For participating physicians, dentists, other health care professionals, facilities and their office staff

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PROVIDER NEWSWhat’s insideClick on a title below to read the article.

DECEMBER 2018

More features for electronic authorizations..... 1-2

Behavioral health must reads ........................... 2

About the newsletter ....................................... 3

Using our website ........................................... 3

Stay up to date ................................................ 3

Share your feedback ........................................ 3

New look for newsletter coming ....................... 3

Pre-authorization list updates .......................... 4

Elective inpatient pre-authorizations ............... 4

Non-reimbursable services ............................. 4

AIM administrative guideline updates ............... 5

eviCore guidelines to be revised ....................... 5

Reimbursement policy updates ........................ 6

Virtual Care reimbursement policy updates ....... 7

Medical policy update ..................................... 8

Medical policy reviews .................................... 8

Clinical Practice Guidelines review ................... 8

Help our members find you .............................. 8

Medication policy updates .......................... 9-10

Non-opioids for chronic pain .................... 11-12

Collaborative care helps patients with behavioral health needs .................................. 13

NDC required on medical drug claims .............. 13

Advance care planning conversation videos ......14

2019 ABA codes .............................................14

ASAM guidelines for substance use ..................14

2019 code changes .........................................14

New population health program ....................... 15

Coding Toolkit updates ................................... 15

CPT Category II codes explained ......................16

Referring to in-network providers ................... 17

This symbol indicates a critical article.

We’ve added more features for electronic authorizationsIn April 2018, Availity’s electronic authorization tool became available to providers for submitting standard medical pre-authorization requests. Since then, we’ve added several new features to help streamline the pre-authorization process and decrease turnaround times to help you and your patients.

On November 10, 2018, we added new features: pre-authorization and benefits check; and direct clinical information. We hope these features have made it even easier to submit pre-authorization requests electronically.

Pre-authorization and benefits checkThe authorization tool will let you know, before submitting the request, whether the service or inpatient level of care is:

• Excluded from coverage

• Doesn’t need pre-authorization

• Needs pre-authorization by BridgeSpan

• Needs pre-authorization through a vendor partner (e.g., AIM Specialty Health [AIM] or eviCore healthcare [eviCore])

Direct clinical informationFor certain CPT codes, the electronic authorization tool will automatically route you to MCG Health’s website and allow you to document specific clinical criteria for your patient. You will then be routed back to the Availity Portal to attach supporting documentation and submit the request. If all criteria are met, you will be able to see the approval on the Auth/Referral Dashboard soon after you click submit. Note: BridgeSpan currently only offers authorizations on the dashboard.

Documenting complete and accurate clinical information for your patients will help to reduce the overall time it takes to review a pre-authorization request. Remember, you can always check on the status of a submitted pre-authorization request on the Auth/Referral Dashboard.

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As a reminder, the features below were added this fall:

• Early eligibility check allows you to know whether a member has:

- Other primary insurance

- Current BridgeSpan coverage

• Auth/Referral Dashboard with status check allows you to view:

- All requests submitted on or after October 21, 2018, via the Availity Portal

- Status of the request (e.g., approved, denied, pending review)

Want to learn more?

Providers have indicated that they had a better user experience after they received training about the tool. We encourage you to complete the training options listed below:

• Training is available in the Availity Learning Center on the Availity Portal at availity.com: Help & Training>Get Trained> Availity Learning Center Catalog.

• A quick reference guide is available from the course contents after you enroll in the authorizations training. It includes instructions and screen shots to help walk you through the electronic authorization process.

• Attend a live training webinar on:

- December 11, 2018, noon to 1:15 p.m.

- December 13, 2018, 9 a.m. to 10:15 a.m.

Both times are Pacific Time. Registration and more information about the webinars will be posted on the home page of our provider website at BridgeSpanHealth.com when they become available.

Electronic authorizations, continued from page 1

Behavioral health must readsThis issue includes the following behavioral health and substance use-specific articles:

• Page 13: Collaborative care helps patients with behavioral health needs

• Page 14: 2019 adaptive behavior assessment (ABA) CPT code changes

• Page 14: American Society of Addiction Medicine (ASAM) guidelines for substance use treatment

Please read the other articles in this newsletter as they may also pertain to behavioral health providers. ■

Join your peers

Start submitting your standard medical pre-authorizations through the Availity Portal today: Login>Patient Registration> Authorizations & Referrals>Authorizations.

How can we keep improving?

Thank you for providing feedback about your experiences submitting electronic authorizations. We appreciate your feedback and will continue to make improvements so that it can be an effective and efficient tool.

