March 2023 Anthem Provider News - Ohio

Contents

AdministrativeCommercialMedicare AdvantageMarch 1, 2023

Statin Therapy Exclusions for Patients With Cardiovascular Disease/Diabetes HEDIS measures

AdministrativeCommercialMedicare AdvantageMarch 1, 2023

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Carelon Medical Benefits Management (formerly AIM Specialty Health) Radiology Clinical Appropriateness Guidelines CPT code list update

AdministrativeCommercialMarch 1, 2023

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

New policy for EMR clinical data sharing and ADT notifications

AdministrativeCommercialMedicare AdvantageMarch 1, 2023

You are invited: Advancing Mental Health Equity for Youth & Young Adults

AdministrativeCommercialMarch 1, 2023

March is National Colorectal Cancer Awareness Month

Reimbursement PoliciesCommercialMarch 1, 2023

Reimbursement policy update: Modifiers 25 and 57 - Professional

Products & ProgramsCommercialMedicare AdvantageMarch 1, 2023

Consumer payment option, Pay Doctor Bill, to terminate effective March 31, 2023

PharmacyCommercialMarch 1, 2023

Pharmacy information available on our provider website

PharmacyCommercialMarch 1, 2023

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Specialty pharmacy updates for March 2023

State & FederalMedicaid Managed CareMarch 1, 2023

Member referrals: Employment Services Program and Housing Flex Funds

State & FederalMedicaid Managed CareMarch 1, 2023

Enhancing Provider News website and email communications

State & FederalMedicaid Managed CareMarch 1, 2023

Member ID cards

State & FederalMedicare AdvantageMarch 1, 2023

Controlling High Blood Pressure and Submitting Compliant Readings

State & FederalMedicare AdvantageMarch 1, 2023

Annual planned visits

State & FederalMedicare AdvantageMarch 1, 2023

Shared savings and transition care management after inpatient discharges

State & FederalMedicare AdvantageMarch 1, 2023

Informational Update Modifier Usage

State & FederalMedicare AdvantageMarch 1, 2023

Keep up with Medicare News - March 2023

AdministrativeCommercialMarch 1, 2023

Reminder - Updated Carelon Musculoskeletal Program effective April 1, 2023: monitored anesthesia care reviews

We communicated in the June 2022 edition of the Provider News that Carelon Medical Benefits Management, Inc.* (then, AIM Specialty Health®), would expand the Musculoskeletal Program for Anthem Blue Cross and Blue Shield (Anthem) fully insured members and select members who are covered under self-insured (ASO) benefit plans with services medically managed by Carelon beginning October 1, 2022. However, the initial program implementation was delayed. The confirmed new implementation date is April 1, 2023.

Unless otherwise stated in the provider’s agreement, for services on or after April 1, 2023, prior authorization will be required for the clinical appropriateness of monitored anesthesia or conscious sedation (MAC) when requested in conjunction with interventional pain codesCarelon will use the following Anthem Clinical UM Guideline: CG-MED-78: Anesthesia Services for Interventional Pain Management Procedures. The Clinical Criteria to be used for these reviews can be found on the Anthem provider website Clinical UM Guidelines page. Clinical site of care review may also apply if these procedures are requested in a hospital outpatient department and could safely be done in an ambulatory surgery center. If you have a member in a current course of treatment for pain management where services were approved without reviewing the MAC, identify the member for us at the next request. Please note, this does not apply to procedures performed on an emergent basis.

The anesthesiologist may determine that a member requires monitored anesthesia on the day of service. A retrospective review may be requested, or a post service claim may be submitted with a clinical record including the pre-anesthesia assessment, the patient’s medical history documenting that patient meets criteria for MAC, and a detailed description of the procedure performed for Carelon to determine coverage for the service as medically necessary.   

