 Provider News New YorkMay 2022 NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Change Healthcare will transition out of the post-payment hospital bill audit (HBA) program by the end of 2022. Effective immediately, Empire BlueCross BlueShield’s (“Empire”) complex and clinical audit (CCA) team will conduct the HBA program. For a short period of time, Change Healthcare may continue to contact you to finalize any work that is in process, or already scheduled.
Empire continues to work with Cotiviti as a post-payment DRG validation audit partner. Effective immediately, the Empire CCA team is assuming a larger role in conducting post-payment DRG validation audits and DRG readmission audits. In addition to receiving requests from Empire’s CCA team, network-participating providers may continue to receive letters from Cotiviti requesting access to medical records for the purpose of conducting these audits. We will do our best to avoid duplicate medical record requests from Empire and Cotiviti.
Thank you for your continued efforts to expedite medical record requests.
This notification applies to all lines of business and all markets. If you have questions about this notification, please contact the Provider Services call center.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The total economic cost of alcohol use disorder has been estimated to be $249 billion according to the Centers for Disease Control and Prevention (CDC) 1, $27 billion of which has been accounted for healthcare costs 2. The CDC projects the economic impact to society is about $807 per person, per year. 3
Alcohol use disorder also impacts the economy through work force disruptions caused by tardiness, absenteeism, employee turnover and conflict in the workplace. It causes a reduction in potential employees, customer and taxpayer bases.4
According to the CDC, alcohol use was directly tied to 95,000 deaths annually between 2011 and 2015. This was more than all illicit substances combined. The CDC estimates that alcohol-attributed disease resulted in almost 685,000 years of potential life lost for the same period.
This chart shows the years of potential life lost (YPLL) related directly or indirectly to alcohol use disorder:
|
Cause
|
YPLL
|
|
Total YPLL
|
>2.7 million
|
|
100% alcohol attributed disease
|
684,750
|
|
Suicide
|
334,058
|
|
Motor vehicle crashes
|
323,610
|
|
Liver disease
|
202,391
|
|
Heart disease
|
118,021
|
|
Cancer
|
88,729
|
If you need assistance connecting your patients to opioid, substance use or alcohol use disorder treatment, contact your Empire BlueCross BlueShield health plan.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. 
Many resources are available for health professionals to support hypertension prevention and management and educate others. To support that effort, the Centers for Disease Control and Prevention (CDC)’s Division for Heart Disease and Stroke Prevention has put together these sets of educational materials for health professionals and patients:
Visit the Million Hearts® website for more resources designed for health professionals. Million Hearts® is a national initiative co-led by CDC and the Centers for Medicare & Medicaid Services (CMS). Million Hearts® aims to prevent 1 million heart attacks and strokes within five years.
Measure Up: Controlling High Blood Pressure (CBP) HEDIS® measure
The HEDIS measure Controlling High Blood Pressure (CBP) assesses adults ages 18–85 with a diagnosis of hypertension and whose blood pressure was properly controlled based on the following criteria:
- Adults 18–59 years of age whose blood pressure was <140/90 mm Hg
- Adults 60–85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg
- Adults 60–85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg
Patient claims should include one systolic reading and one diastolic reading:
|
CPT II Code
|
Most recent systolic blood pressure
|
|
3074F
|
<130 mm Hg
|
|
3075F
|
130-139 mm Hg
|
|
3077F
|
≥ 140 mm Hg
|
|
CPT II Code
|
Most recent diastolic blood pressure
|
|
3078F
|
<80 mm Hg
|
|
3079F
|
80-89 mm Hg
|
|
3080F
|
≥ 90 mm Hg
|
When charting your patient’s blood pressure readings, in addition to the systolic and diastolic readings, and dates, if the patient has an elevated blood pressure, but does not have hypertension, note the reason for follow-up.
Additional tips for talking to patients:
- Continue to educate patients about the risks of hypertension
- Encourage weight loss, regular exercise and diet
- Advise patients who are smoking to quit
- Talk about chronic stress and ways to cope with it in a healthy way
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA)
Resource: Centers for Disease Control and Prevention. https://www.cdc.gov/bloodpressure/educational_materials.htm
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. We’ve heard it all our lives: To be fair, you should treat everybody the same. But the challenge is that everybody is not the same—and these differences can lead to critical disparities not only in how patients access health care, but their outcomes as well. The COVID-19 pandemic has reignited public attention about the serious public health risks and consequences of disparities, and the critical need for health equity.
Health equity means everyone has the opportunity to reach their highest level of health, and barriers to doing so must be removed. Health disparities are health differences that are closely linked with social, economic, and/or environmental disadvantage.1 Achieving health equity requires focus on the elimination of barriers and disparities associated with factors such as race, ethnicity, gender, gender identity, religion, socioeconomic status, disability, and even where you live.2 As a result, it is imperative to offer access to care that is tailored to the unique needs of patients, and Empire BlueCross BlueShield is committed to supporting our providers in this effort.
MyDiversePatients.com is where you can find resources, information, and techniques to help provide individualized care every patient deserves, regardless of their diverse backgrounds. There you can also find opportunities for free Continuing Medical Education (CME) credit for learning experiences on topics related to cultural competency and disparities. Mydiversepatients.com is free and accessible from any device (desktop computer, laptop, phone, or tablet) with no account or log in required. Scan the QR code below for direct access to mydiversepatients.com.
Stronger Together is a website where you can find free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created in collaboration with national organizations and are available for you to share with your patients and communities. Scan the QR code below for direct access to Stronger Together.
While there is no single, easy answer to address health care disparities, the vision of MyDiversePatients.com and Stronger Together is a start to reversing health care inequity one person at a time.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The annual PCP access studies performed by our vendor, North American Testing Organization based in California, were resumed and fielded in the third quarter of 2021. The purpose is to assess adequate appointment timeframes for our members with an urgent condition or for routine.
The main challenges the vendor encounters while attempting to collect this required, essential data are related to inaccurate provider information in Empire BlueCross BlueShield’s (“Empire”) demographic database, i.e., incorrect or non-working phone numbers, practitioner moved, retired, or deceased; the practice has resigned their Empire contract, accepts private pay only or is no longer in practice; as well as, staff refusing to participate in the survey. We ask that you update your office information using the online Provider Maintenance Form and that you participate in quality programs such as this critical survey as a condition of Empire’s contract.
