Questions From All Blue 2009 Workshops

Questions From All Blue 2009 Workshops All Lines of Business 1. Coding question: For Medical Decision Making-is additional work up considered work up only performed outside the office or emergency department? The place of service does not necessarily determine what would be considered additional work up. 2. How can we get out of state BC to pay a CBC when performed same day as TSH & CMP without bundling to 80050? CPT clearly states that a CBC (85004, 85025, or 85027) and a TSH (84443) are components of a General Health Panel (80050). 3. We are having a problem with a CCI edit that was lifted on the new release as of 4/1/09 with two codes we bill. Codes 93320 billed with 93325 are being denied with all products. This code edit has been termed in our system since June 30, 2009. 4. Explain how the NCCI edits to be modified in October (retroactive to 4/1/09) will affect pain management codes. Please refer to CMS NCCI Web site. 5. J Codes - Office Visit and injection administration. NCCI and CPT indicate the editing/reimbursement for an office visit and the injection administration. The J code will be paid separately. 6. How to get paid for 31575 and 31231 with office visit on the same days. We are unable to make a determination without medical records as scenarios vary from one patient encounter to the next. 7. Unclassified drugs J3490 and duplicate denials on doctor and CRNA claims. Anesthesia supplies and drugs are included in the facility fee. 8. Reimbursement for the J3490 CPT code Duplicate Denials on the CRNA and Dr. claims? Anesthesia supplies and drugs are included in the facility fee. 9. Documentation required for miscellaneous codes. Documentation will vary depending on which miscellaneous code billed (e.g., office notes, operative reports, procedure reports, anesthesia flow sheets, radiology reports, pathology and laboratory reports, manufacturer s invoices). CPT is a registered trademark of the American Medical Association This document is classified as public information

10. Where can I find printable guidelines for bundled codes? Code bundling rules are available on the Provider page of the company Web sites, vshptn.com and bcbst.com at www.bcbst.com/providers/code_bundling/. 11. How can a facility log onto MedSolutions to see what the physician has gotten approved. We are having a lot of problems with MedSolutions. You can visit www.medsolutionsonline.com for case status updates or you can call the MedSolutions Customer Service Department at 1-888-693-3211. 12. When will the E0675 no longer be considered an "investigational" code? Once well conducted clinical trials are completed and published and substantiate the device is indeed beneficial to health. 13. Estimated Claim liability: Are there future plans to have room for more than one diagnosis per line? The application has been enhanced to support up to three supplementary diagnosis codes, in addition to the primary diagnosis code. Access to this free Web-based tool is available through BlueAccess, BCBST s secure area on its Web site, bcbst.com. 14. What are the future plans for oxygen rental billing? Does BlueCross BlueShield of Tennessee cap oxygen equipment and if so, at what point is that done? Is this information on the Web site? If so, where can it be located? BlueCross BlueShield of Tennessee will continue to handle all oxygen systems as a continuous rental for its Commercial, BlueAdvantage, and TennCare members. All supplies and oxygen contents will continue to be included in the rental of the oxygen equipment and will not be reimbursed separately. Please see the February 2009 issue of the BlueAlert. 15. 1) Is it a requirement to have the (radiology) authorization # on the claim? It is not required to put a prior auth number on the claim, however, it would be prudent to include the auth number in Block 23 on CMS-1500 claim form to easily match up with the auth on file. 2) Is the authorization CPT or ICD9 specific? Yes, the auth is tied to the CPT. 3) What recourse is there for claim payment after timely filing limits because member didn't notify office of coverage after being billed statements? If the provider has documented evidence the member did not provide BCBST insurance information, the timely filing provision shall begin with receipt of insurance info, subject to limitations of the member's benefit agreement. 16. Bill types for in and outpatient hospice services. For Inpatient - use type of bill 82X in FL 4 on UB-04. For Outpatient- use type of bill 81X in FL4 on UB-04. 17. Billing for PAs. Assistant-at-surgery services provided by a Physician should be reported by appending the Level I HCPCS CPT modifier 80 (Assistant Surgeon), 81 (Minimum Assistant Surgeon) or 82 (Assistant Surgeon when qualified resident surgeon not available) to the procedure code. The 80, 81 or 82 modifier should not be used to report assistant-at-surgery services provided by a Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist. 2

