Blue Cross and Blue Shield of Nebraska Moves to New Building

For the fifth consecutive year, BCBSNE encourages employees in organizations across the state to walk for a minimum of 30 minutes over the lunch hour. Will you join us on Wednesday, April 27?

To register your company and employees, visit BCBSNE.com. Here, you also can print free promotional materials to post at your office or hand out to employees.

Help us, as well as dozens of other statewide organizations, to promote a healthy lifestyle by signing up your company and encouraging your employees to walk.

Have questions or want more information? Contact Nate Odgaard at [email protected] or (402) 982-6528.

P A R T N E R I N G W I T H Y O U F O R A H E A L T H I E R N E B R A S K Abcbsne.com

UpdateS P R I N G 2 0 1 1 | I S S U E 1 An Independent Licensee of the Blue Cross and Blue Shield Association.

Blue Cross and Blue Shield of Nebraska Moves to New Building Blue Cross and Blue Shield of Nebraska has relocated its corporate headquarters to Omaha’s Aksarben Village. In the best interest of our members, we decided it was no longer cost-efficient to own and maintain three separate buildings on our former campus. Those buildings will be marketed and sold.

The move to a leased facility offers several advantages:

• Aminimumcostsavingsof$2million a year

• Freescapitaltoenhancememberservices

• Increasesoperationalefficiency• Supportsourgoalofreducingcosts

Our new physical address is: Blue Cross Centre 1919 Aksarben Dr. Omaha, NE 68106

While the physical address has changed, please note our mailing address, P.O. Box of 3248, Omaha, NE 68180-0001, remains the same.

In addition to Blue Cross Centre, we also have our other two locations:

Member Service Headquarters – Omaha 2707 N. 118th St.Omaha, NE 68164

Lincoln Office1233 Lincoln MallLincoln, NE 68508

We look forward to serving you from our newest location for many years to come.

The Update is a bimonthly provider newsletter that contains up-to-date information about Blue Cross and Blue Shield of Nebraska (BCBSNE) for health care providers. It is published by the Health Network Management Services Department (HNS).

If you are a contracting BCBSNE health care provider, this newsletter serves as an amendment to your agreement and affects your contractual relationship with us. You are encouraged to file every issue of the Update within your BCBSNE Policies and Procedures manual and reference it often. You may also view the current manual in the Provider section at bcbsne.com.

As a service for Blue Cross and Blue Shield members, we also send this newsletter to non-participating Nebraska providers.

We also publish each issue online in the Provider section at: bcbsne.com

For permission to reprint material published in the Update, e-mail the editor, Kimberly Vavra, at:

[email protected]

Blue Cross Centre

Website Enhancements Coming Soon!

National Walk @ Lunch Day April 27

Your online access to member benefits, eligibility, claim status and remittance advice information is coming soon. Stay tuned for future communications.

GO PAPERLESS! Register to receive this newsletter electronically: bcbsne.com/providers/library/newsletter.aspx

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The Identification Card is the Key As groups continue to migrate to NEtwork BLUE each month, members of those groups are issued new I.D. cards.

Each time a member visits your office, please ask to see their identification card. This will help to ensure there isn’t a delay in processing your claim due to an incorrect identification number.

BlueBoard

Newborn Inpatient Claims Require Birth WeightEffective April 1, 2011, BCBSNE will require the birth weight on newborn inpatient claims.

We recommend that you now begin coding the fourth and fifth digit sub-classification values on diagnosis codes to allow for better quality, outcome reporting and case management for members. Your coding input allows us to group according to severity of illness and risk of mortality to provide you with enhanced reporting and analysis. Birth weights may also impact your reimbursement in the future, so start coding it today.

Please populate the newborn weights in the fourth and fifth digits of the following ICD-9 categories: 764.xx – 765.xx or V30.xx – V39.xx

Hourly Pulmonary Rehabilitation Billing ReminderPer-hour pulmonary rehab, which includes exercise and monitoring, should be billed with Revenue Code 948 and HCPCS code G0424. No more than two units are allowed to be billed per day.

Modifiers 25 and 26 Not Valid on Surgery CPT CodesModifier 25 (significant, separately identifiable evaluation and management services by the same physician on the same day of the procedure or other service) and Modifier 26 (Professional Component) are invalid for surgery procedures (CPT codes 10000-69999). Claims with either modifier on a surgery code(s) billed to BCBSNE will be returned. Contact your Health Network Consultant if you have any questions.

One-Month/One-Year Claim Billing SpansClaims need to be split by monthly dates of service, per claim. Claims spanning into the next month will require a new claim for each month that services were provided. Claims spanning the end of a calendar year will need to be split to separately reflect charges and dates of service for the next year.

Time Limit for Medical Records When a medical record request is sent to a provider office by BCBSNE, the information must be received within 21 calendar days to avoid claim denial for insufficient rationale.