Another item captured in the survey is open panel status for new patients. At the office level, we are capturing more closed panel data than is reflected in the provider directory for members. Please keep Empire abreast of the open/close panel status of your practice.
What does this mean for our members? If the directory indicates “open” and the practitioner is not available for new patients, the member is making multiple calls to select a primary care physician. Their experience is reflected in the annual CAHPS® member survey of Empire enrollees, which indicated “not open to new patients” as the number one reason throughout Empire plan’s for not getting a personal doctor.
To be compliant, per the provider manual, participating providers agree to meet the following access standards, whether in person or a telehealth visit:
- Urgent – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within twenty-four (24) hours.
- Explanation – These callers are experiencing a non-emergent condition or injury with acute symptoms that require immediate attention (without prior authorization).
- Routine – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within 10 business days.
- Explanation – A regular routine appointment is a non-symptom related visit for existing patients, such as a check-up, including physicals and chronic monitoring.
- Routine follow-up – The patient must meet with their Practitioner, another Practitioner in the practice or a covering Practitioner within 30 calendar days.
- Explanation – This is for an evaluation of progress or services, including, but not limited to, medication management. This includes new or existing patients.
Note to staff: It is imperative that your office updates any changes to your practice using the online Provider Maintenance Form on empireblue.com.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Submitting your updates in a timely manner helps to ensure we have the most current online provider directory information available to members. We ask that you review your information regularly and let us know as soon as possible if any of your information in our online provider directory has changed.
If updates are needed, you can use our Provider Maintenance Form.
Online update options include:
- add/change an address location
- name change
- tax ID changes
- provider leaving a group or a single location
- phone/fax number changes
- closing a practice location
Once you submit the Provider Maintenance Form, you will receive an email acknowledging receipt of your request. Visit the Provider Maintenance Form landing page for complete instructions.
The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. We appreciate your help in keeping our online provider directories current.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. These guidelines are developed to provide helpful information on how to report services to Empire BlueCross BlueShield for the administration and observation of the drug Spravato®.
Eskatamine is sold under the brand name Spravato® and is indicated for adults with treatment-resistant depression. Based on the prescribing information, patients who have the drug administered in the professional provider’s office should be monitored for 2 hours to assess for complications.
A main component in understanding how to report the administration of this drug is to identify whether the professional provider has purchased the drug for administration or whether the drug has been supplied and reported by a pharmacy. There are specific codes to report for each scenario:
Professional provider purchased and administered:
For professional providers that supply, administer, and provide the required observation of Spravato®, one of the following packaged service codes should be billed and should not include separate billing of the drug or the billing of the post-administration observation:
|
HCPCS Code
|
Description
|
|
G2082
|
Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
|
|
G2083
|
Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
|
Note: When Spravato® is being supplied by the outpatient hospital and administered in an outpatient hospital, the facility should bill G2082 and G2083 in conjunction with revenue center code (RCC) 919 and the drug should not be billed separately. In addition, there should not be a separate professional claim submitted as procedure codes G2082 and G2083 describe both the drug and the professional services.
Pharmacy supplied and professional provider administered:
When a pharmacy supplies Spravato® and is reporting this service in a separate claim, the drug should be billed with the HCPCS code, S0013 – Esketamine, nasal spray, 1 mg.
If the provider administering Spravato® did not purchase the drug, then the provider should not report the supply of the drug on their claim, as this will be reported by the pharmacy.
Post-administration observation:
When the provider does not bill a packaged service code (listed above), the professional provider may report an Evaluation and Management (E/M) service including the appropriate prolonged services code.
|
CPT Codes
|
Description
|
|
99202 - 99205
|
Office or other outpatient visit for the evaluation and management of a new patient
|
|
99212 - 99215
|
Office or other outpatient visit for the evaluation and management of an established patient
|
|
99417
|
Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes
|
In accordance with the American Medical Association’s (AMA’s) CPT® Manual, CPT code 99417 should only be billed when reported with CPT codes 99205 and 99215. Medical records must support coding. Please refer to Empire’s Prolonged Services – Professional Reimbursement Policy for additional information.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (“Empire”) is in the process of converting to a new reimbursement system called Commercial Outpatient Pricing Payment System (COPPS). We will be converting outpatient facility services to the system throughout 2022 and 2023 followed by all other contracted providers shortly thereafter. Make sure you avoid payment disruptions by converting to COPPS prior to us replacing the current system.
COPPS is heavily based on the CMS Outpatient Prospective Payment System (OPPS) and is the preferred commercial reimbursement system for hospitals and Ambulatory Surgery Center outpatient services. Therefore, moving to COPPS will keep our reimbursement system consistent with industry standards, allowing for greater efficiencies and more accurate and predictable pricing of outpatient services.
Other benefits of COPPS:
- Hospitals are already familiar with OPPS based reimbursement under Medicare, on which COPPS is based
- COPPS reimbursement more accurately reflects the resources used based on industry standards
- COPPS reimbursement eliminates an outdated Empire-specific system and promotes more consistent billing on outpatient services
- Hospitals will notice a decrease in audit activities under COPPS reimbursement
To ensure you have a seamless transition to COPPS, we’re taking a phased, multi-year approach that includes collaboration, education, and data transparency. Your Empire Contract Management Lead will soon begin discussions with you on COPPS conversion and what you need to know.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
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.
To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines.
Medical policy updates
Revised medical policy effective March 12, 2022
(The following policy was revised to expand medical necessity indications or criteria.)
- SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations
Revised medical policies effective April 1, 2022
(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)
- DME.00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
- GENE.00023 Gene Expression Profiling of Melanomas
- GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
- LAB.00036 Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
- SURG.00153 Cardiac Contractility Modulation Therapy
Revised medical policy effective April 1, 2022
(The following policy was revised to expand medical necessity indications or criteria.)
- SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
Revised medical policy effective April 1, 2022
(The following policy was reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
- LAB.00015 Detection of Circulating Tumor Cells
Archived medical policy effective April 13, 2022
(The following policy has been archived and its contents have been transferred to a new Medical Policy and to an existing Clinical UM Guideline.)
- GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease [Note: Content for biomarker testing for Alzheimer's Disease moved to new medical policy LAB.00046 Biochemical Markers for Alzheimer's Disease. Content for gene testing for Alzheimer's Disease moved to CG-GENE-13 Genetic Testing for Inherited Diseases.]
Transitioned medical policy effective April 13, 2022
(The following policy was previously in another medical policy and has no significant changes.)
- LAB.00046 Biochemical Markers for Alzheimer's Disease [Note: Moved content related to biomarker testing for Alzheimer’s disease (AD) from GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.]
Revised medical policy effective April 13, 2022
(The following policy was revised to expand medical necessity indications or criteria.)
- GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling [Note: Moved content for measurable residual disease testing to CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing]
Revised medical policies effective April 13, 2022
(The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
- ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
- DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
- DME.00032 Automated External Defibrillators for Home Use
- DME.00041 Low Intensity Therapeutic Ultrasound
- GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer
- GENE.00038 Genetic Testing for Statin-Induced Myopathy
- GENE.00050 Gene Expression Profiling for Coronary Artery Disease
- GENE.00054 Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer
- GENE.00056 Gene Expression Profiling for Bladder Cancer
- LAB.00025 Topographic Genotyping
- LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
- LAB.00038 Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
- LAB.00039 Pooled Antibiotic Sensitivity Testing
- MED.00011 Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
- MED.00024 Adoptive Immunotherapy and Cellular Therapy
- MED.00053 Non-Invasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient Setting
- MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- MED.00059 Idiopathic Environmental Illness (IEI)
- MED.00087 Optical Detection for Screening and Identification of Cervical Cancer
- MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
- MED.00102 Ultrafiltration in Decompensated Heart Failure
- MED.00104 Non-invasive Measurement of Advanced Glycation End Products (AGEs) in the Skin
- MED.00105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
- MED.00111 Intracardiac Ischemia Monitoring
- MED.00112 Autonomic Testing
- MED.00118 Continuous Monitoring of Intraocular Pressure
- MED.00120 Gene Therapy for Ocular Conditions
- MED.00125 Biofeedback and Neurofeedback
- RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
- RAD.00044 Magnetic Resonance Neurography
- RAD.00052 Positional MRI
- RAD.00059 Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver
- SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
- SURG.00053 Unicondylar Interpositional Spacer
- SURG.00056 Transanal Radiofrequency Treatment of Fecal Incontinence
- SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
- SURG.00070 Photocoagulation of Macular Drusen
- SURG.00072 Lysis of Epidural Adhesions
- SURG.00075 Intervertebral Stabilization Devices
- SURG.00089 Self-Expanding Absorptive Sinus Ostial Dilation
- SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
- SURG.00113 Artificial Retinal Devices
- SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
- SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency
- SURG.00137 Focused Microwave Thermotherapy for Breast Cancer
- SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
- SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain
- SURG.00148 Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
- SURG.00149 Percutaneous Ultrasonic Ablation of Soft Tissue
- SURG.00150 Leadless Pacemaker
- SURG.00151 Balloon Dilation of the Eustachian Tubes
- SURG.00152 Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
- SURG.00159 Focal Laser Ablation for the Treatment of Prostate Cancer
- TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
- TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation
- TRANS.00013 Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation
- TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
- TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
- TRANS.00037 Uterine Transplantation
Revised medical policy effective May 14, 2022
(The following policy was revised to expand medical necessity indications or criteria.)
- SURG.00096 Surgical and Ablative Treatments for Chronic Headaches
New medical policies effective August 1, 2022
(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.)
- LAB.00043 Immune Biomarker Tests for Cancer
- LAB.00044 Saliva-based Testing to Determine Drug-Metabolizer Status
- RAD.00067 Quantitative Ultrasound for Tissue Characterization
- TRANS.00038 Thymus Tissue Transplantation
New medical policies effective August 13, 2022
(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.)
- LAB.00045 Selected Tests for the Evaluation and Management of Infertility
- SURG.00160 Implanted Port Delivery Systems to Treat Ocular Disease
Revised medical policy effective August 13, 2022
(The policy below was revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- SURG.00154 Microsurgical Procedures for the Prevention or Treatment of Lymphedema
Clinical guideline updates
Revised clinical guideline effective March 12, 2022
(The following adopted guideline was revised to expand medical necessity indications or criteria.)
- CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
Revised clinical guidelines effective April 1, 2022
(The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)
- CG-DME-06 Compression Devices for Lymphedema
- CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
Archived clinical guidelines effective April 13, 2022
(The following adopted clinical guidelines have been archived and their contents have been transferred to existing Clinical UM Guidelines.)
- CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays [Note: Content moved to CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management]
- CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome [Note: Content moved to CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management]
- CG-GENE-09 Genetic Testing for CHARGE Syndrome [Note: Content moved to CG-GENE-13 Genetic Testing for Inherited Diseases]
Revised clinical guidelines effective April 13, 2022
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-GENE-13 Genetic Testing for Inherited Diseases [Note: Moved content of GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease and CG-GENE-09 Genetic Testing for CHARGE Syndrome into this document.]
- CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management [Note: Moved content of CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays and CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome into this document.]
- CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
Revised clinical guidelines effective April 13, 2022
(The following adopted guidelines were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)
- CG-GENE-07 BCR-ABL Mutation Analysis
- CG-GENE-16 BRCA Genetic Testing
- CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing [Note: Content for measurable residual disease testing moved from GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling into this document.]
- CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions
- CG-MED-26 Neonatal Levels of Care
- CG-MED-37 Intensive Programs for Pediatric Feeding Disorders
- CG-MED-68 Therapeutic Apheresis
- CG-MED-88 Preimplantation Genetic Diagnosis Testing
- CG-SURG-09 Temporomandibular Disorders
- CG-SURG-88 Mastectomy for Gynecomastia
- CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention
- CG-SURG-97 Cardioverter Defibrillators
- CG-SURG-99 Panniculectomy and Abdominoplasty
- CG-SURG-104 Intraoperative Neurophysiological Monitoring
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
- CG-TRANS-02 Kidney Transplantation
Unadopted Clinical Guidelines Effective May 1, 2022
(The criteria in the following guidelines will no longer be applied.)
