#310
September 2009
THORConnect.org
Educational Opportunities
TABLE OF CONTENTS
Provider Education
September 25 Coding conference, Bismarck
Audio conference - LOCUS/CALOCUS................. 1
Coding Counts
September 26 Coding conference, Fargo
THOR
October 6 TRICARE Seminar, Minot
THOR Applications Training.................................. 2
Eligibility Effective Dates...................................... 2
Electronic Remits................................................... 2
October 7 TRICARE Seminar, Grand Forks
HealthCare
October 7 Audio conference, LOCUS/CALOCUS
ThorConnect.org
October 14 Educational Audio Conference
Forms Have New Look!......................................... 2
2009 ND State Legislative Session
THOR Applications Training
Forensic Medical Exam Reimbursement............. 2
September Provider Directory
TRICARE Program
TriWest Healthcare Alliance
Awarded Third TRICARE Contract......................... 2
Fall Seminars Scheduled...................................... 3
HealthCare
Coding Counts
Percutaneous Needle Core
Breast Biopsy with Imaging................................. 3
Claims Submission
Coordination of Benefits (COB)............................ 3
Preauthorization
Participating Provider Requirements................... 4
DVAC Coding Guidelines
DRG Validation Advisory Committee................... 4
Glad You Asked!
PICC Line Removal................................................ 7
Synagis Billing for Multiples................................ 7
Provider Education
Audio conference - LOCUS/CALOCUS
Provider Education is hosting an audio conference
about LOCUS/CALOCUS on Wednesday, October 7,
from 1:00-2:30 PM CDT.
LOCUS/CALOCUS is the tool used to determine the level
of care for psychiatric and substance abuse admissions.
LOCUS = Level of Care Utilization System
CALOCUS = Child and Adolescent Level of Care
Utilization System
Topics covered will include:
•
LOCUS/CALOCUS background
•
Review of the dimensions
•
How to score the evaluation using the here and now
•
What BCBSND looks for regarding medical necessity
of admission and continued stay
To register, e-mail [email protected] with your
name, facility name and phone number. Presentation
handouts and conferencing information will be e-mailed
upon receipt of your registration.
No CEUs are available for participating in this
audio conference.
THOR
HealthCare HealthCare
2009 ND State Legislative Session
THOR Applications Training
Forensic Medical Exam Reimbursement
Throughout the year, Application Support Services offers
WebEx training sessions on THOR applications. The
functionality and benefits of a different application are
featured each month. In September, the focus will be on the
Provider Directory.
In 2007, the North Dakota Legislature passed Senate Bill
#2103 establishing funding to the ND Attorney General’s
Office to pay for acute sexual assault forensic medical
exams for adults for the purpose of gathering evidence for
an alleged crime. The bill never addressed children or the
possibility of ongoing abuse.
To register for a time convenient for your staff, call 800544-8467 or e-mail [email protected] and include your
name, e-mail address, facility name, telephone number and
available dates/times for training.
In 2009, the ND State Legislative Session passed Senate
Bill #2216, which modified the statute regarding sexual
assault medical exams, expanding coverage to include
forensic medical exams for children who are allegedly
victims of sexual assault, and appropriated additional
funding to the ND Attorney General’s office to pay for
these exams.
HealthCare
Eligibility Effective Dates
THOR users can verify coverage using the THOR
Membership application. The eligibility effective dates are
displayed on the “eligibility” tab. If you have questions or
would like further training, contact Application Support
Services at 800-544-8467 or e-mail [email protected].
HealthCare
Electronic Remits
Providers now have the option to receive their weekly
remittances electronically through EDISS 835 or THOR.
A PDF file of the current remittance as well as two prior
remittances will be available for viewing and/or printing.
Electronic Fund Transfers (EFT) is also available for
providers who receive electronic remittances.
To register for these features, go to THORConnect.org,
Provider Services. Under THOR Services, click Register
Now and complete the THOR User Access form.
HealthCare
For EFT information, go to THORConnect.org, Provider
Services. Click on Forms, Participation and Credentialing,
EFT Payment Information.
If you have any questions, contact Application Support
Services at 1-800-544-8467 or e-mail [email protected].
