Policy Review & News. In This Issue. News. PRNJune Important information about Highmark Blue Shield

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1 Policy Review & News PRNJune Important information about Highmark Blue Shield In This Issue Blue Shield seeks approval for UCR and PremierBlue Shield reimbursement increases Blue Shield to begin routine provider practice pattern notification Coverage guidelines for microprocessor-controlled prosthetic knee outlined B Look for this symbol for all BlueCard related information News Blue Shield seeks approval for UCR and PremierBlue Shield reimbursement increases Highmark Blue Shield is filing a broad range of UCR Level II and PremierBlue Shield reimbursement increases with the Pennsylvania Insurance Department (PID). If the PID approves, Blue Shield will increase its UCR and PremierBlue Shield payments for select procedures in these areas: obstetrics and gynecology integumentary musculoskeletal and nervous system surgical procedures vestibular function tests diagnostic sleep studies preventive care visits Highmark Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

2 PRN mammography certain other select evaluation and management services select procedure codes in the range Blue Shield expects to implement these reimbursement increases this summer if they are approved by the PID. Important information about DirectBlue and SelectBlue In the April 2004 issue of PRN, Highmark Blue Shield announced that changes are being made to better serve its DirectBlue and SelectBlue members. Specifically, Central Region and Western Region DirectBlue and SelectBlue members will be able to receive, in both regions, care at the higher level of benefits for covered services, beginning with dates of service on or after July 1, Special note to practices located along border between regions If your practice has locations in both the Central and Western Regions of Highmark s service area, or is located along the border between the regions, please note that your practice s main address, including the ZIP code, determines if your practice is designated as a Central Region provider or a Western Region provider in Highmark s provider file. This distinction is important because it determines how your practice will be reimbursed for services rendered to DirectBlue and SelectBlue members. Please be sure to read the April 2004 PRN article for details. If you need to confirm which of your practice locations is designated as the main address with Highmark, contact your Provider Relations representative. 2

3 6/2004 BlueCard reminders: how to file Medicare supplemental claims B When Medicare is the primary insurer, submit claims to your local Medicare carrier. After you receive the Medicare Summary Notice (MSN) from Medicare, review the indicators. If the indicator on the MSN shows that the claim was crossed-over, Medicare has submitted the claim to the appropriate Blue Plan. The claim is in progress. If you have any questions about the crossover indicator, please contact the Medicare carrier. If supplemental claims have not crossed-over, send them to Highmark Blue Shield only after you receive the Remittance Advice from the Medicare carrier. Here are some additional tips for filing these claims: Submit the alphabetical prefix as it appears on the member s identification card. Report all applicable information about the Medicare payment, including deductibles and payment amount. For electronic claim submissions, enter the Medicare payment information from the Medicare 835 Remittance or MSN into the appropriate data elements of the 837 claim transaction. If you have Other Party Liability (OPL) information, provide this information with the claim. Examples of OPL include Workers Compensation and automobile insurance. Do not send duplicate claims. You can check the status of your claims by using NaviNet or an electronic HIPAA 276 transaction. 3

4 PRN Outpatient therapy reminders Here are some reminders for health care providers who offer outpatient manipulation, physical, speech or occupational therapies: Many Highmark Blue Shield members have benefit limits for outpatient therapies per calendar or benefit year. Calendar year is the most common parameter chosen by group customers. Groups that select this benefit design allow their members to receive a designated number of visits per therapy type within the allotted time frame. Check with your patient to determine how many visits he or she may have already obtained. For services provided on or after July 1, 2004, you do not need to submit treatment plans for outpatient manipulation, physical, speech or occupational therapies for most Blue Shield products. For Medicare patients, treatment plans that are currently required to be sent to Medicare will continue to be required. Be sure to verify the member s eligibility and benefits before you provide services. NaviNet is the fastest and most efficient means to do this. Blue Shield to begin routine provider practice pattern notification Highmark Blue Shield s Provider Claims Review (PCR) department is responsible for notifying health care professionals and providers of potential areas of concern. When necessary, PCR sends educational information specific to those concerns to certain health care professionals and providers. This educational and informational approach opens up a means of communication between the provider and Blue Shield. Later this year, Blue Shield will begin to send routine notifications to health care professionals and providers whose individual reporting patterns are substantially different from their peer group. Blue Shield may send you a letter that outlines procedure codes that were reported more frequently than most other providers in your peer group. Blue Shield will also include a statistical analysis of those particular procedures and an explanation of the analysis. 4 Blue Shield realizes that there are many possible reasons why you may report procedures at an unusually high frequency when compared to your peers. The information that is provided with this letter is a statistical indication of an unusual situation(s), which may be the result of a factor or combination of factors.

