March 2020 Anthem Provider News - Kentucky Page 1 of 25

Kentucky Provider NewsMarch 2020 Anthem Provider News - Kentucky

Administrative:

Pharmacy:

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Provider News site enhancements 3

Anthem Commercial Risk Adjustment (CRA) Program Update:Medical chart collection for ACA members due March 31,2020

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Patient360 enhancement for medical providers 5

Modifier use reminders 7

Important coding reminder for walk-in retail health clinics 8

National Drug Code requirement on outpatient claims 8

Pharmacy information available at anthem.com 9

Medicare News - March 2020 10

Outpatient Rehabilitation Program transition: new priorauthorization requirements

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Complex discharge planning 12

Personal Home Helper benefit 13

Reminder: Mid-level practitioners are required to file using theirNPI

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Non-preferred products and corresponding preferredalternatives

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Medicaid News - March 2020 18

Coding tip for psychological and neuropsychological testing 18

Antibiotic dispensing guidelines 20

Coding spotlight: HIV and AIDS 22

March 2020 Anthem Provider News - Kentucky Page 2 of 25

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO productsunderwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. InMissouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company(HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten byHMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada:Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. dba HMO Nevada. In New Hampshire:Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten byMatthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as AnthemBlue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east ofState Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), which underwrites or administers the PPO and indemnity policiesand underwrites the out of network benefits in POS policies offered by Compcare or WCIC; Compcare Health Services Insurance Corporation(Compcare) underwrites or administers the HMO policies and Wisconsin Collaborative Insurance Company (WCIC) underwrites or administers WellPriority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of AnthemInsurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation. Use of the Anthem websites constitutes your agreement with our Terms of Use.

March 2020 Anthem Provider News - Kentucky Page 3 of 25

Provider News site enhancementsPublished: Mar 1, 2020 - Administrative

Great news! Commercial Provider Communications would like toshare some recent enhancements to the Commercial ProviderNews site:

Article categories are now appearing directly under the articletitle in both the website and PDFs.

PDFs for Individual Articles and Publications have beenimproved with a new look & feel for better readability and easierprinting.

Article Attachments

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March 2020 Anthem Provider News - Kentucky Page 4 of 25

URL: https://providernews.anthem.com/kentucky/article/provider-news-site-enhancements-3

Anthem Commercial Risk Adjustment (CRA) Program Update:Medical chart collection for ACA members due March 31, 2020Published: Mar 1, 2020 - Administrative

Each year, Anthem Blue Cross and Blue Shield (Anthem) requests your assistance in ourCommercial Risk Adjustment (CRA) Program. There are two distinct programs(Retrospective and Prospective) that work to improve risk adjustment accuracy andfocus on performing appropriate interventions and chart reviews for patients withundocumented Hierarchical Condition Categories (HCC), in order to document andclose the coding gaps. The CRA Program is specific to our Affordable Care Act (ACA) Members who havepurchased our individual and small group health insurance plans on or off the HealthInsurance Marketplace (commonly referred to as the exchange). With our Retrospective Program we focus on medical chart collection. We continue torequest members’ medical records to obtain information required by the Centers forMedicare & Medicaid Services (CMS). This particular effort is part of Anthem’s compliancewith provisions of the ACA that require our company to collect and report diagnosis codedata for our ACA membership. The members’ medical record documentation helps supportthis data requirement. Analytics are performed internally on claims which do not have the ICD10 code for which wesuspect a chronic condition. These medical records will be requested, reviewed and anyadditional codes abstracted can be submitted to CMS to increase our risk score values. Anthem network providers -- may be PCPs, specialists, facilities, behavioral health,ancillary, etc. -- may receive letters from vendors such as Inovalon, Verscend, Ciox,Sharecare, and Episource requesting access to medical records for chart review. Thesevendors are independent companies that provide secure, clinical documentation servicesand contact providers on our behalf.

