|
December 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
|
| UPDATES TO PAYABLE PROCEDURES |
G0166 |
Basic benefit and medical policy
Enhanced external counterpulsation
The criteria for the enhanced external counterpulsation policy have been updated. The safety and effectiveness of EECP in the treatment of chronic stable angina have been established. It may be considered as an alternative treatment for chronic stable angina in those patients who are refractory to maximal medical management and who are not suitable for invasive treatment techniques.
The use of EECP in patients with a diagnosis of any medical condition other than stable, chronic angina is experimental or investigational. EECP hasn’t been scientifically demonstrated to improve patient clinical outcomes for other conditions, such as erectile dysfunction, heart failure, ischemic stroke or unstable angina.
This policy is effective Nov. 1, 2015.
Inclusions:
EECP treatment should be limited to one or two times per day with a maximum of 35 one-hour treatments. Maximum treatment hours don’t have to be consecutive.
Patients selected for EECP for the treatment of chronic stable angina should meet the following criteria:
- Angina levels II, III or IV (Canadian Cardiovascular Society Classification) for patients not readily amenable to surgical intervention
- Documented evidence of coronary artery disease evidenced by one of the following criteria:
- > 70% stenosis of at least one or more major coronary arteries, proven angiographically
- History of myocardial infarct documented by electrocardiogram (presence of Q wave) and elevation of cardiac enzymes
- Positive (for myocardial infarct or ischemia) nuclear exercise stress test
- Positive exercise treadmill test
Relative contraindications:
- Atrial fibrillation or frequent premature ventricular contractions that interfere with EECP triggering
- Baseline EKG abnormalities that will interfere with the interpretation of the exercise EKG
- Blood pressure > 180/110 mm Hg
- Cardiac catheterization in the preceding two weeks
- History of varicosities, deep vein thrombosis, phlebitis or stasis ulcer, bleeding diathesis, warfarin use
- Left ventricular ejection fraction <30%
- Myocardial infarction or coronary artery bypass in the preceding three months
- Non-bypassed left main artery stenosis > 50%
- Overt congestive heart failure
- Patients unable to undergo treadmill testing or who are in a cardiac rehabilitation program
- Permanent pacemaker or implantable defibrillator
- Severe symptomatic peripheral vascular disease
- Significant valvular heart disease
- Unstable angina
- Women with childbearing potential or who are pregnant
|
J0178 |
Basic benefit and medical policy
Injection aflibercept 1 mg. is now payable for proliferative diabetic retinopathy. |
Revenue code 0657
E/M codes: 99223, 99233, 99239, 99306,
99309, 99310, 99326, 99327, 99328, 99336, 99337, 99343, 99344, 99345, 99349, 99350 |
Payment policy
Additional evaluation and management codes are payable when reported with revenue code 0657 for hospice physician services, effective Jan. 1, 2015. |
81401, 81403, 81404, 81405, 81406, 81407, 81479 |
Basic benefit and medical policy
The safety and effectiveness of genetic testing for patients with infantile- and early childhood-onset epilepsy syndromes in which epilepsy is the core clinical symptom have been established. It may be considered a useful diagnostic option when indicated.
This policy is effective Sept. 1, 2015.
Inclusions:
Genetic testing of individuals with infantile- and early childhood-onset epilepsy syndromes in which epilepsy is the core clinical symptom may be considered established if positive test results may lead to changes in management, must meet one of the following:
- Medication management
- Diagnostic testing such that alternative potentially invasive tests are avoided
- Reproductive decision-making
Infantile- and early childhood-onset epilepsy syndromes include but aren’t limited to the following:
- Early myoclonic encephalopathy
- Ohtahara syndrome
- West syndrome
- Dravet syndrome (severe myoclonic epilepsy in infancy)
- Lennox–Gastaut syndrome
- Landau–Kleffner syndrome
- Epilepsy with continuous spike and waves during slow-wave sleep (other than Landau-Kleffner syndrome)
- Myoclonic status in nonprogressive encephalopathies
Exclusions:
Genetic testing for all other epilepsy conditions not related to infantile- or early childhood-onset epilepsy.
Benefit policy group variations:
Covered for all autos and URMBT effective Sept. 1, 2015. |
| POLICY CLARIFICATIONS |
0295T, 0296T, 0297T, 0298T |
Basic benefit and medical policy
External electrocardiographic recording HCPCS codes updated
The external electrocardiographic recording HCPCS codes were reviewed and updated.
HCPCS code 0295T is considered not payable and will no longer suspend for individual consideration effective Oct. 1, 2015. HCPCS codes 0296T, 0297T and 0298T are now payable effective May 1, 2014.
Group variations
Chrysler and URMBT are excluded from this change |
S2095, 37243, 79445 |
Basic benefit and medical policy
Radioembolization for primary and metastatic tumors of the liver
The criteria for the radioembolization for primary and metastatic tumors of the liver policy have been updated. This policy is effective Nov. 1, 2015.
