Posted in BCBS (Various States), NY Providers, Training, Updates

HEDIS Measure: Update Colorectal Cancer Screening for 2022

Are you a primary care physician and is reporting HEDIS measures? Then this following blog post is for you.


In this blog post we will discuss the changes/updates that NCQA just released for HEDIS Colorectal Cancer Screening Measure.

Measure Description: Measures the percentage of members 45 to 75 years of age who had appropriate screening for rectal cancer. The Medicaid product was added to the administrative data collection method for this measure and the age range was changed to 45 to 75 years of age.

In order to meet this measure your patients need to fall in ANY of the following criteria:

  • Fecal occult blood test during the measurement year
  • Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year
  • Colonoscopy during the measurement year or the nine years prior to the measurement year
  • CT colonography during the measurement year or the four years prior to the measurement year
  • Stool DNA (sDNA) with FIT test during the measurement year or the two years prior to the measurement year

If you would like to report this measure via Electronic Clinical Data Reporting system you will need to select: Colorectal Cancer Screening (COL-E).


Reminder: please make sure to document all of needed information in the patient medical records.


#HEDIS #Cancer #primarycare #physicians #NCQA


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Posted in BCBS Empire NY, NY Providers, Payers and CPT reinbursement, Pharmacy (Various Insurance Payers), Training, Updates

BCBS Empire NY Medicaid: Reimbursement for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Counseling program

If you are a pediatrician that provides vaccination counseling for patients under 18 years of age and younger then this blog post is for you!

The following is a clarification on the proper coding and billing for or provider reimbursement for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.


This reimbursement policy applies to Medicaid members (Empire BCBS).

Note: Vaccine counseling visits align with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)


The following is the correct CPT code with the ICD-10 code that the providers would use in order to get proper reimbursement.

 CPT® codeFeeNotes
Claims basedCPT 99401DX: Z71.85$12.50A provider submitting professional claims should bill Current Procedure Terminology (CPT) code 99401 for preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required and recommended for ages 18 years or younger.
via Empire BCBS Medicaid Updates

Documentation requirements: In order to get paid for the above mentioned code, the providers need to document the following in either the medical record or a pharmacy record.

  • CPT 99402: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure).
  • Providers should bill CPT 99402 with ICD-10 code Z71.85.
  • Confirm vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible.
  • Providers are encouraged to counsel all members who have not already have an appointment scheduled to receive the vaccine dose for which they are being counseled.
  • For more information, visit https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

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Posted in EmblemHealth NY, NY Providers, Training, Updates

EmblemHealth NY: Covid 19 Testing reimbursement policy update 06/01/22

If your office accepts emblemhealth members and provides COVID-19 testing services, then this blog post is for you!

COVID-19 Tests:

There are 3 main types of tests for COVD-19 (SARS-CoV-2) virus- diagnostic (viral), antigent test and serologic test (antibody.

A diagnostic (molecular and antigen tests tells if you likely have a current infection, by looking for parts of the virus itself in samples taken from an individual’s respiratory system secretion (eg. nasal swab).

A serologic, or anitybody test tells you if you have had a previous infection of COVID-19 by looking at the antibody responses in the blood sample. (In general a serologic test cannot be used for a diagnostic purposes. Antibodies can be detected in individuals that had a distant infection of the virus)


The following policy applies to Commercial, Medicare and Medicaid lines of business: via EmblemHealth Policy#: RPC20210016

Per the CDC, “Cliniciansshould use their judgment to determine if a patient hassigns orsymptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever and/or symptoms of acute respiratory illness (e.g., cough) but some infected patients may present with other symptoms as well.”
▪ Symptomatic individual suspected of having COVID-19.
▪ Testing of asymptomatic patients used as part of a pre-surgical or facility pre-admission screening,
prior to an immunosuppressive procedure, or when a patient is admitted to a Skilled Nursing
Facility in accordance with CMS and CDC testing guidelines.
▪ Known or suspected prolonged, close contact, with an individual with a laboratory confirmed case
of COVID-19 as defined by CDC guidelines.
▪ Coronavirus COVID-19 (SARS-CoV-2) respiratory panel (up to 5 respiratory pathogens) test when
member has signs and symptoms of COVID-19.


SARS-CoV-2 Serology Testing
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) serology (antibody) testing may beconsidered a covered service when the following criteria are met:
▪ An individual seeks and receives a COVID-19 diagnostic test from a licensed or authorized health care provider, OR
• A licensed or authorized health care provider refers an individual for a COVID-19
diagnostic test. AND
▪ FDA approved or cleared or Emergency Use Authorization (EUA) AND
▪ Performed by a CLIA-accredited high or medium-complexity laboratory (per test Instructions for Use) AND
One of the following three conditions is present:
▪ Results of a molecular or antigen test is non diagnostic for COVID-19 and the results of the test will be used to aid in the diagnosis of a condition related to COVID-19 infection (e.g., Multisystem Inflammatory Syndrome [MIS]). OR
▪ Used as a method to support the clinical assessment of acute COVID-19 illness for persons who are being tested 3–4 weeks after illness onset, in addition to recommended direct detection methods such as polymerase chain reaction (PCR). OR
▪ Used as a method to help establish a clinical picture when patients have late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children.


Coding/Billing Information:
Effective 6/1/2022 – EmblemHealth and ConnectiCare will amend the billing
instructions to align with CMS’ instructions on how to bill for COVID-19 test related
services. The plan will require the use of modifier CS when identifying services that
are related to the need determination for a COVID-19 test.

Partial List of CPT/HCPCS codes:

*NY Medicaid covered codes may differ and follow NYS guidelines
CPT/HCPCS Description
U0001* CDC 2019 Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel
U0002(QW) 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes(includes all targets), non-CDC
U0003 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) amplified probe technique, making use of high throughput technologies as described by CMS-2020-01-R
U0004 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19), any technique, multiple types or subtypes (includes all targets), non-CDC, making use of high throughput technologies as described by CMS-2020-01-R
U0005- Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique, CDC or non-CDC, making use of high throughput technologies, completed within 2 calendar days from date and time of specimen collection.(List separately in addition to either HCPCS code U0003 or
U0004)
0224U -Antibody, severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID19]),includes titer(s), when performed
0240U- Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected (Xpert® Xpress SARSCoV-2/Flu/RSV (SARS-CoV-2 & Flu Targets only), Cepheid)
0241U-Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected (Xpert® Xpress SARSCoV-2/Flu/RSV(all targets), Cepheid)
86328- Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

For a complete list of codes, please click here for the complete reimbursement policy.


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