THORConnect.org
Forms Have New Look!
Provider forms on THORConnect.org have been
standardized and can be completed online. Providers can
now complete forms online, then print and send or fax
them to Blue Cross Blue Shield of North Dakota.
Check out the new look at THORConnect.org,
Provider Services, Forms.
Please destroy all past versions and use the new
updated forms.
2
Senate Bill #2216 clarifies that any preliminary medical
screening examination done in preparation of a forensic
medical exam cannot be billed to the insurer. Those costs
are calculated in the fee reimbursed by the ND Attorney
General’s office. For reimbursement, please submit
any claims of this type according to the instructions
established by the ND Attorney General’s office. The bill
became effective on April 23, 2009, but the additional
funding was not available until July 1, 2009.
TRICARE Program
TriWest Healthcare Alliance Awarded
Third TRICARE Contract
On July 13, 2009, TriWest Healthcare Alliance was awarded
the contract to continue providing military families access
to high quality health care and manage the 21-state
TRICARE West Region for the Department of Defense
(DoD). The contract enables TriWest to continue to support
the DoD in meeting the health care needs of 2.7 million
active duty personnel, their families and retirees. The
contract includes a transition period, plus five one-year
option periods for health care delivery beginning
April 1, 2010.
The TRICARE West Region includes Alaska, Arizona,
California, Colorado, Hawaii, Idaho, Iowa, Kansas,
Minnesota, Missouri, Montana, Nebraska, Nevada, New
Mexico, North Dakota, Oregon, South Dakota, Utah,
western Texas, Washington and Wyoming.
Partnering with TriWest is Wisconsin Physicians Service
Insurance Corporation, a premier claims processor for
government programs, which will continue to provide
claims processing and systems support for TriWest in the
TRICARE program. Blue Cross Blue Shield of North Dakota
will continue to provide contracting and support
to providers in North Dakota.
#310 • September 2009 • THORConnect.org
HealthCare
Fall Seminars Scheduled
The TRICARE seminars will be held in October. The cities, dates and times are:
CITY
SEMINAR TYPE
DATE
TIME
LOCATION
Medical/Surgical
Tuesday, October 6
9:00 -11:30 am
Grand International
1505 North Broadway
Behavioral Health
Tuesday, October 6
1:00 – 3:30 pm
Grand International
1505 North Broadway
Medical/Surgical
Wednesday, October 7
9:00 -11:30 am
Hilton Garden Inn
4301 James Ray Drive
Behavioral Health
Wednesday, October 7
1:00 – 3:30 pm
Hilton Garden Inn
4301 James Ray Drive
Minot
Grand Forks
Attendees will receive the 2009 Provider Handbook and Quick Reference Guides. The seminars will cover updates on the
latest enhanced functionality of the secure provider portal, including online referral/authorization submission and new
online tools coming this fall. Providers are invited to attend these seminars free of charge.
Registering online at www.triwest.com/provider is the most convenient way to pre-register for a seminar. When you
provide your e-mail address through online seminar registration, you will receive:
HealthCare
•
An e-mail confirmation of your registration
•
A reminder e-mail notice before your scheduled seminar
•
Eligibility to participate in a drawing for a small prize at the seminar
Educational Opportunities
If you have any questions, please contact Lori Rustad at 701-282-1486.
Claims Submission
Coding Counts
HealthCare
Percutaneous Needle Core
Breast Biopsy with Imaging
If multiple tissue samples are obtained from
one lesion during an image-guided breast core
needle biopsy, CPT® code 19102 (Biopsy of
breast; percutaneous, needle core, using imaging
guidance) and one localization code (i.e. 77031)
are reported.
If separate, multiple lesions are present and
biopsied during the same operative session,
19102 may be reported more than once with
modifier 51. If a separate localization is performed
for multiple lesions, the appropriate code for each
localization is reported with modifier 51.
Coordination of Benefits (COB)
To help avoid delays or incorrect processing of COB claims,
the following information should be submitted with the
secondary claim:
1. “Other insurance information” located in:
•
CMS-1500 - field 9a-d
•
UB-04 - form locator 50-62
2. Primary insurance claim processing information
(payment listing or explanation of benefits). Verify
that all column headings are visible. If they are not
visible, the claim may be deleted and returned
for resubmission.
