Effective for claims processed on or after December 1, 2023, the editing systems at Empire BlueCross BlueShield will be updated to align with the American Medical Association (AMA) CPT^® Manual, HPCPS Level II Manual, and Centers for Medicare & Medicaid Services (CMS) correct coding guidelines, for the following services:

• Ulcer debridement and ulcer staging:

  • According to the ICD-10 Diagnosis Coding Manual, specific diagnosis codes that reflect the stage of the ulcer should be billed with the appropriate CPT code. For example, if billing a stage 3 pressure ulcer code, a stage 4 diagnosis code should not be reported.
  • According to the AMA CPT Manual, a debridement of an ulcer should be reported with the appropriate diagnosis code that reflects that service.

• Billing of anatomical modifiers:

  • According to the AMA CPT and HCPCS Level II manuals, the appropriate anatomical modifier is required to be appended to the appropriate procedure code. If not, the claim line will be denied. These modifiers designate the body part that a service is being performed on (for example, FA: Left hand, thumb, TA: Left foot, great toe).

• Billing of interprofessional telephone/internet consultations:

  • These billed procedure codes will follow the AMA CPT Manual coding guidelines.

Claim lines not billed in accordance with the correct coding guidance outlined above will be denied.

If you disagree with a claim reimbursement decision, please follow the claim dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual.

If you have questions about this communication or need assistance with any other item, contact your provider relationship management representative.

With your help, we can continually build towards a future of shared success.

Empire BlueCross BlueShield (Empire) utilizes post-pay review in certain circumstances to validate the appropriate level for facility emergency department claims. This process identifies the level of ED E&M code by intensity and/or complexity of resources or interventions a facility utilizes to furnish all services indicated on the claim. Providers must utilize appropriate HIPAA-compliant codes for all services rendered during the ED encounter. The highest intervention/resource used will determine the final facility ED level.

Empire defines:

• Interventions: The staff the facility uses and their work performed
• Resources: Facility building, equipment, and/or supplies used
• Note: Professional provider services are not considered facility interventions or resources.
• Intensity and/or complexity: Quantity, type, or specialization of interventions and/or resources used and the nature of the presenting problem, member age, acuity and diagnostic services performed, as indicated on the claim.
• Emergency services: A medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care, could result in (a) placing the health of an individual in serious jeopardy, (b) serious impairment to bodily function, (c) serious dysfunction of any bodily organ or part, (d) serious disfigurement, or (e) in the case of a pregnant woman, serious jeopardy to the health of the woman or her unborn child

** In the event a determination cannot be made based on the guidance in this document, a referral to a medical director for a determination will be made.

The Centers for Medicare and Medicaid Services (CMS) has provided specific guidance regarding the usage of the following modifiers:

It has been determined that these modifiers were used inappropriately for Medicare Advantage (MA) members.

Examples include:

• The member has an enhanced or supplemental benefit above what original Medicare covers and one or more of the above modifiers are applied to the claim:
  • Such as office calls billed by a chiropractor and the service is an enhanced benefit under the member’s Medicare Advantage health plan.
• The item/service is a covered benefit but one or more of the above modifiers is applied to claim:
  • Such as 911 ambulance calls:
    • CMS guidance states that if the call is in accordance with a prudent layperson’s definition of emergency medical condition, regardless of the final diagnosis.

An Advance Beneficiary Notice (ABN) is a written notice given to an original Medicare beneficiary by a provider (including physicians, practitioners, durable medical equipment (DME) companies, laboratories, etc.) when they believe that Original Medicare will deny some or all of the services or items because of medical necessity or the frequency of the service; however, the ABN is optional when original Medicare never covers a service or item. When a provider obtains an ABN along with the original Medicare requirements, the provider may indicate that they have obtained an ABN by billed with modifier GS, GX, GY and/or GZ. As published in the Medicare Claims Processing Manual, Chapter 30, Section 50, the ABN is provided to original Medicare beneficiaries for the above scenarios and is not used for items or services provided/denied under the MA program or for prescription drugs provided under the Medicare Prescription Drug Program (Part D). Under the MA program, MA members and their providers have the option to obtain a coverage decision prior to obtaining the item or service. This request for a pre-service coverage review is known as a request for an organizational determination.

