Friday, May 18, 2018

Basics of Utilization review and medical necessity

UTILIZATION REVIEW AND MEDICAL NECESSITY


The contracting provider agreement requires providers to cooperate in utilization review and medical necessity determinations. Utilization review is the process of determining the appropriateness of services rendered to and payments made on behalf of members. Appropriateness of service and payment determinations consist of the following activities:


A. MEDICAL NEED FOR SERVICES RENDERED

Medical necessity policy applies to all services rendered to BCBSKS members and includes any services or supplies used to diagnose and/or treat illness or injury. The service should be widely accepted by a peer group of practicing providers, based on scientific criteria and determined to be reasonably safe. Health care professionals should discuss all appropriate treatment alternatives available to patients regardless of benefit coverage limitations. To be determined medically necessary, the service must be consistent with the diagnosis and treatment of the condition; be in accordance with standards of good health care practice; and not be for the convenience of the patient or provider. The following procedures/equipment would be subject to medical necessity and utilization review:


1. Established procedures/equipment of questionable current usefulness in the treatment of a specific condition(s).

2. Procedures/equipment which tend to be redundant when performed/supplied in combination with other procedures/equipment; or procedures/equipment which are unlikely to provide additional medical benefits, or are contradicting to one another.

3. Specific procedures/equipment or patterns of care which vary significantly from a peer group.

PRE-ADMISSION CERTIFICATION & CONCURRENT REVIEW


Before admitting a member to a hospital for elective (non-obstetrical, non-life threatening) inpatient care, medical information will need to be supplied to BCBSKS in order to certify medical necessity. A length of stay will be assigned at the time of pre-certification and will be subject to concurrent review. Concurrent review is the process of obtaining current medical information to review for the medical necessity of a requested extension to the length of stay or course of treatment. For the most accurate and complete information, all pre-admission certification should be validated through the BCBSKS provider portal (Availity®).

BCBSKS pre-admission certification and concurrent review activity are conducted in compliance with URAC guidelines. This includes the availability of either the expedited or standard appeal to services denied for medical necessity during the pre-admission certification and concurrent review processes. To initiate an appeal (phone or fax), you must have complete information since the time frame begins with the appeal request. These appeal options are only available prior to claim submission and are subject to time frames as established by BCBSKS, Department of Labor, and URAC. All pre-admission certification appeals for professional and hospital services will be reviewed concomitantly.

OUTPATIENT PRE-CERTIFICATION/PRIOR AUTHORIZATION


Under certain circumstances, pre-certification/prior authorization may be required for outpatient services/procedures. BCBSKS will notify contracting providers at least 30 days in advance of such requirement.

Pre-certification/prior authorization may also be required for other outpatient services such as home medical equipment and case management, including those services specified by employers, and outpatient procedures which necessitate a greater level of facility care than is usually needed.

Following provider notification, continued failure to complete pre-certification/prior authorization activities will result in a 50 percent Maximum Allowable Payment (MAP) reduction up to $200 with the member held harmless. Compliance audits will take place on a post-payment basis, which may result in refunds

CASE MANAGEMENT

Case management is a process that identifies and coordinates alternative treatment plans to enhance care through effective administration of available health care resources in the most cost-efficient manner. The process is accomplished through the development of a treatment plan by the patient or legal representative, the physician, other health care providers, and the BCBSKS case manager.

E. PREPAYMENT AND DATA ANALYSIS

BCBSKS will identify any trends or patterns of patient care, i.e., through data analysis, which appear inconsistent with overall patterns or trends. Prepayment review will be implemented if attempts to work with the provider have failed to resolve the issue. Specific utilization guidelines may be applied to individual prepay members. Prepayment review means all claims will be reviewed before payment and records will be required.

APPROPRIATE PLACE OF SERVICE

The provider agrees to use (to the extent possible) those inpatient, extended care, ancillary services and other health facilities and health professionals which have contracted with BCBSKS. Providers agree to render services to members in the most appropriate and economical setting consistent with the member’s diagnosis, treatment needs, and medical condition. Actions taken for providers' lack of compliance will range from provider education to financial assessments and finally requesting contract cancellation. In the event members request referrals to non-contracting providers, providers should have patients sign a statement acknowledging full understanding of the non-contracting referral and the patient’s financial responsibilities. The statement should be filed in the patient’s chart.