Although the denied claim will be reviewed and adjusted upon receipt of the required medical record information, it is the responsibility of the provider to send the requested information in a timely manner. Please assist us by avoiding unnecessary claim denials resulting in costly claim adjustments.

Revenue Code 360 ClarificationWhen billing for surgical procedure codes under revenue code 360, the units column must always be one. Claims billed with multiple units will be returned for correction.

Question: I’m stumped. Our provider removed a lesion at a preventive medicine well child check. The lesion removal was paid but the well child check was denied as inclusive to the lesion removal. Help!

Answer: The lesion removal has a ten-day post-operative period and the preventative medicine visit conflicts with an edit which says any services provided by the rendering provider during that time are inclusive.

Solution: In these situations, make sure you attach a modifier -25 to the code for the preventive medicine visit.

Q&A - Why was a well child check denied in conjunction with another service?

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Seeking Your Feedback for BlueCard Process ImprovementsYour feedback is important to help us make improvements in our processes and make your interactions with us a smooth and simple experience.

For 2011, you will have an opportunity to tell us how we are doing via phone and/or by completing an online satisfaction survey. The current wave of the BlueCard Provider Office Staff Satisfaction survey began February 14 and runs through May 16, 2011. During this time, you may receive a call on behalf of BCBSNE seeking input on your experience with servicing out-of-area members. Our research vendor may invite you to participate in the online survey and collect your e-mail address.

If your office is contacted, we encourage you to participate. We take your feedback seriously by using the survey results to incorporate improvements to the BlueCard process.

National Blue Doctor and Hospital Finder 2011 Audit ScheduleIn an effort to ensure the accuracy of information published in the National Blue Doctor and Hospital Finder, the Blue Cross and Blue Shield Association

BlueCard Bulletinconducts quarterly audits of the individual provider information sent by each Blue Cross and/or Blue Shield plan. The audit is used to validate provider information such as name, practice address, telephone number, and specialty.

A very important component of the audit is a telephone outreach to the offices of randomly selected providers listed on the website. The calls are conducted by representatives of Thoroughbred Research, the vendor selected by the Blue Cross and Blue Shield Association.

If your office receives a call to validate the provider information that we have published for you on the website, we ask that you take a few minutes to verify your information.

The 2011 call schedule is as follows:• April 11-25 • July 11-25 • October 10-24

At your service: Your BCBSNE Health Network Consultants

West Region, Charlie KennedyP.O. Box 3248, Omaha, NE 68180-0001Phone: (402) 982-7638 or (800) 821-4787 (options 1,1)Fax: (402) 398-3875E-mail: [email protected]

Lincoln, Cindy Rutledge1233 Lincoln Mall, Lincoln, NE 68508-2802Phone: (402) 458-4806 or (800) 821-4787 (options 1,3)Fax: (402) 477-2952E-mail: [email protected]

East Region, Sue McHargue1233 Lincoln Mall, Lincoln, NE 68508-2802Phone: (402) 458-4807 or (800) 821-4787 (options 1,4)Fax: (402) 477-2952E-mail: [email protected]

Central Region, Loraine MillerP.O. Box 3248, Omaha, NE 68180-0001Phone: (402) 982-8321 or (800) 821-4787 (options 1,2)Fax: (402) 343-3404E-mail: [email protected]

Omaha, Vickie RichterP.O. Box 3248, Omaha, NE 68180-0001Phone: (402) 982-6753 or (800) 821-4787 (options 1,7)Fax: (402) 343-3446E-mail: [email protected]

Omaha, Patricia Cavanaugh(The Nebraska Medical Center Paramount, UNMC Physicians, DPM, DDS, Psych, PT, OT, ST, HME, Ambulance, Home Health, Hospice)P.O. Box 3248, Omaha, NE 68180-0001Phone: (402) 982-7639 or (800) 821-4787 (options 1,8)Fax: (402) 343-3441E-mail: [email protected]

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Outpatient Observation Guidelines for NEtwork BLUE and BluePreferred The following charts outline the differences between the NEtwork BLUE and BluePreferred guidelines for outpatient observation. Additional information is also included regarding NEtwork BLUE and BluePreferred inpatient admissions as they are related to outpatient admissions.

NEtwork BLue BluePreferred

Observation definition: Observation Services are outpatient services where the patient is being held to determine if he or she should be admitted, discharged home or sent to another provider

A physician must justify and provide the order on the patient. Medical record documentation must prove that the patient was admitted to observation.

For all networks, BCBSNE will follow the Medicare definition, which requires the use of a bed and nursing services.

Observation is NOT:• A substitute for an inpatient admission• For continuous monitoring• For medically stable patients who need diagnostic testing or

outpatient procedures• For patients who routinely need therapeutic procedures

provided in an outpatient setting• For patients waiting for nursing home placement• To be used as a convenience to the patient, his or her family,

the hospital or the attending physician• For routine prep or recovery prior to or following diagnostic

or surgical services

Also note the following:• Observation services will only be defined under revenue

code 762. • Revenue code 761 is for a treatment room and should not

be used in place of an observation room.

