Important information about Pennsylvania Blue Shield October 2000 Policy Review & News In This Issue Avoid delays: report your tax information changes on Blue Shield s W-9 form...1 UCR and PremierBlue reimbursement changes delayed until November...2 Report specific diagnosis codes for clinical laboratory tests...2 Blue Shield issues new coverage guidelines for Prevnar...3 News Avoid delays: report your tax information changes on Blue Shield s W-9 form You must report your name, address or tax identification number (TIN) changes to Pennsylvania Blue Shield. If Blue Shield does not have your correct legal name and TIN combination, your yearly income will be reported incorrectly to the Internal Revenue Service (IRS). To make it easier for you to send us your tax information changes, Blue Shield has developed a new provider taxpayer identification number form (W-9). The changes you report on the W-9 form will allow Blue Shield to provide accurate information about you to the IRS for tax purposes. Blue Shield uses the information you report on the W-9 form to prepare your miscellaneous income statement (form 1099-Misc). You will receive a 1099-Misc form if you received payments of $600 or more from Blue Shield in any calendar year. Blue Shield will mail your 1099-Misc form for the year 2000 at the end of January 2001. If Blue Shield has an incorrect legal name and TIN combination on its file and it sends that information to the IRS, the IRS will notify Blue Shield of the mismatch. Blue Shield will then contact the provider (through a B notice letter) to request the correct information.
To avoid delays with the 1099 process for 2000, please notify Blue Shield of any changes to your office s legal name, TIN or address by completing a W-9 form. To request a W-9 form, call (717) 763-3328. To change your provider information on Blue Shield s provider file, please call Provider Data Services at (717) 763-3224. Or, complete the coupon on Page 7 of this PRN and return it to us. Call Medigap Customer Service if claim is not received by Blue Shield In the August 2000 PRN we advised you not to send a copy of your Explanation of Medicare Benefits (EOMB) to Pennsylvania Blue Shield s Medigap department if the EOMB indicates the claim was forwarded to the patient s supplemental insurer. (See Do not send EOMBs to Blue Shield on Page 3 of the August PRN.) Blue Shield submits your claims electronically for secondary consideration. This saves your office time and money. If your EOMB indicates that your claim was forwarded for secondary consideration, you can check the status of the claim by using Blue Shield s InfoFax, OASIS or www.careconnect.com. If you find that Blue Shield did not receive the claim, please call the Medigap Customer Service department at (717) 763-6695. The customer service representative will tell you how to submit your claim. Policy UCR and PremierBlue reimbursement changes delayed until November In the June 2000 PRN, Pennsylvania Blue Shield announced changes to its reimbursement for certain services under its UCR and PremierBlue products (See Page 6 of the June issue, UCR and PremierBlue reimbursement changes pending Insurance Department approval ). The reimbursement changes were to become effective for claims processed on or after July 3, 2000. The Pennsylvania Insurance Department has approved these reimbursement changes. However, Blue Shield will delay implementation of these changes until Nov. 20, 2000. Report specific diagnosis codes for clinical laboratory tests 2 Pennsylvania Blue Shield can only reimburse clinical laboratory tests when they specifically relate to a patient s illness or injury.* You must report your patient s diagnosis and/or a definitive set of symptoms for the services you re performing. The diagnosis or symptoms must reflect the reason for your performing the service, not the findings. When the exact disease or diagnosis has not been confirmed, report the appropriate ICD-9 code(s) for the symptoms, signs or condition of the patient. For example, when reporting clinical laboratory tests performed to determine or confirm a suspected diagnosis. Reporting complete and accurate diagnosis information expedites claims processing and proper payment. *These guidelines do not apply to services reimbursed under the preventive care benefit.
10/2000 Independent clinical laboratories must report the most appropriate ICD-9 code in order to demonstrate the medical necessity of reported services. Ordering physicians should always provide independent laboratories with complete diagnosis information in order to expedite the laboratory s claims filing process. If this information is not included at the time of the referral, the clinical laboratory will have to contact the ordering provider for this information. Blue Shield allows bilaminate skin substitutes for diabetic foot ulcers Pennsylvania Blue Shield has re-evaluated its coverage guidelines for bilaminate, bioengineered tissue for treating venous ulcers. (See Page 7 of the June 2000 PRN for coverage criteria). Blue Shield now allows bilaminate, bio-engineered tissue when it s used to treat diabetic foot ulcers. Use these procedure codes to report bilaminate skin substitutes: G0170 Application of tissue cultured skin grafts, including bilaminate skin substitutes or neodermis, including site preparation, initial 25 sq cm G0171 Application of tissue cultured skin grafts, including bilaminate skin substitutes or neodermis, including site preparation, each additional 25 sq cm Electrogastrogram considered investigational Pennsylvania Blue Shield considers an electrogastrogram (EGG) an investigational service. Therefore, it is not eligible for payment. Use code 91299 to report an EGG. Remember to also include a complete description of the service performed. An EGG is a cutaneous recording of the gastric electrical signals that travel through the muscles of the stomach and control the muscles contraction. Electrogastrogram recordings provide a non-invasive measurement of gastric myoelectrical activity. This diagnostic procedure is used in the evaluation of patients with unexplained nausea, vomiting and other poorly defined upper gastrointestinal symptoms. Blue Shield issues new coverage guidelines for Prevnar Effective for claims processed on or after Jan. 1, 2001, Pennsylvania Blue Shield will no longer cover the pneumococcal conjugate, 7-valent vaccine called Prevnar TM (code 90669) for certain children who are at moderate or low risk for contracting pneumococcal infection. The American Academy of Pediatrics continues to investigate the use of Prevnar in children 24 months or older at moderate or lower risk. Current data do not support routine administration for children at moderate risk of pneumococcal invasive infection. This includes children 24 to 35 months old, children 36 to 59 months old who attend out-ofhome care, and children 36 to 59 months old who are of Native American (American Indian and Alaska Native) or African American descent. 3
