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October 2015
Billing chart
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 |
93260, 93261 |
Basic benefit 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 AICD and electronic surveillance of the AICD have been established. It may be considered a useful therapeutic option for patients who meet selection criteria.
Update: Device evaluations are covered for members who have received an implantable subcutaneous cardioverter defibrillator system, effective March 1, 2015. |
J7199 |
Effective April 30, 2015, Ixinity (coagulation factor IX [recombinant]) is covered for FDA approved indications. |
| UPDATES TO PAYABLE PROCEDURES |
81201-81203, 81210, 81288, 81292-81299, 81300, 81301, 81317-81319, 81401, 81403, 81406, 81435, 81436 |
Basic benefit and medical policy
The safety and effectiveness of genetic testing for polyposis and non-polyposis cancer syndromes have been established. They may be considered useful diagnostic options for individuals who meet clinical criteria for increased risk of hereditary colorectal cancer. Inclusionary guidelines have been updated, effective March 1, 2015.
Inclusionary guidelines:
These guidelines refer to the different types of genetic tests available for colorectal cancer.
- Genetic testing of the adenomatous polyposis coli gene is established in the following:
- Patients with greater than 20 colonic polyps or
- First-degree relatives** (i.e., siblings, parents and offspring) of patients with familial adenomatous polyposis or attenuated familial adenomatous polyposis or a known APC mutation.
**Due to the high lifetime risk of cancer of the majority of the genetic syndromes discussed in this policy, “at-risk relatives” primarily refers to first-degree relatives. However, some judgment must be allowed, for example, in the case of a small family pedigree, when extended family members may need to be included in the testing strategy.
- Genetic testing for MYH (MUTYH) gene mutations is established in any of the following:
- Individuals with personal history of adenomatous polyposis who have negative APC mutation testing and a negative family history for adenomatous polyposis or
- Individuals with personal history of adenomatous polyposis whose family history is consistent with recessive inheritance (in other words, family history is positive only for sibling or siblings) or
- Asymptomatic siblings of individuals with known MYH polyposis (for example, an asymptomatic member should be tested if his or her sibling has a known MYH polyposis).
- Genetic testing for MLH1and MSH2 gene mutations to determine the carrier status of Lynch syndrome is established in any of the following:
- Patients with colorectal cancer to test for the diagnosis of Lynch syndrome or
- Patients with endometrial cancer and one first-degree relative diagnosed with a Lynch-associated cancer, for the diagnosis of Lynch syndrome
- Patients without colorectal cancer, but who have a first- or second-degree relative with a known MMR mutation or
- At-risk relatives of patients with Lynch syndrome with a known MMR mutation or
- Patients without colorectal cancer but with a family history meeting the Amsterdam or revised Bethesda criteria, when no affected family members have been tested for MMR mutations. In cases when testing is proposed for an individual without a personal history of colorectal cancer, the revised Bethesda or Amsterdam II criteria would be applicable to that individual’s first- or second-degree relatives.
Note: Amsterdam II criteria must meet all of the following:
- Three or more relatives with a histologically verified Lynch syndrome-associated cancer (colorectal cancer or cancer of the endometrium, small bowel, ureter or renal pelvis), one of whom is a first-degree relative of the other two
- Hereditary nonpolyposis colorectal cancer-associated cancer involving at least two successive generations
- Cancer in one or more affected relatives diagnosed before age 50
- Familial adenomatous polyposis excluded in any cases of colorectal cancer
- Tumors should be verified by pathologic examination whenever possible
As part of revised Bethesda guidelines, patients must meet any of the following:
- Individuals diagnosed with colorectal cancer younger than age 50
- Individuals with Lynch syndrome-related cancer, including synchronous and metachronous colorectal cancers or associated extra colonic cancers** regardless of age
- Individuals with colorectal cancer with the MSI-H histology diagnosed in a patient younger than age 60
- Individuals with colorectal cancer and one or more first-degree relatives with colorectal cancer or Lynch syndrome-related extra colonic cancer**; if one of the cancers was diagnosed at age <50 years
- Individuals with colorectal cancer and colorectal cancer diagnosed in two or more first- or second-degree relatives with Lynch syndrome-related tumors** regardless of age.