Because a MA member can obtain a pre-service coverage decision through the pre-service organizational determination process, the use of the ABN for MA members is not appropriate. This means that the liability modifiers that denote that there is an ABN on file is not appropriate for MA members.

Providers (contracted and non-contracted providers as well as members) have the ability to request an organizational determination (prior authorization) prior to providing an item or service to determine if the item or service will be covered under the member’s health plan benefits. Once an organizational determination has been made, if a denial is warranted, an Integrated Denial Notice (IDN) will be sent to the member and provider. This document provides important appeal rights guaranteed to the member.

If the service is denied, the member will be better informed to choose if they would still like to obtain the item or service at their own expense. Claims are not processed based on the G modifier, but rather on the benefit of the service rendered.

This article should serve as a reminder that effective since April 1, 2023, Medicaid members enrolled in mainstream Medicaid Managed Care (MMC) plan, Health and Recovery Plan, and HIV-Special Needs Plans (SNPs) have transitioned their pharmacy benefits from their MMC plan to NYRx, the Medicaid Pharmacy Program. Information regarding the pharmacy benefit transition is in the October 2022 special edition Medicaid update found here.

Questions and additional information:

• DME providers may review the Durable Medical Equipment, Prosthetic, Orthotic, and Supply Manual Policy Guidelines found here.

Under NY 2022 AB372 - Prohibits Copayments for Opioid Treatment Programs, plans are prohibited from imposing copayments and/or coinsurance during treatment through an in-network opioid addiction outpatient treatment program. The deductible applies for all plans. Once the deductible is met, coinsurance is waived. Outpatient professional and outpatient facility services are in scope for the cost share waiver. Inpatient services are out of scope for this mandate.

To better identify these types of claims, we are asking you to begin billing with the HCPCS modifier “HG” for services provided through an opioid addiction treatment program on an outpatient professional and/or outpatient facility basis. By billing with the modifier “HG,” you will help ensure members are paying the appropriate cost share per the mandated requirements.

The Consolidated Appropriations Act (CAA) of 2021 contains a provision that requires online provider directory information be reviewed and updated as needed at least every 90 days. Maintaining your online provider directory information is essential for members and healthcare partners to connect with you when needed. Please review your information frequently and let us know if any of your information we show in our online directory has changed.

Submit updates and corrections to your directory information by following the instructions on our Provider Maintenance webpage. Online update options include:

• Add/change an address location.
• Name change.
• Provider leaving a group or a single location.
• Phone/fax number changes.
• Closing a practice location.

Reviewing your information helps us ensure your online provider directory information is current. Through genuine collaboration, we can simplify access to care and help you deliver high-quality, equitable healthcare.

As part of our credentialing process, practitioners have certain rights as briefly outlined below.

Practitioners can request to:

• Review information submitted to support their credentialing application.
• Correct erroneous information regarding a credentialing application.
• Be notified of the status of credentialing or recredentialing applications.

We encourage practitioners to begin the credentialing process by going to availity.com as soon as possible when new physicians join a practice. Doing so will help minimize any disruptions to the practice and members’ claims.

As an Empire BlueCross BlueShield HealthPlus (Empire) network provider, you may find yourself in a position to provide trauma-informed care to Medicaid Managed Care (MMC) children/youth in direct placement foster care and in the care of Voluntary Foster Care Agencies (VFCA).

Provision and coordination of services for children/youth in foster care, must be done in compliance with the New York Medicaid Program 29-I Health Facility Billing Manual and the Transition of Children Placed in Foster Care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care guidance documents located at: https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/vol_foster_trans.htm.

