1. health and fitness

April 2015
In this issue
Page
Administrative news
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Access your Empire Paper Remittances through Availity
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Availity to launch new E&B functionality
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Update to the Cancer Care Quality Program

ICD-10 Updates
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Child Health Plus Network Update – Reminder
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ConditionCare Program Benefits Patients and Physicians

New way to expedite the UM Process

Site of Service Update

Clinical Preventive Health Guidelines Available online
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Behavioral news
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Member Outpatient Satisfaction Survey
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Coordination of Care Interactive Tools
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Pharmacy updates
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Empire has Expanded List of Specialty Pharmacy
Drugs for Pre-determination
Pharmacy information available on empireblue.com
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Health care reform updates (including Health Insurance Exchange)
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Integrated Care Model
8
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New Health Insurance Exchange article available online
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Medicare Advantage news

Empire Encourages Medicare Advantage Members To
Stay Up-To-Date on Preventive Care
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ACIP Updates Pneumococcal Vaccine Policy

ClaimCheck Version 55 Upgraded

CMS Weighs Monitoring Statin Use Among Diabetics

OrthoNet to Conduct Post-Service Prepay Medical Necessity
Reviews for Select Cardiac Procedures

Precertification Requests through Availity

Find Medical Record Information through Patient360

Medicare Advantage Reimbursement Policy Changes
posted on empireblue.com/medicareprovider

Clinical Practice Guidelines Assist with Chronic Condition
Management
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ICD-10-CM: Breathe Easy with These Coding Tips for COPD

Precertification Required on Four New Part B Injectables

Individual MA membership moved to new claims system
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EBCBSNL 0415
Quality Initiatives
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HEDIS® 2015: Colorectal Cancer Screening
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Policy Updates
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Medical Policy updates
Clinical Guideline updates
Federal Employee Program® Medical Policy
Reimbursement Policy updates
New Guidelines for Facility reimbursement for
patients with elevated BMI
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Administrative news
Access your Empire Paper Remittances Online through the Availity Web Portal
Are you accessing your Empire BlueCross BlueShield (“Empire”) paper remittances online through the Availity Web Portal?
If not, take the following steps now to begin accessing your paper remittances online.
If your organization is NOT currently registered for the Availity Web Portal:

The designated administrator for your organization should go to www.availity.com.

Click on Get Started under Register now for the Availity Web Portal, and then complete the online registration
wizard.
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The administrator will receive an e-mail from Availity with a temporary password and next steps.
Not sure if your organization is registered?
Call Availity Client Services at 800-AVAILITY (800-282-4548) for registration status of your Tax ID.
Once registered on Availity, complete the Empire Services Registration within the Availity Web Portal
This registration process grants Availity users who are set up with an Empire Physician/Facility Health Plan User ID to
access paper remittances on the Empire Professional / Facility Online Service provider portal through the Availity Web Portal
by using a single sign on feature.

On Availity, from the menu, select My Account | then Empire Services Registration.

Select the user’s organization (if applicable).

Select Non-Registered Users.
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From the Non-Registered Users list, locate your user and type in their Empire Professional/Facility Health Plan User
ID; repeat this step for additional registrations.
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Click Register.
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Log out and log back into Availity in order for the new access to take effect.
Don’t know your Empire Professional / Facility Health Plan User ID?
You may call the Empire eBusiness Helpdesk at 1-866-755-2680 to obtain this information.
How does a user receive an Empire Health Plan User ID?
Your organization’s SuperUser for the Empire Professional / Facility Online Service provider portal will need to register a
user for the Empire provider portal in order to issue an Empire Health Plan User ID. Once the Empire Health Plan User ID
has been issued to a user, the Empire Services Registration described in Step 1 can be completed.
The SuperUser should take the following steps to register users for the Empire Professional/Facility Online Services portal:

Log into Availity | select My Payer Portals| select Empire Professional Portal or Empire Facility Portal then click on
“I Agree” to link out to Professional / Facility Online Services.
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Select Maintenance |then select Managing Practice |then select Manage Office Staff.
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Select Add Office Staff and complete the required fields.
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The SuperUser can also retrieve the Empire Health Plan User ID using the Manage My Users feature.
Note: Only network providers who participate with Empire can register for the Empire Professional / Facility Online Service
provider portal.
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Access your Paper Remittances through the Availity Web Portal
Users can now follow the steps below to access your organization’s paper remittances:

Log into Availity at www.availity.com

Click My Payer Portals| select Empire Professional Portal or Empire Facility Portal | then click on “I Agree” to link
out to Empire Professional / Facility Online Services.
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When the connection finalizes, you are now logged directly to the Empire Professional Portal or Empire Facility
Portal Home page.
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From My Home Page select Remittance to access your remittances.
One last step
Once you have completed the registration to obtain your online “paper” remittances through the Availity Web Portal and no
longer require the delivery of paper remittances by mail, you can discontinue the mailing of paper remittances by completing
the online form at https://anthem-int.columncloud.com/SR/paperSuppressionSR.jsp.
Is Training Available?
Availity offers a variety of ongoing training options, including live and on-demand webinars, online demonstrations, local
workshops, comprehensive help topics, tip sheets and more. For a full list of learning options, login to the Availity portal and
click Free Training at the top of any page. To attend a free in person workshop in your area, click the link to view the
schedule http://www.rsvpbook.com/Northeast.
Have Questions?
If you do not know your Empire Professional / Facility Health Plan User ID:
Call Empire’s eBusiness Helpdesk: 1-866-755-2680
For questions regarding Empire Services Registration:
Call Availity Client Services toll free at 1-800-282-4548
Availity to launch new E&B functionality
Watch for upcoming changes during the 2nd quarter 2015 to the Availity Web Portal which includes the launch of new
eligibility and benefits (E&B) functionality and features. These changes will make finding eligibility and benefits easier and
faster for you. Here’s a list of the new features:
Feature
New Request page
Description
A new design makes it easier for users to find and focus on tasks at hand. Now users can
submit multiple member inquiries without having to wait for individual results before starting
another request.
Patient history list
The results list automatically summarizes user’s most recent member inquiries and stays
visible for 24 hours. Just click the member name and see the results. Plus only information
relevant to that member is displayed.
Menu by benefit type
Located under the ‘Coverage and Benefits’ tab, this interactive list includes key coverage
elements and only shows information that is returned from the payer.
Organization-wide view of
E&B transactions
Users can see transactions by other users within their organization (shared history). This
means less duplication of work.
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Organization drop down
menu
Users responsible for more than one organization can switch organizations while staying on
the same page, resulting in a convenient, streamlined workflow.
Payer section
Includes value-added services on one page so that users can access value-added services,
such as patient care summary, from the same page.
Availity will offer training to learn more about these time-saving features. Details will be shared soon.
Update to the Cancer Care Quality Program
Attention Oncologists, Hematologists and Urologists - As a reminder, Empire launched the Cancer Care Quality Program
("Program"), a quality initiative, on March 1, 2015. The Program provides participating physicians with evidence-based
cancer treatment information that allows them to compare planned cancer treatment regimens against evidence-based
clinical criteria. The Program also identifies certain evidence-based Cancer Treatment Pathways ("Pathways"). Participating
physicians who are in-network for the member's benefit plan are eligible to participate in the Program and for enhanced
reimbursement if an appropriate treatment regimen is ordered that is on Pathway. The Program is administered by AIM
Specialty Health® (AIM), a separate company.
To help ensure the Cancer Treatment Pathways remain consistent with current evidence and consensus guidelines, they will
be reviewed quarterly or more frequently as needed. When it is necessary to make a change to existing Pathways where a
specific Pathway treatment regimen moves from “on Pathway” to “off Pathway,” Empire will provide 30 days’ notice of the
change to physicians in Network Update, our online provider newsletter. After the effective date of the change, physicians
will no longer be eligible to receive enhanced reimbursement for the S codes once the number of months specified in any
previous notification and instructions issued to the physician by AIM via the AIM ProviderPortal or AIM Call Center has
expired. Any new requests will need to be on Pathway to be eligible for enhanced reimbursement.
ICD-10 Updates: Free Coding Practice Tool, End-to-End Testing Results
Visit our ICD-10 Update webpage for these resources, as well as our latest information on ICD-10.
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Free Coding Practice Tool Available to Code Medical Scenarios in ICD-10: Starting in April, we are offering a free
scenario-based coding practice tool designed to give physicians and their coders the opportunity to test their
knowledge of the ICD-10 codes set by applying it to medical scenarios. These customized scenarios are based on
provider type and specialty, so you can practice using codes relevant to you. Registration is required. This tool will
be available until September 2015.
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End-to-End Testing Results: In 2014, we conducted extensive end-to-end claims testing with facility providers,
professional providers and clearinghouses. Visit our ICD-10 webpage to learn about the insights we gained during
the testing. We’ve also included a list of clearinghouses we’ve successfully tested with.
Child Health Plus Network Update – Reminder
Members who were enrolled in Empire's Child Health Plus program, who live in Putnam County, were transitioned to
Amerigroup effective April 1, 2015. Previously, we discontinued participation in the Child Health Plus program in all counties
within Empire’s Service Area, except Putnam. Therefore, as of as of April 1, 2015, Empire will no longer participate in the
Child Health Plus program in any upstate county.
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ConditionCare Program Benefits Patients and Physicians
Empire members have additional resources available to help them better manage chronic conditions. The ConditionCare
