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December Provider News

Date: 12/20/17

In this Issue: 

Thank you for being our partner in care to collectively improve the health of our members. Please call our Provider Services team with questions about these announcements or if you need more information: 1-877-644-4613.

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Notice 1: Holiday Schedule

Coordinated Care will be closed due to Holiday for the following dates:

Friday December 22nd – Half Day
Monday December 25th – Closed
Friday December 29th – Half Day
Monday January 1st – Closed
Monday January 15th – Closed

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Notice 2: Utilization Review Matrix-NIA

NIA has developed the following matrix in an effort to help its clients set up their claim processing systems. This matrix is designed to assist in the resolution of claims adjudication and claims questions related to those services managed by NIA. The matrix below contains all those CPT-4 codes NIA manages on behalf of its clients. The codes listed are set up utilizing what would be seen on a professional HCFA 1500 claim. The inclusion of a code(s) also doesn’t imply that the service would be approved, only that if we received a request for that service, it would be managed by NIA. 

The “Allowable Billed Groupings” is meant to outline that if a given procedure is authorized, that any of the listed procedures codes could be submitted on a claim representing that service. This assumes that the member is eligible at the time of the service, that appropriate rebundling rules are applied, that the claim includes an appropriate diagnosis code for the CPT code and that the service is performed within the date of service validity period.

Codes that are submitted by facilities using CMS Outpatient PPS logic (C codes) are also not incorporated into this table.

If a family of CPT codes is not listed in this matrix, an exact match is required between the authorized CPT code and the billed CPT code. If the exact match does not occur, the charge should be adjudicated accordingly.

This UM Matrix includes a listing of the codes managed by NIA (require Prior authorization). There may be some codes not listed in this matrix that are included as part of Centene’s contract with NIA but no prior auth is required.

*Please note: Services rendered in an Emergency Room, Observation Room, surgery center or hospital inpatient setting are not managed by NIA.

Authorized CPT Code

Description

Allowable Billed Groupings

70336

MRI Temporomandibular Joint

70336

70450

CT Head/Brain

70450, 70460, 70470

70480

CT Orbit

70480, 70481, 70482

70486

CT Maxillofacial/Sinus

70486, 70487, 70488, 76380

70490

CT Soft Tissue Neck

70490, 70491, 70492

70496

CT Angiography, Head

70496

70498

CT Angiography, Neck

70498

70540

MRI Orbit, Face, and/or Neck

70540, 70542, 70543

70551

MRI Internal Auditory Canal

70551, 70552, 70553, 70540, 70542, 70543

70544

MRA Head

70544, 70545, 70546

70547

MRA Neck

70547, 70548, 70549

70551

MRI Brain

70551, 70552, 70553

70554

Functional MRI Brain

70554, 70555

71250

CT Chest

71250, 71260, 71270, G0297

71275

CT Angiography, Chest (non coronary)

71275

71550

MRI Chest

71550, 71551, 71552

71555

MRA Chest (excluding myocardium)

71555

72125

CT Cervical Spine

72125, 72126, 72127

72128

CT Thoracic Spine

72128, 72129, 72130

72131

CT Lumbar Spine

72131, 72132, 72133

72141

MRI Cervical Spine

72141, 72142, 72156

72146

MRI Thoracic Spine

72146, 72147, 72157

72148

MRI Lumbar Spine

72148, 72149, 72158

72159

MRA Spinal Canal

72159

72191

CT Angiography, Pelvis

72191

72192

CT Pelvis

72192, 72193, 72194

72196

MRI Pelvis

72195, 72196, 72197

72198

MRA Pelvis

72198

73200

CT Upper Extremity

73200, 73201, 73202

73206

CT Angiography, Upper Extremity

73206

73220

MRI Upper Extremity, other than Joint

73218, 73219, 73220

73221

MRI Upper Extremity Joint

73221, 73222, 73223

73225

MRA Upper Extremity

73225

73700

CT Lower Extremity

73700, 73701, 73702

73706

CT Angiography, Lower Extremity

73706

73720

MRI Lower Extremity

73718, 73719, 73720, 73721, 73722, 73723

73721

MRI Hip

72195, 72196, 72197, 73721, 73722, 73723

73725

MRA Lower Extremity

73725

74150

CT Abdomen

74150, 74160, 74170

74174

CT Angiography, Abdomen and Pelvis

74174

74175

CT Angiography, Abdomen

74175

74176

CT Abdomen and Pelvis Combination

74176, 74177, 74178

74181

MRI Abdomen

74181, 74182, 74183, S8037

74185

MRA Abdomen

74185

74261

Diagnostic CT Colonoscopy (Virtual Colonoscopy, CT Colonography)

74261, 74262

75557 3

MRI Heart

75557, 75559, 75561, 75563, +75565

75571

 

Coronary Artery Ca Score, Heart Scan, Ultrafast CT Heart, Electron Beam CT

75571, S8092

75572

CT Heart

75572

75573

CT Heart congenital studies, non-coronary arteries

75573

75574

CTA coronary arteries (CCTA)  

75574

75635

CT Angiography, Abdominal Arteries

75635

76380

Follow Up, Limited or Localized CT

76380, 70486, 70487, 70488

76390

MR Spectroscopy

76390

76497

Unlisted Computed Tomography Procedure

76497

76498

Unlisted Magnetic Resonance Procedure

76498

77058

MRI Breast

77058, 77059

77078

CT Bone Density Studies

77078

77084

MRI Bone Marrow

77084

78451

Myocardial Perfusion Imaging – Nuclear Cardiology Study

78451, 78452, 78453, 78454, 78466, 78468, 78469, 78481, 78483, 78499

78459 3

PET Scan, Heart

78459, 78491, 78492, +0482T

78472 3

MUGA Scan

78472, 78473, 78494, +78496

78608

PET Scan, Brain

78608, 78609

78813 1, 2

PET Scan

78811, 78812, 78813, 78814, 78815, 78816

78816 1, 2

PET Scan with concurrently acquired CT for attenuation correction and anatomic, localization.