- CG-MED-63 Treatment of Hyperhidrosis
- CG-MED-65 Manipulation Under Anesthesia
- CG-MED-76 Magnetic Source Imaging and Magnetoencephalography
- CG-SURG-05 Maze Procedure
- CG-SURG-28 Transcatheter Uterine Artery Embolization
- CG-SURG-34 Diagnostic Infertility Surgery
- CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
- CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
- CG-SURG-79 Implantable Infusion Pumps
- CG-SURG-86 Endovascular/ Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
- CG-SURG-94 Keratoprosthesis
- CG-SURG-104 Intraoperative Neurophysiological Monitoring
- CG-SURG-105 Corneal Collagen Cross-Linking
- CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
Revised clinical guideline effective August 1, 2022
(The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary.)
- CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management [Note: Moved content of CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays and CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome into this document effective April 13, 2022.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. 
Everything you need to know about using CPT II Codes
Preferred providers can receive incentives for using specific CPT II codes when filing claims.
CPT II codes are supplemental tracking codes that are used to measure quality performance.
Use these tracking codes to decrease the need for record submissions and chart reviews -
minimizing administrative burden on you and your healthcare teams.
FEP preferred providers can receive incentives for using specific CPT II codes, including blood pressure readings. Join us for a CPT II code webinar to learn more about filing CPT II codes to receive incentives.
Join us for a Live Webinar
Everything you need to know about using CPT II Codes
Tuesday, May 10, 2022
12 noon to 1 p.m. Eastern
Register here
For additional information about the Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com.
This incentive program is for preferred providers who see FEP members. The program can be altered or rescinded at any time.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This is a courtesy reminder that diagnostic imaging services requested on or after November 1, 2021, Empire BlueCross BlueShield (“Empire”) Federal Employee Program (FEP) transitioned to AIM Specialty Health ® (AIM). These services require prior authorization to determine medical necessity prior to rendering the service for Empire Federal Employee members.
Your practice can benefit from participation in several ways, including:
- Improving the clinical appropriateness of imaging services through the application of evidence-based guidelines in an efficient and effective review process. Empire Federal Employee Program (FEP) will be utilizing the FEP Medical Policy to review for medical necessity. In the absence of a controlling FEP Medical Policy, medical necessity determinations will be made using <Empire Coverage Guidelines><Empire Medical Policy>, and/or AIM Clinical Guidelines.
- Maximizing a health plan’s network value through a wide range of solutions including provider assessment tools, cost and quality transparency and reporting.
- Engaging consumers in understanding the range of choices they have in selecting imaging providers and increasing their ability to make informed decisions.
As of November 1, 2021, providers are required to contact AIM prior to rendering the service to obtain pre-service review for the following non-emergency modalities:
- Nuclear imaging, including myocardial perfusion imaging, cardiac blood pool imaging, infarct imaging and positron emission tomography (PET) myocardial imaging
- Computed tomography (CT), including CT angiography, derived fractional flow reserve, structural CT and quantitative evaluation of coronary calcification
- Magnetic resonance imaging (MRI)
- Magnetic resonance angiography (MRA)
- Magnetic resonance spectroscopy (MRS)
- Functional MRI (fMRI)
- Stress echocardiography (SE)*
- Resting echocardiography (TTE)*
- Transesophageal echocardiography (TEE)*
How to submit a request for review:
As a reminder, providers can submit requests for review or can verify order numbers using one of the following methods as a registered AIM portal provider:
For more information about the Radiology Program and to help your practice get started go to: http://www.aimprovider.com/radiology.This website can also help you learn more about provider access to useful information and tools such as order entry checklists and clinical guidelines.
Empire Federal Employee Program values your participation in our network, as well as the services you provide. We look forward to working with you to help improve the health of our members.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In the April 2022 edition of Provider News, we published incorrect information in the heading of the First Prenatal Visit section of the article. We have corrected the information, and the updated article is included below. We apologize for any inconvenience.
The Federal Employee Program (FEP) is introducing a new Quality Reimbursement Program for PPO providers. Coding for CPT II Category Codes for A1c results, blood pressure readings and the first prenatal visit will now be reimbursed at $10 per code.
CPT II codes are supplemental tracking codes that are used to measure quality performance. The use of these tracking codes decreases the need for record submissions and chart reviews, minimizing administrative burden on physicians and other healthcare professionals.
How to use CPT II codes
Use these CPT II codes when submitting a claim. In field 24F on the CMS-1500 claim form, enter the CPT II code along with the amount of $10. In order to receive reimbursement, the exact dollar amount ($10) and the date of service must be entered on the claim along with the appropriate code for the service performed:
Blood Pressure – Receive $10 for the systolic and the diastolic readings:
|
3074F
|
Most recent systolic blood pressure less than 130 mm Hg
|
|
3075F
|
Most recent systolic blood pressure 130-139 mm Hg
|
|
3077F
|
Most recent systolic blood pressure greater than or equal to 140 mm Hg
|
|
3078F
|
Most recent diastolic blood pressure less than 80 mm Hg
|
|
3079F
|
Most recent diastolic blood pressure 80-89 mm Hg
|
|
3080F
|
Most recent diastolic blood pressure greater than or equal to 90 mm Hg
|
Hemoglobin A1c:
|
3044F
|
Most recent hemoglobin A1c (HbA1c) level less than 7.0%
|
|
3046F
|
Most recent hemoglobin A1c (HbA1c) level greater than 9.0%
|
|
3051F
3052F
|
Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0%
Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0%
|
First Prenatal Visit – The first prenatal visit date of service must be on the claim (Field 24A CMS-1500) with the appropriate code:
|
0500F
|
Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care. Report also date of visit, and in a separate field, the date of the last menstrual period [LMP]) (Prenatal)
|
|
0501F
|
Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period [LMP] (Note: If reporting 0501F Prenatal flow sheet, it is not necessary to report 0500F Initial prenatal care visit) (Prenatal)
|
For additional information about the Quality Reimbursement Program, email us at FEPproviderGIC@anthem.com.
