Changes to Anthem Blue Cross reimbursement policies and claims software May 15, 2015 Managed Care Billing/Coding, Insurance, Managed Care, Anthem Blue Cross 0 Anthem Blue Cross recently notified physicians of upcoming changes to the insurer’s reimbursement policies and claims editing software, called ClaimsXten. The changes will go into effect on July 1, 2015. Because of these changes, physicians may notice a difference in how certain codes and code pairs are adjudicated. Along with the notice, Anthem provided a comprehensive grid outlining the new, revised and existing reimbursement policies and claims editing rules as well as copies of Anthem’s reimbursement policies. The changes include additions to the types of service Anthem will consider bundled with another procedure and thus will be ineligible for separate reimbursement (Policy CA – 0008). Anthem has also added to the list of CPT codes that will have a frequency edit (Policy CA – 0016), thus setting a limit on the number of units or number of times a code is eligible for reimbursement on a single date of service. A new frequency edit of note is a limit on the preparation of allergen immunotherapy of 120 doses per 365 days. Anthem has clarified to the California Medical Association (CMA) that it will consider payment for more than 120 doses per 365 days if there is a medical reason, and if the additional doses are actually received by the patient and not discarded as pharmaceutical waste. There are also new policies on cancer treatment planning (Policy CA – 0043) and documentation guidelines on psychotherapy services (Policy CA – 0047). While Anthem’s grid outlining policy changes indicates that the Multiple and Bilateral Surgery Processing policy (Policy CA – 0010) is existing, inferring there are no changes, CMA has identified that while the policy is not new, three new CPT codes (43233, 43266 and 43270) were added to the list of affected codes. These codes were newly added to the CPT manual in 2014. The policy states that when billing multiple esophagogastroduodenoscopy codes, practices will be paid 100 percent of the fee schedule for the primary procedure and 25 percent for subsequent procedures. At CMA’s suggestion, Anthem will update the policy grid to indicate this policy is “revised.” The most significant change, however, is a modification to Anthem’s policy on evaluation and management (E/M) services billed on the same day as a preventive exam (Policy CA – 0026). Effective July 1, 2015, when physicians bill a preventive visit on the same day as a problem-oriented E/M visit, Anthem will only reimburse the problem-oriented E/M visit at 50 percent of the physician’s contracted rate. While some other payors have similar policies, this will reflect a change in reimbursement for affected Anthem claims. To address this change, practices have the option of advising patients that a separate appointment is required to address the problem-focused issue. However, it will be important for practices to manage patient expectations. When the preventive services appointments are scheduled, staff should inquire with patients about whether they wish to discuss any other health issues with the physician and, if so, advise that a separate appointment will be required due to the plan/insurer’s policy. The practice can then schedule the problem-oriented visit first and schedule the preventive service for a later date. Even if the patient indicates he/she has no other health issues to discuss with the physician, the scheduler should advise the patient that if other health issues arise, another visit may be required. Physicians are encouraged to review all of the claims editing changes as well as the corresponding detailed payment policies to understand how the changes will affect their individual practices. Physicians can also access this information via the Blue Cross ProviderAccess website (log in, then select “Reimbursement Policies and McKesson ClaimsXten Rules” under the “What’s New” section). Questions about any of the claims editing rules or payment policies can be directed to the Blue Cross Provider Care Department at (800) 677-6669. Contact: CMA reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org. Comments are closed.