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We ask that our network providers provide the medical record information to the designatedvendor within 30 days of the request (by March 31, 2020). While faxing remains ourprimary method for record retrieval, we offer many other electronic ways for providers tosubmit information. Electronic options that may make medical chart collection easier for providers:

EMR Interoperability

Allscripts (Opt in -- signature required to allow for remote review)

NextGen (Opt out -- auto-enrolled)

Athenahealth (Opt out -- auto-enrolled)

MEDENT

Remote/Direct Anthem access

Vendor virtual or onsite visit

Secure FTP

The goal of these electronic options is to both improve the medical record data extractionand the experience for Anthem’s network-participating hospitals, clinics and physicianoffices. If you are interested in this type of set up or any other remote access options,please contact our Commercial Risk Adjustment Network Education Representative:Mary.Swanson@anthem.com Thank you for your continued efforts with our CRA Program, and expediting these medicalchart collection requests.

URL: https://providernews.anthem.com/kentucky/article/anthem-commercial-risk-adjustment-cra-program-update-medical-chart-collection-for-aca-members-due-march-31-2020-1

Patient360 enhancement for medical providersPublished: Mar 1, 2020 - Administrative

March 2020 Anthem Provider News - Kentucky Page 6 of 25

Patient360 is a real time dashboard you can access through the Availity Portal that givesyou a robust picture of your Anthem Blue Cross and Blue Shield (Anthem) patient’s healthand treatment history and will help you facilitate care coordination. If an Anthem patient has a Care Gap Alert your medical practice can locate Active Alerts onthe Member Summary page of the Patient360 application. What’s new: Medical providers now have the option available on Patient360 to includefeedback for each gap in care that is listed on the patient’s active alerts. However, to be able to access the Care Gap Alert Feedback you will need to provide anindividual NPI. If you select an NPI from Express Entry menu, the feedback options will notbe available.

Once you have completed all the required fields you will land on the Member Summary pageof the application. To provide feedback, select the Resolution Health Index (RHI) within theActive Alerts section. This will open the Care Gap Alert Feedback Entry screen. You canchoose the feedback menu option that applies to your patient’s care gap. Are you using Patient360 for the first time? You can easily access Patient360 on theAvaility Portal. First, you need to be assigned to the Patient360 Role which your AvailityAdministrators can locate within the Clinical Roles options.

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Once you have the Availity role assignment, navigate to Patient360through the Availity Portal by selecting the application on AnthemPayer Spaces or by choosing the Patient360 link located on thepatient’s benefits screen.

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URL: https://providernews.anthem.com/kentucky/article/patient360-enhancement-for-medical-providers-1

Modifier use remindersPublished: Mar 1, 2020 - Administrative

Billing of patient treatment can be complex, particularly when determining whether modifiersare required for proper payment. Anthem Blue Cross and Blue Shield reimbursement policyand correct coding guidelines establish the appropriate use of coding modifiers. We wouldlike to highlight the appropriate use of some commonly used modifiers. Things to remember…

Review the “CPT Surgical Package Definition” found in the current year’s CPTProfessional Edition. Use modifiers such as 25 and 59 only when the services are notincluded in the surgical package.

Review the current year’s CPT Professional Edition Appendix A – Modifiers for theappropriate use of modifiers 25, 57 and 59.

When an evaluation and management (E/M) code is reported on the same date ofservice as a procedure, the use of the modifier 25 should be limited to situations wherethe E/M service is “above and beyond” or “separate and significant” from any proceduresperformed the same day.

When appropriate, assign anatomical modifiers (Level II HCPCS modifiers) to identifydifferent areas of the body that were treated. Proper application of the anatomicalmodifiers helps ensure the highest level of specificity on the claim and can help show thatdifferent anatomic sites received treatment.

Use modifier 59 to indicate that a procedure or service was distinct or independent ofother “non E/M services” performed on the same date of service. The modifier 59represents services not normally performed together but which may be reported togetherunder the circumstances.

