Celebrating 85 Years in Kansas City!
Blue Cross and Blue Shield of Kansas City (Blue KC) is proud to partner with our providers from the same region we have called home since 1938. As the largest not-for-profit health insurer in Missouri and the only not-for-profit commercial health insurer in Kansas City, Blue KC continues to celebrate our 85th anniversary of being part of the Kansas City community.
We hope these updates in our BlueSpeak Newsletter are beneficial to you, as we look to provide helpful information to improve your Blue KC experience. As a fun way to celebrate our anniversary, click on this link to test your knowledge of this beautiful city we call home.
The Kansas City Current and Blue KC founding partner and the Official Health Insurance Partner of the Current held the “Sideline the Stigma” event for the second year on August 26, in partnership with Synergy Services in Kansas City, MO. The event provided youth with the opportunity to participate in various workshops about movement, music, art and have a conversation about mental health. Kansas City Current players Desiree Scott and Jordan Silkowitz joined the event to talk about removing the stigma around mental health challenges.
Kansascitycurrent.com/sidelinethestigma includes access to Mental Health First Aid® training opportunities, mental health statistics and contact information for local and national crisis lines.
Register Now for Implicit Bias Training
On Tuesday, October 3, 2023, Blue KC will team up with the March of Dimes by offering virtual and accredited Implicit Bias Training. The session will take place from 1 p.m. – 5 p.m. CT and will be at no cost to the participant. An experienced March of Dimes Implicit Bias Trainer will lead the session.
The virtual training, Awareness to Action: Dismantling Bias in Maternal and Infant Healthcare™, will provide authentic, compelling content for healthcare providers caring for women before, during and after pregnancy. Implicit Bias will also be covered on a broad scale, so this training will be for all healthcare professionals. Scan the QR code below to pre-register for the session. For questions, email email@example.com.
Pre-register for this session at https://tinyurl.com/2s48wzsz
Or scan below to register!
In support of improving patient care, this activity has been planned and implemented by Amedco LLC and March of Dimes. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medication Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
- Physicians: Amedco LLC designates this live-streaming activity for a maximum of 3.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
- Nurses: Amedco LLC designates this activity for a maximum of 3.50 ANCC contact hours.
New Blue KC Tool to Help KC Community
With the help of the new Blue KC Community Support Tool, Kansas Citians can easily locate free and reduced-cost support services in their neighborhoods. The tool compiles local support services for food, housing, transit, health, education, and so on, in one directory.
People can search for resources anonymously by ZIP code, category, keyword, program name and organization name. The tool filters the results and populates the most relevant organizations.
Each organization provides extensive information, such as eligibility, availability, and cost guidelines. A green button on each organization’s entry connects people to next steps or an electronic contact form.
The Community Support tool is available to Blue KC members and all Kansas Citians at BlueKC.com/CommunitySupport.
Replace Old Forms with New Helpful Forms
Blue KC is seeing a pattern of providers using old forms when it comes to Provider Updates and Credentialing. As reported in previous Blue KC monthly Provider Bulletins, we want to make sure you know we have new versions of these forms available on our Provider Portal, so we will no longer be accepting older versions of these forms. We have an easier-to-use Provider Updates Form (see this helpful video to fill it out) and six different form options to meet your credentialing needs, from initial credentialing to revalidation. To find these enhanced forms, log into Providers.BlueKC.com, click on Forms under Quick Links on the home page and look under the Provider Services header.
And that’s not all! We are pleased to bring you a new field to our Claim Inquiry Form. When the provider selects “Questioning Allowable”, the provider can now enter an expected reimbursement amount for a billing code. You will also be able to enter the Member’s Plan name and attach a copy of a fee schedule that applies to the claim. This enhancement will allow for a more efficient and smooth claims process. To find the claim inquiry form, log into Providers.BlueKC.com, click on Forms under Quick Links on the home page and look under the Claim Forms header.
Timely Filing, Electronic Claim Submission Reminder
Do you know the correct steps to follow for timely filing and electronic claim submission? We receive many provider questions about these topics, and we think it would be beneficial if providers reviewed information from our Blue KC Provider Reference Guide for a refresher on our business processes The information is in our Provider Reference Guide at this link: https://Providers.BlueKC.com/Content/PDFs/PRG/ClaimsBillingRemittance.pdf.