G. RESOLUTION OF PROBLEMS

Providers agree to work with BCBSKS and other providers of care in the resolution of any utilization or medical review problems that may be identified. Actions taken for providers' lack of compliance will range from provider education to financial assessments and finally contract cancellation.

H. MEDICAL NECESSITY/UTILIZATION REVIEW DENIALS

Occasionally BCBSKS does not consider an item or service to be medically necessary. In such situations the item or service becomes a provider write-off. In the few situations where services are known to be denied as not medically necessary (including deluxe items) and the patient insists on the services, the provider must obtain a patient waiver in advance of the services being rendered. (See Section X. WAIVER FORM)

Failure to discuss the above with the patient in advance, document this in the medical record, and obtain the waiver will result in a provider write-off.


Monday, November 13, 2017

What is Respite billing


RESPITE BENEFIT

Respite services provide limited and temporary relief for families caring for beneficiaries with complex health care needs when the care needs require nursing services in lieu of the trained caregivers. Services are provided in the family home by hourly skilled and licensed nursing services as appropriate. To be eligible and authorized for respite, MDHHS must determine the beneficiary to have:

* Health care needs that meet the following criteria:

* That skilled nursing judgments and interventions be provided by licensed nurses in the absence of trained and/or experienced parents/caregivers responsible for the beneficiary’s care;

* That the family situation requires respite; and

* That no other community resources are available for this service.

* No other publicly or privately funded hourly skilled nursing services in the home that would be duplicated by the CSHCS respite benefit.

* Service needs which can reasonably be met only by the CSHCS Respite benefit, not by another service benefit.

Respite is reimbursed when provided by a Medicaid enrolled home health agency, a Medicaid enrolled registered nurse (RN) who is licensed to practice in the state of Michigan, or a Medicaid enrolled licensed practical nurse (LPN) who is licensed to practice in the state of Michigan and working under supervision according to the Michigan Public Health Code. It is the responsibility of the LPN to secure the appropriate supervision and maintain documentation that identifies the supervising professional.

A maximum of 180 hours of CSHCS Respite services may be authorized per family during the 12-montheligibility period. When there is more than one respite-eligible beneficiary in a single home, the respite  service is provided by one nurse at an enhanced reimbursement rate for the services provided to multiple beneficiaries. Allotted respite hours may be used at the discretion of the family within the eligibility period. Unused hours from a particular eligibility period are forfeited at the end of that period and cannot be carried forward into the next eligibility period.

Beneficiaries receiving services through any of the following publicly funded programs and benefits are not eligible for the CSHCS Respite benefit:

* Private Duty Nursing Benefit

* Children’s Waiver

* Habilitation Supports Waiver

* MI Choice Waiver

Requests for respite must be made in writing to MDHHS (refer to the Directory Appendix for contact information) and include
the following information:

* The health care needs of the beneficiary;

* The family situation that influences the need for respite; and

* Other community resources or support systems that are available to the family (e.g., CMH services, MDHHS services, adoption subsidy, SSI, trust funds, etc.).

MDHHS responds to all requests for respite in writing.

Tuesday, October 10, 2017

cpt code for testosterone - j3490, 11980, 84403

CPT/HCPCS Codes

J3490* Testosterone pellets (Testopel®)

11980* Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)

* Providers must bill HCPCS code J3490 and CPT code 11980 on the same claim. If HCPCS code J3490 and CPT code 11980 are not billed on the same claim, the claim will be subject to prepayment review.

