypertension is classified as a complication of surgery, and code I97.3, postprocedural hypertension, is assigned. When the surgical patient has pre-existing hypertension, only codes from categories I10 to I13 are assigned.
Hypertensive heart disease
ICD-10-CM presumes a causal relationship between hypertension and heart involvement and classifies hypertension and heart conditions to category I11 — hypertensive heart disease — because the two conditions are linked by the term with in the alphabetic index of the ICD-10-CM. These conditions should be coded as related even in the absence of provider documentation linking them. First, code I11.0, hypertensive heart disease with heart failure as instructed by the note at category I50, heart failure. If the provider specifically documents different causes for the hypertension and the heart condition, then the heart condition (I50.-, II51.4-I51.9) and hypertension are coded separately.1
Other heart conditions that have an assumed causal connection to hypertensive heart disease
|
Code
|
Description
|
|
I51.4
|
Myocarditis, unspecified
|
|
I51.5
|
Myocardial degeneration
|
|
I51.7
|
Cardiomegaly
|
|
I51.81
|
Takotsubo syndrome
|
|
I51.89
|
Other ill-defined heart diseases
|
|
I51.9
|
Heart disease, unspecified
|
Hypertension, secondary
Two codes are required: one to identify the underlying etiology and one from category I15 to identify the hypertension. For example:
- Hypertension due to systemic lupus erythematosus, M32.10 + I15.8.
Hypertensive crisis
A code from category I16, hypertensive crisis, is assigned for any documented hypertensive urgency (I16.0), hypertensive emergency (I16.1), or unspecified hypertensive crisis (I16.9). Report two codes, at a minimum, for hypertensive crisis. The crisis code is reported in addition to the underlying hypertension code (I10-I15).1
Pulmonary hypertension
Pulmonary hypertension is classified to category I27, other pulmonary heart diseases. For secondary pulmonary hypertension (I27.1, I27.2-), any associated conditions or adverse effect of drugs or toxins should be coded.2
Ischemic heart disease
Category I25, chronic ischemic heart disease, includes coronary atherosclerosis, old myocardial infarction, coronary artery dissection, chronic coronary insufficiency, myocardial ischemia, and aneurysm of the heart.
ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are I25.11, atherosclerotic heart disease with angina pectoris and I25.7, atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris.
When using one of these combination codes, it is not necessary to use an additional code for angina pectoris. A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris, unless the documentation indicates that angina is due to a condition other than atherosclerosis.2
Heart failure
Systolic heart failure is coded as I50.2 and diastolic heart failure is coded as I50.3-; combined systolic and diastolic heart failure is assigned code I50.4. Fifth characters further specify whether the heart failure is unspecified, acute, chronic or acute on chronic.
Other classifications of heart failure include:
- Right heart failure, unspecified (I50.810)
- Acute right heart failure (I50.811)
- Chronic right heart failure (I50.812)
- Acute on chronic right heart failure (I50.813)
- Right heart failure due to left heart failure (I50.814)
- Biventricular heart failure (I50.82)
- High output heart failure (I50.83)
- End-stage heart failure (I50.84)
- Other heart failure (I50.89)
- Unspecified (I50.9)
For a diagnosis of left ventricular, biventricular and end-stage heart failure, two codes are required to completely describe the condition: one to report the left, biventricular or end-stage heart failure, and one to identify the type of heart failure.
Cardiomyopathy
Cardiomyopathy is coded as I42- with the third character describing:
- I42.0 Dilated cardiomyopathy, which includes congestive cardiomyopathy
- I42.1 Obstructive hypertrophic cardiomyopathy, including idiopathic hypertrophic subaortic stenosis
- I42.2 Other hypertrophic cardiomyopathy, including nonobstructive hypertrophic cardiomyopathy
- I42.3 Endomyocardial (eosinophilic) disease, including endomyocardial (tropical) fibrosis and Loffler’s endocarditis
- I42.4 Endocardial fibroelastosis, including congenital cardiomyopathy and elastomyofibrosis
- I42.5 Other restrictive cardiomyopathy, including constrictive cardiomyopathy not otherwise specified
- I42.6 Alcoholic cardiomyopathy due to alcohol consumption: a code for alcoholism (F10.-) is also assigned if present
- I42.7 Cardiomyopathy due to drug and external agent: code first the poisoning due to drug or toxin; if applicable (T36-T65 with fifth or sixth character 1-4 or 6); if the condition is caused by an adverse effect, use an additional code, if applicable, to identify the drug (T35-T50 with fifth or sixth character)
- I42.8 Other cardiomyopathies
- I42.9 Unspecified
Two codes may be required for cardiomyopathy due to other underlying conditions; for example, cardiomyopathy due to amyloidosis is coded E85.4, organ-limited amyloidosis, and I43, cardiomyopathy in diseases classified elsewhere. The underlying disease, amyloidosis, is sequenced first.2
Status Z codes
ICD-10-CM provides several Z codes to indicate that the patient has a health status related to the circulatory system, such as the following:
- Z94.1 Heart transplant status
- Z95.0 Presence of cardiac pacemaker
- Z95.1 Presence of aortocoronary bypass graft
- Z95.810 Presence of automatic (implantable) cardiac defibrillator
- Z95.811 Presence of heart assist device
- Z95.828 Presence of other vascular implants and grafts
These codes are assigned only as additional codes and are reportable only when the status affects the patient’s care for a given episode.
Resources
1 ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC. 2020.
2 ICD-10-CM/PCS Coding. Theory and practice. 2019/2020 Edition. Elsevier
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On March 30, 2020, we introduced the Interactive Care Reviewer (ICR) — a self-service prior authorization (PA) tool that will improve the efficiency of your authorization process for Empire BlueCross BlueShield HealthPlus members. ICR offers a streamlined process to request and check the status of medical and behavioral health inpatient and outpatient procedures. You can easily access ICR through the Availity Portal.*
What benefits/efficiencies does the ICR provide?
- You can determine if PA is needed. For most requests, when you enter patient, service and provider details, you will receive a message indicating whether review is required.
- You receive a comprehensive view of all your PA requests. You have a complete view of all the utilization management requests you submitted online, including the status of your requests and specific views that provide case updates and a copy of associated letters.
- You will have inquiry capability. Ordering and servicing physicians and facilities can locate information on PA requests for those with which they are affiliated; this includes requests previously submitted via phone, fax and ICR.
- You have the ability to request and check the status of clinical appeals. You can use ICR to request a clinical appeal for denied authorizations and access letters associated with the appeal.
- ICR reduces the need to fax. ICR allows text detail as well as images to be submitted along with the request.
- There is no additional cost to you. ICR is a no-cost solution that’s easy to learn and even easier to use.
Follow these instructions to access ICR through the Availity Portal
First, ask your Availity administrator to grant you the appropriate role assignment.
Do you create and submit PA requests?
Required role assignment: Authorization and Referral Request
Do you check the status of the case or results of the authorization request?
Required role assignment: Authorization and Referral Inquiry
Once you have the authorization role assignment, log in to Availity with your unique user ID and password and follow these steps:
- Select Patient Registration from Availity’s home page.
- Select Authorizations & Referrals.
- Select either Authorizations for requests or Auth/Referral Inquiry for inquiries.
Monthly ICR training
Register for one of our free webinars created to familiarize new users with ICR features and navigation. Registration link: https://anthemincub.webex.com/anthemincub/onstage/
g.php?PRID=aa5396352099172976c26a64eacbad6f
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On November 15, 2019, and February 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus. 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 February 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
|