Please continue to tell us about your experiences using the authorization tool by using the feedback form on the Availity Portal. We look forward to hearing from you. ■

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About Provider NewsThis publication includes important updates for you and your staff, in addition to information about updates to policies and procedures, and notices we are contractually required to communicate to you. In the table of contents on page 1, this symbol indicates articles that include critical updates: . To save time, you can click on the titles to go directly to specific articles. You can also return to the table of contents from any page by clicking on the link at the bottom of each page.

Issues of Provider News are published on the first of the following months: February, April, June, August, October and December.

The information in this newsletter does not guarantee coverage. Verify members’ eligibility and benefits via the Availity Portal at availity.com.

The Bulletin

We publish a monthly bulletin as a supplement to this bimonthly provider newsletter. The Bulletin provides you with updates to medical and dental policies, including any policy changes we are contractually required to communicate to you.

Subscribe todayIt’s easy to receive email notifications when new issues of the newsletter and bulletin are available. Simply complete the subscription form available on our website: Library> News and Updates>Subscribe.

Encourage everyone in your office to sign up. ■

Using our websiteWhen you first visit BridgeSpanHealth.com, you will be asked to select an audience type (Individual or provider) and enter a ZIP code for your location. This allows our site to display content relevant to you. Our site remembers your selection and automatically directs you to the same site settings the next time you visit. For most users, this is a convenient, time-saving feature. ■

Stay up to dateView the What's New section on the home page of our provider website, BridgeSpanHealth.com, for the latest news and updates.

Share your feedbackAre our publications meeting your needs?

Please share your feedback about our newsletter and bulletin by completing a short survey this month at surveymonkey.com/r/bsh-nb-2018-survey. You can also access the survey on the home page of our website.

Thanks in advance for your time. and input.

New look for our newsletter coming in FebruaryOur newsletter will have a new look beginning with the February 2019 issue. The newsletter will continue to include important updates and information for physicians, dentists, other health care professionals, facilities and office staff. We hope you'll like the new format. ■

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Pre-authorization updates PROCEDURE/MEDICAL POLICY ADDED CPT CODES EFFECTIVE DECEMBER 1, 2018

Charged-Particle (Proton) Radiotherapy (Medicine #49)

32701, 61796-61800, 63620, 63621, 77371-77373, 77432, 77435, G0339, G0340

Genetic Testing for Epilepsy (Genetic Testing #80)

81401, 81403-81407

PROCEDURE/MEDICAL POLICY ADDING CPT CODE EFFECTIVE MARCH 1, 2019

Sacroiliac Joint Fusion (Surgery #193) 27279

Our complete pre-authorization list is available in the Pre-authorization section of our website. Please review the list for all updates and pre-authorize services accordingly.

You can submit standard medical pre-authorizations through the Availity Portal, availity.com. Learn more on our website: Pre-authorization>Electronic Authorization. Related: See We’ve added more features for electronic authorizations on pages 1-2. ■

Non-reimbursable servicesOur Non-Reimbursable Services (Administrative #107) reimbursement policy, which explains invalid services that are considered to be non-reimbursable, is located on our website: Library> Policies and Guidelines>Reimbursement Policy. If billed, non-reimbursable services are considered not payable, are denied as a provider write-off and cannot be billed to our member.

View specific CPT and HCPCS codes that are considered non-reimbursable services in the Clinical Edits by Code List located on our website: Claims and Payment>Claims Submission> Coding Toolkit.

If the Centers for Medicare & Medicaid Services (CMS) has designated a medication as product not available (PNA) for 90 days, we consider it a non-reimbursable service (NRS) and not eligible for reimbursement. We allow this time to use any existing supply. We review medication codes quarterly and update any medications with a PNA code status to NRS. ■

Elective inpatient services to require pre-authorization We will begin requiring pre-authorization for all professional elective inpatient services, including behavioral health, for dates of service on or after April 1, 2019.

Providers can begin pre-authorizing these services on February 1, 2019. Requests must include the facility where the service and admission will occur.

Pre-authorization requests can be submitted using Availity’s electronic authorization tool. Requests will be reviewed for the procedure and place of service. ■

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AIM administrative guideline updatesWe partner with AIM to administer our radiology and Sleep Medicine programs. AIM is updating their administrative guidelines for diagnostic and therapeutic interventions.

Effective March 9, 2019, repeated testing for the same indication using the same or similar technology may be subject to additional review or require peer-to-peer discussion in the following scenarios.