program is designed to help participants’ improve their health and enhance their well-being. The program is based on
nationally recognized clinical guidelines and serves as an excellent adjunct to physician care.
The ConditionCare program helps members better understand and control certain medical conditions like diabetes, COPD,
heart failure, asthma and coronary artery disease. A team of nurses with added support from other health professionals such
as dietitians, pharmacists and health educators work with members to help them understand their condition(s), their doctor’s
orders and how to become a better self-manager of their condition. Members are stratified into three different risk levels.
Engagement methods vary by risk level but can include:
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Education about their condition through mailings, telephonic outreach, and/or online tools and resources.
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Round-the-clock phone access to registered nurses.
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Guidance and support from Nurse Coaches and other health professionals.
Physician benefits:
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Save time for the physician and staff by answering patient questions and responding to concerns, freeing up
valuable time for the physician and their staff.
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Support the doctor-patient relationship by encouraging participants to follow their doctor’s treatment plan and
recommendations.
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Inform the physician with updates and reports on the patient’s progress in the program.
The goal of our nurse coaches is to encourage participants to follow their physician’s plan of care; not to offer separate
medical advice. In order to help ensure that our service complements the physician’s instructions, we collaborate with the
treating physician to understand the member’s plan of care and educate the member on options for their treatment plan.
Please visit the empireblue.com to find more information about the program such as program guidelines, educational
materials and other resources. Go to empireblue.com > Providers > Your State > Enter > Health and Wellness >
ConditionCare. Also on our website is the Patient Referral Form, which you can use to refer other patients you feel may
benefit from our program.
If you have any questions or comments about the program, call 1-877-681-6694. Our nurses are available Monday-Friday,
8:00 a.m. to 9:00 p.m., and Saturday, 9:00 a.m. to 5:30 p.m.
Please note that we also have a care management program specifically for members with health plans purchased on the
Health Insurance Marketplace (also called the exchange). More information is available in the article entitled “Integrated
Care Model for plans purchased on the Health Insurance Marketplace Benefits Patients and Physicians”.
New way to expedite the UM Process
As part of our continuing efforts to improve efficiencies in the Utilization Management (UM) process, we have identified an
opportunity to expedite information received by fax. We ask that provider include the reference number on fax cover sheets.
This will make it easier to match new information with previously received material.
Action needed:
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Include the reference number on the fax coversheet on all future correspondence.
– The reference number is provided on our fax communications or when a case is set up via phone.
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As a reminder, please do NOT include personal health information (PHI) on fax coversheets.
Site of Service Update
Empire’s Site of Service Reductions listing shows the percentage amount that we use for reducing physician reimbursements
for selected procedures when those procedures are performed in a hospital inpatient, outpatient emergency room or
ambulatory surgical facility. The reduction percentage is based on the Resource Based Relative Value Scale (RBRVS)
calculations of a provider’s actual overhead cost. When the procedure is performed in the facility setting, the provider uses
hospital materials and equipment rather that incurring his or her own expenses. We will be updating our listing by the end of
the 1st Quarter to align with 2014 CMS Region 2 RBRVS calculations.
Clinical Practice and Preventive Health Guidelines Available online
As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted
nationally recognized medical, behavioral health, and preventive health guidelines, which are available to providers on our
website. The guidelines, which are used for our Quality programs, are based on reasonable medical evidence, and are
reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research,.
All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website. To
access the guidelines, go to the "Provider" home page at empireblue.com. From there, select “Provider & Facility” > Enter >
Health & Wellness> Practice Guidelines.
Missing 1099 IRS Form?
Visit [email protected] for more
information or call 1-888-246-4893.
Behavioral Health news
Member Outpatient Satisfaction Survey
Empire is responsible for evaluating our member’s experience and implementing action items to improve the experience by
identifying trends with our outpatient provider network. Assessing member’s satisfaction with their outpatient provider and
the treatment and experience, in general, is important to us. In order to measure the experience, we have instituted an
annual survey sent to our members based on receipt of an outpatient behavioral health claim from a participating
professional behavioral health provider. The survey consists of questions around the ease of scheduling an appointment,
access and availability, wait time at the office, the office environment, receiving appropriate education and general outcome
– including whether the patient feels that therapy has or is helping the issue that brought them into the office as well as other
aspects of the overall outpatient experience. The survey will be mailed to members in the Spring, based on claims
processed through Winter 2015.
Coordination of Care Interactive Tools
Integrating and coordinating healthcare among the providers treating the same member is a key initiative for Empire,
particularly between medical and behavioral health practitioners. Empire has resources to assist providers with coordination
of care activities located on the Plans & Benefits - Behavioral Health Management link on empireblue.com. Feedback from
