BlueSpeak Newsletter

Annual Reminder - Medicare Outpatient Observation Notice (MOON) Required

As of March 8, 2017, hospitals and Critical Access Hospitals (CAH) must give the standardized Medicare Outpatient Observation Notice (MOON) to people who receive Medicare benefits and are observed as outpatients for more than 24 hours. This applies to Medicare and/or Medicare health plans.

This notice lets people know why they are not considered to be inpatient and what their cost sharing and hospital coverage will be. It must be communicated verbally and completed no later than 36 hours after observation begins or sooner if patients are admitted, transferred or released. Patients must sign to confirm they have received and understand the notice. If they decline, the staff member who gave the patient the notice must certify that it was presented.

Additional information on the MOON can be found here.

New Directions ABA Medical Policy/Coverage Criteria Reminder

The New Directions Applied Behavior Analysis (ABA) Medical Policy was revised on January 1, 2019.

The new version includes:

  • New definitions of functional assessments, functional behavior assessments, standardized assessments, non-standardized assessments and custodial care.
  • Emphasis on member progress over time and intensity of treatment.
  • Parent training requirements for monitoring data on parent progress with incorporating treatment techniques in the home and community.
  • More specific transition planning requirements.
  • Parameters on telehealth for ABA.
  • Corrections for spelling errors, abbreviations, and grammar were made and additional references were included.

Noticeable difference include:

  1. Comprehensive Diagnostic Evaluation Changes:
    • None
  2. Initial and Continued Stay Criteria Changes:
    • Focus on active Autism Spectrum Disorder (ASD) core symptoms now includes a specific reference to substantial deficits and clinically significant aberrant behaviors.
    • Initial and ongoing assessments are now required to utilize direct observation of the member.
    • Treatment plan goals have been clarified to include measured baseline of targeted goal, objective present level of behavior, and mastery criteria.
    • Telehealth/telemedicine parameters have been included to allow for supervision and parent training activities through this modality and to exclude direct member care through telehealth.
    • Caregiver participation now indicates that not meeting this criteria will require the treater to supply clinical rationale to address generalization of skills in the community and home setting. Caregiver training requirements have been modified to include the need for data gathering and analysis of caregivers’ ability to implement ABA techniques while the member is in the home and community.
  3. Continue Stay Criteria Changes:
    • Transition of care requirements now include specific tasks to be completed during each review period.

Should you have questions related to these changes or to request a copy of the New Directions ABA Medical Policy, please email Tiara Bonds, Behavioral Health Provider Relations Representative, at Tiara.Bonds@BlueKC.com.

HEALTHCARE

Telemedicine Frequently Asked Questions (FAQs) for Blue KC Providers

What is Telemedicine?
Telemedicine relies on the use of secure electronic communications and software to provide medical care and clinical services to patients without an in-person visit. It is incumbent on the provider to determine whether the standard of care can be met remotely for the diagnosis and treatment of a given medical condition.

Telemedicine technology is frequently used for follow-up visits, minor urgent care, management of chronic conditions, medication management, specialist consultation and a variety of other clinical services that can be offered remotely. Remote visits allow patients to have a brief medical or behavioral health visit with a doctor or therapist in a fast and convenient manner using a computer, tablet or mobile device.

Telemedicine is a service delivery model, not a member benefit. If a provider determines that he or she can effectively treat a patient through this modality, and the diagnosis or treatment is covered per the member’s contract, there is nothing that prohibits that provider from utilizing telehealth technology in the delivery of care.

What are common use cases for telemedicine?
Telemedicine can be used for most care issues that do not require a physical exam, including but not limited to:

  • Follow-up visits.
  • Minor urgent care.
  • Medication discussion, adjustments or refills.
  • Review of test, lab or imaging results.
  • Remote chronic disease management.
  • Specialist referrals.
  • Others issues dependent on specialty.

What type of visits are not optimal for telemedicine?

  • Visits that would require a physical exam to properly diagnose the patient.
  • Always left to the discretion of the provider—it is incumbent on the provider to determine whether the standard of care can be met remotely for the diagnosis and treatment of a given medical condition.

What are unacceptable/non-covered types of telecommunication for telemedicine?

  • Store-and-forward technology.
  • Email messages.
  • Internet-based audio-video communication that is not secure and HIPAA compliant (i.e., Skype).

How will I know if a visit is from a telemedicine encounter?

Blue KC encourages providers to leverage telehealth technology in ways best suited for their patients and their practice. Current CPT coding can support the use of GT (via interactive audio and video telecommunications system) or GQ (via asynchronous telecommunications system) modifiers with specific types of services, including but not limited to standard office visit codes (i.e., 99212). Blue KC recognizes the important value telehealth provides in delivering care to patients. These modifiers are helpful in tracking the use of telehealth-related care delivery.

Remember: Always verify the accepted billing codes for telemedicine before you do the visit.

  • Blue KC does not reimburse providers for any technology fees associated with using a telehealth technology.
  • Blue KC does not cover CPT code 99444.

What are the benefits of offering telemedicine?

  • Real-time interactive access to visit with a doctor or therapist through Blue KC’s local and national provider networks.
  • Increased patient satisfaction.
  • Offload the burden of a full waiting room, limiting the spread of some contagious illnesses.
  • Support the commitment to primary care as the central coordination point for a patient's total care.
  • Improved clinical outcomes.
  • Easier patient access can result in better compliance with treatment plans.

State Parity Laws

Many states have laws that require private payers to reimburse healthcare providers for visits performed with certain types of telemedicine technology. Like other payers, Blue KC is subject to these requirements. Missouri parity law requires equitable reimbursement for services delivered by telehealth.

Each state has made its own determination about what types of telemedicine will be covered, but everyone with a telehealth parity law covers live video visits.

Does Blue KC contract with any independent telehealth providers for acute or urgent care?

Blue KC is contracted with American Well (Amwell) to give members access to a doctor for their acute care needs.

What services are included in the Blue KC - Amwell telehealth offering?

At this time, the telehealth services offered to Blue KC members are limited to medical and children’s medical services only. Other services such as diet and nutrition, lactation counseling and psychology are not supported at this time. Amwell can take care of most common medical issues like, colds, flu, fever, rash, sinusitis, pinkeye, ear infection and migraines.

If you have any additional questions about telemedicine, please contact your Blue KC Provider Representatives or the Provider Hotline at 816-395-3929.

Facility Routine Supplies and Services Reimbursement Policy Reminder

On November 1, 2018, Blue KC adopted a new Facility Routine Supplies and Services (Policy Number: 10.01.532) reimbursement policy.

A complete copy of the policy can be found here.

Should you have questions about this policy, please contact your designated Blue KC Provider Representatives or the Provider Hotline at 816-395-3929.

Contact Us

BlueSpeak is published three times a year as a service to Blue KC network providers.

Reader's comments are welcome. Please send an email to Tasha James at Tasha.James@BlueKC.com.

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