Another section of our Provider Reference Guide that could be helpful for these topics is our Contact Resource Directory, which is at https://Providers.BlueKC.com/Content/PDFs/PRG/ContactResources.pdf.
Important Provider Information
Blue KC wants to make sure you have important information related to five key areas:
- Member Rights and Responsibilities: Blue KC members have certain rights and responsibilities. For a complete list of the Blue KC Member Rights and Responsibilities, please visit:
- Utilization Management Policies: Medical and Pharmacy review criteria, along with Medical policies, are available at https://Providers.BlueKC.com/Content/PDFs/PRG/HealthServices.pdf or by calling 816-395-3989.
- Pharmacy Services: Pharmacy Management policies and current information regarding classes of medications requiring prior authorization, step therapy, specialty pharmacy and/or having dose optimization/quantity limits are available by logging into the provider portal at https://Providers.BlueKC.com. In addition, explanation on limits/quotas, the steps required to initiate an exception request, and the Blue KC process for generic substitution, therapeutic interchange and step therapy protocols are accessible by logging into the provider portal at https://Providers.BlueKC.com or by contacting Pharmacy Services at 816-395-2176.
- Special Notice How Utilization Management Operates: Blue KC’s Population Health division, Pharmacy Services, participating network physicians and providers make decisions about Blue KC members’ healthcare needs based on the medical appropriateness of the care and service. Our goal is to identify and promote cost effective usage of healthcare resources to ensure that quality healthcare services are delivered to our members. Blue KC does not reward its Utilization Management (UM) staff for issuing denial of coverage decisions. There are no financial incentives offered to UM staff to make decisions that would encourage underutilization of services. Learn more at https://Providers.BlueKC.com/Content/PDFs/PRG/HealthServices.pdf.
- Complex Case Management: Information on our Complex Case Management Program, including referral criteria and how to refer patients to the Program, can be found at https://Providers.BlueKC.com/Content/PDFs/PRG/HealthServices.pdf.
Offshore Data Sharing
Blue KC has identified network providers who are sharing PHI or contracting with third parties that share PHI offshore. We want to remind providers that Blue KC is required to attest to CMS when our PHI is being shared offshore.
We are working to provide education on this requirement that providers must notify Blue KC and receive permission from us prior to offshoring agreements being in place. Blue KC also requires providers notify us of any current offshore PHI sharing that is occurring by you or subcontractors that you use.
Thank you in advance for your cooperation and collaboration with us to fulfill this CMS requirement.
Flu Vaccine Awareness for High-Risk Members
This upcoming fall and winter, Blue KC wants to create provider awareness on the importance of our high-risk members receiving the flu vaccine for the best protection against getting the flu. Individuals 65 and older contribute to most seasonal flu-related hospitalizations (50% to 70%) and deaths (50% to 85%). However, people with certain chronic conditions may be associated with an even greater risk of flu complications. These include, but are not limited to the following:
- Lung Disease (Asthma/COPD) Unvaccinated individuals with Chronic Obstructive Pulmonary Disease (COPD) are at significantly greater risk of being hospitalized with flu complications compared to those who have been vaccinated.
- Heart disease (CHF) Individuals with conditions such as Congestive Heart Failure (CHF) may have up to a six times higher risk of having a heart attack within a week of a confirmed flu infection, especially for older adults and those experiencing their first heart attack.
Additionally, Blue KC data suggests that high-risk members with a flu-like diagnosis are hospitalized more often, utilizing more resources with more costly outcomes. We look forward to working together to educate our high-risk members on how to outsmart the flu!
Blue Medicare Advantage Updates
New Peer-to-Peer Timeline for Blue Medicare Advantage
To simplify our Peer-to-Peer process for Urgent/Emergent hospital admissions and continued stay reviews of hospitalizations, Blue KC will now align our Blue Medicare Advantage timeframes with our current Commercial timeframes. Going forward, a physician will have two business days to request a Peer-to-Peer discussion, and the discussion must be completed within seven business days of the denial notification.
Provider Responsibilities for Expedited Member Appeals
Blue KC wants to make sure you have the information you need to make expedited member appeals requests as smooth as possible for our Blue Medicare Advantage line of business.
Who can appeal on behalf of the member?
