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April 2013

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 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
UPDATES TO PAYABLE PROCEDURES
E1161, E1229, E1231-E1238, K0001-K0007, K0009

Inclusionary Guidelines
A manual wheelchair for use inside the home (E1161, K0001 – K0007, K0009) is covered if both of the following are true:

  • Criteria A, B, C, D and E are met.
  • Criterion F or G is met.
  1. The member has a mobility limitation that significantly impairs his or her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming and bathing in customary locations in the home.

    A mobility limitation is one that does one of the following:
    1. Prevents the member from accomplishing an MRADL entirely
    2. Places the member at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL
    3. Prevents the member from completing an MRADL within a reasonable time frame
  2. The member’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
  3. The member’s home provides adequate access between rooms, maneuvering space and surfaces for use of the manual wheelchair that is provided.
  4. Use of a manual wheelchair will significantly improve the member’s ability to participate in MRADLs, and the member will use it on a regular basis in the home.
  5. The member has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
  6. The member has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day.

    Limitations of strength, endurance, range of motion or coordination, presence of pain or deformity, or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
  7. The member has a caregiver who is available, willing and able to provide assistance with the wheelchair.

If the manual wheelchair will be used inside the home and the coverage criteria are not met, it will be denied as not reasonable and necessary.

If the manual wheelchair will only be used outside the home, see the related policy article for information concerning coverage. 

Additional criteria for specific manual wheelchairs (K0002 – K0007)
In addition to the general manual wheelchair criteria above, the specific criteria below must be met for each manual wheelchair.

A standard hemi-wheelchair (K0002) is covered when the member requires a lower seat height (17 to 18 inches) because of short stature or to enable the member to place his or her feet on the ground for propulsion.

A lightweight wheelchair (K0003) is covered when a member meets both criteria:

  1. Cannot self-propel in a standard wheelchair in the home
  2. The member can and does self-propel in a lightweight wheelchair.

A high-strength lightweight wheelchair (K0004) is covered when a member meets one of the criteria below:

  1. The member self-propels the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair.
  2. The member requires a seat width, depth or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair, and spends at least two hours per day in the wheelchair.

A high-strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than three months (for example, post-operative recovery).

An ultra-lightweight manual wheelchair (K0005) is covered for a member who meets all of the following criteria:

  1. The member must be a highly active, full-time manual wheelchair user.
  2. The member must require individualized fitting and optimal adjustments for multiple features that include axle configuration, wheel camber and seat and back angles, in addition to ongoing critical support.
  3. The member must have a specialty evaluation that was performed by a licensed or certified medical professional, such as a physical therapist or occupational therapist, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. (See documentation requirements.) The medical professional may have no financial relationship with the supplier.
  4. The wheelchair is provided by a rehabilitative technology supplier that employs a RESNA-certified assistive technology professional who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.

A heavy-duty wheelchair (K0006) is covered if the member weighs more than 250 pounds or the member has severe spasticity.

An extra heavy-duty wheelchair (K0007) is covered if the member weighs more than 300 pounds.

If a K0002–K0007 wheelchair is provided and the additional coverage criteria are not met, it will be denied as not reasonable and necessary.

Miscellaneous
Payment is made for only one wheelchair at a time. Backup chairs are denied as not reasonable and necessary. One month’s rental for a standard manual wheelchair (K0001) is covered if a member-owned wheelchair is being repaired.
GROUP BENEFIT CHANGES
Burris Logistics

Effective April 1, 2013, Medicare-eligible retirees of Burris Logistics will have Blue Cross Blue Shield of Michigan’s Medicare Advantage prescription drug plan, Prescription BlueSM, for their prescription drug benefits. The group number is 60048 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

For information about our Medicare Advantage plans, go to bcbsm.com/provider/ma.

Charter Township of Waterford

Effective April 1, 2013, Medicare-eligible retirees of the Charter Township of Waterford will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPOSM, for their medical and surgical benefits. The group number is 60027 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma.

Jackson County Medical Care Facility

Effective March 1, 2013, Medicare-eligible retirees of the Jackson County Medical Care Facility have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPOSM, for their medical, surgical and prescription drug benefits. The group number is 59981 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma.

Purity Cylinder Gasses Inc.

Effective March 1, 2013, Medicare-eligible retirees of Purity Cylinder Gasses, Inc. have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPOSM, for their medical, surgical and prescription drug benefits. The group number is 60029 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma.

Saginaw Chippewa Indian Tribe

Effective April 1, 2013, Medicare-eligible retirees of the Saginaw Chippewa Indian Tribe will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPOSM, for their medical and surgical benefits. The group number is 59937 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma.

SEIU Healthcare

Effective April 1, 2013, Medicare-eligible retirees of SEIU Healthcare will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPOSM, for their medical, surgical and prescription drug benefits. The group number is 60100 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma.

Van Buren County Road Commission

Effective March 1, 2013, Medicare-eligible retirees of the Van Buren County Road Commission have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPOSM, for their medical, surgical and prescription drug benefits. The group number is 59993 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma.

W. E. Upjohn Institute

Effective March 1, 2013, Medicare-eligible retirees of the W. E. Upjohn Institute have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPOSM, for their medical, surgical and prescription drug benefits. The group number is 59988 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma.
No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2012 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.