The pharmacy benefit requirements for children/youth placed in foster care include, but are not limited to, rapid replacement of medically necessary prescriptions and transitional fills for children/youth newly placed in foster care. ep Effective April 1, 2023, MMC members, including children/youth placed in foster care, had their pharmacy benefits transitioned to NYRx, the Medicaid Pharmacy program. However, Physician administered drugs, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies are still covered by Empire when billed as a medical or institutional claim. The Pharmacy Procedure Code manual can be found here: https://www.emedny.org/ProviderManuals/Pharmacy/PDFS/Pharmacy_Procedure_Codes.pdf

Upon placement into Foster Care, a child/youth is required to have an Initial Medical Assessment within the first 30 days of the child/youth’s placement. The child/youth may utilize any primary care physician (PCP) or qualified practitioner in the MMC network for the purposes of this Initial Medical Assessment.

For ongoing primary care visits, if there is a discrepancy with the assigned PCP on the MMC member ID card, the child/youth should not be turned away; instead, please immediately call Medicaid Provider Services at (800) 450-8753 to rectify this matter.

The Controlling Blood Pressure (CBP) HEDIS^® measure can be challenging. It not only requires proof of a blood pressure reading, but also that the patient’s blood pressure (BP) is adequately controlled. CBP care gaps can open and close throughout the year depending on if the patient’s most recent BP reading is greater than 138/89 mmHG. As we approach the end of the year, it is important that we have record of your patients’ BP readings and that you schedule any members who have not had a BP reading during 2023 or who have had high readings recorded this year.

Tips when scheduling members to close CBP care gaps

• When scheduling appointments, encourage office staff to ask patients to avoid caffeine and nicotine for at least an hour before their scheduled appointment time.
• If possible, update your scheduling app or your reminder text message campaigns to include a reminder about abstaining from caffeine as well as a reminder to arrive early to avoid a sense of rushing.

Tips for lower BP readings during the appointment

• Ask the patient if they tend to get nervous at appointments and have higher readings as a result. If they do, take their BP at both the start and end of the appointment. Document the lower reading. Reference the Healthy BP Recheck Initiative for more information.
• Readings could vary arm to arm. If slightly elevated in one arm, try the other and document the lower reading.

Getting credit for adequately CBP readings

• Submit readings via Category II CPT^® codes on claims:

• Ensure readings are carefully and appropriately documented within your electronic medical records (EMR) system.
• If you have questions on how to submit readings, speak to your care consultant or program manager.
• Be sure to adequately code patients who meet the exclusion criteria.

To learn more about our commitment to health equity visit My Diverse Patients. Please reference our Heart Healthy Diet Conversation Guide to learn more about engaging patients to make lifestyle changes if they’re of a culture different than your own.

Healthcare Effectiveness Data Information Set (HEDIS^®) is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

HEDIS 2023 documentation for Childhood Immunization Status (CIS) Measure description:

The percentage of children 2 years of age in the measurement year who had the following on or before their second birthday:

• Four DTaP (diphtheria, tetanus, and acellular pertussis)
• Three IPV (polio)
• One MMR (measles, mumps, and rubella)
• Three HiB (haemophilus influenza type B)
• Three Hep B (hepatitis B)
• One VZV (chicken pox)
• Four PCV (pneumococcal conjugate)
• One Hep A (hepatitis A)
• Two or three RV (rotavirus)
• Two flu (influenza)

The measure calculates a rate for each vaccine and three combination rates.

HEDIS 2023 documentation for Immunizations for Adolescents (IMA) Measure description: The percentage of adolescents 13 years of age in the measurement year who had the following:

• One MenACWY (meningococcal)
• One Tdap (tetanus, diphtheria toxoids and acellular pertussis)
• Two or three HPV (human papillomavirus)

The measure calculates a rate for each vaccine and two combination rates.

HEDIS measurement year 2023 documentation for Lead Screening in Children (LSC) Measure description: The percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday.

