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Issue No. 268 April 2006 HealthCare News www.bcbsnd.com www.thor.org Provider Service Toll Free: 1-800-368-2312 Local: 282-1090 Hours: 8:00 am - 4:30 pm CST (Monday, Tuesday, Thursday, Friday) 9:15 am - 4:30 pm CST (Wednesday) FEP Toll Free: 1-800-548-4026 Local: 282-1468 Hours: 8:00 am - 4:30 pm CST (Monday through Friday) IN THIS ISSUE... Symposium Symposium... 2 Coding and Billing Oxygen Equipment... 3 Formulary Formulary... 4 Administrative Medicare Part D Information... 6 Physical & Occupational Therapy Date of Service Required for UB-92 Claims... 7 NPI National Provider Identifier (NPI) Information on Electronic File Interchange (EFI) Released... 7 Centers for Medicare and Medicaid Services (CMS) Posts National Provider Information (NPI) Information for Subparts... 7 PC-ACE Pro32 New Version... 7 Internet Access Improving Service and Quality... 7 WebEx PC-ACE Pro32 - Advanced... 8 BlueCard How to Identify BlueCard Members... 8 Glad you Asked Units for New Radiopharmaceutical HCPCS... 9 State Supplied Vaccine Billing... 9 Use of Modifier 80 and AS...10 Billing for a Recalled Implanted Medical Decide...10 Status of Patient Not Occupying Inpatient Bed...10 Noridian Mutual Insurance Company BlueCross BlueShield HealthCare News of North #268 Dakota An independent licensee of the Blue Cross & Blue Shield Association

Symposium Symposium The HealthCare Symposium is open to all participating providers of Blue Cross Blue Shield of North Dakota (BCBSND). Registration forms for the 2006 HealthCare Symposium were mailed in early April 2006. The coding session will be conducted by a member of the Wisconsin Medical Society. The Wisconsin Medical Society will apply for continuing education credits through professional organizations on behalf of attendees. Please refer to their web site at www. wisconsinmedicalsociety.org to confirm credit approval with your professional organization. The symposium will be held on the following dates: May 9, 2006 - Radisson Hotel, Bismarck May 10, 2006 - Sleep Inn, Minot May 11, 2006 - Hilton Garden Inn, Grand Forks May 16, 2006 - Ramada Plaza Suites, Fargo You will be able to register: On-line through THOR by selecting the HC Registration Icon By going to the URL https://www.thor.org/hcsreg By completing the paper brochure By contacting our Provider Service Department at 1-800-368-2312 or 282-1090 The following information is necessary when registering online or by telephone: Name of each participant Telephone number of each participant Facility Name Indicate date and location you will attend 7:30-8:15 AM Registration and Hot Breakfast General Session 8:15 8:30 - Welcome, Opening Remarks 8:30 9:00 Legislative Update 9:00 9:30 Pick a Category - an entertaining session about BCBSND s products 9:30 10:00 Motivating Personal Health Behavior Change Through Worksite Solutions 10:00-10:15 Break Designated area for questions and training demos throughout the morning: THOR EDISS Provider Networks & Credentialing Provider News

