PLACE OF SERVICE REQUIREMENTS INCLUDED ON CERTAIN HIGHMARK WV MEDICAL POLICIES *

Transcription

1 * PLACE OF SERVICE REQUIREMENTS INCLUDED ON CERTAIN HIGHMARK WV MEDICAL POLICIES * Read this bulletin on-line via NaviNet JANUARY 20, 2011 HWV-PROV TO: (1) CHIEF FINANCIAL OFFICER (2) DIRECTOR/MANAGER OF PATIENT ACCOUNTS (3) BILLING OFFICE STAFF (4) CARE/CASE MANAGEMENT OR UTILIZATION REVIEW DEPT. FROM: SUBJECT: HIGHMARK BLUE CROSS BLUE SHIELD WEST VIRGINIA PROVIDER RELATIONS PLACE OF SERVICE REQUIREMENTS INCLUDED ON CERTAIN HIGHMARK WV MEDICAL POLICIES REFERENCE: BULLETIN MS-PROV , DATED DECEMBER 28, 2010 ======================================================================= PURPOSE This bulletin calls providers attention to certain Highmark Blue Cross Blue Shield West Virginia (Highmark WV) Medical Policies which will include a place of service requirement, as announced in the October 2010 Issue of Provider News. BACKGROUND/OVERVIEW Highmark WV now adds place of service requirements to certain of its medical policies. The October 2010 Issue of Provider News identified 23 such medical policies. For these medical policies, the table below displays the Policy number, the Policy topic, the required place of service and the effective date of the Policy. Providers should be aware that the effective date listed is the claim processed date on and after which the place of service requirement will be applied to a submitted claim.

2 For more information about policies marked with an asterisk (*), please see the Additional Guidelines section below. Policy # Policy Topic Place of Service Effective Date S-40 Implantable Infusion Pump Inpatient February 21, 2011 S-59* Implantable Automatic Inpatient or Outpatient February 21, 2011 Cardioverter-Defibrillator S-77 Endometrial Ablation Outpatient February 21, 2011 S-81 Congenital Cleft Palate Repair Inpatient February 21, 2011 S-82* Intra-Arterial/Intravenous Inpatient or Outpatient February 21, 2011 Therapeutic Procedures S-88 Ilizarov Bone Lengthening Inpatient February 21, 2011 S-99 Meniscal Allograft Inpatient February 21, 2011 Transplantation S-106 Treatment of Urinary Inpatient or February 21, 2011 Incontinence/Periurethral Bulking Agents Outpatient S-113* Pallidotomy and Other Treatments Inpatient February 21, 2011 of Parkinson s Disease S-129 Mastectomy and Reconstructive Inpatient February 21, 2011 Surgery S-130* Cryosurgery of the Liver Outpatient February 21, 2011 S-131* Sacral Nerve Outpatient February 28, 2011 Modulation/Stimulation for Pelvic Floor Dysfunction S-133 Endovascular Aneurysm Repair Inpatient February 21, 2011 S-143 Donor Leukocyte Infusion for Outpatient February 21, 2011 Hematologic Malignancies that Relapse after Allogeneic Stem Cell Transplant S-146* Percutaneous Vertebroplasty Outpatient February 21, 2011 S-148* Kyphoplasty Outpatient February 21, 2011 S-151 Transmyocardial (Laser) Inpatient February 28, 2011 Revascularization (TMR) S-163 Prophylactic Mastectomy Inpatient February 28, 2011 S-167 Lung Volume Reduction Surgery Inpatient February 21, 2011 S-178* Treatment of Hyperhidrosis Inpatient February 28, 2011 S-181* Coronary Revascularization Inpatient February 21, 2011 S-183 Partial and Total Hip Resurfacing Inpatient February 28, 2011 Arthroplasty S-202 Total Ankle Replacement Inpatient February 21, 2011