What we are looking for in provider medical records:

• Immunization records from birth (Department of Health immunization records are acceptable).
• If available, newborn inpatient records documenting Hep B.
• For those immunizations not recorded on the immunization record, provide progress notes for: Immunizations administered, patient’s history of disease (chickenpox, Hep A, Hep B, measles, mumps, rubella).
• Anaphylaxis due to the DTaP, IPV, MMR, HIB, Hep B, VZV, PCV, Hep A, RV, or Influenza vaccines.
• Encephalitis due to the DTaP vaccine.
• Diagnosis of severe combined immunodeficiency, immunodeficiency, HIV, lymphoreticular cancer, multiple myeloma, leukemia, or intussusception.
• Meningococcal vaccine with a date of service on or between the member’s 11th and 13th birthdays.
• Tdap vaccine with a date of service on or between the member’s 10th and 13th birthdays.
• At least two HPV vaccines on or between the member’s ninth and 13th birthdays and with dates of service at least 146 days apart, or at least three HPV vaccines with different dates of service on or between the member’s ninth and 13th birthdays.
• Lead testing results and date (capillary or venous) on or before the child’s second birthday.
• Evidence of hospice services in 2023.
• Evidence patient expired in 2023.

Helpful hints:

• Childhood immunizations and lead blood tests must be completed by the child’s second birthday.
• Assess immunization needs at every clinical encounter, including sick visits and when indicated, immunize.
• Ensure immunization records include all vaccines that were ever given, including hospitals, health departments, all former providers, include refusals, and contraindications.
• FluMist (LAIV) vaccination (only approved for ages 2 to 49) may be used for the second vaccination, however it must be given on the child’s second birthday to be compliant.

Instead of submitting medical records for the HEDIS^® hybrid project, use the Remote Electronic Medical Record (EMR) Access Service provided by Empire. We offer providers the ability to grant access to your EMR system directly to pull the required documentation to aid your office in reaching compliance. Granting our team remote access to your EMR helps reduce the time and costs associated with medical record retrieval while improving efficiency and allowing your office to focus on patient care.

We have a centralized EMR team experienced with multiple EMR systems and extensively trained annually on HIPAA, EMR systems, and HEDIS measure updates. We complete medical record retrieval based on minimum necessary guidelines:

• We only access medical records of members pulled into the HEDIS sample using specific demographic data.
• We only retrieve the medical records that have claims evidence related to the HEDIS measures.
• We only access the least amount of information needed for a use, disclosure, or a request.
• We only save to file and do not physically print any PHI.

Getting started with Remote EMR Access is just one email away. Email Centralized_EMR_Team@empireblue.com today. To learn more about our Remote EMR Access, view the frequently asked questions below. 

Q. How do you retrieve our medical records?

A. We access your EMR using a secure website and retrieve only the necessary documentation by printing it to an electronic file we store internally, on our secure network drives.

Q. Is this process secure?

A. Yes, we only use secure internal resources to access your EMR systems. All retrieved records are stored on Empire secure network drives. 

Q. Why does Empire need full access to the entire medical record?

A. There are several reasons we need to look at the entire medical record of a member, including:

• HEDIS measures can include up to a 10-year look back of a member’s information.
• Medical record data for HEDIS compliance may come from several different areas of the EMR system, including labs, radiology, surgeries, inpatient stays, outpatient visits, and case management.
• Compliant data may be documented or housed in a non-standard format, such as an in-office lab slip scanned into miscellaneous documents.

Q. What information do I need to submit to use your Remote EMR Access Service?

A. Email Centralized_EMR_Team@empireblue.com with the following information:

Practice/facility demographic information (for example, address, National Provider ID, Taxpayer Identification Numbers, etc.)

• EMR system information (for example, type of EMR system, required access forms, access type, etc.)
• List of current providers/locations or a website for accessing this list.

