Big News for BlueSpeak

In 2023, Blue KC is proud to be celebrating 85 years of being part of the Kansas City community. In addition, 2023 also brings an exciting new re-design of our quarterly provider e-Newsletter, BlueSpeak.

With this updated version, the BlueSpeak email features a fresher and more streamlined look to make it easier to click on articles. BlueSpeak will continue to offer the same helpful information, including provider education, policy updates and announcements. We hope you enjoy learning about what is new at Blue KC in this enhanced format.

If you have questions about any of these updates, please call the Blue KC Provider Hotline at 816-395-3929 for Commercial line of business, 866-508-7140 for Blue Medicare Advantage line of business or 866-859-3822 for the ACA Provider Hotline. We value and appreciate you as our partner in providing quality care.

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Behavioral Health

As a founding sponsor and proud partner of the KC Current, Blue KC offered Mental Health First Aid certification training to members of the KC Current front office on Jan. 24-25.

Blue KC and the KC Current know many of us are living with mental health conditions. Together, we’re expanding the network of people who know how to help through Mental Health First Aid training and the #SidelineTheStigma initiative.

Eleven individuals displayed their commitment to addressing behavioral health challenges. This certification will better prepare and equip KC Current leadership to advise and counsel their players with behavioral health needs.

Click here to watch a recap of the event. To learn more about the #SidelineTheStigma initiative, click here.

Lucet Rebrand and Credentialing Assistance

We wanted to make sure you were aware New Directions Behavioral Health merged with Tridiuum and combined to form Lucet, effective January 19, 2023. Last December, In-Network providers were notified about the rebrand. Here is additional info to know:

• The website for the former New Directions organization now redirects to Lucethealth.com
• Lucet’s technology platform, design and navigation now match the company’s new identity.
• Lucet is rolling out a new provider portal designed to streamline the provider experience

To join the Lucet/Blue KC Behavioral Health networks, please visit Lucethealth.com, click on the Providers tab and click on Join Lucet in the drop down. The instructions on how to complete an application and documentation required will be listed on that page.

To add providers to an existing GROUP account, please go to the Provider tab, click the Provider Portal option and create an account. (If you have already created an account, enter your login information. Emails were sent to providers with login credentials). If you have an account, scroll down the page to access the update forms and the group member applications (for providers within a group).

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Attention! Telehealth Place of Service Billing Issue

Blue KC is seeing a pattern of claims that show the incorrect Place of Service (POS) is being used to bill for telehealth and wanted to provide information to help resolve this issue.

As reported in previous updates, effective January 1, 2022, the Centers for Medicare and Medicaid Services (CMS) revised the description of existing POS code 02 and created new POS code 10 to meet the overall insurance industry needs. Effective April 1, 2022, Blue KC modified its claims system to reflect this change.

It is important that providers use the correct coding guidelines published by CMS:

• POS 02: Telehealth Provided Other than in Patient’s Home
  • o Descriptor: The location where health services and health related services are provided or received through telecommunication technology. Patient is not located in his or her home when receiving health services or health related services through telecommunication technology.
• POS 10: Telehealth Provided in Patient’s Home
  • Descriptor: The location where health services and health related services are provided or received through telecommunication technology. Patient is located in his or her home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.
• POS for telehealth is not driven by the provider’s location. It is driven by the member’s location.
• When filing claims with POS code 02 or POS code 10 for telehealth, please remember to follow the correct coding guidelines.

Telehealth services billed by a provider with a POS code 02 is based on the Medicare fee schedule for telehealth services provided in a facility. The Medicare fee schedule for telehealth services in a facility (POS code 02) is reimbursed at a lower amount than telehealth services provided in the patient’s home (POS code 10).

Currently, providers do not see a change in reimbursement due to zero cost-sharing during the public health emergency (PHE). However, post-PHE cost sharing will apply, and this will cause member abrasion if not billed correctly. This will also create unnecessary work for both the provider and Blue KC. Please make sure your billing office understands the importance of billing the correct POS.

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Overpayment Letter Request

Have you ever received a letter from Blue KC stating a claim has been overpaid and requesting reimbursement of the identified overpayment? We appreciate the reimbursement check we receive from you to help resolve this issue, but please make sure to attach your check to the Overpayment Letter when you mail it to our Claims Recovery department within 30 days from the date of the letter.

