As a professional in the healthcare industry, you are surely aware that coding regulations are constantly shifting and changing. Whether these changes relate to the codes that need to be used for certain procedures or updates to specific policies, staying on top of these changes is the best way to keep your practice ahead of the game. At HIS, it is our mission to keep orthopedic and radiology practices up to date on the latest coding updates and changes. Below, we’ve listed out some of the most recent changes regarding insurance carrier policy updates, so read on to learn more.
Aetna’s recent changes include a policy update and two form updates. For patients that would qualify, Aetna’s policy for Autologous Chondrocyte Implantation has been updated. The policy, which can be found here, lists out the criteria required for the carrier to consider this procedure medically necessary to repair cartilage defects of the knee, as well as the criteria for when implants are considered experimental and investigational. Diagnoses that are not covered by adding discoid lateral meniscus tear were updated as well. Aetna’s recent changes also included two form updates: their Viscosupplementation medication request form and their Osteoporosis injectable medication request form.
Cigna updated their medical coverage policy for miscellaneous musculoskeletal procedures, which included the removal of coverage for in-office diagnostic arthroscopy. According to the provider, “in-office diagnostic arthroscopy (e.g., Mi-Eye2™, VisionScope®️) or any upper or lower extremity joint for evaluation of joint pain and/or pathology is considered experimental, investigational, or unproven.” Cigna also made changes to their Medical Coverage Policy for Knee Surgery, which will be updated as of August 15, 2019.
UnitedHealthcare’s policy changes and updates relate mainly to the authorization of services. Beginning on August 2, UnitedHealthcare will begin reviewing the site of service in their prior-authorization process. These reviews will concern certain musculoskeletal surgical procedures, and the site of service will be reviewed for medical necessity. Changes and modifications to approved prior authorization will be allowed within five business days of when the procedure is performed. A crosswalk table of codes will be accepted if a different code than the one authorized was billed- please call 877-842-3210. This service is available only for UHC commercial members, and instructions can be found here.
Blue Cross Blue Shield of Illinois updated their medical policy for Orthopaedic applications of PRP, which is not being covered at this time. They also developed a new policy on non-covered physical therapy services, which includes details about when physical therapy is not considered medically necessary, which modalities are considered experimental, treatments that do not require a licensed physical therapist, and more. For BCBSIL members with the member ID prefixes of PAS, BHP, SFZ, and UAL, benefit reauthorization must be obtained through eviCore beginning August 1st. More information will be available from the carrier in July.
At HIS, we strive to do everything we can to help keep your orthopedic or radiology practice as efficient and profitable as possible, all year long. We are more than a billing company – our revenue cycle management, coding education, and practice management and consulting services are meant to bring your practice to new heights. With HIS, you will gain a true partner that is fully committed to your practice’s success. To learn more about HIS and what we do, or to ask any questions you may have about the recent carrier policy updates listed above, please contact us today! We look forward to hearing from you.