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If you feel that you have received a denial after applying a modifier appropriately undercorrect coding guidelines, please follow the normal claims dispute process and includemedical records that support the usage of the modifiers when submitting claims forconsideration. We will be publishing additional articles on correct coding in upcoming newsletters.

URL: https://providernews.anthem.com/kentucky/article/modifier-use-reminders-2

Important coding reminder for walk-in retail health clinicsPublished: Mar 1, 2020 - Administrative

Some professional (837P / HCFA-1500) claims for services rendered to non-Anthem Blueplan members at retail health locations are being reported with a Place of Service that doesnot reflect a retail health clinic location. Specifically, for services rendered at a retail healthlocation, some providers are submitting values for Office (11) or Urgent Care Facility (20)instead of the value of Walk-in Retail Health Clinic (17). Reporting Place of Service as 11 or20 can cause claims to process incorrectly, and thus result in the need for claim adjustmentsand rework for providers. If your practice is a Walk-in Retail Health Clinic, please remind your coding staff to report themost accurate Place of Service, Walk-in Retail Health Clinic (17), for professional claimswhen submitting claims for non-Anthem members.

URL: https://providernews.anthem.com/kentucky/article/important-coding-reminder-for-walk-in-retail-health-clinics-1

National Drug Code requirement on outpatient claimsPublished: Mar 1, 2020 - Products & Programs / Pharmacy

Anthem Blue Cross and Blue Shield (Anthem) values the quality and commitment with whichyou serve your patients and our members. In this edition of Provider News, we are notifyingyou about a National Drug Code (NDC) requirement for drugs administered in a physician’s

March 2020 Anthem Provider News - Kentucky Page 9 of 25

office or outpatient facility setting for Local Plan and BlueCard member claims only. Thisnotice EXCLUDES claims for members enrolled in the Blue Cross and Blue Shield ServiceBenefit Plan (also called the Federal Employee Program or FEP) and Coordination ofBenefits/secondary claims. For dates of service on and after June 15, 2020, all providers are required to supplythe 11-digit NDC – along with the information below – when billing for injections andother drug items on the CMS-1500 and UB-04 claim forms as well as on 837 electronictransactions.

1. The applicable HCPCS code or CPT code

2. Number of HCPCS code or CPT code units

3. The 11-digit NDC(s), including the N4 qualifier4. Dosage Unit of Measurement (F2, GR, ML, UN, ME)

5. Number of NDC Units dispensed (must be greater than 0)

To ensure accurate and timely claims payments, it is important that you provide the NDCinformation as outlined above when filing claims to us. Anthem will reject any line itemson claims with dates of service on and after June 15, 2020, when the aboveinformation is not included regarding drugs.If you have further questions, please contact Provider Services.

URL: https://providernews.anthem.com/kentucky/article/national-drug-code-requirement-on-outpatient-claims-2

Pharmacy information available at anthem.comPublished: Mar 1, 2020 - Products & Programs / Pharmacy

Visit anthem.com/pharmacyinformation for more information on:

Copayment/coinsurance requirements and their applicable drug classes

Drug lists and changes

Prior authorization criteria

Procedures for generic substitution

March 2020 Anthem Provider News - Kentucky Page 10 of 25

Therapeutic interchange

Step therapy or other management methods subject to prescribing decisions

Any other requirements, restrictions, or limitations that apply to using certain drugs

The commercial and marketplace drug lists are posted to the web site quarterly (the first ofthe month for January, April, July and October). To locate “Marketplace Select Formulary” and pharmacy information, scroll down to “SelectDrug Lists.” This drug list is also reviewed and updated regularly as needed. FEP Pharmacy updates and other pharmacy related information may be accessed atwww.fepblue.org > Pharmacy Benefits.

