Some professional (837P / HCFA-1500) claims for services rendered to non-Empire Blue plan members at retail health locations are being reported with a Place of Service that does not reflect a retail health clinic location. Specifically, for services rendered at a retail health location, some providers are submitting values for Office (11) or Urgent Care Facility (20) instead of the value of Walk-in Retail Health Clinic (17). Reporting Place of Service as 11 or 20 can cause claims to process incorrectly, and thus result in the need for claim adjustments and rework for providers.

 

If your practice is a Walk-in Retail Health Clinic, please remind your coding staff to report the most accurate Place of Service, Walk-in Retail Health Clinic (17), for professional claims when submitting claims for non-Empire members.

 

Billing of patient treatment can be complex, particularly when determining whether modifiers are required for proper payment.  Empire BlueCross BlueShield (“Empire”) reimbursement policy and correct coding guidelines establish the appropriate use of coding modifiers. We would like to highlight the appropriate use of some commonly used modifiers.

 

Things to remember…

• Review the “CPT Surgical Package Definition” found in the current year’s CPT Professional Edition.  Use modifiers such as 25 and 59 only when the services are not included in the surgical package.
• Review the current year’s CPT Professional Edition Appendix A - Modifiers for the appropriate use of modifiers 25, 57 and 59.
• When an evaluation and management (E/M) code is reported on the same date of service as a procedure, the use of the modifier 25 should be limited to situations where the E/M service is “above and beyond” or “separate and significant” from any procedures performed the same day.
• When appropriate, assign anatomical modifiers (Level II HCPCS modifiers) to identify different areas of the body that were treated. Proper application of the anatomical modifiers helps ensure the highest level of specificity on the claim and can help show that different anatomic sites received treatment.
• Use modifier 59 to indicate that a procedure or service was distinct or independent of other “non E/M services” performed on the same date of service. The modifier 59 represents services not normally performed together but which may be reported together under the circumstances.

 

If you feel that you have received a denial after applying a modifier appropriately under correct coding guidelines, please follow the normal claims dispute process and include medical records that support the usage of the modifiers when submitting claims for consideration.

We will be publishing additional articles on correct coding in upcoming newsletters.

 

Each year, Empire requests your assistance in our Commercial Risk Adjustment (CRA) Program. There are two distinct programs (Retrospective and Prospective) that work to improve risk adjustment accuracy and focus on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), in order to document and close the coding gaps. 

 

The CRA Program is specific to our Affordable Care Act (ACA) Members who have purchased our individual and small group health insurance plans on or off the Health Insurance Marketplace (commonly referred to as the exchange).

 

With our Retrospective Program we focus on medical chart collection.  We continue to request members’ medical records to obtain information required by the Centers for Medicare & Medicaid Services (CMS).  This particular effort is part of Empire’s compliance with provisions of the ACA that require our company to collect and report diagnosis code data for our ACA membership.  The members’ medical record documentation helps support this data requirement.

 

Analytics are performed internally on claims which do not have the ICD10 code for which we suspect a chronic condition.  These medical records will be requested, reviewed and any additional codes abstracted can be submitted to CMS to increase our risk score values.

 

Empire network providers -- may be PCPs, specialists, facilities, behavioral health, ancillary, etc. -- may receive letters from vendors such as Inovalon, Verscend, Ciox, Sharecare, and Episource requesting access to medical records for chart review.  These vendors are independent companies that provide secure, clinical documentation services and contact providers on our behalf. 

 

We ask that our network providers provide the medical record information to the designated vendor within 30 days of the request (by March 31, 2020).  While faxing remains our primary method for record retrieval, we offer many other electronic ways for providers to submit information.

 

Electronic options that may make medical chart collection easier for providers:

• EMR Interoperability
  • Allscripts (Opt in -- signature required to allow for remote review)
  • NextGen (Opt out -- auto-enrolled)
  • Athenahealth (Opt out -- auto-enrolled)
  • MEDENT
• Remote/Direct Empire access
• Vendor virtual or onsite visit
• Secure FTP

 

The goal of these electronic options is to both improve the medical record data extraction and the experience for Empire’s network-participating hospitals, clinics and physician offices.  If you are interested in this type of set up or any other remote access options, please contact our Commercial Risk Adjustment Network Education Representative: Alicia.Estrada@Empire.com.  

 

Thank you for your continued efforts with our CRA Program, and expediting these medical chart collection requests.  