Physicians can request a standard or expedited appeal of an adverse determination on behalf of their members. However, if not requested specifically by the attending physician, an Appointment of Representative (AOR) Form to submit an appeal on behalf of a Medicare member may be required. The AOR Form can be found online and downloaded here: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012207.
- Nurse Practitioners, Physician Assistants, nurses and office staff will require an AOR form to appeal on behalf of the member. If the appeal is requested on physician letterhead, the appeal will be accepted.
- The best practice is for the attending physician to sign the appeal request. This will prevent delays in processing the appeal.
What is an expedited appeal?
Expedited appeals for requested services pertain to those services in which the standard appeal time period (30 days for Part C, meaning medical services, procedures, facility admissions etc., and 7 days for Part B, which relates to drugs that are not provided by retail pharmacy under the Part D benefit coverage) could seriously jeopardize the member’s life, physical or mental health or the member’s ability to regain the maximum function. Blue KC must resolve an expedited review within 72 hours or as expeditiously as the member’s physical or mental health requires once complete documentation has been received by Blue KC. An expedited appeal can be made by the member or provider on behalf of the member.
The attending physician may submit an expedited appeal in writing or verbally.
- Written appeals require the physician’s signature or must be submitted on physician letterhead.
- Expedited appeals should state why the normal time period for an appeal could jeopardize the member’s life, health, or ability to regain maximum function. This language is required for verbal expedited appeals.
- Services that have been scheduled prior to obtaining authorization or completing the appeal process do not meet the definition of an expedited appeal.
- Submit documentation supporting the medical necessity of the requested service with your appeal.
- A member’s request for appeal may be expedited if the requested services have not been provided and applying the standard timeframe could seriously jeopardize the life or health of the member. Blue KC may downgrade expedited requests that do not meet these criteria.
Here are examples of appeal requests that meet the expedited appeal criteria.
- Acute Rehabilitation Inpatient Admission or Continued Stay/Long Term Acute Care (LTACH) (continued care must be past the Quality Improvement Organization (QIO) appeal timeframe**).
- Skilled Nursing Facility Admission or Continued Stay (continued care must be past the QIO appeal timeframe**).
- Behavioral Health Inpatient Admission (i.e., homicidal ideation, suicidal ideation).
- Comprehensive Outpatient Rehabilitation Facility (continued care must be past the QIO appeal timeframe**).
- Services related to Cancer diagnosis. Imaging, medications, and surgery fall into this category.
- Transplant appeals.
- Spinal Imaging requests with Red Flag Indications. Red Flag indications for spinal imaging are intended to represent the potential for life or limb threatening conditions. Red Flag indications are clinical situations in which localized spine pain and associated neurological features are likely to reflect serious underlying spinal and/or non-spinal disease and warrant exception to the requirement for documented failure of six weeks of provider-directed treatment. Please see eviCore Spine Imaging Policy SP-1.2 for more details of these Red Flag Indications.
** QIO process occurs at the Utilization Management review level. The member is notified of the intent to discharge the member from an Inpatient stay (IM), Comprehensive Outpatient Rehab Facility, Home Health Service and Skilled Nursing Facility (NOMNC). As a part of this discharge, the member is provided discharge appeal rights. The member contacts the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) if they think services are ending too soon. The BFCC-QIO decides this appeal. The member can request a 2nd level review with the QIO. Blue KC would review these members’ appeal requests if the member missed the timeframe to appeal with the QIO. Otherwise, the QIO appeal decision is final.
Enhancing Strategies to Bridge the Gap in A1C Noncompliance
The American Diabetes Association recommends different A1C testing frequencies based on patients' glycemic control levels, a biannual schedule for those in good control and quarterly tests for those not meeting their goals. As we enter the hectic holiday season, it is crucial to prioritize early A1C testing to accommodate your patients’ busy schedules. Doing this also allows for adjusting medication therapy and retesting before year-end for patients struggling to achieve good control.
When discussing chronic illness management with your diabetic patients, remember to ask about their social determinants of health, such as socioeconomic status and access to nutritious food. These factors consistently play a significant role in predicting disease progression and control.
Reach out to your Provider Engagement or Clinical Transformation Consultant for more information about closing the Hemoglobin A1c Control for Patients with Diabetes (HBD) measure.