This incentive program is for preferred providers who see FEP members. The program can be altered or rescinded at any time.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Specialty pharmacy updates for Empire BlueCross BlueShield (“Empire”) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
Inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.
Prior authorization updates
Effective for dates of service on and after August 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0062
|
Yusimry (adalimumab-aqvh)
|
J3590
|
|
ING-CC-0072
|
Vabysmo (faricimab-svoa)
|
J3490, J3590
|
|
ING-CC-0210
|
Enjaymo (sutimlimab-jome)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0211*
|
Kimmtrak (tebentafusp-tebn)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0212
|
Tezspire (tezepelumab-ekko)
|
C9399, J3590
|
|
ING-CC-0213
|
Voxzogo (vosoritide)
|
C9399, J3490
|
*Oncology use is managed by AIM.
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Step therapy updates
Effective for dates of service on and after August 1, 2022, 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.
Access our Clinical Criteria to view the complete information for these step therapy updates.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0072
|
Non-Preferred
|
Vabysmo (faricimab-svoa)
|
J3490, J3590
|
Quantity limit updates
Effective for dates of service on and after August 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our quantity limit review process.
Access our Clinical Criteria to view the complete information for these quantity limit updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0062
|
Hulio (adalimumab-fkjp)
|
J3590
|
|
ING-CC-0062
|
Ixifi (infliximab-qbtx)
|
Q5109
|
|
ING-CC-0062
|
Yusimry (adalimumab-aqvh)
|
J3590
|
|
ING-CC-0072
|
Vabysmo (faricimab-svoa)
|
J3490, J3590
|
|
ING-CC-0210
|
Enjaymo (sutimlimab-jome)
|
C9399, J3490, J3590, J9999
|
|
ING-CC-0212
|
Tezspire (tezepelumab-ekko)
|
C9399, J3590
|
|
ING-CC-0213
|
Voxzogo (vosoritide)
|
C9399, J3490
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Empire BlueCross BlueShield’s 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 February 25, 2022, Clinical Criteria meeting. To access the clinical criteria information please click here.
Revised clinical criteria effective January 1, 2022
The following clinical criteria was updated with new procedure and/or diagnosis codes.
- ING-CC-0202 Saphnelo (anifrolumab-fnia)
Revised clinical criteria effective March 1, 2022
The following clinical criteria was updated with new procedure and/or diagnosis codes.
- ING-CC-0018 Agents for Pompe Disease
New clinical criteria effective March 16, 2022
The following clinical criteria are new.
- ING-CC-0210 Enjaymo (sutimlimab-jome)
- ING-CC-0211 Kimmtrak (tebentafusp-tebn)
- ING-CC-0212 Tezspire (tezepelumab-ekko)
- ING-CC-0213 Voxzogo (vosoritide)
Revised clinical criteria effective March 28, 2022
The following clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0038 Human Parathyroid Hormone Agents
- ING-CC-0042 Monoclonal Antibodies to Interleukin-17
- ING-CC-0050 Monoclonal Antibodies to Interleukin-23
- ING-CC-0078 Orencia (abatacept)
- ING-CC-0099 Abraxane (paclitaxel, protein bound)
- ING-CC-0108 Halaven (eribulin)
- ING-CC-0110 Perjeta (pertuzumab)
- ING-CC-0115 Kadcyla (ado-trastuzumab)
- ING-CC-0119 Yervoy (ipilimumab)
- ING-CC-0120 Kyprolis (carfilzomib)
- ING-CC-0125 Opdivo (nivolumab)
- ING-CC-0126 Blincyto (blinatumomab)
- ING-CC-0129 Bavencio (avelumab)
- ING-CC-0157 Padcev (enfortumab vedotin)
Revised clinical criteria effective March 28, 2022
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0067 Prostacyclin Infusion and Inhalation Therapy
- ING-CC-0075 Rituximab agents for Non-Oncologic Indications
- ING-CC-0085 Actimmune (interferon gamma-1b)
- ING-CC-0088 Elzonris (tagraxofusp-erzs)
- ING-CC-0089 Mozobil (plerixafor)
- ING-CC-0091 Lartruvo (olaratumab)
- ING-CC-0094 Pemetrexed Agents (Alimta, Pemfexy)
- ING-CC-0096 Asparagine Specific Enzymes
- ING-CC-0103 Faslodex (fulvestrant)
- ING-CC-0109 Zaltrap (ziv-aflibercept)
- ING-CC-0112 Xofigo (Radium Ra 223 Dichloride)
- ING-CC-0113 Sylvant (siltuximab)
- ING-CC-0117 Empliciti (elotuzumab)
- ING-CC-0118 Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Zevalin)
- ING-CC-0121 Gazyva (obinutuzumab)
- ING-CC-0122 Arzerra (ofatumumab)
- ING-CC-0123 Cyramza (ramucirumab)
- ING-CC-0130 Imfinzi (durvalumab)
- ING-CC-0131 Besponsa (inotuzumab ozogamicin)
- ING-CC-0132 Mylotarg (gemtuzumab ozogamicin)
- ING-CC-0135 Melanoma Vaccines
- ING-CC-0140 Zulresso (brexanolone)
- ING-CC-0158 Enhertu (fam-trastuzumab deruxtecan-nxki)
- ING-CC-0164 Jelmyto (mitomycin gel)
- ING-CC-0167 Rituximab Agents for Oncologic Indications
- ING-CC-0177 Zilretta (triamcinolone acetonide extended-release)
- ING-CC-0182 Iron Agents
- ING-CC-0205 Fyarro (sirolimus albumin bound)
Revised clinical criteria effective April 1, 2022
The following clinical criteria were updated with new procedure and/or diagnosis codes.
