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

81243, 81244

Basic Benefit and Medical Policy
Genetic testing for FMR1 mutations (including fragile X syndrome) may be considered established in select patient populations. This policy is effective Jan. 1, 2014.

Inclusionary Guidelines

Individuals of either sex with mental retardation, developmental delay, autism spectrum disorder or isolated cognitive impairment
Asymptomatic individuals with a family history of fragile X syndrome or a family history of undiagnosed mental retardation
Affected individuals or their relatives who have had a positive cytogenetic fragile X test result to determine carrier status
Women with ovarian failure before the age of 40 prior to in-vitro fertilization (refer to member’s specific certificate for coverage of in-vitro services)
Prenatal testing in fetuses from families in which there is a family history of fragile X syndrome
Prenatal testing of fetuses of known carrier mothers
For pre-implantation testing in embryos from carrier mothers (refer to member’s specific certificate for coverage of in-vitro services)
Family history of fragile X syndrome or mental retardation of unknown cause
Individuals with cerebellar ataxia and intentional tremor, especially among men

Exclusionary Guidelines

For screening of asymptomatic individuals in the absence of a family history of fragile X syndrome
Children with isolated attention-deficit or hyperactivity

81252-81254

Basic Benefit and Medical Policy
The safety and effectiveness of genetic testing for nonsyndromic hearing loss mutations (GJB2, GJB6 and other NSHL-related mutations) have been established. It may be considered a useful diagnostic option in specified situations. This policy is effective Jan. 1, 2014.

Inclusionary Guidelines

Individuals with non-syndromic hearing loss to confirm the diagnosis of hereditary non-syndromic hearing loss.

Preconception genetic testing (carrier testing) for non-syndromic hearing loss mutations (GJB2, GJB6 and other NSHL-related mutations) in parents when at least one of the following conditions has been met:

Offspring with hereditary NSHL or
One or both parents with suspected NSHL or
First- or second-degree relative affected with hereditary NSHL or
First-degree relative with offspring who is affected with hereditary NSHL

90688

Basic Benefit and Medical Policy
The safety and effectiveness of the FLULAVAL^® vaccine has been established. It is a useful prophylactic option for patients meeting patient selection guidelines in accordance with the Advisory Committee on Immunization Practices recommendations. This policy is effective Aug. 16, 2013.

Inclusionary Guidelines
FLULAVAL is approved for use in persons 3 years of age and older.

A4456, A4629, A7507-A7509

Basic Benefit and Medical Policy
The following quantity and frequency maximums will apply when billing tracheostomy care supplies:

Procedure code A4456 will have a maximum of 50 units per month.
Procedure code A4629 will have a maximum of 31 units per month.
Procedure codes A7507, A7508 and A7509 will have a maximum of 62 units per month.

The procedure codes list the maximum number of items or units of service that are usually reasonable and necessary. The actual quantity needed for a particular member may be more or less than the amount listed, depending on clinical factors that affect the frequency of supply changes.

The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the member’s medical record. If adequate documentation is not provided when requested, the excess quantities will be considered retrospectively as not reasonable and necessary.

With these changes, we are aligned with Medicare’s quantity maximums.

MESSA is excluded from this change.

UPDATES TO PAYABLE PROCEDURES

83861

Basic Benefit and Medical Policy
Tear osmolarity testing may be considered established as indicated for the diagnosis and monitoring of dry eye syndrome if the slit lamp test, as well as two other tests, fail to establish the suspected diagnosis of dry eye syndrome. Additional tests may include:

Schirmer’s test
Tear evaporation test
Tear break-up time
Ocular staining

Tear osmolarity testing is considered experimental for all other indications.

Group Variations
Payable for MPSERS and State of Michigan groups, effective Sept. 1, 2013

92559-92562, 92564

Basic Benefit and Medical Policy
The list of codes are being changed for facility claims processing because an alternative code is available for use and the liability has changed from subscriber to provider liable.

The Participating Hospital Agreement pay rule has changed from payable (PAY) to alternative code available (ALT) under the “All Other Remainder or AOR” category for procedure codes *92559 and *92561 when reported with revenue code 0471. The service is payable under another code.

