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A NEWSLETTER FOR MONTANA HEALTH CARE PROVIDERS
First Quarter 2014
 

Tips to Simplify Claims Processing

To ensure timely processing and payment of claims and to reduce administrative burdens, Blue Cross and Blue Shield of Montana offers the following tips to help streamline the submission of claims:

  1. It is important to bill the correct Subscriber (Member) identification number along with the correct prefix. When a provider bills the old prefix for a member that has converted to HCSC, the claim may be routed to the wrong department. Claims with incorrect prefixes must be looked up manually and routed to the correct department, which will cause a delay in processing.
  2. Be sure to include the correct Group number. When a claim has an incorrect Group number or no Group number at all, it must be looked up manually, which causes a significant delay in processing. Claims could be denied in error if the correct group number is not billed on the claim. 
  3. Please avoid using a member’s Social Security Number as his or her Subscriber ID. Unless the SSN is the member’s current Subscriber ID, these claims will route to HCSC, where they will be denied or rejected.
  4. There is a new address for dental claim submissions for members who have converted to HCSC. All dental providers need to check the back of the ID card to find the correct address to use.

The sample medical ID card and dental ID card below illustrate the location of the required information:

Sample Medical Card

Sample Dental Card

Update on Confirming Eligibility for BCBSMT Members

With the new federal requirement for individuals to have insurance coverage beginning January 1,2014, along with new commercial groups with coverage starting January 1, Blue Cross and Blue Shield of Montana (BCBSMT) is pleased to be serving many new members. There are some important things to be aware of when verifying eligibility:

Member ID information: Members should receive their member ID card within days of completing their enrollment. However, some of your patients may not have received their member ID card at the time of their appointment. If they have their member identification number and group number from another source, such as their new member welcome letter or phone confirmation, we can verify eligibility and benefits.

  • For patients who do not have this information, direct them to contact our Member Customer Service Center at 800-447-7828 to obtain their information. Or reschedule their appointment to a later date.
  • If the member is exhibiting an urgent need for inpatient services or admission and you are unable to verify their information, please contact 855-313-8914 for pre-authorization.

Confirming coverage: As usual, coverage cannot be used until the member’s first month premium payment has been applied to effectuate coverage. Also, benefits may vary depending on the coverage purchased by the member. It is important to check for eligibility and benefits each time you see a patient. We are experiencing high call volumes and increased hold times due to 2014 updates. At this time, please wait until patients have scheduled appointments before making eligibility and benefit inquires.

Network terms: We want to stress the importance of confirming your network status for the member’s plan before services are provided. As a reminder, the terms of your network contract prevent you from refusing to provide services to a BCBSMT member, irrespective of where they purchased their coverage. Care provided for emergency conditions will follow our standard authorization process.

HCS changes name to Network Management

After 10 years as Health Care Services, the Blue Cross and Blue Shield of Montana department that handles provider services will now be called Network Management. The switch is simply a name change. Network Management will include the same staff as Health Care Services, and that staff will continue to handle the same responsibilities they always have.
 
Network Management better describes the functions of the department, which oversees everything involved with provider services, including contracting and credentialing services. And by renaming the department, we will avoid confusion between Health Care Services (HCS) and Health Care Services Corporation (HCSC).

Effective Date for Provider Fee Schedule Postponed

For 2014, Blue Cross and Blue Shield of Montana (BCBSMT) has made the business decision to postpone the effective date of its provider fee schedule update to September 1, 2014. Typically, provider fee schedule updates become effective May 1.

Two factors contributed to the postponement for 2014:

  1. The Federal government shutdown in 2013 delayed the release by CMS of the Relative Value Unit information used to determine the rate; and
  2. BCBSMT continues to transition its business processes to the claims and membership platform of Health Care Service Corporation (HCSC). Currently, September 1, 2014, is the scheduled date that all claims and membership will have transitioned to HCSC systems.

New CPT codes that became effective January 1, 2014, have been added to the existing provider fee schedule, using the processes identified in our compensation policies. 

New terminology for provider service requests

With the conversion to HCSC processes, Blue Cross and Blue Shield of Montana has changed certain terminology regarding provider service requests. Please note the following changes:

  • Pre-authorization requests: Formerly known as “Precertification,” this now refers to a request for certification of inpatient hospitalization.
  • Predetermination requests: Refers to a request for review of outpatient services. This was formerly known as Prior Authorization*.

