Private Payer Round-Up, May 2013

In case you missed these — here is a roundup of useful items from health care payment plans’ newsletters and updates, compiled by TMA’s reimbursement specialists. If you have questions about billing and coding or payer policies, contact the specialists at for help, or call TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems.

Aexcel Ranking Letters Coming 

TMA’s Payment Advocacy Department has learned Aetna will begin sending physicians letters informing them of their ranking in its Aexcel network in early June. The rankings take effect Jan. 1, 2014. Read TMA’s Action article for more information, including how to appeal your ranking.


Preferred specialty pharmacies for hemophilia (factor) drugs — If Prime Therapeutics is the pharmacy benefit manager for your patient — as it is for most Blue Cross and Blue Shield of Texas (BCBSTX) members — note that BCBSTX contracts with the following specialty pharmacies for hemophilia (factor) products: 

  • Accredo Health Group, Inc. at (800) 800-6606. Fax referral information to (800) 330-0756.
  • Prime Specialty Pharmacy at (877) 627-MEDS (6337). Fax referral information to (877) 828-3939.

Specialty medications such as hemophilia (factor) products used to treat complex health conditions often have unique storage or shipment requirements and usually are not stocked at retail pharmacies. Acquiring hemophilia drugs through these specialty pharmacies will help to ensure your patient gets maximum benefit coverage.

BCBSTX members who do not have Prime Therapeutics assigned as their pharmacy benefits manager may be required to use a preferred specialty pharmacy different from those listed above. Call the number on the member’s ID card to verify coverage or for clarification on the member’s benefits.


Surgical procedures performed in the physician’s office — For surgical procedures performed in a nonfacility setting such as a physician’s office, the BCBSTX payment for its members covers the services, equipment, and some of the supplies needed to perform the procedure. To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, use Clear Claim ConnectionTM (C3), a free, online reference tool that mirrors the logic behind BCBSTX’s code-auditing software. Refer to the BCBSTX provider website for information on gaining access to C3.

Note that the payment includes surgical equipment that an outside surgical equipment or durable medical equipment (DME) vendor may own or supply. BCBSTX will deny claims from the surgical equipment or DME vendor because the global physician payment includes staff and equipment.

AIM RQI/preauthorization reminder — Remember that you have to contact AIM Specialty Health first to obtain a Radiology Quality Initiative (RQI) number (for BlueChoice members) or a preauthorization (for HMO Blue Texas members) when ordering or scheduling the following outpatient, nonemergency diagnostic imaging services performed in a physician’s office, the outpatient department of a hospital, or a freestanding imaging center:

  • CT/CTA,
  • MRI/MRA,
  • SPECT/nuclear cardiology study, or
  • PET scan.

Log in to AIM’s provider portal and complete the online questionnaire that identifies the reasons for requesting the exam. If criteria are met, you will receive a RQI number or preauthorization as applicable. If not, or if additional information is needed, the case will be automatically transferred for further clinical evaluation and an AIM nurse will follow up with your office. Note the following:

  • AIM’s provider portal uses the term “Order” rather than “Preauth” or “RQI.”
  • Facilities cannot obtain an RQI number or preauthorization from AIM on behalf of the ordering physician.
  • The RQI and preauthorization program does not apply to Medicare enrollees with BCBSTX Medicare supplement coverage. Medicare enrollees with BCBSTX commercial preferred provider organization/point-of-service or HMO coverage are included in the program.

National Drug Code reminders — Be sure to include National Drug Codes (NDCs) and related data when billing for drugs under the medical benefit to help ensure accurate payment and better management of drug costs.  Electronic claim submitters should confirm with your software vendor that your practice management system accepts and transmits the NDC data fields appropriately. If you use a billing service or clearinghouse to submit electronic claims on your behalf, check with it to ensure NDC data is not manipulated or dropped inadvertently.

Include the following related information on BCBSTX claims: Include the following related information on BCBSTX claims: the applicable HCPCS or CPT code; number of HCPCS/CPT units; NDC qualifier (N4); NDC unit of measure (unit [UN], milliliter [ML], gram [GR], international unit [F2]); number of NDC units (up to three decimal places); and your billable charge/price per unit. For more information, see the guidelines (PDF) and FAQs (PDF) on the BCBSTX provider website

 Source: Blue Review, Issue 5, 2013 (PDF)


National Drug Code reminders  — Aetna notes the NDC submitted must be the actual NDC number on the medication package or container. On claims, you must include the appropriate HCPCS code and units. For unclassified J codes and other HCPCS/CPT codes that do not describe the dosage per HCPCS/CPT code unit, include the NDC code, NDC units, and HIPAA standard NDC unit of measure qualifier. The NDC units and NDC units qualifier must represent the dosage for the charge. For more information, refer to the NDC Billing Guide on the Pharmacy section of Aetna’s secure provider website.

Certain Medicare Advantage plans cover annual physicals — Although Aetna recently said its Medicare Advantage (MA) plans now cover an annual wellness visit and no longer cover annual routine physical exams, Aetna will cover the annual routine physical exam for some plan sponsors that elected to offer coverage for these exams under their group MA plan in 2013. Among these employers are Aetna, Inc.; Barnes; Cabot Corp.; Dow Chemical; Frontier Communications; GE; IBM; Phoenix Companies; and SERS. 