Observation services will be paid as an outpatient service type under the outpatient provider contract provisions.

Observation claim billing elements:a. Outpatient bill type (i.e.131)b. FL 42 must be revenue code 762c. FL 44 must include a valid CPT or HCPC coded. Each observation day must be billed as a separate line item

with the actual date of service in FL 45e. FL 46 must equal 1 for each 762 line item

There are no limits or parameters around the number of hours of observation or a requirement to roll into an inpatient claim if the patient is admitted and BCBSNE is the primary payer.

For each 24-hour increment or day of an observation stay in the outpatient setting, a separate line item must be billed under revenue code 762 with the service date on each line.

Revenue code 762 for observation requires a CPT or HCPCS code on the line. Claims will be returned if the code is not provided on

In relation to inpatient admissions If an observation stay results in an inpatient admission, you must file the observation stay claim separate from the inpatient claim. Revenue Code 769 is not valid for reporting observation services and will be returned for proper coding.

Observation definition: Observation services refers to the period of treatment when the physician is evaluating the patient’s medical condition to determine whether the patient can be released from the outpatient department or admitted to the facility as an inpatient; the period of treatment following an outpatient procedure when the physician is evaluating the patient’s medical condition to determine whether the patient can be released from the outpatient department.

The observation period is not to be used as a preoperative day or for diagnostic work-ups, and any facility charges for such use are subject to denial.

The maximum reimbursement amount for an observation period is up to one day’s accommodation charge. For the convenience of the facility or the convenience of the patient, the facility may allow the patient to remain longer than 24 hours without further reimbursement.

In relation to inpatient admissions Observation is employed when the necessity of admission is unclear at the time the patient enters the facility. The observation period prior to an impending inpatient admission normally should not exceed one patient day.

If an observation stay results in an inpatient admission, the observation and inpatient stays must be billed together as an inpatient claim in the following manner:

a. Bill the first day as an observation room charge in Revenue Code 762.b. Bill subsequent days as inpatient room charges.c. The billing period in FL 6 reflects the “From” date as the date of inpatient admission, and the “Through” date as the discharge date.

In relation to outpatient admissionsWhen additional observation is necessary for outpatient surgery patients following the post-operative recovery period, the observation charges should be billed in Revenue Code 762. If it is necessary to admit the patient to acute care, follow the billing instructions above.

Occasionally, circumstances may warrant an observation period in excess of one day to determine whether to admit a patient. All hospitals must bill each day of observation as a separate line item under Revenue Code 762.The maximum reimbursement amount for an observation period is up to one day’s accommodation charge. For the convenience of the facility or the convenience of the patient, the facility may allow the patient to remain longer than 24 hours without further reimbursement.

continued on next page

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If you have any questions regarding these guidelines, please contact your appointed Health Network Consultant.

BluePreferred (continued)

In relation to inpatient admissions• Revenue Code 760 is not allowed because it fails to

specify the nature of the services.• Revenue Code 761 is acceptable when an exam or

relatively minor treatment or procedure is performed. If Revenue Code 761 is used for an outpatient bill type, a CPT code describing the treatment or procedure must be also present. The amount of charges for the treatment room that will be considered in the calculation of the reimbursement amount is limited to the contracted rate for the service.

• Revenue Code 762 is acceptable when an outpatient is being observed and treated in a non-ICU/CCU setting for a period of time or when a direct inpatient admission is not clear until the results of tests or procedures are confirmed and clinical care meets the inpatient admission criteria.

• Revenue Code 762 may also be used when a surgical outpatient requires an extended treatment period following an outpatient surgical or major diagnostic procedure. The amount of charges for an observation period as noted in the preceding paragraph that will be considered in the calculation of the reimbursement is limited to the amount of the filed semi-private room rate in effect at the time of service.

• Revenue Code 769 is only to be used when a highly intensive outpatient procedure is performed (i.e., cardiac catheterization, pacemaker procedures, etc.) and an ICU/CCU level of post procedure treatment and observation is necessary and appropriate. The diagnosis code should indicate the need for this level of care. The amount of charges for an observation period as noted in the preceding paragraph that will be considered in the calculation of the reimbursement amount is limited to the amount of the filed ICU or CCU room rate in effect at the time of service.

Question: Does BCBSNE offset BluePreferred and NEtwork BLUE claims?Answer: No, offsetting only applies to NEtwork BLUE claims. We will only offset payments to the exact same provider that received the initial claim payment.

Question: How can I easily identify if a refund request has the potential for offsetting?Answer: On the right hand side of the letter, there will be verbiage that states “30 day offset notification.”

