Policy Review & News. In This Issue. News. B Look for this symbol for all BlueCard related information

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1 Important information about Pennsylvania Blue Shield December In This Issue Policy Review & News Pennsylvania Insurance Department approves UCR and PremierBlue Shield reimbursement increases... 1 Upgrade your Web browser to view Blue Shield s website New national trauma modifier replaces WH modifier Liberty Mutual moving to BlueCard POS Milton Hershey School selects PPOBlue coverage B Look for this symbol for all BlueCard related information News Pennsylvania Insurance Department approves UCR and PremierBlue Shield reimbursement increases On Jan. 1, 2003, Blue Shield increased its UCR Level II and PremierBlue Shield payments for certain inpatient hospital, intensive care and preventive care visits, evaluation and management services, consultations, allergy testing and therapy, and select diagnostic and surgical services. Blue Shield also increased the anesthesia conversion factor to $42 per unit. For more information about Blue Shield s reimbursement increases, see Blue Shield seeks approval for UCR and PremierBlue Shield reimbursement increases on Pages 1 2 in the October 2002 PRN. Note: The inclusion of a procedure code and in the lists on Pages 2-9 does not necessarily indicate that it is eligible for payment under Blue Shield s programs. Blue Shield will apply the appropriate network rules, member benefit limitations and medical policy guidelines to the services you report. Blue Shield may also apply a site of service differential for facility-based services. Allowances are subject to change.

2 Here are new UCR and PremierBlue Shield fees: UCR Level II Procedure Service UCR Level II code G0108 Diabetic training $ G0109 Diabetic training G0241 Medical care Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Excision of lesion Needle localization wire Breast surgery/repair Breast surgery/repair Foreign body removal Foreign body removal Joint injection Joint injection Joint injection Female surgery Spinal puncture Spinal puncture X-ray injection procedure X-ray injection procedure Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection

3 12/ Procedure Service UCR Level II code Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Diagnostic eye exam Diagnostic eye exam Diagnostic eye exam Diagnostic ear/nose/throat procedure Diagnostic ear/nose/throat procedure Diagnostic ear/nose/throat procedure Diagnostic ear/nose/throat procedure Diagnostic ear/nose/throat procedure Vascular diagnostic procedure Breathing test Breathing test Breathing test Allergy testing Allergy testing Allergy testing Allergy testing Allergy testing Allergy testing Allergy testing Allergy therapy Allergy therapy Allergy therapy Allergy therapy Allergy therapy Allergy therapy Allergy therapy Allergy therapy 10.00

4 4 Procedure Service UCR Level II code Allergy therapy Skin treatment Skin treatment Skin treatment Office/outpatient visit Office/outpatient visit Office/outpatient visit Office/outpatient visit Office/outpatient visit Office/outpatient visit Office/outpatient visit Office/outpatient visit Observation care Observation care Observation care Hospital visit Observation care Observation care Observation care Hospital discharge visit Hospital discharge visit Consultation Consultation Consultation Consultation Consultation Consultation Outpatient care Outpatient care Outpatient care Medical care Medical care Medical care Medical care Medical care Medical care 50.00

5 12/2002 Procedure Service UCR Level II code Medical care Medical care Medical care Medical care Medical care Home care Home care Home care Home care Home care Home care Home care Home care Home care Preventive medical care Preventive medical care Preventive medical care Preventive medical care Preventive medical care Preventive medical care Preventive medical care Preventive medical care Preventive medical care PremierBlue Shield 5 Procedure Service PremierBlue Shield code G0108 Diabetic training $ G0109 Diabetic training G0241 Medical care Lesion removal Lesion removal Lesion removal Lesion removal Lesion removal Wound repair Wound repair

6 6 Procedure Service PremierBlue Shield code Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Wound repair Breast biopsy Breast surgery Breast cyst removal Needle localization wire Breast surgery/repair Breast surgery/repair Foreign body removal Foreign body removal Joint injection Joint injection Joint injection Bone cyst injection Larynx surgery Larynx surgery 1, Larynx surgery Amniocentesis Diagnostic maternity surgery Female surgery Female surgery Spinal puncture Spinal puncture X-ray injection procedure X-ray injection procedure

7 12/ Procedure Service PremierBlue Shield code Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve block injection Nerve destruction Diagnostic eye exam Diagnostic eye exam Diagnostic eye exam Diagnostic eye exam Diagnostic ear/nose/throat procedure Diagnostic ear/nose/throat procedure Diagnostic ear/nose/throat procedure Diagnostic ear/nose/throat procedure Diagnostic ear/nose/throat procedure Vascular diagnostic procedure Breathing management Breathing management Breathing test Breathing test Breathing test Breathing test Allergy testing Allergy testing Allergy therapy 15.00