* The term Prior Authorization should no longer be used as it may be confused with Pre-Authorization, which is a request for inpatient stay.

Reference Guide for HCM Processes

The Health Care Management department at BCBSMT created a reference guide to help providers navigate through some recent changes in Health Care  Management processes. The guide contains  information regarding Medical/Surgical Pre-Authorization and Concurrent Review; Predetermination for Outpatient Services, Drugs and Devices; the Behavioral Health program; and the Appeals Process

We hope that you will find this information useful as you provide care for your patients with BCBSMT health care coverage.  Please continue to check the Announcements section on the Provider home page at www.BCBSMT.com for frequent updates.  If you have questions or need further information, please contact Susan Lasich at 406-437-6223 or Susan_Lasich@bcbsmt.com.

Phone number for appeals/peer to peer reviews

An issue has been identified in the routing of calls for providers requesting expedited appeals or peer to peer reviews. Until further notice, please call 800-447-7828, and request extension 6454 to speak directly with the Montana Health Care Management department.   

BCBSMT Access and Availability Standards

Participating providers treat BCBSMT members as they would any other patient and have agreed to cooperate in monitoring accessibility of care for members, including scheduling of appointments and waiting times. Participating providers must meet the following appointment standards:

  1. Emergency services must be made available and accessible at all times.
  2. Urgent care appointments must be available within 24 hours.
  3. Appointments for non-urgent care with symptoms must be made available within 10 calendar days.
  4. Appointments for immunizations must be available within 21 calendar days.
  5. Appointments for routine or preventive care must be available within 45 calendar days.

Emergency Services and Emergency Medical Condition

Participating providers are required to have 24-hour availability of emergency services and qualified on-call coverage available to BCBSMT members.
 
Emergency Services means health care items and services furnished or required to evaluate and treat an emergency medical condition.

Emergency Medical Condition is a condition manifesting itself with symptoms of sufficient severity, including severe pain, in which the absence of immediate medical attention could reasonably be expected to result in any of the following:

  1. The covered person’s health would be in serious jeopardy.
  2. The covered person’s bodily functions would be seriously impaired.
  3. A body organ or part would be seriously damaged.

Urgent Care

Participating providers must see BCBSMT members within 24 hours of their request for an appointment.

Urgent Care is health care that is not an emergency service but is necessary to treat a condition or illness that could reasonably be expected to present a serious risk of harm if not treated within 24 hours.

Non-Urgent Care with Symptoms

Participating providers must see BCBSMT members within 10 calendar days of their request for an appointment.

Non-Urgent Care is health care required for an illness, injury, or condition with symptoms that do not require care within 24 hours to prevent a serious risk of harm but do require care that is neither routine nor preventive in nature.

Routine Care

Participating providers must see BCBSMT members within 45 calendar days of their request for an appointment.
 
Routine Care is health care for a condition that is not likely to substantially worsen in the absence of immediate medical intervention and is not an urgent condition or an emergency. Routine care can be provided through regularly scheduled appointments without risk of permanent damage to the person’s health status.

Preventive Care and Immunizations

Participating providers must see BCBSMT members within 45 calendar days of their request for an appointment for preventive care and within 21 calendar days of their request for an appointment for immunizations.

Preventive Care and Immunizations are health care services designed for the prevention and early detection of illness in asymptomatic people.

More information is available in the BCBSMT Provider Manual. If you have suggestions for improvement or content, email your Provider Account Consultant at HCS-X6100@bcbsmt.com or call 1.800.447.7828, Extension 6100 Option 3.

Administrative Simplification: Updates, Reminders and Resources

Blue Cross and Blue Shield of Montana (BCBSMT) has completed implementation of the Administrative Simplification Phase III Operating Rules for 835 Electronic Funds Transfer (EFT) and 835 Electronic Remittance Advice (ERA), as mandated under the Affordable Care Act (ACA). The 835 EFT/ERA operating rules were authored by the Committee on Operating Rules for Information Exchange (CORE), which is part of the Council for Affordable Quality Healthcare (CAQH) initiative. By increasing uniformity when exchanging health care data, the operating rules are intended to help promote greater adoption and use of electronic transactions.

