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Anthem Reimbursement issues
basbrown
Posted: Sunday, March 19, 2017
Joined: 12/1/2010
Posts: 3


Anthem recently started denying the bulk of US exams performed by emergency physicians. See attached Policy. I have discussed this with the their local rep but have not made any progress. Has anyone else had Anthem specific issues or any suggestions to combat this? I have included my latest correspondence with anthem below.


Thanks,

Bart Brown

St Vincent Emergency Physicians, US Director

Indianapolis, IN





Barrabee, Linda 

To Bart Brown

   

Dr. Brown,

 

Thank you for your message.  While we understand your position on the ultrasound interpretation; Anthem has a different position.  Anthem receives the claim with the 26 modifier for the interpretations from the radiologist.  If approved and a covered benefit, pays the radiologist for this interpretation.  This issue is the same as the EKG issue and was discussed with the ACEP during 2009.  Our position has not changed and we will continue to only pay the radiologist for these interpretations.

 

Thank you

 

Linda S. Barrabee | Anthem Blue Cross and Blue Shield | Phone (317) 287-6270 | Fax (317) 287-8906
Director, Indiana Provider Solutions 

CONFIDENTIALITY NOTICE: This message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information.  Any unauthorized review, use, disclosure or distribution is prohibited.  If you are not the intended recipient, please contact the sender via E-mail and destroy all copies of the original message.

 

Are you preparing for ICD-10?   It’s not that far away, so don’t wait. To learn more about resources that can help you prepare, visit ICD-10 Updates on the Anthem provider home page.

     

From: Bart Brown [mailto:basbrown79@yahoo.com] 
Sent: Tuesday, October 25, 2016 5:43 AM
To: Barrabee, Linda
Subject: Anthem Bundled Svc 09012016

 

Linda --

 

I am one of the board members of INACEP and work with St Vincent Emergency physicians. I am contacting you about concerns your recent policy (attached) and recent denials for appropriately performed clinically indicated Ultrasound studies performed by emergency physicians. Please see the ACEP consensus below.  

 

Bart Brown, MD FACEP

     

The American College of Emergency Physicians (ACEP) believes that emergency physicians have the training and expertise to perform and interpret diagnostic ultrasound examinations and ultrasound guidance procedures in the emergency department (ED) setting and should be fairly paid for providing those services. ACEP recognizes clinical ultrasonography as a modality that provides clinically significant data not obtainable by inspection, palpation, auscultation, or other components of the physical examination. Clinical ultrasonography is a distinct clinical modality, not an adjunct to or extension of the physical examination such as a hand held portable device (e.g. a pocket Doppler).

   

AMA current procedural terminology (CPT) clearly indicates that the actual performance and/or interpretation of ultrasound studies performed during a patient encounter are not included in the levels of evaluation and management (E/M) service and may be separately reported: “The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/ studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with modifier 26 appended.”

 

Emergency physician use of ultrasound provides timely and cost efficient means to accurately diagnosis ED presenting illness and injury in order to provide higher quality lower cost care. ED ultrasound use can often reduce the need for more expensive studies such as CTs or MRIs and reduce unnecessary admissions for more comprehensive diagnostic work ups. Ultrasound use in the ED should be appropriately recognized and fairly compensated.

 


basbrown
Posted: Sunday, March 19, 2017
Joined: 12/1/2010
Posts: 3


Here is a summary of their policy, it was too large to attach, I am including only the relevant parts because it refers to many non-US procedures as well. 


Subject:  Bundled Services and Supplies IN, KY, MO, OH, WI Policy: 0008 Effective: 09/01/2016

 

Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or products and policy criteria listed below.

 

 Description                                                                                                                The Health Plan considers certain services and supplies to be ineligible for separate reimbursement when reported by a professional provider. These services and /or supplies may be reported with a primary service or as a stand-alone service.

 

This policy is divided into 3 sections:

 The first section provides a description and coding grid for services and/or supplies not eligible for

 separate reimbursement.  These services and/or supplies are not eligible for reimbursement whether they

 are reported with another service or as a stand-alone service.

 The second section provides a description and the code pair relationship for a number of procedures that

 are not eligible for separate reimbursement when performed with another specific service or item. See

 also our Modifiers 59 and XE, XP, XS, & XU Reimbursement Policy for additional information.

 The third section provides the code and description for services that are eligible for reimbursement when

 reported as a stand-alone service, but are not eligible for separate reimbursement when performed with

 any other procedure, service, or supply.



Coding Section 1: Services and supplies not eligible for separate reimbursement.

 19. interpretation of a radiology test when performed with an ER or inpatient E/M service 

 35. ultrasonic guidance for needle placement with CPT parenthetical identified procedures (not necessarily new)



Coding Section 2: Procedures, services and supplies not eligible for separate reimbursement when billed with another specific procedure or service,

19. 700XX-788XX, G01XX-G03XX, S8035-S8092, and S9024 (these code ranges include applicable radiology interpretation codes as well as radiology codes which modifier 26 would be added to identify the professional component only)  reported with 99281-99285 and/or 99221-99233

 35.  76942 reported with CPT codes listed in the CPT parenthetical statement 



 
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