5 6/2004 These factors could possibly include a subspecialty, an unusual patient population, an incorrect peer group listing, or the reporting of an incorrect procedure code and/or level of code. Please take time to review the material Blue Shield sends you. Also, be sure to analyze your use of the identified procedures. When you complete your analysis, you can respond to Blue Shield by outlining why your practice patterns differ from that of your peers. Blue Shield will consider your response and will update its records with your response. This will prevent any future miscommunication. Board certification requirements explained Board certification requirements for all allopathic and osteopathic applicants must be from an approved ABMS/AOA board. Health care professionals must complete the board certification process within two years of meeting the eligibility requirement. All non-board certified health care professionals must submit 50 continuing medical education (CME) credits per year for the previous three years. If you do not meet Highmark Blue Shield s board certification requirements, Blue Shield will contact you for additional information about your training and experience. Blue Shield will consider these exceptions to its board certification requirements on a case by case basis when it credentials or recredentials you for the PremierBlue Shield network: The health care professional has graduated from an accredited medical school or osteopathic school. He or she has completed an approved applicable residency or fellowship in the specialty of practice and completed training before The health care professional has not practiced for a sufficient length of time to complete board certification. In the health care professional s practice, 50 percent or more of the practice s associates are board certified and the health care professional has completed an approved, applicable residency or fellowship in the specialty in which he or she is requesting to be credentialed. Rural health care professionals, in addition to meeting the CME criteria, should have greater than 5 years experience in the specialty in which they practice. They should also have completed an approved, applicable residency or fellowship in the specialty of practice. 5 Emergency medicine health care professionals may satisfy the board certification requirement with ABMS/AOA certification in emergency medicine, family practice, internal medicine, pediatrics and general

6 PRN surgery. If an emergency medicine health care professional is not board certified in emergency medicine, he or she must have certifications in ACLS, ATLS and PALS. Policy Blue Shield pays for additional air mileage for air ambulance services under certain conditions Highmark Blue Shield will pay for additional air mileage for medically necessary air ambulance transportation if circumstances occur that are beyond the pilot s control. These circumstances include, but are not limited to: military base and other restricted zones, air-defense zones, and similar Federal Aviation Administration restrictions and prohibitions hazardous weather variances in departure patterns and clearance routes required by an air traffic controller Blue Shield s air ambulance transportation medical necessity criteria If the air ambulance transport meets Blue Shield s medical necessity criteria, you can report mileage from the point of pickup, including where applicable: ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing, and taxiing after landing. Blue Shield considers air ambulance transportation medically necessary only when the patient s condition is such that the time needed to transport a member by land, or the instability of transportation by land, poses a threat to the patient s survival or seriously endangers his or her health. Here are examples of cases for which air ambulance transport could be justified. The list is not intended to be inclusive of all situations that justify air transportation, nor is it intended to justify air transportation in all locales for the circumstances listed: intracranial bleeding requiring neurosurgical intervention cardiogenic shock (785.51) burns requiring treatment in a burn center conditions requiring treatment in a hyperbaric oxygen unit 6