#310 • September 2009 • THORConnect.org
3
Preauthorization
•
Participating Provider Requirements
Preauthorization is the process of notifying Blue Cross Blue
Shield of North Dakota (BCBSND) to request approval for
specified services.
The participating provider is responsible for obtaining
preauthorization of covered services on behalf of the
member. If a patient is transferred from one type of facility
to another, the provider receiving the patient is responsible
for obtaining preauthorization.
•
If preauthorization is not obtained prior to the receipt
of care and services are determined to be medically
appropriate and necessary, a $500 sanction will be
deducted from the provider’s reimbursement.
•
If preauthorization is not obtained prior to the receipt
of care and BCBSND determines that the services are
not medically appropriate and necessary, the provider
will be liable for those services.
HealthCare
Medically appropriate and necessary services are defined
as services, supplies or treatments provided by a health
care provider to treat an illness or injury that satisfy all of
the following criteria as determined by BCBSND:
•
•
The services, supplies or treatments are medically
required and appropriate for the diagnosis and
treatment of the member’s illness or injury.
The services, supplies or treatments are consistent
with professionally recognized standards of
health care.
HealthCare
•
The services, supplies or treatments do not involve
costs that are excessive in comparison with alternative
services that would be effective for diagnosis and
treatment of the member’s illness or injury (i.e.
appropriate place of service, homebound, outpatient
versus inpatient).
Preauthorization is required for the services listed below.
To obtain preauthorization for these services, call Case
Management at 800-336-2488 or 277-2100.
4
Inter-facility transfers, including transfers from an
acute bed to the following units: Skilled Nursing,
Transitional Care, Rehabilitation or Psychiatric/
Substance Abuse
Preauthorization for psychiatric and substance abuse
admissions, including partial hospitalization and
residential treatment, may be requested through THOR.
To register for the Preauthorization application, go to
THORConnect.org, Provider Services. Under THOR
Services, click Register Now and complete the THOR User
Access form. If you have questions, contact Application
Support Services at 800-544-8467.
This list does not apply to the Federal Employee
Program (FEP).
DVAC Coding Guidelines
DRG Validation Advisory Committee
The following guidelines are for coding assistance only
and are not to be used in determinations for appropriate
level of care. They are not meant to replace the official
coding guidelines contained in Coding Clinic but are
to be used as a tool for determining if documentation
supports coding a condition. The use of physician queries
is suggested to clarify ambiguous documentation.
PAIN CODING GUIDELINE
PREAMBLE
Pain is a complex syndrome with causes arising from a
variety of sources. Three main categories include acute,
chronic and neuropathic. Acute and chronic pain are
classified as somatogenic indicating there is a physical
cause, however, when no physical cause for the pain
can be identified it is classified as psychogenic. Pain
caused by damage to nervous tissue or disorders of the
nervous system is classified as neuropathic pain. Trying to
determine if pain is acute or chronic may present difficulty
and may require querying the physician to clarify the type
of pain.
•
Skilled Nursing Facility
For more information reference the ICD-9-CM pain coding
guidelines and ICD-9-CM neoplasm coding guidelines.
•
Long Term Acute Care Facility
CHARACTERISTICS OF ACUTE AND CHRONIC PAIN
•
Transitional Care Unit
•
Inpatient Admission to a Rehabilitation Facility
*Per ICD-9: there is no time frame defining when pain
becomes chronic pain. The provider’s documentation
should be used as a guide in the selection of these codes.