Question: I received a refund/offsetting request from BCBSNE. What is the best way to initiate an appeal on this refund/offset request?Answer: You can fax all refund appeals information to (402) 343-3322. The subject line must include “Offset” or “Offset Rush” and the offset notification letter must also be

Everything You Ever Wanted to Know about Refunds/OffsettingBut were afraid to ask!

included in the fax. If it’s a BluePreferred refund request, you can call (800) 562-3381. If it’s a NEtwork BLUE refund/offsetting request, you can call (877) 888-2374. Note: The receipt of an appeal will not stop the offsetting process. If an appeal results in overturning the original overpayment decision, the claim will be adjusted to reissue payment.

Question: When a refund is due from Bob Smith’s claim, will the offsetting take place against John Doe’s claim?Answer: No, the offset amount will be deducted from the total remit amount not taken from an individual’s claim. • $50isduetobeoffsetforaclaimoverpaymenton

member Bob Smith.• Totalremitreimbursementissupposedtobe$300.• Totalremitpaymentwillbe$250($300-$50=$250).

Question: Should I ever send in a refund check that is less than the amount requested? Answer: You should always refund the entire amount requested. Refunds received for less than the amount requested will be returned to the provider and will not disrupt the 30-day timeframe.

Question: Is there a timeframe that BCBSNE must receive my refund check? Answer: Yes, the refund check must be received in our office and processed within 30 days from the date on our refund request letter. We prefer to offset your next payment. Offsetting is much more efficient and saves time and money for both of us!

Question: Why do you sometimes return my check or send a BCBSNE check to me?Answer: When a refund request is sent, a refund check must be received within 30 days or offsetting will begin. If BCBSNE receives your refund check and does not get it deposited prior to the offsetting taking place, we will return your check to you. If BCBSNE deposits your check and offsetting has occurred, we will mail a new check to you. As you can see, offsetting is much simpler and much more efficient.

Question: Will I get a new remit following the offset process?Answer: New remits will be generated once a successful offset has occurred. The remits will show the original claim and the new adjusted claim.

Question: Do I need to send in a refund check if BCBSNE has provided notice of an offset of future payment?Answer: No. The offsetting process is designed to save resources for the provider and for BCBSNE. By sending in a check, instead of allowing the offset of future payment, this increases the time, effort, and resources used to handle the refund. All information to account for the refund is provided on the remittance when an offset of future payment is taken. Accordingly, BCBSNE strongly encourages all providers to allow the offset of future payment to occur in order to most efficiently handle this transaction.

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New Home Hospice Billing Guidelines for NEtwork BLUE ClaimsBCBSNE has recently encountered some issues when processing home hospice NEtwork BLUE claims. To correct the issues, we have developed new billing guidelines for ALL NEtwork BLUE claims, including those that have been previously submitted (but not yet paid) and future claims. These billing guidelines are effective immediately.

This change ONLY affects NEtwork BLUE member claims. NEtwork BLUE members can be identified by the following:

• NEtwork BLUE on I.D. card• Members covered by another Blue Plan• Federal Employee members (I.D. number begins with a

single ‘R’)

This change does not include or affect claims processed under the BluePreferred network. NEtwork BLUE inpatient hospice billing guidelines remain unchanged.

Please resubmit previously submitted home hospice claims as a new claim using the guidelines listed below. The newly submitted claims will not deny as duplicate. They also do not need a reconsideration form with the claim.

Home Hospice billing guidelines for NEtwork BLUE members:

Bill Type: 81X or 82X

Revenue Code 651: To be used for hospice skilled nursing visits by an RN or LPN, home health aide services and hospice social worker services

Revenue code 651 must be billed with the appropriate Q code:• Q5001 Hospice care provided in patient’s home/residence• Q5002 Hospice care provided in assisted living facility• Q5003 Hospice care provided in nursing long term care

facility (ltc) or non-skilled — nursing facility • Q5004 Hospice care provided in skilled nursing facility

(snf )• Q5005 Hospice care provided in inpatient hospital• Q5006 Hospice care provided in inpatient hospice

facility• Q5007 Hospice care provided in long term care facility• Q5008 Hospice care provided in inpatient psychiatric

facility• Q5009 Hospice care provided in place not otherwise

specified (nos)

For each day that a hospice nurse, an aide or a social worker saw the patient in an outpatient/home setting, the provider should bill the 651 Revenue Code (with the appropriate Q code). If more than one discipline has seen the patient that day, all charges must be lumped together under Revenue Code 651 and billed on a single line.

Note: Revenue Code 651 does not include drugs, infusion supplies, or any Home Medical Equipment (HME) items. These will continue to be billed by the HME company providing the service.

We apologize for the confusion and appreciate you working with us during this transitional period. If you have any questions, please contact your appointed Health Network Consultant.

Inpatient Certification RequirementsPlease be aware that BCBSNE has different requirements for member inpatient certifications based on their contract language.

For FEP members:All inpatient admissions must be certified by all hospitals within two days of admission to avoid a penalty.

For BCBSNE members:Inpatient precertification guidelines for BCBSNE members are divided into three categories. The categories and guidelines are:

• Critical access hospitals are not required to call us for precertification purposes

• Omaha and Lincoln hospitals are required to call us on the patient’s fifth inpatient day

• All other hospitals must call us on the first inpatient day

Adhering to these requirements will prevent pre-certification penalties from being passed to members.