BlueCross BlueShield of Tennessee will reimburse eligible assistant-at-surgery services provided by a Physician based on the lesser of total covered charges or 16% of the maximum allowable fee schedule amount for all BlueCross BlueShield of Tennessee networks. 18. Billing guide lines on the fabricated helmet. Cranial Orthotic helmets are considered cosmetic and/or Investigational depending on whether they are for non-surgical treatment or post-surgery. 19. Incorrect lab contractuals or RA. When will online claim corrections be available on line? BlueCross BlueShield of Tennessee accepts corrected claims online. Instructions for submitting corrected claims online can be viewed at bcbst.com/providers/ecomm/electroniccorrectedclaims.pdf. 20. Please explain claims that deny for "exceeds DRG rate." This explanation code means the total billed charges are greater than the contracted DRG rate for this stay. 21. Time Frame for processing corrected claims. Electronic claims duplicating. Corrected claims must be submitted within 2 years of the end of the year claim was originally submitted. For professional electronic claims, claim frequency type code should end in "7" (REPLACEMENT-Replacement of prior claim); on institutional electronic claims, the third digit should end in "6" (CORRECTED- Adjustment of prior claim). 22. What is proper UB04 setup when you are a skilled nursing facility billing rehab services for patients in a Medicare certified bed, but not skilled? Outpatient rehab services should be billed with appropriate type of bill in FL 4 according to type of facility. For SNF providing OP therapy services, 23X should be used. 23. Provider Dispute should be updated to allow information to key on form. Document can be printed and mailed hardcopy to BC appeals. Currently we do not have the capability to edit PDF file. This will be researched for future Web enhancements. BlueCard 24. Are rules different for out of state BlueCross Blue Shield, i.e., we have been told Blue Cross of Alabama does not pay for nurse practitioners? The BlueCard Program links health care providers and the independent Blue Cross and Blue Shield plans across the country and around the world through a single electronic network for claims processing reimbursement. Each member s plan is different so it is important to verify benefits prior to submitting claims. 25. Is there any better way to resolve problems on BlueCard claims? We ask the question to the TN office but then we have to wait until the out of state office responds to TN with an answer. The process is really drawn out. BlueCross BlueShield of Tennessee works to process each claim efficiently and effectively. If there are specific issues that you may be having with a claim, please contact us 1-800-705-0391 or visit bcbst.com. While there you can check claim status and benefits on BlueAccess. 3

26. Claims for out-of-state plans were a PA assists at Surgery. Mine always deny as charge exceeds max allowable under patients coverage. Verify that you are using the correct and accurate modifier when billing for Physician Assistant (PA). 27. Why code 31 used on the ITS (out of state) remits? This code translates into "Process has been suspended until we receive additional information needed to complete our review of this claim." Customer Service must be called on all of these claims to find out exactly what the reason is. Normally, on calling the CSR will instruct that they show COB, or Non Authorized Service or pending pre-existing review, etc. Why not code the pending claim or denied claim exactly as to the reason? We can only map what the Home Plan sends back on the DF and if they reject it with one of the codes that means additional information is required, then we map to remark code 31. There are dozens of additional information needed codes in ITS but only one for COB and one for everything else on our provider remittances. As we move forward with our new Host processing system in Facets, we will be able to create additional explanation codes to map more specific denials. BlueCare/TennCareSelect 28. NDC numbers required by TennCare Effective for dates of service on or after Jan. 1, 2008, Institutional providers must include NDC information for all J codes for BlueCare and TennCareSelect claims. Claims containing an NDC number with less than 11 digits and the new data elements will be processed and only the line containing the J codes with missing NDC information will be rejected. 