Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 11|02|2021 POLICY LAST REVIEWED: 05|03|2023

Beginning with dates of service on or after July 10, 2023, this policy will no longer be in effect and claims filed in accordance with this policy will not be separately reimbursed.

OVERVIEW This policy documents Blue Cross & Blue Shield of Rhode Island (BCBSRI) coverage of pediatric preventative medicine counseling services for Commercial members related to the administration of COVID-19 vaccinations for members under the age of 18.

This policy applies to BCBSRI participating providers only.

BCBSRI reserves the right to implement changes to this policy without the contractual sixty-day (60) notification that is normally required under BCBSRI contracts with its providers due to the urgent nature of a pandemic related service.

The termination date of this policy shall be effective sixty (60) calendar days after the termination of the State of Rhode Island Executive Order 20-02; Declaration of Disaster Emergency or at an alternative date determined solely by BCBSRI that extends this policy past that date.

Note: This policy is only effective for specific COVID-19 vaccines that the U.S. Food and Drug Administration (FDA) has amended the Emergency Use Authorization (EUA) for the vaccine to also include children ages 5 to 11 years in addition to vaccines approved for children ages 12-17. The effective date for any specific vaccine may vary, however this Policy will apply to any vaccine that is approved for children/pediatric populations under BCBSRI’s COVID-19 Vaccine Policy.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION
Not applicable

POLICY STATEMENT Commercials Products BCBSRI recognizes the importance of providing accurate information to its pediatric members, their parents and/or caregivers related to the COVID-19 vaccine. BCBSRI also understands the additional administrative time and effort providers may face related to thoroughly and appropriately educating parents and/or caregivers, including, but not limited to, the risk/benefit of the vaccine which may be over and above that of other common vaccines provided to their patients, since it is new, obtaining informed consent, as well as post-vaccine observation vaccination services, etc. Research performed nationally has shown medical professionals, in particular pediatric providers, are a trusted source for information about COVID-19 vaccines for patients.

As a result, BCBSRI will be recognizing separate reimbursement for preventative medicine counseling services up to 15 minutes under CPT code 99401-CR that are performed in an office setting/place of service (POS code 11) or provided via telephone and telemedicine (POS code 02) in addition to the reimbursement Payment Policy | TEMPORARY COVID-19 Pediatric Vaccination Preventative Medicine Counseling Services for Commercial Members

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

for the administration of the vaccine. Further information related to COVID-19 vaccines approved for children/pediatric populations as well as the coding for the administration of the vaccine can be found in BCBSRI’s COVID-19 Vaccination Policy.

This policy does not apply;

 to services provided to groups of patients and/or for practices that set up vaccination clinics for the sole purpose of providing vaccinations to its patients;
 any services billed under this policy must be separately identifiable for an individual patient and/or multiple patients within the same family where the preventative medicine counseling is provided to multiple family members at the same time. For multiple family members it is acceptable to file a claim under this policy for one individual.  when preventative medicine counseling services are provided on the same day as a Preventative Medicine Service CPT codes 99381-99384 or 99391-99394.

It is BCBSRI’s intent that this additional payment for preventative counseling services will support pediatric providers and family practice providers in taking the time needed to understand a patient’s concerns, answer their questions and increase vaccination rates among pediatric patients.

The allowance for filing a separate preventative medicine counseling services e.g. 99401-CR in addition to the COVID-19 vaccine administration code is limited to those patients who require more than the standard education related to the risks and benefits of receiving the COVID-19 vaccination as well as what to expect related to common side effects, etc. Based on American Medical Association (AMA) CPT Coding guidelines, the CPT codes for the administration of the vaccine includes vaccine risk/benefit counseling when performed, and the time needed to monitor the member for any adverse reactions. As a result, pediatric providers shall only bill for 99401-CR when the time and content of the counseling exceeds that of the typical education.

Reimbursement of preventative medicine counseling services for COVID-19 vaccinations, is limited to;  pediatric primary care providers and family practice providers that have been credentialed as such by BCBSRI e.g. MD/DO PCP’s, NP/PCP’s and PA/PCP’s; o Services provide by nurse care managers, RN’s, LPN’s or any other paraprofessional in a provider’s office is not reimbursable/separately reimbursable and as a result a pediatric provider or family practice provider should not submit claims using code 99401-CR for those services.
 billed once (or 1 unit) for each individual member and/or family if more than one pediatric patient is counseled at the same time.