Repeated diagnostic testing:

• At the same facility because of technical issues

• Requested at a different facility because of provider preference or quality concerns

• Of the same anatomic area by different providers for the same member over a short period of time

• Of the same anatomic area based on persistent symptoms with no clinical change, treatment or intervention since the previous study

View all administrative and clinical guidelines on AIM’s website at aimspecialityhealth.com. ■

eviCore guidelines to be revisedEffective March 1, 2019, eviCore will revise its guidelines for several components of our Physical Medicine program.

Chiropractic guideline revisions • Adding requirements for chiropractic visits that:

- Clarify that medical necessity requires significant functional limitation and pain

- Address treatment frequency and duration

Interventional pain management guideline revisions • Revising two guidelines: Regional Sympathetic

Blocks and Spinal Cord Stimulators

Physical therapy and occupational therapy guideline revisions • Adding eight guidelines: Vestibular Hypofunction;

Progressive Neuromuscular Disorders; Down Syndrome (Pediatric); Lymphedema; General Debility Impaired Mobility; Systemic Autoimmune Arthropathy; Concussion in Children and Adolescents (Pediatric); and Neurological Rehabilitation for Concussion

Speech therapy guideline revisions • Adding four guidelines: Selective Mutism; Bilingual

Service Criteria; Central Auditory Processing Disorder (CAPD); and Augmentative and Alternative Communication (AAC)

Spine surgery guideline revisions • Revising five guidelines: Anterior Cervical

Discectomy and Fusion; Posterior Cervical Decompression (Laminectomy/Hemilaminectomy/Laminoplasty) with or without Fusion; Lumbar Fusion (Arthrodesis); Sacroiliac Joint Fusion or Stabilization; and Grafts

eviCore has published redlined versions of these revisions on its website, evicore.com. ■

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Reimbursement policy updatesWe review our reimbursement policies on an annual basis. Included below are updates to existing policies that will be added to our Reimbursement Policy Manual.

View our reimbursement policies on our website: Library>Policies and Guidelines>Reimbursement Policy.

To see how a claim will be processed, access the Clear Claim Connection tool on the Availity Portal at availity.com: More>Claims>Research Procedure Code Edits.

UPDATED POLICIES DESCRIPTION OF ADDITION OR CHANGEADMINISTRATIVE EFFECTIVE JANUARY 1, 2019

Virtual Care (#132) • Adding CPT 90837 (with GT modifier) Psychotherapy, 60 minutes, to the list of reimbursable behavioral health telehealth codes

• The member-to-provider scenario in the store and forward section for Idaho, Oregon and Utah (Note: This was included for Washington in 2018.)

• Updating the list of references

• Related: See Virtual Care reimbursement policy updates on page 7

FACILITY EFFECTIVE MARCH 1, 2019

• Reimbursement of Medications for Facilities (#102)

• Reimbursement of Multi-Dose Inhaled Medications for Facilities (#106)

• Reimbursement of Multi-Dose Topical Medications for Facilities (#107)

• Adding requirement that medications administered in an office or outpatient facility setting must be submitted with a National Drug Code (NDC)

• Related: See NDC required on medical drug claims on page 13

MEDICINE EFFECTIVE MARCH 1, 2019

Discarded Drugs and Biologicals (#108) • Adding requirement that medications administered in an office or outpatient facility setting must be submitted with an NDC

Drugs and Radiopharmaceuticals Reimbursed Under Medical Coverage (#104)

• Adding requirement that medications administered in an office or outpatient facility setting must be submitted with an NDC

• Removing NDC verbiage from average wholesale price (AWP) portion of policy statement

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Our members have convenient options for accessing medical and behavioral health services. Reimbursement for virtual care services is defined in our Virtual Care (Administrative #132) reimbursement policy, available on our website: Library>Policies and Guidelines> Reimbursement Policy.

On January 1, 2019, the policy will be updated to include:

• CPT 90837 (with GT modifier) Psychotherapy, 60 minutes, in the list of reimbursable behavioral health telehealth codes

• The member-to-provider scenario in the store and forward section for Idaho, Oregon and Utah (Note: This was included for Washington in 2018.)

• New and updated references

Verify your patients’ benefit using the Availity Portal at availity.com.

As a reminder, when submitting claims for these virtual care services, use:

• Place of service 02 (POS 02): Include POS 02 for the distant site when submitting claims for telehealth, telemedicine and store and forward services to differentiate these claims from in-person visits.

• Modifier GT: For the distant site, this modifier must be submitted with telehealth and telemedicine services. While CMS no longer requires modifier GT for professional services, please continue to use this modifier with POS 02 when submitting claims for BridgeSpan members. (Note: Professional providers should submit claims using modifier 26 [instead of modifier GT] for radiology services.)

• Modifier GQ: This modifier must be submitted for store and forward services, along with POS 02.