Thank you for your cooperation to expedite resolution of the overpayment.

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Blue Medicare Advantage Information

The CMS CAHPS Annual Surveys Arrive in Patient Mailboxes

Last quarter, we reviewed the background on the Centers for Medicare & Medicaid Services (CMS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey administration and noted the CAHPS survey has demonstrated that reflecting on the patient’s feedback regarding their healthcare is imperative.

Each year, CMS selects a sample of Medicare Advantage (MA) and Prescription Drug Program (PDP) beneficiaries to receive a CAHPS survey. To increase focus on patient experiences, CMS has made CAHPS survey results the most significant contributor to an overall STAR rating.

The surveys started getting mailed to your MA patients this month and will continue through May. As a trusted provider of our members, we ask that you encourage your patients to participate and complete the survey if they receive one.

References: Al-Abri, R., & Al-Balushi, A. (2014). Patient satisfaction survey as a tool towards quality improvement. Oman medical journal, 29(1), 3. Michael, M., Schaffer, S. D., Egan, P. L., Little, B. B., & Pritchard, P. S. (2013). Improving wait times and patient satisfaction in primary care. Journal for Healthcare Quality, 35(2), 50-60. Xu X, Buta E, Price RA, Elliott MN, Hays RD, Cleary, PD. Methodological considerations when studying the association between patient-reported care experiences and mortality. Health Serv Res, 2015, 50 (4): 1146-1161.

2023 ICD-10 Code Changes

Here’s a look at the 2023 International Classification of Diseases, Tenth Revision (ICD-10) Code Changes:

1176 New codes added in 2023

251 Deleted codes in 2023

36 Codes converted into Parent Codes

Significant Guideline updates

Coding updates have been released at a more frequent rate than previous years – This is caused from transitioning from a fee for service structure to a value-based care system.

Dementia is one of the top categories that have 2023 changes:

Mixed Dementia is from more than one cause. There is an important ICD-10 guideline update for dementia which states:

“The ICD-10-CM classifies dementia (categories F01, F02, and F03) on the basis of the etiology and severity (unspecified, mild, moderate or severe). Selection of the appropriate severity level requires the provider’s clinical judgment and codes should be assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification. If the documentation does not provide information about the severity of the dementia, assign the appropriate code for unspecified severity.

If a patient is admitted to an inpatient acute care hospital or other inpatient facility setting with dementia at one severity level and it progresses to a higher severity level, assign one code for the highest severity level reported during the stay.”

Dementia has 87 additional codes added for 2023. Codes for Dementia are expanded to include:

• Type (Alzheimer’s, Lewy Body, Vascular, Frontotemporal, or Other etc.)
• Severity (Mild, Moderate, Severe, Unspecified)
• Specificity (Behavior Disturbances, Mood Disturbances, Psychotic Disturbances, Agitation, Anxiety etc.)

Use the combination code when the word “with” is documented by the provider. Follow all conventions, general coding guidelines and chapter specific guidelines when selecting appropriate codes. Read all instructional notes in the tabular list. Look for “code first”, “use additional code”, “excludes 1” and “excludes 2” notations to select the appropriate codes.

References: CMS. (2022, October 1). ICD-10-CM Official Guidelines for Coding and Reporting FY 2023. p. 43.
https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines-updated-01/11/2023.pdf
https://www.cdc.gov/nchs/icd/comprehensive-listing-of-icd-10-cm-files.htm

Primary Care Provider on Blue Medicare Advantage Member ID Cards

For all Blue Medicare Advantage plans in 2023, the primary care provider (PCP) is listed on the member's ID card. Members with PPO plans are not required to use the PCP on their cards.

• This is to help with coordination of care between providers.
• PPO members can see a PCP who is different than the one on their card.
• Members can change the PCP name on their card at any time.
• The PCP name on the card has no impact on network coverage.

Diabetic Testing Supplies

Please be aware that the preferred brand of testing supplies for our Blue Medicare Advantage plans is Contour. This includes meter, test strips and lancets. Contour brand supplies are a $0 cost share at retail pharmacies.

Non-preferred brands such as One Touch, Accu-Chek and Freestyle will lead to a 20% cost share for your patients.

