|
August 2015
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 |
33270, 33271, 33272 **, 33273
** Payable effective 1/1/2015 |
Basic benefit and medical policy
The safety and effectiveness of an automatic implantable cardioverter defibrillator and electronic surveillance of the AICD have been established. It may be considered a useful therapeutic option for patients who meet selection criteria.
The safety and effectiveness of a subcutaneous automatic implantable cardioverter defibrillator and electronic surveillance of the AICD have been established. It may be considered a useful therapeutic option for patients who meet selection criteria, effective March 1, 2015.
Inclusionary guidelines
FDA-approved subcutaneous cardioverter-defibrillators are established for adult or pediatric persons who meet patient selection criteria for an implanted cardioverter-defibrillator and do not need pacing and the placement of a conventional AICD is precluded due to any of the following conditions:
- Poor vascular access secondary to dialysis or
- other vascular conditions
- A high risk for infection, e.g., immune-
- compromised patients or those with a history
- of a previous transvenous infection
- History of congenital heart disease with
- anatomic limitations for transvenous
- placement of the AICD
- Pediatric patients with primary cardiac diseases that display electrical conductivity problems, such as those with Brugada syndrome, LQTS disease or hypertrophic cardiomyopathy
Note: The criteria for standard automatic implantable cardioverter defibrillators was published in the December 2013 edition of The Record, and is available in the medical policy. |
90620 |
Basic benefit and medical policy
The safety and effectiveness of Bexsero®, a two-dose schedule intramuscular Serogroup B meningococcal recombinant protein and outer membrane vesicle vaccine, is established, effective Feb. 1, 2015. It is recommended by the Advisory Committee on Immunization Practices for persons meeting select criteria.
Basic benefit policy group variations
Refer to member’s policy for coverage status.
Inclusionary guidelines
Children age 10 through 18 at increased risk for meningococcal disease, attributable to serogroup B, including:
- Children who have persistent complement component deficiencies (including inherited or chronic deficiencies in C3, C5-C9, properdin, factor H or factor D, or taking eculizumab [Soliris®])
- Children who have anatomic or functional asplenia, including sickle cell disease
- Children identified to be at increased risk because of a meningococcal disease outbreak attributable to serogroup B
|
90630 |
Basic benefit and medical policy
The safety and effectiveness of Fluzone® QIV ID, a quadrivalent inactivated influenza vaccine designed for intradermal administration have been established. It may be considered a useful therapeutic option when administered according to U.S. FDA-approved guidelines. This policy is effective Jan. 1, 2015. |
90651 |
Basic benefit and medical policy
The safety and effectiveness of Gardasil®9 have been established, effective Jan. 1, 2015.
Basic benefit policy group variations
Refer to member’s policy for coverage status.
Inclusionary guidelines
The Advisory Committee on Immunization Practices recommends that routine HPV vaccination be initiated at age 11 or 12. The vaccination series can be started beginning at age 9. Vaccination is also recommended for females ages 13 through 26 and for males ages 13 through 21 who have not been vaccinated previously or who have not completed the three-dose series. Males ages 22 through 26 years may be vaccinated. Vaccination of females is recommended with 2vHPV, 4vHPV (as long as this formulation is available), or 9vHPV. Vaccination of males is recommended with 4vHPV (as long as this formulation is available) or 9vHPV.
2vHPV, 4vHPV and 9vHPV all protect against HPV 16 and 18, types that cause about 66 percent of cervical cancers and the majority of other HPV-attributable cancers in the United States. 9vHPV targets five additional cancer causing types, which account for about 15 percent of cervical cancers. 4vHPV and 9vHPV also protect against HPV 6 and 11, types that cause anogenital warts.
Administration: 2vHPV, 4vHPV, and 9vHPV are each administered in a 3-dose schedule. The second dose is administered at least 1 to 2 months after the first dose and the third dose at least 6 months after the first dose. If the vaccine schedule is interrupted, the vaccination series does not need to be restarted.
If vaccination providers do not know or do not have available the HPV vaccine product previously administered, or are in settings transitioning to 9vHPV, any available HPV vaccine product may be used to continue or complete the series for females for protection against HPV 16 and 18; 9vHPV or 4vHPV may be used to continue or complete the series for males. There are no data on efficacy of fewer than 3 doses of 9vHPV.
