Category: BCBS Empire NY

Find medical coding and medical billing guidance for BCBS Empire NY Plans

Posted in #reimbursement, BCBS Empire NY, NY Providers, Training

Anthem BCBS (NY providers): PA/NP reimbursement

Posted on by KR2Medical Billing

According to Anthem BCBS (NY) starting for any DOS 11/1/24- the PA/NP will be updated to align with CMS guidelines.

Please note the following services will be eligible to be performed by the PAs/NPs and reimbursement reduction will apply:

– Preventative care services

-Radiology services

Services that are not going to be reimbursed separately:

-Drugs

-Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS)

-Laboratory Services and Laboratory Screening Services

Billing: PA/NP has to bill with their own TIN and NPI number.

For the full policy please click here:https://www.anthembluecross.com/provider/policies/reimbursement/

CMS payment for NP/PA services:

-NP services: 85% of Physician Fee for outside of hospital setting or SNF, or 80% of lesser billed charge

-NP services : incident to services done by auxiliary personnel outside hospital or SNF setting – 85% of Physician Fee Schedule

CMS link: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/advanced-practice-registered-nurses-aprns

-PA services: 85% of PFS- physician fee schedule.

CMS link: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-nonphysician-practitioners/physician-assistants-pas

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Posted in #reimbursement, BCBS (Various States), BCBS Empire NY, Cinga Insurance, EmblemHealth NY, HEDIS Measures, NY Providers, Training

HEDIS Measure: Immunizations for Adolescent

Posted on by KR2Medical Billing

This measure represents the percentage of children who turned 13 years old and received the following immunizations before their 13th birthday.

  • One dose of meningococcal vaccine
  • One tetanus, diphtheria toxoids and one acellular pertussis vaccine (Tdap): and
  • Completed the human papillomavirus (HPV) series.*

*HPV requires 2 shots, at least 146 days apart.

Meningococcal recombinant (serogroup B) (MenB) vaccines- DO NOT COUNT towards the HEDIS measure.

For Meningococcal Serogroups A, C, W, Y:

  • At least one meningococcal serogroups A, C, W, Y vaccine, with a date of service on or between the member’s eleventh and 13th birthdays
  • Anaphylaxis due to the meningococcal vaccine any time on or before the member’s 13th birthday meets criteria

For Tdap: generic documentation (Tdap/Td) can be counted towards this HEDIS measure.

  • At least one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, with a date of service on or between the member’s tenth and 13th birthdays.
  • If patient has anaphylaxis due to Tdap vaccine during or before pt turns 13 years old
  • Encephalitis due to the tetanus, diphtheria, or pertussis vaccine

For HPV:

  • At least two HPV vaccines on or between the member’s ninth and 13th birthdays and with dates of service at least 146 days apart
  • At least 3 HPV vaccines – w/ different DOS before or on the date when patient turns 13 years of age
  • Anaphylaxis due to the HPV vaccine any time on or before the member’s 13th birthday meets criteria

Accepted documentation:

  • A note with the specific antigen/vaccine and the date of administration of the vaccine
  • A certificate of immunization prepared by an authorized health care provider or agency with information of each vaccine and their administration dates

Not accepted documentation:

A note that says the member is up to date and does not have the actual vaccines listed w/ administration dates

Via Anthem (NY) provider news.

PROVIDERS-some things you can do in your practice in order to meet this measure:

  • Have standing orders for adolescent vaccines- the visit can be performed by a Nurse
  • Use appointment reminders to schedule vaccine appointments
  • For HPV  vaccines make sure to schedule a f/u appt for the next dosage.
  • Educate parents on the importance of the vaccines and their on time administration.

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Posted in #reimbursement, BCBS Empire NY, NY Providers, Updates

Empire BCBS NY: Pharmacy Reimbursement Policy update 1/1/24

Posted on by KR2Medical Billing

According to the announcement by Empire BCBS for the state of NY- the payer added a new INFORMATIONAL modifier to represent the unused drug when the provider uses a single vial of medication/biologic. This policy applies to commercial Plan types.

Reimbursement Policy Number: C-11031. https://www.empireblue.com/docs/public/inline/C-18001_NY.pdf

Although the effective date of the policy is 6/17/23 the policy will only apply to the drugs/biologics that are administered to the member for DOS 1/1/24 and thereafter

JW modifier is not permitted when the actual dose of a covered drug/biologic administered from a single dose vial is less than the billing unit, as indicated in the HCPCS code description.

When administering medication/biologic, the provider needs to be conscious of what amount of medication the patient needs for their treatment. For example, if the provider requires 20 units and the medication/biologic drug comes in a 10 or 50 mil vial, then the provider should use the 2 10 mil vials to administer the needed dosage instead of using the 50 mil vial and appending the JW modifier to the unused portion of the medication/biologics.

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