Important information about Highmark Blue Shieldwww.highmarkblueshield.com

June 2005

In This Issue

Provider Data Services replaces fax number; adds new fax number forcredentialing information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Blue Shield to integrate behavioral health medical managementservices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Blue Shield expands coverage for MRI of the breast . . . . . . . . . . . . . . . . . .7

Menactra vaccine eligible for payment . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

News

Provider Data Services replaces fax number; adds new fax number forcredentialing information

Provider Data Services is replacing the fax number you use to send changes to your provider information. It’salso adding a second fax number for you to submit your information to be credentialed for one of HighmarkBlue Shield’s networks.

As of July 31, 2005, the fax number you’ve been using—(866) 731-2896—will no longer be in service.

Beginning Aug. 1, 2005, these two new toll-free fax numbers will be available:

• To make changes to your assignment account or current provider information such as your practice, mailing or check address, send them to Provider Data Services at (800) 236-8641.

For your convenience, the coupon for transmitting changes to your provider information to Blue Shield will continue to appear on the inside back page of PRN.

PRNPolicy Review & News

Highmark is a registered mark of Highmark Inc. Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

2

PRN• To submit your information to be credentialed for one of Blue Shield’s networks, send those documents to

(800) 236-5907.

Blue Shield to integrate behavioral health medical management services

Company assumes responsibilities from Magellan July 1, 2005

Highmark Blue Shield’s contract with Magellan Health Services for behavioral health utilization and casemanagement services expired on June 30, 2005. Blue Shield decided not to renew the contract beyond that date.

Continuation of multi-year strategy of integrating medical, behavioral health services

“In keeping with our multi-year strategy of integrating medical and behavioral health utilization and casemanagement activities, Highmark has decided to assume all internal responsibility for administering behavioralhealth services,” says Donald R. Fischer, MD, senior vice president and chief medical officer. Highmark BlueShield currently administers many important portions of the behavioral health program, including contractingdirectly with behavioral health providers for its western and central Pennsylvania networks.

Blue Shield also:

• pays claims

• handles member appeals

• handles member grievances

• reviews provider appeals

• develops and implements quality improvement programs

• develops and implements medical policy

• develops payment schedules

“This integration will afford Highmark the opportunity to work with providers to coordinate services formembers with both medical and behavioral health conditions, and to help them tailor treatment programs basedon members’ needs,” Dr. Fischer says.

Blue Shield is working closely with Magellan to ensure a smooth transition for all members who received casemanagement support services from Magellan. Blue Shield is assuming responsibility for all open authorizationsfor behavioral health services as of July 1, 2005.

6/2005With this change, Blue Shield anticipates an enhanced working relationship with providers by coordinatingmedical and behavioral health care needs for Highmark Blue Shield members, especially those with chronicmedical conditions complicated by conditions such as anxiety or depression.

In addition, physicians and members will be offered more opportunities to access Blue Shield support programsand services, including those focused on condition management and preventive health services.

Transition includes FEP

The transition of case management support services from Magellan to Highmark Blue Shield will also apply tothe Federal Employees Health Benefits Program (FEP). On July 1, 2005, Blue Shield began to administer FEPbehavioral health utilization and case management services for professional outpatient services.

FEP benefits, authorization telephone numbers remain the same

However, this change will have no impact on FEP benefits. PremierBlue Shield providers will continue tosubmit treatment plans for outpatient, partial hospitalization and intensive outpatient mental health and substanceabuse services for FEP enrollees. Benefits will be provided at the preferred level as long as the preferredprovider and the member follow approved treatment plan protocols and receive authorization for services basedon review of the treatment plan. Treatment plans must be submitted prior to the patient’s ninth outpatient visitper calendar year, as soon as it is determined that the course of treatment will extend beyond eight visits. BlueShield is currently developing a new treatment plan form for FEP. Watch your mail for additional informationabout the treatment plan form.

The telephone numbers for authorization will also remain the same.

Deductible and coinsurance information available through various sources

You cannot collect charges from members for covered services, with the exception of applicable deductibles andcoinsurance, before you receive a claim disposition from Highmark Blue Shield.

Here are some ways through which you can obtain the member’s deductible and coinsurance information:

• NaviNet in the Benefits and Eligibility area,

• a HIPAA 270 transaction (from your practice management system), or

• call Blue Shield’s customer service area.

3

PRN

4

How to report unlisted procedure codes

The Healthcare Common Procedure Coding System (HCPCS) has been developed as the national standard forreporting medical procedures and services. For each procedure or service you report, choose the HCPCS codethat most accurately identifies the procedure or service you performed. Do not select a procedure code thatmerely approximates the procedure or service you provided. If no appropriate HCPCS code exists, then reportthe service using the appropriate unlisted procedure code.

When you report an unlisted procedure code, include a detailed narrative description of the service or procedurein the narrative section of the electronic or paper claim.

Please remember to adequately document any service or procedure you provided in the patient’s medicalrecord.