Online Enrollment Available Now

Participation in EFT and ERA is strongly encouraged for all BCBSMT-contracted providers. As we have outlined in many previous communications, EFT, ERA and other electronic transactions have many advantages, including providing greater security of your patients’ health care data, decreasing paper waste and possibly reducing the amount of time your staff may spend on manually processing the paper version of these transactions. 

If you are already enrolled for electronic payment and remittance transactions, you will not need to enroll again. However, if you have not signed up for EFT and ERA, now is the time, as the enrollment process is easier than ever. BCBSMT-contracted providers who are registered with HeW may complete the EFT and ERA electronic enrollment process online via the secure HeW provider portal. Please note that you must be a registered HeW user to complete the online enrollment process. Visit hewedi.com for more information.

Reassociation Reminder: Contact Your Bank

New and current EFT and ERA users should contact their financial institutions to request that the necessary data for reassociation is sent with each payment. Reassociation is a process that supports matching of payments with claim data for posting to your patient accounts. A sample letter you can customize and send to your bank is available in the CORE section of the CAQH website at http://www.caqh.org/benefits.php. (Go to Mandated Operating Rules; then select EFT and ERA. Scroll down to Implementation Resources section and look for the Sample Provider EFT Reassociation Data Request Letter link.) This document includes instructions to assist you with requesting delivery of the reassociation data, as well as a glossary of key terms.

For clarification regarding the Administrative Simplification operating rules, you should refer to the CAQH CORE website at http://www.caqh.org/CORE_rules.php. As indicated on the site, any questions not addressed by CAQH CORE online resources may be directed to CORE@caqh.org.

CAQH CORE is a multi-stakeholder collaboration of more than 130 organizations representing providers, health plans, vendors, government agencies and standard-setting bodies developing operating rules to help simplify health care administrative transactions. For additional information, refer to the CORE section of the CAQH website at http://www.caqh.org/benefits.php.

Removal of Barriers to Access

The Montana Managed Care Plan Network Adequacy and Quality Assurance law requires health carriers in the state of Montana to adopt standards that promote access to the services offered by a managed care plan.
 
BCBSMT provides an equal opportunity to access health plan services by making accommodations for members who have physical and mental disabilities, those who are illiterate or those who have diverse cultural and ethnic backgrounds. An example of a service for members with sensory and speech impairment includes use of the Montana Telecommunications Relay Program, http://www.dphhs.mt.gov/detd/mtap/. The Montana Relay makes it possible to make phone calls between a standard telephone and a text telephone, as is often used by individuals with hearing or speech impairments. 

Other accommodations available for sensory and speech impairment include providing written communications, sign-language interpreter services, and online member services. BCBSMT offers reading services for members with impaired vision.

Members with limited English proficiency are accommodated through a BCBSMT subscription to an on demand language services vendor that provides both verbal and written interpreter services.  

If you have any questions about these services or require clarification, please contact Customer Service at 1-800-447-7828.

BCBSMT to Selectively Test ICD-10 Transition Soon

The U.S. Department of Health and Human Services has mandated that as of October 1, 2014, all HIPAA transactions must use ICD-10 codes where ICD-9 codes are currently used. In anticipation of this transition date, BCBSMT has published regular articles in the Capsule News and provided information on the Provider website.

In 2014, we will continue to publish information that may help providers with their transition to ICD-10. We will be conducting end-to-end testing with a select number of providers this year, the results of which will be shared in the coming months with our entire provider community. Our testing will cover a wide range of provider types and claims scenarios, enabling us to share information with our provider community that will address as many potential transition risks as possible.

For more information about the transition to ICD-10, continue to read future issues of the Capsule News and visit the ICD-10 page located in the Provider Education section of the Provider page on our website, bcbsmt.com

ICD-10 Resource Guide Now Available Online

Later this year, all HIPAA-covered entities will be required to transition from using ICD-9 codes to using ICD-10 codes. The transition requires careful planning for practices of all sizes to meet the October 1, 2014, deadline. Blue Cross and Blue Shield of Montana (BCBSMT) has created an online resource guide to help providers prepare for the transition.
 