Certification for Psychological Outpatient Visits/Psychological TestingAs of January 1, 2011, BCBSNE covered members (including those covered under the Federal Employee Program) are allowed 30 outpatient visits (therapy, partial hospitalization, intensive outpatient) and four units of psychological testing per calendar year before a medical necessity review is required.

Please note:• For Intensive Outpatient Programs, each day will

count as one visit.• Medication checks (90862) will not be included in

the count or medical necessity review.• Electroshock treatments are not included in the

count or medical necessity review.


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Additional visits beyond 30 or psychological testing beyond four units in a calendar year will require a medical necessity review prior to approval.

For BCBSNE members falling under this situation, the following are available at BCBSNE.com, under the green “Provider -09)

The applicable form(s) must be completed for FEP members and BCBSNE covered members needing more than 30 visits per calendar year or more than four hours of psychological testing in a calendar year.

2011 Federal Employee Program ClarificationsThe Federal Employee Program (FEP) has provided additional clarifications regarding the following services for members. Continue reading for additional information.

Smoking Cessation ProgramSmoking cessation treatment, classes and individual counseling services are available with no copay or deductible when provided by a covered Preferred provider. Standard Option and Basic Option members who complete the Blue Health Assessment and the Breathe™ smoking cessation module are eligible to receive smoking cessation products for free. Both over-the-counter (OTC) and prescription smoking cessation products obtained from a Preferred Retail Pharmacy are included in this program.

Members must be 18 years of age or older to participate in the Smoking Cessation Program. Eligible members may receive up to one 12-week course of therapy every 90 days. A prescription will be required for all medications; including OTC to be covered in the preventive health and smoking cessation programs.

Residential Treatment Centers

The 2011 Blue Cross and Blue Shield Service Benefit Plan brochure states that admissions to residential treatment centers (RTC) and services performed or billed by residential treatment centers are not covered.

However, covered services performed by covered mental health and substance abuse professional providers (e.g., clinical psychologist, psychiatric nurse, licensed professional counselor) while a member is either admitted to or receiving outpatient services at an RTC are eligible for benefit reimbursement only if the services are submitted with the professional provider’s billing information. If an RTC bills for the professional services, benefits are not available.

Preventive Care Preventive care benefits have been expanded and are covered in full for adults and children when provided by a Preferred provider. If the primary purpose of the visit is other than preventive care, a copay may apply even if preventive services are provided during the visit.

Some of the expanded benefits are explained in further detail below.

Preventive care benefits are covered in full for nutritional counseling visits for adults and children when provided by Preferred providers. Previously, children meeting certain criteria could receive up to four nutritional counseling visits per year at no charge through our Jump 4 Health Weight Management Program.

Nutritional counseling benefits apply when billed by a covered provider such as a physician, nurse, nurse practitioner, licensed certified nurse midwife, dietician or nutritionist, who bills independently for nutritional counseling services. Benefits are limited to individual nutritional counseling services. Benefits are not provided for group counseling services.

Preventive care benefits for adult screenings for gonorrhea, Human Immunodeficiency Virus (HIV) and syphilis are now available. Previously, preventive care benefits were not available for these services.

Maternity-Related Depression

Benefits for up to four mental health visits per year are provided in full (copay is waived when provided by a Preferred provider) for treatment of maternity-related depression during pregnancy or postpartum or both.

Mental Health and Substance Abuse Treatment Members are no longer required to obtain prior approval before receiving outpatient professional or outpatient facility care for mental health and substance abuse treatment. Previously, prior approval was required.

Hearing Aids Benefitsarepaidinfullforhearingaidsupto$1,000perearpercalendaryearforchildren,and$1,000per ear per 36 months for adults age 22 and over when provided by any qualified hearing aid provider. Members are responsible for any amount over the $1,000per-ear-allowance(nodeductible).Previously,Standard and Basic Option benefits were subject to


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member cost-sharing amounts and Basic Option benefits were limited to the services of Preferred providers.

Speech-Generating Devices Benefitsarenowprovidedinfullupto$1,000percalendar year for speech-generating devices obtained from any qualified provider. Previously benefits were subject to member cost-sharing and Basic Option benefits were limited to services of Preferred providers.

Osteopathic and Chiropractic Manipulative Treatment Benefits for osteopathic and chiropractic manipulative treatment are now provided. This includes extra spinal manipulations performed by chiropractors, limited to a combined total of 12 manipulation visits per year under Standard Option and 20 manipulation visits per year under Basic Option.

Surgery for Morbid Obesity Members must now meet specific pre-surgical criteria before receiving surgery for morbid obesity.

Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the following pre-surgical requirements:

• Diagnosis of morbid obesity per FEP definition for a period of two years prior to surgery

• Participation in a medically supervised weight loss program, including nutritional counseling, for at least three months prior to the date of surgery. Note: Benefits are not available for commercial weight loss programs.

• Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating and exercise (evidence that proves attempts at weight loss in the one-year- period prior to surgery have been ineffective)

• Psychological assessment of the member’s ability to understand and adhere to the pre- and post-operative program, performed by a psychiatrist, clinical psychologist, psychiatric social worker or psychiatric nurse

• Patient has not smoked in the six months prior to surgery

• Patient has not been treated for substance abuse for one year prior to surgery

Benefits for subsequent surgery for morbid obesity, performed on an inpatient or outpatient basis, are subject to the following additional pre-surgical requirements:

• All criteria listed above for the initial procedure must be met again

• Previous surgery for morbid obesity was at least two years prior to repeat procedure

• Weight loss from the initial procedure was less than 50 percent of the member’s excess body weight at the time of the initial procedure

• Member complied with previously prescribed postoperative nutrition and exercise program

Claims for the surgical treatment of morbid obesity must include documentation from the patient’s provider(s) that all pre-surgical requirements have been met.

Intensity-Modulated Radiation Therapy (IMRT) Members are no longer required to obtain prior approval for outpatient intensity-modulated radiation therapy (IMRT) related to the treatment of head, neck, breast or prostate cancer. Previously, prior approval was required for all outpatient IMRT services.

continued on page 12

Updating Your Facility’s MedicareBlue PPO (Medicare Advantage) Reimbursement RatesWhen Critical Access Hospital (CAH) payment rates are adjusted by the Medicare Administrative Contractor (MAC), these providers are encouraged to give the most recent copy of the MAC letter(s) to BCBSNE. Since Medicare Advantage (MA) reimbursement rates are based on the most recent MAC letter and, for MA, these rates are prospective, not retroactive, it is extremely important to submit this documentation to BCBSNE upon receipt from the MAC.

Rates will be adjusted upon receipt of these letters by BCBSNE, to be effective the next business day. Attaching the MAC letter to a submitted claim will not be considered as notification. Failure to submit this documentation to BCBSNE in a timely manner will result in claims processing at an incorrect and final rate.

The documentation can be faxed to Kirk Delperdang or Tina Sturm at (402) 398-3640 or e-mailed to [email protected] or [email protected]. You may also mail the letters addressed to Kirk’s or Tina’s attention to:

Blue Cross and Blue Shield of Nebraska, Government Programs P.O. Box 3248 Omaha, NE 68180-0001

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Secondary Claim Filing Tips and Guidelines When filing paper secondary claims to BCBSNE, please adhere to the following claim filing guidelines:

• CMS 1500 claim forms must include the secondary I.D. number in box 1 and must always include a copy of the primary payor’s remit. The primary I.D. number is not needed.

• UB-04 claim forms must include the primary and secondary I.D. numbers in chronological order in FL 51 and must always include a copy of the primary payor’s remit.

BCBSNE prefers that secondary claims are submitted electronically. Please reference our companion document online at: BCBSNE.com/PDFs/Provider/NEBlue_Connect/BCBSNE%20837.pdf.

Blue-on-Blue Claim Filing Tip If a member is covered under two BCBSNE policies or covered under a BCBSNE policy and a Federal Employee Program policy, there is no need to send in a secondary claim. These will automatically cross over internally.

Secondary claims for out-of-state members must always be submitted with the primary payor’s remit.

If you have questions, your EDI vendor or clearinghouse should be able to help you. However, if you have additional questions after talking with your vendor or clearinghouse, please contact our EDI Department staff.

Retired Policies:I.18 PUVAI.66 Extracorporeal Membrane OxygenationI.124 Photodynamic TherapyI.130 Levulan KerastickI.150 Breast Duct EndoscopyI.158 Microwave Thermotherapy for Primary Breast CancerI.160 XStop Interspinous Process DecompressionIII.40 Organ Transplantation (this is a contract review, not a medical policy review at this time)III.104 Fetal Mesencephalic Transplantation for the treatment of Parkinson’s DiseaseIII.106 Meniscal Allograft TransplantationIII.157 Autologous Islet Cell TransplantationIII.111 and III.114 were combined with III.78 and are now titled “Treatments for Parkinson’s Disease and Other Movement Disorders”

Retired Policies:I.172 Visual Evoked PotentialsIII.168 Percutaneous Vertebroplasty/KyphoplastyIII.177 Balloon SinuplastyIV.79 3-Dimensional and 4-Dimensional Fetal Ultrasound X.17 Oral Antibiotics for Acne TreatmentX.25 ACE and ARB Therapy (this is a contract buy up and no groups are currently using)

X.26 Medications to Treat Crypopyrin Associated SyndromesX.27 GilenyaX.26 Tryosine Kinase Inhibitors

New policies and revisions to current policies: Anterior Eye Segment Optical Imaging – Investigative for all uses