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providers has indicated that more resources including a general information template would be helpful. An interactive
coordination of care form that can be completed and printed down, along with other templates can be found at
empireblue.com >Provider & Facilities >Enter >Plan and Benefits>Behavioral Health Management.
Pharmacy news
Empire has Expanded List of Specialty Pharmacy Drugs for Pre-determination
Empire has revised and standardized what is reviewed for specialty pharmacy for pre-service review. Effective
July 1, 2015 pre-determination review is recommended for the following services:
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DRUG.00072- Alpha-1 Proteinase Inhibitor Therapy Code added for clinical review:
– Codes added for clinical review: J0256, J0257
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DRUG.00073-Rilonacept (Arcalyst®)
– Code added for clinical review: J2793
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DRUG.00074-Alemtuzumab (Lemtrada™)
– Code added for clinical review: J3590, J3490
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CG-DRUG-42- Asparagine Specific Enzymes (Asparaginase)
– Codes added for clinical review: J9019, J9020, J9266
These changes will apply only to Empire local plans. National Accounts, Medicare, Medicare Supp., Medicaid, and FEP are
excluded. If the service is not requested as a pre-determination, records may be requested for post service review based on
the same criteria listed.
Pharmacy information available online
For more information on 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, and any other requirements, restrictions, or limitations that apply to using certain
drugs, visit empireblue.com/pharmacyinformation. The commercial drug list is reviewed and updates are posted to the web
site quarterly (the first of the month for January, April, July and October).
Health Care Reform updates (including Health Insurance
Exchange)
Integrated Care Model for plans purchased on the Health Insurance Marketplace benefits patients
and physicians
An Integrated Care Model affords members with plans purchased on the Health Insurance Marketplace (also called the
exchange) the ability to have continuity of care with each care management case. A single Primary Care Nurse provides
case and disease assessment and management. This continuity provides opportunity for the member to get assistance
working through an acute phase of an illness and then work with their nurse on the necessary behavioral changes needed to
improve their health and enhance their well-being. The program is based on nationally recognized clinical guidelines and
serves as an excellent adjunct to physician care.
The Integrated Care Model helps exchange members better understand and control certain medical conditions like diabetes,
COPD, heart failure, asthma and coronary artery disease. Our nurse care managers are part of an interdisciplinary team of
clinicians and other resource professionals that are there to support members, families, primary care physicians and
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caregivers. The integrated model utilizes experience and expertise of the care coordination team whose goal is to educate
and empower our members to increase self management skills, understand their illness, and learn about care choices in
order to access quality, efficient health care.
Nurse Care Managers encourage participants to follow their physician’s plan of care; not to offer separate medical advice. In
order to help ensure that our service complements the physician’s instructions, we collaborate with the treating physician to
understand the member’s plan of care and educate the member on options for their treatment plan.
Members or caregivers can refer themselves or family members by calling the number located in the grid below. They will be
transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or
through electronic means. We can help with transitions across level of care so that patients and caregivers are better
prepared and informed about healthcare decisions and goals.
How do you contact Case Management?
CM Telephone Number
1-800-563-5909
CM Email Address
[email protected]
CM Business Hours
Monday - Friday
8:00 a.m. – 9:00 p.m.
Saturday
9:00 a.m. – 5:30 p.m.
New Health Insurance Exchange article available online
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Claim adjustments for members reaching out-of-pocket maximums
Preventive care services covered with no member cost-share - Updated 2/12/15
Updated contact information for ERA and EFT registration
We invite you to visit our website, empireblue.com to learn about the many ways health care reform and the health
insurance exchange may impact you. New information is added regularly. To view the latest articles on health care reform
and/or health insurance exchange, and all archived articles, go to empireblue.com , select the Provider link in the top center
of the page, and click Enter. From the Provider Home page, select the link titled Health Care Reform Updates and
Notifications or Health Insurance Exchange Information.
Medicare Advantage news
Empire encourages Medicare Advantage members to stay up-to-date on Preventive Care
Empire is committed to helping your Medicare Advantage patients maintain good health habits and stay up-to-date on
preventive screenings. We encourage you to check in with your senior patients about the following issues to help ensure they
are monitoring their own health and receiving needed care.
Physical Health/Monitor Physical Activity
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Discuss and encourage the importance and benefits of exercise
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Discuss applicable exercise options
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Discuss any problems/pain members are having with accomplishing daily activities
Mental Health
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Discuss overall mental health and if physical and emotional health is affected
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Discuss feelings of anxiety, blues, depression
Discuss members’ overall energy level
Bladder Control
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Assess whether the member has had any leaking of urine
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Advise the member of bladder treatment options such as bladder training, exercises, medication and surgery
Breast Cancer Screening

