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April 2016
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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| UPDATES TO PAYABLE PROCEDURES |
98940, 98941, 98942 |
Basic benefit and medical policy
Chiropractic manipulations are now covered for the following:
- Strain of muscle and tendon of back wall of thorax, initial encounter
- Strain of muscle and tendon of back wall of thorax, subsequent encounter
- Strain of muscle, fascia and tendon of lower back, initial encounter
- Strain of muscle, fascia and tendon of lower back, subsequent encounter
- Strain of muscle, fascia and tendon of pelvis, initial encounter
- Strain of muscle, fascia and tendon of pelvis, subsequent encounter
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| POLICY CLARIFICATIONS |
43201, 43210, 43212, 43236, 43257, 43499 |
Basic benefit and medical policy
Transesophageal endoscopic therapies are considered experimental as a treatment of gastroesophageal reflux disease. These procedures include:
- Transesophageal endoscopic gastroplasty (gastroplication or transoral incisionless fundoplication) procedures, including the EndoCinch™ procedure, the EsophyX® procedure, the Syntheon ARD Plicator, the Bard™ Endoscopic Suturing System, StomaphyX™, the Endoscopic Plication System.
- Transesophageal radiofrequency to create submucosal thermal lesions of the gastroesophageal junction (for example, the Stretta™ procedure).
- Endoscopic submucosal implantation of a prosthesis or injection of a bulking agent (for example, polymethylmethacrylate beads, zirconium oxide spheres).
These procedures haven’t been scientifically demonstrated to be as safe and effective for the treatment of GERD as conventional medical or surgical management. The policy was updated, effective March 1, 2016. |
20999 |
Basic benefit and medical policy
Mesenchymal stem cell therapy is considered experimental for all orthopedic applications, including use in repair or regeneration of musculoskeletal tissue.
Allograft bone products containing viable stem cells, including demineralized bone matrix with stem cells, are considered experimental for all orthopedic applications.
Allograft or synthetic bone graft substitutes that must be combined with autologous blood or bone marrow are considered experimental for all orthopedic applications.
The safety and effectiveness of these treatments haven’t been established.
The medical policy statement was updated, effective March 1, 2016. |
32701, 77520, 77522, 77523, 77525 |
Basic benefit and medical policy
Charged-particle (proton or helium ion) radiation therapy
The criteria for charged-particle (proton or helium ion) radiation therapy policy have been updated. This policy was effective March 1, 2016.
Charged-particle irradiation with proton or helium ion beams may be considered established in the following clinical situations:
- Primary therapy for melanoma of the uveal tract (iris, choroid or ciliary body), with no evidence of metastasis or extrascleral extension, and with tumors up to 24 millimeters in largest diameter and 14 millimeters in height, and particularly when plaque brachytherapy isn’t a feasible option.
- Postoperative therapy (with or without conventional high-energy X-rays) in patients who have undergone biopsy or partial resection of chordoma or low-grade (I or II) chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma), cervical spine, or sacral/lower spine. Patients eligible for this treatment have residual localized tumor without evidence of metastasis.
- In the treatment of intracranial arteriovenous malformation not amenable to surgical excision or other conventional forms of treatment or adjacent to critical structures such as the optic nerve, brain stem or spinal cord.
- Primary or metastatic central nervous system malignancies, such as gliomas, when adjacent to critical structures such as the optic nerve, brain stem or spinal cord and when other standard radiation techniques such as Intensity modulated radiation therapy or standard stereotactic modalities wouldn’t reduce the risk of radiation damage to the critical structure.
- In the treatment of all pediatric tumor types (through 21 years of age).
Other applications of charged-particle irradiation with proton beams are considered experimental. This includes:
- Clinically localized prostate cancer, non-small-cell lung cancer at any stage or for recurrence, breast cancer, pancreatic cancer, hepatocellular carcinoma, macular degeneration or choroidal neovascularization and hemangiomas.
Note: The evidence doesn’t support that proton beam radiation therapy provides an incremental benefit in the treatment of localized prostate cancer when compared with low cost alternative procedures. Use of proton beam therapy may require prior authorization to verify that Blue Cross Blue Shield of Michigan and Blue Care Network criteria are met and, where appropriate, to explore the appropriateness of using alternative therapeutic modalities such as Intensity modulated radiation therapy and 3-D conformal radiation therapy.
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| GROUP BENEFIT CHANGES |
Copper Country Mental Health |
Effective April 1, 2016, Medicare-eligible retirees of Copper Country Mental Health 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.
For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma.
Group number: 67797
Suffix: 600
Prefix: XYL
Plan offered:
Medicare Plus Blue Group PPO
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Township of Independence |
Effective April 1, 2016, Medicare-eligible retirees of the Township of Independence 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.
For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma.
Group number: 67811
Suffixes: 600, 601
Prefix: XYL
Plan offered:
Medicare Plus Blue Group PPO |
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