Category: BCBS Empire NY

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

Posted in BCBS Empire NY, Training, Updates

BCBS (NY): Proper coding for INR In-home patient monitoring

Posted on by KR2Medical Billing

This following policy is part of BCBS (NY) administrative policy guidelines (07/01/2021)

This blog post is for providers that need to meet the INR (in-home) monitoring quality measure.

What you will learn?

  1. What is INR monitoring Quality measure?
  2. Proper coding for in-home INR monitoring
  3. Documentation requirements to meet the INR in home monitoring measure

What is INR (International normalized ratio)?:

International normalized ratio (INR) is blood-clotting test. It is a test used to measure how quickly your blood forms a clot, compared with normal clotting time.

Background:

International normalized ratio is part of the 2021 Quality Measure Set (Pharmacy Quality Alliance (PQA) measures.

The QRS measure set is comprised of clinical quality measures, including the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures and Pharmacy Quality Alliance (PQA) measures.

Previously, patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. However, currently there is a small, portable device that patients on warfarin, can now self-test with a finger prick drop of blood.

Is there a provider type restriction for this quality Measure?

No, there is not provider type restriction.

As a provider, which proper codes should I use for INR in-home patient monitoring?

Below please see the proper codes that providers should use for INR in-home patient monitoring.

Meeting INR monitoring Quality Measure:

Definition: The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.

INR quality measure requirements.

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Posted in BCBS Empire NY, Updates

Empire BCBS (NY) and SOMOS IPA Utilization Management

Posted on by KR2Medical Billing

Reminder that effective 10/01/2020- SOMOS IPA will assume the administrative functions for several Empire HealthPlus Plans:

Medicaid Managed Care (MMC)

Health and Recovery Plan (HARP)

Child Health Plus (CHPlus)

Essential Plan programs

SAMPLE EMPIRE SOMOS IPA CARDS:

FRONT OF THE CARD
BACK OF THE CARD

Contacting SOMOS for patient Eligibility, benefits and authorizations: OON and IN providers

Credentialing process:
• SOMOS IPA providers: SOMOS will handle all credentialing for its participating providers. This
includes the submission of any demographic changes or terminations.
• Non-SOMOS IPA providers: Providers who are not contracted with the IPA must continue to follow the Empire processes.

For more information please click here.

Posted in BCBS Empire NY, Updates

Empire BCBS (NY) Voluntary Cancer Care Quality Program (changes 07/01/2021)

Posted on by KR2Medical Billing

According to Empire BCBS NY: in order to align the program intention to support member care coordination and to ensure compliance with regulatory requirements surrounding the program, Empire BCBS is amending the approach for enhanced reimbursement that accompanies selection of ‘on-pathway’ chemotherapy drug regimens as part of the AIM Oncology/Cancer Care Quality Program. 

Starting 07/01/2021, authorization process for on-pathway drug regimens as part of the AIM Oncology/Cancer Care Quality Program chemotherapy, will be adjusted to reflect specific regiments and enhanced reimbursements, for the medical oncologists.

Which regiments are affected?

Only select oral and hormonal agents for which a monthly in-office visit may not be required.

For the complete list please click here.

Which Authorizations will be affected?

This will impact all authorizations submitted through the AIM authorization process on or after July 1, 2021, regardless of planned treatment dates. 

Which HCPCS codes will be affected?

Billable S-codes for treatment planning and care coordination management for cancer.

How will be the payment affected for the billable S-codes?

The optional enhanced reimbursement award will be reduced from a monthly award during each month of treatment to a single award to accompany treatment initiation (S0353)

AIM/Empire will continuously review the regimen library to ensure S-code award levels remain consistent with program goals regarding care coordination support. 

If you have any questions, please Contact your Empire network representative or your oncology provider engagement liaison for more information.

Click here for the full updated Cancer Treatment Planning and Care Coordination policy (Commercial Plans)