URL: https://providernews.anthem.com/kentucky/article/pharmacy-information-available-at-anthemcom-22

Medicare News - March 2020Published: Mar 1, 2020 - State & Federal / Medicare

Please continue to check Important Medicare Advantage Updates atanthem.com/medicareprovider for the latest Medicare Advantage information, including:

Benefits update for special supplemental benefits for the chronically ill

Prior authorization requirements for CardioMEMS

URL: https://providernews.anthem.com/kentucky/article/medicare-news-march-2020

Outpatient Rehabilitation Program transition: new priorauthorization requirementsPublished: Mar 1, 2020 - State & Federal / Medicare

March 2020 Anthem Provider News - Kentucky Page 11 of 25

Effective April 1, 2020, Anthem Blue Cross and Blue Shield (Anthem) will transition theutilization management of our Outpatient Rehabilitation Program to AIM Specialty Health(AIM). AIM is a specialty health benefits company. The Outpatient Rehabilitation Programincludes physical, occupational and speech therapy services. Anthem has an existingrelationship with AIM in the administration of other programs. This relationship with AIM will enable Anthem to expand and optimize this program, furtherensuring that care aligns with established evidence-based medicine. AIM will follow theclinical hierarchy established by Anthem for medical necessity determination. Anthem makescoverage determinations based on guidance from CMS, including national coveragedeterminations, local coverage determinations, other coverage guidelines and instructionsissued by CMS, and legislative changes in benefits. When existing guidance does notprovide sufficient clinical detail, AIM will determine medical necessity using an objective,evidence-based process. AIM will continue to use criteria documented in Anthem clinical guidelines CG.REHAB.04,CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelinescan be reviewed online at https://medicalpolicies.amerigroup.com/am_search.html. Detailed prior authorization requirements are available online https://www.availity.com byaccessing the Precertification Lookup Tool under Payer Spaces. Contracted and non-contracted providers should call Provider Services at the phone number on the back of themember’s ID card for prior authorization requirements. Prior authorization review requirementsFor services to be rendered for dates of service from October 1, 2019, through March 31,2020, no prior authorization is required for outpatient rehabilitation services. For theseservice dates, in addition to all other rights Anthem has under our provider contract and law,Anthem and AIM will continue to monitor claims history and utilization trends and willvalidate provider and member information. AIM will facilitate training sessions to provide an overview of the program and demonstratethe AIM ProviderPortal . Please access the AIM Rehabilitation Provider Portal to registerfor an upcoming session.

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For services that are scheduled on or after April 1, 2020, providers must contact AIM toobtain prior authorization. Beginning March 19, 2020, providers will be able to contact AIMfor prior authorization of services to take place on or after April 1, 2020. Providers arestrongly encouraged to verify that they have obtained prior authorization before schedulingand performing services. How to place a review requestYou may place a prior authorization request online via the AIM ProviderPortal. This serviceis available 24/7 to process requests in real time using clinical criteria. Go towww.providerportal.com to register. You can also call AIM at 1-800-714-0040, Mondaythrough Friday 7 a.m. to 7 p.m. Central time. For more informationFor resources to help your practice get started with the Outpatient Rehabilitation Program,go to www.aimproviders.com/rehabilitation. For portal login Issues, call 1-800-252-2021. The AIM website provides access to useful information and tools, such as order entrychecklists, clinical guidelines and an FAQ. 506914MUPENMUB

URL: https://providernews.anthem.com/kentucky/article/outpatient-rehabilitation-program-transition-new-prior-authorization-requirements-1

Complex discharge planningPublished: Mar 1, 2020 - State & Federal / Medicare

As we begin 2020, we are adding utilization management complex discharge planning andcase management complex discharge planning roles to our teams. We are excited to offermembers, their families and caregivers someone to work with them while the member isinpatient and after discharge. This team member will work with the facility to understand the member’s needs, dischargeplan and possible home needs. If your patient is sent to a post-acute setting, we will alsowork with that facility to understand any barriers to discharge and referrals to other Medicareprograms.