Measure description

The percentage of discharges for members 18 years of age and older who had each of the following:

• Notification of inpatient admission (can only be captured through medical record review)
• Receipt of discharge information (can only be captured through medical record review)
• Patient engagement
• Medication reconciliation post-discharge

What we are looking for in care provider records:

• Notification of inpatient admission — documentation in the outpatient medical record must include evidence of receipt for notification of inpatient admission on the day of admission through two days after the admission (three total days) with evidence of the date when the documentation was received. Any of the following examples meet criteria:
  • Communication about admission between inpatient care providers or ER and the member’s PCP or ongoing care provider (for example, phone call, e-mail, fax, information exchange, automated alert system, shared electronic medical record, or from the member’s health plan)
  • Indication that the PCP or ongoing care provider admitted the member to the hospital
  • Indication that a specialist admitted the member to the hospital and notified the member’s PCP or ongoing care provider
  • Indication that the PCP or ongoing care provider placed orders for tests and treatments any time during the member’s inpatient stay
  • Documentation that the PCP or ongoing care provider performed a preadmission exam or received communication about a planned inpatient admission. The time frame that the preadmission exam or planned inpatient admission must be communicated is not limited to the day of admission through two days after the admission (three total days)
• Receipt of discharge information — documentation in the outpatient medical record must include evidence of receipt of discharge information on the day of discharge through two days after the discharge (three total days) with evidence of the date when the documentation was received. Discharge information may be included in, but not limited to, a discharge summary or summary of care record, or in the structured fields in an electronic health record. At a minimum, the discharge information must include the following:
  • The practitioner responsible for the member’s care during the inpatient stay
  • Procedures or treatments provided
  • Diagnoses at discharge
  • Current medication list
  • Testing results, or documentation of pending tests or no tests pending
  • Instructions for patient care post-discharge
• Patient engagement — documentation in the outpatient medical record must include evidence of patient engagement within 30 days after discharge. Any of the following meet criteria:
  • An outpatient visit, including office visits and home visits
  • A telephone visit
  • A synchronous telehealth visit where real-time interaction occurred between the member and care provider using audio and video communication
  • An e-visit or virtual check-in (asynchronous telehealth where two-way interaction, which was not real-time, occurred between the member and care provider)
• Medication reconciliation — documentation in the outpatient medical record must include evidence of medication reconciliation and the date when it was performed. Medication reconciliation must be conducted by a prescribing practitioner, clinical pharmacist, physician assistant, or registered nurse. Any of the following meet criteria:
  • Documentation of the current medications with a notation that the care provider reconciled the current and discharge medications
  • Documentation of the current medications with a notation that references the discharge medications (for example, no changes in medications since discharge, same medication at discharge, discontinue all discharge medications)
  • Documentation of the member’s current medications with a notation that the discharge medications were reviewed
  • Documentation of a current medication list, a discharge medication list and notation that both lists were reviewed on the same date of service
  • Documentation of the current medications with evidence that the member was seen for post-discharge hospital follow-up with evidence of medication reconciliation or review:
    • Evidence that the member was seen for post-discharge follow-up requires documentation that indicates the care provider was aware of the member’s hospitalization or discharge
  • Documentation in the discharge summary that the discharge medications were reconciled with the most recent medication list in the outpatient medical record. There must be evidence the discharge summary was filed in the outpatient chart on the date of discharge through 30 days after discharge (31 total days).
  • Notation that no medications were prescribed or ordered upon discharge
• Exclusions:
  • Evidence of hospice or palliative services in 2023

• Evidence patient expired in 2023

Helpful hints:

• Documentation of a procedure/surgery that is typically performed inpatient (such as, aortic bypass) does not indicate that the care provider is aware of the hospitalization. Documentation of post-op/surgery follow-up alone does not indicate the care provider was aware of the hospitalization or discharge. Make sure documentation references the hospitalization, admission, or inpatient stay.
• If performing a pre-admission exam, document that it is a pre-admission exam.
• If performing a pre-surgical, pre-operative, or surgical clearance exam, the date of the admission must be documented.

• Implement process to receive automated alerts when a member is admitted or discharged from an inpatient facility.
• Review discharge medications with the member.

• Schedule post-hospital discharge following appointments and have the office call the member to remind them.
• Document a received date for discharge summaries and notification of inpatient admissions.

