Blue Review

Physician Performance Insights Reports Available

For Providers

August 2024

BEHAVIORAL HEALTH

Provider Depression Disorder Prescribing

Because depression can create barriers to management of other chronic conditions, we recommend using telemedicine to help reluctant patients remain treatment compliant.

CLAIMS & ELIGIBILITY

CPT^® Category II Codes Can Help Close Care Gaps

Using the proper Current Procedural Terminology Category II codes when filing claims can help streamline your administrative processes and close gaps in care. Learn how CPT codes ease administrative burdens and how to submit them.

Proper Billing for Supplies for Transcutaneous Electrical Nerve Stimulation Units

Proper coding for Transcutaneous Electrical Nerve Stimulation Units and necessary supplies eliminates additional costs to you and our members. This article provides tips to ensure you and your patients get what you need.

Technical and Professional Components

Modifier 26 denotes professional services for lab and radiological services. Modifier TC denotes technical components for lab and radiological services. These modifiers should be used in conjunction with the appropriate lab and radiological procedures only. Note: When a health care provider performs both the technical and professional services for a lab or radiological procedure, they must submit the total service, not each service individually.

Fighting Fraud, Waste and Abuse

Every year, analysts and investigators for BCBSTX review claims data, industry trends and investigative results to identify potential areas of fraud, waste and abuse. For more information refer to these informational resources:

If you encounter potential fraud, waste or abuse:

Please file a report online
Call our Fraud Hotline at 800-543-0867

All online reports and calls are confidential, and you may remain anonymous.

Clinical Payment and Coding Policy Updates

Our website’s Clinical Payment and Coding Policies describe payment rules and methodologies for CPT, HCPCS and ICD-10 coding for claims submitted as covered services. This information is a resource for our payment policies and does not address all reimbursement-related issues. We may add and modify clinical payment and coding policies. The following policies were added or updated:

Reminders

HEALTH & WELLNESS

Breast Cancer Screening for Members Ages 40 to 74

As you know, routine screening for breast cancer is the best way to detect it early. As such, we’re recommending that breast cancer screening for our members begin at age 40 rather than 50. We’re updating our Preventive Care Guidelines to reflect this change.

MEDICARE ADVANTAGE PLANS

Medicare Providers May Treat Blue Cross Group Medicare Advantage Open Access (PPO)^SM Members

If you’re a Medicare provider, you can treat Blue Cross Group Medicare Advantage Open Access (PPO) members. This is an open access, non-differential national PPO plan without network restrictions. Learn about Open Access advantages, and remember to check ID cards.

MEDICAID

Access all 2023 and 2024 news and updates for BCBSTX Medicaid (STAR), STAR Kids and CHIP providers.

Reminder

Billing Telehealth Services with Place of Service Code 10

NETWORK PARTICIPATION

Physician Performance Insights Reports Are Now Available

Physician Performance Insights reports are available for physicians who are eligible for our Physician Efficiency, Appropriateness and Quality^SM (PEAQ) program. The reports show how physicians compare to their peers and include information on how to improve performance.

Provider Finder^® Ranks Providers to Help PPO Members Find Care

Later this year, Provider Finder will add a tiering feature that shows members how providers rank against their peers. Tiering is based on composite results of the PEAQ program.

Has Your Information Changed? Update Us and the NPI Registry

Our members rely on accurate provider information to find care. As such, when your practice address, phone number or other demographic information changes, please make sure to update the proper systems.

Hospitals, and Routine Services and Supplies

Providers usually include routine services and supplies in charges related to other procedures or services. As such, those services/supplies are considered non-billable for separate reimbursement. The following guidelines identify items, supplies and services that are not separately billable. (Note: This is not an all-inclusive list.)

Any supplies, items and services that are necessary or otherwise integral to the provision of a specific service and/or the delivery of services in a specific location are considered routine services and not separately billable in the inpatient and outpatient environments.
All items and supplies that may be purchased over the counter are not separately billable.
All reusable items, supplies and equipment that are provided to all patients during an inpatient or outpatient admission are not separately billable.
All reusable items, supplies and equipment that are provided to all patients admitted to a given treatment area or units are not separately billable.
All reusable items, supplies and equipment that are provided to all patients receiving the same service are not separately billable.

PHARMACY

Pharmacy Program Quarterly Update, Part 2: Changes Effective July 1, 2024

Review important pharmacy benefit reminders, drug list and dispensing limit changes, and Utilization Management program changes.

UTILIZATION MANAGEMENT

Check Prior Authorization Requirements for Procedure Codes through Availity^® Essentials or Our IVR System

Prior authorization requirements for procedure codes can be checked online by using Availity Essentials Eligibility and Benefits. If you aren’t able to check online, our IVR phone system has a new menu option to quickly confirm requirements for our commercial members.

Prior Authorization Code Changes for Commercial Members Effective Oct. 1

Soon, we’ll update our list of codes requiring prior authorization to reflect new, replaced or removed codes.

NICU Utilization Management Update Effective Sept. 1, 2024, for ERS Plans

Effective Sept. 1, ProgenyHealth^® will be delegated for all neonatal intensive care unit admissions and concurrent reviews for the ERS plans. Providers will have the option to notify ProgenyHealth pre-service to ensure medical necessity, level of care and that other plan requirements are met prior to submitting claims.

Reminders

Regulatory & Requirements

This section includes additional items related to regulatory requirements and operational processes to assist provider offices with servicing our members. Access this month’s articles.

We are required to provide certain notices in all published correspondence with health care providers. For the latest updates, visit the News and Updates section on the BCBSTX provider website.

Printable PDF

View a printable PDF of the non‑Medicaid information in this newsletter.

Contact Us

View our quick directory of contacts for BCBSTX.

Verify and Update Your Information

Verify your directory information every 90 days. Use the Provider Data Management feature on Availity^® or our Demographic Change Form. You can also use this form to submit email addresses for you and your staff to receive the Blue Review each month.

bcbstx.com/provider

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