TESTOSTERONE CPT CODE: 84403

Covered ICD code for 84403

E89.5 Post procedural testicular hypofunction L63.8 Other alopecia areata
E29.1 Other testicular hypofunction N40.0 Enlarged prostate without LUT symptoms (BPH)
E29.8 Other testicular dysfunction N40.1 Enlarged prostate with LUTS
E34.9 Hormonal imbalance (elevated testosterone)
ICD-10 description: Endocrine disorder unspecified N41.0 Acute prostatitis
F52.22 Female sexual arousal disorder N42.89 Other specified disorders of prostate (Atrophy of prostate)
F52.0 Sexual dysfunctin not due to a substance or known physiological condition (may not be a covered indication for all payers) N46.01 Organic azoospermia
R68.82 Decreased libido N46.11 Organic oligospermia
F52.0 Hypoactive sexual desire disorder N46.029 Infertility due to extratesticular causes
F52.21 Male erectile disorder N52.9 Azoospermia due to other extratesticular causes
F52.31 Female orgasmic disorder L65.9 Alopecia, unspecified
F52.32 Male orgasmic disorder L63.2 Ophiasis
F52.4 Premature ejaculation

Indications and Limitations of Coverage and/or Medical Necessity

Testosterone is an endogenous androgen. Endogenous androgens are responsible for the normal growth and development of the male sex characteristics. Testosterone levels vary from hour to hour; periodic declines below the normal range can occur in some otherwise normal men. An overall diurnal rhythm is also present, the highest levels of circulating testosterone occurring during the early morning hours. In certain medical conditions such as hypogonadism, the endogeonous level of testosterone falls below normal levels. The diagnosis of androgen deficiency is made in men with consistent signs and symptoms and unequivocally low serum testosterone levels. Testosterone levels should be determined in the morning, and studies should be repeated in patients with subnormal levels.

Testosterone pellets (Testopel®) have been approved by the Food and Drug Administration (FDA) for the treatment of primary hypogonadism (congenital or acquired) and hypogonadotrophic hypogonadism (congenital or acquired). Primary hypogonadism includes such conditions as testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testes syndrome; or orchidectomy. Hypogonadotrophic hypogonadism (secondary hypogonadism) includes conditions such as idiopathic or gonadotropic luteinizing hormone releasing hormone (LHRH) deficiency or pituitary-hypothalamic injury from tumors, trauma or radiation.

Indications:

Testosterone pellets (Testopel®) will be considered medically reasonable and necessary for the following indications:

• Second line testosterone replacement therapy in males with congenital or acquired endogenous androgen absence or deficiency associated with primary or secondary hypogonadism when other standard replacement [intramuscular (IM), buccal, transdermal is not clinically effective; OR,
• For treatment of delayed male puberty

Limitations:

Androgens are contraindicated in men with carcinomas of the breast or with known or suspected carcinomas of the prostate. For patients that clearly meet the indication for testosterone replacement, the reason(s) for a transition to pellets from other effective replacement (IM, buccal, transdermal) must be specifically addressed in the medical record.

Clinical diagnosis of androgen deficiency (non-specific symptoms, low normal testosterone levels, and normal free testosterone) is not a covered indication. Office practices with high utilization of testosterone pellet implantations can be subject to pre- or post-payment review.

Implantable testosterone pellets for the treatment of symptoms associated with menopause is considered not reasonable and necessary as there is insufficient clinical evidence to support this use and is therefore non-covered.



Documentation Requirements

The medical record must substantiate the medical need for testosterone pellets (Testopel®) with documentation of unsuccessful treatments of standard replacement (IM, buccal, transdermal) on more than one occasion, in men with clinically significant symptoms of androgen deficiency.

The reason(s) for a transition to pellets from other effective replacement (IM, buccal, transdermal) must be specifically addressed in the medical record.

The medical record should reflect two total testosterone levels and free testosterone levels when indicated to determine the medical necessity of testosterone replacement. It is suggested to measure morning testosterone level by a reliable assay on two different days. The results of both tests must fall below the normal laboratory reference range. The medical record should include the Clinical Laboratory Improvement Amendments (CLIA) approved reference normal range for the testosterone assay used.

Medical record documentation must be made available upon request. When the documentation does not meet the criteria for the services rendered, or the documentation does not establish the medical necessity for the service(s), such services will be denied as not reasonable and necessary under Section 1862(a)(1) (A) of the Social Security Act.