• HCPCS Q3014: For telemedicine claims, if the originating site is a health care facility:

- Submit claims by billing via an:

- ANSI 837i; the charge must be submitted using HCPCS Q3014 with no modifier.

- ANSI 837p; the charge must be submitted as an outpatient service with revenue code 0780 range and corresponding HCPCS Q3014 with no modifier.

- Providers at the distant site must submit the appropriate HCPCS/CPT codes for the services rendered, in addition to modifier GT and POS 02.

- Claims should be submitted using the same dates of service for the originating site and distant site.

Members’ benefits may include coverage for the following virtual care services:

• Telehealth: Real-time virtual care interaction (phone or video) with a provider where the patient is not located at a health care facility.

• Telemedicine: Real-time virtual care interaction (phone or video) where the patient is located at a health care facility.

• Store and forward: Transmission of a patient’s medical information to a provider that results in medical diagnosis or management. Provider-to-provider e-consultation and member-to-provider scenarios are addressed in the reimbursement policy.

We encourage our participating providers to offer these services to our members. Participating providers may qualify to be listed as a telehealth provider in our provider search tool if they diagnose and/or treat a member who is not located in a health care facility and the telehealth visit replaces the need for an in-person visit.

To be listed as a telehealth provider in our provider search tool, Find a Doctor, please contact your provider relations representative.

Related: See Reimbursement policy updates on page 6. ■

Virtual Care reimbursement policy updates

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Medical policy updateWe publish updates to medical policies, dental policies and Clinical Position Statements in our monthly publication The Bulletin.

You can read issues of The Bulletin or subscribe to receive an email notification when issues are published on our website: Library>News and Updates. The Medical Policy Manual includes a list of recent updates and archived policies: Library> Policies and Guidelines>Medical Policy> Recent Updates.

All policies and Clinical Position Statements are available on our website: Library> Policies and Guidelines. ■

Medical policy reviewsOur medical policies are reviewed because of the following:

• Updates from CMS

• Regularly scheduled review

• Changes in published scientific literature

• Requests from physicians, other health care professionals or facilities

• Addition, deletion or revision of codes published in the CPT, HCPCS and ICD-10 manuals

Clinical Practice Guidelines updatesClinical Practice Guidelines are systematically developed statements on medical and behavioral health practices that help physicians and other health care professionals make decisions about appropriate health care for specific conditions.

View the guidelines on our website: Library> Policies and Guidelines. ■

Help our members find youOur members rely on the information in our online provider search tool, Find a Doctor, to determine whether physicians, other health care professionals and facilities are included in their health plan’s provider network. The link to Find a Doctor is available on every page of our website.

We require verification of your practice information and the networks you participate in at least once every 30 days.

Validate your practice information Take time now to validate your practice information by following the steps outlined on our website: Contact Us>Update Your Information.

Ensuring your information is up-to-date and accurate helps our members find you. When information is missing or inaccurate, members may be denied care or receive unexpected medical bills.

Verifying your information in our provider search tool is also a requirement for compliance with the Affordable Care Act (ACA) and your agreement as a participating provider.

Please contact your provider relations representative immediately if you have changes to your practice information. Thank you for helping our members connect with you. ■

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Medication policy updatesListed below is a summary of medication policy additions and changes. Links to all medication policies, medication lists and pre-authorization information for our members, including real-time deletions from our pre-authorization lists, are available on our website: Programs>Pharmacy.

New U.S. Food & Drug Administration (FDA)-approved medications: New-to-market medications are subject to pre-authorization based on their FDA-labeled indication and dosage limitations until we complete a full medication review and develop a coverage policy.

Product not available (PNA) status: We allow a 90-day grace period to use any existing supply for medications that CMS has designated as PNA before they become ineligible for reimbursement.

Related: See Non-reimbursable services article on page 4.

NEW MEDICATION POLICIES EFFECTIVE DATE DESCRIPTIONLucemyra, lofexidine, dru557 November 1, 2018 • Limits coverage to patients who need opioid

withdrawal support management when clonidine has been ineffective

Braftovi, encorafenib, dru555

Mektovi, binimetinib, dru556

November 1, 2018 • Limits coverage to patients with BRAF-mutated advanced melanoma and the setting in which it has a labeled indication

Rituxan Hycela, rituximab SC, dru559

November 1, 2018 • Replaces dru214

• No change to coverage criteria

Tavalisse, fostamatinib, dru560 December 1, 2018 • Limits coverage to patients with refractory immune thrombocytopenia (ITP), the setting in which it was studied and for which it has a labeled indication

Qbrexza, glycopyrronium tosylate, dru561

December 1, 2018 • Considered not medically necessary (and therefore not covered) for the treatment of primary axillary hyperhidrosis

