Lumbar, cervical and thoracic spine surgery (open, closed or minimally invasive) Adult deformity surgery Implantable infusion pump insertion

Transcription

1 July 30, 2015 Effective Oct. 1, NIA Magellan to Manage Spine Surgery and Interventional Pain Management Program Dear Provider: ConnectiCare is introducing a spine surgery and interventional pain management program to better manage these medical and surgical services for our members so they will receive clinically appropriate care. Starting Oct. 1, 2015, we will require preauthorization for the following non-emergency inpatient and outpatient procedures for all our members with commercial plans (including plans purchased through the Connecticut health insurance exchange, Access Health CT): Lumbar, cervical and thoracic spine surgery (open, closed or minimally invasive) Adult deformity surgery Implantable infusion pump insertion NIA Magellan will manage the preauthorization request-and-approval process under your existing contract with ConnectiCare. Providers can start calling NIA at on Sept. 21, 2015, to seek preauthorization for procedures scheduled on or after Oct. 1. Our current process will remain in place until Sept. 21; you will not have to contact NIA for additional authorization. Preauthorization for these services will also be required for our ConnectiCare VIP Medicare Plan members in 2016 (more information will be provided prior to implementation). The decision to establish a spine surgery and interventional pain management program is consistent with industry-wide efforts to manage costs while improving outcomes. In this program, ConnectiCare will work with NIA, which has an evidence-based program designed to effectively manage the quality of care, patient safety and appropriate utilization of resources for our members. All preauthorization requests will be reviewed by the appropriate practicing, board-certified orthopedic spine surgeons, neurosurgeons and interventional pain management specialists familiar with these surgeries and services. ConnectiCare will oversee the NIA program and continue to be responsible for claims adjudication and medical policies. Key provisions you need to know: It is the responsibility of the ordering physician to obtain preauthorization through NIA for all spine surgeries (open, closed or minimally invasive) and implantable infusion pump insertions outlined above. Doctors providing the affected services should verify all necessary authorizations have been obtained prior to performing the procedures. Failure to do so may result in nonpayment of claims. Pediatric deformity spine surgery for patients under 18 will require pre-registration through NIA but will not be subject to medical review or submission of documentation. NIA will not manage the preauthorization process for emergency spine surgery cases when the patients are admitted through the emergency room or for spine surgery procedures not listed above. These cases may be subject to retrospective review ConnectiCare Spine Management Program

2 Facilities must continue to follow ConnectiCare s current notification requirements for urgent/emergent hospital admissions and elective surgery based on a member s benefit and coverage requirements. Inpatient admissions, including emergency admissions for spine surgery, will continue to be subject to concurrent review by ConnectiCare. All spine procedures and spine devices that were previously considered investigational will continue to be considered investigational by ConnectiCare. A provider performing such a procedure will also be required to submit the clinical information to NIA for a formal review. We appreciate your support and look forward to your help in assuring that ConnectiCare members receive quality pain management services delivered in a clinically appropriate setting. We will provide more information before Oct. 1. Should you have questions, please call ConnectiCare Provider Services at from 8 a.m. to 6 p.m. Monday through Thursday, 9 a.m. to 5 p.m. Friday. Sincerely, John F. Harper, MD, PhD ConnectiCare Vice President, Chief Medical Director Michael Pentecost, M.D. National Imaging Associates, Inc. Chief Medical Officer Radiology Utilization Review Matrix ConnectiCare Spine Management Program