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If the member requires assistance after discharge, we will offer a team member to help themember receive necessary referrals to identified programs, help the member follow theirdischarge plan and assist in making any necessary appointments to see their doctors. This is a collaborative program; we need your help to understand what your patients need tobe successful upon discharge and to reach our common goal – avoidance of readmissionsand ER utilization. We look forward to working with you, and the acute and post-acute facilities that offer thisvalue added program to our Medicare Advantage population. 507415MUPENMUB

URL: https://providernews.anthem.com/kentucky/article/complex-discharge-planning

Personal Home Helper benefitPublished: Mar 1, 2020 - State & Federal / Medicare

Your patient’s current supplemental benefit for Personal Home Helper has been reauthorizedfor 2020. For billing in 2020, use the new authorization number. For more information or toview the new authorization number, sign into the Availity Portal or call Provider Services at 1-800-499-9554.

Submit claims electronically through AvailityAvaility is well known as a web portal and claims clearinghouse, but they are much more.Availity also functions as an electronic data interchange (EDI) gateway for multiple payersand is the single EDI connection for all of Anthem, Inc. It will allow you to submit claimselectronically, verify pre-authorization and member information, check claims status, andmuch more. To get started, go to https://www11.anthem.com/edi and select your state. 507288MUPENMUB

March 2020 Anthem Provider News - Kentucky Page 14 of 25

URL: https://providernews.anthem.com/kentucky/article/personal-home-helper-benefit-1

Reminder: Mid-level practitioners are required to file using theirNPIPublished: Mar 1, 2020 - State & Federal / Medicare

Anthem Blue Cross and Blue Shield (Anthem) provides benefits for covered servicesrendered by nurse practitioners (NPs) and physician assistants (PAs) when operating withinthe scope of their license. Our policy states that these mid-level practitioners are required tofile claims using their specific NPI number — not that of the medical doctor. We will continue to monitor this area of concern through medical chart review and dataanalysis. Billing non-compliance can be considered a contract breach. Anthem recognizes the quality of care delivered to our members can be improved by theproper use of NPs and PAs. This notice is in no way intended to discourage their proper use,but rather to clearly define how services should be appropriately billed. Thank you for your continued participation. Should you have any questions, please call theProvider Services number located on the back of the member’s card. 507411MUPENMUB

URL: https://providernews.anthem.com/kentucky/article/reminder-mid-level-practitioners-are-required-to-file-using-their-npi-1

Non-preferred products and corresponding preferred alternativesPublished: Mar 1, 2020 - State & Federal / Medicare

Beginning January 1, 2020, patients using non-preferred products with a high patient costshare are now contacted about the availability of lower patient cost share preferredalternatives. If the patient is interested in switching, we will call or fax their provider who candetermine whether the preferred alternative is clinically appropriate. This is strictlyinformational and not a substitute for physician‑directed medical evaluations or treatments.

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A list of the included non-preferred products and corresponding preferred alternatives arelisted here.

March 2020 Anthem Provider News - Kentucky Page 16 of 25

Non-preferred products Preferred alternative(s)Aciphex DR omeprazole

pantoprazoleActos pioglitazone HCLAdvair Diskus fluticasone-salmeterol

Wixela InhubAggrenox aspirin-dipyridamole ERAmpyra ER dalfampridine ERBreo Ellipta fluticasone-salmeterol

Wixela InhubCambia diclofenac

sumatriptanchlorzoxazone cyclobenzaprineCoumadin warfarinCrestor rosuvastatinDexilant omeprazole

pantoprazoleDilantin phenytoinDiovan HCT valsartan/hydrochlorothiazideDuexis ibuprofen & famotidineDymista fluticasone & azelastineEpzicom abacavir-lamivudineEvzio naloxone HCLFarxiga JardianceGleevec imatinibGlumetza metformin ER (generic Glucophage XR)Incruse Ellipta SpirivaInvega paliperidone ERInvokana JardianceJublia ciclopiroxKerydin ciclopiroxKombiglyze Janumet XRLamictal lamotrigineLanoxin digoxin

Lipitor atorvastatin

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Livalo atorvastatinlovastatinpravastatinsimvastatin

Lovaza omega-3 acid ethyl estersMestinon pyridostigminemetformin ER (genericGlumetza)

metformin ER (generic Glucophage XR)

metformin ER OSM(generic Fortamet)

metformin ER (generic Glucophage XR)