At this time, the codes that will be reviewed are 01991, 01992, 01937, 01938, 01939, and 01940. A complete list of CPT® codes requiring prior authorization for the Carelon Monitored Anesthesia Care for Interventional Pain program is available on the Carelon Musculoskeletal microsite. To determine if prior authorization is needed for a member on or after April 1, 2023, contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers using the Interactive Care Reviewer (ICR) tool on the Availity Essentials* platform to pre-certify an outpatient musculoskeletal service will receive a message referring the provider to Carelon. (Note: ICR cannot accept prior authorization requests for services administered by Carelon.)

Members included in the new program

All fully insured members currently participating in the Carelon Musculoskeletal Program are included. This program will be offered to self-funded (ASO) groups that currently participate in the Carelon Musculoskeletal Program to add to their members’ benefit package as of April 1, 2023.

Members of the following products are excluded:  Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, Federal Employee Program® (FEP®). 

Pre-service review requirements

For services provided on or after April 1, 2023, ordering and servicing providers may begin contacting Carelon as early as March 20, 2023, for review. Providers may submit prior authorization requests to Carelon in one of the following ways:

  • Access Carelon’s ProviderPortalSM directly at www.providerportal.com. Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization. Initiating a request on Carelon’s ProviderPortalSM and entering responses to all the requested clinical questions will allow you to receive an immediate determination.
  • Access Carelon via Availity Essentials* at www.availity.com in Payer Spaces under the Resources tab.
  • Call the Carelon Contact Center’s toll-free number at 877-291-0360, Monday through Friday, 8 a.m. to 5 p.m. ET.

Training webinars

Carelon will be offering two Monitored Anesthesia Care training sessions that providers are invited to attend:

  • Thursday March 30, 2023 – 12 p.m. ET
    Register here.
  • Thursday April 6, 2023 – 12 p.m. ET
    Register here.

We value your participation in our network and look forward to working with you to help improve the health of our members.

* CarelonRx, Inc. is a separate company providing utilization review services on behalf of the health plan. Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

MULTI-BCBS-CM-017598-23

AdministrativeCommercialMedicare AdvantageMarch 1, 2023

Statin Therapy Exclusions for Patients With Cardiovascular Disease/Diabetes HEDIS measures

The Statin Therapy Exclusions for Patients With Cardiovascular Disease (SPC) HEDIS® measures examines the percentage of patients with atherosclerotic cardiovascular disease (SPC) who received and adhered to statin therapy throughout the measurement year. However, statin therapy does not work for everyone, and alternative therapies are necessary to minimize their risk for future complications. If you have patients who cannot tolerate statin therapy, it is important that you document and notify us annually so we can exclude the patients from your list of open care gaps. Refer to NCQA guidelines for a complete listing of exclusion criteria.

How to submit exclusion data:

  • Indicate the appropriate ICD-10 code for encounters.
  • Use standard data file submission or EMR/EHR access for supplemental data collection.

Exclusions are applied based on diagnosis codes on the date of service provided on the claim or through supplemental data collection. Based on the timing of your data submission and when reports are generated, it may take several weeks for exclusions to be reflected on your reports.

Please note, if exclusions are not coded properly or given to Anthem Blue Cross and Blue Shield in the proper format, the care gap will remain open until the failure reason is corrected. Patients listed on the open care gap report are assumed to tolerate statin therapy and will have their care gaps closed after claims for moderate to high intensity statins are adjudicated by Anthem.

Tips for implementing best practices and improving your quality scores:

  • Educate your patients on the importance of adhering to their statin therapy regime and on potential side effects. If they start to experience muscle pain or weakness, have them contact you to discuss their options.
  • Statin therapy should also 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. Discuss creating a realistic, individualized exercise routine based on the patient’s ability and interests. Encourage a healthy diet based on the patient’s culture and locally available produce, stores, and resources.

If you have any questions or concerns about Anthem Blue Cross and Blue Shield you can contact the phone number on the back of the member’s ID card for Provider Services.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

MULTI-BCBS-CRCM-015194-22-CPN14452

AdministrativeCommercialMedicare AdvantageMarch 1, 2023

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Carelon Medical Benefits Management (formerly AIM Specialty Health) Radiology Clinical Appropriateness Guidelines CPT code list update

This communication applies to Commercial and Medicare Advantage plans from Anthem Blue Cross and Blue Shield.