Neulasta, pegfilgrastim, dru563 April 1, 2019 • Includes both Neulasta and Neulasta OnPro

• Limits coverage to patients with a documented medical rationale that Fulphila is not a treatment option

REVISED MEDICATION POLICIES EFFECTIVE DATE DESCRIPTIONKymriah, tisagenlecleucel, dru523 October 1, 2018 • Added coverage criteria for large B-cell

lymphomas, a new FDA-approved indication

• Limits coverage to diffuse large B-cell lymphoma (DLBCL), high-grade B-cell lymphoma, and DLBCL arising from follicular lymphoma

Actonel, risedronate, dru155 November 1, 2018 • Actonel and risedronate no longer require pre-authorization

• Other products in dru155 continue to require pre-authorization

continued on page 10

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REVISED MEDICATION POLICIES EFFECTIVE DATE DESCRIPTIONAfinitor, Afinitor Disperz, everolimus dru178

November 1, 2018 • Added coverage criteria for partial-onset seizures associated with tuberous sclerosis complex (TSC), a new FDA-approved indication

• Limits coverage to patients in which at least three antiepileptic drugs are ineffective, are not tolerated or are contraindicated

Mekinist, trametinib, dru307

Tafinlar, dabrafenib, dru308

November 1, 2018 • Added coverage criteria for adjuvant use in early-stage, resectable melanoma, locally advanced or metastatic anaplastic thyroid cancer and new FDA-approved indications

Keytruda, pembrolizumab, dru367 November 1, 2018 • Added coverage criteria for two new FDA-approved indications:

- Recurrent or metastatic cervical cancer

- Primary mediastinal B-cell lymphoma (PMBCL)

Opdivo, nivolumab, dru390 November 1, 2018 • Added coverage criteria for metastatic small cell lung cancer (SCLC), a new FDA-approved indication

Tagrisso, osimertinib, dru441 November 1, 2018 • Added coverage criteria for first-line use as monotherapy when documentation of an EGFR exon 19 deletion or exon 21 (L858R) substitution mutation is provided, a new FDA-approved indication

Triptan products, dru475 November 1, 2018 • Eletriptan (generic Replax) no longer requires pre-authorization for quantities of less than 12 tablets per month

• Other products in dru475 continue to require pre-authorization

Blincyto, blinatumomab, dru388 December 1, 2018 • Added coverage criteria for minimum residual disease, a new FDA-approved indication

Darzalex, daratumumab, dru452 December 1, 2018 • Added coverage criteria for front-line use in multiple myeloma, a new FDA-approved indication

ARCHIVED MEDICATION POLICIES EFFECTIVE DATE DESCRIPTIONEntresto, sacubitril-valsartan, dru414 October 1, 2018 • Entresto no longer requires pre-authorization

Rituxan, rituximab containing products, dru214

November 1, 2018 • Rituxan IV no longer requires pre-authorization

• Rituxan Hycela continues to require pre-authorization under dru559

Medication policy updates, continued from page 9

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Use non-opioids as first-line treatment for chronic painThere is lack of information on the clinical effectiveness of opioids in treating chronic, noncancer pain; this has resulted in wide variability in prescribing practices across the United States. An estimated 11.5 million adults were prescribed long-term opioid therapy for chronic pain (pain lasting longer than three months) in 2005.

Treatment of chronic pain is dependent on the type of pain and must be individualized to the patient. The evidence-based guidelines from national and international medical societies listed below can help you evaluate when to prescribe opioids for chronic pain conditions. Some of the key findings supported in these guidelines are:

• Opioids are not recommended as first-line therapy for chronic pain. For all conditions evaluated, opioids were only recommended after patients had tried and failed first- or second-line therapy or were refractory/have contraindications to first- and/or second-line treatment options. Harms of opioid therapy outweigh the benefits despite the evidence showing moderate benefit in pain reduction for neuropathic and low back pain.

• Opioid treatment lacks outcomes and long-term benefits. Long-term outcomes, including improvement in daily physical and emotional function, quality of life, ability to return to work and reduction in work disability, and global improvement scores are lacking for opioids in treatment of chronic pain.

• Harms outweigh benefits when using opioids as first-line therapy. Long-term opioid therapy is associated with an increased risk of opioid abuse and dependence, as well as fatal and nonfatal overdose.