Mirapex pramipexoleMyrbetriq ER oxybutyninNexium omeprazole

pantoprazoleNilandron nilutamideNovolin N Humulin NNovolog Humalogomeprazole-bicarbonate omeprazole

pantoprazoleOnfi clobazamOnglyza JanuviaPennsaid meloxicamProtonix omeprazole

pantoprazoleRenvela sevelamerRequip ropiniroleRestasis XiidraSoolantra metronidazole

azelaic acidSymbicort fluticasone-salmeterol

Wixela InhubSynthroid levothyroxineTresiba Basaglar

LantusToujeo

Trokendi XR topiramateTudorza Pressair SpirivaVasotec enalapril

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Vimovo naproxen & omeprazoleWellbutrin XL bupropion XLXalatan latanoprostXenazine tetrabenazineZestoretic lisinopril/hydrochlorothiazideZestril lisinoprilZileuton ER montelukast

507643MUPENMUB

URL: https://providernews.anthem.com/kentucky/article/non-preferred-products-and-corresponding-preferred-alternatives

Medicaid News - March 2020Published: Mar 1, 2020 - State & Federal / Medicaid

Please continue to check Medicaid Provider Communications & Updates on the providerwebsite for the latest information, including:

New specialty pharmacy medical injectable step therapy requirements

URL: https://providernews.anthem.com/kentucky/article/medicaid-news-march-2020-1

Coding tip for psychological and neuropsychological testingPublished: Mar 1, 2020 - State & Federal / Medicaid

A change to CPT codes for psychological and neuropsychological test administration andevaluation services was effective January 1, 2019.* The new codes do not crosswalk on aone-to-one basis with the deleted codes.

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These coding changes separate test administration from test evaluation, psychologicaltesting evaluation from neuropsychological testing evaluation and define the testingperformed by a professional or technician. The information below clarifies coding for theseservices. Please note: Prior authorization (PA) requirements have not changed. Please checkthe Precertification Look Up Tool for PA requirements for each code. Neurobehavioral status examsNeurobehavioral status exams are clinical interview examinations performed by apsychologist or neuropsychologist to assess thinking, reasoning and judgment. Providers should continue to use CPT code 96116 when billing for the first hour. Test administration and scoring by a psychologist or neuropsychologistTwo or more tests using any method should now be billed using CPT code 96136 for the first30 minutes and 96137 for each additional 30 minutes. Test administration and scoring by a technicianTwo or more tests using any method should now be billed using CPT code 96138 for the first30 minutes and 96139 for each additional 30 minutes. Testing evaluation services Testing evaluation services include the selection of the appropriate tests to be administered;integration of patient data; interpretation of standardized test results and clinical data; clinicaldecision-making; treatment planning; and reporting and interactive feedback to the patient,family members, or caregivers (when performed). There are distinct testing evaluationservice codes for psychological testing and for neuropsychological testing. Providers should now use CPT code 96130 to bill for the first hour of psychological testingevaluation services and 96131 for each additional hour. Neuropsychological evaluation services should now be billed using CPT code 96132 for thefirst hour and 96133 for each additional hour. Single automated test administration

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Single automated test administration should be reported with newly created code 96146 fora single automated psychological or neuropsychological instrument that is administered viaelectronic platform and formulates an automated result. Psychologists should not use thiscode if two or more electronic tests are administered and/or if administration is performed bythe professional or technician. Instead, the psychologist should use the appropriate codeslisted above for test administration and scoring. A single automated test as the only serviceis not considered appropriate for the many elements seen with test evaluation. Screening and risk assessment (repetitive assessment after screening)Screening and risk assessment (repetitive assessment after screening) includes briefemotional/behavioral assessment (for example, a depression inventory or ADHD scale) withscoring and documentation, per standardized instrument. This should be billed using CPTcode 96127 separately from testing. Brief emotional/behavioral assessments should not bebilled as psychological or neuropsychological testing. For questions, please contact Provider Services at 1-855-661-2028. * American Psychological Association website: 2019 Psychological and NeuropsychologicalTesting Billing and Coding Guide: https://www.apa.org