Kidney Health Evaluation (KED) HEDIS Quality Measure Details
Blue Medicare Advantage wants to provide the following helpful information and details to providers, regarding the KED HEDIS Quality Measure:
Population: Anyone older than 64 with diabetes (type 1 or 2)
Preventive Screening Criteria: Receive an annual kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a urine albumin-creatinine ratio (uACR), during the measurement year. (Note: uACR can be completed as a standalone test or through both a quantitative urine albumin test and a urine creatine test within 4 days of each other).
Data Collection Method: Lab claims, data file feeds, and nonstandard supplemental (medical record submission). Documentation (tied to coding OR submitted as nonstandard) should include date of service and results.
Recommended Considerations for Gap Closure:
|1. Prior to or during an encounter, review the diabetic patients medical record to see if they are due for annual KED testing or are excluded from the measure. If they are due order an eGFR and uACR lab test.|
|2. If labs are ordered, let your patient know that blood work and a urine specimen will be collected.|
|3. Your Health Information Management (HIM) department or internal staff confirm receipt of lab results, if labs were completed at an outside facility.|
|4. Providers/Provider staff enters the lab results into the outpatient medical record. This document must include a collected, result/reported or a claim date and the result.|
|5. Coders verify lab codes that are billed for labs performed in house or confirm that the codes submitted by an outside lab were coded correctly.|
|6. Best practice: When submitting records for nonstandard supplemental review, submit all lab testing together in one document so the HEDIS nurses can verify all requirements were met.|
|7. KED coding: If you are coding a patient that has CKD, make sure to code the N18.x to show the stage. Coding to the highest level of specificity is the only way to accurately capture a person’s full disease burden. With diabetes and CKD diagnosed concomitantly, please consider coding DM with CKD and include the N18.x to express the stage.|
|8. Veradigm (formerly Pulse8) offers a CKD coding training through the AAPC. Registration link: https://pulse8.zoom.us/calendar/list?timeZone=America%2FNew_York&showType=2&startDate=2023-09-25|
|Estimated Glomerular Filtration Rate Lab Test (eGFR)|
|CPT®||80047, 80048, 80050, 80053, 80069, 82565|
|LOINC||48642-3, 48643-1, 50044-7, 50210-4, 50384-7, 62238-1, 69405-9, 70969-1, 77147-7, 88293-6, 88294-4, 94677-2, 96591-3, 96592-1, 98979-8, 98980-6|
|Quantitative Urine Albumin Lab Test|
|LOINC||14957-5, 1754-1, 21059-1, 30003-8, 43605-5, 53530-2, 53531-0, 57369-1, 89999-7|
|Urine Creatinine Lab Test|
|LOINC||20624-3, 2161-8, 35674-1, 39982-4, 57344-4, 57346-9, 58951-5|
|Standalone Urine Albumin Creatinine Ratio Test (uACR)|
|LOINC||13705-9,14958-3, 14959-1, 30000-4, 32294-1, 44292-1, 59159-4, 76401-9, 77253-3, 77254-1, 89998-9, 9318-7|
Coding For Hypertension
Blue Medicare Advantage is pleased to offer the following education to providers and their coding/billing staff on the proper way to code for Hypertension with a chronic condition:
ICD-10-CM Hypertension coding highlights:
- Hypertension is classified by type: Essential or Primary (I10-I13) and secondary (I15)
- ICD-10-CM presumes a causal relationship between hypertension and heart involvement and classifies hypertension and heart conditions to category I11 (hypertensive heart disease) because the two conditions are linked by the term “with” in the Alphabetic Index of ICD-10-CM. Additionally, code from category I50 is required to specify the type of heart failure if known.
- For hypertension and conditions not specifically linked by relational terms such as “with,” “associated with”, or “due to” in the classification, provider documentation must link the conditions to code them as related.
- Hypertensive crisis can involve hypertensive urgency or emergency.
- Hypertensive can occur with heart disease, chronic kidney disease (CKD) or both.
Hypertension Secondary to other disease
- Secondary hypertension is due to an underlying condition. Two codes are required: one to identify the underlying etiology and one from category I15 to identify hypertension. The sequencing of codes is determined by the reason for admission/encounter.