Effective for dates of service on and after June 1, 2023, the following code updates will apply to the Carelon Medical Benefits Management, Inc. Radiology Clinical Appropriateness Guidelines.

Advanced imaging of the abdomen and pelvis

CPT®

 code

Description

0648T

Quantitative magnetic resonance for analysis of tissue composition (for example, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation, and report, obtained without diagnostic MRI examination of the same anatomy (for example, organ, gland, tissue, target structure) during the same session.

Oncologic imaging

CPT code

Description

0633T

CT Breast W/3d Rendering Uni without contrast

0634T

CT Breast W/3d Rendering Uni with contrast

0635T

CT Breast W/3d Rendering Uni with or without contrast

0636T

CT Breast W/3d Rendering Bi without contrast

0637T

CT Breast W/3d Rendering Bi with contrast

0638T

CT Breast W/3d Rendering Bi with or without contrast

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon in one of several ways:

  • Access the ProviderPortalSM directly at providerportal.com.
    • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
  • Access the Availity* website at availity.com.

If you have questions related to guidelines, please email MedicalBenefitsManagement.guidelines@carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Carelon Medical Benefits Management, Inc. is an independent company providing some utilization review services on behalf of Anthem Blue Cross and Blue Shield.

MULTI-BCBS-CRCM-013590-22-CPN12763

AdministrativeCommercialMarch 1, 2023

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

New policy for EMR clinical data sharing and ADT notifications

Effective June 1, 2023, Anthem Blue Cross and Blue Shield (Anthem) is implementing a new policy related to submission of certain clinical data that builds upon our 2021 policy regarding sharing of ADT notifications.

When requested by Anthem, providers will be required to submit clinical data (such as discharge summaries, consult notes, and medication lists) and admission, discharge, and transfer (ADT) data to Anthem for certain healthcare operations functions. We collect this data to improve the quality and efficiency of healthcare delivery to our members. Providers are required to submit:

  • ADT data to Anthem on a near real-time basis (no later than 24 hours) from the time of admission, discharge, or transfer of a member.
  • Clinical data for a member on a daily, weekly, or monthly basis, based on the provider's electronic medical record (EMR) or other electronic data sharing capabilities.

Anthem’s permitted uses of the data with respect to clinical data requests include utilization management, case management, identification of gaps in care, conducting clinical quality improvement, risk adjustment, documentation in support of HEDIS® and other regulatory and accrediting reporting requirements, and for any other purpose permitted under HIPAA.

Anthem has determined the data requested is the minimum necessary for Anthem to accomplish its intended purposes. The data will be provided in accordance with data layout and format requirements defined by Anthem.

We value you as our partner in providing quality care and appreciate your continued participation in our network.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

MULTI-BCBS-CM-017652-23

AdministrativeCommercialMedicare AdvantageMarch 1, 2023

You are invited: Advancing Mental Health Equity for Youth & Young Adults

Register today for the Advancing Mental Health Equity for Youth & Young Adults forum hosted by Anthem Blue Cross and Blue Shield (Anthem) and Motivo* for Anthem providers on March 15, 2023.

Anthem is committed to making healthcare simpler and reducing health disparities for youth and young adults. We believe that advancing health equity for young people is critical to not only improving their experience, but also ensuring the mental health system is a safe and trusted resource. Authentic conversations lead to reducing implicit bias and improving the health and wellbeing of all Americans and the communities in which we live and serve.

Wednesday, March 15, 2023
4 to 5:30 p.m. ET

Please register for this event by visiting this link.

Please join us to hear from a diverse panel of experienced professionals from Motivo and Anthem as we discuss the intersection of mental health, race, sexual orientation, gender identity, disability, and supporting youth and young adults on their mental health journey.

Each quarterly forum will continue the exploration of ways we can reduce disparities in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase diversity equity and inclusion in healthcare.

* Motivo is an independent company providing a virtual forum on behalf of Anthem Blue Cross and Blue Shield.