**Extra colonic cancers include stomach, bladder, ureter and renal pelvis, biliary tract, brain (usually glioblastoma), pancreas, sebaceous gland adenomas, keratoacanthomas, carcinoma of the small bowel and endometrial or ovarian cancer.
- MSH6 and PMS2 gene sequence analysis are established in patients meeting the Bethesda criteria for genetic testing for Lynch syndrome:
- Who do not have mutations in either the MLH1 or MSH2 genes or
- Who meet the first Amsterdam II criteria that describes the relatives
- Single site MSH6 or PMS2 testing is established for family members (up to third degree) of people with Lynch syndrome with an identified MSH6 and/or PMS2 gene mutation. (An example would be a member who meets any of the revised Bethesda criteria and whose second cousin has a confirmed MSH6 and/or PMS2 gene mutation).
- Patients with endometrial cancer and one first-degree relative diagnosed with a Lynch-associated cancer who do not have mutations in either the MLH1 or MSH2 genes, for the diagnosis of Lynch syndrome.
- Genetic testing for EPCAM mutations is established in any of the following:
- Patients with colorectal cancer, for the diagnosis of Lynch syndrome when all of the three criteria are met:
- Tumor tissue shows a high level of microsatellite instability
- Tumor tissue shows lack of MSH2 expression by immunohistochemistry
- Patient is negative for a germline mutation in MSH2, MLH1, PMS2, and MSH6 or
- At-risk relatives of patients with Lynch syndrome with a known EPCAM mutation or
- Patients without colorectal cancer but with a family history meeting the Amsterdam or revised Bethesda criteria, when no affected family members have been tested for MMR mutations or when sequencing for MMR mutations is negative. In cases when testing is proposed for an individual without a personal history of colorectal cancer, the revised Bethesda criteria would be applicable to that individual’s first- or second-degree relatives.
- Genetic testing for BRAF V600E mutations or MLH1promoter methylation is established to exclude a diagnosis of Lynch syndrome when MLH1 protein is not expressed in a colorectal cancer on immunohistochemical analysis.
Pre- and post-test genetic counseling should be provided as an adjunct to genetic testing. |
J9310 |
Basic benefit and medical policy
Injection, rituximab, 100 mg, is now payable for
- Pemphigoid
- Benign mucous membrane pemphigoid – with ocular involvement
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| POLICY CLARIFICATIONS |
0071T
0072T
76999 |
Basic benefit and medical policy
MRI-guided focused ultrasound
The safety and effectiveness of MRI-guided high-intensity ultrasound ablation has been established. It may be a considered a useful therapeutic option in specified situations.
This policy is effective Sept. 1, 2015.
Inclusions:
Pain palliation in adult patients with metastatic bone cancer who failed or are not candidates for radiotherapy
Exclusions:
All other situations including but not limited to:
- Treatment of uterine fibroids
- Treatment of other tumors, such as brain cancer, prostate cancer and breast cancer
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| POLICY CLARIFICATIONS |
Q4145 |
Epifix® injectable is experimental, effective Sept. 1, 2015 |
| GROUP BENEFIT CHANGES |
City of Highland Park |
Effective Oct. 1, 2015, Medicare-eligible retirees of the City of Highland Park 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 67503 with suffixes 600, 601 and 602. 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. |
Diversified Members Credit Union |
Effective Oct. 1, 2015, Medicare-eligible retirees of the Diversified Members Credit Union will have Blue Cross’ Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical, surgical and prescription drug benefits. The group number is 67474 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. |
Ironworkers Local 340 Health Care Fund |
Effective Oct. 1, 2015, Ironworkers Local 340 Health Care Fund is merging with Ironworkers Health Fund of Eastern Michigan Local 25. Due to the merger, the group will have changes in name, address and tax identification number, as follows:
New group name: Ironworkers Health Fund of Eastern Michigan – Local 25
New address: 25130 Trans X Road, Novi, MI 48376
New tax ID number: 38-6216995
The group number will remain the same: 27203-600. |
Otsego County Road Commission |
Effective Oct. 1, 2015, Medicare-eligible retirees of the Otsego County Road Commission will have Blue Cross’ Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical, surgical and prescription drug benefits. The group number is 67494 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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