Blue Shield s coverage guidelines for Prevnar continue to include all infants up to age 23 months old, and children 36 to 59 months old with sickle cell disease, human immunodeficiency virus (HIV) infection or primary immunodeficiency and children who are receiving immunosuppressive therapy. Ocular photodynamic therapy eligible for specific conditions Pennsylvania Blue Shield will now pay for ocular photodynamic therapy (PDT) when it s performed for the treatment of classic or predominantly classic choroidal neovascularization in patients with age-related wet macular degeneration (362.16, 362.52). All other applications of ocular photodynamic therapy are considered investigational. Please use these codes, as appropriate, to report the services performed: S0086 Verteporfin 15 mg 67220 Destruction of localized lesion of choroid (e.g., choroidal neovascularization), one or more session, photocoagulation (e.g., laser, ocular photodynamic therapy) PDT is a new treatment for certain types of ophthalmic diseases characterized by neovascularization, for example, age-related wet macular degeneration. It uses a combination of a photosensitizing drug (verteporfin, Visudyne) and non-thermal laser light to treat diseased tissue. PDT takes approximately 20 minutes and can be performed in the office. Subsequent courses of PDT may be needed until all of the fluorescein leakage has stopped. Procedure code 67220 is considered to be a staged eye procedure if it s reported by the same provider within the postoperative period. Code 67220 is also considered to be a staged procedure when reported within the postoperative period of procedure codes 67101-67110, 67141-67228. In this instance, Blue Shield will not make additional payments beyond that already allowed for the initial procedure. PDT performed on the other eye is not considered part of the original surgery and is eligible for payment. Reminder: Synagis may be eligible for reimbursement For those Pennsylvania Blue Shield contracts that provide benefits for immunization, coverage for synagis may be available. Certain childhood immunizations are covered by Blue Shield in compliance with Pennsylvania s childhood immunization mandate. Coverage for other immunizations, however, will vary by program. Synagis is not covered under Pennsylvania s childhood immunization mandate. Synagis is classified as an immunization and is also not eligible under the pharmacy benefit. See Synagis eligibility explained in the February 2000 PRN for synagis coverage guidelines, how to report synagis and how to find out if your patient has coverage for immunizations. 4
10/2000 Questions or comments on these new medical policies? We want to know what you think about our medical policy changes. Send us an e-mail with any questions or comments that you may have on the new medical policies discussed in this edition of PRN. Write to us at medicalpolicy@highmark.com. Codes 2000 PTM changes Please make these changes to your 2000 PTM: Page Modifier Terminology Action A-8 G1 Most recent URR reading of less than 60 Change terminology A-8 G2 Most recent URR reading of 60 to 64.9 Change terminology A-8 G3 Most recent URR reading of 65 to 69.9 Change terminology A-8 G4 Most recent URR reading of 70 to 74.9 Change terminology A-8 G5 Most recent URR reading of 75 or greater Change terminology A-8 NN PET scan - negative/negative Change terminology A-11 Y7 Polycarbonate lenses Add modifier to PTM. Effective Nov. 1, 2000 to identify polycarbonate eyeglass lens, V2100- V2199, V2200-V2299, V2300-V2399, Y0107, Y0108 and Y0109. 5
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10/2000 Notes Need to change your provider information? Fax the information to us! You can fax us changes about your practice information, such as the information listed on the coupon below. The fax number is (717) 731-2896. You may also continue to send information by completing the coupon below. Coupon for changes to provider information Please clip and mail this coupon, leaving the PRN mailing label attached to the reverse side to: Pennsylvania Blue Shield Provider Data Services PO Box 898842 Camp Hill, Pa. 17089-8842 7 Name Provider ID number Electronic media claims source number Please make the following changes to my provider records: Practice name Practice address Mailing address Telephone number ( ) Fax number ( ) E-mail address Tax ID number Specialty Provider's signature Date signed
Contents Vol. 2000, No. 5 News Avoid delays: report your tax information changes on Blue Shield s W-9 form... 1 Call Medigap Customer Service if claim is not received by Blue Shield... 2 Policy UCR and PremierBlue reimbursement changes delayed until November... 2 Report specific diagnosis codes for clinical laboratory tests... 2 Blue Shield allows bilaminate skin substitutes for diabetic foot ulcers... 3 Electrogastrogram considered investigational... 3 Blue Shield issues new coverage guidelines for Prevnar... 3 Ocular photodynamic therapy eligible for specific conditions... 4 Reminder: Synagis may be eligible for reimbursement... 4 Questions or comments on these new medical policies?... 5 Codes 2000 PTM changes... 5 Need to change your provider information?... 7 Acknowledgement The five-digit numeric codes that appear in PRN were obtained from the Physician's Current Procedural Terminology, as contained in CPT-2000, Copyright 1999, by the American Medical Association. PRN includes CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials that are copyrighted by the American Medical Association. Our web address: http://www.highmark.com PRN Policy Review & News Pennsylvania Blue Shield Camp Hill, Pennsylvania 17089 PRSRT STD U.S. POSTAGE PAID HARRISBURG, PA Permit No. 320 8