- ING-CC-0018 Agents for Pompe Disease
- ING-CC-0196 Zynlonta (loncastuximab tesirine-lpyl)
- ING-CC-0202 Saphnelo (anifrolumab-fnia)
- ING-CC-0203 Ryplazim (plasminogen, human-tvmh)
- ING-CC-0204 Tivdak (tisotumab vedotin-tftv)
- ING-CC-0205 Fyarro (sirolimus albumin bound)
Revised clinical criteria effective May 1, 2022
The following clinical criteria was updated with new procedure and/or diagnosis codes.
- ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
Revised clinical criteria effective August 1, 2022
The following 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-0033 Xolair (omalizumab)
- ING-CC-0043 Monoclonal Antibodies to Interleukin-5
- ING-CC-0062 Tumor Necrosis Factor Antagonists
- ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
- ING-CC-0078 Orencia (abatacept)
- ING-CC-0086 Spravato (esketamine) Nasal Spray
- ING-CC-0090 Ixempra (ixabepilone)
- ING-CC-0099 Abraxane (paclitaxel, protein bound)
- ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0166 Trastuzumab Agents
- ING-CC-0186 Margenza (margetuximab-cmkb)
- ING-CC-0209 Leqvio (inclisiran)
The following clinical criteria documents were endorsed at the March 24, 2022, Clinical Criteria meeting. To access the clinical criteria information please click here.
New clinical criteria effective April 4, 2022
The following clinical criteria is new.
- ING-CC-0214 Carvykti (Ciltacabtagene autoleucel)
Revised clinical criteria effective April 4, 2022
The following clinical criteria was revised to expand medical necessity indications or criteria.
- ING-CC-0194 Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection
Revised clinical criteria effective April 25, 2022
The following clinical criteria was revised to expand medical necessity indications or criteria.
- ING-CC-0125 Opdivo (nivolumab)
Revised clinical criteria effective April 25, 2022
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0037 Kanuma (sebelipase alfa)
- ING-CC-0070 Jetrea (ocriplasmin)
- ING-CC-0159 Scenesse (afamelanotide) ING-CC-0167 Rituximab Agents for Oncologic Indications
- ING-CC-0182 Iron Agents
Revised clinical criteria effective May 1, 2022
The following clinical criteria wase reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0075 Rituximab Agents for Non-Oncologic Indications
Revised clinical criteria effective August 1, 2022
The following clinical criteria wase reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0166 Trastuzumab Agents
Revised clinical criteria effective August 1, 2022
The following 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-0010 Proprotein Convertase Subtilisin Kexin Type 9 (PCSK9) Inhibitors
- ING-CC-0029 Dupixent (dupilumab)
- ING-CC-0072 Vascular Endothelial Growth Factor (VEGF) Inhibitors
- ING-CC-00208 Adbry (tralokinumab)
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. Effective March 1, 2022, the following Part B medications from the current Clinical Utilization Management (UM) Guidelines will be included in our medical step therapy precertification review process. Step therapy review will apply upon precertification initiation, in addition to the current medical necessity review (as is current procedure). Step therapy will not apply for members who are actively receiving medications listed below.
Clinical UM Guidelines are publicly available on the provider website. Visit the Clinical Criteria page to search for specific criteria.
|
Clinical UM Guidelines
|
Preferred drug(s)
|
Nonpreferred drug(s)
|
|
ING-CC-0062
|
Inflectra
Remicade, Infliximab (unbranded)
|
Avsola
Renflexis
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The National Committee for Quality Assurance (NCQA) has changed, revised, and retired HEDIS ® measures for measurement year 2022. Below is a summary of the key changes to be aware of.
Diabetes measures
NCQA has separated the Comprehensive Diabetes indicators into stand-alone measures:
- Hemoglobin A1c Control for Patients with Diabetes (HBD) (HbA1c Control < 8 and Poor Control HbA1c)
- Eye Exam Performed for Patients with Diabetes (EED)
- Blood Pressure for Patients with Diabetes (BPD)
- Kidney Health Evaluation for Patients with Diabetes (KED)
The process measure Comprehensive Diabetes HbA1c testing was retired as the goal is to move towards more outcome measures.
Race/ethnicity stratification
To address healthcare disparities, the first step is reporting and measuring performance. Given this, NCQA has added race and ethnicity stratifications to the following HEDIS measures:
- Colorectal Cancer Screening (COL)
- Controlling High Blood Pressure (CBP)
- Hemoglobin A1c Control for patients with Diabetes (HBD)
- Prenatal and Post-Partum Care (PPC)
- Child and Adolescent Well Care Visits (WCV)
NCQA plans to expand the race and ethnicity stratifications to additional HEDIS measures over several years tohelp reduce disparities in care among patient populations. This effort builds on NCQA’s existing work dedicated to the advancing health equity in data and quality management.
New measures
Antibiotic Utilization for Respiratory Conditions (AXR): The percentage of episodes for members 3 months of age and older with a diagnosis of a respiratory condition that resulted in an antibiotic dispensing event
This measure was added given antibiotics prescribed for acute respiratory conditions are a large driver of antibiotic overuse. Tracking antibiotic prescribing for all acute respiratory conditions will provide context about overall antibiotic use. Given this new measure, the Antibiotic Utilization measure has been retired.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Deprescribing of Benzodiazepines in Older Adults (DBO): The percentage of Medicare members 65 years of age and older who were dispensed benzodiazepines and achieved a 20% decrease or greater in benzodiazepine dose during the measurement year
Guidelines recommend that benzodiazepines be avoided in older adults, and deprescribing benzodiazepines slowly and safely, rather than stopping use immediately. There is an opportunity to promote harm reduction by assessing progress in appropriately reducing benzodiazepine use in the older adult population.
Advanced Care Planning (ACP): The percentage of adults 65 to 80 years of age, with advanced illness, an indication of frailty or who are receiving palliative care, and adults 81 years of age and older, who had advance care planning during the measurement year
Advance care planning is associated with improved quality of life, this measure will allow an understanding if it is provided to those who are most likely to benefit from it. Given this new measure, the Care for Older Adults measure has been retired.
Measure changes
Use of Imaging Studies for Low Back Pain (LBP): This measure was expanded to the Medicare line-of-business and the upper age limit for this measure was expanded to age 75. Additional exclusions to the measure were also added.