BCBSRI understands it is possible the initial preventative medicine counseling may not result in a decision by the member and/or their parents/caregiver to receive the vaccination and as a result there may be a need for future/further preventative medicine counseling services, however additional services shall not be separately reimbursed by BCBSRI under this policy.

Evaluation & Management Service and Preventative Medicine Counseling Services
Evaluation & Management (E/M) services should not be filed along with the vaccine administration codes or the preventative medicine counseling code outlined in this policy, unless the E/M represents a separately identifiable service and modifier 25 is appended to the E/M code.

The submission of modifier 25 appended to a procedure code indicates that documentation is available in the patient’s records, which supports the distinct, significant, separately identifiable nature of the E&M service submitted with modifier 25, and the fact that these records will be provided in a timely manner for review upon request.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Example: It is considered incorrect coding to file code 99211 or any other E/M code when the intent of the visit is for the administration of COVID-19 vaccination only.

BCBSRI will be performing routine reviews of claim submissions for compliance with this Policy as well as correct coding and adherence to other BCBSRI policies. BCBSRI maintains the right to audit medical records related to services provided to our members. It is required that the patients’ medical record specifically outline the time and specificity of the preventative medicine counseling services. All documentation must be available to BCBSRI upon request. Failure to produce the requested information may result in denial or retraction of payment.

COVERAGE BCBSRI will not impose any cost sharing (e.g. deductibles, copayments, and coinsurance) on COVID-19 preventative medicine counseling services related to COVID-19 during the timeframe this policy is in effect.

This waiver of cost share may not apply to BlueCard HOST members/members of other Blue Cross Blue Shield Plans nationally.

If a BCBSRI member is receiving services from a provider outside of BCBSRI’s network e.g. a BlueCard network provider in another state, the codes and service limitations in this policy, as well as other aspects of this policy may not apply.

BACKGROUND BCBSRI, the Rhode Island Department of Health, the Office of the Health Insurance Commissioner, in partnership with our community of pediatricians and family practice providers is dedicated to the health and wellbeing of the children in our state and taking action related to the recent FDA approval of COVID-19 vaccinations for pediatric populations. As a result, BCBSRI is working to support state and local efforts to get the children of Rhode Island vaccinated.

According to the CDC, over 423 million doses of COVID-19 vaccine have been given in the United States from December 14, 2020, through November 1, 2021. COVID-19 vaccines are safe and effective. COVID- 19 vaccines were evaluated in tens of thousands of participants in clinical trials including studies with pediatric populations. Vaccines approved for pediatric populations have met the Food and Drug Administration’s (FDA) rigorous scientific standards for safety, effectiveness, and manufacturing quality needed to support approval or authorization of a vaccine. These vaccines have undergone and will continue to undergo the most intensive safety monitoring in U.S. history. This monitoring includes using both established and new safety monitoring systems to make sure that COVID-19 vaccines are safe.

CODING
Commercial Products
The following code is covered for Commercial Products when filed with the CR modifier:
99401 Preventative medicine counseling and/or risk factor reduction intervention (s) provided to an

individual, up to 15 minutes

CR Modifier: Catastrophe/Disaster related

Note: In order for services to be considered separately reimbursed and also ensure no cost share applies for BCBSRI members, services must be filed with the combination of 99401 and the CR modifier. The CR modifier must appear in the first modifier position on all claims. Other modifiers e.g. 95 can appear in additional modifier fields.

ICD-10 Diagnosis Code(s): As with all services, providers should report the most appropriate ICD-10 diagnostic code(s) for any patient encounter. However, the following ICD-10 code is acceptable for administration of COVID-19 vaccine: Z23 - Encounter for immunization

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

To ensure correct claims processing for Telephone only or Telemedicine Services, claims for telemedicine services must be filed with both of the following:

Place of Service (POS) 02: Telehealth: The location where health services and health related services are provided or received, through telehealth telecommunication technology AND;

Modifier 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System

Claims for telephone only services must only be filed with:

Place of Service (POS) 02: Telehealth: The location where health services and health related services are provided or received, through telehealth telecommunication technology

RELATED POLICIES COVID-19 Vaccinations
Coding and Payment Guidelines Telemedicine/Telephone Services for Commercial Products – Effective 1/1/2021

PUBLISHED BCBSRI’s website Provider Communication sent May 3, 2023 Provider Update, July 2023

REFERENCES

1. Centers for Disease Control and Prevention. (2021, November). Selected Adverse Events Reported after COVID-19 Vaccination. CDC.gov. https://www.cdc.gov/coronavirus/2019- ncov/vaccines/safety/adverse-events.html i

   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS