ANTHEM BLUE CROSS REIMBURSEMENT POLICIES AND MCKESSON CLAIMSXTEN RULES Overview This document provides all new, revised and existing Policies and all new, revised and existing claims editing rules administered by ClaimsXten TM that are effective October 1, 2016, except Policies #51 and #52 which are effective October 17, 2016. Claims submitted in a CMS-1500 format will be subject to the editing rules. This document is organized into two sections: McKesson ClaimsXten TM s: The enclosed grid includes all claims editing rules (new, revised and existing). This grid lists all claims editing rules (new, revised and existing). Policies: Copies of all Policies are enclosed, which includes all new, revised and existing reimbursement policies. Claims must be submitted in accordance with the reporting guidelines and instructions contained in the American Medical Association (AMA) CPT Manual, CPT Assistant, and HCPCS publications. Providers are responsible for accurately reporting the medical, surgical, diagnostic, and therapeutic services rendered to a member with the correct CPT and/or HCPCS codes, and for appending the applicable modifiers, when appropriate. Updates to claims editing rules may be implemented from time to time to reflect the addition of new/revised CPT/HCPCS codes and their associated edits, Correct Coding Initiative (CCI) revisions, and changes identified through regular review or inquiry. In addition to updates that are implemented from time to time to reflect the addition of new/revised CPT/HCPCS codes and their associated edits, CCI revisions, and changes identified through regular review or inquiry, we will be updating the rules as outlined below.
ANTHEM BLUE CROSS CLAIMS XTEN TM RULES 10/1/2016 Update /Policies Documentation policy Documentation Guidelines for Adaptive Behavior Assessments and Treatment for Autism Spectrum Disorder #0052 new No edits involved; this is a documentations guidelines policy. N/A Date of service 10/01/2016 Frequency/Maximum Occurances Once per Lifetime Procedures #0049 new When the Health Plan identifies a once per lifetime procedure on the current claim and also identifies a historical claim with the same or different procedure code that includes the current procedure in the description (code grouping), the current procedure will not be eligible for reimbursement. This will include those once per lifetime procedures processed and approved either by a previous carrier or with another Anthem, Inc. affiliated health plan. Units Frequency Maximum for Drugs and Biologic Substances #0048 new Code Description J0180 Injection, agalsidase beta, 1 mg (Fabrazyme) J0490 Injection, belimumab, 10 mg (Benlysta) J1602 Injection, golimumab, 1 mg (Simponi) J1745 Injection infliximab, 10 mg (Remicade) J2796 Injection, romiplostim, 10 mcg (Nplate) J9035 Injection, bevacizumab, 10 mg (Avastin) J9041 Injection, bortezomib, 0.1 mg (Velcade) J9055 Injection, cetuximab, 10 mg (Erbitux) J9171 Injection docetaxel 1 mg (Docetaxel) J9206 Injection irinotecan 20 mg (Camptosar) J9228 Injection, ipilimumab, 1 mg (Yervoy) J9263 Injection, oxaliplatin, 0.5 mg (Eloxatin/Oxaliplatin) J9305 Injection pemetrexed 10 mg (Alimta) J9310 Injection, rituximab, 100 mg (Rituxan) See policy for rationales and maximum units for each drug. Pay percent multiple diagnostic cardiology Multiple Diagnostic Cardiology #0051 new New policy we will apply a multiple procedure payment reduction (MPPR) of 25% to the technical component of diagnostic cardiology services that have a multiple procedure indicator (MPI) of six (6) in the multiple procedure column of the CMS National Physician Fee Schedule (NPFS). Based on CMS Date of service 10/17/2016 Pay percent multiple diagnostic ophthalmology Multiple Diagnostic Ophthalmology #0050 new New policy we will apply a multiple procedure payment reduction (MPPR) of 20% to the technical component of diagnostic ophthalmology services that have a multiple procedure indicator (MPI) of seven (7) in the multiple procedure column of the CMS National Based on CMS Physician Fee Schedule (NPFS). Date of service 10/17/2016 1
ANTHEM BLUE CROSS CLAIMS XTEN TM RULES 10/1/2016 Update /Policies Always Supplies This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure is not provided for the following codes: G0151 G0164, Q5001 Q5002 and Q5009 (skilled services provided in the home or hospice settings) This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure is not provided for the following codes: G0151 G0164, Q5001 Q5002 and Q5009 (skilled services provided in the home or hospice settings) Always Supplies This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure is not provided for the following codes: G0299 G0300, G9473 G9479 This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure is not provided for the following codes: G0299 G0300, G9473 G9480 Always Supplies is not provided for the following code: S9484, S9485, S9990 and S9992 is not provided for the following code: S9484, S9485, S9990 and S9993 Health Plan non approved drugs, programs, services, and supplies identified by certain Healthcare Common Procedural Coding System (HCPCS Level II) S codes including, but not limited to, disease management programs, or when another current Current Procedural Terminology (CPT ) or HCPCS code exists Always Supplies This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure is not provided for the following code: 80300 80304, 80320 80377 and 83992 is not provided for the following code: 80300 80304, 80320 80377 and 83993 Bundled Service and Supplies Modifiers 59 and XE, XP, XS, & XU (Distinct Procedural/Separate/U nusual Service) This edit will deny A4648 (tissue marker) when reported with 19081 19101 (breast biopsy) or 19281 19288 (placement of breast localization device(s)). Modifiers will not override this edit. RVUs for the breast biopsy and clip placement codes include the cost of the clip (tissue marker). 2
ANTHEM BLUE CROSS CLAIMS XTEN TM RULES 10/1/2016 Update /Policies Bundled Service and Supplies Modifier 59 #0023 Procedure 29875 denies when reported with other arthroscopic knee procedure codes (29880, 29881, 29882 and 29883) performed on the same knee; modifiers 59, XE, XP, XS or XU will not override the edit. Supplies Supplies Supplies Modifier 59 #0023 Modifier 59 #0023 Obstetrics Services #0011 Deny validity testing (82570 and 83986) when reported with lab toxicology codes (80300 80377, 83992, G0477 G0483); modifiers will not override this edit Deny validity testing (82570 and 83986) when reported with lab toxicology codes (80300 80377, 83992, G0477 G0483); modifiers will not override this edit Deny 95940 as mutually exclusive when reported with 95941 (intraoperative neurophysiologic monitoring procedures) by the same provider, for the same member, on the same date of service. Modifiers will not override this edit. This edit will deny procedures 76801 76802, 76805, 76810 or 76815 76817 when reported with an ICD10 Routine Diagnosis Code [only taken from the routine Obstetrics services policy] This edit will deny procedures 76801 76802, 76805, 76810 or 76815 76817 when reported with an ICD10 Routine Diagnosis Code [only taken from the routine Obstetrics services policy] Frequency/Maximum Occurances revised Limit procedure code 86160 (COMPLEMENT; ANTIGEN, EACH COMPONENT) to 4 units per day with no modifier override. Based on CMS MUEs Process Date 08/22/2016 This will add a limit of one unit per date of service for 87529 (herpes simplex virus, amplified probe technique). This will add a limit of one unit per date of service for 87529 (herpes simplex virus, amplified probe technique). 10/1/2016 This will add a limit of 1 unit per date of service for J9031 (Theracys / Tice BCG). This will add a limit of 10 units per date of service for J2649 (Aloxi, 25 mcg). This will add a limit of 10 units per date of service for J9217 (Lupron Depot, Eligard, 7.5 mg).. This will add a limit of 600 units per date of service for J0585 (Botox/Botox Cosmetic) and 400 units per date of service for J0717 (Cimzia).. This will add a limit of 200 units per date of service for J0586 (Dysport).. This will add a limit of 20 units per date of service for J9395 (Faslodex) and a limit of 20 units per date of service for J1750 (Dextran). 3
ANTHEM BLUE CROSS CLAIMS XTEN TM RULES 10/1/2016 Update /Policies This will add a limit of 8 units per date of service for J2507 (Krystexxa). This will add a limit of 60 units per date of service for J9047 (Kyprolis). This will add a limit of 100 units per date of service for J0129 (Orencia). This will add a limit of 120 units per date of service for J0897 (Prolia/Xgeva). This will add a limit of 40 units per date of service for J2353 (Sandostatin, Depot). This will add a limit of 150 units per date of service for J1453 (Emend). This will add a limit of 3 units per date of service for J9202 (Zoladex). This will add a limit of 5 units per date of service for J3489 (Zoledronic Acid). This will add a limit of 96 units per date of service for J7325 (Synvisc/Synvisc one). This will add a limit of 90 units per every 28 days for J3357 (Stelara, 1 mg). This will add a limit of one unit per every 60 days for 11720 (debridement for one to five nails) and a limit of one unit per every 60 days for 11721 (debridement for six or more nails). Based on CMS This will add a limit of one unit per every 60 days for 11720 (debridement for one to five nails) and a limit of one unit per every 60 days for 11721 (debridement for six or more nails). This will add a limit of 90 units per every 14 days for J2357 (Xolair, 5 mg). 4
ANTHEM BLUE CROSS CLAIMS XTEN TM RULES 10/1/2016 Update /Policies This will add a limit of 14 units per every 90 days for J7312 (Ozurdex). This will add a limit of one unit for 96401 with the administration of Xolair and a diagnosis of idiopathic urticaria. Limit is 1 injection per drug; this drug administration code is for the administration of a drug, not the number of injections needed to administer the correct dosage of the drug. This will add a limit of 18 units per every 365 days for 80320 80377 and 83992 (confirmation testing codes) for participating providers. This will add a limit of 18 units per every 365 days for 80320 80377 and 83992 (confirmation testing codes) for participating providers. Modifier to Procedure Validation Durable Medical Equipment #0022 This edit denies codes when reported with inappropriate modifiers. when reported with purchase modifiers is not provided for the following codes, which are classified as Rent to Purchase items and are not eligible for up front purchase: E0601, E0470, E0471, E0561, E0562 (BiPAP, CPAP, humidifiers) when submitted with purchase modifiers NR, NU, and UE when reported with purchase modifiers is not provided for the following codes, which are classified as Rent to Purchase items and are not eligible for up front purchase: E0601, E0470, E0471, E0561, E0562 (BiPAP, CPAP, humidifiers) when submitted with purchase modifiers NR, NU, and UE Modifier to Procedure Validation Modifier s #0017 This denies codes when reported with inappropriate modifiers. is not provided for surgeries reported with modifier SA This denies codes when reported with inappropriate modifiers. is not provided for surgeries reported with modifier SA Pay percent radiology Modifier s #0017 We will apply a 5% reduction for dates of service beginning October 1, 2016 through December 31, 2016 and a 15% reduction for dates of service on or after January 1, 2017 to the technical component of diagnostic computed tomography services for the head/brain, Based on CMS guideline abdomen, pelvis, upper extremity, lower extremity, etc. in the following code ranges and any succeeding codes: 70450 70498, 71250 71275, 72125 72133, 72191 72194, 73200 Computed tomography services that are furnished on non NEMA Standard XR 29 2013 compliant CT equipment must include modifier CT 73206, 73700 73706, 74150 74178, 74261 74263, and 75571 75574. 5
ANTHEM BLUE CROSS CLAIMS XTEN RULES 10/1/2016 Update /Policies Always Supplies This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure is not provided for the following codes: G0151 G0164, Q5001 Q5002 and Q5009 (skilled services provided in the home or hospice settings) This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure is not provided for the following codes: G0151 G0164, Q5001 Q5002 and Q5009 (skilled services provided in the home or hospice settings) Always Supplies This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure is not provided for the following codes: G0299 G0300, G9473 G9479 This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure is not provided for the following codes: G0299 G0300, G9473 G9480 Always Supplies is not provided for the following code: S9484, S9485, S9990 and S9992 is not provided for the following code: S9484, S9485, S9990 and S9993 Health Plan non approved drugs, programs, services, and supplies identified by certain Healthcare Common Procedural Coding System (HCPCS Level II) S codes including, but not limited to, disease management programs, or when another current Current Procedural Terminology (CPT ) or HCPCS code exists Always Supplies This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure This edit denies codes for which Anthem does not reimburse when reported alone or with any other procedure is not provided for the following code: 80300 80304, 80320 80377 and 83992 is not provided for the following code: 80300 80304, 80320 80377 and 83993 Bundled Service and Supplies Modifiers 59 and XE, XP, XS, & XU (Distinct Procedural/Separate/U nusual Service) This edit will deny A4648 (tissue marker) when reported with 19081 19101 (breast biopsy) or 19281 19288 (placement of breast localization device(s)). Modifiers will not override this edit. RVUs for the breast biopsy and clip placement codes include the cost of the clip (tissue marker). 2
ANTHEM BLUE CROSS CLAIMS XTEN RULES 10/1/2016 Update /Policies Bundled Service and Supplies Modifier 59 #0023 Procedure 29875 denies when reported with other arthroscopic knee procedure codes (29880, 29881, 29882 and 29883) performed on the same knee; modifiers 59, XE, XP, XS or XU will not override the edit. Supplies Supplies Supplies Modifier 59 #0023 Modifier 59 #0023 Obstetrics Services #0011 Deny validity testing (82570 and 83986) when reported with lab toxicology codes (80300 80377, 83992, G0477 G0483); modifiers will not override this edit Deny validity testing (82570 and 83986) when reported with lab toxicology codes (80300 80377, 83992, G0477 G0483); modifiers will not override this edit Deny 95940 as mutually exclusive when reported with 95941 (intraoperative neurophysiologic monitoring procedures) by the same provider, for the same member, on the same date of service. Modifiers will not override this edit. This edit will deny procedures 76801 76802, 76805, 76810 or 76815 76817 when reported with an ICD10 Routine Diagnosis Code [only taken from the routine Obstetrics services policy] This edit will deny procedures 76801 76802, 76805, 76810 or 76815 76817 when reported with an ICD10 Routine Diagnosis Code [only taken from the routine Obstetrics services policy] Frequency/Maximum Occurances revised Limit procedure code 86160 (COMPLEMENT; ANTIGEN, EACH COMPONENT) to 4 units per day with no modifier override. Based on CMS MUEs Process Date 08/22/2016 This will add a limit of one unit per date of service for 87529 (herpes simplex virus, amplified probe technique). This will add a limit of one unit per date of service for 87529 (herpes simplex virus, amplified probe technique). 10/1/2016 This will add a limit of 1 unit per date of service for J9031 (Theracys / Tice BCG). This will add a limit of 10 units per date of service for J2649 (Aloxi, 25 mcg). This will add a limit of 10 units per date of service for J9217 (Lupron Depot, Eligard, 7.5 mg).. This will add a limit of 600 units per date of service for J0585 (Botox/Botox Cosmetic) and 400 units per date of service for J0717 (Cimzia).. This will add a limit of 200 units per date of service for J0586 (Dysport).. This will add a limit of 20 units per date of service for J9395 (Faslodex) and a limit of 20 units per date of service for J1750 (Dextran). 3
ANTHEM BLUE CROSS CLAIMS XTEN RULES 10/1/2016 Update /Policies This will add a limit of 8 units per date of service for J2507 (Krystexxa). This will add a limit of 60 units per date of service for J9047 (Kyprolis). This will add a limit of 100 units per date of service for J0129 (Orencia). This will add a limit of 120 units per date of service for J0897 (Prolia/Xgeva). This will add a limit of 40 units per date of service for J2353 (Sandostatin, Depot). This will add a limit of 150 units per date of service for J1453 (Emend). This will add a limit of 3 units per date of service for J9202 (Zoladex). This will add a limit of 5 units per date of service for J3489 (Zoledronic Acid). This will add a limit of 96 units per date of service for J7325 (Synvisc/Synvisc one). This will add a limit of 90 units per every 28 days for J3357 (Stelara, 1 mg). This will add a limit of one unit per every 60 days for 11720 (debridement for one to five nails) and a limit of one unit per every 60 days for 11721 (debridement for six or more nails). Based on CMS This will add a limit of one unit per every 60 days for 11720 (debridement for one to five nails) and a limit of one unit per every 60 days for 11721 (debridement for six or more nails). This will add a limit of 90 units per every 14 days for J2357 (Xolair, 5 mg). 4
ANTHEM BLUE CROSS CLAIMS XTEN RULES 10/1/2016 Update /Policies This will add a limit of 14 units per every 90 days for J7312 (Ozurdex). This will add a limit of one unit for 96401 with the administration of Xolair and a diagnosis of idiopathic urticaria. Limit is 1 injection per drug; this drug administration code is for the administration of a drug, not the number of injections needed to administer the correct dosage of the drug. This will add a limit of 18 units per every 365 days for 80320 80377 and 83992 (confirmation testing codes) for participating providers. This will add a limit of 18 units per every 365 days for 80320 80377 and 83992 (confirmation testing codes) for participating providers. Modifier to Procedure Validation Durable Medical Equipment #0022 This edit denies codes when reported with inappropriate modifiers. when reported with purchase modifiers is not provided for the following codes, which are classified as Rent to Purchase items and are not eligible for up front purchase: E0601, E0470, E0471, E0561, E0562 (BiPAP, CPAP, humidifiers) when submitted with purchase modifiers NR, NU, and UE when reported with purchase modifiers is not provided for the following codes, which are classified as Rent to Purchase items and are not eligible for up front purchase: E0601, E0470, E0471, E0561, E0562 (BiPAP, CPAP, humidifiers) when submitted with purchase modifiers NR, NU, and UE Modifier to Procedure Validation Modifier s #0017 This denies codes when reported with inappropriate modifiers. is not provided for surgeries reported with modifier SA This denies codes when reported with inappropriate modifiers. is not provided for surgeries reported with modifier SA Pay percent radiology Modifier s #0017 We will apply a 5% reduction for dates of service beginning October 1, 2016 through December 31, 2016 and a 15% reduction for dates of service on or after January 1, 2017 to the technical component of diagnostic computed tomography services for the head/brain, Based on CMS guideline abdomen, pelvis, upper extremity, lower extremity, etc. in the following code ranges and any succeeding codes: 70450 70498, 71250 71275, 72125 72133, 72191 72194, 73200 Computed tomography services that are furnished on non NEMA Standard XR 29 2013 compliant CT equipment must include modifier CT 73206, 73700 73706, 74150 74178, 74261 74263, and 75571 75574. 5
SUMMARY OF ANTHEM BLUE CROSS PROFESSIONAL REIMBURSEMENT POLICIES Anthem Blue Cross is updating its PPO professional reimbursement policies by adopting the new policies and updating existing policies as of October 1, 2016. NOTE: For ease of searching for policies of most interest, the policies are referenced below in alpha order by policy name. The actual policies that follow are in order of the Anthem Blue Cross number (format: : CA - 00##). New Policies Unit Frequency Maximums for Drugs and Biologic Substances -- (: CA - 0048) Once per Lifetime Procedures --------------------------------------------- (: CA - 0049) Multiple Diagnostic Ophthalmology Procedures ---------------------- (: CA - 0050) Multiple Diagnostic Cardiovascular Procedures ----------------------- (: CA - 0051) Documentation Guidelines for Adaptive Behavior Assessments and Treatmnet for Autism Spectrum Disorder.------- (: CA - 0052) Existing, Updated Policies After Hours, Emergency, and Miscellaneous E/M Services (: CA - 0001) Anesthesia Services ----------------------------------------------------- (: CA - 0020) Assistant Surgeon Services -------------------------------------------- (: CA - 0009) Supplies -------------------------------------- (: CA - 0008) Cancer Treatment Planning and Care Coordination------------- (: CA - 0043) Claims Editing Overview ---------------------------------------------- (: CA - 0027) Co-Surgeon/Team Surgeon Services -------------------------------- (: CA - 0006) Documentation and Reporting Guidelines for Consultations ------------------------------------------------------ (: CA - 0030) Documentation and Reporting Guidelines for Evaluation and Management Services ------------------------- (: CA - 0024) Documentation Guidelines for Central Nervous System Assessments and Tests--------------------------------------------- (: CA - 0046) Documentation Guidelines for Psychotherapy Services-------------- (: CA - 0047) Drug Screen Testing ----------------------------------------------------- (: CA - 0038) Duplicate Reporting of Diagnostic Services) --------------------------- (: CA - 0045) Durable Medical Equipment ------------------------------------------- (: CA - 0022) Evaluation and Management Services and Related Modifiers -25 & -57 ------------------------------------------- (: CA - 0026) ------------------------------------------------------- (: CA - 0016) Global Surgery ----------------------------------------------------------- (: CA - 0012) Health and Behavior Assessment/Intervention --------------------- (: CA - 0033) Incident To Services --------------------------------------------------- (: CA - 0032) Injectable Substances with Related Injection Services---------------- (: CA - 0039) Injection and Infusion Administration and Related Services and Supplies ----------------------------------- (: CA - 0015) Laboratory and Venipuncture Services ---------------------------- (: CA - 0029) Moderate Sedation ----------------------------------------------------- (: CA - 0014) Page 1of 2
SUMMARY OF ANTHEM BLUE CROSS PROFESSIONAL REIMBURSEMENT POLICIES Anthem Blue Cross is updating its PPO professional reimbursement policies by adopting the new policies and updating existing policies as of October 1, 2016. NOTE: For ease of searching for policies of most interest, the policies are referenced below in alpha order by policy name. The actual policies that follow are in order of the Anthem Blue Cross number (format: : CA - 00##). Existing Policies (continued) Modifier s ---------------------------------------------------------- (: CA - 0017) Modifier 22 (Increased Procedural Services) ---------------------- (: CA - 0037) Modifier 59 and XE, XP, XS &XU (Distinct Procedural/Separate/Unusual Service) ----------------------------- (: CA - 0023) Overhead Expense For Office Based Surgery and Diagnostic Testing -------------------------------------------------- (: CA - 0041) Multiple Diagnostic Imaging Procedures---------------------------- (: CA - 0034) Multiple and Bilateral Surgery Processing ------------------------ (: CA - 0010) Office Place of Service --------------------------------------------------- (: CA - 0042) Pharmaceutical Waste --------------------------------------------------- (: CA - 0031) Physical and Manipulative Maintenance Services ----------------- (: CA - 0035) Place of Service ---------------------------------------------------------- (: CA - 0018) Prolonged Services ------------------------------------------------------ (: CA - 0019) Routine Obstetric Services -------------------------------------------- (: CA - 0011) of Eight Reporting Guidelines for Physical Medicine and Rehabilitation Services -------------------------------- (: CA - 0005) Screening Services with Related Evaluation and Management Services ---------------------------------------------------- (: CA - 0036) Sleep Studies and Related Bundled Services & Supplies --------- (: CA - 0028) Standby Services ----------------------------------------------------------- (: CA - 0021) Surgical Pathology and Related Prostate Needle Biopsy------------ (: CA - 0044) Telehealth Services ------------------------------------------------------- (: CA - 0007) Three-Dimensional (3D) Radiology Services) ------------------------ (: CA - 0040) Urgent Care (Coding and Bundled Supplies) ------------------------ (: CA - 0025) Please note that the following policies first effective 11/7/2009 have been archived and replaced with the policies referenced: CA 0002 Modifier 52 (Refer to : CA 0017 - Modifier s) CA 0003 Modifier 53 (Refer to : CA 0017 - Modifier s) CA 0004 Lab Combo (Refer to : CA 0029 - Laboratory and Venipuncture Services) CA 0013Venipuncture (Refer to : CA 0029 - Laboratory and Venipuncture Services) Page 2 of 2