A complete summary of 2022 HEDIS changes and more information, can be found online.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield has partnered with Everlywell* to provide at-home lab tests for a subset of our eligible patients. We mail at-home test kits directly to patients’ homes with instructions on how to complete and return the kits. Clinical Laboratory Improvement Amendments-certified labs process the tests, and an independent physician reviews the results.
We provide PCPs a list of their patients who receive test kit(s) and send individual results to the patient and their doctor. You can help your patients navigate needed testing by encouraging them to complete kits mailed to them. A physician’s recommendation is a significant factor in patient screenings.
A patient may receive up to two at-home test kits:
- Fecal immunochemical test for colorectal cancer screening
- Hemoglobin A1c test to measure average glucose levels over the past two to three months for those with diabetes
How the program works:
- Test kit(s) are automatically mailed to eligible patients, and patient lists are sent to physicians.
- Patients collect samples at home, using instructions provided.
- Patients mail samples to Everlywell in the provided, postage-paid envelope.
- Individual test results are sent to patients and their primary care physician, providing evidence of preventive screening completion.
If you have questions about the at-home testing program, contact your local representative. For additional information about Everlywell, visit everlywell.com.
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. Providers can earn additional reimbursement on health and wellness services provided to Empire BlueCross BlueShield HealthPlus (Empire) members. Empire is offering reimbursement for the use of CPT ® Category II codes to encourage continued improvements in member care. The use of CPT Category II codes benefits the healthcare system by providing more specific information about healthcare encounters, such as how data can be used to help Empire providers work more efficiently and effectively in the best interest of each member.
Reimbursement for the administrative work and effort of completing and reporting CPT Category II codes can only be claimed once per service, per member, per year and are earned by completing the criteria for billing the CPT Category II codes listed in Table 1. Please continue to bill appropriate office visits, CPT Category II codes, and diagnosis codes that are currently in production in order to receive your reimbursement listed in Table 2. CPT Category II codes must be billed with one of these outpatient visit codes: 99201 through 99215.
The additional reimbursement applies to physicians and qualified healthcare-allied practitioners, including PCPs, cardiologists, endocrinologists, pulmonologists, internal medicine practitioners, nephrologists, rheumatologists, nurse practitioners, physician assistants, federally qualified health centers, and rural health clinics.
What is a CPT Category II code?
- A CPT Category II code provides more detailed information about the clinical service(s) performed.
- CPT Category II codes are billed similar to the way your office bills for regular CPT codes and are placed in the same location on the claim form.
Benefits of using CPT Category II codes include:
- A reduction in the need for Empire to review your medical records by providing more detailed information through your claims submissions.
- Better tracking and management of member care needs from the use of detailed information provided with the billing of CPT Category II codes.
Next steps you need to take:
- Review the CPT Category II code billing opportunities in Table 1 and Table 2 to set up your billing system to bill us for the codes when applicable.
- Be sure that you meet the criteria for billing the CPT Category II codes in Table 1 and Table 2 by matching the diagnosis codes and age ranges and set up your billing system to bill appropriately.
Note: All CPT Category II codes are eligible for payment only once per member, per calendar year. Continuation of payment and payment rates for billing the CPT Category II codes in Table 1 and Table 2 will be evaluated annually.
If you have questions about this communication call Provider Services at 800-450-8753.
Take advantage of this great revenue opportunity by enhancing your billing processes.
Table 1
|
CPT II code
|
Description
|
Diagnosis category code
|
Criteria
|
2022 pay
|
|
3023F
|
Spirometry results documented and reviewed.
|
J40-J44.9
|
- Provider conducts office evaluation for a member with a chronic respiratory condition.
- Provider documents and reviews spirometry results in the medical record.
- Provider reports appropriate office visit, diagnosis code(s), and Category II code 3023F.
|
$20
|
|
2022F
|
Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy.
|
E08.00 to E13.9
|
- Provider reports appropriate office visit, diagnosis code(s), and Category II code 2022F.
|
$20
|
|
2023F
|
Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy.
|
E08.00 to E13.9
|
- Provider reports appropriate office visit, diagnosis code(s), and Category II code 2023F.
|
$20
|
|
3074F
|
For patients with the most recent systolic blood pressure reading < 130 mm Hg.
|
I10-I16.9, N18.1-N18.9
|
- Document blood pressure and diagnosis of hypertension in the medical record.
- On the claim, include diagnosis code for hypertension/hypertensive condition and report CPT II code 3074F.
|
$20
|
|
3075F
|
For patients with the most recent systolic blood pressure 130-139 mm Hg.
|
I10-I16.9, N18.1-N18.9
|
- Document blood pressure and diagnosis of hypertension in the medical record.
- On the claim, include diagnosis code for hypertension/hypertensive condition and report CPT II code 3075F.
|
$20
|
|
3078F
|
For patients with the most recent diastolic blood pressure < 80 mm Hg.
|
I10-I16.9, N18.1-N18.9
|
- Document blood pressure and diagnosis of hypertension in the medical record.
- On the claim, include diagnosis code for hypertension/hypertensive condition and report CPT II code 3078F.
|
$20
|
|
3079F
|
For patients with the most recent diastolic blood pressure 80-89 mm Hg.
|
I10-I16.9, N18.1-N18.9
|
- Document blood pressure and diagnosis of hypertension in the medical record.
- On the claim, include diagnosis code for hypertension/hypertensive condition and report CPT II code 3079F.
|
$20
|
Table 2
|
CPT II code
|
Description
|
Diagnosis category code
|
Criteria
|
2022 pay
|
|
3117F
|
For patients who have congestive heart failure: heart failure
disease-specific structured assessment tool completed.
|
I50.1-I50.9
|
- Provider conducts office evaluation for a member with a heart condition.
- Provider completes heart failure
disease-specific structured assessment tool (includes lab tests, examination procedures, radiologic examination, and/or results and medical decision making).
- Provider reports appropriate office visit, diagnosis code(s), and Category II code 3117F.
|
$20
|
|
0513F
|
For patients who have hypertension: elevated blood pressure plan of care.
|
I10-I16.9, N18.1-N18.9
E08.00-E13.9
|
- Provider conducts office evaluation for a member with hypertension or hypertensive diseases.
