A new code for this year! G9153

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1 SM Volume 5, Issue 1 February Incentive Payments: A new code for this year! G9153 The South Carolina Department of Health and Human Services (SCDHHS) has identified and targeted certain Healthcare Effectiveness Data and Information Set (HEDIS *) measures in support of improving quality outcomes. BlueChoice HealthPlan Medicaid has identified incentive opportunities that correspond to the targeted HEDIS measures and quality goals identified by the state of South Carolina s Healthy Connections Program. The Quality Incentive Program offers incentive payments for certain well-child visits for all qualifying members. Participation is limited to primary care physicians (PCPs) in good standing with BlueChoice HealthPlan Medicaid and inclusive of the following specialty types: internal medicine, general practice, pediatrics and family medicine. Greenville Health Hospital System physicians in Greenville County are excluded from this incentive program. This year, we began our incentive program on Jan. 1; we will end the program on Dec. 31. The services for which providers may be eligible for payments are listed below: Service Description CPT-4 ICD-10 Well-Baby Visits, 0 to 15 months Well-Child Visits, ages 3 through 6 Adolescent Well-Care Visits, ages 12 through 20 A $30 incentive is offered for members 0 to 15 months old in 2017 with four to six visits documented on the medical record. The record must indicate evidence of physical exam, health and developmental history, health education and anticipatory guidance. A $30 incentive is offered for members ages 3 through 6 in 2017 with a documented visit. The medical record must indicate evidence of health and developmental history, a physical exam and health education/anticipatory guidance. A $30 incentive is offered for members ages 12 through 20 in 2017 with a documented visit. The medical record must indicate evidence of health and behavioral assessment, a physical exam and health education/anticipatory guidance. Please read the following important information pertaining to the incentive program: The incentives will only apply to the specific CPT codes listed. The appropriate well-child CPT code should be filed on the same claim as the G9153. The G9153 should be filed on the line directly after the well-child CPT code. For additional information, please contact your Provider Relations representative. * HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA) , 99382, 99391, and are billed for children 0 to 15 months 99382, 99383, 99392, are billed for children ages 3 through , 99385, 99394, are billed for children ages 12 through 20 Z0000, Z0001, Z005, Z0070, Z0071, Z008, Z00121, Z00129, Z020, Z021, Z022, Z023, Z024, Z025, Z026, Z0282, Z0289 Z0000, Z0001, Z005, Z0070, Z0071, Z008, Z00121, Z00129, Z020, Z021, Z022, Z023, Z024, Z025, Z026, Z0282, Z0289 Z0000, Z0001, Z005, Z0070, Z0071, Z008, Z00121, Z00129, Z020, Z021, Z022, Z023, Z024, Z025, Z026, Z0282, Z0289

2 Flu Prevention And Treatment Save Lives Flu season is upon us. Patients with certain chronic conditions including asthma, diabetes and chronic heart disease are at increased risk for illnesses and hospitalizations caused by the seasonal flu. The Centers for Disease Control and Prevention (CDC) estimates more than 200,000 people are hospitalized from flu complications annually. It is also estimated that between 3,000 and 49,000 die each year from flu-related causes. Please educate your patients about the risks of the flu and provide flu vaccines. Remember that adult members with BlueChoice HealthPlan Medicaid pharmacy benefits can get a free flu shot. They just need to show their member ID cards at participating pharmacies during flu shot clinic hours. Coverage for children s vaccines varies. For coverage information, contact your local Provider Relations representative. An ounce of prevention While the CDC recommends everyone 6 months of age and older receive the vaccine, flu shots are especially important for your high-risk patients. Encourage patients to be vaccinated as soon as possible. A flu shot is still the best prevention method. For the 2017 season, the CDC recommends use of the flu shot (inactivated influenza vaccine) and the recombinant influenza vaccine. The nasal spray flu vaccine (live attenuated influenza vaccine) should not be used during Tamiflu is available in generic form as of Jan. 1, Those at highest risk for influenza include: Children younger than 5, but especially younger than 2 years old Children between the ages of 6 months and 8 years of age who are receiving a flu vaccine for the first time will need to have two doses with at least four weeks between doses Adults 65 and older Women who are pregnant or expect to become pregnant Patients with certain chronic diseases Native Americans and Alaska Natives Antiviral drugs If patients do get sick, antiviral drugs not only lessen flu duration and symptoms but decrease the risk for flu-related complications. Antiviral drugs, as well as many cough and cold products, are on our Preferred Drug List posted at Restrictions apply. Stay informed Find the latest flu updates, health care recommendations and printable patient education materials at Remember to protect yourself and your patients by getting your vaccine, too. Source: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, "Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices United States," ( 2