The PHA Pay Rule has changed from not a covered benefit to alternative code available (ALT) under the AOR category for procedure codes *92560, *92562 and *92564 when reported with revenue code 0471. The service is payable under another code.

Procedure codes *92559 and *92560 are eligible to quantity process.

Procedure codes *92561, *92562 and *92564 are not eligible to quantity process.

93293-93299

Basic Benefit and Medical Policy
These cardiovascular monitoring procedure codes are now payable in location 4 (home) for Michigan providers.

POLICY CLARIFICATIONS

64561, 64581, 64585, 64590, 64595, 95970-95973, A4290, E0745, E1399, L8680, L8685-L8688

Basic Benefit and Medical Policy
The criterion for the Sacral Nerve Neuromodulation/Stimulation policy has been updated. This policy is effective Nov. 1, 2013.

Urinary incontinence and non-obstructive retention
Inclusionary Guidelines

A trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead is established in patients who meet all of the following criteria:

There is a diagnosis of at least one of the following:

Urge incontinence
Urgency-frequency syndrome
Non-obstructive urinary retention

There is documented failure or intolerance to at least two conventional therapies (e.g., behavioral training, such as bladder training, prompted voiding or pelvic muscle exercise training; pharmacologic treatment for at least a sufficient duration to fully assess its efficacy or surgical corrective therapy).
The patient is an appropriate surgical candidate.
Incontinence is not related to a neurologic condition.

Permanent implantation of a sacral nerve neuromodulation device is established in patients who meet all of the following criteria:

All of the criteria in A (1-4) above are met.
A trial stimulation period demonstrates at least 50 percent improvement in symptoms over a period of at least one week.

Exclusionary Guidelines
Other urinary or voiding applications of sacral nerve neuromodulation are considered experimental, including, but not limited to, treatment of stress incontinence or urge incontinence due to a neurologic condition (e.g., detrusor hyperreflexia, multiple sclerosis, spinal cord injury or other types of chronic voiding dysfunction.)

Fecal incontinence
Inclusionary Guidelines
Sacral nerve neuromodulation is established for the treatment of fecal incontinence when all of the following criteria are met:

A trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead may be considered established in patients who meet all of the following criteria:

There is a diagnosis of chronic fecal incontinence of greater than two incontinent episodes on average per week with duration greater than six months or for more than 12 months after vaginal childbirth.
There is documented failure or intolerance to conventional conservative therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment for at least a sufficient duration to fully assess its efficacy, performed more than 12 months — or 24 months in case of cancer — previously).
The patient is an appropriate surgical candidate.
The condition is not related to an anorectal malformation (e.g., congenital anorectal malformation, defects of the external anal sphincter over 60 degree,; visible sequelae of pelvic radiation, active anal abscesses and fistulae) or chronic inflammatory bowel disease.
Incontinence is not related to a neurologic condition.

Permanent implantation of a sacral nerve neuromodulation device may be considered established in patients who meet all of the following criteria:

All of the criteria in A (1-5) above are met.
A trial stimulation period demonstrates at least 50 percent improvement in symptoms over a period of at least one week.

Exclusionary Guidelines
Sacral nerve neuromodulation is experimental for the treatment of chronic constipation or chronic pelvic pain

GROUP BENEFIT CHANGES

City of Alpena

Effective April 1, 2014, Medicare-eligible retirees of the City of Alpena will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue^SM Group PPO, for their medical, surgical and prescription drug benefits. The group number is 60603 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.

Hope College

Effective April 1, 2014, Medicare-eligible retirees of Hope College will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue^SM Group PPO, for their medical, surgical and prescription drug benefits. This is an existing BCBSM Medicare Advantage PPO group that has added the home infusion benefit to its coverage. The group number is 51623 with suffix 601. 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.

Michigan Municipal League

Effective April 1, 2014, Medicare-eligible retirees of the Michigan Municipal League will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue^SM Group PPO, for their medical, surgical and prescription drug benefits. The group number is 60605 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 2013 American Medical Association. All rights reserved.