News
Q1 2024 PROVIDER NEWSLETTER
Date: 02/21/24
When it comes to RSV, you call the shots.
Your patients trust you more than any other source when it comes to vaccines. And your recommendation is the most effective way to ensure they get the ones they need.
RSV is the leading cause of childhood respiratory illness in the United States, resulting in thousands of hospitalizations and hundreds of deaths per year. Two FDA approved, and CDC recommended solutions can help protect the communities you serve from severe respiratory syncytial virus (RSV).
For the 2023-2024 RSV season, there are known supply shortages of the infant RSV Monoclonal Antibody Nirsevimab. In areas with shortages, guidance is to encourage maternal RSV vaccination as an alternative.
Infant RSV Monoclonal Antibody (Nirsevimab)
- A single intramuscular injection for infants younger than 8 months of age born during or entering into their first RSV season to prevent severe RSV disease.
Maternal RSV Vaccination (Abrysvo)
Pfizer’s bivalent RSVpreF vaccine, Abrysvo is the only RSV vaccine approved for use during pregnancy.
- A single injection given to pregnant individuals at 32 weeks through 36 weeks gestational age have shown reduction in severe RSV infection in infants by 81% within 90 days of life, and 69% within 180 days of life.
- Provides protection for infant if maternal vaccination occurred at least 14 days prior to birth.
Thank you for being a trusted partner in the healthcare decisions of those you care for.
The attached flyer provides additional information and resources for your use.
Clinical Policy Updates
View all Ambetter of North Carolina Inc. clinical policies online.
| CP.MP.101 Donor Lymphocyte Infusion | Revised | More and less restrictive. Updated policy description. Updated all criteria in statements I. and II. |
| CP.MP.57 Lung Transplantation | Revised | More and less restrictive. Revised adult and pediatric criteria to align with ISHLT 2021 consensus document. References reviewed and updated. |
| CP.MP.246 Pediatric Kidney Transplant | Revised | More and less restrictive. Annual review. Description updated to include source information for policy criteria. Updated Criteria I.A.1. from glomerular filtration rate (GFR) ≤ 15 mL/min/1.73m2 to GFR < 15 mL/min/1.73m2 to align with Kidney Disease: Improving Global Outcomes (KDIGO) guidance and Organ Procurement Transplant Network (OPTN) guidance. Updated Criteria I.A.2. to include members/enrollees with CKD stage 4 with GFR < 30 mL/min/1.73m2 who are expected to reach end stage renal disease (ESRD) to align with KDIGO guidance and OPTN guidance. Updated contraindications in I.B. consistent with KDIGO guidelines. References reviewed and updated. |
| CP.MP.250 Lantidra (donislecel) Allogenic Pancreatic Islet Cellular Therapy | New | Policy developed. |
| CP.MP.107 Durable Medical Equipment and Orthotics and Prosthetics Guidelines | Revised | Annual review. Updated description with no impact on criteria. Changed Orthopedic Care Equipment to Prosthetics and Orthotics Equipment. Table of contents updated. Retired pneumatic compression device criteria (E0675) for IQ. Updated "Cabinet style..." note under Ultraviolet panel lights. Under “Other Equipment” added code E0240 to “Specialized supply or equipment” section and added section, criteria, and coding (E1399, A9900) for “ROMTech device”. Reformatted Foot orthotics, custom criteria in “Prosthetics and Orthotics Equipment” section. Added criteria for Prosthetics and additions: Upper Extremity and Myoelectric in “Prosthetics and Orthotics Equipment” section. Added section, criteria, and coding (L8701, L8702) for “MyoPro Orthosis” under “Prosthetics and Orthotics Equipment”. Removed code L8035 from "other surgical supplies" and added section and criteria for "Breast Prosthetics" (L8030, L8035). Removed pediatric wheelchair codes (E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1037) from manual wheelchair section. References reviewed, updated, and reformatted. Internal specialist review. |
Payment Integrity Updates
Thank you for your continued partnership with Ambetter of North Carolina Inc. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim auditing. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.
For claims received on or after 5/1/2024, providers may experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.
| Editing Area | Description |
|---|---|
| Critical Care Coding | Medical record review to determine if critical care CPT codes are properly supported based on diagnosis codes and documentation. |
| Tongue-Tie & Frenulum Procedures | Medical record review to determine if the proper coding of tongue-tie and frenulum procedures are utilized based on correct coding guidelines. |
| Adjacent Tissue Transfer | When billing for adjacent tissue transfer services, providers must take great care to follow the coding guidelines, since this area presents very complex billing rules that need to be followed. Medical record review will be performed to determine if an adjacent tissue transfer was performed and if the reported defect size is supported by documentation. |
| NCCI Modifier Override – Procedure Overlap (Professional) | This review seeks to prevent overpayment of inappropriately unbundled procedures per the NCCI coding guidelines. |
| NCCI Modifier Override – Misuse of Column Two Code with Column One Code (Professional) | The review ensures that procedures are reported with the most comprehensive CPT that describes the services performed. |
| Color Flow Doppler Echocardiography Code Review | This review seeks to ensure that an echocardiography is billed at the appropriate level based on the documentation in the medical record. |
| Cross-coder Outpatient Facility CTA Claims | The review ensures the facility claim is appropriately coded based on documentation and what is submitted on the professional claim. |
| Associated EX code for EOP | Description |
|---|---|
| EXbo | DENY: MEDICAL RECORDS AND/OR OTHER SERVICE DOCUMENTATION REQUIRED |
Antidepressant Medication Management (AMM) Provider Tip Sheets
Ambetter of North Carolina Inc. recognizes that wellness in all facets of health, physical and emotional, is key to full spectrum wellbeing. With that mission in mind, we strive to provide tools to help you deliver whole-person care.
Anti-depressant Medication Management (AMM)
Consecutive days on antidepressant therapy have been found to increase effectiveness. Allowing for a member’s appropriate follow-up care to monitor for clinical worsening and suicide risk is essential when starting a new antidepressant.
- AMM Provider Tip Sheet (PDF)
- For additional tip sheets for the top prescribed medications included in the AMM measure, see the Behavioral Health Quality Measures page and expand the medications table!
Provider Manual
Visit Provider Resources for the most up-to-date version of the Ambetter of North Carolina Inc. Provider and Billing Manual.