The Record - for physicians and other health care providers to share with their office staffs Forward to a friend  |  Subscribe  |  The Record Archive  |  Contacts  |  bcbsm.com  |  Print this article
November 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
NEW PAYABLE PROCEDURES

81406

Basic Benefit and Medical Policy
Genetic testing of CADASIL (Cerebral Autosomal-Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy) syndrome is considered established in select patient populations who meet clinical criteria. This testing may be a useful diagnostic option when indicated. The policy is effective Nov. 1, 2014.

Group Variations
Not a benefit for MPSERS, Chrysler or URMBT groups

Inclusionary Guidelines

  • Genetic testing to confirm the diagnosis of CADASIL syndrome may be considered established under the following conditions:
    • Clinical signs, symptoms and imaging results are consistent with CADASIL, indicating that the pre-test probability of CADASIL is at least in the moderate to high range (see the Policy Guidelines section below) and
    • The diagnosis of CADASIL is inconclusive following alternate methods of testing, including MRI and skin biopsy.
  • Genetic testing for CADASIL syndrome of asymptomatic patients who have a first- or second-degree relative with CADASIL

Exclusionary Guidelines
All other situations not addressed in the inclusionary guidelines above

90670

Group Variations
Procedure code *90670 is payable for all Federal Employee Program® enrollees, effective Feb. 1, 2010.

99324-99328, 99334-99337

Basic Benefit and Medical Policy
Effective April 30, 2014, domiciliary or rest home visits for the evaluation and management of a patient are payable.

Payment Policy
The services are payable when provided by a physician or a nurse practitioner in an inpatient hospital, home or a nursing home.
UPDATES TO PAYABLE PROCEDURES

78579, 78582

Basic Benefit and Medical Policy
The PPO Radiology Management Program has removed procedure codes *78579 and *78582 from the existing list of procedure codes that are payable to nuclear medicine providers, effective Jan. 11, 2011.

99174

Basic Benefit and Medical Policy
Ocular photoscreening in a primary care office location has been established for the detection of visual disorders that can predispose children to amblyopia who are disabled or otherwise unable to perform conventional visual screening tests.

Group Variations
Payable for GM hourly and salaried enrollees, effective July 1, 2014.

J3490

Basic Benefit and Medical Policy
Effective Aug. 6, 2014, the FDA-approved ORBACTIV™ (oritavancin) will be covered under not-otherwise-classified code J3490 for its FDA-approved indications as follows:

  • ORBACTIV is an antibacterial drug to treat adults with skin infections and is available for intravenous use.

ORBACTIV is indicated for the treatment of acute bacterial skin and skin structure infections caused by certain susceptible bacteria, including staphylococcus aureus (including methicillin-resistant and methicillin-susceptible isolates), various Streptococcus species and enterococcus faecalis.

J7199

Basic Benefit and Medical Policy
Effective June 6, 2014, ELOCTATE™ is considered established as safe and effective for its FDA-approved indication. It is indicated for adults and children with hemophilia A (congenital Factor VIII deficiency) for:

  • Control and prevention of bleeding episodes
  • Perioperative management
  • Routine prophylaxis to prevent or reduce the frequency of bleeding episodes.
ELOCTATE is not indicated for the treatment of von Willebrand disease.
POLICY CLARIFICATIONS

Established procedures
0295T-0298T, 33282, 33284, 93268, 93270, 93271, 93272

Experimental procedures
0302T-0307T, 93228, 93229

Basic Benefit and Medical Policy
Medical Policy reviewed the Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry policy and determined that they are considered useful diagnostic options when indicated (reference guidelines below). This policy is effective May 1, 2014.

Procedure code *0295T requires supporting documentation. Reference inclusionary guidelines below.

Procedure codes *0296T-*0298T are not payable when billed separately.