Fees for unlisted procedure codes available through NaviNet

Highmark Blue Shield has developed fee information for procedures that do not have a specific HCPCS codeassigned to them. This information is available on an “Unlisted Fee Bulletin” found through NaviNet. Thisbulletin includes potentially covered unlisted procedures for which Blue Shield has established allowances..

Blue Shield is making these fees available to you so that you have as much reimbursement information aspossible.

The fee bulletin is organized according to anatomic sections. Each section includes the terminology for theunlisted procedures in alphabetical order.

Remember, when you report an unlisted procedure code or not otherwise classified (NOC) code, be sure toinclude the complete terminology in the narrative section of the electronic or paper claim.

Blue Shield begins to refund Medicare for COB overpayments

Sometimes Medicare has incorrectly paid as the primary insurer on a claim where Highmark Blue Shield shouldhave been the primary payer. Blue Shield has also paid as primary insurer on these claims. When this hashappened, Medicare sends a Medicare Demand Notice to Blue Shield asking for a refund for the amountMedicare paid in error.

Because of these mistakes, Blue Shield is making changes to notify Medicare of these overpayments. BlueShield then reimburses Medicare for erroneous primary payments. The Centers for Medicare and MedicaidServices’ regulation 411.25 obligates Blue Shield to refund Medicare in situations where an overpayment isidentified and the provider has not refunded Medicare.

Blue Shield will contact the provider before it repays Medicare to determine if the provider has initiated arefund to Medicare. If the provider has refunded or plans to refund Medicare, Blue Shield will document thisinformation on its inquiry and will close the case. If the provider has not or does not intend to repay Medicare,Blue Shield will refund Medicare. Blue Shield will either pay the difference between what Medicare has alreadypaid and Blue Shield’s approved amount, or Blue Shield will seek a refund from the provider if he or she hasreceived a primary payment from Blue Shield.

Modifier 22 process explained

When you perform an unusual service—one that is of greater complexity than that usually required for the listedprocedure—identify that service by adding a 22 modifier to the standard procedure code. The 22 modifierdistinguishes the procedure you performed as an unusual service, including extenuating medical circumstances.

When you report a procedure code with a 22 modifier, Highmark Blue Shield recommends that you submit yourclaim electronically. You can submit the claim through an 837 transaction and use the Paperwork (PWK)Segment to report the type and transmission of the attachment. For more information about the PWK process,see “Electronic claims submission is easier than ever” on Pages 5-6 in the April 2005 PRN. Please sendsupporting medical documantation to:

• Fax number (717) 302-3686, or

• By mail:PWK Additional DocumentationPO Box 890176Camp Hill, Pa. 17089-0176

Once Blue Shield receives the claim and supporting medical records, one of its Professional Consultants willreview the information. Blue Shield uses approximately 260 active Pennsylvania practitioners to assist in manyoperations, including the review of modifier 22 claims.

The Consultant will review your claim and supporting documentation. He or she will then determine whetheradditional reimbursement is warranted based on the clinical circumstances documented in the medical records,and if so, how much additional reimbursement is appropriate.

Claims with a procedure code with a 22 modifier that Blue Shield has received after June 10, 2005 will beadjudicated and will receive one of these message codes:

• J6056—unusual procedural services were reported with no supporting documentation, therefore, no additionalpayment can be considered

6/2005

5

PRN

6

• J6057—unusual procedural services were reported and the supporting documentation was considered, but does not warrant an additional payment

• J6058—unusual procedural services were reported and the supporting documentation was considered for the additional payment reflected under the allowance

Remember to send your supporting documentation to Blue Shield when you submit a claim for a procedure witha 22 modifier. For claims received after June 10, 2005, Blue Shield will conduct a one-time review of thesupporting medical documentation that was submitted with the claim. If, after reviewing the claim, Blue Shielddetermines that additional payment is not warranted, it will not review the supporting documentation a secondtime. In this case, Blue Shield will deny your claim and you’ll receive message code J6057.

If you submit a claim for a procedure with a 22 modifier and you do not send the supporting medical recordswithin 21 days, Blue Shield will process the claim without considering the 22 modifier. When this happens,Blue Shield will notify you by including message code J6056 on your Explanation of Benefits form. Blue Shieldwill consider the procedure you reported at the standard allowance.

If you’d like to send supporting documentation to Blue Shield after your claim was processed, you shouldperform a claim investigation through NaviNet. Specific instructions as to where to submit supportingdocumentation will be included in the response to your claim investigation.

If you are not NaviNet-enabled, contact Provider Services for instructions on how to submit your supportingdocumentation.

Blue Shield expands coverage for MRI of the breast

Highmark Blue Shield has expanded coverage for MRI breast studies for high-risk patients when priormammography and/or ultrasound studies are inconclusive or unclear, or when a diagnosis of breast cancer isconfirmed and requires further evaluation for lesion characterization before treatment.