The resource guide, available on the ICD-10 page of the Provider Education section, contains information and many resources to help your practice get ready for ICD-10. Learn about:

  • The benefits of being prepared
  • Financial implications of ICD-10
  • Training and education resources
  • Industry and government guides

In addition to the resource guide, continue to read the Capsule News over the coming year for information about ICD-10. More ICD-10 topics can be found in previous issues of the Capsule News, available online in the News and Reports section of the Provider website.

Code Correctly - Avoid the ICD-10 Coding Pitfalls!

Blue Cross and Blue Shield of Montana (BCBSMT) conducted preliminary ICD-10 testing with a subset of providers in 2012 and 2013. Although we are planning a larger scale testing phase in second quarter 2014, we wanted to share some of the common issues identified in our initial testing. Submitting claims with the following errors after October 1, 2014, may delay or negatively impact reimbursement.

Use of Invalid Diagnosis Codes

Invalid diagnosis codes were common for three reasons, all of which would cause a claim to get rejected. Providers who use billing services or practice management systems that have claims scrubbers may avoid these problems; however, they should serve as test conditions for any provider.

1. Confusion between letters and numbers. We saw several examples where numbers were used in place of letters or vice versa. This confusion happened most frequently with the following commonly used numbers and letters in ICD-10:

Number  Letter 
 3  S
 0  O
 1  I
 2  Z

Examples:

  • A pediatrician used diagnosis code 301.80XA — Unspecified open wound of other part of head, initial encounter, and should have used diagnosis code S01.80XA. The "S" was incorrectly sent as a "3."
  • A hospital trying to send a procedure code for a C-section — Extraction of products of conception, low cervical, open approach conception, low cervical, open approach -- sent a procedure code of I0DOO21 when they were trying to send 10D00Z1. The letter "I" was used in place of the number "1," the letter "O" was used twice rather than the number "0," and the number "2" was used in place of the letter "Z."

2. Transposed digits and typographical errors. For example, a hospital used diagnosis code K45.909 when they should have used diagnosis code J45.909 for unspecified asthma, uncomplicated. A "K" was used in place of a "J" in error.

3. Truncated and incomplete diagnosis codes. These types of errors are primarily received from physicians’ offices. They are not as common with submissions from hospitals.

  • For example, a physician’s office used diagnosis code R50 – Fever – when only diagnosis codes R50.2, R50.81-R50.84, and R50.9 are valid for that use. 

Inappropriate Use of ICD-10 Diagnosis Codes

Many providers struggled with the combination diagnosis codes available in ICD-10 and continued to bill conditions separately in error. In some cases, they used two diagnosis codes that are mutually exclusive, as in this example:

  • A hospital sent a claim with diagnosis code I25.10 – Atherosclerotic heart disease of native coronary artery without angina pectoris –  along with a second diagnosis of I20.9 – Angina pectoris, unspecified. However, they should have used a single diagnosis code of I25.119 – Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris.

Lack of Trimester or Encounter Sequence When Needed

Some ICD-10 diagnosis codes require identification of the encounter or trimester sequence. There were numerous claims received that did not specify or provided incorrect trimester/encounter information. Consider the following two examples:

Trimesters: A hospital sent a series of obstetrical claims that involved the treatment of a patient who had low weight gain during her pregnancy. The diagnosis codes for the trimesters were submitted out of sequence. The hospital used a diagnosis code of O26.12 – Low weight gain in pregnancy, second trimester -- then on a later date of service used a diagnosis code of O26.11 – Low weight gain in pregnancy, first trimester.

Encounters: The injuries section (S00.00XA-S99.929S) in ICD-10-CM and poisonings/external causes section (T07-T88.9XXS) is full of diagnosis codes that contain encounter sequence information. We saw many of these miscoded, such as billing the subsequent encounter diagnosis code T23.161D – Burn of first degree of back of right hand, subsequent encounter – without billing the initial encounter with diagnosis code T23.161A – Burn of first degree of back of right hand, initial encounter.

Use of “Unspecified” Diagnosis Codes

Some providers were using unspecified diagnosis codes when a more specific diagnosis was available.

