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September 2014
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
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| NEW PAYABLE PROCEDURES |
81302-81304 |
Basic Benefit and Medical Policy
The safety and effectiveness of genetic testing for Rett syndrome have been established. It may be considered a useful diagnostic option when indicated, effective March 1, 2014.
Group Variations
Excludes auto groups and URMBT
Payment Policy
Not payable in an office location; modifiers 26 and TC do not apply
Inclusionary Guidelines
When testing is performed to confirm a diagnosis of Rett syndrome in a female child with developmental delay and signs or symptoms of Rett syndrome, but when there is uncertainty in the clinical diagnosis.
Exclusionary Guidelines
All other indications for mutation testing for Rett syndrome, including but not limited to, prenatal screening and testing of family members. |
| UPDATES TO PAYABLE PROCEDURES |
86711 |
Basic Benefit and Medical Policy
The safety and effectiveness of Anti-John Cunningham virus antibody testing has been established for assessing the risk of developing progressive multifocal leukoencephalopathy in patients considering or receiving natalizumab therapy. It may be a useful diagnostic option when indicated.
Group Variations
Payable for all General Motors (hourly and salaried) groups, effective April 1, 2014.
Inclusionary Guidelines
Anti-John Cunningham virus antibody testing prior to or periodically during natalizumab therapy if antibody status is unknown to assess the risk of developing progressive multifocal leukoencephalopathy. |
99495 |
Basic Benefit and Medical Policy
Procedure code *99495 is not payable for BCBSM, effective Aug. 1, 2014.
This change excludes the Federal Employee Program®. |
J3490 |
Basic Benefit and Medical Policy
Effective Feb. 25, 2014, Monovisc™ is considered established as safe and effective for its FDA-approved indication. In the United States, it is indicated for the treatment of pain in osteoarthritis of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy or simple analgesics (e.g., acetaminophen).
Monovisc is injected intra-articularly (directly into affected knee joints) to help restore lubrication and cushioning. Unlike most other products of its type, however, Monovisc is given in one injection, rather than a series of three or four weekly injections.
It is supplied in a 5.0 mL syringe containing 4.0 mL of Monovisc. The contents of the syringe are sterile, non-pyrogenic and non-inflammatory. |
J3490 |
Basic Benefit and Medical Policy
Effective May 23, 2014, the FDA-approved DALVANCE™ (dalbavacin) will be covered under not-otherwise-classified procedure code J3490 for it's FDA-approved indications as follows:
DALVANCE is indicated for acute bacterial skin and skin structure infections caused by designated susceptible strains of Gram-positive microorganisms. To reduce the development of drug-resistant bacteria and maintain the effectiveness of DALVANCE and other antibacterial drugs, DALVANCE should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria
- Two-dose regimen: 1000 mg followed one week later by 500 mg
- Dosage adjustment for patients with creatinine clearance less than 30mL/min and not receiving regularly scheduled hemodialysis: 750 mg followed one week later by 375 mg
- Administer by intravenous infusion over 30 minutes
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| J3490 |
Basic Benefit and Medical Policy
Effective June 20, 2014, the FDA-approved SIVEXTRO™ (tedizolid phosphate) will be covered under NOC code J3490 for it's FDA-approved indications as follows:
SIVEXTRO™ (tedizolid phosphate) is an antibacterial drug to treat adults with skin infections and is available for intravenous and oral use.
SIVEXTRO is indicated for the treatment of acute bacterial skin and skin structure infections caused by susceptible isolates of the following Gram-positive microorganisms: Staphylococcus aureus (including methicillin-resistant [MRSA] and methicillin-susceptible [MSSA] isolates), Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus anginosus group (including Streptococcus anginosus, Streptococcus intermediusand Streptococcus constellatus) and Enterococccus faecalis.
200mg daily infused over one hour. |
| GROUP BENEFIT CHANGES |
Charter Township of Plymouth |
Effective Sept. 1, 2014, Medicare-eligible retirees of the Charter Township of Plymouth will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical, surgical and prescription drug benefits. The group number is 60671 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. |
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