Continuous Glucose Monitors

Blue Medicare Advantage has two preferred Continuous Glucose Monitors (CGM) products: Freestyle and Dexcom. Any other CGM product will require approval through the normal exception process

Reminder – CGM products should only be prescribed to patients who meet the current CMS criteria. This includes:

Member is diagnosed with diabetes

Member is treated with 3+ daily administrations of insulin (or continuous insulin infusion)

Insulin regimen requires frequent adjustment based on BGM or CGM testing results

In-person visit within 6 months

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Prior Authorization Updates

New Go-Live Date for Pain Management, Radiology and Cardiology Prior Authorization with eviCore

• Our revised go-live date for transitioning prior authorization for Pain Management procedures over to eviCore took place on March 1, 2023. eviCore started accepting Pain Management requests for Blue KC members through the CareCore National portal on February 24, 2023 for dates of service March 1, 2023 or later.
• When submitting a request on the CareCore National portal for a Blue KC member, please note the 3-digit alpha prefix in the Member ID is not required, but the last 2 digits are required.
• Note: Any Pain Management Procedures already authorized by Blue KC before March 1, 2023 remain in effect and do not need to be resubmitted to eviCore, regardless of whether the date of service is on March 1, 2023 or later. Procedures that were not on the prior authorization list prior to March 1, 2023 and are being performed on or after March 1, 2023 REQUIRE a prior authorization to be in place.
• *Important Update: Below is the complete list of additional codes that moved to eviCore. We recently updated this list, so please make sure you have the correct impacted codes:

  01939	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	ANESTHESIA
  01940	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	ANESTHESIA
  01941	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	ANESTHESIA
  01942	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	ANESTHESIA
  0213T	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  0214T	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  0215T	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  0216T	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  0217T	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  0218T	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  0627T	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	PERCUTANEOUS INJECTION
  0628T	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	PERCUTANEOUS INJECTION
  0629T	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	PERCUTANEOUS INJECTION
  0630T	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	PERCUTANEOUS INJECTION
  22526	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	THERMAL INTRADISCAL
  22527	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	THERMAL INTRADISCAL
  27096	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	SI JOINT
  62263	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	ADHESIOLYSIS
  62264	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	ADHESIOLYSIS
  62280	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	ADHESIOLYSIS
  62281	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	ADHESIOLYSIS
  62282	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	ADHESIOLYSIS
  62287	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	DECOMPRESSION PROCEDURE
  62292	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	CHEMONUCLEOLYSIS
  62320	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  62321	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  62322	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  62323	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  62324	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  62325	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  62326	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  62327	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  62350	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	SPINAL IMPLANT	DRUG PUMP
  62351	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	SPINAL IMPLANT	DRUG PUMP
  62360	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	SPINAL IMPLANT	DRUG PUMP
  62361	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	SPINAL IMPLANT	DRUG PUMP
  62362	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	SPINAL IMPLANT	DRUG PUMP
  63650	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	SPINAL IMPLANT	NEUROSTIMULATOR IMPLANT
  63655	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	SPINAL IMPLANT	NEUROSTIMULATOR IMPLANT
  63663	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	SPINAL IMPLANT	NEUROSTIMULATOR IMPLANT
  63664	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	SPINAL IMPLANT	NEUROSTIMULATOR IMPLANT
  63685	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	SPINAL IMPLANT	NEUROSTIMULATOR IMPLANT
  64451	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	SI JOINT
  64479	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  64480	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  64483	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  64484	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	EPIDURAL STEROID
  64490	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  64491	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  64492	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  64493	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  64494	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  64495	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	FACET JOINT
  64510	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	REGIONAL SYMPATHETIC BLOCK
  64520	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	REGIONAL SYMPATHETIC BLOCK
  64625	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	SI JOINT
  64633	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	SPINAL DENERVATION RFA
  64634	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	SPINAL DENERVATION RFA
  64635	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	SPINAL DENERVATION RFA
  64636	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	SPINAL DENERVATION RFA
  G0260	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	SI JOINT
  M0076	CPT/HCPCS	MSK	INTERVENTIONAL PAIN	INJECTIONS	PROLOTHERAPY

