The Record - Blues highlight medical, benefit policy changes

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:

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

NEW PAYABLE PROCEDURES

81599, 0005M**

**Use procedure code 0005M after July 1, 2013.

Basic Benefit and Medical Policy
Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 may be considered established in women with high-risk singleton pregnancies undergoing screening for trisomy 21, effective May 1, 2013. Karyotyping would be necessary to exclude the possibility of a false positive nucleic acid sequencing–based test. Before testing, women should be counseled about the risk of a false positive test.

Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 in women who do not meet the above criteria is considered experimental.

Group Variations
Excludes Chrysler, Delphi, Ford, General Motors and UAW Retiree Medical Benefits Trust groups.

Inclusionary Guidelines
High-risk singleton pregnancies, as defined by the American College of Obstetricians and Gynecologists Committee Opinion, Number 454, December 2012 include women who meet at least one of the following criteria:.

Maternal age 35 years or older at delivery
Fetal ultrasonographic findings indicating increased risk of aneuploidy
History of previous pregnancy with a trisomy
Standard serum screening test positive for aneuploidy
Parental balanced robertsonian translocation with increased risk of fetal trisomy 13 or trisomy 21
Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 with confirmatory testing of positive results using karyotyping in high-risk pregnant women with singleton pregnancies

Exclusionary Guidelines

Women with singleton pregnancies at average and low risk
Nucleic acid sequencing-based testing of maternal plasma for trisomy 21 in women with twin multiple gestations pregnancies
DNA-based sequencing methods for detection of trisomy 13 and 18

UPDATES TO PAYABLE PROCEDURES

77520, 77522, 77523, 77525

Revenue code 0333

Basic Benefit and Medical Policy
The safety and effectiveness of charged-particle irradiation with proton or helium ion beams have been established. It may be considered a useful therapeutic option when indicated for patients who meet the patient selection criteria and for the indications listed in the inclusions section, effective March 1, 2013.

Proton beam therapy for all other indications, including localized prostate cancer and non-small-cell lung cancer at any stage or for recurrence, is experimental.

Group Variations
The auto groups and URMBT will be communicating their benefit decision separately.

Payment Policy
Proton treatment delivery is payable to a facility only. Professional services should be submitted with an appropriate clinical treatment planning procedure code.

Inclusionary Guidelines
Charged-particle irradiation with proton or helium ion beams is established for the following indications:

Primary therapy for melanoma of the uveal tract (iris, choroid or ciliary body), with no evidence of metastasis or extrascleral extension and with tumors up to 24 mm in largest diameter and 14 mm in height.
Postoperative therapy (with or without conventional high-energy X-rays) in patients who have undergone biopsy or partial resection of chordoma or low-grade (I or II), chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma) or cervical spine. Patients eligible for this treatment have residual localized tumor without evidence of metastasis.

Exclusionary Guidelines
All other applications of charged-particle irradiation, including localized prostate cancer and non-small-cell lung cancer at any stage or for recurrence, are experimental.

A9900, E0955-E0957, E0960, E2601-E2617, E2620-E2625, K0108, K0669

Inclusionary Guidelines
A general use seat cushion (E2601, E2602) and a general use wheelchair back cushion (E2611, E2612) is covered for a patient who has a manual wheelchair or a power wheelchair with a sling or solid seat or back that meets BCBSM coverage criteria. If the patient does not have a covered wheelchair, then the cushion will not be covered. If the patient has a POV or a power wheelchair with a captain's chair seat, the cushion will not be covered.

For patients who meet coverage criteria for a power wheelchair and who do not have special skin protection or positioning needs, a power wheelchair with captain’s chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling or solid seat or back instead of a captain’s chair, the wheelchair and the cushion(s) will be covered if either criterion 1 or criterion 2 is met:

The cushion is provided with a covered power wheelchair base that is not available in a captain’s chair model – i.e., procedure codes K0839, K0840, K0843, K0860-K0864, K0870, K0871, K0879, K0880, K0886, K0890, K0891.
A skin protection or positioning seat or back cushion that meets coverage criteria is provided.

