Important information about Pennsylvania Blue Shield April 2000

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1 Important information about Pennsylvania Blue Shield April 2000 In This Issue Policy Review & News Special Investigations Unit works with doctors and members to prevent fraud PTM mailed in March... 3 The LINK moves from paper to on-line newsletter... 4 Blue Shield allows positron emission tomography for specific situations... 4 News Special Investigations Unit works with doctors and members to prevent fraud Fraud is a significant concern to the health care insurance industry and to Pennsylvania Blue Shield. The National Health Care Anti-Fraud Association estimates three to 10 percent of dollars spent on health care in the United States is lost to fraud. Based on the federal General Accounting Office s estimate that the nation spent $1 trillion in health care last year that means at least $300 billion is paid out each year under fraudulent circumstances. During 1999, Blue Shield s Special Investigations Unit s (SIU) savings and recoveries totaled approximately $10 million. The SIU protects health care dollars that otherwise might have been lost. Blue Shield s members expect it to manage their health care premiums wisely and detecting and preventing fraud is part of that. SIU s mission statement reflects the aggressive approach to the investigation of potential health care fraud cases: Maintain the integrity of Pennsylvania Blue Shield, its subsidiaries, affiliates and employees through the proactive detection, investigation and the pursuit of potential fraud and abuse. When necessary, take internal and/or external corrective action ultimately enabling Pennsylvania Blue Shield to provide quality, affordable health care insurance to all its clients.

2 Referrals of suspected fraud originate from a variety of sources in a number of ways. Providers, facilities, suppliers, pharmacies, members and internal Blue Shield departments may report alleged fraud. Established in 1983, the SIU is dedicated to taking a proactive approach to health care fraud. Its role is to detect and investigate alleged fraud and abuse in all lines of Blue Shield business, except Medicare, which has its own fraud investigation unit. The SIU works closely with federal, state and local law enforcement agencies. Another role of the SIU is providing fraud awareness training sessions. Thomas P. Brennan, Jr., director of SIU since 1995, has an extensive law and investigation background. This includes experience in the Dauphin County District Attorney s Office, the Federal Bureau of Investigation s Behavioral Science Unit and the Pennsylvania State Police. If you suspect a fraudulent situation or if you have any questions, the SIU has a fraud hotline. Call the hotline at (800) between 8 a.m. and 4 p.m. Appeal for professional consultants is successful The response to Pennsylvania Blue Shield s request for professional consultants has been positive nearly 200 providers and suppliers expressed interest in this opportunity. (See October 1999 PRN, Physicians and suppliers needed to expand professional consultant network. ) Blue Shield s 275 professional consultants are actively practicing health care providers or suppliers who are currently engaged in the medical equipment, prosthetic or orthotic, or other medically-related businesses. These individuals must be licensed in Pennsylvania and maintain active businesses, or practices within the state. Professional consultants work with Blue Shield by providing their input on medical necessity issues, reimbursement levels and utilization reviews. Blue Shield s professional consultant coordinator is reviewing the information that was received from potential consultant candidates. The coordinator is identifying those individuals in the specific medical specialties or medically-related fields where the company has a need or where it expects to see a significant increase in workload. Blue Shield received several responses from out-of-state providers and suppliers. Blue Shield will consider these candidates only if they meet its requirements of being licensed in Pennsylvania and maintaining an active business, or practice within Pennsylvania. 2

3 4/2000 As candidates are selected, the professional consultant coordinator will contact them. The remainder of the selection process includes a review of the candidate s credentials and billing history, arranging for the candidate s participation in a training and orientation class and the completion of the necessary contracts and questionnaires. If you ve submitted your curriculum vitae or resume, you do not need to do anything else. Blue Shield has added you to our list of active candidates for participation in the professional consultant network. Blue Shield would like to thank everyone who responded to its appeal for consultant candidates PTM mailed in March In March, Pennsylvania Blue Shield mailed the 2000 edition of the Procedure Terminology Manual (PTM) to you and your fellow health care professionals. If you are an out-of-state provider, you must have contracted with Blue Shield as a participating provider to receive a 2000 PTM. Blue Shield designs the PTM as a reference to assist your staff in submitting claims to Blue Shield. Always report the appropriate procedure code on your claims. The 2000 PTM includes the 2000 Health Care Financing Administration Common Procedure Coding System (HCPCS) and the American Medical Association s Current Procedure Terminology (CPT) changes. These additions, revisions and deletions were effective Jan. 1, If you report deleted codes, it will delay your claims and some claims may be denied incorrectly. The listing of a procedure in the PTM does not necessarily indicate that it is eligible for reimbursement under Blue Shield s programs. If you have not received your copy of the 2000 PTM, please contact: Pennsylvania Blue Shield Shipping Control Department PO Box Camp Hill, Pa (717)