Inclusionary Guidelines

  • Patient-activated or auto-activated external ambulatory event monitors are established as a diagnostic alternative to holter monitoring in patients
    • Who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (e.g., palpitations, dizziness, presyncope or syncope) or
    • Patients with atrial fibrillation who have been treated with catheter ablation and in whom discontinuation of systemic anticoagulation is being considered.
  • Implantable ambulatory event monitors, either patient-activated or auto-activated, are established for the small subset of patients who experience recurrent symptoms so infrequently that a prior trial of holter monitor and other external ambulatory event monitors has been unsuccessful.
  • The use of long-term (longer than 48 hours) external electrocardiogram monitoring by continuous rhythm recording and storage (e.g., Zio Patch®) is established for the evaluation of patients suspected of having an arrhythmia who:
    • Are suspected of having a possible arrhythmia but have had a non-diagnostic holter monitor recording, or
    • Whose arrhythmias/symptoms occur so infrequently (less frequently than daily) such that the arrhythmia is unlikely to be diagnosed by holter monitoring (which only monitors the patient for 24 to 48 hours), or
    • Would be unlikely to recognize symptoms as being cardiac-related, or
    • Would likely be unable or unwilling to initiate the recording of their arrhythmia when symptoms occur, or
    • Who are asymptomatic during an arrhythmia, or
    • Who have had a recent radiofrequency ablation for an arrhythmogenic focus to monitor for possible post-procedure arrhythmias.

Exclusionary Guidelines

  • Real-time outpatient cardiac telemetry (also known as mobile cardiac outpatient telemetry or MCOT) as a diagnostic alternative in patients who experience infrequent symptoms (less frequently than every 48 hours) suggestive of cardiac arrhythmias (e.g., palpitations, dizziness, presyncope or syncope). This technology is considered not medically necessary because the clinical health) outcomes with this technology have not been shown to be superior to other available approaches.
  • Other uses of ambulatory event monitors, including outpatient cardiac telemetry, are considered experimental, including but not limited to:
    • Monitoring the effectiveness of antiarrhythmic medications
    • Monitoring patients with cryptogenic stroke (stroke of unknown cause)
    • Detection of myocardial ischemia by detecting ST segment changes (intracardiac ischemia monitoring systems)

Group Variations
HCPCS procedure codes *0295T-*0298T are not payable for MPSERS members.
GROUP BENEFIT CHANGES
City of Flint - Alternative Plan Option 1

Effective Nov. 1, 2014, Medicare-eligible retirees of the City of Flint-Alternative Plan Option 1 will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical and surgical benefits. The group number is 25161 with suffixes 610-618. You can identify members by the XYL prefix on their ID cards, such as those of other Medicare Plus Blue Group PPO plans.

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

Effective Nov. 1, 2014, Medicare-eligible retirees of the City of Marquette 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 60679 with suffix 600. You can identify members by the XYL prefix on their ID cards, such as those of other Medicare Plus Blue Group PPO plans.

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

Effective Nov. 1, 2014, Medicare-eligible retirees of the City of Southgate will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical and surgical benefits. The group number is 50737 with suffix 602. You can identify members by the XYL prefix on their ID cards, such as those of other Medicare Plus Blue Group PPO plans.

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

Inteva Products LLC, group number 71597, will join the Blues Jan. 1, 2015.

The group will offer seven PPO plans with medical-surgical coverage, one EPO plan with medical-surgical coverage, 11 prescription drug plans, one hearing plan, three consumer-directed health plans and three flexible spending account options (full FSA, limited purpose FSA and dependent care FSA.).

Member ID cards will show alpha prefix TEV for PPO coverage.

MEP Services

MEP Services will migrate from the Michigan Operating System to the NASCO platform, under new group number 71594, with the Blues on Dec. 1, 2014. The group will offer one PPO plan with medical-surgical coverage, two prescription drug plans, one VSP vision plan and one dental plan.

Member ID cards will show alpha prefix JXP for PPO coverage.
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.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.