• Pharmacologic treatment involves a variety of therapies and are specific to the diagnosis. The following table summarizes commonly recommended treatments for various types of chronic pain:

CONDITION GUIDELINE SUMMARYNeuropathic pain Special Interest

Group on Neuropathic Pain (NeuSPIG) 2015

Strong Grading of Recommendations Assessment, Development and Evaluation (GRADE) recommendation for first-line treatment with the following:

• Serotonin and norepinephrine reuptake inhibitors (SNRIs) (duloxetine/venlafaxine)

• Tricyclic antidepressants (TCAs)

• pregabalin

• gabapentin

• gabapentin ER/enacarbil

Fibromyalgia European League Against Rheumatism (EULAR) Guidelines 2017

• “Strong for” GRADE recommendation for physical activity

• “Weak for” GRADE recommendation for treatment with the following:

- amitriptyline (at low dose)

- cyclobenzaprine

- duloxetine

- milnacipran

- pregabalin

- tramadol

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CONDITION GUIDELINE SUMMARYTrigeminal neuralgia National Institute

for Health and Care Excellence (NICE) 2017

• First-line: carbamazepine

• Referral to an expert if carbamazepine doesn’t work

• oxcarbazepine and lacosamide lack good quality evidence

Chronic low back pain American College of Physicians (ACP) 2017

Weak GRADE recommendation for the following:

• First-line: nonsteroidal anti-inflammatory drug

• Second-line: tramadol or duloxetine

• Third-line: opioids

Chronic noncancer pain Center for Disease Control (CDC) 2016

• Nonpharmacological and nonopioid therapy is preferred for chronic pain

• Opioid therapy should only be considered if benefits outweigh the risks

• Opioids should be started at the lowest effective dose

• Immediate release (IR) should be used first before extended-release (ER) or long-acting (LA) opioids for chronic pain

A recent study published in the Journal of the American Medical Association (JAMA) evaluated patients with moderate to severe chronic back pain or lower extremity (hip or knee) osteoarthritis pain. The study compared patients who received opioid intensive treatment to opioid avoidant treatment. Study results showed similar pain-related function improvement and physical and mental quality of life scores. Use of intensive opioids was associated with higher rates of adverse outcomes (0.9; CI 0.3 to 1.5; p-value: 0.03).

Findings indicate that opioids do not offer superior pain-related function and result in a higher rate of medication-related events. Alternative pharmacological and nonpharmacological therapy should be considered before prescribing opioids for chronic pain. ■

Use non-opioids as first-line treatment, continued from page 11

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Collaborative care helps patients with behavioral health needs Primary care providers (PCPs) often care for patients who need behavioral health services. There are instances when PCPs may lack the clinical expertise and/or resources to provide effective behavioral health treatment within their practice setting. In addition, behavioral health providers may not be available within the practice to help support the PCP.

Many patients with mild to moderate behavioral health needs can be treated in a rapid and effective manner within the primary care setting. The Collaborative Care Model (CoCM) is a solution that meets this need by integrating the delivery of behavioral health treatment in the primary care practice. Using the CoCM model, a behavioral health care manager and psychiatric consultant work closely with the PCP to provide the necessary care management and clinical guidance recommendations. This allows the patient to receive appropriate behavioral health treatment without the need for referral outside of the primary care practice.

The CoCM consists of three core elements:

1. Care coordination and management provided by a behavioral health care manager or psychiatric consultant working closely with the PCP

2. Regular treatment and monitoring with standardized outcome measures/rating scales based on targeted quality outcomes

3. Regular caseload review with a psychiatrist and/or psychiatric-trained nurse practitioner/physician assistant whose primary responsibility is to make treatment recommendations

Successful implementation of the CoCM allows the primary care practice to submit claims for these services using the collaborative care CPT codes:

• 99492: Initial collaborative care management, 70 minutes, first month

• 99493: Subsequent collaborative care management, 60 minutes, subsequent months

• 99494: Subsequent 30 minutes increments of collaborative care billed in conjunction with 99492 and 99493

Billing with the codes by the PCP (with appropriate documentation) should provide adequate revenue to cover the expense of the embedded behavioral health team members.

The CoCM has demonstrated improvement of access to effective behavioral health treatment, as well as clinical outcomes, while increasing patient satisfaction. More information about the CoCM is available at: aims.uw.edu/collaborative-care. ■

NDC required on medical drug claimsEffective March 1, 2019, we will require National Drug Codes (NDCs) on all claim lines billing a medical drug where the HCPCS code starts with the letter “J” (commonly known as J codes). Any claims billed with a J code that do not have the NDC information will be rejected with a request to complete the additional claim fields. This requirement applies to drugs administered in an office by a physician or other health care professional or administered in an outpatient facility setting. If you’re not already including the NDC for medical drugs with a HCPCS J code, please begin doing so now before the requirement goes into effect.