4 EMC News The LINK moves from paper to online newsletter Direct Access Services (DAS) quarterly newsletter, the LINK, will only be available as an on-line publication beginning with the July 2000 issue. You will continue to receive all the information you need to successfully do business with Pennsylvania Blue Shield electronically without the additional paper. You can easily access the LINK through No longer will you misplace copies of the LINK as DAS has included past issues (from 1996 to present) on its website. You do not need to wait until July to view the LINK on-line. Simply access click on The LINK along the left navigation bar. DAS realizes this is a major change. It will provide you with reminders about reading the LINK on-line on your submission summary reports as the July timeframe approaches. Policy Blue Shield allows positron emission tomography for specific situations 4 Pennsylvania Blue Shield considers positron emission tomography (PET) studies to be medically necessary and eligible in these situations: Brain imaging PET imaging of the brain is eligible in the presurgical evaluation of epilepsy patients and for the evaluation of brain tumors. Use procedure code or to report PET studies of the brain. Myocardial imaging PET imaging of the myocardium is eligible for payment in these situations: To assess myocardial perfusion in the diagnosis and treatment of coronary artery disease. To assess myocardial viability as a technique to determine a patient s candidacy for a revascularization procedure. Myocardial PET is not eligible as a screening tool, or when used in place of, or to confirm the results obtained from, myocardial SPECT imaging. Use procedure codes 78459, 78491, 78492, or G0030-G0047, as appropriate, to report myocardial PET imaging. Tumor imaging of the lung coverage for PET imaging of lung malignancies is limited to these situations: To image patients who have a solitary pulmonary nodule and in whom chest X-ray and computed tomography (CT) studies have failed to distinguish benign from malignant disease, when the results of the test could change the management of the patient. For the staging of lung cancer (including the assessment of the status of mediastinal lymph nodes).

5 4/2000 Use code G0125 or G0126 to report PET imaging of the lung. Blue Shield considers PET imaging for monitoring lung cancer investigational. It is not eligible for reimbursement. Report code for PET imaging for monitoring lung cancer. Tumor imaging of other anatomic areas Blue Shield considers PET imaging of colorectal cancer (code G0163), lymphoma (code G0164) and melanoma (code G0165) investigational. It is not eligible for payment in these instances. Blue Shield also considers PET tumor imaging of other anatomic areas (code 78810) investigational. Examples include, but are not limited to, the detection, staging or monitoring of treatment for other diseases and malignancies, including but not limited to, breast cancer, pancreatic cancer, head and neck cancer, musculoskeletal cancers, thyroid cancer, ovarian cancer, thymoma, prostate cancer, germ-cell cancer and esophageal cancer. PET imaging in a freestanding setting Total charge reimbursement for PET services performed in a freestanding facility includes the professional interpretation component and the technical component. The technical component involves the calculation of the following: Machine component The costs specific to each practice relating directly to the acquisition and installation of the medical equipment. Non-machine component The indirect costs associated with performing the service, such as utility expenses. Before you submit claims for total charge reimbursement for PET procedures performed in a freestanding setting, you must contact Blue Shield s Benefits Cost Management department. The department s telephone number is (717) Coverage policies for refractions explained 5 A refraction is most commonly performed for purposes of prescribing corrective lenses. It is not a benefit under most Pennsylvania Blue Shield medical-surgical contracts. Blue Shield does not cover the determination of refractive state (92015) when performed for these conditions: routine eye examination (V72.0) hypermetropia (367.0) myopia (367.1) astigmatism ( ) anisometropia and aniseikonia ( ) presbyopia (367.4) transient refractive change (367.81) unspecified disorder of refraction and accommodation (367.9) aphakia (379.31) A participating or preferred provider may bill the member for the denied refraction in these instances.