Bronchial Thermoplasty to Treat Severe Asthma – Investigative

Capsaicin Patch – Criteria developed for appropriate use

Gastric Electrical Stimulation – Added to I.105 Electrical Stimulation investigative for all uses

KRAS and BRAF Mutation Analysis – KRAS validated for colorectal cancer and investigative for all other uses and BRAF investigative for other uses

Stem Cell Transplantation for Primary Amyloidosis and Macroglobulinemia – Added to II.2 Stem Cell Transplantation, both conditions allow for autologous transplant only

GI Biologics—Change to dosing criteria in policy

Botox – Treatment of migraines with botulinum toxin is investigativeElaprase – Validated for use in Hunter Syndrome only

Medical Policy Updates – February 23, 2011 The BCBSNE Medical Policy Committee (MPC) met on February 23, 2011. This committee, composed of practicing physicians within the BCBSNE network, utilizes contract criteria summarized online at BCBSNE.com to determine whether a new technology or new application of an existing technology is scientifically valid or investigative.

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2011 CPT Code Updates for Radiology Quality Initiative Each year, The American Medical Association (AMA) adds and deletes codes listed in the Current Procedural Terminology (CPT) book.

Unique changes for 2011 include adding new codes for certain procedures when performed together without deleting the existing codes for those same procedures when performed separately. This specifically includes CT scans of the abdomen and pelvis.

The 2011 CPT code updates have been applied to our Radiology Quality Initiative, through American Imaging Management (AIM). Providers can access the CPT codes that are included in the AIM program through the AIM Provider Portal at americanimaging.net by viewing the “Reference Desk” tool located at the top of their Home page.

Please remember ordering providers are not required to provide CPT codes when requesting order approvals through AIM. Please continue to provide the exam, modality and body part only.

Rural Health Clinic Reminder When BCBSNE is the primary payor, rural health clinics (RHC) must always file claims on a CMS 1500 claim form under the provider of service name, credentials and individual NPI. BCBSNE does not follow CMS’s incident-to-rules.

When BCBSNE is the supplemental or secondary payor to CMS, you must include the rendering provider’s name and NPI and the CPT and/or HCPC codes identifying the services provided on the UB-04. The claims will automatically cross over to BCBSNE from Medicare and the RHC will be paid directly if the appropriate information is on the claim. RHCs should never submit Medicare supplemental/secondary claims on a CMS 1500.

If you haven’t received payment within 60 days of the CMS paid date on your remit, you should contact GABBI at (800) 635-0579 to check the claim status. If GABBI doesn’t give enough information, transfer to a Customer Service Representative to verify the status of the claim. If the claim has not crossed over from Medicare, you will need to submit a UB-04 claim with the EOMB for processing.

Countdown to 5010The Health Insurance Portability and Accountability Act requires the adoption of specific standards for electronic health care transactions (claims, eligibility inquiries, claims status requests and responses).

Per federal regulation, all health care entities (insurance plans, clearinghouses and providers) must transition from the current standard 4010A1 to 5010 on January 1, 2012.

The biggest concern for providers will be complete implementation and full functionality of 5010 transactions at or before the compliance deadline to avoid transaction rejections and subsequent payment delays.

To ensure you are prepared for this transition, we want to remind you about developing your own implementation plan. The following are various tasks that should be included in your plan:

• Talk to your current practice management system vendor. The potentially largest expense is the practice management system changes that will be required for implementing the 5010 transactions.

• Depending on your contract with your vendor, the system upgrades may be included in your current maintenance. Some vendors may charge for the upgrades. Review your contract to determine if regulatory updates are included in your maintenance. This step should be done as soon as possible.

When reviewing your contract, be sure to ask your vendor the following questions:

• Will my current system be upgraded to accommodate the 5010 transactions?

• Can my current system accommodate both the data collection and transaction conduction for 5010?

• Will there be a charge for the upgrade?• When will the upgrade be available?• When will the upgrade to my system be installed?• Talk to your clearinghouses or billing service, if you use

either one, and health insurance payers• Identify changes to data reporting requirements

Policies (continued)

To view these medical policies as well as others developed for use at BCBSNE.com, go to the Provider page at BCBSNE.com, then to “Library,” “Policies and Procedures” and then click on the “Medical Policies” link. Proceed to accept the disclaimer and then go to the specific policy number.

Comments on these and other medical policies are welcomed. Please direct comments and/or inquiries to BCBSNE’s Health Program Research Administrator, Heather Scholting, at [email protected] or (402) 982-6401.


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• Identify potential changes to existing practice work flow and business processes

• Identify staff training needs• Test with your trading partners (e.g., payers and

clearinghouses)• Budget for implementation costs, including expenses

for system changes, resource materials, consultants, and training

For any questions regarding BCBSNE’s transition to 5010, e-mail [email protected].