8 8 Procedure Service PremierBlue Shield code Allergy therapy Allergy therapy Allergy therapy Allergy therapy Allergy therapy Allergy therapy Allergy therapy Allergy therapy Skin treatment Skin treatment Skin treatment Office/outpatient visit Office/outpatient visit Office/outpatient visit Office/outpatient visit Office/outpatient visit Office/outpatient visit Office/outpatient visit Observation care Observation care Observation care Hospital visit Hospital visit Observation care Observation care Observation care Hospital discharge visit Hospital discharge visit Consultation Consultation Consultation Consultation Consultation Consultation Consultation Consultation

9 12/2002 Procedure Service PremierBlue Shield code Outpatient care Outpatient care Outpatient care Medical care Medical care Medical care Medical care Medical care Medical care Medical care Medical care Medical care Medical care Medical care Home care Home care Home care Home care Home care Home care Home care Home care Home care Preventive medical care Preventive medical care Preventive medical care Preventive medical care Preventive medical care Preventive medical care Preventive medical care Preventive medical care

10 Upgrade your Web browser to view Blue Shield s website To maintain maximum security, Pennsylvania Blue Shield has upgraded all areas of its website, to 128-bit encryption. Blue Shield completed the upgrades on Jan. 1, Make sure that your browser is upgraded so that you can continue to access Blue Shield s website. The most common browsers are Internet Explorer and Netscape Navigator. If you re a NaviNet user, your Web browser already supports 128-bit encryption. If you are not yet NaviNet-enabled, you should upgrade your Web browser. If you do not upgrade to a browser that supports 128-bit encryption, you may not be able to view Blue Shield s website after Jan. 1, How to check your browser s encryption level To check your browser s encryption level: 1. select the Help option from your browser s menu options 2. select About Internet Explorer or About Netscape Navigator/Communicator. In Internet Explorer, the encryption level is listed in the cipher strength section. If you cannot find the 128-bit encryption reference in Netscape Navigator/ Communicator, look for this verbiage: Contains encryption software from RSA Data Security, Inc. If the next paragraph states This version supports U.S. security, you have 128-bit security. If you see a statement telling you that you have International security, you ll know that you have 40-bit security. If you have 40-bit security, you must upgrade your browser. If you need to upgrade your browser, click the link under Happenings on Next, click on the Internet Explorer or Netscape icon and follow the instructions. Blue Shield revamps Access Care II and comprehensive major medical EOBs Pennsylvania Blue Shield is changing the format of the Explanation of Benefits (EOB) statements for the Access Care II and comprehensive major medical products offered by Pennsylvania Blue Shield and Blue Cross of Northeastern Pennsylvania. The format of the EOBs will be similar to those you now receive for northeastern Pennsylvania members with indemnity coverage. See Page 11 for a sample of the new EOB. 10

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12 New PO Box available for Access Care II and comprehensive major medical claims In March 2003, a new post office box will be available for you to send your Access Care II and comprehensive major medical (CMM) paper claims, inquiries and predeterminations. Here is the new address: Pennsylvania Blue Shield PO Box Camp Hill, Pa You can submit your electronic claims as you do today. Please continue to send preauthorizations for Access Care II and CMM members to: Pennsylvania Blue Shield PO Box Camp Hill, Pa, You can call Blue Cross of Northeastern Pennsylvania at (888) , Monday through Friday, 8 a.m. to 5:30 p.m., with inquiries or for precertifications. If you need more information about Access Care II or CMM, please go to Complementary Medicare Part B EOB page now available A separate Complementary Medicare Part B Explanation of Benefits (EOB) page now appears at the end of the standard Medigap EOB. The Complementary Medicare Part B EOB contains the patient s name, claim number and dollar amount for any offsets taken against that week s check. The Complementary Medicare Part B EOB page became available on Dec. 6, Policy Endovenous radiofrequency obliteration of the greater saphenous vein eligible for reimbursement Pennsylvania Blue Shield now pays for endovenous radiofrequency obliteration of the greater saphenous vein, for example, the VNUS closure procedure. Beginning Jan. 1, 2003, report this procedure with code S2130 endoluminal radiofrequency ablation of refluxing saphenous vein. If you performed this procedure before Jan. 1, 2003, use code to report the service. Please include a complete description of the service performed when reporting code Endovenous radiofrequency obliteration of the greater saphenous vein is a minimally invasive treatment. It is used as an alternative to saphenous vein ligation and stripping for patients with symptomatic venous insufficiency of the lower limbs. A catheter is temporarily inserted into the patient s saphenous vein. Radiofrequency applied at the catheter tip heats the vein. As the catheter is slowly withdrawn from the vein, the heat causes the vein to collapse and occlude, thus terminating the reflux that causes the patient s symptoms. 12