 Applicable CPT codesThe CPT codes for routine physicals are 99381-99397 and 99401-99404, or 99201-99205 and 99211-99215 with primary diagnosis of preventive. The preventive diagnosis codes are V03.0-V03.9; V04.0-V04.89; V05.0-V05.9; V06.0-V06.9; and V70.5.

Check patient eligibilityFind out if an Aetna MA plan member has coverage for annual routine physical exams, and check eligibility and cost sharing information before you see them, either through Aetna’s secure provider website or by calling (800) 624-0756.

 Aetna will automatically reprocess any denied claims for an annual routine physical exam if the exam meets both of these criteria:

  • Performed on or after Jan. 1, 2013, and
  • Performed for a patient enrolled in an Aetna group MA plan that includes coverage for the exam. 

Use only participating laboratories — Aetna reports that some physician offices may have been asked by LabCorp to sign laboratory services agreements. However, LabCorp and its affiliates are not contracted with Aetna and are nonparticipating. Remember, you can help your patients save money by referring them to in-network labs; referral to a nonparticipating lab means they will have to pay more out of pocket.

For a list of in-network labs, use the Advanced Search tab in Aetna’s DocFind online provider directory.  In the “Search for” menu, select “Labs-including Quest Diagnostics.” For “Type,” select “National Lab Listing.”

Proper mid-level practitioner billing requirements — Under Aetna requirements and following the Centers for Medicare and Medicaid Services’ (CMS’) guidelines for incident-to and split/shared services, you must bill these services as follows: 

  • Submit claims with the supervising physician’s name as the servicing provider. You should also use the SA modifier.
  • For claims that are not incident-to or split/shared services, you must list the midlevel practitioner’s name as the servicing provider when filing claims for services he or she provides.

Confirm that your midlevels are listed as participating Aetna’s network by calling the Provider Service Center at (800) 624-0756 (HMO-based plans and Medicare Advantage plans) or (888) 632-3862 (all other plans).

If your midlevel practitioners are not listed as participating in our network, visit Aetna’s Health Care Professionals page for guidance. If credentialing is not required, you can load the midlevel practitioner directly by following directions on the link. The midlevels practitioners appear asparticipating in DocFind.

Note: Aetna defines midlevel practitioners as nurse practitioners (NPs), physician assistants, nurse midwives, and clinical nurse specialists/registered nurses (RNs). Clinical nurse specialists may be NPs or RNs. If an RN is providing services as a clinical nurse specialist, the billing requirements will apply.

See also:

 Additional reminders and updates 

  • Global surgical days — Effective for dates of service on or after Sept. 1, 2013, Aetna’s global surgery periods will be applied to codes listed on the CMS physician fee schedule with a value of YYY. Refer to Claim Payment Policy, Evaluation and Management (E&M) Services during the Global Surgery Period on Aetna’s secure provider website.
  • Drug frequency — Aetna’s maximum dosage limit for medications (including injectable drugs) is based on Food and Drug Administration-approved guidelines and/or the manufacturers’ recommended frequency.
  • Immunizations and injectable drugs —Aetna quarterly adjusts drug code and immunization payment for all its plans in Texas. The injectable payment is based on that of CMS with market relativities. For codes not valued by CMS and for immunizations, Aetna’s source for average wholesale price with market relativities is R.J. Health. You can access these quarterly rates on Aetna’s secure provider website; select “Claims” then “Fee Schedules.” Or call the Provider Service Center at (800) 624-0756 (HMO-based plans and Medicare Advantage plans) or (888) 632-3862 (all other plans).
  • Precertification for lumbar laminectomy and laminotomy proceduresWhen seeking precertification for inpatient and outpatient cervical, thoracic, or lumbar laminectomy and laminotomy procedures, be sure to submit supporting clinical information well in advance of the procedure’s scheduled date. These procedures require medical review, and Aetna says it needs at least seven days when the procedure is scheduled well ahead of time. See Clinical Policy Bulletins16, 591, and 743.
  • Pap smears — Aetna’s Cervical Cancer Screening and Diagnosis clinical policy now allows Pap smear screenings only for female members who have reached age 21 (effective April 23, 2013). In Texas, this applies only to self-funded insurance products (for fully insured members, Texas mandates coverage for screenings starting at age 18.) Also, Aetna continues to allow pap smear screenings for females under age 21 who have a diagnosis of cervical dysplasia, cervical cancer, DES exposure, or HIV infection, or are classified as immuno-compromised women. Pap smear screenings are considered experimental and investigational for a woman under age 21 because it was found the practice causes more medical harm than benefit Aetna’s policy change aligns with those of the U.S. Preventive Services Task Force American College of Gynecologists, and other leading medical societies that recently raised their guidelines to age 21. Aetna’s policy change does not apply to members enrolled in Medicare products.