3 * Additional Guidelines Highmark WV will consider each person s unique clinical circumstances when a service that is typically performed in an outpatient setting is requested to be performed inpatient. In addition to the policies in the table above, some of those circumstances are provided in these examples: Medical Policy S-59, Implantable Automatic Cardioverter-Defibrillator, Effective February Inpatient: The implantation of an automatic cardioverter-defibrillator is performed as an inpatient procedure when the procedure is urgent or when it is performed by thoracotomy or through the subxiphoid approach. Outpatient: Elective, percutaneous procedures are typically outpatient procedures. Highmark WV covers these procedures when they re performed in an outpatient setting. Highmark WV does not cover percutaneous procedures when they re performed as inpatient procedures. Medical Policy S-82, Intra-Arterial/Intravenous Therapeutic Procedures, Effective February 21, 2011 Inpatient or Outpatient: Intra-arterial or intravenous therapeutic procedures can be performed either inpatient or outpatient. Urgent coronary angioplasties are typically performed inpatient. Intra-arterial therapeutic procedures performed on peripheral vessels, such as femoral arteries and venous percutaneous transluminal angioplasty (PTA) are typically outpatient procedures. Highmark WV covers these procedures when they are performed in an outpatient setting. Intra-arterial therapeutic procedures performed on peripheral vessels, such as femoral arteries and venous PTA are not eligible for coverage when they are performed as an inpatient procedure, except in specific situations -- including, but not limited to, those clinical situations in which the patient presents with coldness, mottling, pallor, numbness of the extremity, or pain in the extremity at rest. Additional examples of appropriate criteria for inpatient venous PTA includes oliguria with Blood Urea Nitrogen (BUN) >45 and creatinine>3 or refractory fluid overload. Medical Policy S-113, Pallidotomy and Other Treatments of Parkinson s Disease, Effective February 21, 2011 Inpatient: Pallidotomy, stereotactic lesion creation performed on the globus pallidus, is an inpatient procedure. Medical Policy S-130, Cryosurgery of the Liver, Effective February 21, 2011 Outpatient: Cryosurgery of the liver is typically an outpatient procedure. Highmark WV covers this prodecure when it is performed outpatient. Cryosurgery of the liver is not eligible for coverage when it is performed as an inpatient procedure, except in specific situations including, but not

4 limited to, patients with intractable pain or jaundice with International Normalized Ratio (INR) >2. Medical Policy S-131, Sacral Nerve Modulation/Stimulation (SNS) for Pelvic Floor Dysfunction, Effective February 28, 2011 Outpatient: Placement of electrodes used for the peripheral nerve stimulation test performed as a component of sacral nerve modulation or stimulation for pelvic floor dysfunction is an outpatient procedure. Medical Policy S-146, Percutaneous Vertebroplasty, Effective February 21, 2011 Outpatient: Percutaneous vertebroplasty is typically performed as an outpatient procedure. It can be performed inpatient under special conditions including, but not limited to, patients with intractable pain with neurologic deficits such as paresis or paralysis of an extremity. Medical Policy S-148, Kyphoplasty, Effective February 21, 2011 Outpatient: Kyphoplasty is typically performed as an outpatient procedure. It can be performed inpatient under special conditions including, but not limited to, patients with intractable pain with neurologic deficits such as paresis or paralysis of an extremity. Medical Policy S-178, Treatment of Hyperhidrosis, Effective February 28, 2011 Inpatient: Thorocoscopic and open sympathectomy performed for the treatment of hyperhidrosis is an inpatient procedure. Medical Policy S-181, Coronary Revascularization, Effective February 21, 2011 Inpatient or Outpatient: Percutaneous coronary artery revascularization can be performed either inpatient or outpatient. Highmark WV considers coronary artery bypass grafting or percutaneous coronary revascularization performed as an urgent procedure as inpatient procedures. Percutaneous coronary revascularization performed electively is typically an outpatient procedure. IMPACT/ACTION Providers are advised to evaluate the information in this bulletin and determine to what degree and in what way it will affect their business. In the near future, this information will also be added to the reference tool titled Highmark WV Medical Policies with Place of Service Requirements. This tool will be made available via a link from the Facility Information page of the NaviNet Provider Resource Center. Providers will be notified when the tool becomes available. Providers should be alert for further announcements about the addition of place of service requirements to other Highmark WV Medical Policies. TIME FRAME

5 The place of service requirements identified in this bulletin become effective as designated for each individual medical policy. Note that the effective date for each medical policy represents the processed date on and after which the identified place of service requirement will be applied to processed claims. ASSISTANCE This Bulletin Questions regarding this bulletin may be directed to your assigned External Provider Relations representative. Inquiries about Eligibility, Benefits, Claim Status or Authorizations For inquiries about eligibility, benefits, claim status or authorizations, Highmark WV encourages providers to use the electronic resources available to them NaviNet and the applicable HIPAA transactions prior to placing a telephone call to the Customer Service Center. NaviNet is a registered trademark of NaviNet, Inc. NaviNet, Inc., is an independent company that provides a secure, Web-based portal between providers and health care insurance plans.