10:15-12:00 Breakout Sessions Room 1 10:15-12:00 - Deciphering the Complex Coding of the Infusions, Chemo and Injections with the new 2006 codes Sandy Giangreco, CPC, CPC-H PMCC Approved Instructor Coding and Reimbursement Educator Wisconsin Medical Society Room 2 10:15-10:45 - Credentialing: As Easy As 1. 2. 3. 4. 10:50-11:20 - THOR - Claims Status and Eligibility 11:25-12:00 - It s in the Numb3rs NPI Basics 12:00 Symposium Concludes Coding and Billing Oxygen Equipment Reference HealthCare News #267. Changes are indicated in bold. When billing the HCPCS listed below for oxygen systems and concentrators, the appropriate coding and billing should be completed according to the code description. These codes are specific to type of system (stationary vs portable), oxygen type (gaseous vs liquid), and billing method (rental vs purchase). Modifiers are not required on the oxygen system CPT code as the description reflects whether it is for rental or purchase. However, modifiers are required to be submitted on the concentrator codes, as they do not differentiate between rental or purchase. When a member rents oxygen equipment for more than one month, we require a separate claim for each monthly increment. It is not appropriate to submit multiple claims within the same month for the same member. The medical record documentation should continue to support the services rendered. Previously, reimbursement for oxygen systems and concentrators was capped at the purchase price amount. Effective January 1, 2006, this cap has been removed and rental is allowed based on medical necessity. A member is allowed to purchase the oxygen equipment. Once purchased, rental claims are no longer allowed for that same piece of equipment and claims will be returned to the provider. Reimbursement for oxygen equipment accessories such as stands, regulators, and humidifiers will continue to be capped at the purchase amount. Oxygen Systems E0424 E0425 E0430 E0431 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing Portable gaseous oxygen system, rental; includes regulator, flowmeter, humidifier, cannula or mask, and tubing

E0434 E0435 E0439 E0440 E1405 E1406 E1390 E1391 E1392 Portable Liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, content gauge, cannula or mask, and tubing Portable liquid oxygen system, purchase; includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, content gauge, cannula or mask, and tubing Stationary liquid oxygen system, rental; includes container, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing Stationary liqiud oxygen system, purchase; includes use of reservoir, content indicator, regulator, flowmeter, humidifier, nebulizer, and cannula or mask, and tubing Oxygen and water vapor enriching system with heated delivery Oxygen and water vapor enriching system without heated delivery Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each Portable oxygen concentrator, rental Formulary Formulary Additions GENERIC PRODUCTS ADDED Brand products (in parentheses) are non-formulary and listed for reference only azithromycin tabs, 250 mg, 500 mg, 600 mg (ZITHROMAX) cabergoline tabs (DOSTINEX) cefprozil oral susp, tabs (CEFZIL) fluticasone nasal spray (FLONASE) lamotrigine chew tabs (LAMICTAL) promethazine tabs, 12.5 mg ribavirin tabs, 200 mg (COPEGUS) zonisamide caps (ZONEGRAN) BRAND PRODUCTS ADDED ACTOPLUS MET (pioglitazone/metformin tabs) ACULAR LS (ketorolac ophth soln, 0.4%) ALBUTEROL SULFATE HFA (albuterol sulfate inhalation aerosol) ARRANON (nelarabine inj) EMTRIVA (emtricitabine oral soln) GEODON (ziprasidone caps)

PROVENTIL (albuterol inhalation aerosol) SUTENT (sunitinib caps) VENTOLIN HFA (albuterol sulfate inhalation aerosol) OTHER ADDITIONS INCRELEX (mecasermin inj) Prior Approval Required NEXAVAR (sorafenib tosylate tabs) Prior Approval Required REVLIMID (lenalidomide caps) Prior Approval Required Deletions BRAND PRODUCTS REMOVED Generics remain CEFZIL (cefprozil oral susp, tabs) COPEGUS (ribavirin tabs, 200 mg) DOSTINEX (cabergoline tabs) LITHOBID (lithium carbonate extended-release tabs) SALAGEN (pilocarpine tabs, 5 mg) ZITHROMAX (azithromycin tabs, 250 mg, 500 mg, 600 mg) ZONEGRAN (zonisamide caps, 25 mg, 100 mg) ALL VERSIONS, BRAND AND/OR GENERIC, REMOVED FROM FORMULARY amantadine caps, syrup, tabs FLUMADINE (rimantadine syrup, tabs) ZYPREXA (olanzapine tabs) DISCONTINUED BRAND PRODUCTS The following discontinued brand products have been removed from formulary; generic remains if noted chlorpromazine hcl oral soln, 100 mg/ml OXYCONTIN 160 mg (oxycodone extended-release tabs) THIOTEPA for inj, 30 mg ZONEGRAN (zonisamide caps, 50 mg), generics remain The following insulin products will be removed from the North Dakota formulary effective 8/1/06 NOVOLIN N (human insulin isophane susp inj) NOVOLIN R (human insulin inj) NOVOLIN 70/30 (70% human insulin isophane susp inj and 30 % human insulin inj) NOVOLOG (insulin aspart inj) NOVOLOG MIX 70/30 (70% insulin aspart protamine susp inj and 30% insulin aspart inj) RELION N (human insulin isophane susp inj) RELION R (human insulin inj) RELION 70/30 (70% human insulin isophane susp inj and 30 % human insulin inj) 5