URL: https://providernews.anthem.com/kentucky/article/coding-tip-for-psychological-and-neuropsychological-testing-5

Antibiotic dispensing guidelinesPublished: Mar 1, 2020 - State & Federal / Medicaid

Overuse of antibiotics is directly linked to the prevalence of antibiotic resistance. Promotingjudicious use of antibiotics is important for reducing the emergence of harmful bacteria thatis unresponsive to treatment. The following HEDIS® measures assess appropriate antibioticdispensing for pharyngitis, upper respiratory infection and bronchitis/bronchiolitis. Changesfor HEDIS 2020 include expanded age range and additional stratifications. Appropriate Testing for Pharyngitis (CWP)

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Pediatric Clinical Practice Guidelines recommend only children with lab‑confirmed group Astrep or other bacteria-related ailments be treated with appropriate antibiotics. This measurereports the percentage of episodes for members 3 years of age and older where themember was diagnosed with pharyngitis, prescribed an antibiotic at an outpatient visit andreceived a group A strep test. A higher rate indicates better performance (in other words,appropriate testing). Appropriate Treatment for Upper Respiratory Infection (URI)This measure calculates the percentage of episodes for members 3 months of age and olderwith a diagnosis of upper respiratory infection that did not result in an antibiotic dispensingevent. Reducing unnecessary use of antibiotics is the goal of this measure. It is reported asan inverted rate. A higher rate indicates appropriate upper respiratory infection treatment (inother words, the proportion of episodes that did not result in an antibiotic dispensing event). Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis (AAB)There is considerable evidence that prescribing antibiotics for uncomplicated acutebronchitis is not indicated unless it is associated with a comorbid diagnosis. This measureassesses the percentage of episodes for members ages 3 months and older with adiagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.It is reported as an inverted rate. A higher rate indicates appropriate acutebronchitis/bronchiolitis treatment (in other words, the proportion of episodes that did notresult in an antibiotic dispensing event). Helpful tips:

When patients present with symptoms of pharyngitis, ensure proper testing (for strep)is performed to avoid the unnecessary prescribing of antibiotics. Record the results of thestrep test.

If prescribing an antibiotic to members with acute bronchitis, be sure to use thediagnosis code for the bacterial infection and/or comorbid condition.

Educate members on the difference between bacterial and viral infections. Refer to theillness as a common cold, sore throat or chest cold. Parents and caregivers tend toassociate these labels with a less frequent need for antibiotics.

Write a prescription for symptom relief, such as rest, fluids, cool mist vaporizers andover‑the‑counter medicine.

If a patient insists on an antibiotic, consider using delayed prescribing. Refer to theCDC handout for patients titled What is Delayed Prescribing? available at the link below.

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Resources:

1. CDC’s Be Antibiotics Aware campaign: https://www.cdc.gov/antibiotic-use/index.html

2. CDC handouts for patients: https://www.cdc.gov/antibiotic-use/community/materials-references/index.html

URL: https://providernews.anthem.com/kentucky/article/antibiotic-dispensing-guidelines

Coding spotlight: HIV and AIDSPublished: Mar 1, 2020 - State & Federal / Medicaid

Code only confirmed casesAccording to ICD-10-CM coding guidelines for Chapter One, code, only confirmed cases ofHIV infection/illness. This is an exception to the hospital inpatient guideline Section II, H. Inthis context, “confirmation” does not require documentation of positive serology or culture forHIV. The provider’s diagnostic statement that the patient is HIV positive or has an HIV-related illness is sufficient.