 

Patient360 is a real time dashboard you can access through the Availity Portal that gives you a robust picture of your Empire BlueCross BlueShield (“Empire”) patient’s health and treatment history and will help you facilitate care coordination.

 

If an Empire patient has a Care Gap Alert your medical practice can locate Active Alerts on the Member Summary page of the Patient360 application.

 

What’s new:  Medical providers now have the option available on Patient360 to include feedback for each gap in care that is listed on the patient’s active alerts.

 

However, to be able to access the Care Gap Alert Feedback you will need to provide an individual NPI. If you select an NPI from Express Entry menu, the feedback options will not be available.

Once you have completed all the required fields you will land on the Member Summary page of the application. To provide feedback, select the Resolution Health Index (RHI) within the Active Alerts section. This will open the Care Gap Alert Feedback Entry screen. You can choose the feedback menu option that applies to your patient’s care gap.

 

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal.

First, you need to be assigned to the Patient360 Role which your Availity Administrators can locate within the Clinical Roles options.

 

Once you have the Availity role assignment, navigate to Patient360 through the Availity Portal by selecting the application on Empire Payer Spaces or by choosing the Patient360 link located on the patient’s benefits screen.

Members must be able to access their PCP 24 hours a day, 7 days a week. As the member's healthcare manager, the PCP is responsible for providing or arranging healthcare services on a 24/7 basis. (An answering machine does not suffice as access to the provider.) The PCP must also have a method to inform his or her Empire BlueCross BlueShield (“Empire”) members about regular office hours and how to obtain care after office hours. PCPs must proactively notify members in their care of any of the following changes: Tax ID, location/demographic and/or mergers/acquisitions, which may impact a member's PCP assignment.  This will allow member to contact Empire's member services team to mitigate any disruption in care.

 

Great news! Commercial Provider Communications would like to share some recent enhancements to the Commercial Provider News site:

 

• Article categories are now appearing directly under the article title in both the website and PDFs. Example below:

• PDFs for Individual Articles and Publications have been improved with a new look & feel for better readability and easier printing.

On April 1, 2017, the New York State Department of Health issued a revised version of the Provider Contract Guidelines for Article 44 MCOs, IPAs, and ACOs (“Provider Contract Guidelines”). According to the new Provider Contract Guidelines, managed care organizations must amend all existing participating provider agreements to include a new mandatory provision.  Therefore, your existing agreement with Empire HealthChoice HMO, Inc. (d/b/a Empire BlueCross BlueShield HMO or Empire BlueCross HMO) and Empire HealthChoice Assurance, Inc. (d/b/a Empire Blue Cross BlueShield or Empire BlueCross) (collectively, “Empire”) is hereby unilaterally amended effective immediately to replace the “Regulatory Approval” provision of your Agreement with the following: 

 

Regulatory Approval. To the extent Provider participates in Networks under this Agreement, which are subject to review by the New York State Department of Health, this Agreement is subject to the approval of the New York State Department of Health as to form. If this Agreement is implemented prior to such approval, the parties agree to incorporate into this Agreement any and all modifications required by the Department of Health for approval or, alternatively, to terminate this Agreement if so directed by the Department of Health. The "New York State Department of Health Standard Clauses for Managed Care Provider/IPA/ACO Contracts", attached to the Agreement as Attachment A, are expressly incorporated into this Agreement and are binding upon the Article 44 plans and providers that contract with such plans, and who are a party to this Agreement. In the event of any inconsistent or contrary language between the Standard Clauses and any other part of the Agreement, including but not limited to appendices, amendments, exhibits, the parties agree that the provisions of the Standard Clauses shall prevail, except to the extent applicable law requires otherwise and/or to the extent a provision of the Agreement exceeds the minimum requirements of the Standard Clauses.”

 

Please click here to view the new Standard Clauses Appendix . 

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

• Prior authorization requirements for CardioMEMS
• Benefits update for Special Supplemental Benefits for the Chronically Ill

(Policy 06-010, effective 05/01/2020)

 

Effective May 1, 2020, the following updates have been made to the policy:

• Empire BlueCross BlueShield (Empire) allows reimbursement to professional providers and facilities for multiple and bilateral surgery. Reimbursement is based on multiple and bilateral procedure rules in accordance with contracts and/or state guidelines for applicable surgical procedures performed on the same day by the same provider to the same patient.
• Empire also added language under the Multiple Surgery section to state that a single procedure will be subject to a multiple procedure reduction when submitted with multiple units.