• Use the appropriate billing codes for Medication Reconciliation and Patient Engagement.

Each year, the CDC encourages care providers and individuals to learn more about antibiotics by promoting antibiotic awareness in November. The CDC’s Be Antibiotics Aware educational effort encourages care providers to: 

• Prescribe antibiotics only when they are clinically indicated. Antibiotics are only needed to treat certain infections caused by bacteria, not viruses like those that cause COVID-19. Harm can be done by prescribing antibiotics that aren’t needed.
• Talk to patients about why they don’t need antibiotics for a viral respiratory infection, what to do to feel better, and when to seek care again if they don’t feel better.
• Write a prescription for symptom relief, such as rest, fluids, cool mist vaporizers, and over-the-counter medicine.

CDC’s Be Antibiotics Aware offers resources that help educate patients about antibiotic use at Antibiotic Use | CDC. This includes waiting/treatment room posters, pamphlets such as Antibiotics Aren’t Always the Answer, prescription pads for cold relief, and more.  

HEDIS^® Measures that assess antibiotic prescribing   

The following HEDIS measures assess appropriate antibiotic dispensing for bronchitis/bronchiolitis, upper respiratory infection, and pharyngitis. These measures are used to identify, monitor, and improve antibiotic prescribing practices.

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

This measure assesses the percentage of episodes for patients ages three months and older with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event. If prescribing an antibiotic to patients with acute bronchitis, be sure to use the diagnosis code for the bacterial infection and/or comorbid condition.

Appropriate Treatment for Upper Respiratory Infection (URI):

This measure calculates the percentage of episodes for patients three 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. Educate patients on the difference between bacterial and viral infections. Refer to the viral illnesses as a common cold, sore throat, or chest cold.

Appropriate Testing for Pharyngitis (CWP):

This measure reports the percentage of episodes for patients three years of age and older where the patient was diagnosed with pharyngitis, dispensed an antibiotic, and received a group A strep test. 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.

For more information and coding guidelines, reference the HEDIS guides on the Empire provider website.

You may have patients who cannot tolerate moderate or high-dose statin therapy but appear in your HEDIS^® denominator for Statin Use in Persons With Cardiovascular Disease (SPC). By properly submitting the required exclusion criteria for this measure, you can improve your quality scores before the end of the year. The Statin Therapy Exclusion Guide is a great resource to learn more on what qualifies as an exclusion and how to submit the proper criteria.

Tips for implementing best practices and improving your quality scores before the end of the year:

• Properly code and submit exclusion criteria for members who cannot tolerate moderate or high-dose statin therapy. Reference the Statin Therapy Exclusion Guide.
• Educate members on the importance of adhering to their statin therapy regime and educate them on potential side effects. If they start to experience muscle pain or weakness, have them contact you to discuss their options.
• Statin therapy should be accompanied by lifestyle modifications, such as a healthy diet and exercise. Work with your patients to proactively identify and overcome any barriers that may prevent lifestyle modifications:
• If they cannot make it to the gym, talk with them about exercising at home.
• Encourage a healthy diet based on the patient’s culture and local availability:
  • Reference this conversation guide for more information on how to discuss lifestyle modifications if your patient is of a different culture than your own.
• For those patients who can tolerate moderate or high-dose statin therapy, encourage them to do 90-day prescriptions or mail order to eliminate barriers that may prevent them from getting their prescription.

on-time. As the SPC measure is reliant on pharmacy claims to close the care gap, try to prescribe the lowest cost medication that will work for them to eliminate any undue financial burdens on the patient and discourage the use of pharmacy discount cards.

Patient care opportunities

You can find patient care opportunities within the Patient360 application located on Availity Essentials* Payer Spaces. To access the Patient360 application, you must have the Patient360 role assignment. From Availity’s home page, select Payer Spaces, then choose the health plan from the menu. Select the Patient360 tile from the Payer Space Applications menu and complete the required information on the screen. Gaps in care are located in the Active Alerts section of the Member Summary.