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Status ICD-10-CM codeAsymptomatic HIV Assign code Z21 – Asymptomatic human

immunodeficiency virus [HIV] infection status when thepatient without any documentation of symptoms is listedas being ‘HIV positive’, ‘known HIV’, ‘HIV test positive’ orsimilar terminology. Assign code B20 – Human immunodeficiency virus [HIV]disease on the claim when the term AIDS is used, whenthe patient is being treated for HIV-related illness orwhen the patient is described as having any active HIV-related condition.

Patients withinconclusive HIVserology

Assign code R75 – Inconclusive laboratory evidence ofhuman immunodeficiency virus [HIV] when the patient’srecord is documented with inconclusive HIV serology, butthere is no definitive diagnosis or manifestations of theillness.

Previouslydiagnosed HIV-related illness

Code B20 if you document a patient as having had anyknown prior diagnosis of an HIV-related illness – Z21 isno longer reported. If the patient develops an HIV-relatedillness, they should be assigned code B20 on everysubsequent admission/encounter.

HIV infection inpregnancy,childbirth and thepuerperium

Assign code O98.7 – Human immunodeficiency virus[HIV] disease complicating pregnancy, childbirth and thepuerperium first when a patient presents for treatment ofan HIV-related illness during pregnancy, childbirth or thepuerperium followed by code B20. Also assign additional code(s) for HIV-related illness(es).Keep in mind that codes from Chapter 16 take prioritywhen sequencing codes on the claim. If a patient with asymptomatic HIV infection statuspresents for a routine visit during pregnancy, childbirth orthe puerperium, the correct code assignment would beO98.7 followed by code Z21.

Assign code B20 for all types of HIV infections, which may be described by a variety ofterms including:

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AIDS.

Acquired immune deficiency syndrome.

Acquired immunodeficiency syndrome.

AIDS-related complex (ARC).

AIDS-related conditions.

HIV infection, symptomatic.

Testing for HIV:

Assign code Z11.4 – Encounter for screening for human immunodeficiency virus [HIV]when seeing a patient with no prior diagnosis of HIV infection or positive HIV-status todetermine their HIV-status.

Code the signs and symptoms when seeing a patient with signs or symptoms for HIVtesting. If you provide counseling during the encounter, assign additional code

Z71.7 – Human immunodeficiency virus [HIV] counseling.

Assign code Z71.7 if a patient’s test results are negative for HIV.

Assign code Z72.8 if a patient is known to be in a high-risk group for HIV infection.Other problems related to lifestyle can be assigned as an additional code.

Major HIV-related conditions HIV-related condition ICD-10-CM codePneumonia, unspecified organism J18.9Tuberculosis of other sites A18.89Sepsis, unspecified organism A41.9Candida stomatitis (thrush) B37.0Herpes zoster (any site) B02.9Encephalopathy, unspecified G93.40

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Other HIV-related conditions ICD-10-CM codeTinea cruris B35.6Anemia, unspecified D64.9Underweight R63.6Acute lymphadenitis L04.9Arthropathy, unspecified M12.9Splenomegaly, not elsewhere classified R16.1Weakness R53.1

HIV/AIDS preventionThe CDC works with other federal agencies, state and local health departments, nationalorganizations, and other entities to reduce the spread of HIV in the United States. This workcovers several components:

Behavioral interventions – These interventions ensure people have the information,motivation and skills necessary to reduce the risk of infection.

HIV testing – Testing is critical to prevent the spread of HIV.

Treatment and care – Treatment and care enable individuals with HIV to live longer,healthier lives.

The CDC remains on the forefront of pursuing high-impact prevention. This approach isdesigned to maximize the impact of prevention efforts for all Americans at risk for HIVinfections and the CDC is aligning its efforts with the first National HIV/AIDS Strategy for theUnited States (NHAS). The Division of HIV/AIDS Prevention has developed a strategicthree-year plan for 2017-2020 with the goal of one day achieving a future free of HIV. Resources:

1. ICD-10-CM Expert for Physicians. The complete official code set. Optum360, LLC.2019.

2. http://www.cdc.gov: HIV/AIDS.

URL: https://providernews.anthem.com/kentucky/article/coding-spotlight-hiv-and-aids