78811, 78812, 78813, 78814, 78815, 78816

 

93307 3, 4

Transthoracic Echocardiography (TTE)

93303, 93304, 93306, 93307, 93308, +93320, +93321, +93325

93312 3

Transesophageal Echocardiography (TEE)

93312, 93313, 93314, 93315, 93316, 93317, 93318, +93320, +93321, +93325

93350 3

Stress Echocardiography

93350, 93351, +93320, +93321, +93325, +93352

0159T

CAD Breast MRI for Lesion Detection

0159T

G0297

Low Dose CT For Lung Cancer Screening

G0297

S8037

MR Cholangiopancreatography

S8037, 74181, 74182, 74183

S8042

MRI low field

S8042

  1. NIA will not be making a medical necessity determination as to which of these codes are appropriate. Instead, we will make a determination as to whether the PET scan itself is indicated and then expect the imaging facility to bill in a fashion that accurately describes what was performed.
  2. The 78814 series describes a PET scan where CT technology is used to better “focus” the PET scanning. When an ordering physician requests a PET scan, they won’t know whether or not an older machine will be used without the CT component. NIA’s tumor imaging clinical guidelines does not make a distinction between which technique is used. If a PET scan is clinically indicated, use of either series of codes is acceptable.  Accordingly, we are expanding the list of “Allowable Billable Groupings” to take this into account.  These codes are NOT to be used for a study typically called PET fusion. A PET fusion study is where a PET scan and a diagnostic CT scan are performed on the same machine simultaneously. Under this situation one is instructed by CPT to bill using both the PET CPT code and the CT scan code describing the body region and procedure performed. The CT code should be appended with a modifier 59 to ensure proper payment. When receiving such requests, NIA will review the medical necessity for both the PET scan and the CT scan and issue UM determinations on both codes.
  3. Payment for add-on codes may depend upon the appropriateness of the application of such codes related to the approved primary code.
  4. Per the CPT® Reference Guide for Cardiovascular Coding, authored by the AMA and the American College of Cardiology, 93303 and 93304 should not be used when complex congenital heart disease is suspected but not found on echocardiographic evaluation or for ‘simple’ congenital anomalies.

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Notice 3: Upcoming Apple Health Core Connections Provider Webinars 

On April 1, 2016, Coordinated Care became the single managed care organization to administer the Apple Health Foster Care program in collaboration with the Health Care Authority and Children’s Administration. This program serves children and youth in foster care, adoption support, and alumni of foster care (ages 18-26). Coordinated Care’s program is named “Apple Health Core Connections.” 

If you are interested in an office presentation overview of this program, policies and procedures which affect these members, please contact the Manager of Community Education at Danielle.E.Cannon@coordinatedcarehealth.com

Impact of Trauma – Webinar

The impact of trauma on the brain and the associated symptomatic manifestations

Wednesday January 3, 2018
1:00 – 3:00 pm
Register here

Workshop – How to Navigate Amidst Overwhelming Times – Tacoma

By The Trauma Stewardship Institute

Wednesday January 10, 2018
8:30 am – 3:00 pm
Register here

National Landscape and State Level Efforts to Address Childhood Adversity

Hosted by the California Campaign to Counter Childhood Adversity (4cAkids.org) and ACES Connection Network (acesconnection.com)

Speakers: Elizabeth Prewitt, ACEs Connection/CTIPP; Mandy Davis, Co-Director of Trauma-Informed Oregon; Elizabeth Hudson, Director, Office of Children’s Mental Health, Wisconsin; and Linda O’Neal, Executive Director, Tennessee Commission on Children and Youth

Wednesday January 10, 2018
10:00 am
Register here

Youth Suicide Prevention – Webinar

When working with youth and individuals with developmental disabilities, learn how to recognize some warning signs and symptoms of self-harming behaviors as well as the treatment options and reasons for such behaviors

Wednesday, January 19, 2018
7:00 – 8:30 am
Register here

To learn more about these and other trainings provided at no cost visit the Provider Events page at www.coordinatedcarehealth.com

MOVING TOWARD TRAUMA-INFORMED APPROACHE

Consider IMPLEMENTING policies and procedures that support people with a history of trauma and the staff who work with them. Examples include:

  • Review current policies, procedures and physical space and see what you already have in place that is trauma-informed, or could be enhanced to be trauma-informed.
  • Support and promote self-care for staff.
  • Look at your physical space – Is it safe? Is it welcoming?
  • School and early learning discipline policies and practices, including decreasing out of school suspension and expulsion.
  • Policies and practices related to arriving late and/or missing appointments, providing support and assistance with problem solving rather than discontinuing services. How can you work with the people you serve and community partners to remove barriers?

Resources for staff and agencies moving toward Trauma-informed Approaches

Creating Accessible, Culturally Relevant, Domestic Violence-and Trauma-Informed Agencies: A Self-Reflection Tool 
Accessing Safety and Recovery Initiative and National Center on Domestic Violence, Trauma & Mental Health, 2012.

ARC Model (Attachment, Self-Regulation and Competency) - Trauma Center at Justice Resource Institute 
ARC is a comprehensive framework for intervention with youth exposed to complex trauma.  It is recognized by the NCTSN as a promising practice. For more information: 

The town of The Dalles, OR, remakes itself as a trauma-sensitive sanctuary
ACEs Too High, 11/13/14

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Please reach out to your Provider Services team if you have question about any of these announcements or need more information. 

Coordinated Care Provider Services: (877) 644-4613