7 6/2004 multiple severe injuries life-threatening trauma Blue Shield also covers the transfer of a patient from one hospital to another if the medical appropriateness criteria are met and the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. Examples of such services include burn units, cardiac care units, and trauma units. Blue Shield will cover the ambulance transport only if the hospital to which the patient is transferred is the nearest one with appropriate facilities. Use code A0435 or A0436 to report air mileage. Blue Shield determines coverage for ambulance services according to individual or group customer benefits. For more information about ambulance services, please refer to the October 2003 PRN. Liver biopsy, upper gastrointestinal endoscopy and EGD considered part of bariatric surgical procedures Highmark Blue Shield considers a liver biopsy (10021, 10022, 47001, 47100, 47120, 47122, 47379), upper gastrointestinal endoscopy, and esophagogastroduodenoscopy (EGD) (43234, 43235, 43236, 43237, 43238, 43239, 43241, 43259) an inherent part of all bariatric surgical procedures. These services are not eligible for separate payment when reported on the same day as a bariatric surgical procedure. When a health care professional reports a liver biopsy, upper gastrointestinal endoscopy, or EGD with a bariatric surgical procedure, Blue Shield will combine the charges under the appropriate bariatric surgery procedure code. A participating, preferred or network health care professional cannot bill the member for the liver biopsy, upper gastrointestinal endoscopy, or EGD. Here are the applicable bariatric surgical procedure codes: S S S2085

8 PRN Use procedure code to report a laparoscopic biopsy of the liver. When you report code 47379, please provide a complete description of the service in the narrative field of the electronic or paper claim. Electromagnetic therapy now eligible for managing certain chronic ulcers On July 1, 2004, Highmark Blue Shield began to pay for electromagnetic therapy (G0329) for the management of the following types of chronic ulcers when it is used as adjunctive therapy after there are no measurable signs of healing after 30 days of treatment with conventional wound care: arterial ulcers diabetic ulcers pressure ulcers (Stage III or Stage IV) venous stasis ulcers Measurable signs of improved healing include a decrease in wound size (either in surface area or volume), decrease in amount of exudates, and decrease in amount of necrotic tissue. Blue Shield does not pay for electromagnetic therapy when it is used as an initial treatment modality. Blue Shield will not pay for electromagnetic therapy for wound healing in the home setting. Blue Shield does not consider unsupervised use of electromagnetic therapy by patients in the home as medically reasonable or necessary. Blue Shield will deny all other uses of electromagnetic therapy for the treatment of chronic ulcers as not medically necessary. A participating, preferred or network provider cannot bill the member for the denied therapy. Blue Shield will allow treatment for either electrical stimulation (G0281) or electromagnetic therapy (G0329). It is not appropriate for a patient to receive both of these services. Blue Shield does not cover ocular photoscreening Highmark Blue Shield considers ocular photoscreening investigational. It is not covered. A participating, preferred or network provider can bill the member for the denied photoscreening. 8 Report this service with code 0065T ocular photoscreening with interpretation and report, bilateral.

9 6/2004 Venous percutaneous transluminal angioplasty eligible for some conditions Highmark Blue Shield will cover venous percutaneous transluminal angioplasty when it s performed for superior vena cava obstruction from benign and malignant diseases. Blue Shield will also pay for venous percutaneous transluminal angioplasty when it s performed: on renal patients who have peripheral arterial or venous fistulas for dialysis (403.01, , , , , , , , , , 585, 586, ), as part of the transjugular intrahepatic portosystemic shunt (TIPS) procedure. Blue Shield will give individual consideration to venous percutaneous transluminal angioplasty when it s performed for the treatment of congenital heart disease ( ). Blue Shield considers venous percutaneous transluminal angioplasty experimental or investigational when it s used in the treatment of any other conditions. In this case, a participating, preferred or network provider can bill the member for the denied surgery. Use these codes to report venous percutaneous transluminal angioplasty: transluminal balloon angioplasty, percutaneous; venous transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision and interpretation HIV genotyping and phenotyping coverage guidelines clarified Highmark Blue Shield will pay for testing for HIV resistance to antiretroviral drugs, that is, HIV genotyping or phenotyping, for patients who have failed a prior course of antiviral therapy. Because of a lack of documented studies, Blue Shield considers other applications of HIV resistance testing, including, but not limited to, its use in patients with previously untreated HIV, investigational. These tests are not eligible for payment. 9