The 11-digit NDC number must be accompanied by the basis of measurement (UN, ML, etc.) and the NDC units. The claim should also include the corresponding HCPCS and CPT codes and the units administered for each code.

Learn more about submitting NDC claims on our website: Claims and Payment>Claims Submission> Medication Claims. ■

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Advance care planning conversation videosAs a part of our ongoing effort to inspire, educate and empower the public and providers, we continue to encourage you to begin or resume advance care planning (ACP) conversations with all of your patients.

We offer two short videos to help you start the conversation process with your patients:

1. Starting an ACP Conversation—For Providers, Part 1: Questions

2. Starting an ACP Conversation—For Providers, Part 2: Broaching the Topic of ACP

Links to the videos and more information about our Personalized Care Support program are available on our website: Programs>Personalized Care Support. ■

ASAM guidelines for substance use treatmentWe are committed to ensuring members have access to and receive quality substance abuse treatment, including for opioids, at the right time in the right setting. To support this objective, we are adopting American Society of Addiction Medicine (ASAM) criteria effective January 1, 2019.

We believe adopting the ASAM criteria will make it easier for you to understand the levels of care definitions and the criteria used to make coverage determinations. ■

2019 code changes 2019 brings code changes for many services and supplies. Please remember to review your 2019 CPT, HCPCS and CDT coding publications for codes that have been added, deleted or changed and to use only valid codes.

You can purchase the:

• CDT manual by calling the American Dental Association at 1 (800) 947-4746 or online at ebusiness.ada.org

• CPT and HCPCS manuals through your preferred vendor or online through the American Medical Association (AMA) at commerce.ama-assn.org/store

2019 ABA CPT code changesEffective January 1, 2019, eight Category I and two modified Category III CPT codes will replace the Category III (temporary) CPT codes for adaptive behavior assessment (ABA) and treatment.

The new codes are the result of an application to the American Medical Association (AMA) CPT Editorial Panel that was developed by the Steering Committee for the ABA Services Work Group, which included representatives of the Association of Professional Behavior Analysts, Association for Behavior Analysis International, Behavior Analyst Certification Board and Autism Speaks, as well as CPT consultants.

Please begin using the new codes for dates of service on and after January 1, 2019. View the crosswalk from the old to the new codes on our website: Claims and Payment>Claims Submission> Other Billing Information or at bacb.com/wp-content/uploads/CPT_Codes_Crosswalk_.pdf. ■

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BridgeSpan implements population health programThis month, we are implementing a population health management (PHM) strategy designed to align the health care needs of our members with programs and services that can best support them. Our strategy places the member at the center—reflecting our ongoing transformative work to create a health care system that is person-focused in design and throughout the member/patient experience.

We evaluated the needs of our member population using multiple sources of member health care data. Based on our evaluation, we divided the continuum of care into five segments:

• Healthy members

• Members with emerging risk and managed conditions

• Members experiencing multiple chronic conditions

• Members facing major illness

• Members diagnosed and living with serious illness

We are continuing our chronic condition management programs to support members diagnosed with chronic obstructive pulmonary disease (COPD), asthma, diabetes, congestive heart failure (CHF) and coronary artery disease (CAD). We are also continuing to offer our clinical support programs, interventions and services to help meet our members’ needs across all population segments. Examples include:

• Palliative care

• Maternity support

• Hospital readmission prevention

• Behavioral health care management

• Preventive and clinical care reminders

A component of our new strategy features a mailed outreach to members newly diagnosed with prevalent conditions—such as cancer, depression and neck and back pain—to offer support, resources and assistance, if desired. As a reminder, whenever one of your patients would benefit from the assistance of a [plan name] case manager, please refer them to us using the Care Management Referral Request form. The form is available on our website: Library>Forms.

Our PHM strategy includes case management support to address the complex and unique needs of members with major illness episodes or severe illness conditions.

Patient safety is an important aspect of every program across the continuum, especially during care transitions. Our case managers recommend and refer members to local community service organizations based on members’ individual needs to augment provider and health plan resources, when appropriate. In addition, we partner with providers in value-based contracts to help them meet population health goals by sharing data, information and support to inform patient management. Related: See Advance care planning conversation videos on page 14. ■

Coding Toolkit updatesOur Coding Toolkit lists our clinical edits and includes information specific to Medicare’s National Correct Coding Initiative (NCCI). These coding requirements are updated on a monthly basis in the Clinical Edits by Code List in the Coding Toolkit.

We have enlisted the support of Change Healthcare and their claims management solution for ClaimsXten bundling edits. Additional ClaimsXten correct coding edits will continue to be implemented on an ongoing basis. The Coding Toolkit provides a high-level description of the ClaimsXten-sourced edits.