•
Hospice
•
Home Health Care
#310 • September 2009 • THORConnect.org
Characteristic Acute Pain
Chronic Pain
Onset and
duration
Abrupt onset;
duration short
Gradual onset;
persists longer
than the expected
healing time
Intensity
Moderate to severe
Moderate to
severe
Cause
Specific; biologically
identifiable
Cause may or
may not be well
defined
Predictable
autonomic
hyperactivity:
increased blood
pressure, pulse and
respiratory rate;
dilated pupils; pallor;
perspiration; nausea
and/or vomiting
Normal
autonomic
activity
Anxious; unable
to concentrate;
restless; distressed
but optimistic about
relief from pain
Depression
and fatigue;
immobility
or physical
inactivity; social
withdrawal; sees
no relief in sight,
expects longterm pain
Physiologic
response
HealthCare
Emotional/
behavioral
response
Responses to
analgesic
Effective pain relief
Often ineffective
pain relief
HealthCare
1. GENERAL CODING INFORMATION
A. If the pain is not specified as acute or chronic,
do not assign codes from category 338, except
for post-thoracotomy pain, postoperative pain,
neoplasm related pain, or central pain syndrome.
B. The ICD-9 instructional note indicates to assign
307.89 for any pain associated with psychological
factors. If that kind of pain is documented
as coexisting with any other pain condition
classifiable to a code from the 338 category,
then 307.89 should be assigned as an additional
code. If the only kind of pain documented is
due to psychological factors, then the only code
that should be assigned is 307.80. This is per the
excludes notes under the 338 code category.
C. The same principles apply to pain documented
as due to trauma. Limit the use of these codes
to when the encounter is primarily for pain
management subsequent to or after the initial
encounter for the injury. Use an additional code
to specify the site of the pain.
D. When an admission or encounter is for a
procedure aimed at treating the underlying
condition (e.g., spinal fusion, kyphoplasty), a
code for the underlying condition (e.g., vertebral
fracture, spinal stenosis) should be assigned as
the principal diagnosis. No code from category
338 should be assigned unless criteria is met to
qualify as postoperative pain.
E. When an admission or encounter is for a
procedure aimed at treating the underlying
condition and a neurostimulator is inserted
for pain control during the same admission/
encounter, a code for the underlying condition
should be assigned as the principal diagnosis and
the appropriate pain code should be assigned as a
secondary diagnosis.
2. Pain due to devices, implants and grafts
A. Pain associated with devices, implants or grafts
left in a surgical site (for example painful hip
prosthesis) is assigned to the appropriate code(s)
found in Chapter 17, Injury and Poisoning. Use
additional code(s) from category 338 to identify
acute or chronic pain due to presence of the
device, implant or graft (338.18, 338.19
or 338.28-338.29).
3.
Postoperative Pain
A. Post-thoracotomy pain and other postoperative
pain are classified to subcategories 338.1 and
338.2, depending on whether the pain is acute
or chronic. The default for post-thoracotomy and
other postoperative pain not specified as acute or
chronic is the code for the acute type of pain.
B. Postoperative pain must be documented as
pain beyond that which is normal in order to be
appropriate to assign a code. Routine or expected
postoperative pain immediately after surgery
should not be coded.
4. Acute Pain
A. Generally acute pain patients will have resources
expended on finding the cause of the pain.
This would include diagnostic workup (lab,
ultrasounds, CTs) and may include consulting with
a variety of physicians to determine the cause or
probable cause of the pain. Documentation may
indicate a new/recent onset of pain not present in
the patient’s past medical history.
5. Chronic Pain
A. Chronic pain is usually long-lived and may stem
from prolonged stimulation of nerve fibers that
sense pain.
#310 • September 2009 • THORConnect.org
5
B. Persisting pain that was originally the result of an
injury is also classified as chronic pain.
C. Persistent pain out of proportion of the original
insult or injury.
D. Pain that persists longer than the expected
healing time.
E. The focus is on controlling pain rather than
expending extensive resources on finding the
cause of the pain. Diagnostics may be done, but
usually not as extensive as with acute or new
onset of pain. Documentation may reflect a history
of pain and control or attempts to control. There
is no time frame for defining when pain becomes
chronic. Chronic pain may require referrals to pain
clinics and/or implantation of pain control pumps.
6. Acute on Chronic Pain
HealthCare
A. The first-listed diagnosis should be based on the
principle reason for the encounter. If an acute
injury was the reason for the encounter it should
be sequenced first. Secondary codes may include
the code for the anatomical site of the chronic pain
and the chronic pain code. These codes should be
assigned if the chronic condition was still present
and/or affected the patient care and treatment for
that particular encounter.
7.