3 ConnectiCare Commercial & Exchange Members Spine Surgery, Implantable Infusion Pump Insertion & Other Spine Procedures The matrix below contains all of the CPT-4 codes for which NIA Magellan 1 authorizes on behalf of its clients. This matrix is designed to assist in the resolution of claims adjudication and claims questions related to those procedures authorized by NIA Magellan. If a procedure is billed under any one of the given codes for that allowable billed groupings and a valid authorization number has been issued within the date of service validity period, the charge for any of the allowable billed grouping codes should be allowed. If a family of CPT codes is not listed in this matrix, an exact match is required between the authorized CPT code and the billed CPT code. If the exact match does not occur, the charge should be adjudicated accordingly. *Please note: Pediatric deformity spine surgery for patients under 18 will require preregistration but will not be subject to preauthorization review including submission of documentation. NIA will not manage the preauthorization process for emergency spine surgery cases when the patients are admitted through the emergency room or spine surgery procedures not listed above. Facilities must continue to follow ConnectiCare s current notification requirements for urgent/emergent hospital admissions and elective surgery based on a member s benefit and coverage requirements. Inpatient admissions will continue to be subject to concurrent review by ConnectiCare. Inpatient and Outpatient: Non-Emergency Spine Surgery Implantable Infusion Pump Insertion 1 NIA Magellan refers to National Imaging Associates, Inc ConnectiCare Spine Management Program

4 Authorized CPT Code LUMBAR SPINE SURGERY Description Allowable Billed Groupings Lumbar Microdiscectomy 63030, Lumbar Decompression Lumbar Fusion Single Level** Lumbar Fusion Multiple Levels** 63030, , 63005, 63012, 63017, 63042, , 63047, , 63056, , 22558, 22612, 22630, , 22558, 22612, 22630, 22633, , , , , Lumbar Artificial Disc - Single Level 22857, 22862, Authorized CPT Code CERVICAL SPINE SURGERY Description Allowable Billed Groupings Anterior Cervical Decompression with Fusion (ACDF) Single Level** Anterior Cervical Decompression with Fusion (ACDF) Multiple Level** Cervical Posterior Decompression (without fusion) Cervical Posterior Decompression with Fusion Single Level** Cervical Posterior Decompression with Fusion Multiple Levels** 22548, 22551, , 22551, 22554, , , 63015, 63020,+63035, 63040, , 63045, , 63050, , 22595, , 22595, 22600, Cervical Artificial Disc - Single Level 22856, 22861, 22864, 0095T Cervical Anterior Decompression (without fusion) 63075, DEFORMITY SURGERY, THORACIC SURGERY & OTHER SPINE SURGERY Authorized CPT Description Allowable Billed Groupings ConnectiCare Spine Management Program

5 Code Deformity Surgery (Adult)** (Pediatric Deformity: NIA requires registration of all pediatric deformity surgeries performed on patients who are age 17 years of age.) Thoracic Surgery (Non-Deformity)** Spine Surgery Other: Neoplasm, Lesion, Infection (All Regions)** 22800, 22802, 22804, 22808, 22810, 22812, 22830, 22630, 22632, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, , 22534, 22556, 22585, 22610, 22614, 22830, 63003, 63016, 63046, 63048, 63055, 63057, 63064, 63066, 63077, , 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22554, 22556, 22558, 22585, 22532, 22533, Authorized CPT Code IMPLANTABLE INFUSION PUMP INSERTION Description Allowable Billed Groupings Implantable Infusion Pump Insertion 62350, 62351, 62355, 62360, 62361, ConnectiCare Spine Management Program

6 Other Spine Procedures or Devices- No or Limited Evidence of Effectiveness ConnectiCare will not provide reimbursement for the following CPT codes as there is no or limited evidence these procedures are effective. NIA prior authorization may be requested to review extenuating or unique clinical circumstances on a case-by-case basis. Representative CPT Code Procedure Description CPT Code Groupings Cervical Artificial Disc - Multiple Levels 22858, 0098T, 0375T 0163T Lumbar Artificial Disc - Multiple Levels 0163T, 0164T, 0165T Epidural Lysis of Adhesions (Racz procedure) 62263, Minimally Invasive Decompression (including MILD) 62287, 0274T, 0275T Percutaneous Thermal Intra-Discal Procedures (including IDET) 22526, 22527, Pre-Sacral/Axial Interbody Fusion 22586, 0195T, 0196T, 0309T Sacroiliac Joint Arthrodesis (percutaneous or open) 27279, T Interspinous Spacer Device (X-Stop) 0171T, 0172T, C T Total Facet Arthroplasty 0202T 0219T Posterior Intra-Facet Implants 0219T, 0220T, 0221T, 0222T M0076 Prolotherapy M ConnectiCare Spine Management Program