 

Please visit www.empireblue.com/medicareprovider to view the Multiple and Bilateral Surgery reimbursement policy for additional information regarding percentages and reimbursement criteria.

 

EBSCRNU-0061-19 January 2020

504986MUPENMUB

This communication applies to the Medicaid and Medicare Advantage programs for Empire BlueCross BlueShield (Empire).

 

Empire provides benefits for covered services rendered by nurse practitioners (NPs) and physician assistants (PAs) when operating within the scope of their license. Our policy states that these mid-level practitioners are required to file claims using their specific NPI number — not that of the medical doctor.

 

We will continue to monitor this area of concern through medical chart review and data analysis. Billing noncompliance can be considered a contract breach.

 

Empire recognizes the quality of care delivered to our members can be improved by the proper use of NPs and PAs. This notice is in no way intended to discourage their proper use, but rather to clearly define how services should be appropriately billed.

 

Thank you for your continued participation. Should you have any questions, please call Provider Services:

• Medicaid: 1-800-450-8753
• Medicare Advantage: Call the number on the back of members’ ID cards.

 

NYE-NU-0191-19 January 2020

507411MUPENMUB

Beginning January 1, 2020, patients using nonpreferred products with a high patient cost share are now contacted about the availability of lower patient cost share preferred alternatives. If the patient is interested in switching, we will call or fax their provider who can determine whether the preferred alternative is clinically appropriate. This is strictly informational and not a substitute for physician‑directed medical evaluations or treatments.

 

A list of the included non-preferred products and corresponding preferred alternatives are listed here. 

 

Non-preferred products	Preferred alternative(s)
Aciphex DR	omeprazole pantoprazole
Actos	pioglitazone HCL
Advair Diskus	fluticasone-salmeterol Wixela Inhub
Aggrenox	aspirin-dipyridamole ER
Ampyra ER	dalfampridine ER
Breo Ellipta	fluticasone-salmeterol Wixela Inhub
Cambia	diclofenac sumatriptan
chlorzoxazone	cyclobenzaprine
Coumadin	warfarin
Crestor	rosuvastatin
Dexilant	omeprazole pantoprazole
Dilantin	phenytoin
Diovan HCT	valsartan/hydrochlorothiazide
Duexis	ibuprofen & famotidine
Dymista	fluticasone & azelastine
Epzicom	abacavir-lamivudine
Evzio	naloxone HCL
Farxiga	Jardiance
Gleevec	imatinib
Glumetza	metformin ER (generic Glucophage XR)
Incruse Ellipta	Spiriva
Invega	paliperidone ER
Invokana	Jardiance
Jublia	ciclopirox
Kerydin	ciclopirox
Kombiglyze	Janumet XR
Lamictal	lamotrigine
Lanoxin	digoxin
Lipitor	atorvastatin
Livalo	atorvastatin lovastatin pravastatin simvastatin
Lovaza	omega-3 acid ethyl esters
Mestinon	pyridostigmine
metformin ER (generic Glumetza)	metformin ER (generic Glucophage XR)
metformin ER OSM (generic Fortamet)	metformin ER (generic Glucophage XR)
Mirapex	pramipexole
Myrbetriq ER	oxybutynin
Nexium	omeprazole pantoprazole
Nilandron	nilutamide
Novolin N	Humulin N
Novolog	Humalog
omeprazole-bicarbonate	omeprazole pantoprazole
Onfi	clobazam
Onglyza	Januvia
Pennsaid	meloxicam
Protonix	omeprazole pantoprazole
Renvela	sevelamer
Requip	ropinirole
Restasis	Xiidra
Soolantra	metronidazole azelaic acid
Symbicort	fluticasone-salmeterol Wixela Inhub
Synthroid	levothyroxine
Tresiba	Basaglar Lantus Toujeo
Trokendi XR	topiramate
Tudorza Pressair	Spiriva
Vasotec	enalapril
Vimovo	naproxen & omeprazole
Wellbutrin XL	bupropion XL
Xalatan	latanoprost
Xenazine	tetrabenazine
Zestoretic	lisinopril/hydrochlorothiazide
Zestril	lisinopril
Zileuton ER	montelukast

 

EBSCRNU-0094-20 January 2020

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Please continue to check Medicaid Provider Communications & Updates at www.empireblue.com/nymedicaiddoc

for the latest Medicaid information, including:

• Revision to evaluation and management services — over-coded services postponed
• New specialty pharmacy medical step therapy requirements
• New specialty pharmacy medical injectable step therapy requirements

 

A change to CPT® codes for psychological and neuropsychological test administration and evaluation services was effective January 1, 2019.* The new codes do not crosswalk on a

one-to-one basis with the deleted codes.