For example, a general practitioner billed diagnosis code J20.9 – Acute bronchitis – when a more specific diagnosis code J21.0 – Acute bronchiolitis due to respiratory syncytial virus – was available. The practitioner coded the same claim in ICD-9 with the additional diagnosis of respiratory syncytial virus, so the underlying virus was most likely documented in the patient's chart. Coding guidelines dictate that diagnosis code assignment should fully identify the diagnostic condition including specificity in describing causal conditions, secondary processes, manifestations, and complications.

Whether you are conducting testing with BCBSMT or other Payers/Clearinghouses, paying attention to the ICD-10 coding issues identified above is essential. Good documentation practices and accurate coding with ICD-10 upon the October 1, 2014, transition date will help avoid delayed, rejected, and incorrect claims.

A Closer Look: Documentation and Coding for Pulmonary Diagnoses

On October 1, 2014, all HIPAA-covered entities must transition from ICD-9-CM to the ICD-10-CM/PCS code sets. At that time, claims with ICD-9-CM codes will not be accepted unless they are for service dates or discharge dates prior to October 1, 2013.

As we draw closer to the 2014 ICD-10 implementation date, it is essential to take note of the key differences to coding in the ICD-10-CM code set. The goal of this article is to take a closer look at documentation and diagnosis coding for these chronic pulmonary conditions to successfully achieve accurate and compliant practices.

Asthma
The ICD-9-CM code structure classifies asthma into a single code category, 493. Accurate code assignment involves determination of specific fourth- and fifth-digit subclassifications. The fourth digit identifies the asthma type, while the fifth digit identifies the presence of an acute exacerbation, status asthmaticus or an unspecified episode as follows:

Fourth-digit subclassification:

0 = Extrinsic Asthma  493.0X
1 = Intrinsic Asthma  493.1X
2 = Chronic Obstructive Asthma  493.2X

Fifth-digit subclassification: 

0 = Unspecified 493.X0
1 = with status asthmaticus 493.X1
2 = with (acute) exacerbation    493.X2

When selecting the appropriate ICD-9-CM fifth-digit subclassification, an important consideration is to distinguish between an acute asthma exacerbation versus a status asthmaticus episode. The ICD-9-CM coding guidelines define status asthmaticus as a “severe, intractable episode of asthma unresponsive to normal therapeutic measures.”1 An acute asthma exacerbation, on the other hand, is an increase in severity of asthma symptoms such as shortness of breath, wheezing, coughing and chest tightness. When a status asthmaticus episode occurs, documentation should be concise and include specific terms such as intractable asthma attack; severe, intractable wheezing; and severe prolonged asthma attack.2 Concise documentation will allow for unambiguous interpretation and code assignment.

Chronic Obstructive Pulmonary Disease (COPD) AND Chronic Bronchitis

Over time, asthma may develop into COPD and one diagnosis may exacerbate the other. As such, clinical documentation for these pulmonary diagnoses is key to accurate code assignment. The ICD-9-CM code structure represents a relationship between COPD and Chronic Bronchitis. When both of these conditions occur together, the two diagnoses are grouped into a single code category, 491.1 These conditions represent instances when an individual may have a combination of pulmonary disorders that fall within the COPD category. For example, the fifth-digit assignment identifies obstructive chronic bronchitis with the presence of an acute exacerbation, acute bronchitis or obstructive chronic bronchitis with no exacerbation as follows:

Fifth-digit subclassification: 

0 = without exacerbation  491.20
1 = with (acute) exacerbation  491.21
2 = with (acute) bronchitis 491.22

Code 491.20, obstructive chronic bronchitis without exacerbation, is reported for a diagnosis of COPD with bronchitis without acute bronchitis or an acute exacerbation.1 This is commonly documented as chronic obstructive bronchitis. Conversely, code 491.21, obstructive chronic bronchitis with (acute) exacerbation is reported to capture a diagnosis of acute bronchitis with chronic obstructive bronchitis. From an ICD-9-CM coding perspective, this is considered an acute exacerbation and is often documented as COPD with acute exacerbation.1,2,3

Over the coming months, BCBSMT will be providing more information about impacts of coding and documentation that may help your practice with the transition to ICD-10, Risk Adjustment, and more.

1. American Hospital Association (AHA). (2013). ICD-9-CM for Physicians-Volumes 1&2. Salt Lake City: Optum.
2. Brown, F. (2012). Faye Brown's ICD-9-CM Coding Handbook . Chicago: Health Forum, Inc.
3. AHA. (2002, Q3). AHA Coding Clinic. COPD with Exacerbation.