Testosterone is an endogenous androgen. Endogenous androgens are responsible for the normal growth and development of the male sex characteristics. Testosterone levels vary from hour to hour; periodic declines below the normal range can occur in some otherwise normal men. In certain medical conditions such as hypogonadism, the endogenous level of testosterone falls below normal levels. The diagnosis of androgen deficiency is made in men with consistent signs and symptoms and unequivocally low serum testosterone levels. Testosterone levels should be determined in the morning, and studies should be repeated in patients with subnormal levels.

Testosterone pellets (Testopel®) have been approved by the Food and Drug Administration (FDA) in adult males for the treatment of primary hypogonadism (congenital or acquired) and hypogonadotrophic hypogonadism (congenital or acquired). Primary hypogonadism includes such conditions as testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testes syndrome; or orchidectomy. Hypogonadotrophic hypogonadism (secondary hypogonadism) includes conditions such as idiopathic or gonadotropic luteinizing hormone releasing hormone (LHRH) deficiency or pituitary-hypothalamic injury from tumors, trauma or radiation. Testopel Pellets are not FDA-approved for administration to females.

Guidelines

Medicare will consider testosterone pellets (Testopel®) medically reasonable and necessary for the following indications:

* Second line testosterone replacement therapy in males with congenital or acquired endogenous androgen absence or deficiency associated with primary or secondary hypogonadism when other standard replacement [intramuscular (IM), buccal, transdermal] is not clinically effective; OR,
* For treatment of delayed male puberty.

Testosterone pellets (Testopel®) method of administration is subcutaneously by a health care professional. 

Limitations

Androgens are contraindicated in men with carcinomas of the breast or with known or suspected carcinomas of the prostate.

For patients that clearly meet the indication for testosterone replacement, the reason(s) for a transition to pellets from other effective replacement (IM, buccal, transdermal) must be specifically addressed in the medical record. Clinical diagnosis of androgen deficiency (non-specific symptoms, low normal testosterone levels, and normal free testosterone) is not a covered indication. Office practices with high utilization of testosterone pellet implantations can be subject to pre- or post-payment review.

Implantable testosterone pellets for the treatment of symptoms associated with menopause is considered not reasonable and necessary as there is insufficient clinical evidence to support this use and is therefore non-covered.


CPT Code Description

11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)


HCPCS Code Description

J3490 Unclassified drugs (Testopel)
S0189 Testosterone pellet, 75 mg (Not recognized by Medicare)


ICD-10 Diagnosis Code Description

C75.1 Malignant neoplasm of pituitary gland
C75.2 Malignant neoplasm of craniopharyngeal duct
D35.2 Benign neoplasm of pituitary gland
D35.3 Benign neoplasm of craniopharyngeal duct
E23.6 Other disorders of pituitary gland
E29.1 Testicular hypofunction
E30.0 Delayed puberty
N44.00 Torsion of testis, unspecified
N44.01 Extravaginal torsion of spermatic cord
N44.02 Intravaginal torsion of spermatic cord


Friday, October 6, 2017

INTERMITTENT NURSING VISITS/AIDE VISITS/THERAPIES Billing Guide

INTERMITTENT NURSING VISITS/AIDE VISITS/THERAPIES

Each visit must be reported on a separate claim line: Medicaid follows Medicare policy on the requirement that each home health agency visit (e.g., nursing, therapy) must be billed on an individual line. This policy includes two visits performed on the same day (i.e., two visits on the same day must be billed on individual lines of the same claim).