 

These coding changes separate test administration from test evaluation, psychological testing evaluation from neuropsychological testing evaluation and define the testing performed by a professional or technician. The information below clarifies coding for these services.

 

Please note: Prior authorization (PA) requirements have not changed. Please check Precertification Look Up Tool for PA requirements for each code.

 

Neurobehavioral status exams

Neurobehavioral status exams are clinical interview examinations performed by a psychologist or neuropsychologist to assess thinking, reasoning and judgment.

 

Providers should continue to use CPT code 96116 when billing for the first hour.

 

Test administration and scoring by a psychologist or neuropsychologist

Two or more tests using any method should now be billed using CPT code 96136 for the first 30 minutes and 96137 for each additional 30 minutes.

 

Test administration and scoring by a technician

Two or more tests using any method should now be billed using CPT code 96138 for the first 30 minutes and 96139 for each additional 30 minutes.

 

Testing evaluation services 

Testing evaluation services include the selection of the appropriate tests to be administered; integration of patient data; interpretation of standardized test results and clinical data; clinical decision-making; treatment planning; and reporting and interactive feedback to the patient, family members, or caregivers (when performed). There are distinct testing evaluation service codes for psychological testing and for neuropsychological testing.

 

Providers should now use CPT code 96130 to bill for the first hour of psychological testing evaluation services and 96131 for each additional hour.

 

* American Psychological Association website: 2019 Psychological and Neuropsychological Testing Billing and Coding Guide: https://www.apa.org

 

Neuropsychological evaluation services should now be billed using CPT code 96132 for the first hour and 96133 for each additional hour.

 

Single automated test administration

Single automated test administration should be reported with newly created code 96146 for a single automated psychological or neuropsychological instrument that is administered via electronic platform and formulates an automated result. Psychologists should not use this code if two or more electronic tests are administered and/or if administration is performed by the professional or technician. Instead, the psychologist should use the appropriate codes listed above for test administration and scoring. A single automated test as the only service is not considered appropriate for the many elements seen with test evaluation.

 

Screening and risk assessment (repetitive assessment after screening)

Screening and risk assessment (repetitive assessment after screening) includes brief emotional/behavioral assessment (for example, a depression inventory or ADHD scale) with scoring and documentation, per standardized instrument. This should be billed using CPT code 96127 separately from testing. Brief emotional/behavioral assessments should not be billed as psychological or neuropsychological testing.

                                                                                                                                                                            

For questions, please call Provider Services at 1-800-450-8753.

 

NYE-NU-0184-19 January 2020

 

This communication applies to the Medicaid and Medicare Advantage programs for Empire BlueCross BlueShield (Empire).

 

Empire provides benefits for covered services rendered by nurse practitioners (NPs) and physician assistants (PAs) when operating within the scope of their license. Our policy states that these mid-level practitioners are required to file claims using their specific NPI number — not that of the medical doctor.

 

We will continue to monitor this area of concern through medical chart review and data analysis. Billing noncompliance can be considered a contract breach.

 

Empire recognizes the quality of care delivered to our members can be improved by the proper use of NPs and PAs. This notice is in no way intended to discourage their proper use, but rather to clearly define how services should be appropriately billed.

 

Thank you for your continued participation. Should you have any questions, please call Provider Services:

• Medicaid: 1-800-450-8753
• Medicare Advantage: Call the number on the back of members’ ID cards.

 

NYE-NU-0191-19 January 2020

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Code only confirmed cases

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

 

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

 

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

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

 

Testing for HIV:

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

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

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

 

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

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

 

HIV/AIDS prevention

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

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

 

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

three-year plan for 2017-2020 with the goal of one day achieving a future free of HIV.

 

Resources:

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

 

NYE-NU-0188-19 January 2020

 

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

 

Appropriate Testing for Pharyngitis (CWP)

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

 

Appropriate Treatment for Upper Respiratory Infection (URI)

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

 

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

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

 

Helpful tips:

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

 

Resources:

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

 

NYE-NU-0186-19 January 2020