- Per Coding Clinic 2023 Q2, page 16, the term “endocrine disorders” (15.2) is very broad; it can be applied to many conditions in the endocrine system; and the "With" guidance does not apply to index entries that cover broad categories of conditions. For those conditions, the provider must clearly document a causal relationship.
- Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis. Code also any identified hypertensive disease (I10-I15). The sequencing is based on the reason for the encounter.
Excludes 1 to coding for Hypertension
Be sure to pay attention to the “Excludes 1” notes. Hypertension codes in ICD-10-CM exclude several conditions: Hypertension complicating pregnancy, neonatal hypertension, primary pulmonary hypertension, and primary and secondary hypertension involving vessels of the brain or the eye. Postprocedural hypertension is also excluded from the secondary hypertension codes.
- Definition of Excludes1: A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
- Definition of Excludes2: An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.
Hypertension (Primary and Secondary) category codes
|I10||Essential (primary) hypertension|
|I11.0||Hypertensive heart disease with heart failure|
|I11.9||Hypertensive heart disease without heart failure|
|I12.0||Hypertensive CKD with stage 5 CKD or end-stage renal disease (ERSD)|
|I12.9||Hypertensive CKD with stage 1 through stage 4 CKD or unspecified CKD|
|I13.0||Hypertensive heart and CKD with heart failure and stage 1 through stage 4 CKD or unspecified CKD|
|I13.10||Hypertensive heart and CKD without heart failure with stage 1 through stage 4 CKD or unspecified CKD|
|I13.11||Hypertensive heart and CKD without heart failure with stage 5 CKD or ERSD|
|I13.2||Hypertensive heart and CKD with heart failure and with stage 5 CKD or ERSD|
|I15.1||Hypertension secondary to other renal disorders|
|I15.2||Hypertension secondary to endocrine disorders|
|I15.8||Other secondary hypertension|
|I15.9||Secondary hypertension, unspecified|
|I16.9||Hypertensive crisis, unspecified|
Primary Hypertension Codes
|Hypertension||Heart Disease||Heart Failure||Kidney Disease||ICD-10 Code & Description|
|Yes||No||No||No||I10, Essential (primary) hypertension|
|Yes||Yes||Yes*||No||I11.0,Hypertensive heart disease with heart failure|
|Yes||Yes||No||No||I11.9, Hypertensive heart disease without heart failure|
|Yes||No||No||Yes**||I12.0, Hypertensive CKD with stage 5 CKD or end-stage renal disease (ERSD)|
|Yes||No||No||Yes**||I12.9, Hypertensive CKD with stage 1 through stage 4 CKD or unspecified CKD|
|Yes||Yes||Yes*||Yes**||I13.0, Hypertensive heart and CKD with heart failure and stage 1 through stage 4 CKD or unspecified CKD|
|Yes||Yes||Yes*||Yes**||I13.2, Hypertensive heart and CKD with heart failure and with stage 5 CKD or ERSD|
|Yes||Yes||No||Yes**||I13.10, Hypertensive heart and CKD without heart failure with stage 1 through stage 4 CKD or unspecified CKD|
|Yes||Yes||No||Yes**||I13.11, Hypertensive heart and CKD without heart failure with stage 5 CKD or ERSD|
*Requires additional code for the type of heart failure
**Requires additional code for the stage of kidney disease
References: ICD10 CM 2023, Guidelines, chapter 9, section A, 6 https://www.encoderprofp.com/epro4payers/rcpDocHandler.do?_a=view&_dk=ICD10_CM_Chapter_Guidelines_Examples_Hospital.
Prior Authorization Updates
Easiest Way to Complete Your Prior Authorization Task
Want a stress-free prior authorization experience? We have what the doctor ordered! Use Blue KC’s enhanced prior authorization function at Providers.BlueKC.com, check out these steps below and watch this video to learn more:
To take advantage of an easier prior authorization experience, make sure you have a Blue KC Provider Portal account. Once you log in and arrive on the home page, click on Prior Authorizations, and you are ready go:
- Enter the Member ID to submit prior authorizations or view if a prior authorization is required. You can input the prefix or exclude it.
- Then select, “Lookup”. We do want to note that if you input an FEP Member ID number, and then select “Lookup”, you will be immediately directed to the Guiding Care site. If the ID is related to more than one member on the plan, you will be directed to all the members on that plan. So, just choose the member you want to get to the code selection screen.