3 We re In Your Community! The Horry County Library was filled with excitement during the Winter Warm Up Event in Little River. Attendees received free winter gear. BlueChoice HealthPlan Medicaid Outreach Specialist Allene Glapion-Tellis and Provider Relations Representative Ty Westbrook shared health/service information and health tips. Even though it was sunny and warm for our Winter Warm Up Event, attendees enjoyed hot cocoa and their new winter gear. BlueChoice HealthPlan Medicaid supported Charleston County Library in Charleston, South Carolina. More than 100 parents and children filled the auditorium to view the bilingual play Pinochle. BlueChoice HealthPlan Medicaid Outreach Specialist Chimere Platt provided health tips as well as benefits and services information. Platt also provided several interested individuals with educational giveaways. Website Enhancements has gone through a recent refresh to improve the look and navigation of the website. The refresh includes navigation improvements to many areas and new features, such as the Express Scripts, Inc. (ESI) Pharmacy Search Locator Tool to help you and your patients find a preferred pharmacy near you. We have also moved our prior authorization of benefits fax forms specific to certain conditions and medications under Pharmacy Information. Take a closer look and let us know what you think! For comments and questions concerning the website, contact your Provider Relations representative. Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members. 3

4 Intracardiac Electrophysiological Studies And Catheter Ablation To Require Prior Authorization Beginning April 1, 2017, intracardiac electrophysiological studies and catheter ablation will require prior authorization (PA). All requests with dates of service beginning on or after April 1, 2017, must be reviewed by BlueChoice HealthPlan Medicaid for PA. Noncompliance with new requirements may result in denied claims. PA requirements will be added to the following codes: 93600, 93602, 93603, 93609, 93613, 93619, 93620, 93621, 93622, 93624, 93650, 93653, and Please use one of the following methods to request PA: Phone: Fax: Federal and state law, state contract language, Centers for Medicare & Medicaid Services (CMS) guidelines and definitions and contract provisions and exclusions take precedence over these PA rules and must be considered first when determining coverage. Did You Know Behavioral Health Resources Available BlueChoice Health Plan Medicaid has a team of behavioral health case managers who can provide additional support to your members as they manage their recovery from behavioral health and substance use issues. Our case management team consists of independently licensed behavioral health clinicians, an outreach support specialist and a peer support recovery specialist. We provide telephone case management support to our members who have been referred to case management services from hospitalizations, by community referral sources or their treating provider. If you have a member you believe might benefit from behavioral health case management services, please contact us at We welcome the opportunity to provide additional support to our members in their recovery and management of behavioral health and substance use concerns. All Noncapitated Claims Must Have An Individual Attending Provider NPI (Type 1) On Institutional Medicaid Claims In an effort to more closely align with CMS guidelines, effective Jan. 1, 2017, BlueChoice HealthPlan Medicaid will require all noncapitated claims to have an individual attending provider National Provider Identifier (NPI, type 1) on institutional Medicaid claims. Claims submitted without the required NPI information in the attending field will be denied, with the exception of emergency claims. Per HIPAA regulations, attending provider name and identifiers (including NPI) are required on institutional claims for all services other than nonscheduled transportation. The attending provider is the individual who has overall responsibility for the patient s medical care and treatment. Please refer to ANSI X Technical Report Type 3 (TR3) found in CMS and the SCDHHS guidelines for required electronic data interchange transaction standards. If you have additional questions, please call the provider Customer Care Center at (fax: or ), Monday through Friday, from 8 a.m. until 6 p.m. 4

5 Antidepressant Medication Management This HEDIS measure looks at members who are 18 and older and have been diagnosed with Major Depressive Disorder. The members were newly treated with an antidepressant medication and remained on antidepressant medication treatment. There are two timelines for this measure: HEDIS General Announcement Each year, as part of the HEDIS quality study, BlueChoice HealthPlan Medicaid reviews a sample of our members medical records to measure the quality of care you provide. We are pleased to participate in this study as a means of pursuing continuous improvements in the services you provide to our members. Your assistance is crucial to ensuring that our data is statistically valid, auditable and accurately reflects quality performance. Should your office be contacted by one of our HEDIS staff, please accommodate them as quickly as your schedule permits. No special authorization is required to share member medical record information with BlueChoice HealthPlan Medicaid. The form you obtain from your patients permitting you to bill for care is sufficient under HIPAA regulations. Please take a moment to review the following federal regulations. Pursuant to 45 CFR , the routine form you have the member sign is sufficient to permit disclosure of protected health information to carry out health care operations. In addition, 45 CFR defines health care operations to include quality assessment and improvement activities. What is HEDIS? HEDIS is part of a nationally-recognized quality improvement initiative. HEDIS is used by the CMS, NCQA and several states to monitor the performance of managed care organizations. We look forward to demonstrating the quality care you provide in our statistics this year. If you have any questions or concerns, please call Effective acute phase treatment: Patients newly diagnosed and treated who remained on an antidepressant medication for at least 84 days (12 weeks). Effective continuation phase treatment: Patients newly diagnosed and treated who remained on an antidepressant medication for at least 180 days (six months). Providers are encouraged to code behavioral health services correctly by the NCQA. The NCQA recognizes the following codes for major depression: Description: ICD-10-CM diagnosis Major depression: F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 Helpful tips for providers: Educate your patients and their spouses, caregivers and/or guardians about the importance of: Staying on long-term medications. Consulting you before abruptly stoping medications. Contacting you immediately if they experience any unwanted/adverse reactions so that their treatment can be re-evaluated. Scheduling and attending follow-up appointments to review the effectiveness of their medications. Calling your office if they cannot get their prescriptions refilled. In addition, discuss the benefits of participating in behavioral health case management programs. Ask your patients who have a behavioral health diagnosis to provide you access to their behavioral health records if you are the PCP. Feel free to contact your Provider Relations representative if you have additional questions about this measure. 5