Our Correct Code Editor (CCE), also located in the Coding Toolkit, has additional CPT and HCPCS code pair edits that we have identified and are used as a supplement to Medicare’s NCCI. This supplemental list of code groupings in the CCE is updated quarterly in January, April, July and October. We reserve the right to take up to 30 calendar days to update our systems with CCE updates, CMS-sourced changes and Change Healthcare-sourced changes. Claims received before our systems are updated will not be adjusted. The Coding Toolkit is available on our website: Claims and Payment>Claims Submission> Coding Toolkit.

We perform retrospective review on claims that should be processed against our clinical edits. We follow our existing notification and recoupment process when we have overpaid based upon claims processing discrepancies and incorrect application of the clinical edits. View the notification and recoupment process on our website: Claims and Payment> Receiving Payment>Overpayment Recovery.

Please remember to review your current coding publications for codes that have been added, deleted or changed and to use only valid codes. ■

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Please take time now to review the information below about CPT Category II codes (CPT II codes) and use them as applicable when submitting claims.

Who creates, reviews and manages CPT II codes? The Performance Measures Advisory Group (PMAG) adopts and reviews CPT II codes. PMAG consists of experts in performance measurement from organizations, including the AMA, National Committee for Quality Assurance (NCQA), CMS, Agency for Healthcare Research and Quality (AHRQ) and Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

What are CPT II codes? CPT II codes are tracking codes that relay performance measurement information and health outcomes. This information can be used to close care gaps and report performance on specific Healthcare Effectiveness Data and Information Set (HEDIS®) measures.

Where can I find a listing of CPT II codes and the description? CPT II codes and descriptions are available on the AMA website at ama-assn.org/practice-management/ category-ii-codes.

Why should I use CPT II codes? Using CPT II codes helps minimize the burden experienced from chart requests and enables the monitoring of internal quality performance.

How should CPT II codes be billed? CPT II codes are billed in the procedure code field, like CPT Category I codes. CPT II codes describe clinical components usually included in evaluation and management or clinical services and are not associated with any relative value. Therefore, CPT II codes are billed with a $0.00 billable charge amount.

Here are a few examples that can help reduce the number of medical record reviews:

MEASURE DESCRIPTION CPT II CODE(S)Comprehensive diabetes care—A1c control

Routine monitoring of HbA1c level 3044F–3046F

Comprehensive diabetes care—neuropathy monitoring

Screening or monitoring for the presence or progress of nephropathy

3060F–3062F, 3066F, 4010F

Comprehensive diabetes care—eye exam

Retinal eye exam (must be performed by an eye care specialist)

2022F, 2024F, 2026F, 3072F

Comprehensive diabetes care—blood pressure control

Both systolic and diastolic measurements must be submitted

• Systolic: 3074F, 3075F, 3077F

• Diastolic: 3078F–3080F

Controlling blood pressure Both systolic and diastolic measurements must be submitted

• Systolic: 3074F, 3075F, 3077F

• Diastolic: 3078F–3080F

Medication reconciliation post-discharge

Medication reconciliation must be completed within 31 days of discharge from inpatient setting

1111F

Prenatal and postpartum care Evidence of visits during the prenatal and postpartum periods

0500F–0503F

You can review the Quality Measures Guide on our website for a complete list of the codes for each measure: Programs>Cost and Quality>Quality Program>HEDIS Reporting. ■

CPT Category II codes explained

PROVIDER NEWS

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Paula Russell: Managing editor, designer and writer

Sheryl Johnson: Writer

Cindy Price: Writer

Jayne Drinan: Writer

Janice Farley: Writer

Referring to in-network providers As a reminder, except in cases of an emergency, you must refer members to participating in-network medical and dental providers.

Referring members to in-network providers, including laboratories, is critical for our exclusive provider organization (EPO) members. EPO members in Idaho have limited out-of-network coverage and are responsible for 90 percent of out-of-network costs. In Oregon, Utah and Washington, EPO members are responsible for 100 percent of out-of-network costs.

Making referrals to in-network providers and facilities helps your patients make more informed choices about how they spend their health care dollars. By staying in-network, your patients will:

• Minimize their out-of-pocket expenses

• Receive the highest level of medical and dental benefits

• Ensure that they have convenient access to quality services

Referrals to non-participating providers should only be made after notifying the member in writing that services may not be covered or may result in higher out-of-pocket costs.

Use the Find a Doctor tool on our website to locate in-network providers. Locate providers by name, location or specialty type. ■

We're here for youOur Provider Relations and Provider Contact Center teams are dedicated to helping you. Visit the Contact Us section of our website for details.