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 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

81161, 81408

Basic benefit and medical policy
Genetic testing for DMD gene mutations has been established. It may be considered a useful diagnostic option when indicated. This policy is effective Nov. 1, 2013.

Group variations
Not payable for Chrysler, Ford, GM, Delphi, URMBT, MESSA, MPSERS, SOM and FEP members

Payment policy
Not payable in an office location

Note: Documentation required for individual consideration procedures
Inclusionary guidelines:

For a male with signs and symptoms of a dystrophinopathy in order to confirm the diagnosis and direct treatment (See testing strategy of a male suspected of dystrophinopathy below.)
For at-risk female relatives (See testing strategy for carrier testing in at-risk female relatives below.)

At-risk females include:

Sisters, daughters, mother and maternal female relatives of an affected male
First-degree relatives of a known carrier female

Testing strategy of a male suspected of dystrophinopathy
To establish the diagnosis of a male with clinical findings that suggest DMD or BMD:

Perform DMD genetic testing for deletion or duplication analysis first.
If a mutation is not identified, perform sequence analysis for a point mutation.
If a disease-causing DMD mutation is identified, the diagnosis of a dystrophinopathy is established.
In cases where a distinction between DMD and BMD is difficult, the reading frame “rule” states that the type of deletion or duplication (those that alter the reading frame [out-of-frame], which correlates with the more severe phenotype of DMD versus those that do not alter the reading frame [in-frame], which correlate with the milder BMD phenotype), can distinguish the DMD and BMD phenotypes with 91 to 92 percent accuracy
If no disease-causing DMD mutation is identified, skeletal muscle biopsy is warranted for western blot and immunohistochemistry studies of dystrophin.

Testing strategy for carrier testing in at-risk female relatives

When there is a known DMD mutation, test for that deletion, duplication or point mutation using appropriate testing method.
When an affected male is not available for testing, perform testing by deletion or duplication first, and if no mutation is identified, by sequence analysis

Exclusionary guidelines:
All other indications

81209

Medical policy
Genetic testing for Bloom syndrome
The safety and efficacy of genetic testing for Bloom syndrome have been established. It may be considered a useful diagnostic option when indicated. This policy is effective March 1, 2015.

Inclusions:
Genetic testing for Bloom syndrome (BLM mutation) is considered established in any of the following circumstances:

For an infant or child suspected of having Bloom syndrome based on physical characteristics including, but not limited to, pre- and postnatal growth retardation that persists into infancy and childhood, sun-sensitive skin which results in a butterfly rash to the face, increased susceptibility to infections and cancer, etc., elevated sister chromatid exchanges, etc., in order to confirm the diagnosis.
For carrier screening for BSyn in individuals with at least one grandparent of Eastern European (Ashkenazi) Jewish ancestry before or during pregnancy. (This is recommended by the American College of Medical Genetics.)
Carrier testing of at-risk relatives when there has been prior identification of the BLM disease-causing mutations in the family.
For prenatal diagnosis of at-risk pregnancies using cytogenetic or molecular genetic testing of fetal cells obtained by amniocentesis or chorionic villus sampling.

Exclusions:
Screening for Bloom syndrome in the general population

Group variations
MPSERS is excluded from this change.

UPDATES TO PAYABLE PROCEDURES

11100
11101
20220

Payment policy
Effective Aug. 1, 2013, procedure codes 11100, 11101 and 20220 are payable to dentists and oral surgeons.

81401, 81403

Experimental:
81440, 81460, 81465

Basic benefit and medical policy
The safety and effectiveness of genetic testing to confirm the diagnosis of a specific mitochondrial disorder or for at-risk female relatives to determine carrier status prior to conception, have been established. It is an effective diagnostic option for patients meeting patient selection criteria.

Genetic testing for mitochondrial disorders using expanded panel testing is considered experimental.

Group variations
Covered for Chrysler members effective Jan. 1, 2015; excludes group number 82600 enrollees

87430
87651

Payment policy
Procedure codes 87430 and 87651 have been added to the Physician Office Lab List, effective May 1, 2015. These procedures are now allowed in the office setting.

90791 and 90792

BCBSM changes to medical policy guidelines
Payable for obesity and morbid obesity diagnoses 278.00 and 278.01.

J3490

Basic benefit and medical policy
Effective Feb. 26, 2015, the FDA approved drug Liletta (levonorgestrel releasing IUD) will be covered under NOC J3490 for its FDA-indicated approval for prevention of pregnancy for up to three years.

POLICY CLARIFICATIONS

81324
81325
81326
81404
81405
81406
81479

Basic benefit and medical policy

Genetic testing for inherited peripheral neuropathies
The safety and effectiveness of genetic testing for hereditary neuropathies have been established. It may be considered a useful diagnostic option for patients meeting the specified selection criteria. This policy is effective March 1, 2015.

Inclusions:

To confirm a diagnosis in an individual with demyelinating neuropathy when Charcot-Marie-Tooth is suspected
To avoid toxic effects of chemotherapy in oncology patients with unexplained or pre-existing familial neuropathy that is consistent with CMT
To prevent pressure palsies in an unaffected person with a known first-degree relative with CMT1A
To avoid invasive procedures in children suspected of CMT
For prenatal diagnosis, in couples with known CMT1A

Exclusions:

For all other indications

Group variations
Chrysler and URMBT are excluded from this change.

99184

Basic benefit and medical policy
The safety and effectiveness of total body or selective head hypothermia have been established. It is a useful therapeutic option for the treatment of neonates meeting patient selection criteria. The policy has been updated, effective March 1, 2015.

Inclusionary guidelines:
Appropriate candidates for hypothermia therapy are newborn infants who are diagnosed with moderate to severe hypoxic ischemic encephalopathy and who are (must meet all criteria below):

Exhibiting signs of prolonged lack of oxygenation during birth (perinatal asphyxia)
At risk of developing hypoxic-ischemic encephalopathy.
Less than six hours old.

Note: Moderate HIE is defined as slow gasping breathing or an Apgar score of four to six at one minute of age. Other symptoms may include:

Lethargy (difficult to rouse)
Reduced tone of the extremities or trunk
Diminished brainstem reflexes (pupil/gag/suck)
Possible clinical seizures

Severe asphyxia is defined as absent breathing or an Apgar score of zero to three at one minute of age. Other symptoms may include:

Coma (cannot be roused)
Weak or absent respiratory drive
No response to stimuli (may have spinal reflex to painful stimuli)
Flaccid tone of the extremities and trunk (floppy)
Diminished or absent brainstem reflexes (pupil/gag/suck)
Diminished tendon reflexes
EEG severely abnormal (suppressed or flat EEG with or without seizures)

Exclusionary guidelines:
Patients not meeting inclusionary guidelines

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 2014 American Medical Association. All rights reserved.