If one of these criteria is not met, both the power wheelchair with a sling or solid seat and the general use cushion will not be covered.

If the patient has a POV or a power wheelchair with a captain’s chair seat, a separate seat or back cushion will not be covered.

A skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a patient who meets both of the following criteria:

The patient has a manual wheelchair or a power wheelchair with a sling or solid seat or back and the patient meets the BCBSM coverage criteria for it.
The patient has either of the following:
- Current pressure ulcer (ICD-9-CM codes lower back, hip, buttock) or past history of a pressure ulcer (lower back, hip, buttock) on the area of contact with the seating surface.
- Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia (quadriplegia unspecified and C1-C4 complete); other spinal cord disease (syringomyelia and syringobulbia, vascular myelopathies, subacute combined degeneration of spinal cord in diseases classified elsewhere; myelopathy in other diseases classified elsewhere), multiple sclerosis; other demyelinating disease; neuromyelitis optica; Schilder's disease; acute (transverse) myelitis; acute (transverse) myelitis NOS; acute (transverse) myelitis in conditions classified elsewhere; idiopathic transverse myelitis; other demyelinating diseases of central nervous system; demyelinating disease of central nervous system, unspecified; cerebral palsy (diplegic, hemiplegic, quadriplegic, monoplegic, infantile hemiplegia, other specified infantile cerebral palsy, unspecified infantile cerebral palsy; anterior horn cell diseases, including amyotrophic lateral sclerosis; Werding-Hoffmann disease; spinal muscular atrophy; spinal muscular atrophy, unspecified; Kugelberg-Welander disease, other; motor neuron disease; amyotrophic lateral sclerosis; progressive muscular atrophy; pseudobulbar palsy; primary lateral sclerosis, other; other anterior horn cell diseases; anterior horn cell disease, unspecified); post-polio paralysis (late effects of acute poliomyelitis); traumatic brain injury resulting in quadriplegia, other; spina bifida (spina bifida with hydrocephalus, unspecified region; spina bifida with hydrocephalus, cervical region; spina bifida with hydrocephalus, dorsal [thoracic] region; spina bifida with hydrocephalus, lumbar region; spina bifida without mention of hydrocephalus, unspecified region; spina bifida without mention of hydrocephalus, cervical region; spina bifida without mention of hydrocephalus, dorsal (thoracic) region; spina bifida without mention of hydrocephalus, lumbar region); childhood cerebral degeneration (leukodystrophy, cerebral lipidoses, cerebral degeneration in generalized lipidoses, cerebral degeneration of childhood in other diseases classified elsewhere, other specified cerebral degenerations in childhood, unspecified cerebral degeneration in childhood); Alzheimer's disease; Parkinson's disease (paralysis agitans); muscular dystrophy (congenital hereditary muscular dystrophy, hereditary progressive muscular dystrophy); hemiplegia (flaccid hemiplegia affecting unspecified side, flaccid hemiplegia affecting dominant side, flaccid hemiplegia affecting nondominant side, spastic hemiplegia, spastic hemiplegia affecting unspecified side, spastic hemiplegia affecting nondominant side, other specified hemiplegia, other specified hemiplegia affecting dominant side, other specified hemiplegia affecting nondominant side, unspecified hemiplegia, unspecified hemiplegia affecting dominant side, unspecified hemiplegia affecting nondominant side; hemiplegia affecting unspecified side, hemiplegia affecting dominant side, hemiplegia affecting nondominant side); Huntington's chorea; idiopathic torsion dystonia (genetic torsion dystonia); athetoid cerebral palsy.

A positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621) and positioning accessory (E0955-E0957, E0960) is covered for a patient who meets both of the following criteria:

The patient has a manual wheelchair or a power wheelchair with a sling or solid seat or back and the patient meets BCBSM coverage criteria for it.
The patient has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 2b above or to one of the following diagnoses: monoplegia of the lower limb (affecting unspecified side, affecting dominant side, affecting nondominant side, due to stroke, traumatic brain injury or other etiology; spinocerebellar disease (Friedreich's ataxia, hereditary spastic paraplegia, primary cerebellar degeneration, other cerebellar ataxia, cerebellar ataxia in diseases classified elsewhere, other spinocerebellar diseases, spinocerebellar disease, unspecified); above-knee leg amputation (unilateral, at or above knee, without mention of complication; unilateral, at or above knee, complicated; unilateral, level not specified, without mention of complication; unilateral, level not specified, complicated; bilateral [any level], without mention of complication; bilateral [any level], complicated); osteogenesis imperfecta; transverse myelitis (other causes of myelitis).

A headrest (E0955) is also covered when the patient has a covered manual tilt-in-space, manual semi- or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair or power tilt or recline power seating system.

If the patient has a POV or a power wheelchair with a captain's chair seat, a headrest or other positioning accessory will not be covered.

A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.

If a skin protection seat cushion, positioning seat cushion or combination skin protection and positioning seat cushion is provided and if the stated coverage criteria are not met, it will not be covered.

If a positioning back cushion is provided for a patient who does not meet the stated coverage criteria, it will not covered.

If a positioning accessory is provided and the criteria are not met, the item will not be covered.

A custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom fabricated back cushion (E2617) is covered if criteria (2) and (3) are met:

Patient meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion.
Patient meets all of the criteria for a prefabricated positioning back cushion.
There is a comprehensive written evaluation by a licensed or certified medical professional, such as a physical therapist or occupational therapist, which clearly explains why a prefabricated seating system is not sufficient to meet the patient’s seating and positioning needs. The PT or OT may have no financial relationship with the supplier.

If a custom fabricated cushion is provided for a patient who does not meet the stated coverage criteria, it will not be covered.

A seat or back cushion that is provided for use with a transport chair (E1037, E1038) will not be covered.

The effectiveness of a powered seat cushion (E2610) has been established.

A prefabricated seat cushion, a prefabricated positioning back cushion, or a brand name custom fabricated seat or back cushion that does not meet the criteria stated in the BCBSM inclusionary coverage guidelines will not be covered.

When billing for a custom fabricated cushion (E2609, E2617), the claim must include the manufacturer and model name or number of the product (if applicable), or if not, a detailed description of the product that was provided.

E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0271-E0274, E0280, E0290-E0297, E0301-E0305, E0310, E0315, E0316, E0328, E0329, E0910-E0912, E0940

Inclusionary Guidelines
Effective May 1, 2013, BCBSM has adopted Medicare’s policies for hospital beds. Medicare has the following criteria for a fixed hospital bed (E0250, E0251, E0290, E0291 and E0328) to be covered. They must have one or more of the following criteria for the service:

The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head or upper body less than 30 degrees does not usually require the use of a hospital bed.
The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain.
The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out.
The patient requires traction equipment that can only be attached to a hospital bed.

BCBSM has adopted Medicare’s criteria for the variable hospital beds. A variable height hospital bed (E0255, E0256, E0292 and E0293) is covered if the patient meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.

BCBSM has adopted Medicare’s criteria for the following criteria for the semi-electric hospital beds. A semi-electric hospital bed (E0260, E0261, E0294, E0295 and E0329) is covered if the patient meets one of the criteria for a fixed height bed and requires frequent changes in body position or has an immediate need for a change in body position.

BCBSM has adopted Medicare’s criteria for the heavy duty extra wide hospital bed. A heavy duty extra wide hospital bed (E0301, E0303) is covered if the patient meets one of the criteria for a fixed height hospital bed and the patient's weight is more than 350 pounds, but does not exceed 600 pounds.

BCBSM has adopted Medicare’s criteria for the following criteria for an extra heavy-duty hospital bed (E0302, E0304) is covered if the patient meets one of the criteria for a hospital bed and the patient's weight exceeds 600 pounds.