Blue Shield considers high risk factors to include:

• the presence of known BRCA1 or BRCA2 genetic mutation (V84.01),

• possible BRCA1 or BRCA2 genetic mutation in a high risk patient consistent with a known BRCA1 or BRCA2 mutation in a family member with breast cancer (V16.3), or

• a history of breast cancer in multiple first-degree relatives, often occurring at a young age and with bilaterality, consistent with a high probability of harboring BRCA mutations or other hereditary breast cancer (V16.3).

Blue Shield also covers MRI of the breast in these situations:

• Evaluation for the presence of breast cancer, or, for additional lesions following a diagnosis and/or treatment of breast cancer in male or female patients. Examples include, but are not limited to, very dense breast tissue, mammographic microcalcification, dysplasia or severe fibrocystic changes, infiltrating lobular or ductal carcinoma, presence of pectoralis major muscle or chest wall invasion in patients with a posteriorly located tumor, or carcinoma invasion deep to fascia (174.0-174.9, 175.0-175.9, 198.81, 233.0, 238.3, 239.3, 610.2, 611.72, 611.79, 611.8, 793.80, 793.81, 793.89, 793.9).

• Detection of suspected occult breast primary tumor in patients with axillary nodal adenocarcinoma (785.6).

• For presurgical planning in patients with locally advanced breast cancer before, during and/or after completion of neoadjuvant chemotherapy, for example, to permit tumor localization and characterization, evaluate chemotherapeutic response and/or residual disease prior to surgery.

• Detection of a rupture of silicone or non-silicone breast augmentation or implant(s) (996.54).

Blue Shield considers MRI studies of the breast for all other indications, including its use as a screeningprocedure, experimental or investigational. Scientific evidence does not demonstrate that MRI of the breastimproves health outcomes. A participating, preferred, or network provider can bill the member for services BlueShield denies as experimental or investigational.

6/2005

7

Policy

PRN

8

Use these codes, as appropriate, to report MRI of the breast:

76093—magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral

76094—magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral

Pharmacogenomic and metabolite markers for IBD treated with azathioprineare investigational

Highmark Blue Shield considers genotypic analysis of the thiopurine methyltransferasethe (TPMT) gene andanalysis of the metabolite markers of azathioprine and 6-mercaptopurine, including 6-MMP and 6-TG, forpatients with inflammatory bowel disease (IBD) being treated with azathioprine, experimental or investigationallaboratory tests.

Blue Shield will not pay for these tests because there is a lack of prospective studies on the use ofpharmacogenomic or metabolite testing in the management of the IBD patient. Prospective trials are needed todetermine whether or not these tests result in improved health outcomes compared to drug therapy based onclinical assessment.

A participating, preferred, or network provider can bill the member for the denied tests.

Use code 89240—unlisted miscellaneous pathology test—to report this testing. When you report code 89240,please provide a complete description of the service in the narrative field of the electronic or paper claim.

The use of azathioprine for patients with IBD is limited by both its long onset of action and drug toxicities.Conventional monitoring of drug therapy has been based on clinical assessment of response, in addition tomonitoring blood counts, liver function, and pancreatic function tests. Recently, there has been an interest inmonitoring intracellular levels of azathioprine metabolites to predict response and complications, with theultimate aim of tailoring drug therapy to each individual patient. The determination of TPMT enzyme status bygenotyping or phenotyping is intended as a one-time screening assay for patients being considered forazathioprine therapy.

Menactra vaccine eligible for payment

Highmark Blue Shield now covers the new vaccine MenactraTM. Blue Shield will determine coverage forMenactra in accordance with the Childhood Immunization Act for dependent children as well as applicants ormembers and their spouses who are up to and including 20 years of age. For individuals outside this population,Blue Shield will base coverage for Menactra on the member’s contract.

6/2005

9

Menactra is a meningococcal polysaccharide (serogroups A, C, and W-135) Diphtheria Toxoid conjugatevaccine. The Food and Drug Administration has approved Menactra for active immunization of adolescents andadults 11-55 years of age for the prevention of invasive meningococcal disease caused by Neisseria meningitidisserogroups A, C, Y and W-135.

Use code 90734—Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (Tetravalent), forintramuscular use—to report this vaccine.

How to report epidural anesthesia provided during labor and cesareandelivery

As of July 11, 2005, when you report procedure code 01967 in conjunction with code 01968 or 01969,Highmark Blue Shield will pay for the base units (BU) and time for each code.

When you report time, it should reflect the actual time you spent in personal attendance, that is, “face time” withthe patient. Report time in minutes. Blue Shield will convert those minutes into time units (TU).

Report the appropriate anesthesia modifier with each code so that Blue Shield can determine the level ofreimbursement for each code, for example, 100 percent or 50 percent of the anesthesia allowance.

Here are examples of how to report epidural anesthesia and the corresponding method of how Blue Shield willcalculate the reimbursement.