- Open the dropdown, and you can search through any procedure, code or drug name and make your selection. And you also have the option to do a “type-ahead capability” for things like CPT code, the name of the procedure or the name of the drug. The procedure or drug will appear.
- After making your selection, you will be presented with a Disclaimer and a “Submit Prior Authorization” button if a prior authorization is needed for the code, service or drug name you entered. In some cases, an “Authorization Type” dropdown will display. This is based on whether the selected code is a Medical Service for Inpatient, Outpatient or a drug on the medical benefit.
- Finally, you will be directed to the proper Blue KC vendor Portal to complete entry of “electronic prior authorization”. Keep in mind you may be routed to other partner sites for different types of prior authorization requests, such as eviCore or Avalon.
- To view an existing electronic prior authorization request, once logged in to the Provider Portal, select Prior Authorizations. You will be directed immediately to the Member ID input page, and you can select the “View History” button. Then, you will be routed to the Guiding Care Portal for a list of previously entered prior authorizations.
- What happens if you are unable to get a user ID on the Blue KC Provider Portal? On the log-in page, click the Forms button to get to our Forms page. Then, scroll down to the prior authorization section. You will land on the first step of beginning a prior authorization. Select “Submit or Review a prior authorization”. On that page, you should select the “Review or Submit Prior Authorizations” button to log in and enter a Prior Authorization electronically on the Portal. As a last resort, you can choose a fax, mail, or e-form option.
Medical Drug Prior Authorization Removal
To provide for greater efficiencies, Blue KC wants to inform you of the following medical benefit drug listed below that no longer requires prior authorization for all lines of business, except the Federal Employee program, effective August 1, 2023. Note: Our Commercial line of business already does not require prior authorization for this drug.
GLP-1 Prior Authorization Update
Starting August 1, 2023, the following medications received updated utilization management requirements that only impacted our Blue Medicare Advantage line of Business.
Previously, there were step therapy requirements, which have been updated to a prior authorization requirement. Chart documentation is required to show these medications are being used for their intended indication. As a reminder, medications used for weight loss are excluded (non-covered) under Medicare.
The codes below will be added to our prior authorization list, effective November 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.
|93228||External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional||11/1/2023||MA|
|93229||External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional||11/1/2023||MA|
|0640T||Noncontact near-infrared spectroscopy studies of flap or wound (eg, for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [StO2]); image acquisition, interpretation and report, each flap or wound||11/1/2023||CHANGE FROM COVERED TO NONCOVERED (NCVD) FOR COMMERCIAL|
|0642T||Noncontact near-infrared spectroscopy studies of flap or wound (eg, for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [StO2]); interpretation and report only, each flap or wound||11/1/2023||CHANGE FROM COVERED TO NCVD FOR COMMERCIAL|
|0644T||Transcatheter removal or debulking of intracardiac mass (eg, vegetations, thrombus) via suction (eg, vacuum, aspiration) device, percutaneous approach, with intraoperative reinfusion of aspirated blood, including imaging guidance, when performed||11/1/2023||CHANGE FROM COVERED TO NCVD FOR COMMERCIAL|
|0646T||Transcatheter tricuspid valve implantation (TTVI)/replacement with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed||11/1/2023||CHANGE FROM COVERED TO NCVD FOR COMMERCIAL|
|S9355||Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem||11/1/2023||CHANGE FROM COVERED TO NCVD FOR COMMERCIAL|
|50300||Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral||11/1/2023||COMMERCIAL|
|50320||Donor nephrectomy (including cold preservation); open, from living donor||11/1/2023||COMMERCIAL|
|50323||Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary||11/1/2023||COMMERCIAL|
|27280||Arthrodesis, sacroiliac joint, open, includes obtaining bone graft, including instrumentation, when performed||11/1/2023||ACA|
|50325||Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary||11/1/2023||COMMERCIAL|
|50327||Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastomosis, each||11/1/2023||COMMERCIAL|
|50328||Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; arterial anastomosis, each||11/1/2023||COMMERCIAL|
|50329||Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; ureteral anastomosis, each||11/1/2023||COMMERCIAL|
|50340||Recipient nephrectomy (separate procedure)||11/1/2023||COMMERCIAL|