OTHER BLOOD GLUCOSE STRIP CHANGES All blood glucose test strips OTHER THAN FROM ABBOTT DIAGNOSTICS and ROCHE DIAGNOSTICS will be removed from the North Dakota formulary effective 8/1/06 Formulary products include: Abbott Diagnostics: FREESTYLE, PRECISION QID, PRECISION XTRA Roche Diagnostics: ACCU-CHEK ACTIVE, ADVANTAGE, AVIVA, COMPACT, COMFORT CURVE, INSTANT Administrative Medicare Part D Information Blue Cross Blue Shield of North Dakota (BCBSND), along with six other Blue Cross Blue Shield plans, contracted with AmeriHealth to assist with Medicare Part D inquiries. AmeriHealth staff has received in-depth training and are certified to assist Medicare Beneficiaries with questions and enrollment processes. For questions or concerns regarding Medicare Part D, see below for the appropriate location/entity. Provider With questions on: Contact: Healthcare Providers or Hospitals Eligiblity Claims Benefits AmeriHealth at 1-888-457-3009 Healthcare Providers Non-formulary requests for Medicare Part D members Access the forms required at www.yourmedicaresolutions. Select For Providers and Forms. Non-formulary requests for Medicare Part D members received by BCBSND will be returned. Healthcare Providers Assisting a patient and calling on their behalf AmeriHealth at 1-866-434-2033 (Member # Only). For faster service, be prepared to provide: a list of the medications patient is taking the dosage, and a calculation of how much they are spending on medications per month and per year. Pharmacies ID cards Eligibility on file with CMS No acknowledgement letter presented by the member Processing information or claims questions Prime Therapeutics Help Desk at 1-800-693-6619 or access www.primetherapeutics.com for information regarding Medicare Part D. Select the Contact Us function on the website to send an email directly to Prime with any questions. 6

Physical & Occupational Therapy Date of Service Required for UB-92 Claims Outpatient physical and occupational therapy services billed on the UB-92 require a date of service for each line item billed. Claims not meeting this requirement will be returned to the provider for correction. Our claims processing system can only accept 32 lines or less for a UB-92 claim. Claims submitted with more than 32 lines will be split into multiple claims for processing. NPI National Provider Identifier (NPI) Information on Electronic File Interchange (EFI) Released The Centers for Medicare and Medicaid Services (CMS) released several documents on the EFI process. EFI, also referred to as bulk enumeration, is a process by which a health care provider or group of providers can have a particular organization (the EFIO ) apply for National Provider Identifiers (NPI) on their behalf. EFI documents posted to the web include a summary, user s guide and technical companion manual. For more information visit http://www.cms.hhs.gov/ NationalProvIdentStand/07_efi.asp. Centers for Medicare and Medicaid Services (CMS) Posts National Provider Information (NPI) Information for Subparts The NPI Final Rule requires health care providers who are organizations and who are covered entities under HIPAA to determine if they have subparts that should be assigned NPIs. The NPI Final Rule provides guidance to health care providers in making those determinations. CMS has posted a document describing the subpart concept and its relationship to the way in which Medicare enrolls its organization providers at www.cms. hhs.gov/nationalprovidentstand/06_implementation. asp#topofpage on the web. Blue Cross Blue Shield of North Dakota encourages providers to review the subparts document listed above. PC-ACE Pro32 New Version For All PC-ACE Pro32 Trading Partners An updated version of the HIPAA-compliant PC-ACE Pro32 software is now available for download. The new version, NAS06.02 (1.76.0.100), will contain new payer code changes and HCPCS table updates as well as changes initiated by CMS. To obtain the latest version, go to bcbsnd.com and in the Provider s section, select PC-ACE Pro 32 Software and then select pcaceup.exe. Users who have requested the software via CD and have paid the associated $25 maintenance fee will receive software updates automatically by mail. THOR Internet Access One of Blue Cross Blue Shield of North Dakota s (BCBSND) goals is to improve access and service to our providers. BCBSND believes technology is one way we can improve service and quality. We understand there may be barriers to this and are working towards breaking down those barriers. To accomplish this, we would like to hear if your facility does NOT have access to the Internet. Please call Kim at 701-282-1308. Leave your name, facility name, and phone number. 7