A Closer Look: Documentation and Coding for Chronic Kidney Disease

This Quarter’s Capsule News highlights documentation and coding for Chronic Kidney Disease (CKD) under the ICD-9-CM and ICD-10-CM code sets.

The National Kidney Foundation defines CKD as a “condition characterized by a gradual loss of kidney function over time.” 1 CKD is classified to category 585–Chronic Kidney Disease, in ICD-9-CM. Fourth-digit assignment indicates the stage of the disease which is based on severity. The stage is determined by the degree of kidney damage and the Glomerular filtration rate (GFR), an indicator of how well the kidneys are functioning. The severity is designated by Stages I–V. CKD can progress to End Stage Renal Disease (ESRD), which is also reported using a code from the 585 category. The code for end stage renal disease (585.6) cannot be assigned without supporting documentation from the provider.

Under ICD-10-CM, CKD is reported under category N18, with fourth-digit assignment indicating the stage of the disease. In ICD-9-CM and ICD-10-CM, the code for ESRD is found in the same category as the codes for CKD.
When coding CKD in ICD-9-CM or ICD-10-CM, coding guidelines provide instruction to also assign diagnosis codes for any associated conditions.

Hypertensive Chronic Kidney Disease
Hypertension is one of the leading causes of CKD and, together with diabetes, is responsible for nearly two-thirds of CKD cases. ICD-9-CM presumes a cause-and-effect relationship and classifies CKD with hypertension as hypertensive CKD. The Official ICD-9-CM Guidelines for Coding and Reporting provide guidance related to hypertensive CKD coding. Assign codes from category 403-Hypertensive CKD, when conditions classified to category 585-CKD are present with hypertension.

To accurately report a diagnosis of hypertensive CKD using diagnosis code 403, it is important to select the appropriate fourth digit to indicate whether the hypertension is classified as malignant (0), benign (1) or unspecified (9). Fifth-digit assignment identifies the stage of the kidney disease. CKD stage I-IV or unspecified is indicated by a fifth-digit assignment of (0), while CKD stage V or ESRD is indicated by a fifth-digit assignment of (1).

The appropriate code from category 585-CKD, should be reported as discussed above, to identify the stage of CKD. Similar to the current ICD-9-CM coding system, ICD-10-CM requires two codes to accurately report a diagnosis of hypertensive CKD. The first code indicates the presence of both hypertension and CKD, the second code identifies the stage of CKD. Under the ICD-10-CM coding system, there is no distinction between benign, malignant, or unspecified hypertension as is under the ICD-9-CM code set.

Diabetic Chronic Kidney Disease
Diabetes is responsible for nearly two-thirds of CKD cases. Under category 250 Diabetes mellitus, ICD-9-CM requires a fourth digit to identify associated conditions and a fifth digit to identify the type of diabetes mellitus, and whether the diabetes is controlled or uncontrolled.

In ICD-9-CM, when CKD is due to diabetes, it is reported with code 250.4X and the documented stage of CKD is reported with code 585.X.

Under ICD-10, CKD due to diabetes has a fourth- and fifth-digit designation. The fourth digit “2” indicates the underlying condition is a kidney complication. The fifth digit, also a “2”, indicates the complication is associated with chronic kidney disease. Additionally, assign a code from category N18 to identify the stage of the CKD.

End Stage Renal Disease (ESRD)
In the United States, ESRD is an administrative term based on conditions for health care payment by the Medicare ESRD Program for patients treated with dialysis or transplantation due to permanent kidney failure. ESRD is the most severe form of CKD and should only be assigned when the provider documents ESRD. If both a stage of CKD and ESRD are documented, ESRD is the only code that should be assigned per ICD-9-CM and ICD-10-CM guidelines. ESRD is reported as 585.6 in ICD-9-CM and N18.6 in ICD-10-CM. Additional guidance is provided in ICD-10-CM under N18.6 to use additional code to identify dialysis status (Z99.2).