Women 50-74 need to have a mammogram at least every 24 months
ACIP updates Pneumococcal Vaccine policy
Empire would like to make you aware that the Advisory Committee on Immunization Practices (ACIP) has changed its policy
regarding pneumococcal vaccines for persons over the age of 65.
Effective 9/19/2014, Empire covers:

An initial pneumococcal vaccine to all Medicare beneficiaries who have never received the vaccine under Medicare
Part B; and
A different, second pneumococcal vaccine one year after the first vaccine was administered (that is, 11 full months have
passed following the month in which the last pneumococcal vaccine was administered).
ClaimCheck Version 55 upgraded
Effective April 1, 2015, ClaimCheck upgraded to version 55 of ClaimCheck® 10.1 a nationally recognized code auditing
system.
Empire uses the auditing software product from McKesson to reinforce compliance with standard code edits and rules.
Additionally, ClaimCheck increases consistency of payment to providers by ensuring correct coding and billing practices are
being followed. Using a sophisticated auditing logic, ClaimCheck determines the appropriate relationship between thousands
of medical, surgical, radiology, laboratory, pathology and anesthesia codes and processes those services according to
industry standards.
ClaimCheck is updated periodically to conform to changes in coding standards and include new procedure and diagnosis
codes.
Empire uses ClaimCheck to analyze outpatient services, including those that are considered:

Rebundled or unbundled services
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Inappropriately billed medical visits
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Multichannel services
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Diagnosis to procedure mismatch
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Mutually exclusive services
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Upcoded services
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Incidental procedures
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Fragmented billing of pre- and postoperative care
Other procedures and categories reviewed include:
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Cosmetic procedures
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Obsolete or unlisted procedures
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Age/sex mismatch procedures
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Investigational or experimental procedures
Procedures billed with inappropriate modifiers
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The information above is applicable to claims for individual Medicare Advantage members only. It is not applicable to groupsponsored Medicare Advantage claims.
CMS weighs monitoring statin use among Diabetics
Endocrinologists and primary care providers (PCPs) please note: In November of 2013 the ACC/AHA released new
guidelines for the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults. One major focus in
this recommendation is reducing the risk of atherosclerotic cardiovascular disease (ASCVD) in persons with diabetes who
are 40-75 years of age. According to the ACC/AHA guideline, “Moderate-intensity statin therapy should be initiated or
continued for adults 40-75 years of age with diabetes mellitus,” and “High-intensity statin therapy is reasonable for adults 4075 years of age with diabetes mellitus with a ≥7.5% estimated 10-year ASCVD risk unless contraindicated.” *
To align practice standards, the Pharmacy Quality Alliance (PQA) has developed a measure to support the ACC/AHA
guidelines. The measure is labeled “Statin Use in Persons with Diabetes,” and calculates the percentage of patients ages 4075 years who received a medication for diabetes that also receive a statin medication during the measurement period. The
Center for Medicare and Medicaid Services (CMS) is closely following this measure and is evaluating the addition of this
measure as a future Medicare Part D health plan rating.
Please consider initiating statin therapy in patients who fit these criteria in conjunction with the recommendations from 2013
ACC/AHA Guidelines for the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. The
2013 ACC/AHA Guidelines for the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
can be found at: http://circ.ahajournals.org/content/129/25_suppl_2/S1
*Formulary moderate-intensity statin therapies include atorvastatin 10-20 mg, Crestor 5-10 mg, simvastatin 20-40 mg,
pravastatin 40-80 mg, lovastatin 40 mg; while formulary high-intensity statins include atorvastatin 40-80 mg and Crestor 2040 mg. Simvastatin currently costs our members $0 to $5 (varies by plan) for a 30-day fill at a preferred pharmacy. This
would be the least expensive option for them.
OrthoNet to conduct post-service prepay Medical Necessity reviews for select cardiac procedures
Appropriate care is the key to achieving the best outcomes for our Medicare Advantage members. To help reach that goal
Empire is collaborating with OrthoNet to help ensure that invasive cardiac procedures are reasonable and necessary for the
diagnosis and/or treatment of coronary artery disease.
Effective April 1, 2015, Empire is contracted with OrthoNet to conduct post-service prepay medical necessity reviews of
selected cardiac procedures, including reviews of facility and professional Cardiac Catheterizations and Percutaneous
Coronary Interventions (PCIs). These reviews will apply to individual Empire Medicare Advantage members.
Providers who submit claims for these services for individual Empire Medicare Advantage members after the effective date
may receive a request for records and related digital images. The process for submitting records and related images will be
streamlined by providing you with a HIPAA-compliant, secure internet portal for uploading the needed information.
Instructions for completing this process will be included with the request.
A board-certified cardiologist will review the records and images to determine if the services were reasonable and necessary
to diagnose and/or treat the patient. Should you receive a medical record request, Empire would appreciate your timely
compliance.
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OrthoNet will use Medicare national coverage determinations, local coverage determinations, Empire’s medical policies, and
clinical utilization management guidelines to determine medical necessity of the requested therapies. You may access these
coverage determinations, medical policies and clinical guidelines here.
If you have questions about this communication or need assistance with any other item, contact OrthoNet:
Phone: 1-844-278-5477
Fax: 1-844-876-4924
To verify member eligibility, benefits or account information, please call the telephone number listed on the back of the
member’s identification card.
Y0071_15_23430_I 02/04/2015
Precertification requests and information available through Availity
Precertifications for Empire individual Medicare Advantage members can be initiated via the Availity web portal at
www.Availty.com. To access this new functionality, go to Auths and Referrals/Authorizations from the left navigation menu.
Select Empire Medicare Advantage from the drop down box. You will be directed to the Medicare Advantage Precertification
site which includes the precertification submissions and inquiries link and Patient360, which can be found under the Patient
Information tab. Providers will find precertification requirements there as well via the Precertification look-up tool.
Please visit www.empireblue.com/medicareprovider to learn more about this online provider self-service tool.
Find medical record information through Patient360
Patient360 is a read-only dashboard available through our secure provider portal that gives you instant access to detailed
individual Medicare Advantage member information. By clicking on each tab in the dashboard, you can drill down to specific
items in a patient’s medical record:

Demographic information – member eligibility, other health insurance, assigned PCP and assigned case managers

Care summaries – emergency department visit history, lab results, immunization history, and due or overdue
preventive care screenings

Claims details – status, assigned diagnoses and services rendered

Authorization details – status, assigned diagnoses and assigned services

Pharmacy information – prescription history, prescriber, pharmacy and quantity

Care management-related activities – assessment, care plans and care goals
Medicare Advantage reimbursement policy changes posted on empireblue.com/medicareprovider
Empire Medicare Advantage published Medicare Advantage Reimbursement Policy Changes in your October 2014 provider
newsletter and posted the information under Important Medicare Advantage Updates in August 2014. Empire has updated
and expanded this initial communication to help address any questions you may have. To view this communication, please
click here.
Medicare Advantage information is located at www.empireblue.com/medicareprovider. For Empire Medicare Advantage
reimbursement policy updates, please visit our website and select Important Medicare Advantage Updates. To review our
complete set of reimbursement policies, select Medicare Advantage Reimbursement Policies. Our reimbursement policies
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apply to participating providers who serve Individual Empire Medicare Advantage business unless provider, federal or CMS
contracts and/or requirements indicate otherwise.
Clinical Practice Guidelines assist with Chronic Condition Management
Clinical Practice Guidelines (CPGs) are resources to assist providers and members in the management of chronic medical
conditions. They are reviewed by board-certified practitioners and distributed to network providers to reduce unnecessary
variation in care. Empire CPGs are located on the provider website under the Health &Wellness tab.
ICD-10-CM: Breathe easy with these coding tips for COPD
In ICD-9, COPD code 496 is not to be used with any code from categories 491 (chronic bronchitis), 492 (emphysema), or 493
(asthma). In ICD-10, code category J44 encompasses asthma and bronchitis associated with COPD. Code category J44
includes other COPD, asthma with COPD, chronic asthmatic (obstructive) bronchitis, chronic bronchitis with airways
obstruction, chronic bronchitis with emphysema, chronic emphysematous bronchitis, chronic obstructive asthma, chronic
obstructive bronchitis and chronic obstructive tracheobronchitis. Furthermore, in ICD-10 there is a note to use an additional
code to identify exposure to environmental tobacco smoke (Z77.22), history of tobacco use (Z87.891), occupational exposure
to environmental tobacco smoke (Z57.31), tobacco dependence (F17.-), or tobacco use (Z72.0).
The table below reflects the crosswalk from ICD-9 to ICD-10.
ICD-9
ICD-10
(COPD documented with a more specific
(COPD documented with a more specific respiratory
respiratory condition fell under multiple code
condition falls under one code category)
categories)
491.2-, Obstructive chronic bronchitis
J44.-, Other chronic obstructive pulmonary disease
493.2-, Chronic obstructive asthma
Code also type of asthma, if applicable (J45.-)
496, COPD
In future articles, we will continue to bring you helpful coding tips to assist you and your coding staff with the transition from
ICD-9 to ICD-10.
As a reminder, claims/encounters with dates of service Oct 1, 2015 and later must be submitted with ICD-10 codes. CMS will
reject those submitted with ICD-9 codes resulting in delay or denial of payment. We must all be prepared to meet CMS
guidelines.
Y0071_15_23499_I 02/12/2015
Precertification required on four new Part B Injectables
Empire is adding the following four new injectable drugs to the 2015 Medicare Advantage list of Part B Injectables / Infusibles
requiring precertification. As of March 1, 2015, providers must call for prior authorization of these drugs.
1.
2.
Benlysta (belimumab) for treatment of lupus (SLE) (J0490)
Drugs billed with NOC HCPCS J code (J3490)
Iluvien (fluocinolone acetonide injection): for treatment of diabetic macular edema (DME) (unlisted, no J code
established at this time)
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3.
4.
Lemtrada (alemtuzumab injection): for treatment of relapsing forms of multiple sclerosis (MS) (unlisted, no J code
established at this time)
Opdivo (nivolumab) for treatment of unresectable or metastatic melanoma (unlisted, no J code established at this
time)
Please note for drugs currently billed under the Not Otherwise Classified J code (J3490), the plan’s denial will be for the
drug, and not the HCPCS. This applies to all Medicare Advantage Group Sponsored and Individual Medicare Advantage
plans.
To contact the plan for prior authorization of these services, see below:
Phone: 1-866-797-9884 Option 5
Fax: 1-866-959-1537
Email: [email protected]
51763WPSENABC 02/09/15
Reminder: Individual MA membership moved to new claims system
Effective January 1, 2015, Empire moved Individual (non-group) MA members to a new claims processing system. Please
continue to check Important Medicare Advantage Updates on your provider portal for additional information.
Y0071_14_22758_I 12/10/2014
Quality Initiatives
HEDIS® 2015: Colorectal Cancer Screening
One of the HEDIS measures we are collecting this year is Colorectal Cancer Screening. This measure is collected to ensure
that our members between the ages of 50 and 75 have been screened appropriately for colorectal cancer. The following
items are needed from the member’s medical record:
1. Documentation must indicate the date that the member had one of the following screenings:
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Colonoscopy – Completed within the last 10 years (1/1/05- 12/31/14)
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Flexible Sigmoidoscopy - Completed within the last 5 years (1/1/10 – 12/31/2014)
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Fecal Occult Blood Test (FOBT) – ALL tests that were completed in 2014. There are two types of FOBT tests:
guaiac (gFOBT stool card with 3 samples) and immunochemical (iFOBT– sometimes referred to as FIT-1 sample).
Depending on the type of FOBT test, a certain number of samples are required, so please send all tests
A result is NOT required if the documentation is clearly part of the “Medical History” section of the record. If this is not clear,
the result or finding must also be present to ensure that the screening was performed and not merely ordered. Hemoccult
tests taken during a routine rectal exam do not count towards this screening measure.
2. Documentation of a history of one of the following at any time through December 31, 2014:
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Colorectal cancer
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Total colectomy
We have found that evidence of colorectal cancer screening is not always found in the same part of every medical record.
We encourage your staff to check the History & Physical, Consultation Reports, Procedure List, Progress Notes and Lab
Sections of the chart for the required documentation before indicating that a screening was not completed. Please submit
any documentation that is found to serve as evidence of screening.
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Our goal is to make the record retrieval process as easy as possible for your office. We also want you to know that we are
available to answer any questions you have about HEDIS or any of the measures.
We look forward to working with you this HEDIS season and thank you in advance for your continued cooperation and
support of HEDIS.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
Policy Updates
These updates list the new and/or revised Empire medical policies, clinical guidelines and reimbursement policies. The
implementation date for each policy or guideline is noted for each section. Implementation of the new or revised medical
policy, clinical guideline or reimbursement policy is effective for all claims processed on and after the specified
implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the
changes. If there is any inconsistency or conflict between the brief description provided below and the actual policy or
guideline, the policy or guideline will govern.
Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take
precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and
must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the
services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates
that may have been issued by Empire. Please include this update with your provider manual for future reference.
Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in
adjudication. Empire’s medical policies and clinical guidelines can be found at www.empireblue.com.
Medical Policy Updates
Revised Medical Policy Effective 02-09-2015
(The following policy was revised to expand medical necessity indications or criteria.)
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DRUG.00064 - Enteral Carbidopa and Levodopa Intestinal Gel Suspension
Revised Medical Policy Effective 04-07-2015
(The following policy was revised to expand medical necessity indications or criteria.)

DRUG.00044 - Belimumab (Benlysta®)
Revised Medical Policies Effective 04-07-2015
(The following policies were reviewed and had no significant changes to the policy position or criteria.)