MULTI-BCBS-CRCM-017473-23-CPN17407

ATTACHMENTS (available on web): MULTI-BCBS-CRCM-017473-23-CPN17407 EXPRESS Racial Equity Forum Q1 2023_FINAL.pdf (pdf - 0.49mb)

AdministrativeCommercialMarch 1, 2023

March is National Colorectal Cancer Awareness Month

In conjunction with National Colorectal Cancer Awareness Month, Anthem Blue Cross and Blue Shield (Anthem) would like to remind healthcare professionals to raise awareness to their patients about colorectal cancer screenings.

Encourage your patients to make time for regular colorectal cancer screenings. It’s one of the most valuable ways they can protect their health and peace of mind. Colorectal cancer is the third most common type of cancer among adults, but it often doesn’t show any symptoms, especially at first.

The good news is that the survival rate for colorectal cancer is about 90% when it’s caught early, before it’s had the chance to spread. Regular screenings are the number one way to detect it, but many adults who need screenings don’t get them. Making these important tests a priority is about your patients staying healthy and strong for the ones they love.

The American Cancer Society[1] recommends that most adults have regular colorectal cancer screenings from age 45 to age 75. Talk to your patients about when and how often they should be tested and what kind of screening is right for them.

You and your Anthem patients have access to high-quality, low-cost colorectal cancer screening fecal immunochemical test (FIT) kits by Labcorp and Quest Diagnostics. If you have specific questions, contact the labs directly:

To find Labcorp, Quest Diagnostics and other participating labs in your patient’s plan network, select Find Care from the Provider Resources menu at https://www.anthem.com.

[1] Colorectal Cancer Guideline | How Often to Have Screening Tests

MULTI-BCBS-CM-018516-23

Reimbursement PoliciesCommercialMarch 1, 2023

Reimbursement policy update: Modifiers 25 and 57 - Professional

Effective March 1, 2023, the Modifiers 25 and 57: Evaluation and Management with Global Procedures reimbursement policy will be renamed Modifiers 25 and 57 - Professional. Additionally, the Nonreimbursable section of the Modifiers 25 and 57 policy was updated to indicate that CPT® code 99211 is not eligible for reimbursement when billed with modifier 25. This update was previously communicated in the July 2022, edition of the Provider News article titled Reimbursement Policy update:Modifier Rules – Professional:

For specific policy details, visit the following Reimbursement Policy pages at the Anthem Blue Cross and Blue Shield website:

MULTI-BCBS-CM-018757-23

Products & ProgramsCommercialMedicare AdvantageMarch 1, 2023

Consumer payment option, Pay Doctor Bill, to terminate effective March 31, 2023

The provider payment option, Pay Doctor Bill, offered to consumers via InstaMed,* will be terminated effective March 31, 2023. Anthem contracted with InstaMed to deliver options for consumers to view their claims and pay their out-of-pocket responsibility to doctors from the Sydney Health mobile app or from https://www.anthem.com/provider.This is not related to the payment of health insurance premiums.

Even though this option will no longer be available, consumers still have other ways of paying doctors:

  • Through a Health Savings Account (HSA) or Flexible Spending Account (FSA) if they have this type of account
  • Through their bank’s bill pay feature on a mobile app or website
  • Directly through doctor’s secure payment website or at the doctor’s office with a debit or credit card

A month prior to the termination of Pay Doctor Bill from the Sydney Health mobile app and the Anthem website, we will notify consumers within these applications.

* InstaMed is an independent company providing consumers with access to provider payment options on behalf of the health plan.

MULTI-BCBS-CRCM-015142-22-CPN14680

PharmacyCommercialMarch 1, 2023

Pharmacy information available on our provider website

Visit the Drug Lists page on our provider website at https://www.anthem.com/ms/pharmacyinformation/home.html for more information about:

  • Copayment/coinsurance requirements and their applicable drug classes.
  • Drug lists and changes.
  • Prior authorization criteria.
  • Procedures for generic substitution.
  • Therapeutic interchange.
  • Step therapy or other management methods subject to prescribing decisions.
  • Any other requirements, restrictions, or limitations that apply to using certain drugs.

The commercial and exchange drug lists are posted to the website quarterly on the first day of the month in January, April, July, and October.

To locate the exchange, select Formulary and Pharmacy Information, and scroll down to Select Drug Lists. This drug list is also reviewed and updated regularly as needed.

Federal Employee Program pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.

MULTI-BCBS-CM-018448-23, MULTI-BCBS-CM-024728-23-CPN24621

PharmacyCommercialMarch 1, 2023

Notice of Material Amendments to Contract and/or Change to Prior Authorization Requirements

Specialty pharmacy updates for March 2023

Prior authorization clinical review for non-oncology use of specialty pharmacy drugs is managed by the Anthem Blue Cross and Blue Shield medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by Carelon Medical Benefits Management, Inc., 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 submit a prior authorization review for your patients’ continued use of these medications.

Including the national drug code on your claim may help expedite claim processing for drugs billed with a not otherwise classified code.

Prior authorization updates

Effective for dates of service on and after June 1, 2023, 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)

CC-0227

Briumvi (ublituximab)

J3490, J3590

CC-0228

Leqembi (lecanemab)

J3490, J3590

CC-0229

Sunlenca (lenacapavir)

J3490, C9399

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 January 17, 2023, 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)

CC-0227

Non-preferred

Briumvi (ublituximab)

J3490, J3590

 Quantity limit updates

Effective for dates of service on and after June 1, 2023, 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)

CC-0227

Briumvi (ublituximab)

J3490, J3590

CC-0229

Sunlenca (lenacapavir)

J3490, C9399

* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

MULTI-BCBS-CM-019364-23-CPN18451

State & FederalMedicaid Managed CareMarch 1, 2023

Member referrals: Employment Services Program and Housing Flex Funds

If you work with a patient who is an Anthem Blue Cross and Blue Shield (Anthem) consumer, they may be eligible for Anthem’s Employment Services and Housing Flex Funds programs.

Referring patients:

  • Visit the Employment Services Program or the Housing Flex Funds page on The Community Resource Link.*
  • Search for the programs using The Community Resource Link here. Enter your ZIP code and search for Employment Services Program or Housing Flex Funds. Select Apply Here and fill out the required information.

What if I have questions?

If you have any question, reach out to employmentservicesohio@anthem.com or housingohio@anthem.com.

* Availity, LLC, offering The Community Resource Link, is an independent company providing administrative support services on behalf of the health plan.

OHBCBS-CD-017798-23

State & FederalMedicaid Managed CareMarch 1, 2023

Enhancing Provider News website and email communications

We are committed to improving the way we do business with our provider community. Listening to your feedback, we are pleased to announce a new look and feel is coming to Provider News in the first half of 2023, with additional improvements planned throughout the rest of the year.

Stay tuned for more updates.

OHBCBS-CD-018148-22-CPN15788

State & FederalMedicaid Managed CareMarch 1, 2023

Member ID cards

On February 1, 2023, the Ohio Department of Medicaid (ODM) launched the Next Generation Managed Care Plans. On the same day, the fiscal intermediary and electronic data interchange was implemented. Information regarding ODM’s Next Generation program can be found here.

Providers should verify eligibility at each member appointment. If you have an ODM approved established trading partner, you can check eligibility on ODM’s Provider Network Management website (PNM) or thru Availity Essentials.* If you do not have a relationship with an established ODM trading partner, you can check eligibility and benefits on Availity Essentials.

All claims and prior authorization requests should be submitted utilizing the member ID. If you have an established ODM approved trading partner, submit claims thru ODM’s fiscal intermediary via your approved trading partner. If you do not have an approved ODM trading partner, submit claims thru Availity Essentials.

Submit all prior authorization requests directly to Anthem Blue Cross and Blue Shield (Anthem) either thru Availity Essentials or by fax. Anthem’s payer ID for Ohio Medicaid claims is 0002937.

You can find more information on:

  • Verifying eligibility, submitting claims, and requesting prior authorization in our provider manual.
  • Availity Essentials at availity.com/Essentials-Portal-Registration:
    • To register for Availity Essentials training, select Help & Training | Get Trained from Availity’s home page once you have an Availity user ID and password.

The ODM logo and information for both Member and Provider Services is displayed on the back of the member ID card. If you have any questions, contact your Provider Relationship Account Manager directly, or submit your question to our shared email at OhioMedicaidProvider@anthem.com.



* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

OHBCBS-CD-018512-23

State & FederalMedicare AdvantageMarch 1, 2023

Controlling High Blood Pressure and Submitting Compliant Readings

The Controlling High Blood Pressure (CBP) HEDIS® measure can be challenging as it not only requires proof of a blood pressure (BP) reading, but also that the patient’s blood pressure 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 140/90 mmHG. As we start a new year, it’s important that we have record of your patients’ blood pressure readings and that you continue to monitor patients with elevated readings.

Tips when scheduling members to close CBP care gaps:

  • When scheduling appointments, have staff ask patients to avoid caffeine and nicotine for at least an hour before their scheduled appointment time.
  • If possible, update your scheduling app and/or your reminder text message campaigns to include reminders about abstaining from caffeine and nicotine prior to appointment time 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 blood pressure at both the start and end of the appointment and document the lower reading.
  • Readings can also vary arm to arm. If slightly elevated in one arm, try the other and document the lower reading.


Getting credit for adequately controlled blood pressure readings:

  • Submit readings via Category II CPT® codes on claims.

    Description

    Code

    Diastolic BP

    CAT II: 3078F-3080F

    LOINC: 8462-4

    Diastolic 80 to 89

    CAT II: 3079F

    Diastolic greater than/equal to 90

    CAT II: 3080F

    Diastolic less than 80

    CAT II: 3078F

    Systolic BP

    CAT II: 3074F, 3075F, 3077F

    LOINC: 8480-6

    Systolic greater than/equal to 140

    CAT II: 3077F

    Systolic less than 140

    CAT II: 3074F, 3075F

  • Ensure readings are carefully and appropriately documented within your electronic medical record system.
  • If you have questions on how to submit readings, speak to your care or practice consultant.
  • Also, be sure to adequately code patients who meet the exclusion criteria:
    • Exclusions:
      • Palliative care
      • Enrolled in hospice
      • Frailty and/or advanced illness
      • Living in long-term care
    • Optional exclusions:
      • Dialysis (ESRD), kidney transplant, nephrectomy
      • Female members with a diagnosis of pregnancy
      • Non-acute inpatient admissions

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

MULTI-BCBS-CR-012306-22-CPN10532

State & FederalMedicare AdvantageMarch 1, 2023

Annual planned visits

An annual planned visit (APV) can be a significant driver of positive health outcomes and engagement with a patient’s provider. There are three main types of important, but often underutilized, APVs: initial preventive physical exam (IPPE), annual wellness visit (AWV), and annual routine physical (ARP). By engaging your patient early in the year to schedule these visits, there is opportunity to increase your APVs in 2023, and, in turn, improve the health of your patients and increase your success in the value-based programs (VBPs) you may participate in.


The AWV is an important opportunity to address up to 20 Medicare Advantage Stars measures that encompass both clinical quality and patient experience. The development of a personalized prevention plan is a required component of the AWV and can be a useful tool in leading these conversations with patients.

(AMJC).

The terms AWV and ARP are often incorrectly used interchangeably, which can cause confusion as these services are vastly different. AWVs are visits that are focused on preventive care, screenings, and the development of a personalized prevention plan. While an AWV includes taking standard measurements such as blood pressure, height, and weight, no hands-on physical exam is performed. The ARP is more extensive than an AWV in that it consists of a comprehensive, multi-system physical exam and includes bloodwork and other lab tests that are all based on the patient’s age, gender, and identified risk factors.

Note: An AWV and ARP may be performed during the same visit and providers can submit one claim that includes codes for both.



While the AWV may seem to have many requirements, several components of this visit can be performed by care team members other than the provider. See the sample workflow below that highlights steps that office staff can complete.