Special populations: HPV vaccination is recommended through age 26 years for men who have sex with men and for immunocompromised persons (including those with HIV infection) who have not been vaccinated previously or have not completed the three-dose series. |
Condition codes:
R1, R2, R3, R4, R5, R6, R7, R8, and R9 |
Payment policy
The National Uniform Billing Committee approved these condition codes, effective April 1, 2015. BCBSM also accepts these codes, effective April 1, 2015. |
| UPDATES TO PAYABLE PROCEDURES |
33228 |
Payment policy
Revenue codes:
0450 - Emergency Room-General
0480 - Cardiology-General
0510 - Clinic-General classification
0514 - Clinic-OB/GYN Clinic
0515 - Clinic-Pediatric Clinic
0516 - Clinic-Urgent Care Clinic
0517 - Clinic-Family Practice Clinic
0519 - Clinic-Other Clinic
0761 - Specialty Services-Treatment Room has been added to fee-based reimbursement, effective Oct. 1, 2013.This process is in alignment with hospital outpatient pricing.
The revenue codes listed above requires the reporting of a valid CPT or HCPCS code when services are performed in Location 22 (outpatient hospital). |
73020, 73030, 73050, 73060, 73070, 73080, 73090, 73100, 73110, 73120, 73130, 73140, 73500, 73550, 73560, 73565, 73590, 73600, 73620, 73630 |
Basic benefit and medical policy
Chiropractors are now payable providers for these procedure codes as part of the Radiology Management Program. The Federal Employee Program® is not included in this change. |
99204, 99211, 99212, 99213, 99214, 98943, 97014, 97018, 97022, 97024, 97026, 97028, 97032, 97034, 97035, 97110, 97112, 97113, 97116, 97124,
97140, G0283 |
Basic benefit and medical policy
Chiropractors are now payable providers for these procedure codes in an office setting. |
A4639, A7025, E0984, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1014, E1029, E2227, E2310, E2311, E2321, E2322, E2325,
E2326, E2327, E2328, E2329, E2330, E2351, E2373, E2374, E2375, E2376, E2377, K0607, K0730 |
Basic benefit and medical policy
Effective Sept. 1, 2015, Blue Cross will allow HCPCS codes listed to pay as a capped rental, allowing one monthly rental for up to 10 months. Then the item is considered purchased and you cannot balance-bill the member for further rental payments.
Items are also available as a purchase.
This change does not apply to groups that have DME/P&O benefits carved out to a vendor. |
J0178 |
Basic benefit and medical policy
J0178 is now payable for the following additional diagnosis of 362.36, effective Oct. 6, 2014. |
J7182 |
Basic benefit and medical policy
Novoeight (turoctocog alfa) received approval from the FDA on Oct. 16, 2013, and is covered under this procedure code, effective Jan. 1, 2015.
Novoeight (turoctocog alfa), a parenterally-administered drug, for adults, adolescents and children with Hemophilia A for:
- Control and prevention of bleeding episodes
- Perioperative management of patients with hemophilia A
- Routine prophylaxis to prevent or reduce the frequency of bleeding in adults, adolescents and children
This drug will not require prior authorization through the Specialty Pharmacy Program. |
J3490, Q9976 |
Basic benefit and medical policy
Effective Jan. 23, 2015, Triferic™ is covered under J3490 for the replacement of iron to maintain hemoglobin in adult patients with hemodialysis-dependent chronic kidney disease. Beginning July 1, 2015, report Triferic™ with HCPCS code Q9976. |
| GROUP BENEFIT CHANGES |
City of Brighton |
Effective Aug. 1, 2015, Medicare-eligible retirees of the City of Brighton 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 67371 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. |
City of Jackson |
Effective Aug. 1, 2015, Medicare-eligible retirees of the City of Jackson 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 67373 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. |
Halla Visteon Climate Control USA LLC |
Halla Visteon Climate Control USA LLC, group number 007041050, joins Blue Cross Blue Shield of Michigan, effective Aug. 1, 2015. The members in this group were previously in a Visteon Salaried group.
The group is offering one PPO, one HSA plan and one HMO, consisting of a medical and prescription drug plan.
Member ID cards will show the following alpha prefixes:
- XYQ for PPO plans
- XYY for Traditional plans
- XYR for Complementary plans
- XYH for HMO plans
|
National Heritage Academies |
Effective Sept. 1, 2015, National Heritage Academies joins Blue Cross Blue Shield of Michigan.
Group number: 71440
Alpha prefix: NHT
Plan offered:
One health savings account plan |
|