• These codes are the same for Commercial, Blue Medicare Advantage, ACA QHP and Small Group ACA. Previously, some of these codes did not require a prior authorization, so we encourage you to become familiar with this change. JAA Note: Blue KC is managing these additional Pain Management prior authorization codes for our Joint Administrative Account (JAA) line of business.
• Also, the transition of Radiology and Cardiology from one eviCore platform to another took place on March 1, 2023. This means eviCore started accepting Radiology and Cardiology requests for Blue KC members through the CareCore National portal on March 1, 2023. Previously, eviCore administered prior authorization reviews for High-Tech Imaging and Cardiology on the MedSolutions portal for Commercial, Blue Medicare Advantage, ACA QHP and Small Group ACA. As of March 1, 2023, those reviews are being administered through the CareCore National portal.
• eviCore recently held nine online training sessions to assist you and your staff with the prior authorization changes to Pain Management Procedures and Radiology/Cardiology.
• These sessions included information about the prior authorization process, accessing information from the eviCore website and a question-and-answer period.
• If you were unable to participate in a session, you can obtain a copy of the presentation, as well as other important documents, at https://www.evicore.com/resources/healthplan/blue-cross-blue-shield/kansas-city. Once you arrive on that page, you can find the presentation by going to the Solutions Resources tab, clicking on Radiology and then selecting Resources. Documents are available in PDF format. If you need Adobe Reader, you can download it from adobe.com/products/reader.
• If you have any questions regarding the eviCore web portal, please contact the Web Support team via email at portal.support@evicore.com or via phone at 800.646.0418 (Option 2). For any Client or Provider inquiries not associated with this training, please email ClientServices@evicore.com.

Code Updates

The codes below will be added to our prior authorization list, effective May 1, 2023. Be sure to use your log-in credentials at Providers.BlueKC.com, and click on our newly transformed Prior Authorization function on the home page to view current prior authorization lists.

Code	Description	Effective date	Line of Business
S9123	Nursing care, in the home; by registered nurse, per hour	5/1/2023	Commercial and ACA
S9124	Nursing care, in the home; by licensed practical nurse, per hour	5/1/2023	Commercial and ACA
T1000	Private duty/independent nursing service(s), licensed, up to 15 minutes	5/1/2023	Commercial, ACA and MA
T1001	Nursing assessment/evaluation	5/1/2023	Commercial, ACA and MA
T1002	RN services, up to 15 minutes	5/1/2023	Commercial, ACA and MA
T1003	LPN/LVN services, up to 15 minutes	5/1/2023	Commercial, ACA and MA
T1030	Nursing care, in the Home, by registered nurse, per diem	5/1/2023	Commercial, ACA and MA
T1031	Nursing care, in the Home, by licensed practical nurse, per diem	5/1/2023	Commercial, ACA and MA

Change for ACA Member Prior Authorization/Concurrent Review Requests

Do you have the new phone and fax numbers for ACA Member Prior Authorization and Concurrent Review Requests after they recently changed? ACA member requests for Prior Authorizations should now be called into 816-395-3989 or faxed to 816-926-4253. This fax number should also be used for additional clinical information for authorizations already initiated. Inquiries regarding ACA Prior Authorization can be directed to these contact numbers, as well. Concurrent Review documents and Notice of Admissions for ACA members should be faxed to 816-395-2363.

The easiest way to submit a prior authorization for ACA members is by logging into our Provider Portal at Providers.BlueKC.com and clicking on the prior authorization box on the home page.

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Payment Policy Updates

30-day Readmission

Blue KC wants to inform you that our new 30-day Readmission Payment Policy will be effective May 1, 2023.

This payment policy will apply to all lines of business, including, but not limited to, Commercial, Blue Medicare Advantage, Federal Employee Program, ACA QHP for Individual/Family and Small Group ACA.

With this new policy, Blue KC will not allow payment for the second or subsequent admission when a member is readmitted for the same or similar diagnosis within 30 days of discharge. Facilities are to submit a replacement claim for the originally submitted inpatient stay to seek reimbursement for the additional covered days.

A hospital readmission is an episode where a patient, who has been discharged from a hospital, is admitted again to the same or similar hospital for the same or related care within 30 days.

A same or similar hospital is defined as a hospital that is a part of a hospital system operating under the same hospital agreement, and/or if the hospital shares the same tax identification number with one or more other hospital(s).