ADMIN.00001 - Medical Policy Formation
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ADMIN.00007 - Immunizations
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BEH.00001 - Opioid Antagonists Under Heavy Sedation or General Anesthesia as a Technique of Opioid
Detoxification
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BEH.00002 - Transcranial Magnetic Stimulation
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DME.00012 - Oscillatory Devices for Airway Clearance including High Frequency Chest Compression and
Intrapulmonary Percussive Ventilation (IPV)
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DME.00025 - Self-Operated Spinal Unloading Devices
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DRUG.00004 - Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial
Hypertension
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DRUG.00009 - Growth Hormone
DRUG.00013 - Administration of Immunoglobulin as a Treatment of Recurrent Spontaneous Abortion
DRUG.00027 - Ziconotide Intrathecal Infusion (Prialt®) for Severe Chronic Pain
DRUG.00045 - Tesamorelin (Egrifta®)
DRUG.00054 - Ocriplasmin (Jetrea®) Intravitreal Injection Treatment
GENE.00007 - Cardiac Ion Channel Genetic Testing
GENE.00012 - Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent
GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Screening for Fetal Aneuploidy
GENE.00034 - SensiGene® Fetal RhD Genotyping Test
GENE.00039 - Genetic Testing for Frontotemporal Dementia
LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
LAB.00029 - Rupture of Membranes (ROM) Testing in Pregnancy
LAB.00030 - Measurement of Serum Concentrations of Tumor Necrosis Factor Antagonist Drugs and Antibodies to
Tumor Necrosis Factor Antagonist Drugs
MED.00002 - Selected Sleep Testing Services
MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
MED.00041 - Microvolt T-Wave Alternans
MED.00051 - Real-Time Remote Heart Monitors
MED.00065 - Hepatic Activation Therapy
MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
MED.00077 - In Vivo Analysis of Gastrointestinal Lesions
MED.00091 - Rhinophototherapy
MED.00092 - Automated Nerve Conduction Testing
MED.00097 - Neural Therapy
MED.00100 - Diaphragmatic/ Phrenic Nerve Stimulation and Diaphragm Pacing Systems
MED.00109 - Corneal Collagen Cross-Linking
MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue
Grafting
RAD.00035 - Coronary Artery Imaging: Contrast-Enhanced Coronary Computed Tomography Angiography (CCTA),
Coronary Magnetic Resonance Angiography (MRA), and Cardiac Magnetic Resonance Imaging (MRI)
RAD.00043 - Computed Tomography Scans with or without Computer Assisted Detection (CAD) for Lung Cancer
Screening
RAD.00051 - Functional Magnetic Resonance Imaging (fMRI)
RAD.00053 - Cervical and Thoracic Discography
RAD.00055 - Magnetic Resonance Angiography (MRA) of the Spinal Canal
SURG.00007 - Vagus Nerve Stimulation
SURG.00019 - Transmyocardial Revascularization
SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
SURG.00046 - Gastric Electrical Stimulation
SURG.00052 - Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET],
Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])
SURG.00067 - Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
SURG.00081 - Total Ankle Replacement
SURG.00086 - Reduction Mammaplasty
SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
SURG.00094 - High Intensity Focused Ultrasound (HIFU) for the Treatment of Prostate Cancer
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SURG.00097 - Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
SURG.00099 - Convection Enhanced Delivery of Therapeutic Agents to the Brain
SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
SURG.00106 - Ablative Techniques as a Treatment for Barrett’s Esophagus
SURG.00107 - Prostate Saturation Biopsy
SURG.00108 - Endothelial Keratoplasty
SURG.00109 - Surgical Treatment of Femoroacetabular Impingement Syndrome
SURG.00115 – Keratoprosthesis
SURG.00119 - Endobronchial Valve Devices
SURG.00123 - Transmyocardial/ perventricular Device Closure of Ventricular Septal Defects
SURG.00127 - Sacroiliac Joint Fusion
SURG.00130 - Annulus Closure After Discectomy
SURG.00134 - Interspinous Process Fixation Devices
SURG.00138 - Laser Treatment of Onychomycosis
TRANS.00004 - Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
TRANS.00009 - Lung and Lobar Transplantation
TRANS.00010 - Autologous and Allogeneic Pancreatic Islet Cell Transplantation
TRANS.00015 - Meniscal Allograft Transplantation of the Knee
TRANS.00026 - Heart/Lung Transplantation
Recategorized Medical Policy Effective 04-07-2015
(The following policy was created and has no significant changes to the policy position or criteria)

MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium (NOTE: This policy has been
renumbered, formerly TRANS.00022)
Archived Medical Policy Number Effective 04-07-15
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TRANS.00022 - Autologous Cell Therapy for the Treatment of Damaged Myocardium (NOTE: This policy has been
renumbered to MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium)
Revised Medical Policies Effective 04-18-2015
(The following policies were revised to expand medical necessity indications or criteria.)
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GENE.00008 - Analysis of Fecal DNA for Colorectal Cancer Screening
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GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
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GENE.00036 - Genetic Testing for Hereditary Pancreatitis
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SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue
Grafting
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SURG.00136 - Intraocular Telescope
Revised Medical Policy Effective 04-18-2015
(The following policy was reviewed and had no significant changes to the policy position or criteria.)

SURG.00001 - Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
New Medical Policies Effective 07-18-2015
(The policies below were created and might result in services that were previously covered but may now be found to be
either not medically necessary and/or investigational.)
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DRUG.00072 - Alpha-1 Proteinase Inhibitor Therapy
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DRUG.00073 - Rilonacept (Arcalyst®)
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DRUG.00074 - Alemtuzumab (Lemtrada™)
GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases [NOTE: Content for ‘Diagnostic
Genetic Testing of a Potentially Affected Individual (Adult or Child)’ and ‘Predictive Genetic Testing for NonMalignant Diseases’ has been moved from GENE.00013 and GENE.00015 to this new policy].
MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
MED.00116 - Near-Infrared Spectroscopy Brain Screening for Hematoma Detection
Revised Medical Policies Effective 07-18-2015
(The policies below were revised and might result in services that were previously covered but may now be found to be either
not medically necessary and/or investigational.)
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GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
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SURG.00010 - Treatments for Urinary Incontinence
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SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue
Grafting
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SURG.00117 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and
Fecal Incontinence; Urinary Retention
Archived Medical Policy Effective 07-18-2015
The following medical policies have been archived:
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GENE.00013 - Diagnostic Genetic Testing of a Potentially Affected Individual (Adult or Child) [Note: Content has
been moved to new policy GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases].
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GENE.00015 - Predictive Genetic Testing for Non-Malignant Diseases [Note: Content has been moved to new policy
GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases].
Clinical Guideline Updates
Revised Clinical Guidelines Effective 02-09-2015
(The following adopted guideline was revised to expand medical necessity indications or criteria.)

