Annually BlueCross BlueShield of Kansas sends a letter outlining changes to be effective the following January for the Competitive Allowance Program (“CAP”). We have received the changes to be effective January 1, 2011. There are a few changes to the Policy Memo we would like to bring to your attention. Please review the following changes and feel free to call our office if you have any questions. (Bold lettering delineates added verbiage and brackets “[]” delineates deleted verbiage.) If you would like to review the policy changes in full, please go to 2011 Policy Memos “CAP Letter and Policy Memo Summary” located at: http://www.bcbsks.com/CustomerService/Providers/Publications/professional/PolicyMemos/index.htm
Policy Memo No. 1
SECTION VII. EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES (Previously Section VI.)
- Page 8: In the last paragraph, second sentence, after section D., verbiage was added to outline documentation requirements for use of the waiver form.
…must have a signed waiver in his/her file. The provider must discuss this with the patient in advance, document this in the medical record, and include the GA modifier (waiver on file) on the claim form (electronic or paper). (See Section X. WAIVER FORM) Failure to discuss and obtain a signed waiver in advance of the service will result in provider write-off. Denied experimental or investigational services are not eligible for appeal.
Policy Memo No. 9
SECTION I. GLOBAL FEE CONCEPT
- Page 2: Under A.3., the first full paragraph on the page was removed as it did not apply to the Global Fee Concept.
[Medically necessary moderate sedation when performed by a trained observer and directed by the surgeon will be allowed when performed in an office setting, except when the surgery procedure code is on CPT Appendix G or a corresponding HCPCS code. (Anesthesia for procedures on Appendix G and corresponding HCPCS codes is included in the MAP for the surgery and not separately payable.)]
- Page 3: Section B. MODERATE (CONSCIOUS) SEDATION was added to define when and how payment is allowed.
B. MODERATE (CONSCIOUS) SEDATION
When provided in an inpatient or outpatient facility, BCBSKS will allow payment for medically necessary moderate sedation to an anesthesia provider, other than the provider of the primary service, who is authorized under state law to administer general anesthesia. Moderate sedation, when performed in an office setting, is considered content of service to the office procedure rendered by the performing provider and will be denied as a provider write-off. (Dental providers please refer to Dental Policy Memo, Section XXXIV.)
Policy Memo No. 12
SECTION VI. RELATED POLICIES
- Page 4: Under Section E. MODERATE (CONSCIOUS) SEDATION, second paragraph, verbiage clarifies that payment will be allowed for medically necessary moderate sedation in an inpatient or outpatient facility to an authorized provider other than the provider of the primary service. However, moderate sedation in an office setting will be considered content of service and will deny as a provider write-off.
When provided in an inpatient or outpatient facility, BCBSKS will allow payment for medically necessary moderate sedation to an anesthesia provider, other than the provider of the primary service, who is authorized under state law to administer general anesthesia. [Medically necessary] Moderate sedation, [when performed in an office setting, [except when the surgery procedure code is on CPT Appendix G or a corresponding HCPCS code. (Anesthesia for procedures on Appendix G and corresponding HCPCS codes is included in the MAP) for the surgery and not separately payable.)] is considered content of service to the office procedure rendered by the performing provider and will be denied as a provider write-off.
DENTAL Policy Memo
SECTION XXXIV. MODERATE (CONSCIOUS) SEDIATION
- Page 18: A new section was added to define the use of medically necessary moderate sedation.
Section I.B. MODERATE (CONSCIOUS) SEDATION of Policy Memo No. 9 is not applicable to dental and oral surgery procedures. Medically necessary moderate sedation, when performed by a trained observer and directed by the dentist, will be allowed when performed in an office setting when the dental service is covered under a medical benefit. Moderate (conscious) sedation, even when medically necessary, is a non-covered service under the dental contract, and is a member responsibility if requested by the member.
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Editor: Philip Blann (pblann@anesthesiabilling.com).
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