Report 15-minute time increments: Medicaid follows Medicare policy for reporting home health visits in 15-minute increments. When billing on the NUBC form, each home health visit revenue code that is reported must have a corresponding 15-minute increment HCPCS code along with the number of15-minute increments reported in the Service Units as follows:

Units Time Requirements

1 1 minute to < 23 minutes

2 23 minutes to < 38 minutes

3 38 minutes to < 53 minutes

4 53 minutes to < 68 minutes

5 68 minutes to < 83 minutes

6 83 minutes to < 98 minutes

7 98 minutes to < 113 minutes

8 113 minutes to < 128 minutes

If services continue for longer periods of time, the home health agency would follow the above pattern. Time of Service Visit: The timing of the visit begins at the beneficiary's home when services actively begin and ends when services are completed. The time counted must be the time spent actively treating the beneficiary. For example:

* If a beneficiary interrupts a treatment to talk on the telephone for other than a minimal amount of time (less than three minutes), then the time the beneficiary spends on the telephone and not engaged in treatment does not count in the amount of service.

* The home health aide completed bathing and transferring the beneficiary into a chair, and now begins to wash the kitchen dishes before leaving. Washing the dishes is considered incidental nd does not meet the definition of a home health aide service. Therefore, the time to perform  this activity would not be included in the 15-minute incremental reporting to Medicaid.


Other nontreatment-related interruptions would follow the same principle. If the beneficiary is late returning home from a doctor’s appointment, the waiting time of the home health agency personnel cannot be counted as treatment time.

However, if the professional spends time with family or other caretakers in the home teaching them to care for the beneficiary, this activity is counted as treatment time. Calls to the physician by the nurse while in the beneficiary’s home to report on the beneficiary’s condition can also be counted as treatment time.

Monday, September 11, 2017

pyelonephritis icd 10 code


N10 Acute tubulo-interstitial nephritis

Includes: acute infectious interstitial nephritis acute pyelitis acute pyelonephritis acute tubular necrosis hemoglobin nephrosis myoglobin nephrosis Use additional code (B95-B97), to identify infectious agent.

N11 Chronic tubulo-interstitial nephritis

Includes: chronic infectious interstitial nephritis chronic pyelitis chronic pyelonephritis Use additional code (B95-B97), to identify infectious agent.

N11.0 Nonobstructive reflux-associated chronic pyelonephritis Pyelonephritis (chronic) associated with (vesicoureteral) reflux

Excludes1: vesicoureteral reflux NOS (N13.70)

N11.1 Chronic obstructive pyelonephritis

Pyelonephritis (chronic) associated with anomaly of pelviureteric junction
Pyelonephritis (chronic) associated with anomaly of pyeloureteric junction
Pyelonephritis (chronic) associated with crossing of vessel
Pyelonephritis (chronic) associated with kinking of ureter
Pyelonephritis (chronic) associated with obstruction of ureter
Pyelonephritis (chronic) associated with stricture of pelviureteric junction
Pyelonephritis (chronic) associated with stricture of ureter
Excludes1: calculous pyelonephritis (N20.9) obstructive uropathy (N13.-)

N11.8 Other chronic tubulo-interstitial nephritis Nonobstructive chronic pyelonephritis NOS

N11.9 Chronic tubulo-interstitial nephritis, unspecified


Chronic interstitial nephritis NOS
Chronic pyelitis NOS
Chronic pyelonephritis NOS

N12 Tubulo-interstitial nephritis, not specified as acute or chronic Includes: interstitial nephritis NOS pyelitis NOS pyelonephritis NOS Excludes1: calculous pyelonephritis (N20.9)

N13 Obstructive and reflux uropathy

Excludes2: calculus of kidney and ureter without hydronephrosis (N20.-) congenital obstructive defects of renal pelvis and ureter (Q62.0-Q62.3) hydronephrosis with ureteropelvic junction obstruction (Q62.1) obstructive pyelonephritis (N11.1)

N13.1 Hydronephrosis with ureteral stricture, not elsewhere classified

Excludes1: Hydronephrosis with ureteral stricture with infection (N13.6)

N13.2 Hydronephrosis with renal and ureteral calculous obstruction Excludes1: Hydronephrosis with renal and ureteral calculous obstruction with infection (N13.6)

N13.3 Other and unspecified hydronephrosis

Excludes1: hydronephrosis with infection (N13.6)

N13.30 Unspecified hydronephrosis

N13.39 Other hydronephrosis

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