CG-ANC-04 - Ambulance Services: Air and Water
Revised Clinical Guidelines Effective 04-07-2015
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
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CG-BEH-02 - Applied Behavioral Analysis for Autism Spectrum Disorder
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CG-BEH-07 - Psychological Testing
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CG-DME-10 - Durable Medical Equipment
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CG-DME-31 - Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, with or without Power Seating Systems
and Power Operated Vehicles (POVs)
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CG-DME-33 - Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight
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CG-DRUG-01 - Off-Label Drug and Approved Orphan Drug Use
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CG-MED-19 - Custodial Care
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CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices
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CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
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CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
New Clinical Guideline Effective 07-18-2015
(The following guideline will be applied and might result in services that were previously covered but may now be found to be
not medically necessary.)
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CG-DRUG-42 - Asparagine Specific Enzymes (Asparaginase)
Revised Clinical Guidelines Effective 07-18-2015
(The following adopted guidelines were revised and might result in services that were previously covered but may now be
found to be not medically necessary.)
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CG-MED-46 - Ambulatory and Inpatient Video Electroencephalography
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CG-REHAB-08 - Private Duty Nursing in the Home Setting
Federal Employee Program® Medical Policy
The FEP Medical Policy Manual may be accessed at www.fepblue.org > Benefit Plans > Brochures and Forms > Medical
Policies. Here providers can review specific medical policies that pertain to the Blue Cross and Blue Shield Service Benefit
Plan, also known as FEP. The policies contained in the FEP Medical Policy Manual are developed to assist in administering
plan benefits and do not constitute medical advice. They are not intended to replace or substitute for the independent
medical judgment of a practitioner or other health care professional in the treatment of an individual member. The Blue Cross
and Blue Shield Association does not intend by the FEP Medical Policy Manual, or by any particular medical policy, to
recommend, advocate, encourage or discourage any particular medical technologies. Medical decisions relative to medical
technologies are to be made strictly by members/patients in consultation with their health care providers. The conclusion that
a particular service or supply is medically necessary does not constitute a representation or warranty that FEP covers (or
pays for) this service or supply for a particular member.
Reimbursement Policy updates
Bundled Services and Supplies
For dates of service on or after July 1, 2015 we are updating Section 1 of the policy to include Current Procedural
Terminology (CPT®) codes 98961 and 98962 (education and training for patient self-management by a qualified, nonphysician health care professional) as always bundled services. The Health Plan considers these services to be part of the
overall care management of the patient.
As we advised in our August 2014 Network Update, we are reviewing and adding HCPCS “S” codes to our always bundled
services edit. Unless there are specific, specialized contracts or criteria for a provider to report their services using a HCPCS
“S” code, we will consider these codes to be always bundled. Therefore, effective with dates of service on or after July 1,
2015 HCPCS codes S8415, S9098, and S9110 will not be eligible for reimbursement.
Under the Coding Section of Section 2 in our policy, we are updating the bullet for CPT code 76942 to remove the individual
procedure codes that 76942 is not reportable with and have included a reference to the CPT parenthetical statement. This
will provide the most up-to-date information. This information has also been updated in our Modifier 59 Reimbursement
Policy.
Drug Screen Testing
Effective May 1, 2015 the “Qualitative Drug Screen” policy title will be changed to “Drug Screen Testing” and includes
information on coding updates. In addition, as communicated in our February 2015 Network Update Bundled Services and
Supplies article, the Health Plan considers G0431 and G0434 to be always bundled services and not eligible for
reimbursement.
Modifier 59 (Distinct Procedural Services)
In this policy, starting with effective date January 1, 2015, we are including language for the new XE, XP, XS, and XU
modifiers that were effective January 1, 2015- however there is no change to the policy position. As a reminder, these
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modifiers will process equivalent to our modifier 59 edits. In addition we are changing the title of our policy to “Modifiers 59
and XE, XP, XS, & XU (Distinct Procedural/Separate/Unusual Service).” We will add information regarding the “X” modifiers
to our other professional reimbursement policies as applicable.
Multiple and Bilateral Surgery Processing
In our policy effective January 1, 2015, we have updated the arthroscopic and endoscopic surgical procedures coding table
to include new HCPCS colonoscopy codes G6024 and G6025. In addition, new CPT codes 45388, 45389, and 45390 are
within the colonoscopy code range of 45378-45392 therefore they are not individually listed in the code table. We have also
made minor language changes for clarification of the endoscopy/arthroscopy multiple surgical procedure reimbursement
process.
Coding Tip – Adaptive Behavioral Follow-Up Assessments 0360T-0363T
Based on CPT’s description for CPT codes,
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0360T-0361T (Observational behavioral follow-up assessment, includes physician or other qualified health care
professional direction with interpretation and report, administered by one technician; first and each additional 30
minutes of technician time, face-to-face with the patient ) and
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0362T-0363T (Exposure behavioral follow-up assessment, includes physician or other qualified health care
professional direction with interpretation and report, administered by physician or other qualified health care
professional with the assistance of one or more technicians; first and each additional 30 minutes of technician(s)
time, face-to-face with the patient), these services are to be reported based on the time that the patient is face-toface with one or more technician(s) however only the time of one technician is counted and reported.
If the physician or other qualified health care professional personally performs the technician activities, his or her time
engaged in these activities may be included as part of the required technician time to meet the elements of the code.
In addition, the Health Plan follows CPT’s “Time-Rule for Face-to-Face Technician Time” guidelines that a unit of time is
attained when the mid-point is passed and that the time reported is for a single day and is not cumulative over a longer
period of time.
New Guidelines for Facility reimbursement for patients with elevated BMI
Effective July 1, 2015 the following criteria shall be met to support additional reimbursement in conjunction with the diagnosis
coding of Body Mass Index (BMI) ≥40:
1. Body Mass Index (BMI) ≥40 is reported as a secondary diagnosis.
2. The BMI ≥40 must be documented in the medical record by the physician, or by another clinician (e.g., a nutritionist
or nurse).
3. There must also be a clinical diagnosis or condition documented by the physician that corresponds to the BMI ≥40
and thereby explains its significance.
4. The physician medical record documentation or the hospital medical record documentation must demonstrate that
the presence of the BMI ≥40 led to substantially increased hospital resource use because of the need for such
services as intensive monitoring, technically complex services, extensive care requiring a greater number of
caregivers, or extended length of hospital stay. When there is insufficient documentation to support the above
criteria, services for such diagnoses shall be ineligible for reimbursement. The diagnosis shall not be considered in
the grouping to the DRG, if applicable
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