- Provider completes and documents elevated blood pressure plan of care.
- Provider reports appropriate office visit, diagnosis code(s), and Category II code 0513F.
|
$20
|
|
3011F
|
Lipid panel results documented and reviewed.
|
I25.10-I25.9
|
- Provider conducts office evaluation.
- Provider documents and reviews lipid panel results in the medical record.
- Provider reports appropriate office visit, diagnosis code(s), and Category II code 3011F.
|
$20
|
|
3044F
|
For patients who have diabetes: most recent HbA1c less than 7.
|
E08.00-E13.9
|
- Provider conducts office evaluation for a member with diabetes mellitus (any type).
- Provider completes and documents hemoglobin A1C results when less than 7.
- Provider reports appropriate office visit, diagnosis code(s), and Category II code 3044F.
|
$20
|
|
3046F
|
For patients who have diabetes: most recent HbA1c greater than 9.
|
E08.00-E13.9
|
- Provider conducts office evaluation for a member with diabetes mellitus (any type).
- Provider completes and documents hemoglobin A1C results when greater than 9.
- Provider reports appropriate office visit, diagnosis code(s), and Category II code 3046F.
|
$20
|
|
3051F
|
Most recent HbA1c level greater than or equal to 7% and less than 8%.
|
E08.00-E13.9
|
- Provider conducts office evaluation for a member with diabetes mellitus (any type).
- Provider completes and documents HbA1c results 7 to 8.
- Provider reports appropriate office visit code, diagnosis code(s), and Category II code 3051F.
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$20
|
|
3052F
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Most recent HbA1c level greater than or equal to 8% and less than 9% .
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E08.00-E13.9
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- Provider conducts office evaluation for a member with diabetes mellitus (any type).
- Provider completes and documents HbA1c results when 8 to 9.
- Provider reports appropriate office visit code, diagnosis code(s), and Category II code 3052F.
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$20
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2014F
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Mental status assessed (normal, mildly impaired, or severely impaired) (cap).
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F90.0-F90.9
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- Provider completes office visit for member with ADD or ADHD.
- Provider completes and documents mental status assessment.
- Provider reports appropriate office visit, diagnosis code(s), and CPT Category II code 2014F.
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$20
|
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3085F
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Suicide risk assessed (MDD).
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F32.0-F33.9
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- Provider completes office visit for member with major depressive disorder.
- Provider completes and documents assessment of suicide risk.
- Provider reports appropriate office visit, diagnosis code(s), and CPT Category II code 3085F.
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$20
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3066F
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Documentation of treatment for nephropathy (for example, patient receiving dialysis, patient being treated for).
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N04.0-N18.9; E08.00-E11.9; E13.00-E13.9
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- Provider conducts office evaluation for a member with nephropathy or CKD diagnosis.
- Provider completes and documents treatment for nephropathy/CKD in the medical record.
- Provider reports appropriate office visit, diagnosis code(s), and Category II code 3066F.
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$20
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Strategic Provider System to launch in May
In May 2022, Empire BlueCross BlueShield HealthPlus (Empire) will replace the current data management system with the new and significantly improved Strategic Provider System (SPS). The SPS data portal will increase website data accuracy, transparency, and timeliness, creating an enhanced provider experience.
SPS offers robust support features that will improve the ability of Empire to match submitted claims, resulting in more accurate pricing and processing. The easy-to-use website will allow you to:
- Digitally submit demographic data to one location.
- Maintain, update, and verify demographic data using a single website.
- Receive clear on-screen alerts and guidance as you maintain your data.
- Obtain access to a simplified quick verification process that will allow you to complete required verifications online, eliminating the need to fax, email, or use separate online forms.
- Receive periodic reminders to help you keep your information current.
What you need to do to get ready for the change
If already enrolled in Availity,* no further action is needed. If you are not enrolled, go to availity.com and select the orange Register button. Availity is a secure provider website where you can enjoy the convenience of digital transactions, including prior authorization and claims submission, as well as benefit and eligibility look-up.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. High-prevalence demographics
The lifetime prevalence of AUD in the U.S. population is approximately 29.1%. However, only 19.8% of people with AUD receive treatment. Prevalence of AUD is high in white and Indigenous people, younger men (age < 65), unmarried people, and those with low incomes.1
22.8 million people over the age of 12 reported having a substance use disorder (SUD) in 2019; AUD accounted for 63% of this population. An additional 12% presented with AUD and another SUD (excluding nicotine) according to the National Survey on Drug Use and Health (NSDUH).2
AUD and COVID-19
Evidence suggests that alcohol consumption increased during the COVID-19 pandemic. One study found that 60% of respondents reported increased alcohol-intake.3 In 2020, alcohol sales increased by 262% online and 21% in stores, which participants reported was due to increased stress, alcohol availability, and lockdown boredom.4 This increase was most substantial between March to April 2020. The study suggests those most affected by COVID-19 (job loss, friend loss, family loss, and isolation) may be more at risk of AUD.3
AUD co-occurring with mental health conditions
People with a variety of mental health conditions are at increased risk of developing an AUD or have an existing co-occurring AUD.5 While the rates are higher for co-occurring disorders with mental health conditions, there is also a higher risk of greater severity and a worse prognosis for both the mental condition and AUD.
Trauma, including adverse childhood events (ACEs) and post-traumatic stress disorder (PTSD), are often precursors for AUD.6 Traumatic brain injuries (TBI) are also associated with AUD. Alcohol intoxication is one of the strongest predictors of a TBI. In addition, people with a TBI are more likely to abuse alcohol.7
In most co-occurring disorders, the mental health condition preceded the AUD. This indicates that people diagnosed with a mental health condition should be screened for AUD. Preventive work should begin at the onset of symptoms of a mental health condition.5
What if I need assistance?
If you have difficulty connecting patients with AUD to treatment, please contact Empire BlueCross BlueShield HealthPlus. If you have questions about this communication or need assistance with any other item, call Provider Services at 800-450-8753.
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