29. How do we distinguish between BlueCare and TennCareSelect when patient doesn t have a member ID card and think they have BlueCross BlueShield of TN? If a member presents to a provider s office without an ID card, by using BlueAccess providers can key in the member s name, social security number and date of birth to get eligibility information if the member is enrolled in either plan. Providers can also use the state s eligibility system, www.tennesseeanytime.org which provides all MCO information, not just BlueCare and TennCareSelect. There is an annual $75 subscription fee for using this service for up to 10 IDs. If more than 10 IDs are needed additional $75 subscriptions fees are required. 30. Why does Blue Care take 6-8 weeks to process claims? We are currently meeting all 30/60 day contractual goals for processing. However, we do have a backlog of adjustments and we have hired staff to improve that area and make a positive impact on turnaround time. You should see improvements shortly. 31. Are you going to add any more specialists for BlueCare network? We are always seeking providers who are interested in joining the BlueCare Network. 32. How often can a patient receive a new CPAP, or nebulizer that was previously purchased by BlueCare? How often can a patient receive CPAP supplies? Do the oxygen concentrators ever have a cap? If so, who retains ownership? (1) CPAP requirements - If the CPAP is purchased, and is under warranty, the replacement is based on the warranty requirements. Providers are required to honor all warranties. The providers should follow the CMS guidelines for replacement, unless there is a medical policy that indicates otherwise. (2) CPAP supplies - Supply schedule should follow CMS schedule. 4

(3) Oxygen Concentrators - we do not cap oxygen concentrators. An article regarding this was in the February 2009 BlueAlert http://www.bcbst.com/providers/bluealert/2009/february%202009.pdf. (4) Contractually, "All equipment purchased outright or purchased via a "rent to own" arrangement is the property of VSHP. Title to said equipment will remain with VSHP until such time as VSHP relinquishes title to the member or negotiates a trade in on new equipment with Medical Service Supplier." 33. How do you access the excluded benefits under the Blue Cross program? Exclusions for BlueCare are specific to TennCare Rules that can be found for Medicaid at http://state.tn.us/sos/rules/1200/1200-13/1200-13-13.20090701.pdf - Standard Rules are found at http://state.tn.us/sos/rules/1200/1200-13/1200-13-14.20090701.pdf. The exclusions are rule 10 (i.e. 12-13-13.10 and 1200-1300-14.10) DME items excluded from the fee schedule would follow CMS guidelines, unless otherwise specified in the billing guidelines. These are generally for services that are bundled and included in the reimbursement for another service. Benefit exclusions are listed under the Benefits section of both the VSHP and BCBST provider administration manuals, found on our company Web sites, vshptn.com and bcbst.com. 34. Why are secondary electronic billings out of state BlueCare EOBs not showing the modifier for PT, OT/ claims denying as a duplicate? If the claim is being filed with the correct CPT and Revenue codes they should not deny as a duplicate. Please contact your local Network Manager with specific examples. 35. The BlueCare presentation at the All Blue Workshop mentioned that EPSDT exams can be billed to BlueCare first, even if there is another insurance primary. What about Vaccines for Children (VCF) services? See the provider manual Section V. Billing and Reimbursement, D Third Party Liability. It states the following under the pay and chase section: Effective 3/1/2006, and in accordance with the contractual agreement between Volunteer State Health Plan, Inc. (VSHP), and the Bureau of TennCare, Providers may opt to file claims to VSHP as the primary carrier for the following services when the Member has been identified as having other insurance: * TENNderCare; * Prenatal or preventive pediatric care including Vaccines for Children (VFC) services; and * All claims covered by absent parent maintained insurance under Part D of Title IV of the Social Security Act. As the primary payer, VSHP will bill the responsible carrier for these services. However, in order to receive the higher reimbursement rate, it is to the provider s advantage to submit these claims to the other carrier first. 