WebEx PC-ACE Pro32 - Advanced The next scheduled EDI WebEx session will be held Tuesday, April 11, 2006, from 10:00-11:00 AM CST and again from 1:00-2:00 PM CST. The topic is PC-ACE Pro32 Advanced. Topics that will be covered are: Claim Importing Processing Claims 835 (ERA) Importing Electronic Transaction Remittance Advice (ETRA) Modules 997 Importing Claim Status Requests To register for this session, please contact Kim.Grimley@ bcbsnd.com with the time selected, your name, facility name, city, state and phone number of the person(s) to be registered. WebEx is software that allows live meetings via the internet to show you examples and demonstrations while discussing the topics on the phone. BlueCard How to Identify BlueCard Members Member ID Cards When members of Blue Plans arrive at your office or facility, be sure to ask them for their current Blue Plan membership ID card. The main identifier for out of area members is the alpha prefix and the suitcase logo the ID card. Important facts concerning the member s ID cards: Do not assume that the member s ID number is the social security number. The alpha prefix is critical for the electronic routing of specific HIPAA transactions to the appropriate Blue Plan. A correct member ID number includes the alpha prefix (first three positions) and all subsequent characters, up to 17 positions total. Federal Employee Program (FEP) members will have the single letter "R" in front of their member ID number. The alpha prefix on a member s ID must be three characters. Some member ID numbers may include alphabetic characters in other positions following the alpha prefix. Others may be fewer than 17 positions. Sample ID Card The suitcase logo may appear anywhere on the front of the card. The three-character alpha prefix. 8