Meet the BCBSNE Bill Audit Staff

AMY GOHR - Medical Bill Audit Analyst

Amy has worked for BCBSNE for 32 years, starting as a file clerk in the records center. She’s worked in a variety of departments, including Benefits Auditing, Health Service Programs/Precertification and Appeals. She joined the Special Investigations Unit in May 2009.

BECKY HOFFMAN - Medical Bill Audit Specialist

Several years of hospital experience and the desire to expand her nursing career brought Becky Hoffman to BCBSNE eight and a half years ago. Becky joined the Bill Audit staff in May 2009. She’s previously worked in Appeals, Utilization Review and Case Management departments.

CHARLENE PICKERING - Hospital Bill Audit Specialist

Charlene has been with BCBSNE for seven and a half years. Charlene’s background includes a Bachelor’s degree in Nursing and a Master’s degree in Healthcare Administration. In addition to her duties on the Bill Audit Staff, she currently works on call providing inpatient care.

The Bill Audit Staff is a part of BCBSNE’s Special Investigations Unit. As a team, Amy Gohr, Becky Hoffman and Charlene Pickering perform hospital bill audits and ensure protection of provider and company assets.

Reminder: Get Ahead – Get an NPIMedicare now requires providers to submit claims with their National Provider Identifier (NPI). Having an NPI allows for greater ease in claims processing with our new claims processing system.

If you currently do not have an NPI, visit the Regulations and Guidance page, located under the National Provider Identifier Standard section at cms.hhs.gov.

Once you have your NPI, mail or fax a copy of your confirmation letter or confirmation e-mail to:

BCBSNE Attn: Health Network AdministrationP.O. Box 3248Omaha, NE 68180-0001Fax: (402) 343-3455

Article Correction Regarding SG and NU modifiers for Ambulatory Surgery Center ClaimsIn a November 2010 Update article, it was incorrectly noted that ambulatory surgery centers can omit the –SG

modifier for fluoroscopy codes. Be advised you should include –SG on all surgery and fluoroscopy codes, but do not include it for implant codes (e.g. L8699).

The –SG modifier has been a BCBSNE coding requirement for ASC claims for several years. It is needed to apply correct pricing for BluePreferred claims. Because NEtwork BLUE prices ASC charges according to provider specialty, the –SG modifier is not required for NEtwork BLUE claims.

However, until the NEtwork BLUE migration is completed in 2012 and while claims are still processing on the BluePreferred network, BCBSNE recommends you continue to use modifier –SG on CPT (surgery and fluoroscopy) codes and omit it from HCPCS codes (implants) for all claims.

An –NU modifier must be attached to the implant procedure code (e.g. L8699) or the claim will be returned.

As a reminder, always populate the ASC’s NPI in Box 24J on the CMS 1500. The surgeon’s name or NPI should never be included on the ASC claim.

Please contact your HNS Consultant for questions.

Access HIPAA 5010 Information Online For additional information regarding the HIPAA 5010 transition, go to BCBSNE.com and click “5010 Updates” located in the left menu.

P.O.Box3248•Omaha,NE68180-0001

Blue Cross and Blue Shield of Nebraska Moves to New Building 1

Website Enhancements Coming Soon! 1

National Walk @ Lunch Day April 27 1

BlueBoard: The Identification Card is the Key 2

BlueBoard: Newborn Inpatient Claims Require Birth Weight 2

BlueBoard: Hourly Pulmonary Rehabilitation Billing Reminder 2

BlueBoard: Modifiers 25 and 26 Not Valid on Surgery CPT Codes 2

BlueBoard: One-Month/One-Year Claim Billing Spans 2

BlueBoard: Time Limit for Medical Records 2

BlueBoard: Revenue Code 360 Clarification 2

Q&A - Why was a well child check denied in conjunction with another service? 2

BlueCard Bulletin: Seeking Your Feedback for BlueCard Process Improvements 3

BlueCard Bulletin: National Blue Doctor and Hospital Finder 2011 Audit Schedule 3

At your service: Your BCBSNE Health Network Consultants 3

Outpatient Observation Guidelines for NEtwork BLUE and BluePreferred 4-5

Everything You Ever Wanted to Know about Refunds/Offsetting 5

New Home Hospice Billing Guidelines for NEtwork BLUE Claims 6

Inpatient Certification Requirements 6

Certification for Psychological Outpatient Visits/Psychological Testing 6-7

2011 Federal Employee Program Clarifications 7-8

Updating Your Facility’s MedicareBlue PPO (Medicare Advantage) Reimbursement Rates 8

Secondary Claim Filing Tips and Guidelines 9

Blue-on-Blue Claim Filing Tip 9

Medical Policy Updates – February 23, 2011 9-10

2011 CPT Code Updates for Radiology Quality Initiative 10

Rural Health Clinic Reminder 10

Countdown to 5010 10

Meet the BCBSNE Bill Audit Staff 11

Reminder: Get Ahead – Get an NPI 11

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An Independent Licensee of the Blue Cross and Blue Shield Association.

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Blue Cross and Blue Shield of Nebraska Moves to New Building

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