10 PRN Blue Shield does not cover these HIV resistance tests because it considers them investigational: combined genotyping and phenotyping drug susceptibility phenotype prediction using genotypic comparison to known genotypic or phenotypic database, for example, VirtualPhenotype In these cases, a participating, preferred or network provider can bill the member for the denied tests. How to report HIV genotyping and phenotyping Use code to report HIV genotyping. Report HIV phenotyping with code or Use code 0023T to report drug susceptibility phenotype prediction using genotypic comparison to known genotypic or phenotypic database. Blue Shield pays for TandemHeart device Highmark Blue Shield pays for the insertion and removal of the TandemHeart ventricular assist device. Use these codes, as appropriate, to report the insertion and removal of the TandemHeart device: 0048T implantation of ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual cannulation 0049T prolonged extracorporeal percutaneous transseptal ventricular assist device, greater than 24 hours, each subsequent 24 hour period 0050T removal of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual cannulation Focused ultrasound ablation of uterine leiomyomata is investigational Highmark Blue Shield considers focused ultrasound ablation of uterine leiomyomata investigational. Blue Shield will deny claims reporting this service. A participating, preferred or network provider can bill the member for the denied service. 10

11 6/2004 Magnetic resonance guided focused ultrasound ablation therapy is a non-invasive method that may control uterine fibroids without a surgical resection. However, the device used to perform the procedure, the ExAblate 2000, is limited to investigational use by United States law. Use these codes to report this service: 0071T focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue 0072T focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue Selective internal radiation therapy considered investigational Highmark Blue Shield considers selective internal radiation therapy (SIRT) using intra-arterial injections of radiolabeled microspheres an investigational procedure. Blue Shield will deny claims reporting this procedure. A participating, preferred or network health care professional can bill the member for a service denied as investigational. Articles published in peer-reviewed medical journals report on the technical aspects of SIRT and recent experiences with SIRT in clinical trials. These reviews provide favorable preliminary evidence of the effects of SIRT on hepatic tumors. However, these clinical trials have been limited, yielding insufficient data on long-term follow-up. Additional research is necessary to document the duration of responses to, and patient survival after SIRT. SIRT uses intra-arterial injections of radiolabeled microspheres, such as SIR-Spheres or TheraSpheres, to treat primary or metastatic liver tumors. Small beads (microspheres) impregnated with a radioactive source, for example, yttrium 90 ( 90 Y), are delivered through a catheter into the liver to destroy liver tumors. Through this method, a very high radiation dose can be used to destroy liver tumors with limited damage to normal, healthy liver tissue. Report SIRT with procedure code S2095 transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium 90 microspheres. 11

12 PRN Percutaneous balloon valvuloplasty of the aortic valve eligible for specific conditions Highmark Blue Shield recognizes percutaneous balloon valvuloplasty of the aortic valve as an eligible surgical procedure for adults who are at high risk for aortic valve replacement surgery. Use code percutaneous balloon valvuloplasty; aortic valve to report this service. Blue Shield also will pay for percutaneous balloon valvuloplasty of the aortic valve in the treatment of calcified valves (424.1), and in the treatment of congenital aortic stenosis. Blue Shield considers this treatment for any other conditions experimental or investigational. A participating, preferred, or network provider can bill the member for the denied service. Coverage guidelines for microprocessor-controlled prosthetic knee outlined On Aug. 2, 2004, Highmark Blue Shield will begin to pay for microprocessor-controlled prosthetic knees, for example, C-Leg, for patients whose functional level is 3 or above. Please report modifier K3 or K4 to show that the patient s functional level is 3 or above. If the microprocessor-controlled prosthetic knee is provided for a functional level other than 3 or above, Blue Shield will deny it as not medically necessary. A network provider cannot bill the member for the denied prosthetic knee. On-board, real-time gait analysis is accomplished by the microprocessors in this knee (L5846, L5847) and by the pylon sensors (L5989). Blue Shield will not pay separately for the gait analysis if it s billed separately with code L5999. Blue Shield includes the allowance for this function in the reimbursement for code L5847. A network provider cannot bill the member for the denied service. 12