6 Refraction to assess or monitor a medical condition is covered Occasionally, a patient s visual acuity may be impacted by a medical condition that can affect the ocular system, for example, diabetes, macular degeneration, glaucoma, systemic diseases that affect neurological, vascular, endocrine or immune body systems, etc. In these cases, a refraction may be performed as part of the evaluation and monitoring of that condition. When the purpose of the refraction is to assess or monitor progression of a medical condition, rather than to evaluate the patient s degree of refractive error for the prescription of corrective lenses, Blue Shield considers it a covered service. However, if the exam and refraction result in the prescription of corrective lenses, the services are not covered under most medical-surgical programs. A participating or preferred provider may bill the member for these services. Please document the patient s medical condition warranting the refraction on the claim. Refraction performed for evaluating medical conditions will typically be reported in conjunction with ophthalmological exam codes Blue Shield will use code to process claims for a refraction performed for assessment or monitoring of medical conditions that affect the eye. Blue Shield may review cases reporting refractions at unusually frequent intervals to verify the medical necessity of the services. Refraction payment included in ocular surgery allowances Blue Shield considers a refraction performed following ocular surgery as part of the doctor s normal postoperative care. Therefore, Blue Shield s payment for the surgical procedure also includes the refraction performed during the postoperative period for a definitive surgical procedure. Refraction is defined as determination of the nature and degree of the refractive errors of the eye and correction of the same by lenses. This may be done with or without eye drops in the eye. Refraction is performed by interposing lenses of different kinds in front of the eye until visual acuity is maximized. This examination provides the degree to which the eye differs from normal, which determines whether or not the patient needs corrective lenses and, if so, how strong they should be. Blue Shield considers H-wave stimulation investigational Pennsylvania Blue Shield considers therapeutic H-wave stimulation an investigational procedure. Blue Shield does not cover the H-wave device (E1399 durable medical equipment, miscellaneous) used in the home or H-wave stimulation performed in the provider s office (97799 unlisted physical medicine/rehabilitation service or procedure). H-wave electrical stimulation performed as a therapeutic service is not the same as H- waves that are a component of diagnostic electromyography. 6

7 4/2000 Blue Shield s eligibility requirements for supportive personnel Under its private business programs, Pennsylvania Blue Shield recognizes covered services for its members only when performed by eligible health care providers. To be considered eligible, these health care providers must be duly licensed and acting within the authority of their licenses. The types of health care providers eligible to participate with Blue Shield are defined in its enabling legislation. Eligible health care providers are: Audiologists Nurse midwives Certain certified registered nurses Chiropractors Clinical laboratories Dentists Doctors of medicine Doctors of osteopathy Optometrists Physical therapists Podiatrists Psychologists Speech-language pathologists Teachers of the hearing impaired In some instances, Blue Shield will make payment for covered services that are performed under the direct, personal supervision of the eligible health care providers when rendered by a licensed health care practitioner in his or her employment. Personal supervision means that the health care provider must be on-site, in the immediate vicinity so that he or she can personally assist in the procedure, or assume primary care of the patient, if necessary. Availability of the licensed health care provider by telephone or radio does not constitute direct personal supervision. Blue Shield will pay for such services only if all criteria of appropriate licensure, employment and supervision are met. If you bill for eligible services that do not meet these guidelines, your claim may be delayed. Contact your Provider Relations representative for additional information about this policy. Indications for interferon alpha Interferon alpha (J9213, J9214, J9215) is a family of highly hemologous, speciesspecific proteins that possess antiviral, antineoplastic and immunomodulating activities. When a benefit, Pennsylvania Blue Shield will allow reimbursement for interferon alpha when it is used to treat: AIDS-related Kaposi s sarcoma (042, ) Cervical cancer, advanced ( , , 233.1) Chronic hepatitis B ( , ) Condyloma acuminata (078.11) Hairy cell leukemia (202.4) Hepatitis C (070.41, , , ) 7

