Tag: #Anthem

Posted in BCBS (Various States), Training, Updates

Anthem BCBS California: administration of drug Spravato-proper medical billing and coding.

Posted on by KR2Medical Billing

If you are a physician that accepts patients with Anthem BCBS plans then this blog post is for you.

Eskatamine is sold under the brand name Spravato® and is indicated for adults with treatment-resistant depression.  Based on the prescribing information, patients who have the drug administered in the professional provider’s office should be monitored for 2 hours to assess for complications.

There are 2 ways physicians can code the administration of this drug:

Option 1 (Professional Services) – The physician buys the drug and administers it to the patient as well as provides the observation services- Anthem BCBS of California will NOT cover the drug itself or the post administration observation. Instead physicians should use the 2 following codes:

HCPCS CodeDescription
G2082Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
G2083Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare professional and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation.
via Anthem BCBS California

Option 1 Outpatient Hospital – the facility is allowed to bill codes G2082 and G2083 in conjunction with revenue center code (RCC) 919 and the drug should not be billed separately. Anthem BCBS of California will not reimburse a separate professional claim with code G2082 and G2083.

Option 2: The drug is obtained through a pharmacy. Pharmacy bills the code S0013 – Esketamine, nasal spray, 1 mg. 

Post-administration observation: if physician falls into the option 2 category then the physician is allowed to bill the following code:

CPT CodesDescription
99202 – 99205Office or other outpatient visit for the evaluation and management of a new patient
99212 – 99215Office or other outpatient visit for the evaluation and management of an established patient
99417Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes
via Anthem BCBS California

In accordance with the American Medical Association’s (AMA’s) CPT® Manual, CPT code 99417 should only be billed when reported with CPT codes 99205 and 99215. Medical records must support coding.  Please refer to Anthem’s Prolonged Services – Professional Reimbursement Policy for additional information.

Please remember that codes exist but that doesn’t mean that all of them will be reimbursed. In order to reduce denials and get your claims paid please follow the reimbursement policy of a specific Insurance Payer.

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Posted in BCBS (Various States), Payer Updates, Training, Updates

BCBS of Virginia and It’s affiliate Healthkeepers, Inc 3 new Lab coverage-07/01/22

Posted on by KR2Medical Billing

If you are a provider or a LAB that is ordering or offering the following tests for your Anthem BCBS of Virginia and its Affiliate Healthkeepers Inc. patients this blog post is for you! Effective date is 07/01/2022

These following NEW LAB guidelines impact all our products – with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan, and the BlueCross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or
FEP®). Furthermore, the guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on February 17, 2022.

LAB.00043-Immune Biomarker Tests for Cancer -This new lab policy addresses the coverage for immune response algorithmic tests for oncologic disease management At least one test, Immunoscore® (Veracyte Inc.), which has been investigated for management of colon cancer, is commercially available. According to this policy Anthem BCBS of Virginia and its affiliate Healthkeepers Inc., consider oncologic immune biomarker tests are considered investigational and not medically necessary for all indications. CPT codes: 0261U

LAB.00044-Saliva-based Testing to Determine Drug-Metabolizer Status– this new lab policy addresses the coverage for saliva-based testing to determine drugmetabolizer status. Saliva-based testing to determine drug-metabolizer status is considered investigational and not medically necessary for all indications. The CPT code associated with this new coverage guideline is 84999.

LAB.00045-Selected Tests for the Evaluation and Management of Infertility– this NEW Lab policy addresses the coverage for selected tests that are part of the diagnostic work-up to determine the cause of infertility or manage infertility treatment. According to Anthem BCBS of Virginia and its affiliate the following tests or procedures are considered investigational and not medically necessary for diagnosing or managing infertility:

• Endometrial receptivity analysis;

• Sperm-capacitation test;

• Sperm deoxyribonucleic acid (DNA) fragmentation test;

• Sperm penetration assay; and

• Uterine natural killer (uNK) cells test.

The CPT codes associated with this new coverage guideline are 86357, 89329, 89330, 89398, 0253U, and 0255U.

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Posted in BCBS (Various States), Training, Updates

BCBS Kentucky: prior authorization requirements for admissions to in-network skilled nursing facilities

Posted on by KR2Medical Billing

The following information applies to Kentucky Anthem BCBS local Commercial health plans.

Updated guidance for prior authorization requirements for admissions to in-network skilled nursing facilities (SNFs).

The Updated process applies to hospital inpatient transfers to SNFs only.

NOT TO  transfers from Acute inpatient Rehab, LTAC to SNF, or SNF to SNF.

Note: This updated process does not apply to admissions to out-of-network SNF facilities.

According to Anthem BCBS of Kentucky-effective August 1, 2021, Anthem will allow a 5-day initial length of stay upon notification of an admission to an in-network SNF facility for Kentucky local Commercial members.

  • Facility and physician must be in-network for the member.
  • Anthem will require notification of the SNF admission, which includes sending demographics and verification of benefits via the usual channel.
  • Anthem will approve an initial 5-day length of stay without the need to provide clinical information.
  • SNF providers will need to submit the clinical information within two business days after the admission to aid in our members’ care coordination, discharge planning and member management. Note that prior authorization is still required but we allow the transfer to SNF, and then allow provider to send clinical within 2-days after the admission.
  • Concurrent review will be required starting on day 5 of the SNF stay.
  • Anthem may apply monetary penalties such as a reduction in payment, for failure to provide timely notice of admission.

Anthem BCBS of Kentucky also stated that they will monitor this process through December 31, 2021 and conduct random audits and monitor trends to evaluate its effectiveness.

Looking for more information? The following FAQs will help you answer some of the questions:

1. As a SNF provider, do I need to send information and notification to Anthem as I would normally do for a prior authorization?

Yes, notification is still required. However, you can notify Anthem of the admission and move the member without having to send in clinical information or wait for an approval. It will be important to verify member benefits.

2. When do I need to submit clinical information?

For the initial SNF admission, no later than two business days after the admission and for continued stay, prior to the last covered day.

3. Does this apply to SNF, IP Rehab and LTAC admissions and related transportation (air or ground ambulance)?

This process is only applicable to the initial SNF admission. Follow standard prior authorization process for IP Rehab, LTAC and any related transportation.

4. For the SNF initial authorization of 5 days, will Anthem assign a level of care?

Anthem UM will assign Level of care once the clinical information is received from the SNF.

5. What if a member needs to be admitted for wound care and IV antibiotics?

If a SNF has any concerns about the criteria for admission, they may still do the full prior authorization process.

6. If the physician and/or facility are out-of-network for the member, does this process apply?

No, the facility AND physician both need to be in network. All out-of-network facilities and providers must follow the full prior authorization process.

7. What if I am uncertain if the member is a local commercial member?

This process is applicable to local commercial accounts only.  It does not apply to FEP, National, Medicaid, Medicare, or IHM. If you are uncertain, reach out to the Anthem dedicated nurse for your facility.

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