6 POLICY UPDATE Modifier 91: Repeat Clinical Diagnostic Laboratory Test (Policy , effective 07/01/17) BlueChoice HealthPlan Medicaid allows reimbursement of claims for repeat clinical diagnostic laboratory tests appended with Modifier 91, and reimbursement is based on 100 percent of the applicable fee schedule or contracted/negotiated rate. Medical documentation may be requested to support the use of Modifier 91, and failure to use the modifier appropriately may result in denial of the repeated laboratory test as a duplicate service. It is inappropriate to use Modifier 91 when only a single test result is required. Refer to the Modifier 91: Repeat Clinical Diagnostic Laboratory Test reimbursement policy at 6

7 Modifier 26 And TC: Professional And Technical Component (Policy , effective 07/01/17) BlueChoice HealthPlan Medicaid allows reimbursement of the professional component and technical component of a global procedure or service when appended with Modifier 26 and Modifier TC. Professional Component (Modifier 26) The professional component: Is used to indicate when a physician or other qualified health care professional renders only the professional component of a global procedure or service. Includes the supervision and interpretation portion of a procedure and the preparation of a written report. Technical Component (Modifier TC) NEW POLICY The technical component includes the technician, equipment, supplies and institutional charges associated with the performance of the service or procedure. Unless otherwise indicated in the policy, when a physician or other qualified health care professional performs a service in a facility, only the facility may be reimbursed for the technical component of the service; facility is defined in Exhibit A. To view Exhibit A, refer to the Modifier 26 and TC: Professional and Technical Component reimbursement policy at The physician or other qualified health care professional should make an arrangement with the facility for reimbursement to perform any technical components of a service. Please note that portable X-ray suppliers should bill only for the technical component by appending Modifier TC. Global Procedure In the absence of Modifier TC and Modifier 26, the same physician or other qualified health care professional will be reimbursed for the global procedure if they performed both the professional component and technical component of that service. BlueChoice HealthPlan Medicaid will reimburse the global procedure of newborn hearing screening codes performed in a facility (defined in Exhibit A). BlueChoice HealthPlan Medicaid does not allow reimbursement for use of Modifier 26 or Modifier TC when: They are reported with an Evaluation and Management (E&M) code. There is a separate stand-alone code that describes the professional component only, technical component only or global test only of a selected diagnostic test. BlueChoice HealthPlan Medicaid reserves the right to perform postpayment review of claims submitted with Modifier 26 or Modifier TC. The Modifier 26 and TC: Professional and Technical Component reimbursement policy can be found at 7

8 AX-400-Co1 P.O. Box 6170 Columbia SC PRSRT STD US POSTAGE PAID PERMIT NO 1240 COLUMBIA SC BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association. BlueChoice HealthPlan has contracted with Amerigroup Partnership Plan, LLC, an independent company, for services to support BlueChoice HealthPlan Medicaid. Some links in this newsletter lead to third party sites. Those organizations are solely responsible for the content and privacy policies on these sites. In this issue Page Incentive Payments: A New Code For This year! G9153 Page 2 Flu Prevention And Treatment Save Lives Page 3 We re In Your Community Website Enhancements Page 4 Intracardiac Electrophysiological Studies And Catheter Ablation To Require Prior Authorization All Noncapitated Claims Must Have An Individual Attending Provider NPI (Type 1) On Institutional Medicaid Claim Page 4 (continued) Did You Know Behavioral Health Resources Available Page 5 HEDIS General Announcement Antidepressant Medication Management Page 6 Modifier 91: Repeat Clinical Diagnostic Laboratory Test Page 7 Modifier 26 And TC: Professional And Technical Component