13 12/2002 Gastric electrical stimulation eligible in certain cases Pennsylvania Blue Shield considers gastric electrical stimulation (Enterra Therapy or gastric pacing) for payment on an individual consideration basis under the humanitarian use device exemption. If Blue Shield does not approve gastric electrical stimulation, it will deny it as not being medically necessary. A participating, preferred or network health care professional cannot bill the member for the denied service. Use procedure code or 43999, as appropriate, to report the service. You must submit the patient s medical records with the claim. The Gastric Electrical Stimulator (GES) System/Enterra Therapy System, manufactured by Medtronic, is the only gastric electrical stimulator that has received approval from the Food and Drug Administration (FDA). The GES System received FDA approval through a humanitarian device exemption. This regulatory category was established in It applies only to devices intended to benefit less than 4,000 patients. A humanitarian device may only be used in facilities that have an institutional review board to supervise clinical testing of the device. Gastric electrical stimulation is performed with an implantable device designed to treat chronic drug-refractory nausea and vomiting secondary to gastroparesis of diabetic or idiopathic etiology. Nucleoplasty considered investigational Pennsylvania Blue Shield considers nucleoplasty an investigational procedure. Therefore, it is not eligible for payment. Use code to report nucleoplasty. When reporting code 62287, also include a complete description of the procedure performed. Nucleoplasty is a minimally invasive percutaneous procedure performed under local anesthesia to decompress herniated vertebral discs. Nucleoplasty is performed to relieve chronic back pain. A special radiofrequency probe, Perc-D SpineWand, is inserted percutaneously into the affected disc under fluoroscopic guidance. Radiofrequency energy is used to break up the molecular bonds of the gel in the nucleus of the disc. This causes decompression and relieves pressure on surrounding nerve roots. Blue Shield allows separate payment for certain venipuncture procedures Pennsylvania Blue Shield now pays separately for these venipuncture procedures: venipuncture, under 3 years; femoral or jugular venipuncture, under 3 years; scalp vein venipuncture, under 3 years; other vein Blue Shield no longer includes the s for these procedures with medical or surgical care. Use code 36400, or to report these venipuncture procedures. 13

14 Ultraviolet light therapy now eligible for cutaneous T-cell lymphoma Pennsylvania Blue Shield will pay for ultraviolet light therapy when it s used to treat patients with cutaneous T-cell lymphoma (mycosis fungoides and Sezary s disease). Blue Shield now pays for ultraviolet light for these indications. Report ICD-9-CM diagnosis codes for mycosis fungoides, or codes for Sezary s disease. New national trauma modifier replaces WH modifier On Jan. 1, 2003, Pennsylvania Blue Shield deleted local modifier WH trauma case. The national modifier ST related to trauma or injury replaces the deleted WH modifier. Blue Shield defines trauma cases as those situations requiring necessary surgery because of a traumatic diagnosis. When surgical procedures are required due to trauma, report modifier ST with the surgical procedure code(s) to ensure appropriate reimbursement according to the member s benefits. Questions or comments on these new medical policies? We want to know what you think about our new 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 2002 PTM changes Please make these changes to your 2002 Pennsylvania Blue Shield Procedure Terminology Manual (PTM). Page Modifier Terminology Action A-10 ST Related to trauma or injury Add modifier. Effective 1/1/03. A-11 WH Trauma case Delete modifier. Effective 1/1/03. 14

15 12/2002 Patient News - Information about your patients who are Pennsylvania Blue Shield customers Central and Eastern Region Liberty Mutual moving to BlueCard POS B The Liberty Mutual group has elected a BlueCard point-of-service processing arrangement beginning Jan. 1, The alphabetical prefix for Liberty Mutual employees has changed from LMI to XXK. Report the XXK alphabetical prefix on claims for services you provide on or after Jan. 1, You can report the LMI alphabetical prefix for services you performed before Jan. 1, 2003 for Liberty Mutual employees. NASCO business converts to BlueCard B On Jan. 1, 2003, these Central Site NASCO accounts transitioned to a BlueCard processing arrangement for these Blue Cross Blue Shield Plans: Anthem Blue Cross Blue Shield Bayer Corporation Federal Reserve Bank Oaktree Packaging CareFirst Blue Cross Blue Shield AstraZeneca Baltimore Life Homewood Retirement Center Whiting Turner Blue Cross Blue Shield of Massachusetts Liberty Mutual Osram Sylvania Parexel International TJX Companies 15