13 6/2004 Blue Shield determines medical necessity for the microprocessor-controlled prosthetic knee based on the patient s potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist and treating health care professional, considering factors including, but not limited to, the patient s: past history (including prior prosthetic use, if applicable), current condition including the status of the residual limb and the nature of other medical problems, and desire to ambulate. Base your clinical assessments of patient rehabilitation potential on these classification levels: Level 0 (indicated by modifier K0). The patient does not have the ability or potential to ambulate or transfer safely with or without assistance. A prosthesis does not enhance their quality of life or mobility. Level 1 (indicated by modifier K1). The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator. Level 2 (indicated by modifier K2). The patient has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator. Level 3 (indicated by modifier K3). The patient has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. Level 4 (indicated by modifier K4). The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. Bilateral amputees often cannot be strictly bound by functional level classifications. Blue Shield will pay for the prosthetic knee only if there is sufficient documentation in the patient s medical record showing functional need for the technologic or design feature of the prosthetic knee. 13

14 PRN The expected patient functional ability information must be clearly documented and retained in the prosthetist s records. Information about the patient s history and current condition that supports the designation of the functional level by the prosthetist should also be included in their records. Use codes L5846, L5847 and/or L5989 to report a microprocessor-controlled prosthetic knee. You must also report modifier K0-K4, as appropriate, to indicate the expected patient functional level. Blue Shield determines coverage for prosthetics and orthotics according to individual or group customer benefits. Blue Shield denies claims for spectroscopy, expired gas analysis Highmark Blue Shield considers spectroscopy, expired gas analysis, investigational and will deny claims reporting this procedure. A participating, preferred or network provider can bill the member for the denied service. Use code 0064T spectroscopy, expired gas analysis (eg, nitric oxide/carbon dioxide test) to report this service. Acoustic heart sound recording and computer analysis not covered Highmark Blue Shield considers acoustic heart sound recording and computer analysis investigational. Blue Shield will deny claims reporting this service. A participating, preferred or network provider can bill the member for the denied service. Here are the procedure codes you can use to report this service: 0068T acoustic heart sound recording and computer analysis; with interpretation and report (List separately in addition to codes for electrocardiography) 0069T acoustic heart sound recording and computer analysis; acoustic heart sound recording and computer analysis only (List separately in addition to codes for electrocardiography) 0070T acoustic heart sound recording and computer analysis; interpretation and report only (List separately in addition to codes for electrocardiography) 14

15 6/2004 Acoustic heart sound recording and computer analysis differs from an electrocardiogram by including preparation and placement of an acoustic sensor, acquisition of the acoustic recordings, computer analysis and display of the acoustic information, and health care professional interpretation of the information. This test is performed in conjunction with an electrocardiogram. Codes Terminology changes for code G0295 The terminology for procedure code G0295 changed on July 1, Here is the new terminology: G0295 electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses. Changes to 2004 PTM for Ancillary Providers Please make these changes to your 2004 Procedure Terminology Manual for Ancillary Providers. Page Code Terminology Action 3 T2005 Non-emergency transportation; stretcher van Revise terminology. Effective 7/1/04. 3 T2049 Non-emergency transportation; stretcher van, Add. Effective 7/1/04. mileage, per mile. 15 S8301 Infection control supplies, not otherwise specified Add. Effective 7/1/ K0650 General use wheelchair seat cushion, width less Add. Effective 7/1/04. than 22 inches, any depth 28 K0651 General use wheelchair seat cushion, width Add. Effective 7/1/ inches or greater, any depth 28 K0652 Skin protection wheelchair seat cushion, width Add. Effective 7/1/04. less than 22 inches, any depth 28 K0653 Skin protection wheelchair seat cushion, width Add. Effective 7/1/ inches or greater, any depth 28 K0654 Positioning wheelchair seat cushion, width less Add. Effective 7/1/04. than 22 inches, any depth 15