Glad you Asked Question: Will there be any changes to our billing now that Blue Cross Blue Shield of North Dakota (BCBSND) is reimbursing the ND Department of Health (NDDOH) for state supplied vaccines? Response: There will NOT be any billing changes by the providers to BCBSND. The NDDOH will submit the necessary data directly to BCBSND. There will be a new edit added to the BCBSND claims system to check for State supplied vaccines that have been billed by the provider. Since there is no cost for the vaccine serum to the provider, the provider should not be billing for the serum. If a claim is submitted by a provider for a State supplied vaccine, it will be denied (or reprocessed if already submitted and paid). Refer to HealthCare News bulletin #236 for instructions on billing for the administration of a state supplied vaccine. Please note the NDDOH is requesting insurance information on the North Dakota Immunization Information System (NDIIS) for all patients that have health insurance and receive a State supplied vaccine. This will help the NDDOH seek reimbursement from all insurers to help alleviate the increasing costs of vaccines. Training will be provided by the NDDOH in the near future to answer any questions. The NDDOH is also requesting that the NDIIS be updated within two weeks of the date of inoculation. Question: How should we bill units for the new radiopharmaceutical HCPCS codes that have the description per study dose up to xx mci or uci when we use more than the maximum dosage in one study? For example, A9549 has a description of Technetium Tc-99m arcitumomab, diagnostic, per study dose, up to 25 mci and our physicians occasionally use 28 mci per study dose. Response: Due to the confusion caused by the new radiopharmaceutical descriptions, we presented this question to the Society of Nuclear Medicine (SNM). They responded by forwarding the following Q&A that has been published by the SNM and approved by the Blue Cross Blue Shield Association and the Centers for Medicare and Medicaid Services (CMS): Q: With the new 2006 Radiopharmaceutical HCPCS Level II descriptors for A9500 and A9502 defining doses up to 40 millicuries, what is appropriate to submit in terms of units if the administered dose is 45 millicuries? A: The intent of the up-to dose range used with per study dose radiopharmaceutical descriptions, as developed by the HCPCS workgroup, was to identify the maximum amount of a radiopharmaceutical that is administered to a patient during a single study. At the recommendation of industry and professional societies, CMS often used the maximum dose for each radiopharmaceutical per the manufacturer package insert as the up-to maximum dose. We are aware of protocols and procedure guidelines which administer study doses in excess of the package insert. If you are administering outside the package insert dose recommendation, the SNM does not recommend that you use this minor detail to code and bill two (2) units. We recommend that you code and bill the number of study doses that are administered. For example, in a single rest myocardial perfusion study, code and bill one (1) dose of either HCPCS A9500 or A9502. If you perform both a Rest study and a Stress study as part of a single CPT procedure such as 78465, then it would be appropriate to code and bill two (2) units as you administered two study doses. Therefore, Blue Cross Blue Shield of North Dakota (BCBSND) is recommending that when a provider exceeds the up to dosage on one study for a radiopharmaceutical code that has a description of per study dose or per treatment, that the provider only bill and code one unit. Refer to HealthCare News bulletin #265 pgs. 8&9 for the article on the radiopharmaceutical description changes.) In the original question, one unit should be coded and billed for A9549 when 28 mci s are administered for one study. A9549 should only have more than one unit when more than one study is completed. 9

Glad you Asked Question: There are two modifiers for providers assisting at surgery (modifier 80 and AS). Is there a difference between them? Response: Yes, when a provider assists a surgeon, one of two modifiers can be coded based on the particular situation: Modifier 80: Assistant Surgeon Modifier AS: Assistant at Surgery Service Modifier 80 refers to a surgeon (a physician that performs surgery). Only the following provider types may use modifier 80: MD- Medical Doctor DO- Osteopath DDS- Dentist OD- Optometrist DPM- Podiatrist DDS/MD- Oral Surgeon All other provider types must use modifier AS when assisting at surgery. The procedure must be within the provider s scope of practice and appear on the Blue Cross Blue Shield of North Dakota (BCBSND) defined Assistant at Surgery List to be reimbursed when billed with modifier 80 or AS. An assistant at surgery must be involved in the actual performance of the procedure, not simply in other ancillary services. Question: How should we bill for surgically implanted medical devices that have been recalled by the manufacturer and the replacements are provided to our facility at no cost? Response: The recalled medical device should be identified by the appropriate revenue code and HCPCS (if outpatient) with a zero charge. If the hospital billing system requires a charge, the hospital should submit a token charge (e.g. $1.00) on the line for the device. The other charges in relation to the re-insertion of the device should be submitted as usual. Question: Can our facility submit an inpatient claim for a patient who receives doctor s orders to be admitted to inpatient status but either dies or is discharged prior to being assigned and/or occupying a room? Response: An inpatient claim should not be submitted in this situation. Facilities should submit an outpatient type of bill (131) with the appropriate revenue and HCPCS codes. Examples: A patient presents to the emergency room with orders for admission and either expires prior to admission or is transferred to another facility. A patient who presents to the emergency room and goes directly to the operating room but expires before an inpatient bed is occupied. Claims submitted with an inappropriate modifier will be returned to the provider for correction. 10

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29309175ave (4891) 3-06 HealthCare News is published as a service to health care providers. Please send all written inquiries to: Provider Service Department BlueCross BlueShield of North Dakota 4510 13th Avenue South Fargo, ND 58121-0001 PRSRT STD U.S. POSTAGE PAID Fargo, North Dakota Permit No. 1397 RETURN SERVICE REQUESTED 12