|
October 2018
Billing chart: Blues highlight medical, benefit policy changes
You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.
This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.
You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.
We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.
For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:
- Log in to web-DENIS.
- Click on BCBSM Provider Publications & Resources.
- Click on Benefit Policy for a Code.
- Click on Topic.
- Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
- Enter the procedure code.
- Click on Finish.
- Click on Search.
| Code* |
BCBSM changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines
|
| NEW PAYABLE PROCEDURES |
J2182 |
Basic benefit and medical policy
HCPCS procedure code J2182
Effective Dec. 12, 2017, HCPCS procedure code J2182 is payable when reported with the following ICD-10 diagnoses:
- J45.50
- J45.51
- J45.52
- J82
- M30.1
These diagnostic edits only apply to the groups that are opted out of the Specialty Drug Prior Authorization program. Prior authorization is still required for those groups that are in the Specialty Drug Prior Authorization program. |
J3490 |
Basic benefit and medical policy
FDA approves Vabomere
Effective Aug. 29, 2017, the FDA approved Vabomere™ (meropenem/vaborbactam) to be covered under NOC J3490 with NDC 65293-0009-06 and 65293-0009-01 for its FDA-approved indications.
Vabomere is used for the treatment of patients ages 18 and older with complicated urinary tract infections, including pyelonephritis caused by the following susceptible microorganisms:
- Escherichia coli
- Klebsiella pneumoniae
- Enterobacter cloacae species complex
To reduce the development of drug-resistant bacteria and maintain the effectiveness of Vabomere and other antibacterial drugs, Vabomere should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.
Preauthorization isn’t required.
Note: This drug is not a benefit for URMBT. |
| UPDATES TO PAYABLE PROCEDURES |
J0570 |
Basic benefit and medical policy
Probuphine doesn’t require prior authorization
The prior authorization requirement has been removed from Probuphine (buprenorphine) — NDC 58284-0100-14. Effective July 15, 2018, this drug no longer requires preauthorization. |
| POLICY CLARIFICATIONS |
40806, 40819 |
Basic benefit and medical policy
Surgery to the maxillary anterior labial (Class III or IV) frenulum in an infant
The safety and effectiveness of surgery to the maxillary anterior labial (Class III or IV) frenulum in an infant have been established. It may be considered a useful therapeutic option when the patient selection criteria are met.
Inclusions:
Indications for surgery:
- Infant with history of not gaining weight
- A poor latch
- Mother experiencing painful breastfeeding
- Class III lip-tie: frenum inserts between the areas where the maxillary incisors will erupt
- Class IV lip-tie: the frenum wraps into the hard palate and into the anterior papilla
Exclusions:
Routine frenulum (clipping) surgery at the time of delivery. |
55874 |
Basic benefit and medical policy
Intensity-modulated radiation therapy of the prostate
Intensity-modulated radiation therapy may be considered established for the treatment of localized prostate cancer and after radical prostatectomy when specified criteria are met.
Procedure code *55874 is now payable.
This policy is effective July 1, 2018. |
|