16 PRN Page Code Terminology Action 28 K0655 Positioning wheelchair seat cushion, width 22 Add. Effective 7/1/04. inches or greater, any depth 28 K0656 Skin protection and positioning wheelchair seat Add. Effective 7/1/04. cushion, width less than 22 inches, any depth 28 K0657 Skin protection and positioning wheelchair seat Add. Effective 7/1/04. cushion, width 22 inches or greater, any depth 28 K0658 Custom fabricated wheelchair seat cushion, Add. Effective 7/1/04. any size 28 K0659 Wheelchair seat cushion, powered Add. Effective 7/1/ K0660 General use wheelchair back cushion, width less Add. Effective 7/1/04. than 22 inches, any height, including any type mounting hardware 28 K0661 General use wheelchair back cushion, width Add. Effective 7/1/ inches or greater, any height, including any type mounting hardware 28 K0662 Positioning wheelchair back cushion, posterior, Add. Effective 7/1/04. width less than 22 inches, any height, including any type mounting hardware 28 K0663 Positioning wheelchair back cushion, posterior, Add. Effective 7/1/04. width 22 inches or greater, any height, including any type mounting hardware 28 K0664 Positioning wheelchair back cushion, Add. Effective 7/1/04. posterior-lateral, width less than 22 inches, any height, including any type mounting hardware 28 K0665 Positioning wheelchair back cushion, Add. Effective 7/1/04. posterior-lateral width 22 inches or greater, any height, including any type mounting hardware 28 K0666 Custom fabricated wheelchair back cushion, any Add. Effective 7/1/04. size, including any type mounting hardware 28 K0667 Mounting hardware, any type, for seat cushion Add. Effective 7/1/04. or seat support base attached to a manual wheelchair or lightweight power wheelchair, per cushion/base 16

17 6/2004 Page Code Terminology Action 28 K0668 Replacement cover for wheelchair seat cushion Add. Effective 7/1/04. or back cushion, each 28 K0669 Wheelchair seat or back cushion, no written Add. Effective 7/1/04. coding verification from SADMERC New codes available July 1 These new codes became available July 1, You can use these codes to report these services on your claims. Code 0062T 0063T 0064T 0065T 0066T 0067T 0068T 0069T 0070T 0071T 0072T 0073T Terminology Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; single level Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; one or more additional levels (List separately in addition to 0062T for primary procedure) Spectroscopy, expired gas analysis (eg, nitric oxide/carbon dioxide test) Ocular photoscreening, with interpretation and report, bilateral Computed tomographic colonography (ie, virtual colonoscopy); screening Computed tomographic colonography (ie, virtual colonoscopy); diagnostic Acoustic heart sound recording and computer analysis; with interpretation and report (List separately in addition to codes for electrocardiography) Acoustic heart sound recording and computer analysis; acoustic heart sound recording and computer analysis only (List separately in addition to codes for electrocardiography) Acoustic heart sound recording and computer analysis; interpretation and report only (List separately in addition to codes for electrocardiography) Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session 17

18 PRN Code 0074T G0329 S0116 S0117 Terminology Online evaluation and management service, per encounter, provided by a physician, using the Internet or similar electronic communications network, in response to a patient s request; established patient Electromagnetic therapy to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care Bevacizumab, 100 mg Tretinoin, topical, 5 grams Patient News - Information about your patients who are Highmark Blue Shield customers Central and Eastern Region UPS members receive new identification cards in July B On July 1, 2004, Blue Cross Blue Shield of Illinois issued new identification cards to UPS members whose identification numbers carry a UPP alphabetical prefix. The new identification cards have a 12 character identification number the three character UPP alphabetical prefix followed by a 9 byte randomly generated number in the 820xxxxxx to 850xxxxxx range. The new identification cards replace UPS members former cards that contained their Social Security numbers. Here is a sample of a new identification card: BlueCross BlueShield Select Blue Point-of Service Program Subscriber Last_First_M PLAN CODE 455 Group No Participant s Name Member_Full_Name Copays: Office Visit $10 Identification No. UPP Specialist $20 Participant s PCP Name Emergency $50 PCP_NAME Non-Emergency $100 PCP Effective Date PCP_EFF_ 18

