• Level of Care medical necessity reviews for upper and lower endoscopy procedures begin June 1, 2020*
• National Drug Code requirement on outpatient claims*

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

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

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

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

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

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

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

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

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

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

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

Patient360 is a real time dashboard you can access through the Availity Portal that gives you a robust picture of your Anthem Blue Cross and Blue Shield (Anthem) patient’s health and treatment history and will help you facilitate care coordination.

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

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

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

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

Are you using Patient360 for the first time? You can easily access Patient360 on the Availity Portal. First, you need to be assigned to the Patient360 Role which your Availity Administrators can locate within the Clinical Roles options.

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

Things to remember…

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

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

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

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

Effective with dates of service on or after June 1, 2020, members with commercial plans covered by Anthem will require a medical necessity review of the hospital outpatient level of care for certain upper endoscopy and colonoscopy procedures. The clinical guideline, Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services, CG-SURG-52, will apply to the review process. The review will be administered by AIM Specialty Health_® (AIM).

AIM will evaluate the clinical information in the request against CG-SURG-52, to determine if the hospital-based outpatient setting is the appropriate level of care for the endoscopy service. Your office may contact AIM to request a peer-to-peer discussion before or after the determination.

The level of care medical necessity review only applies to procedures performed in an outpatient hospital setting. This does not apply to requests for review of endoscopy performed in a non-hospital setting or as part of an inpatient stay. Reviews also do not apply when Anthem is the secondary payer.

For a complete list of procedures subject to the medical necessity level of care review, and additional information, such as Frequently Asked Questions, visit aimproviders.com/surgicalprocedures.

Submit a request for review

Starting May 18, 2020, ordering providers may submit prior authorization requests for the hospital outpatient level of care for these procedures for dates of service on or after June 1, 2020 to AIM in one of the following ways:

• Access AIM ProviderPortal_SM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
• Access AIM via the Availity Web Portal at availity.com
• Call the AIM Contact Center toll-free number: 800-554-0580, Monday – Friday, 8:30 a.m. – 7:00 p.m. ET.

AIM will offer webinars, beginning in May, to provide information on navigating the AIM ProviderPortalSM. To register for a webinar visit aimproviders.com/surgicalprocedures.

Please note, this review does not apply to the following plans: BlueCard_®, Federal Employee Program_® (FEP_®), Medicaid, Medicare Advantage, Medicare Supplemental plans. Providers can view prior authorization requirements for Anthem members on the Medical Policy & Clinical UM Guidelines page at anthem.com.

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

Note: In some plans “site of service” or another term such as “setting” or “place of service” may be the term used in benefit plans, provider contracts or other materials instead of or in addition to “level of care” and in some plans, these terms may be used interchangeably.  For simplicity, we will use “level of care.”

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

• Benefits update for special supplemental benefits for the chronically ill
• Prior authorization requirements for CardioMEMS

This relationship with AIM will enable Anthem to expand and optimize this program, further ensuring that care aligns with established evidence-based medicine. AIM will follow the clinical hierarchy established by Anthem for medical necessity determination. Anthem makes coverage determinations based on guidance from CMS, including national coverage determinations, local coverage determinations, other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.

AIM will continue to use criteria documented in Anthem clinical guidelines CG.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://medicalpolicies.amerigroup.com/am_search.html.

Detailed prior authorization requirements are available online https://www.availity.com by accessing the Precertification Lookup Tool under Payer Spaces. Contracted and non-contracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.

Prior authorization review requirements

For services to be rendered for dates of service from October 1, 2019, through March 31, 2020, no prior authorization is required for outpatient rehabilitation services. For these service dates, in addition to all other rights Anthem has under our provider contract and law, Anthem and AIM will continue to monitor claims history and utilization trends and will validate provider and member information.

AIM will facilitate training sessions to provide an overview of the program and demonstrate the AIM ProviderPortal_SM. Please access the AIM Rehabilitation Provider Portal to register for an upcoming session.

For services that are scheduled on or after April 1, 2020, providers must contact AIM to obtain prior authorization. Beginning March 19, 2020, providers will be able to contact AIM for prior authorization of services to take place on or after April 1, 2020. Providers are strongly encouraged to verify that they have obtained prior authorization before scheduling and performing services.

How to place a review request

You may place a prior authorization request online via the AIM ProviderPortal. This service is available 24/7 to process requests in real time using clinical criteria. Go to www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday through Friday 7 a.m. to 7 p.m. Central time.

For more information

For resources to help your practice get started with the Outpatient Rehabilitation Program, go to www.aimproviders.com/rehabilitation. For portal login Issues, call 1-800-252-2021.

The AIM website provides access to useful information and tools, such as order entry checklists, clinical guidelines and an FAQ.

506914MUPENMUB

This team member will work with the facility to understand the member’s needs, discharge plan and possible home needs. If your patient is sent to a post-acute setting, we will also work with that facility to understand any barriers to discharge and referrals to other Medicare programs.

If the member requires assistance after discharge, we will offer a team member to help the member receive necessary referrals to identified programs, help the member follow their discharge plan and assist in making any necessary appointments to see their doctors. 

This is a collaborative program; we need your help to understand what your patients need to be successful upon discharge and to reach our common goal – avoidance of readmissions and ER utilization.

We look forward to working with you, and the acute and post-acute facilities that offer this value added program to our Medicare Advantage population.

507415MUPENMUB

Submit claims electronically through Availity

Availity is well known as a web portal and claims clearinghouse, but they are much more. Availity also functions as an electronic data interchange (EDI) gateway for multiple payers and is the single EDI connection for all of Anthem, Inc. It will allow you to submit claims electronically, verify pre-authorization and member information, check claims status, and much more.

To get started, go to https://www11.anthem.com/edi and select your state.

507288MUPENMUB

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

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

Thank you for your continued participation. Should you have any questions, please call the Provider Services number located on the back of the member’s card.

507411MUPENMUB

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

507643MUPENMUB

This communication applies to the Medicaid and Medicare Advantage programs for Anthem Blue Cross and Blue Shield (Anthem).

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

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

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

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

• Medicaid: 1-855-558-1443
• Medicare Advantage: Call the number on the back of members’ ID cards.

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

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

Neurobehavioral status exams

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

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

Test administration and scoring by a psychologist or neuropsychologist

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

Test administration and scoring by a technician

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

Testing evaluation services 

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

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

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

Single automated test administration

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

Screening and risk assessment (repetitive assessment after screening)

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

For questions, please contact Provider Services at 1-855-558-1443.

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

Appropriate Testing for Pharyngitis (CWP)

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

Appropriate Treatment for Upper Respiratory Infection (URI)

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

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

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

Helpful tips:

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

Resources:

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

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

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

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

Testing for HIV:

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

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

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

Major HIV-related conditions

HIV/AIDS prevention

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

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

The CDC remains on the forefront of pursuing high-impact prevention. This approach is designed to maximize the impact of prevention efforts for all Americans at risk for HIV infections and the CDC is aligning its efforts with the first National HIV/AIDS Strategy for the United States (NHAS). The Division of HIV/AIDS Prevention has developed a strategic three-year plan for 2017-2020 with the goal of one day achieving a future free of HIV.

Resources:

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