|50360||Renal allotransplantation, implantation of graft; without recipient nephrectomy||11/1/2023||COMMERCIAL|
|50365||Renal allotransplantation, implantation of graft; with recipient nephrectomy||11/1/2023||COMMERCIAL|
|50547||Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor||11/1/2023||COMMERCIAL|
|48550||Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation||11/1/2023||COMMERCIAL and MA|
|48551||Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery||11/1/2023||COMMERCIAL|
|48552||Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each||11/1/2023||COMMERCIAL|
|48554||Transplantation of pancreatic allograft||11/1/2023||COMMERCIAL|
|44720||Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each||11/1/2023||COMMERCIAL|
|32856||Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral||11/1/2023||COMMERCIAL|
|33933||Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation||11/1/2023||COMMERCIAL|
|33944||Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation||11/1/2023||COMMERCIAL|
|Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification|
|In accordance with existing policy:||
|What’s New with the SNF Waiver|
|In-Network facilities in our service area:||
|J7330||Autologous cultured chondrocytes, implant||11/1/2023||COMMERCIAL|
|E0328||Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress||11/1/2023||COMMERCIAL|
Payment Policy Updates
Post FDA Approved Pharmaceutical Products, Medical Therapies and Devices
Blue KC’s new “Post FDA Approved Pharmaceutical Products, Medical Therapies and Devices Payment Policy” became effective September 1, 2023. This policy only applies to our Commercial, ACA QHP for Individual/Family and Small Group ACA lines of business.
New pharmaceutical products, medical therapies and devices shall be excluded from reimbursement for the first six months following FDA approval, (including new indications) unless the Pharmacy and Therapeutics Committee recommends a shorter exclusion period. During this period, the Pharmacy and Therapeutics Committee analyzes current literature to determine, among other things, the benefits and risks of each new FDA approved product, medical therapy and devices under review.
The new payment policy is available to view any time by going to the log-in page at Providers.BlueKC.com and clicking on Go to Payment Policies.
As a reminder, Blue KC’s new payment policy for Esketamine (SPRAVATO) became effective August 1, 2023. Esketamine is sold under the brand name SPRAVATO and is indicated for adults with treatment-resistant depression. For policy details, visit the log-in page at Providers.BlueKC.com, and click on Go to Payment Policies.
Facility Routine Supplies and Services
Blue KC wants to educate providers to avoid claim denials for our Facility Routine Supplies and Services Payment Policy and specifically the service codes in the following table:
Please note the language below in the Facility Routine Supplies and Services Payment Policy:
- "In the facility setting, routine medical and/or surgical supplies are not separately billable on the facility claim. Routine supplies include items normally found in floor stock, items customarily used in the course of treatment, items considered incident to a physician service (e.g., status indicator A), reusable supplies, equipment (whether facility-owned or rented) and items related to and/or integral to the performance of services reported elsewhere on the claim. Routine supplies and services should not be separately billed to a patient. Per CPT and CMS guidelines, heparin flushes, saline flushes, IV flushes of any type and solutions used to dilute or administer substances, drugs or medications are included in the administration service."
- These items are considered routine supplies and are not eligible for separate reimbursement.
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.
|New Blue KC Policies|
|Effective date - 6/1/2023||
APEA–G2181 Colorectal Cancer Screening
- Omidubicel is considered investigational in individuals with hematologic malignancies planning myeloablative allogenic umbilical cord transplantation.
In response to Medicare’s recent decision to cover the cost of the Alzheimer’s drug, Leqembi, Blue KC created a new Leqembi Medical Policy that became effective on September 1, 2023 and only impacts our Blue Medicare Advantage line of business.
The initial authorization will be for an Individual who is 50 to 90 years of age and has been diagnosed with one of the following:
- Diagnosis of mild cognitive impairment due to Alzheimer's disease
- Diagnosis of probable Alzheimer's disease dementia
To view this policy and find out details, including all medically necessary criteria for the initial authorization and reauthorization, see the Medical Policies section on the home page of Providers.BlueKC.com.
Commercial and ACA
The COVID-19 National Emergency ended on May 11, 2023, but includes an additional 60-day period to extend deadlines for COBRA elections/payments, HIPAA Special Enrollment, Appeals and member submitted Claims. These deadlines will return to normal timeframes starting July 11, 2023.