36. Can a BlueCare member be billed if they did not give the provider their BlueCare information during the 120 days for timely filing? According to TennCare Rule 1200-13-01-.05, providers can bill a TennCare member if the member does not provide their TennCare MCO (BlueCare or TennCareSelect) information to the servicing provider. However, when the determination is made that the patient is a BlueCare or TennCareSelect member and the provider is participating with BCBST, he/she must file the claim to BlueCare or TennCareSelect. 37. Once a claim has been posted, maybe (4) lines, BlueCare will pay (3) lines and need additional information on the line, that was not paid. But instead, letting us send records and copy of the EOB, they want us to send the whole claim back, which makes us have to either remove the money and re-bill or re-post a new claim to the system. 5

If the provider does not send back the whole claim the system would treat as a corrected bill and either deny for a possible corrected bill or take back the money on the 3 codes that didn t get billed the second time. Commercial 38. Why is it so difficult to submit a BlueCross BlueShield secondary when BlueCross BlueShield is primary? We get them back stating it is not legible and we are sending a copy of what we can print out from you. The BCBST secondary claims filing process is an automated process. If you are experiencing problems with this process, we would need to discuss what the providers are experiencing. Please call 1-800-924-7141 and put in Ext. 7299 to talk with a representative. 39. Is anatomic survey on an OB ultrasound a medical necessity? This procedure has not been reviewed for Medical Policy, therefore, medical necessity and covered services would be based upon the Member's benefits. 40. What is the pre-existing conditions time limit? Pre-existing condition time can vary based upon the patient's member benefits. The best way to get the actual pre-existing time limit is by calling the 1-800 # listed on the members BCBS identification card. Commercial/BlueCare/TennCareSelect 41. What is the correct way to bill claim for a patient with another primary insurance which does not cover services but TennCare will? When a commercial insurance is involved, the claim must be filed first with the primary insurance, and then filed to BlueCare/TennCareSelect with the corresponding explanation of benefits from the commercial carrier. BlueCare/TennCareSelect will process the claim for possible payment of the TennCare Allowable amount. 42. How do I get secondary billing to the correct destination when BlueCross BlueShield of TN is primary and BlueCare/TennCareSelect is secondary. BlueCare/TennCareSelect is always the payer of last resort. When a commercial insurance is involved, the claim must be filed first with the primary insurance, then filed to BlueCare/ TennCareSelect with the corresponding explanation of benefits from the commercial carrier. 43. Additional information needed about CRNA billing. Anesthesia billing guidelines for Anesthesiologists and CRNAs are detailed in billing sections of both BCBST and VSHP Provider Administration Manuals. 44. Pre-authorization of DME For TennCare, the authorization requirements for DME state "Prior authorization is required for any DME purchase or rental where the allowed amount of the rental equipment would be over $500 if purchased. All new requests for wheelchairs and accessories require prior authorization regardless of purchase or rental price (effective 11/01/06)." For Commercial, most of the member groups do not require an authorization for DME. However, if an authorization for DME is required, it is for equipment with a purchase price of $500 or more. The member's benefits determine whether an authorization is necessary. Please keep in mind, that although a group may not require an authorization, all DME is subject to retrospective review. 6

45. What is the best way to get paper UB04 claims to process correctly? (ie, detailed HCPCS Coding, field 80 remarks, attachments, follow-up phone call, provider rep e-mail other) When completing paper claims, medical/clinical codes including modifiers should be reported in accordance with the governing coding organizations. Required data elements and billing and reimbursement guidelines can also be found in both the BCBST and VSHP provider administration manuals. Cover Tennessee 46. For patients with CoverKids and TennCare coverage, who is the primary payer? Since TennCare is always a payer of last resort, CoverKids would be the primary payer. Eligibility 47. How can benefits be verified online? BlueAccess, the secure area of our company Web site, is an online benefits information resource available any time at your convenience 24 X 7. Medicare/Medicare Advantage 48. How is an inpatient claim billed when the patient has Part B outpatient coverage with Medicare? The claim should be billed the same as if there was no Part B. Include the Medicare EOB if it applies. 