16 Blue Cross Blue Shield of Michigan Bissell Budd DELPHI Automotive Systems Ford Motor Company (hourly) Ford Motor Company (salary) General Motors Letica Corporation DaimlerChrysler (As of Jan. 1, 2003, the new alphabetical prefixes for DaimlerChrysler are DCC and DCH.) Pennsylvania Blue Shield will process services you perform on or after Jan. 1, 2003 as BlueCard. Pennsylvania Blue Shield will process services performed before Jan. 1, 2003, and adjustments to claims with services before Jan. 1, 2003, through NASCO for a 12- month period. Reporting tips for BlueCard claims Please follow these helpful tips when submitting BlueCard claims: You must verify and report the patient s current alphabetical prefix. The three-character alphabetical prefix at the beginning of the member s identification number is key to identifying and correctly routing claims. This alphabetical prefix identifies the plan or national account to which the member belongs. Here is how you can verify and report the correct alphabetical prefix: At each visit ask to see the patient s most current identification card. Make sure you have a copy of the most recent card in their file. Remember, alphabetical prefixes change with coverage changes. Include the most current identification number and alphabetical prefix on all claim submissions. If you are an electronic biller, verify if your software vendor has programmed the member s alphabetical prefix to appear on the claim format. Also, make sure that the alphabetical prefix has been mapped to transmit properly. If you refer your patient for auxiliary services, that is, laboratory tests or X-rays, always supply the performing provider with the patient s full identification number, including the alphabetical prefix. When laboratories or hospitals perform these services, they are responsible for billing the services. They must report the alphabetical prefix to receive correct reimbursement. If you have questions about how to submit BlueCard claims, call Pennsylvania Blue Shield s provider/host unit at: Customer Service Central: (866) , or Customer Service East: (215)

17 12/2002 Central Region Blue Shield adds two new senior indemnity plans to MedigapBlue Pennsylvania Blue Shield has added two new senior indemnity plans to its MedigapBlue Medicare supplement product line. The new MedigapBlue plans E and I became effective Jan. 1, Plans E and I offer the same basic benefits as MedigapBlue plans A, B, C and H, including a drug discount program. Plan I has a prescription drug benefit like Plan H. This benefit pays 50 percent of the prescription drug cost, with a calendar year maximum of $1,250. Plans E and I also include a discount vision program, and access to the Blues on Call program. Plan E includes a benefit for preventive care services. An at home recovery benefit is included with Plan I. The at home recovery benefit allows for at home assistance with activities of daily living in addition to Medicare-covered home health visits. Milton Hershey School selects PPOBlue coverage On Jan. 1, 2003, Pennsylvania Blue Shield began to administer benefits for Milton Hershey School (MHS) employees. The school s 1200 employees live primarily in Dauphin County. MHS employees are enrolled in the PPOBlue program. PPOBlue uses the PremierBlue Shield provider network. When MHS employees use PremierBlue Shield network health care professionals they will pay only a $10 copayment for office visits and a $35 copayment for emergency room services. 17

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19 12/2002 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 (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: Pennsylvania 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

20 Contents Vol. 2002, No. 6 News Pennsylvania Insurance Department approves UCR and PremierBlue Shield reimbursement increases... 1 Upgrade your Web browser to view Blue Shield s website Blue Shield revamps Access Care II and comprehensive major medical EOBs New PO Box available for Access Care II and comprehensive major medical claims Complementary Medicare Part B EOB page now available Policy Endovenous radiofrequency obliteration of the greater saphenous vein eligible for reimbursement Gastric electrical stimulation eligible in certain cases Nucleoplasty considered investigational Blue Shield allows separate payment for certain venipuncture procedures Ultraviolet light therapy now eligible for cutaneous T-cell lymphoma New national trauma modifier replaces WH modifier Questions or comments on these new medical policies? Codes 2002 PTM changes Patient News Liberty Mutual moving to BlueCard POS NASCO business converts to BlueCard Blue Shield adds two senior indemnity plans to MedigapBlue Milton Hershey School selects PPOBlue coverage Need to change your provider information? Acknowledgement The five-digit numeric codes that appear in PRN were obtained from the Physician's Current Procedural Terminology, as contained in CPT-2002, Copyright 2001, 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. Visit us at PRN Policy Review & News Pennsylvania Blue Shield Camp Hill, Pennsylvania PRSRT STD U.S. POSTAGE PAID HARRISBURG, PA Permit No