The COVID-19 Public Health Emergency ended on May 11, 2023, removing the federal mandated coverage requirements for COVID-19 testing, related services, treatments and vaccinations. Here’s a summary of the changes that became effective on May 12, 2023:
|Benefits||Effective May 12, 2023|
|COVID-19 Lab Test & Related Services||Diagnostic (FDA approved) COVID-19 lab tests that are medically necessary and ordered by a health care provider (including testing related services) are covered in accordance with the terms of the member's Health Benefit Certificate.|
|Over-the-Counter (OTC) COVID-19 Home Tests||No coverage for OTC COVID-19 home tests. Members may use their Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) to purchase OTC tests.|
|COVID-19 Anti-viral Medications (i.e., Paxlovid and Lagevrio)||
Zero member cost share for these prescriptions while the government supply is available.
Once the government supply ends, these prescriptions will be covered in accordance with the terms of the member's Health Benefit Certificate.*
*Plans who carve out pharmacy benefits to a third-party administrator need to consult the Pharmacy Benefit Manager.
|Telehealth - Includes Medical and Behavioral||Coverage for Telehealth visits are covered in accordance with the terms of the member's Health Benefit Certificate.|
|COVID-19 Vaccines & Boosters||
Zero member cost share for COVID-19 vaccines/boosters while the government supply is available.
Once the government supply ends, COVID-19 vaccines/boosters will be covered in accordance with the terms of the preventive benefits in the member's Health Benefit Certificate.
For more details on updated COVID-19 policies, coding and billing, see the COVID-19 Information section (under Quick Links) on the home page of Providers.BlueKC.com.
Blue Medicare Advantage
Now that the COVID-19 National Emergency and Public Health Emergency have ended, providers should follow Medicare guidelines when it comes to their billing practices and seeing patients for our Blue Medicare Advantage (MA) line of business.
Here’s a summary of the MA change that became effective on May 12, 2023:
|New Pharmacy Policies|
|Policy Number||Policy Name||Summary|
|COVID-19 Vaccines & Boosters||$0 member cost share for COVID-19 vaccines/boosters as stated in the member’s Evidence of Coverage.|
Reminder: Self-Administered Xolair is Billed Through the Pharmacy Benefit
In early 2022, Blue KC started transitioning members starting or renewing maintenance self-injectable Xolair from medical benefit billing to pharmacy benefit, as is industry standard. For patients who were already established on this product, this includes a grace period of three months to allow time for the necessary arrangements to be made with the new pharmacy by both the provider and the patient.
For a patient established on therapy, you will have received an approval letter with a section such as below:
|Service Code(s)||Service Code(s) Description||Approved Units||Authorized Dates|
|J2357||Omalizumab injection; Xolair, Subsequent doses will need to be processed via the patient’s specialty pharmacy benefit (Preferred: Optum Specialty Pharmacy)/td>||180.0 total units approved; 60 billable units every 28 days approved for three months/td>||June 1, 2022 to September 1, 2022|
Please note, medication approval letters for both the medical and pharmacy benefit will come from the Pharmacy Services Department – the benefit to use for the approved drug product will be noted in the body of the letter.
Blue KC’s preferred specialty pharmacy is Optum Specialty Pharmacy, and their contact info is included here for convenience.
|Optum Specialty||Address||Contact Numbers||NPI & NCPDP numbers for location|
11142 Renner Boulevard
Lenexa, KS 66219
Toll Free: 1-877-307-9905
8:30 a.m. - 5:00 p.m. CT
Please note that arrangements for the switch from medical benefit billing to the member’s specialty pharmacy benefit must be made during this three-month grace period, after which claims billed to the medical benefit will be denied without reconsideration.
Billing Continuous Glucose Monitor (CGM) Supplies through DME
Blue Medicare Advantage wants to remind providers that the codes for billing CGM supplies via a DME provider have changed, as of April 2022. Please ensure that your billing team utilizes updated CPT codes to bill for these supplies.
References for correct coding practices for insulin pumps and CGM supplies include CMS Local Coverage Articles such as A52464 – Glucose Monitor and Blue KC Payment Policy POL-PP-195: Durable Medical Equipment.
|Preferred CGM Devices|
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 the 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.
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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