BCBSM has adopted Medicare’s criteria for a total electric hospital bed (E0265, E0266, E0296 and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary.

BCBSM has adopted Medicare’s criteria for the following statement for any of the above hospital beds and procedure code E1399, if documentation does not justify the medical need of the type of bed billed, payment will be denied as not reasonable and necessary.

If the patient does not meet any of the coverage criteria for any type of hospital bed it will be denied as not reasonable and necessary.

Hospital Bed Accessories
BCBSM has adopted Medicare’s criteria for the following hospital bed accessories:

Trapeze equipment (E0910, E0940) is covered if the patient needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed.
Heavy duty trapeze equipment (E0911, E0912) is covered if the patient meets the criteria for regular trapeze equipment and the patient's weight is more than 250 pounds.
A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings.
Side rails (E0305, E0310) or safety enclosures (E0316) are covered when they are required by the patient's condition and they are an integral part of, or an accessory to, a covered hospital bed.
A replacement innerspring mattress (E0271) or foam rubber mattress (E0272) is covered when they are required by the patient's condition for a patient owned hospital bed.

L3250

Inclusionary Guidelines
Prosthetic shoes (L3250) are covered if they are an integral part of prosthesis for patients with a partial foot amputation for the following diagnosis:

Congenital transverse deficiency of lower limb
Congenital longitudinal deficiency, tarsals or metatarsals, complete or partial (with or without incomplete phalangeal deficiency)
Congenital longitudinal deficiency, phalanges, complete or partial
Traumatic amputation of toe(s) (complete) (partial), without mention of complication
Traumatic amputation of toe(s) (complete) (partial), complicated
Traumatic amputation of foot (complete) (partial)
Traumatic amputation of foot (complete) (partial), unilateral, without mention of complication
Traumatic amputation of foot (complete) (partial), unilateral, complicated
Traumatic amputation of foot (complete) (partial), bilateral, without mention of complication
Traumatic amputation of foot (complete) (partial), bilateral, complicated

When billing for prosthetic shoes (L3250) and related items, an ICD-9 diagnosis code (specific to the fifth digit), describing the condition which necessitates the prosthetic shoes, must be included on each claim for the prosthetic shoes and related items.

POLICY CLARIFICATIONS

90849, G9012, H0031, H0032, H2019

The effectiveness of applied behavior analysis in the treatment of autism spectrum disorder has been established. It may be a useful therapeutic option when inclusionary and certificate guidelines are met. This policy is effective July 1, 2013.

Refer to member’s certificate for benefit specific coverage guidelines.

Inclusionary Guidelines

Full diagnostic criteria for autism spectrum disorder, as published in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual,” are met.
The maladaptive behavior must impact the child’s personal safety, the safety of others within the child’s environment, or must significantly interfere with the child’s ability to function.
Services must be provided by or supervised by a therapist who is certified by the Behavior Analyst Certification Board.
There is a treatment plan that:

Is child-centered
Defines target behaviors
Records objective measures of baseline levels and progress
Identifies and documents specific interventions and techniques
Documents transitional and discharge plans

Exclusionary Guidelines

People who do not meet the diagnostic criteria based on the most recent criteria by the American Psychiatric Association (e.g., the most current version of the Diagnostic and Statistical Manual).
Therapy delivered by clinicians who are neither certified by the Behavior Analyst Certification Board nor supervised by therapists with this certification
Therapy for people older than 18

GROUP BENEFIT CHANGES

City of Taylor

Effective Aug. 1, 2013, Medicare-eligible retirees of the City of Taylor will have an additional option for its Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO^SM, covering its medical, surgical and prescription drug benefits. The group number is 59819 with suffix 605. 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.

Mt. Morris Charter Township

Effective Aug. 1, 2013, Medicare-eligible retirees of the Mt. Morris Charter Township will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO^SM, for its medical, surgical and prescription drug benefits. The group number is 60256 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.