Any readmission to the same hospital within the 30 days of initial discharge is subject to a medical record review on a pre-adjudication or post-payment basis.

For more details about this new payment policy, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Change to Durable Medical Equipment

Effective April 1, 2023, Blue KC will enforce the Durable Medical Equipment (DME) National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) allowed amounts as outlined in the DME Payment Policy, POL-PP-195. This is to ensure subscribers are receiving the correct number of resources necessary, but not in excess.

As a reminder, for Commercial, FEP, ACA and Host Claims:

When billing for monthly DME supplies that exceeds one unit per date of service, please submit units for each day on separate claim lines. Examples: DOS 1/1/2023 A4332 2 units DOS 1/2/2023 A4332 2 units DOS 1/3/2023 A4332 2 units When billing for monthly supplies that equal one unit per day, please use a date range. Example: DOS 1/1/2023-1/30/2023 A4259 30 units

For Blue Medicare Advantage Claims, the following DME items require a date span on all claims submitted:

Diabetic testing supplies (i.e., test strips, lancets) Continuous passive motion devices (CPM) Parenteral and enteral nutrition and administration kits External infusion pump supplies Suppliers must span the dates of service using “from” and “to” dates on any claim for items listed above. The “from” date is when the items were provided to the member. The “to” date is the last date the supplies are expected to be used.

For more details, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

2023 CPT Evaluation and Management Guidelines

Effective January 1, 2023, Blue KC added a new payment policy for 2023 CPT Evaluation and Management (E/M) Guidelines (POL-PP-236). The policy addresses the following changes:

Deletion of Hospital Observation Services E/M codes 99217-99220. Hospital inpatient admit, subsequent and discharge codes will now be used for observation services, as well.

Revision of Hospital Inpatient and Observation Care Services.

Deletion of Consultations E/M codes 99241 and 99251.

Revision of Consultations E/M codes 99242-99245, 99252-99255.

This policy replaces Observation Services, Consultations, Evaluation and Management Services and 2021 Office and Outpatient Evaluation Services, which have been archived. Emergency Care, Prolonged Services and Critical Care have been updated to reflect the 2023 Evaluation and Management updates/revisions.

For more details, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Chiropractic Care Payment Policy Reminder

According to the Chiropractic Care Payment Policy, Chiropractic Manipulative Treatment (CMT) CPT codes 98940-98942 are used to indicate the number of spinal areas manipulated. Per the payment policy, CPT codes for musculoskeletal adjustments must have a specific coinciding ICD-10 diagnosis code to support each region of manipulation.

Blue KC will be enforcing this policy on a prepayment basis, which means that claims will be denied if appropriate diagnosis codes are not assigned. For more details on this policy, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

Organ Acquisition Costs

Effective January 1, 2023, Blue KC has a new payment policy for Organ Acquisition Costs. Any claim submitted by a certified transplant center (CTC) that contains organ acquisition costs will be stopped, and a request will be sent for form CMS‐2552‐10, Worksheet D4 (Parts I‐IV). The form and Worksheets are Computation of Organ Acquisition Costs and Charges for Hospitals that Are CTCs.

Any facility claim that is billed for organ acquisition costs that does not send form CMS‐2552‐10 and Worksheets I‐IV to Blue KC upon request will be denied as an incomplete claim submission. To view this payment policy, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

IOP, PHP and Inpatient Treatment Services for Substance Abuse and Psychiatric Care

Effective February 1, 2023, Blue KC has a new payment policy for IOP, PHP and Inpatient Treatment Services for Substance Abuse and Psychiatric Care.

This policy outlines program criteria and documentation requirements for partial hospitalization, intensive outpatient and short term residential mental health and substance abuse treatment. To view this payment policy, go to the log-in page at Providers.BlueKC.com and click on Go to Payment Policies.

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Medical Policy Updates

New Blue KC Policies

The most up-to-date Medical Policy can be found by logging into Providers.BlueKC.com and clicking on the Medical Policies section. While on that web page, you can also find a link to view Milliman Care Guidelines (MCG), which complement our Blue KC policies.

The Blue KC Medical Policy encompasses internal Blue KC Medical Policy, Blue Cross Blue Shield Association derived Medical Policy and policies adopted from our vendor partners, such as Avalon (APEA), MCG and EviCore.