Inclusions:
- Primary hepatocellular carcinoma that is unresectable and limited to the liver, or
- Hepatic metastases from neuroendocrine tumors (carcinoid and noncarcinoid) with diffuse and symptomatic disease when systemic therapy has failed to control symptoms, or
- Unresectable hepatic metastases from colorectal carcinoma, melanoma (ocular or cutaneous) or breast cancer that are both progressive and diffuse, in patients with liver-dominant disease who are refractory to chemotherapy or are not candidates for chemotherapy, or
- Primary intrahepatic cholangiocarcinoma in patients with unresectable tumors.
- Primary hepatocellular carcinoma as a bridge to liver transplantation
- Treatment of other radiosensitive tumors metastatic to the liver with liver-limited or liver-dominant disease for symptom palliation or prolongation of survival
Criteria for unresectable hepatocellular carcinoma:
- Multiple liver metastases together with involvement of both lobes, or
- Tumor invasion where the three hepatic veins enter the inferior vena cava, or
- None of the hepatic veins could be preserved if the metastases were resected, or
- Tumor invasion of the porta hepatis such that neither the origin of the right nor left portal veins could be preserved if resection were undertaken, or
- Widespread metastases such that resection would leave less liver than is compatible with survival
Exclusions:
- Radioembolization for all other hepatic metastases not described above.
- Yttrium-90 is contraindicated for patients who have:
- Had previous external beam radiation therapy of the liver
- Ascites or are in clinical liver failure
- Bleeding diathesis not correctable using standard medical means
- Severe pulmonary insufficiency
- Markedly abnormal liver function tests
- Treatment that would result in greater than 30 Gy dose to the lung in one session or 50 Gy cumulative as assessed by Technetium MAA scan
- Pre-assessment angiogram that demonstrates vascular anatomy abnormalities that would result in significant reflux of hepatic arterial blood to the stomach, pancreas or bowel
- Disseminated and significant extrahepatic malignant disease
- History of treatment with capecitabine within two previous months, or who will be treated with capecitabine at any time following treatment with SIR-Spheres®
- Portal vein thrombosis (relative)
Radioembolization is not recommended in pregnant women, nursing mothers or children. |
| GROUP BENEFIT CHANGES |
ABC Group Holdings |
ABC Group Holdings is joining Blue Cross Blue Shield
of Michigan, effective Dec. 1, 2015.
Group number: 71723
Alpha prefix: PPO (LXY)
Platform: NASCO
Plans offered:
PPO, medical/surgical
Prescription drug
|
Dematic |
Dematic is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2016.
Group number: 71708
Alpha prefix: DNW-PPO
Plans offered:
PPO
PPO with HSA
Note: Prescription drugs are covered through Express Scripts.
|
Dialog Direct |
Dialog Direct is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2016.
Group number: 71722
Alpha prefix: PPO (DDD)
Platform: NASCO
Plans offered:
PPO, medical/surgical
Prescription drug
Consumers Direct Health — HSA
|
FANUC America |
FANUC American is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2016.
Group number: 71716
Alpha prefix: PPO (FRQ)
Platform: NASCO
Plans offered:
PPO, medical/surgical
EPO, medical/surgical
Hearing plans
HSA plan
Prescription drug plans
|
Freudenberg North America |
Freudenberg North America is adding autism spectrum condition, effective Jan. 1, 2016. Change prescription copays to apply after the deductible.
Group number: 71700
Alpha prefix: FND
Plans offered:
PPO
HRA
HSA
Prescription drug
|
Guardian Industries and Guardian Building Products |
For new pre-65 retirees who retire after Jan. 1, 2016, Guardian Industries and Guardian Building Products members will be offered a GlidePath™ product option. Routine eye exams are included as part of the medical plan.
Group number: 71385
Alpha prefix: PPO (GUR and GIJ)
Platform: NASCO
Plans offered:
Simply Blue 250
Simply Blue 500
Simply Blue 1000
Simply Blue 2500
Drug plan: $10/$40/$80
|
Miller Canfield Paddock and Stone |
Miller Canfield Paddock and Stone is joining Blue Cross Blue Shield of Michigan, Jan. 1, 2016
Group number: 71710
Alpha prefix: PPO MFX
Platform: NASCO
Plans offered:
PPO
HDHP — HRA
HSA
Vision (VSP)
Dental
|
MPS Group |
MPS group is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2016.
Group number: 71718
Alpha prefix: PPO (MSG)
Platform: NASCO
Plans offered:
PPO, medical/surgical
Hearing plans
Prescription drug plans
|
Plymouth-Canton Community Schools |
Plymouth-Canton Community Schools is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2016.
Group number: 7171
Alpha prefix: JXP
Plans offered:
PPO, medical/surgical
Hearing (only for screenings for children younger than age 6)
Prescription drug |
|