• The anesthesiologist personally performs the labor epidural and anesthesia during the cesarean section:

How to report epidural anesthesia Reimbursement calculation

Line 1 – 01967AA BU + TU x conversion factor = 100 percent

Line 2 – 01968AA BU + TU x conversion factor = 100 percent

• The anesthesiologist personally performs the labor epidural and medically directs a CRNA (nonemployee) during the cesarean section:

How to report epidural anesthesia Reimbursement calculation

Line 1 – 01967AA BU + TU x conversion factor = 100 percent

Line 2 – 01968QK BU + TU x conversion factor ÷ 2 = 50 percent

For guidelines on how to report epidural anesthesia provided during labor and/or vaginal delivery, see theFebruary 2004 PRN.

PRN

10

Assays of genetic expression in tumor tissue for determining prognosis inbreast cancer patients considered investigational

Highmark Blue Shield considers assays of genetic expression in tumor tissue, including but not limited to theOncotype DX, as a technique to determine prognosis in breast cancer patients experimental or investigational.

Blue Shield will not pay for this testing because there is a lack of prospective studies on the use of these assaysin patient management. More data that show this technology can be used either to select or deselect patients foradjuvant therapy after primary surgical excision of breast cancer are needed.

A participating, preferred, or network provider can bill the member for the denied tests.

Use code 89240—unlisted miscellaneous pathology test—to report this testing. When you report code 89240,please provide a complete description of the service in the narrative field of the electronic or paper claim.

Currently, prognosis in breast cancer is based on patient age, tumor size, histology, status of the axillary lymphnodes, histologic type, and hormone receptor status. Recently, there has been interest in examining geneexpression in tumor tissue as a prognostic factor. The Oncotype DX assay analyzes the expression of a panel of21 genes. It is intended for use in conjunction with other conventional methods of breast cancer analysis.

PUVA eligible for graft-versus-host-disease

Highmark Blue Shield will now pay for psoralens and ultraviolet light therapy (PUVA) when it’s used to treatcutaneous graft-versus-host-disease (GVHD) that has occurred as a result of allogenic bone marrow transplants.

Report ICD-9-CM diagnosis code 996.85 for acute or chronic GVHD.

Blue Shield determines coverage for PUVA according to individual or group customer benefits.

Certain category III pathology services not eligible

Highmark Blue Shield considers these pathology services experimental or investigational:

• 0103T—Holotranscobalamin quantitative

• 0111T—Long-chain (C20-22) omega-3 fatty acids in red blood cells (RBC) membranes

When Blue Shield denies these services, a participating, preferred, or network provider can bill the member forthem.

Retinal telescreening eligible for diabetic patients

Highmark Blue Shield pays for retinal telescreening by digital imaging for the detection and evaluation of

diabetic retinopathy only for patients with diabetes mellitus (250.00-250.93).

If any other conditions are reported, Blue Shield will deny retinal telescreening as not medically necessary. A

participating, preferred, or network provider cannot bill the member for the denied service.

Use code S0625—retinal telescreening by digital imaging of multiple different fundus areas to screen for vision-

threatening conditions, including imaging, interpretation and report—to report this service.

Retinal telescreeing involves the use of a digital fundus camera to acquire a series of standard field color images

and/or monochromatic images of the retina of each eye. This type of retinopathy screening and risk assessment

is an alternative to conventional dilated fundus examination, particularly in those diabetic individuals who are

not compliant with recommended periodic retinopathy screenings. The digital images that are captured may be

evaluated on site and stored for comparison with subsequent retinal images of the same individual. They may

also be transmitted to a remote center for interpretation, storage and subsequent comparison.

The American Diabetic Association recommends an annual retinal eye examination for patients with diabetes

mellitus for detection and evaluation of diabetic retinopathy.

Concurrent medical care guidelines outlined

Highmark Blue Shield defines concurrent care as care provided to an inpatient of a hospital or skilled nursingfacility, simultaneously by more than one physician during a specific period of time.

Such care is usually provided when:

• Two or more separate conditions require the services of two or more physicians.

• The severity of a single condition requires the services of two or more physicians for proper management of the patient.

Establishing medical necessity for concurrent care

Blue Shield establishes the medical necessity for concurrent care based on the patient’s condition, asdemonstrated by the reported diagnosis and other documentation. The necessity of each physician’s particularskills is determined by considering the respective specialties and the diagnosis for which services were provided.

6/2005

11

PRN

12

If Blue Shield requires additional information to establish medical necessity, it may review hospital records.These records should:

• document the primary physician’s request for the consultant to see the patient

• include sufficient documentation to indicate the seriousness of the patient’s condition

Concurrent medical care guidelines

1. The admitting physician should be responsible for the patient’s primary care. He or she may be paid for medical care unless the patient is transferred to a consultant or specialist.

2. When two or more physicians each submit claims with multiple diagnoses on an inquiry basis, Blue Shield will evaluate each claim for payment or denial based on the conditions that each physician was treating.

3. Payment may be made for the concurrent treatment of two or more separate conditions by physicians of different specialties.

4. Payment may not be made for the concurrent treatment of two or more separate conditions by physicians of the same specialty.