7 Code Notes: + codes (add-on codes) do not require separate authorization* and are to be used in conjunction with approved primary code for the service rendered. * There are two exceptions to this add-on comment for the following: o Multiple level fusion add-on codes require an authorization prior to o payment; Multiple level artificial disc add-on codes should not be assumed payable with a single level artificial disc authorization. ** Decompression procedures, instrumentation, and bone grafts do not require a separate authorization when done in combination with a fusion. These are assumed as part of the fusion authorization. Spine surgeries typically have more than one CPT associated with each case and often times a decompression is performed during the fusion surgery both will be billed. Multiple units may be required to accommodate the surgeon, cosurgeon and outpatient facility billing where applicable ConnectiCare Spine Management Program

8 Spine Surgery and Interventional Pain Management Program ConnectiCare Provider Educational Webinars ConnectiCare has entered into an agreement with NIA Magellan to implement a spine surgery and interventional pain management program. This program includes preauthorization requirements for inpatient and outpatient spine surgeries (open, closed and minimally invasive). This decision is consistent with industry-wide efforts to manage costs while improving outcomes. This program includes preauthorization for all inpatient and outpatient spine surgeries including cervical, lumbar, thoracic, adult deformity (pediatric deformity surgeries require registration of patients who are under 18 years of age), and implantable infusion pump insertions for all ConnectiCare members with commercial plans (including plans purchased through the Connecticut health insurance exchange, Access Health CT). ConnectiCare and NIA Magellan invite you to attend an upcoming spine management educational session to learn more about NIA Magellan and requesting preauthorization for these services. An hour-long health plan educational session will take place on the following dates: Tuesday September 15, :00 a.m. Tuesday September 15, :00 p.m. Wednesday September 16, :00 a.m. Wednesday September 16, :00 p.m. Wednesday September 23, :00 a.m. Wednesday September 23, :00 p.m. Thursday September 24, :00 a.m. Thursday September 24, :00 p.m. Please RSVP at least 1 week prior to the education seminar you plan to attend by ing NIAWebinar@magellanhealth.com.. Please include the following information in your RSVP request: RSVP Date Group Name TIN Address Phone # of Participants Attending You will receive a confirmation from NIA Magellan for the Webinar session you selected. Please see Access Instructions. NIA Magellan looks forward to working with you to ensure your ConnectiCare patients receive spine management procedures delivered in a quality, clinically appropriate fashion ConnectiCare Spine Management Program

9 Access Instructions You will need a computer with Internet access to view the educational materials presented during the webinar. Please sign in 15 minutes prior p to the meeting start time. To join education session, please follow these instructions: Step 1: Open a browser on your computer and go to: Step 2: Fill in the following fields: Enter ( ) in the Meeting Number field. Enter ( ) in the Code field. Enter your address in the Address field. Enter your First Name and Last Name in the name field Step 3: Click on Submit Choose Participant for the login information Click on Join Note: Select the type of AT&T Connect client software you want to use to connect to this event. Step 4: Select Web-based based We recommend using the Web-based based participant application, since some firewalls may prevent the downloading of an application. Or To use the Windows-based recommended application, the first time you use the AT&T TeleConference Service you will need to download the participant application. Step 5: To join the teleconference, choose one of the following: a) Click the Call Me option (to have AT&T call you) Or b) Pick up your phone and dial: When you are prompted enter the access code to be entered into the audio connection. All ConnectiCare-approved training/education materials are posted on the NIA Magellan website, For new users to access these web-based documents, a RadMD account ID and password must be created. To get started, simply go to click the New User button and submit a RadMD Application for New Account. Once the application has been processed and a password link delivered by NIA Magellan via , you will then be invited to create a new password. Links to the approved training/education documents are found on the My Practice page for those providers logged in as a Facility/Place of Service provider and among the RadMD Menu Options for those logged in as Ordering Physician. If you are a Facility/Place of Service provider or Hospital that performs the services, an administrator must accept responsibility for creating and managing all logins to RadMD. Your RadMD login information should not be shared ConnectiCare Spine Management Program