Effective date – 4/1/2023	5.02.632 Hemgenix® 5.02.632 Hemgenix® (etranacogene dezaparvovec-drlb)
Effective date – 4/1/2023	5.02.633 5.02.633 Leqembi (lecanemab-irmb)

Knee Arthroscopy

Updates to Blue KC’s Knee Arthroscopy guidelines related to meniscectomy or meniscal repair became effective on March 1, 2023. Changes include:

• X-rays clearly identifying the Kellgren-Lawrence grade will be required.
• History must document specific details about function-limiting pain.
• Exam must document several specific abnormal findings.
• MRI must show a meniscal tear extending to the articular surface that corresponds to symptoms and exam.
• A minimum of three (3) consecutive months of provider-directed non-surgical management must be documented, including specific medications, injections and a minimum of 6-weeks of supervised physical therapy.
• A locked knee on office physical exam that interferes with ambulation will allow exceptions to some requirements.

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Pharmacy Policy Updates

Upcoming Removal of Abiraterone Drug from Formularies

On Feb. 1 2023, Blue KC removed the drug, Abiraterone 500 mg, from our formularies. A specific generic version of Abiraterone 250 mg made by CivicaRx is covered.

Abiraterone is used together with steroid medication (prednisone) to treat prostate cancer that has spread to other parts of the body. The medication is available through a singular partnership with OrchestraRx Specialty Pharmacy.

We made this change because the generic product made by CivicaRx is now available and is the most cost-effective product available. This product contains the same active ingredient as the abiraterone product.

Commercial Preferred Formulary Updates

Here’s a look at new Blue KC pharmacy polices that will require prior authorization and went into effect on March 1, 2023 for our Commercial Preferred Formulary members:

New Pharmacy Policies
Policy Number	Policy Name	Summary
5.01.806	Zoryve (roflumilast) cream	FDA approved for Plaque Psoriasis; Topical; Pharmacy benefit
5.01.807	Relyvrio (sodium phenylbutyrate and taurursodiol)	FDA Approved for Amyotrophic Lateral Sclerosis (ALS); Oral; Specialty pharmacy benefit
5.01.809	Continuous Glucose Monitors, Sensors, and Transmitters	Converted MCG Guidelines which mirrored the Optum Guidelines into our own Blue KC pharmacy policy template.

See below for Pharmacy Policies that will go undergo changes for our Commercial Preferred Formulary members, effective April 1, 2023:

Pharmacy Policies with Changes
Policy Number	Policy Name	Summary of Changes
5.01.642	Keveyis (dichlorphenamide)	Added step requirement through new generic dichlorphenamide
5.01.524	Step Therapy Policy	Added generic topiramate ER to step before brand name Trokendi
5.01.611	Esbriet (pirfenidone)	Added step requirement through new generic pirfenidone
5.01.687	Hetlioz (tasimelteon)	Added step requirement through new generic tastimelteon

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Provider Portal Enhancements

Blue KC’s Provider Portal is now better than ever! Our powerful digital tool for providers can be accessed 24/7 with a click of a button!

Provider Portal Features include:

• Search and review claims
• Submit and view electronic prior authorizations
• Look up member eligibility and benefits
• Access Medical and Payment Policies
• See provider remittances
• View Provider Reference Guides
• Check out recent news updates
• Read BlueSpeak provider e-Newsletter
• Find helpful provider forms
• Use dental resources
• And so much more!

Blue KC is proud of recent enhancements that were made to the Portal.

A new-look home page gives you one- to two-click access to core health insurance functions, including member eligibility and benefits, prior authorization, claims inquiry and remittances.

The new enhancements provide quicker account registration and a much easier prior authorization experience. To learn more, click here to view a written summary and video about each enhancement.

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Contact Us

Please join the BlueSpeak email distribution list by sending a request to BlueSpeak@BlueKC.com. You can also use this email address to give us any feedback about BlueSpeak. We would love to hear from you!

If you have questions about any of these updates, please call the Blue KC Provider Hotline at 816-395-3929 for Commercial line of business, 866-508-7140 for Blue Medicare Advantage line of business or 866-859-3822 for the ACA Provider Hotline. We value and appreciate you as our partner in providing quality care.

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