5. Payment may not be made for the concurrent treatment of the same condition by physicians of the same specialty.

6. Payment may not be made for the concurrent treatment of the same condition by physicians of different specialties.

For example:

a. Two cardiologists are treating a patient for multiple cardiovascular conditions. Blue Shield will not pay for concurrent medical care.

b. A cardiologist and a general practitioner are treating a patient for multiple cardiovascular conditions. Blue Shield will not pay for concurrent medical care.

c. A urologist is treating a patient for a urinary condition and an orthopedist is treating the same patient for a musculoskeletal condition. Blue Shield will pay for concurrent medical care.

Blue Shield will establish the medical necessity of concurrent care on the basis of the patient’s condition, asdemonstrated by the reported diagnoses and the documentation in the patient’s medical records.

To enable Blue Shield to appropriately apply the concurrent care guidelines, please report only the diagnosis ordiagnoses for which you are treating the patient. Reporting all diagnoses for which the patient is being treatedby multiple physicians may cause unnecessary denials.

Blue Shield will not pay for concurrent care that does not meet its medical necessity criteria. A participating,preferred, or network provider may not bill the patient for denied concurrent care.

These guidelines are applicable to all of Highmark Blue Shield’s products. They also apply to authorizedinpatient admissions.

Cooling devices used in the home not covered

Highmark Blue Shield considers active cooling devices not medically necessary. Study results suggest that theactive cooling device is similar to ice packs, but there is no proof that it has any benefit beyond an ice pack. Aparticipating, preferred, or network provider cannot bill the member for the denied device.

Blue Shield does not consider passive cooling devices as durable medical equipment (DME). Therefore, they arenot covered. There is not enough scientific literature to prove that passive cooling systems provide a benefitbeyond convenience. A participating, preferred, or network provider can bill the member for the denied service.

A variety of continuous cooling devices are commercially available. They can be subdivided into thoseproviding passive cold therapy and those providing active cold therapy using a mechanical device.

Passive cooling devices include, but are not limited to, the CryoCuff and the Polar Care Cub. Active coolingdevices include, but are not limited to, the AutoChill device, the Hot/Ice Thermal Blanket, and the Game ReadyAccelerated Recovery System.

Use code E0218 or E0236 to report an active cooling device.

Use code A9270 when reporting a passive cooling device. When you report code A9270, please include the term“passive cooling device,” along with the brand name of the passive cooling device, in the narrative section ofthe electronic or paper claim.

Blue Shield determines coverage for DME according to the individual or group customer benefits.

Blue Shield now pays anesthesia for a nerve block

On July 11, 2005, Highmark Blue Shield began to pay for anesthesia administered for diagnostic or therapeuticnerve blocks and injections when the block or injection is performed by a different provider.

Use code 01991 or 01992 to report this anesthesia service.

6/2005

13

PRN

14

Blue Shield will pay for these types of anesthesia:

• inhalation• regional• intravenous• rectal• conscious sedation

Blue Shield does not pay for local anesthesia, which is direct infiltration of the incision, wound, or lesion. Aparticipating, preferred, or network provider can bill the member for the denied anesthesia.

Laparoscopic and percutaneous myolysis to treat uterine fibroids consideredinvestigational

Highmark Blue Shield considers laparoscopic and percutaneous techniques of myolysis experimental orinvestigational in the treatment of uterine fibroids. Such techniques include laser and bipolar needles,cryomyolysis, and laparoscopic radiofrequency ablation (HALT procedure).

Blue Shield will deny surgical myolysis, whether it’s performed through a laparoscope or percutaneously, as notcovered. The procedure is not eligible for payment. A participating, preferred, or network provider can bill themember for these denied procedures.

Report these techniques with the appropriate code:

• 58578 for laparoscopic techniques of myolysis

• 58999 for percutaneous techniques of myolysis

When you report code 58578 or 58999, please include a complete description of the procedure you performed inthe narrative section of the electronic or paper claim.

Uterine fibroids are the most common type of abnormal growth in the uterus. They can cause symptoms ofmenorrhagia (abnormally heavy bleeding), pelvic pressure, and pain. Laparoscopic and percutaneous techniquesof myolysis involve the insertion of probes multiple times into the fibroid. When activated, the various energysources induce devascularization and ultimately ablation of the target tissue.

6/2005Blue Shield covers seat lift mechanism for certain criteria

Highmark Blue Shield considers a seat lift mechanism medically necessary and eligible for reimbursement whenordered by the treating health care professional and all of these criteria are met:

1. the patient must have severe arthritis of the hip or knee, or have a severe neuromuscular disease,

2. the seat lift mechanism must be prescribed to cause improvement, or arrest or retard deterioration in the patient’s condition,

3. the patient must be completely incapable of standing up from a regular armchair or any chair in their home, and

4. once standing, the patient must be able to ambulate.