Hypertensive Heart and Chronic Kidney Disease
When both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis, ICD-9-CM guidelines require assignment of codes from category 404-Hypertensive heart and CKD. With hypertensive CKD, ICD-9-CM and ICD-10-CM assumes a relationship between the hypertension and the CKD, whether or not the condition is so designated. This assumption is the same under ICD-10-CM. Assign an additional code from category 428-Heart failure, to identify the type of heart failure. If a causal relationship is not documented, the heart condition and hypertension are coded separately and sequenced according to the circumstances of the admission/encounter.

ICD-10-CM guidelines for reporting hypertensive heart and CKD are very similar to ICD-9-CM. ICD-10-CM instructs the user to assign codes from category I13-Hypertensive heart and CKD, when both conditions are stated in the diagnosis. Category I13 represents combination codes that include hypertension, heart disease and CKD. Therefore, if a patient has each of these conditions, a code from I13 should be assigned.  Additionally, the appropriate code to identify the stage of the CKD is assigned in both ICD-9-CM and ICD-10-CM.

References:
1. The National Kidney Foundation About Chronic Kidney Disease
Optum ICD-9-CM for Hospitals-Volumes 1, 2 & 3 2014 Professional
Optum ICD-10-CM The Complete Official Draft Code Set 2014 Draft
KDIGO 2012 Clinical Practice Guidelines for CKD Evaluation and Management

Timeline Reminder: CMS-1500 Paper Claim Form (Version 02/12)

 Previous articles have referenced the transition from the previous version of the paper CMS-1500 claim form (08/05) to the revised version (02/12). As a reminder, the transition timeline, which aligns with Medicare’s timeline, is as follows:

  • January 6, 2014 through March 31, 2014 – Dual-use period during which payers continue to receive and process paper claims submitted on the old CMS-1500 claim form (version 08/05), as well as claims submitted on the revised CMS-1500 claim form (version 02/12).
  • April 1, 2014 – Payers receive and process only those claims that are submitted on the revised CMS-1500 claim form (version 02/12). As mandated by the Centers for Medicare & Medicaid Services (CMS), claims submitted on the old form (version 08/05) will no longer be accepted.

What’s different?
If you’ve submitted claims on the revised form (version 02/12) during the dual-use period, you may have noticed that Field 21 now requires users to specify whether they are using ICD-9 or ICD-10 diagnoses codes. Additionally, eight diagnosis codes have been added on the revised form. There are other minor changes as well. If you use a practice management system, billing service or clearinghouse, it’s important to check with your vendor(s) to ensure they are aware and can accommodate any changes.

Don’t Forget to Recycle…
As noted above, the previous version of the CMS-1500 claim form (08/05) will be discontinued as of April 1, 2014. This means you should discard or recycle any unused forms as of this date. For more information on the revised CMS-1500 claim form (version 02/12) such as specific changes, technical specifications and how to order a new supply of printed forms, visit the National Uniform Claim Committee (NUCC) website at nucc.org.

Why not take this opportunity to make the switch to paperless transactions?
Electronic claim submission can help streamline your administrative processes, help protect your patients’ information and may result in faster claims processing and payment. To learn more, visit the Provider Education/Claims section of our website at bcbsmt.com/provider.

ClaimsXtenTM Second Quarter 2014 Updates

Blue Cross and Blue Shield of Montana (BCBSMT) reviews new and revised Current Procedural Terminology (CPT®) and HCPCS codes on a quarterly basis. Codes are periodically added to or deleted from the ClaimsXten software by McKesson and are not considered changes to the software version. BCBSMT will normally load this additional data to the BCBSMT claim processing system within 60 to 90 days after receipt from McKesson and will confirm the effective date on the BCBSMT website. Advance notification of updates to the ClaimsXten software version (i.e., change from ClaimsXten version 4.1 to 4.4) will continue to be posted on the BCBSMT Provider website.
 
Beginning on or after May 19, 2014, BCBSMT will enhance the ClaimsXten code auditing tool by adding the second quarter codes and bundling logic into our claim processing system. 

For updates on the ClaimsXten implementation and other BCBSMT news, programs and initiatives, refer to the Provider Education section of our website at bcbsmt.com. Additional information also may be included in upcoming issues of the Capsule News.

ClaimsXten is a trademark of McKesson Information Solutions, Inc., an independent third-party vendor that is solely responsible for its products and services.

CPT copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

 

 
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