Source: Aetna OfficeLink Updates (PDF), June 2013


Sequestration reductions — In line with the Centers for Medicare & Medicaid Services’ (CMS’) 2-percent payment drop because of the federal budget sequester, Humana has applied the same reduction to network and non-network provider payments based on the Medicare payment methodology. This includes using a fee schedule based off Medicare’s fee schedule, percentage of Medicare Advantage premium, Medicare allowed amount, or other Medicare calculations (e.g., resource-based relative value scale). This reduction applies to all Medicare Advantage plans. You may not collect the 2-percent reduction from your Humana patients.

If you have questions, call Humana provider relations at a (800) - 626-2741, 8 am-5 pm CDT, Monday through Friday.

Document accurately to bill correctly for pressure ulcers — To accurately document a pressure ulcer in the patient’s medical record, you must identify the site of the ulcer, the stage, and laterality so you can bill with the correct ICD-9 codes. Remember these key points about the codes:

  • Two codes are required to report pressure ulcers:
      1. A code is assigned from the 707.00-707.09 series to report the site.
      2. A second-listed code is assigned from the 707.20-707.25 series to report the stage. The National Pressure Ulcer Advisory Panel classifies pressure ulcers according to severity from Stage I to Stage IV.
  • Use the codes in subcategory 707.2X to classify the stage of pressure ulcers only, not with any other type of ulcer.
  • Do not confuse code 707.25 for unstageable pressure ulcer with code 707.20 for unspecified stage of pressure ulcer. Assign code 707.25 when the stage of the pressure ulcer cannot be determined (for example, the ulcer is covered by eschar, a tissue graft, or a dressing) or for pressure ulcers documented as deep tissue injury but not documented as due to trauma.
  • Code bilateral pressure ulcers with the same stage and site with only one code for the site and one code for the stage.
  • Code bilateral pressure ulcers at the same site but with different stages with one code for the site and the appropriate codes for each stage.
  • Code multiple pressure ulcers at different sites and stages with the appropriate codes for each site and each stage.
  • If the documentation states a pressure ulcer is completely healed, do not assign a code.
  • If the documentation states a pressure ulcer is healing, assign appropriate codes based on the documentation in the record.
  • If a patient is admitted with a pressure ulcer in one stage that progresses to a higher stage, assign the code for the highest stage reported.

Note to coders: Be aware that diabetic foot ulcers have their own classification systems (e.g., Wagner or University of Texas classifications). Do not confuse foot ulcers documented with a stage with pressure ulcers. Code foot or heel ulcers as pressure ulcers only when the documentation clearly states they are pressure ulcers. If the documentation is not clear, coders should ask the physician for more details

Coding Examples 

Final Diagnostice Statement        ICD-9 Codes 
1.0 cm decubitus ulcer, sacral region       707.03, 707.20
Gangrenous pressure ulcer, right heel       707.07, 785.4, 707.20
Pressure ulcer coccyx, not staged since covered with dressing       707.03, 707.25
Stage I foot ulcer       707.15

  ICD-10 Sneak Peek 

Under ICD-10, coding pressure ulcers will no longer need a separate code for site and stage. A combination code will be available to report both conditions. Example: coding a pressure ulcer of the left elbow, stage II:

  • ICD-10-CM would report L89.022
  • ICD-9-CM would report 707.01 and 707.22

Clinical practice guidelines — Humana adopts clinical practice guidelines from national organizations generally accepted as experts in their fields. While following these Humana-approved guidelines does not guarantee coverage, it can help improve quality measures. The following guidelines are recent updates by their organizations:

New and revised medication and medical coverage policies — You can find information about Humana’s medical and medication coverage policies on by selecting Medical Coverage Policies under Critical Topics. Policies on the following topics are recent additions or revisions:

New medication policies:

  • Jetrea (ocriplasmin),
  • Cometriq (cabozantinib),
  • Gattex (teduglutide),
  • Vascepa (icosapent ethyl), and
  • Iclusig (ponatinib).

New medical policies:  

  • Defecography,
  • Ovarian Vein and/or Internal Iliac Vein Embolization, and
  • Whole Genome/Exome Sequencing and Genome-Wide Association Studies

Medical policies with significant revisions:

  • Allograft Transplantation of the Knee,
  • Artificial Intervertebral Disc Replacement,
  • Bariatric Surgery: Surgical Treatment for Severe Obesity,
  • Bone Growth Stimulators,
  • Cardiac Monitoring Devices,
  • Durable Medical Equipment (DME),
  • Genetic Testing and Genetic Counseling for Hereditary Cancer Syndromes,
  • Genetic Testing and Genetic Counseling for Marfan Syndrome and Related Conditions,
  • Glaucoma — Emerging Treatments,
  • Molecular Diagnostic Assays and Breath Testing for Transplant Rejection, and
  • Noninvasive Prenatal Screening for Chromosomal Abnormalities.

Doing business with Humana — Check out Humana’s Education on Demand webpage for quick audio PowerPoint presentations on topics about doing business with Humana. If your computer is not configured for streaming audio, you can listen to the presentations over the phone while viewing the slides on screen. Instructions are on the webpage.

Source: Humana’s YourPractice, April 2013

Published May 28, 2013 

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