Blue Shield limits coverage of seat lift mechanisms to those types that operate smoothly, can be controlled bythe patient, and effectively assist a patient in standing up and sitting down without other assistance. Blue Shielddoes not cover seat lifts that operate by spring release mechanism with a sudden, catapult-like motion that joltsthe patient from a seated to a standing position. A participating, preferred, or network provider can bill themember for the denied seat lift.

You must include the medical necessity for the seat lift mechanism in the patient’s medical record. Thoserecords must be available upon request.

An order for each item billed must be signed and dated by the treating health care professional. That order mustbe kept on file by the supplier. The supplier must provide the order if Blue Shield requests it. For Blue Shield topay for the seat lift mechanism, this order must be received by the supplier prior to the delivery of the item.

Blue Shield limits coverage to the seat lift mechanism, even if it is incorporated into a chair.

Use code E0627 when providing a seat lift mechanism that is incorporated into a chair as a complete unit at thetime of purchase. In this situation, use code E0627 to bill the seat lift mechanism and A9270 for the chair. Whenyou report code A9270, please include the term “chair into which the seat lift mechanism is incorporated,” in thenarrative section of the electronic or paper claim.

Use code E0628 or E0629, as appropriate, if the seat lift mechanism is supplied as an individual unit to beincorporated into a chair that a patient owns.

15

PRN

16

Seat lift mechanisms are designed to assist patients to stand from a sitting position. Seat lifts can be built intochairs or can be separate for use with other furniture.

Blue Shield determines coverage for durable medical equipment according to the individual or group customerbenefits.

Treatment of acne guidelines explained

Highmark Blue Shield does not cover acne surgery or the destruction of acne lesions with a laser. Aparticipating, preferred, or network provider can bill the member for the denied services.

• Report acne surgery with code 10040. This service includes marsupialization, opening, or removal of comedones, milia, and pustules.

• Report laser destruction of acne lesions with codes 17000-17004. You should also report ICD-9-CM diagnosis code 706.1 on the claim when you report codes 17000-17004.

Blue Shield will pay for surgical treatment, such as excision or incision and drainage, of true cysts resultingfrom acne. Report these services with the appropriate surgical procedure code.

Blue Shield pays for medical visits for the treatment of acne. Report these services with the appropriate visitcode.

Blue Shield determines coverage for medical visits according to the individual or group customer benefits.

High-energy extracorporeal shock wave therapy not covered

Highmark Blue Shield does not cover extracorporeal shock wave therapy used to treat plantar fasciitis or anyother musculoskeletal conditions. This includes services performed with high-energy shock waves. Aparticipating, preferred, or network provider can bill the member for the denied service.

Here are the procedure codes you can use to report high-energy shock wave therapy:

0101T—extracorporeal shock wave involving musculoskeletal system, not otherwise specified; high energy

0102T—extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other thanlocal, involving lateral humeral epicondyle

For additional information about this therapy, see “Extracorporeal shock wave therapy for plantar fasciitis notcovered” on Page 23 in the August 2004 PRN

Blue Shield covers real time on-site and remote-location intraoperativeneurophysiological monitoring

Highmark Blue Shield will cover intraoperative neurophysiological monitoring when it’s performed by a healthcare professional who performs the service in real time.

The health care professional may be present either in the operating room suite or at a remote site with themonitoring performed through digital transmission or closed circuit television. When digital transmission orclosed circuit television is used, continuous or immediate contact with the operating surgeon must be availableto ensure that information about the patient’s status can be immediately communicated.

Use procedure code 95920 to report intraoperative neurophysiological monitoring, regardless of the specificmonitoring performed, for example, brainstem auditory evoked response, somatosensory evoked potentials and others.

Intraoperative neurophysiological monitoring involves the application of electrodiagnostic modalities to identifyand monitor the functional integrity of neurological structures to prevent injury and complications duringsurgery on the nervous system, its blood supply, or adjacent tissue. The intent of this monitoring is to alert thesurgeon so that the surgical procedure may be altered to avoid permanent neurological damage.

Blue Shield denies inert gas rebreathing for cardiac output measurement

Highmark Blue Shield considers inert gas rebreathing for cardiac output measurement experimental orinvestigational. Blue Shield will deny claims reporting this service. A participating, preferred, or networkprovider can bill the member for the denied service.

Here are the procedure codes you can use to report this service:

0104T—inert gas rebreathing for cardiac output measurement; during rest

0105T—inert gas rebreathing for cardiac output measurement; during exercise

Ventavis to be reimbursed at 95 percent of AWP

Highmark Blue Shield will set its UCR and PremierBlue Shield reimbursement at 95 percent of the averagewholesale price (AWP) for all new therapeutic injections and chemotherapy drugs approved by the Food andDrug Administration (FDA) on or after Jan. 1, 2005.

6/2005

17

PRN

18

These reimbursement rates will remain in effect for one year from the date the drug is approved by the FDA.After the one-year introductory period expires, Blue Shield will price the drug or biological at 85 percent of theAWP.

Here is a new drug that Blue Shield will price at 95 percent of the AWP for one year.