It is essential for providers to complete an APV for each of their assigned Medicare members. These visits help keep patients healthy and can increase practice revenue. For more tools and resources, please visit https://www.anthem.com/provider/medicare-advantage/ or reach out to your provider representative.

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State & FederalMedicare AdvantageMarch 1, 2023

Shared savings and transition care management after inpatient discharges

Anthem Blue Cross and Blue Shield is actively seeking to promote CMS’s transition care management (TCM) program for its Medicare members.

The goal is to ensure comprehensive physician follow-up and management of patients within seven and/or 14 days of discharge from hospital, skilled nursing facility (SNF), inpatient rehabilitation hospital (IRF), or long-term acute care hospitals (LTAC). And thus, to minimize clinical relapses, that often result in acute hospital readmissions, within 30-days of discharge.

CPT® codes for these visits are:

  • 99496 (post-discharge comprehensive follow-up within seven days): pays between $250 to $350, depending on region, and;
  • 99495 (post-discharge follow-up within 14 days): pays between $190 to $260, depending on region. 

The primary intent for these visits is close post-discharge patient follow up with comprehensive physician/provider management of ongoing chronic comorbidities. So, visits should include:

  • Review of the discharge information
  • Medication reconciliation
  • Treatment of acute exacerbations and/or fluctuations in the physician office as appropriate
  • Active management of and attention to chronic renal, lung, cardiac, skeletal, social, caregiver, etc. conditions, and providers should:
    • Review the need for pending diagnostics, and/or follow up of said diagnostics.
    • Interact with other healthcare professionals who may assume care of any system-specific problems.
    • Educate the patient, family, and caregiver.
    • Establish referrals, arrange needed community resources, address/assist/advise the member/family with relevant caregiver needs.
    • Help schedule required community providers and services follow-up.
    • Comprehensively and holistically manage common chronic/acute medical conditions seen after hospital discharge, such as (but not limited to): Heart failure, COPD, DM, AFIB, DVT, cellulitis, pneumonia, dehydration, AMS, encephalopathy, AKI, polypharmacy/medication reconciliation, and even custodial/social needs impacting/resulting in admission(s).

CMS encourages TCM for Medicare members. CMS has detailed fact sheets explaining the program, and billing, see resources below:

Appendix

CPT 99496 coding requirements:

  1. Attestation that the initial communication between patient/practitioner began within two business days of discharge:
    1. Geared to patients with conditions requiring medium or high-level decision-making
    2. Direct contact: telephone/electronic
  2. Face-to-face visit within seven days of DC. Cannot be virtual
  3. Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
  4. Includes DC from hospitals, SNFs, IRFs, and LTACs
  5. Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living

    CPT 99495 coding requirements:
  6. Attestation that the initial communication between patient/practitioner began within two business days of DC:
    1. Geared to patients with conditions requiring at least moderate complexity decision-making
    2. Direct contact: telephone/electronic
  7. Face-to-face visit within 14 days of discharge. Cannot be virtual
  8. Clinician-patient visit can be done by physician, PA, or nurse practitioner, or other practitioners as authorized by state law
  9. Includes DC from hospitals, SNFs, IRFs, and LTACs
  10. Includes time spent coordinating patient services for specific medical care or psychosocial needs and guiding them through activities of daily living

MULTI-BCBS-CR-018709-23-CPN18422

State & FederalMedicare AdvantageMarch 1, 2023

Informational Update Modifier Usage

(Policy G-06006)

The Modifier Usage policy is aligning with Medicare modifier requirements by adding the following to our Related Coding section:

  • Modifier CO — Outpatient occupational therapy assistant services
  • Modifier CQ — Outpatient physical therapy assistant services

Additionally, Modifier FB (Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples) was expanded to facility providers.

For additional information, please review the Modifier Usage reimbursement policy at https://www.anthem.com/medicareprovider.

MULTI-BCBS-CR-015034-22-CPN10025

State & FederalMedicare AdvantageMarch 1, 2023

Keep up with Medicare News - March 2023