January 2019

Featured Story: Provider Portal

Our Provider Portal is your primary resource for managing your AllWays Health Partners patients. Access the Provider Portal today at allwaysprovider.org.

In This Issue:


 

Provider Portal

Allways Health Partners' Provider Portal is your primary resource for managing your AllWays Health Partners patients. Through the Provider Portal, you will have 24/7 instant access to:

  • Confirming receipt and status of a claim
  • Verifying member eligibility
  • Your Explanation of Payments
  • Submitting and reviewing authorization requests
  • A roster view of credentialed providers
  • And much more

 


 

Quick Reference Guides

We've created some quick reference guides to support you with our transition to AllWaysHealth Partners. Available resources include an FAQ, sample images of our new member ID card and information about our Partners HealthCare Plans. Please share these resources with your staff.

 


 

Claims Information

We're now AllWays Health Partners, but our claims process hasn't changed. For the fastest processing and to get paid sooner, claims should be electronically submitted.

Payer ID: 04293
HMO Paper Claims Address: P.O. Box 853908, Richardson, TX 75085-3908
PPO Paper Claims Address: P.O. Box 852099, Richardson, TX 75085-2099

 


 

Reminder: Notification to Medicare of Insurance Changes

As a reminder, when a Medicare primary patient notifies you of a change to their secondary coverage, please remember it is the responsibility of the provider to send the new insurance information to Medicare. By sending this information to Medicare timely, this will ensure that claims are appropriately processed, avoid any delays to payment and ensure that the patient isn't caught in the middle when Medicare sends the secondary claim to the incorrect health plan.

 


 

New January 2019 Codes

During a recent review, we identified an update to the 2018 EAPG hospital claims processing for My Care Family members. As a result, we will reprocess some 2018 EAPG hospital claims and reimburse accordingly. You will see reprocessed claims on your July 3rd payment.

The following CPT codes are not covered as experimental and investigational:

Code Description
33274 Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging
33275 Transcatheter removal of permanent leadless pacemaker, right ventricular
33289 Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed
53854 Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy
76391 Magnetic resonance (e.g., vibration) elastography
76981 Ultrasound, elastography; parenchyma (e.g., organ)
76982 Ultrasound, elastography; first target lesion
76983 Ultrasound, elastography; each additional target lesion (List separately in addition to code for primary procedure)
93264 Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care
0509T Electroretinography (ERG) with interpretation and report, pattern (PERG)
0510T Removal of sinus tarsi implant
0511T Removal and reinsertion of sinus tarsi implant
0512T Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound
0513T Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure)
0514T Intraoperative visual axis identification using patient fixation (List separately in addition to code for primary procedure)
0515T Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; complete system (includes electrode and generator [transmitter and battery])
0516T Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; electrode only
0517T Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; pulse generator component(s) (battery and/or transmitter) only
0518T Removal of only pulse generator component(s) (battery and/or transmitter) of wireless cardiac stimulator for left ventricular pacing
0519T Removal and replacement of wireless cardiac stimulator for left ventricular pacing; pulse generator component(s) (battery and/or transmitter)
0520T Removal and replacement of wireless cardiac stimulator for left ventricular pacing; pulse generator component(s) (battery and/or transmitter), including placement of a new electrode
0521T Interrogation device evaluation (in person) with analysis, review, and report, includes connection, recording, and disconnection per patient encounter, wireless cardiac stimulator for left ventricular pacing
0522T Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, wireless cardiac stimulator for left ventricular pacing
0523T Intraprocedural coronary fractional flow reserve (FFR) with 3D functional mapping of color-coded FFR values for the coronary tree, derived from coronary angiogram data, for real-time review and interpretation of possible atherosclerotic stenosis(es) intervention (List separately in addition to code for primary procedure)
0524T Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring
0525T Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; complete system (electrode and implantable monitor)
0526T Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; electrode only
0527T Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable monitor only
0528T Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report
0529T Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report
0530T Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor)
0531T Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only
0532T Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only
0533T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes set-up, patient training, configuration of monitor, data upload, analysis and initial report configuration, download review, interpretation and report
0534T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; set-up, patient training, configuration of monitor
0535T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
0536T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
0541T Myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning-derived clinical scoring, and automated report generation, single study;
0542T Myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning-derived clinical scoring, and automated report generation, single study; interpretation and report

 


 

The following CPT codes are covered when prior authorized:

Code Description
20932 Allograft, includes templating, cutting, placement, and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (List separately in addition to code for primary procedure)
20933 Allograft, includes templating, cutting, placement, and internal fixation, when performed; hemicortical intercalary, partial (i.e., hemicylindrical) (List separately in addition to code for primary procedure)
20934 Allograft, includes templating, cutting, placement, and internal fixation, when performed; intercalary, complete (i.e., cylindrical) (List separately in addition to code for primary procedure)
33285 Insertion, subcutaneous cardiac rhythm monitor, including programming
76978 Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); initial lesion
76979 Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); each additional lesion with separate injection (List separately in addition to code for primary procedure)
77046 Magnetic resonance imaging, breast, without contrast material; unilateral
77047 Magnetic resonance imaging, breast, without contrast material; bilateral
77048 Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis), when performed; unilateral
77049 Magnetic resonance imaging, breast, without and with contrast material(s), including computer-aided detection (CAD real-time lesion detection, characterization, and pharmacokinetic analysis), when performed; bilateral
81163 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis
81164 BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (i.e., detection of large gene rearrangements)
81165 BRCA1 (BRCA1, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis
81166 BRCA1 (BRCA1, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (i.e., detection of large gene rearrangements)
81167 BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (i.e., detection of large gene rearrangements)
81173 AR (androgen receptor) (e.g., spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant
81185 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (e.g., spinocerebellar ataxia) gene analysis; full gene sequence
81186 CACNA1A (calcium voltage-gated channel subunit alpha1 A) (e.g., spinocerebellar ataxia) gene analysis; known familial variant
81189 CSTB (cystatin B) (e.g., Unverricht-Lundborg disease) gene analysis; full gene sequence
81190 CSTB (cystatin B) (e.g., Unverricht-Lundborg disease) gene analysis; known familial variant(s)
81286 FXN (frataxin) (e.g., Friedreich ataxia) gene analysis; full gene sequence
81289 FXN (frataxin) (e.g., Friedreich ataxia) gene analysis; full gene sequence
81306 NUDT15 (nudix hydrolase 15) (e.g., drug metabolism) gene analysis, common variant(s) (e.g., *2, *3, *4, *5, *6)
81336 SMN1 (survival of motor neuron 1, telomeric) (e.g., spinal muscular atrophy) gene analysis; full gene sequence
81337 SMN1 (survival of motor neuron 1, telomeric) (e.g., spinal muscular atrophy) gene analysis; known familial sequence variant(s)
81443 Genetic testing for severe inherited conditions (e.g., cystic fibrosis, Ashkenazi Jewish-associated disorders [e.g., Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachs disease], beta hemoglobinopathies, phenylketonuria, galactosemia), genomic sequence analysis panel, must include sequencing of at least 15 genes (e.g., ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH)
81518 Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy
81596 Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scores for fibrosis and necroinflammatory activity in liver
0537T Chimeric antigen receptor T-cell (CAR-T) therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR-T cells, per day
0538T Chimeric antigen receptor T-cell (CAR-T) therapy; preparation of blood-derived T lymphocytes for transportation (e.g., cryopreservation, storage)
0539T Chimeric antigen receptor T-cell (CAR-T) therapy; receipt and preparation of CAR-T cells for administration
0540T Chimeric antigen receptor T-cell (CAR-T) therapy; CAR-T cell administration, autologous

 


 

The following CPT codes are covered but not reimbursed (resubmit w/ HCPCS):

Code Description
97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes
97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes
97155 Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes
97156 Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes
97157 Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes
97158 Group adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, face-to-face with multiple patients, each 15 minutes

 


 

The following CPT codes redirect to Optum for consideration under the BH benefit:

Code Description
96130 Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s), or caregiver(s), when performed; first hour
96131 Psychological testing evaluation services by physician or other qualified health care professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s), or caregiver(s), when performed; each additional hour (List separately in addition to code for primary procedure)

 


 

Hospital Inpatient Utilization Report

The latest quarterly hospital inpatient utilization report is now available. To review this report, click on the Reports tab in the Provider Portal and select Clinical Reports. If you do not have access to the Provider Portal, you may register online at allwaysprovider.org.

 


 

Medical Policy

The following medical policy updates are effective January 1, 2019:

  • Bariatric Surgery - Annual review without substantial changes in medically necessary indicators. References updated
  • Breast Surgeries - Annual review without substantial changes in medically necessary indicators.
  • Phototherapy and Photochemotherapy for Dermatologic Conditions - Annual review. Under UVB Excimer Laser Therapy section, changed trial from 3 months to 2 months. References updated.
  • Reconstructive and Cosmetic Procedures - Annual review. Added CPT codes. References updated.
  • UVB Home Phototherapy Units for Skin Disease - Annual review without substantial changes in medically necessary indicators.

Click Here to view all medical policies.