Drug name: Ventavis (Iloprost)FDA approval: Dec. 29, 2004Effective date: Jan. 1, 2005Revision date: Jan. 1, 2006

New codes and modifiers now available

Here are new procedure codes and modifiers and the dates they became available.

Code Terminology Effective date

0089T Actigraphy testing, recording, analysis and interpretation (minimum of 7/1/2005three-day recording)

0090T Total disc arthroplasty (artificial disc), anterior approach, including diskectomy 7/1/2005to prepare interspace (other than for decompression) single interspace; cervical

0091T Total disc arthroplasty (artificial disc), anterior approach, including diskectomy 7/1/2005to prepare interspace (other than for decompression) single interspace; lumbar

0092T Total disc arthroplasty (artificial disc), anterior approach, including diskectomy 7/1/2005to prepare interspace (other than for decompression) single interspace; each additional interspace (List separately in addition to code for primary procedure)

0093T Removal of total disc arthroplasty, anterior approach, single interspace; cervical 7/1/2005

0094T Removal of total disc arthroplasty, anterior approach, single interspace; lumbar 7/1/2005

0095T Removal of total disc arthroplasty, anterior approach, single interspace; each 7/1/2005additional interspace (List separately in addition to code for primary procedure)

0096T Revision of total disc arthroplasty, anterior approach, single interspace; cervical 7/1/2005

0097T Revision of total disc arthroplasty, anterior approach, single interspace; lumbar 7/1/2005

Codes

Code Terminology Effective date

0098T Revision of total disc arthroplasty, anterior approach, single interspace; each 7/1/2005additional interspace (List separately in addition to code for primary procedure)

0099T Implantation of intrastromal corneal ring segments 7/1/2005

0100T Placement of a subconjunctival retinal prosthesis receiver and pulse generator, 7/1/2005and implantation of intra-ocular retinal electrode array, with vitrectomy

0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise 7/1/2005specified; high energy

0102T Extracorporeal shock wave, high energy, performed by a physician, requiring 7/1/2005anesthesia other than local, involving lateral humeral epicondyle

0103T Holotranscobalamin quantitative 7/1/2005

0104T Inert gas rebreathing for cardiac output measurement; during rest 7/1/2005

0105T Inert gas rebreathing for cardiac output measurement; during exercise 7/1/2005

0106T Quantitative sensory testing (QST), testing and interpretation per extremity; 7/1/2005using touch pressure stimuli to assess large diameter sensation

0107T Quantitative sensory testing (QST), testing and interpretation per extremity; 7/1/2005using vibration stimuli to assess large diameter fiber sensation

0108T Quantitative sensory testing (QST), testing and interpretation per extremity; 7/1/2005using cooling stimuli to assess small nerve fiber sensation and hyperalgesia

0109T Quantitative sensory testing (QST), testing and interpretation per extremity; 7/1/2005using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia

0110T Quantitative sensory testing (QST), testing and interpretation per extremity; 7/1/2005using other stimuli to assess sensation

0111T Long-chain (C20-22) omega-3 fatty acids in red blood cells (RBC) membranes 7/1/2005

G0235 PET imaging, any site, not otherwise specified 4/1/2005

K0730 Controlled dose inhalation drug delivery system 7/1/2005

6/2005

19

PRN

20

Code Terminology Effective date

K0731 Lithium ION battery for use with cochlear implant device speech processor, 7/1/2005other than ear level, replacement, each

K0732 Lithium ION battery for use with cochlear implant device speech processor, ear 7/1/2005level, replacement, each

Q4080 Iloprost, inhalation solution, administered through DME, up to 20 mcg 7/1/2005

Q9945 Low osmolar contrast material, up to 149 mg/ml iodine concentration, per ml 4/1/2005

Q9946 Low osmolar contrast material, 150-199 mg/ml iodine concentration, per ml 4/1/2005

Q9947 Low osmolar contrast material, 200-249 mg/ml iodine concentration, per ml 4/1/2005

Q9948 Low osmolar contrast material, 250-299 mg/ml iodine concentration, per ml 4/1/2005

Q9949 Low osmolar contrast material, 300-349 mg/ml iodine concentration, per ml 4/1/2005

Q9950 Low osmolar contrast material, 350-399 mg/ml iodine concentration, per ml 4/1/2005

Q9951 Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml 4/1/2005

Q9952 Injection, gadolinium-based magnetic resonance contrast agent, per ml 4/1/2005

Q9953 Injection, iron-based magnetic resonance contrast agent, per ml 4/1/2005

Q9954 Oral magnetic resonance contrast agent, per ml 4/1/2005

Q9955 Injection, perflexane lipid microspheres, per ml 4/1/2005

Q9956 Injection, octafluoropropance microspheres, per ml 4/1/2005

Q9957 Injection, perflutren lipid microspheres, per ml 4/1/2005

Q9958 High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml 7/1/2005

Q9959 High osmolar contrast material, 150-199 mg/ml iodine concentration, per ml 7/1/2005