49. What is the correct process for billing a payor secondary to Medicare? If filed to Medicare electronically, the claim should crossover to the appropriate secondary payor. Paper claims can be submitted with the primary Medicare EOB attached to the back of the claim and mailed to the claims P.O. Box. 50. How is an inpatient claim billed when the patient has Part B outpatient coverage with Medicare? The claim will be billed the same as if there was no Part B. Include the Medicare EOB if it applies. 51. Can Medicare Advantage be filed electronically and what are the timely filing guidelines? Yes, BCBST Medicare Advantage claims for both PFFS and PPO products can be filed electronically. The timely filling guidelines for PFFS are the same as Medicare fee for service claims. In general, such claims must be filled on, or before, December 31 of the calendar year following the year in which the services were furnished. (See section 70.7 for details of the exceptions.) Services furnished in the last quarter of the year are considered furnished in the following year, i.e., the time limit is the second year after the year in which such services were furnished. BlueCross BlueShield of Tennessee Medicare Advantage PPO claims should be filed within 60 days of the date of service; if the claim is not filed and any revisions or adjustments submitted within 365 days of the date of service then the claim will not be paid. 52. What is the status of electronic submission of secondary claims? BCBS is the only payer that requires a separate form completed and submitted for electronic submission of claims. Why is that not automatically done in the credentialing process? BlueCross BlueShield of Tennessee accepts professional and institutional secondary claims in the 7

ANSI-837 electronic format. The ANSI-837, version 4010A1, is the required format for electronic transmissions under HIPPA. Electronic submitters are encouraged to review the standard ANSI-837 Implementation Guides for specific requirements regarding these electronic claims types. Providers should not submit secondary to Medicare claims electronically. For secondary to Medicare payments, Group Health Incorporated (GHI), Medicare's coordination of benefits contractor, will coordinate transfer of the claim to the supplemental or retiree group insurers for the payment of secondary benefits. For more information, contact our ebusiness Service Center @ 423-535-5717 during normal business hours. BlueCross BlueShield of Tennessee does have a consolidated Provider Application that is sent to providers who request to be a participating with BCBST, which includes fields for network participation, credentialing and electronic claims submission. The separate ecommerce Profile form is used when a provider fails to fill out the Electronic Claims Submission section of the application OR if the provider has a change of Vendor OR provider information for electronic claims submission. 53. Corrected Bills, Appeals BCBST Medicare Advantage follows the appeals process outlined by Medicare. Additionally, all BCBST providers have access to the BCBST provider dispute resolution process. The process is outlined in the Provider Administration Manual. 54. Lately our hospital has received a 13% reduction in Medicare payments. Can physicians expect a similar reduction in BlueAdvantage payments? BCBST Medicare Advantage PFFS and PPO products pay providers based on the Medicare Fee schedule. Any changes reflected in the payment that facility or provider receives from Medicare would be the same from BCBST. Keep in mind that payment from BCBST is based on the Medicare Fee Schedule, based on the published rates. This does not include any changes to Medicare reimbursement that may be a part of cost report settlements, area based rate changes, etc. 55. Will Blue Cross be considering reworking their ER visit levels to be more in line with the levels that CMS proposed back in 2003? (The one that was submitted by AHA & AHIMA) BCBST Medicare Advantage has just adopted an audit tool for review of ER visit levels that uses medicare logic. It was distributed at the All Blue workshops. 56. Will the transition to Cahaba affect Blue Medicare? The transition to Cahaba is for traditional Medicare business only - all BCBST MedAdvantage plans will continue to be paid by BCBST. 8