19 6/2004 Report correct identification number for services requiring authorization All services for UPS members that require managed care authorization after July 1, 2004 must have those authorizations submitted and approved under the member s new identification number. Updating records that overlap the effective dates of the two identification numbers will ensure proper processing of these services for the higher level of payment. Examples of services impacted include those that require precertification of a series of therapies or visits. Here are examples of how to report these services for updating the managed care records: Current record in system UPP Updated record with new identification information UPP Patient Sam Jones Patient Sam Jones Provider MA12536 Provider MA12536 Procs/mods Procs/mods Start date 06/15/2004 Start date 07/01/2004 End date 08/30/2004 End date 08/30/2004 Total approved treatments 10 Total approved treatments 8 The current record will be used for services performed June 15, 2004 through June 30, Because these services were performed before July 1, 2004, they are reported on claims with the member s Social Security based identification number. The managed care record reflects the Social Security based identification number for this period of time. The updated record is for the remaining services that would be performed July 1, 2004 through Aug. 30, Those services should be reported with the new member identification number. The updated managed care record will reflect the new member identification for services performed during this period of time. 19

20 PRN Central Region Praxair, Inc. new BlueCard POS account Praxair, Inc. members claims began processing through a BlueCard Point of Service processing arrangement for services provided beginning July 1, Blue Cross Blue Shield of Western New York is the control plan for Praxair, Inc. You can identify Praxair, Inc. members by the three-character alphabetical prefix PXR preceding their identification number. For services you provide on or after July 1, 2004, submit the member s claim and applicable managed care information with the complete identification number including the PXR alphabetical prefix to Highmark Blue Shield. You can submit claims for Praxair, Inc. members either electronically or on a 1500A claim form. Send 1500A claim forms to: Highmark Blue Shield PO Box Camp Hill, Pa

21 6/2004 Notes 21

22 PRN Notes 2 2

23 6/2004 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 (866) 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: Highmark Blue Shield Provider Data Services PO Box Camp Hill, Pa 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 ( ) address Tax ID number Specialty Provider s signature Date signed 2 3

24 PRN Contents Vol. 2004, No. 3 News Blue Shield seeks approval for UCR and PremierBlue Shield reimbursement increases...1 Important information about DirectBlue and SelectBlue...2 BlueCard reminders: how to file Medicare supplemental claims...3 Outpatient therapy reminders...4 Blue Shield to begin routine provider pattern notification...4 Board certification requirements explained...5 Policy Blue Shield pays for additional air mileage for air ambulance services under certain conditions...6 Liver biopsy, upper gastrointestinal endoscopy and EGD considered part of bariatric surgical procedures...7 Electromagnetic therapy now eligible for managing certain chronic ulcers...8 Blue Shield does not cover ocular photoscreening...8 Venous percutaneous transluminal angioplasty eligible for some conditions...9 HIV genotyping and phenotyping coverage guidelines clarified...9 Blue Shield pays for TandemHeart device...10 Focused ultrasound ablation of uterine leiomyomata is investigational...10 Selective internal radiation therapy considered investigational...11 Percutaneous balloon valvuloplasty of the aortic valve eligible for specific conditions...12 Coverage guidelines for microprocessor-controlled prosthetic knee outlined...12 Blue Shield denies claims for spectroscopy, expired gas analysis...14 Acoustic heart sound recording and computer analysis not covered...14 Codes Terminology changes for code G Changes to 2004 PTM for Ancillary Providers...15 New codes available July Patient News UPS members receive new identification cards in July...18 Praxair, Inc. new BlueCard POS account...20 Need to change your provider information?...23 Acknowledgement The five-digit numeric codes that appear in PRN were obtained from the Current Procedural Terminology, as contained in CPT-2004, Copyright 2003, by the American Medical Association. PRN includes CPT descriptive terms and numeric procedure codes and modifiers that are copyrighted by the American Medical Association. These procedure codes and modifiers are used for reporting medical services and procedures. Visit us at PRN Policy Review & News PRSRT STD U.S. POSTAGE PAID HARRISBURG, PA Permit No. 320 Highmark Blue Shield Camp Hill, Pennsylvania 17089