Neoplasm Related Pain
A. Code 338.3 is assigned to pain documented as
related, associated or due to cancer, primary or
secondary malignancy, or tumor. This code is
assigned regardless of whether the pain is acute
or chronic.
HealthCare
B. This code may be assigned as the principal or
first-listed code when the stated reason for the
admission/encounter is documented as pain
control/pain.
C. Neoplasm-related pain not only results from the
advancement of the disease, but also from cancer
treatments that damage nervous tissue.
8. Chronic pain syndrome
A. This condition is different than the term “chronic
pain,” therefore this code should only be used
when the provider has specifically documented
chronic pain syndrome.
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#310 • September 2009 • THORConnect.org
Glad You Asked!
PICC Line Removal
Question: Can I bill for removal of a PICC line?
Response: No, removal of a peripherally inserted central catheter (PICC) line is reported using an appropriate
evaluation and management (E&M) code based on the cumulative services provided during that visit or day.
Synagis Billing for Multiples
Question: How do I bill for administration of Synagis® to a set of twins? Twin A received 67 milligrams and Twin B received
70 milligrams. I used a 100 mg vial and a 50 mg vial.
Answer: Claims for Synagis administration must be submitted with CPT® code 90378 (Respiratory syncytial virus immune
globulin (RSV-IgIM), for intramuscular use, 50 mg each). An intramuscular injection code (CPT® 96372) should also be
billed for the administration of Synagis. The correct number of units (1 unit=50 mg) is recorded in field 24G. The number
of milligrams administered is recorded in the description field on EMC claims or in field 19 on the CMS-1500 claim form. If
this information is not included, it will be requested from the provider and could delay processing of the claim.
HealthCare
Reimbursement will be for the LOWEST number of vials required for both doses, and the allowance will be prorated across
each member’s claims.
For example:
The claim for Twin A is billed with 2 units in field 24G and 67 milligrams in field 19.
HealthCare
The claim for Twin B is billed with 2 units in field 24G and 70 milligrams in field 19.
#310 • September 2009 • THORConnect.org
7
BlueCross BlueShield
of North Dakota
HealthCare
An independent licensee of the Blue Cross & Blue Shield Association
4510 13th Ave S Fargo, ND 58121
PRSRT STD
U.S. POSTAGE
PAID
Fargo, North Dakota
Permit No. 1397
RETURN SERVICE REQUESTED
Routing Box
Date received:________
Please route to:
m Office manager
m Physician
m Nurse
m Billing manager
m Billing agency
m Receptionist
m Other:_ ____________
Noridian Mutual Insurance Company
HealthCare
HealthCare News is published as a service to health care providers.
Please send all written inquiries to:
Provider Service
Blue Cross Blue Shield
of North Dakota
4510 13th Avenue S.
Fargo, ND 58121
BlueCrossFEP
BlueShield
Provider Service
of North Dakota
800-368-2312
800-548-4026
An independent licensee of the Blue Cross & Blue Shield Association
701-282-1090
701-282-1468
8 a.m. – 4:30 p.m. CST
8 a.m. – 4:30 p.m. CST
Monday through Friday
Monday, Tuesday,
HealthCare
Thursday, Friday
Case Management
800-336-2488
701-277-2100
Fax: 701-277-2253
8 a.m. – 4:30 p.m. CST
Monday through Friday
9:15 a.m. – 4:30 p.m. CST
Wednesday
THOR is a user-friendly tool that can virtually eliminate the need for lengthy telephone
inquiries—not to mention lots of paper documents—by electronically connecting
providers, payers and other professionals.
The
Healthcare
Online
Resource
THOR Applications: Bulletin Board, Claim Inquiry, Claim Adjustment, Claim Correction,
Contraceptive Medication Request, FEP Outpatient Prior Approval for Mental Health
Substance Abuse, Membership, Injectables/Other Pharmacy Fee Schedule, Non-Formulary
Medication Request, Physician Payment Schedule, Preauthorization and Referral, Provider
Data Exchange, Reference Lab List and Provider Directory.
Register online at www.THORConnect.org
Call Application Support Services at 1-800-544-THOR (8467) for a demonstration
Noridian Mutual Insurance Company
29312484
(4891) 8/09