Q9960 High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml 7/1/2005

Q9961 High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml 7/1/2005

Q9962 High osmolar contrast material, 300-349 mg/ml iodine concentration, per ml 7/1/2005

Code Terminology Effective date

Q9963 High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml 7/1/2005

Q9964 High osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml 7/1/2005

S0118 Injection, ziconotide, for intrathecal infusion, 1 mcg 7/1/2005

S0133 Histrelin implant, 50 mg 7/1/2005

S0145 Injection, pegylated interferon alfa-2A, 180 mcg/ml 7/1/2005

S0146 Injection, pegylated interferon alfa-2B, 10 mcg/0.5ml 7/1/2005

S0198 Injection, pegaptanib sodium (macugen), 0.3 mg 7/1/2005

S0265 Genetic counseling, under physician supervision, each 15 minutes 7/1/2005

S0613 Annual gynecological examination; clinical breast examination without 7/1/2005pelvic examination

S2900 Surgical techniques requiring use of robotic surgical system (List separately in 7/1/2005addition to code for primary procedure)

S8270 Enuresis alarm, using auditory buzzer and/or vibration device 7/1/2005

Modifier Terminology Effective date

BL Special acquisition of blood and blood products 7/1/2005

TS Follow-up service 4/1/2005

Modifier MN deleted

Highmark Blue Shield deleted modifier MN—medically necessary ambulance transfer—on April 1, 2005.

6/2005

21

PRN

22

Terminology revised for modifier RD and code 0078T

Here is the revised terminology for modifier RD and for procedure code 0078T:

RD—Drug provided to beneficiary, but not administered incident-to

0078T—Endovascular repair using prosthesis of abdominal aortic aneurysm, pseudoaneurysm or dissection, abdominalaorta, involving visceral branches (superior mesenteric, celiac and/or renal artery(s))

6/2005

23

Need to change your provider information?

Fax the information to us!

You can fax us changes about your practice information, such as the information listed on the coupon below. The fax number is (800) 236-8641. You may also continue to send information by completing the coupon below.

Coupon for changes to provider information

Please clip and mail this coupon, leaving the PRN mailing label attached to the reverse side, to:

Highmark Blue Shield Provider Data Services

PO Box 898842Camp Hill, Pa. 17089-8842

Name Provider ID number

Electronic media claims source number

Please make the following changes to my provider records:

Practice name

Practice address

Mailing address

Telephone number ( ) Fax number ( )

E-mail address

Tax ID number

Specialty

Provider’s signature Date signed

PRN

PRSRT STDU.S. POSTAGE

PAIDHARRISBURG, PAPermit No. 320

Contents Vol. 2005, No. 3

News

Provider Data Services replaces fax number; adds new faxnumber for credentialing information..........................................1Blue Shield to integrate behavioral health medicalmanagement services ..................................................................2Deductible and coinsurance information available throughvarious sources ............................................................................3How to report unlisted procedure codes......................................4Fees for unlisted procedure codes available through NaviNet....4Blue Shield begins to refund Medicare for COBoverpayments ..............................................................................4Modifier 22 process explained ....................................................5

Policy

Blue Shield expands coverage for MRI of the breast ................7Pharmacogenomic and metabolite markers for IBD treatedwith Azathioprine are investigational ..........................................8Menactra vaccine eligible for payment ......................................8How to report epidural anesthesia provided during labor andcesarean delivery ........................................................................9Assays of genetic expression in tumor tissue fordetermining prognosis in breast cancer patients consideredinvestigational ............................................................................10PUVA eligible for graft-versus-host-disease ............................10Certain category III pathology services not eligible ................10Retinal telescreening eligible for diabetic patients....................11Concurrent medical care guidelines outlined ............................11Cooling devices used in the home not covered ........................13Blue Shield now pays anesthesia for a nerve block ..................13

Laparoscopic and percutaneous myolysis to treat uterinefibroids considered investigational ............................................14Blue Shield covers seat lift mechanism for certain criteria ......15Treatment of acne guidelines explained ....................................16High-energy extracorporeal shock wave therapy not covered ..16Blue Shield covers real time on-site and remote-locationintraoperative neurophysiological monitoring ..........................17Blue Shield denies inert gas rebreathing for cardiac outputmeasurement ..............................................................................17Ventavis to be reimbursed at 95 percent of AWP......................17

Codes

New codes and modifiers now available ..................................18Modifier MN deleted ................................................................21Terminology revised for modifier RD and code 0078T............22

Need to change your provider information?..............................23

Acknowledgement

The five-digit numeric codes that appear in PRN were obtainedfrom the Current Procedural Terminology, as contained inCPT-2005, Copyright 2004, by the American MedicalAssociation. PRN includes CPT descriptive terms andnumeric procedure codes and modifiers that are copyrightedby the American Medical Association. These procedurecodes and modifiers are used for reporting medical servicesand procedures.

PRNPolicy Review & News

Highmark Blue ShieldCamp Hill, Pennsylvania 17089

Visit us at www.highmarkblueshield.com