8 Malignant melanoma ( , , , 184.4, 187.1, 187.9, , , 190.9) Multiple myeloma ( ) Mycosis fungoides (202.1) Non-Hodgkin s lymphoma ( ) Papillomatosis, laryngeal (148.9, , , 197.3, , 230.0, 231.0) Renal cell cancer as a debulking agent ( , 198.0, 233.9) Polycythemia vera (when other treatments have failed) (238.4, 289.0, 776.4) Chronic phase, Philadelphia chromosome-positive chronic myelogenous leukemia (205.1) If interferon alpha is used in the treatment of other conditions, Blue Shield will deny it as not medically necessary. Participating or preferred providers cannot bill the member for services that are denied based on medical necessity. Radiofrequency ablation of nasal turbinates Pennsylvania Blue Shield will pay for radiofrequency ablation of nasal turbinates when it is used to reduce hypertrophic inferior turbinates (478.0). Radiofrequency ablation of nasal turbinates, also known as somnoplasty of nasal turbinates, is designed to improve chronic nasal congestion by reducing the volume of tissue in the nasal turbinates. Blue Shield does not reimburse for somnoplasty when reported for socially disruptive snoring and obstructive sleep apnea. When somnoplasty is reported for obstructive sleep apnea, Blue Shield considers it investigational. Participating or preferred providers may bill the member for the somnoplasty in this instance. Please use code Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method, intramural to report radiofrequency ablation of nasal turbinates. Blue Shield may pay for FDAapproved pneumococcal vaccines Pennsylvania Blue Shield determines coverage for pneumococcal vaccines according to FDA approval and the member s benefits. The FDA has granted approval for the pneumococcal 7-valent conjugate vaccine. The pneumococcal 7-valent conjugate vaccine is used to prevent invasive pneumococcal disease in infants and toddlers. Use procedure code to report this vaccine. Here are the Advisory Committee on Immunization Practices (ACIP) recommendations for pneumococcal vaccines: For infants up to age 23 months. 8

9 4/2000 For children ages 24 months to 59 months, including African Americans, Native Americans, Alaskan Natives; children with sickle cell anemia, HIV, chronic diseases, and those who are immunocompromised. For other children ages 24 months to 59 months with priority given to children in group daycare, children who are socially or economically disadvantaged, and children with frequent/recurrent otitis media. Safety and immunogenicity data are limited or are not available for children in high-risk groups for invasive pneumococcal disease. Please report procedure code for the pneumococcal 23-valent polysaccharide vaccine. Blue Shield will pay for these vaccines according to the individual member s benefits. Reporting guidelines for Synagis change Palivizumab (Synagis) is now available in 50 mg and 100 mg vials. To report Palivizumab, use code Respiratory syncytial virus immune globulin (RSV-IgIM), for intramuscular use. Indicate the appropriate multiple service code in the number of services field for each 50 mg administered. For example, if a total of 100 mg is administered, place a 2 in the number of services field. Blue Shield has adjusted the fee for Palivizumab to reflect this change in reporting. New codes for routine eye exams and refractions introduced Pennsylvania Blue Shield is deleting the procedure code for routine eye examination and refraction. Effective April 3, 2000, code Y9780 will no longer be valid. It is being replaced with these new procedure codes: S0620 Routine ophthalmological examination including refraction; new patient S0621 Routine ophthalmological examination including refraction; established patient Please add these codes to Page 308 of the 2000 PTM. 9

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11 4/2000 Notes Need to change your provider information? Fax the information to us! You can fax us changes about your practice information, such as the information listed on the coupon below. The fax number is (717) 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

12 Contents Vol. 2000, No. 2 News Special Investigations Unit works with doctors and members to prevent fraud... 1 Appeal for professional consultants is successful PTM mailed in March... 3 EMC News The LINK moves from paper to on-line newsletter... 4 Policy Blue Shield allows positron emission tomography for specific situations... 4 Coverage policies for refractions explained... 5 Blue Shield considers H-wave stimulation investigational... 6 Blue Shield s eligibility requirements for supportive personnel.. 7 Indications for interferon alpha... 7 Radiofrequency ablation of nasal turbinates... 8 Blue Shield may pay for FDA-approved pneumococcal vaccines... 8 Reporting guidelines for Synagis change... 9 New codes for routine eye exams and refractions introduced... 9 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-2000, Copyright 1999, by the American Medical Association. PRN includes CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures and other materials that are copyrighted by the American Medical Association. Our web address: PRN Policy Review & News Pennsylvania Blue Shield Camp Hill, Pennsylvania PRSRT STD U.S. POSTAGE PAID HARRISBURG, PA Permit No