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August 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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| NEW PAYABLE PROCEDURES |
95199**
** Not otherwise classified code represents professional services |
Basic benefit and medical policy
Sublingual immunotherapy using Oralair®, Grastek® or Ragwitek® may be considered established for the treatment of pollen-induced allergic rhinitis
Sublingual immunotherapy using Oralair, Grastek or Ragwitek may be considered established when used according to U.S Food and Drug Administration labeling for the treatment of pollen-induced allergic rhinitis when the following conditions are met:
- Patient has a history of rhinitis or rhinoconjunctivitis symptoms related to grass or short ragweed pollen exposure.
- Patient has a documented positive pollen-specific skin test or pollen-specific immunoglobulin E (IgE) test.
- Patient’s symptoms aren’t adequately controlled by appropriate pharmacotherapy.
Sublingual immunotherapy as a technique of allergy immunotherapy is considered experimental for all other uses.
This policy was effective July 1, 2016.
Group variations
Benefits may vary. Allergy testing and therapy aren’t a benefit on all contracts, so verification is recommended.
Payment policy
Oralair, Grastek and Ragwitek are oral medications available through a pharmacy by prescription, and they may be subject to copays unless otherwise determined by group coverage. |
J3490 |
Basic benefit and medical policy
Effective Feb. 1, 2016, Briviact (brivaracetam) (IV) is covered for its FDA-approved indications for adjunctive therapy in the treatment of partial-onset seizures in patient aged 16 and older with epilepsy in the form of an injection for intravenous use when oral administration isn’t feasible.
Report procedure code J3490 for Briviact (brivaracetam) (IV)
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J7199 |
Basic benefit and medical policy
Kovaltry covered for its FDA-approved indications
Effective March 17, 2016, Kovaltry (factor VIII full-length recombinant) is covered for its FDA-approved indications for use in adults and children with hemophilia A (congenital Factor VIII deficiency) for:
- On-demand treatment and control of bleeding episodes
- Perioperative management of bleeding
- Routine prophylaxis to reduce the frequency of bleeding episodes
Report procedure code J7199 for Kovaltry. |
| UPDATES TO PAYABLE PROCEDURES |
E0561, E0562 |
Basic benefit and medical policy
Some humidifiers are now payable for purchase
Humidifiers used with continuous positive airway pressure, or CPAP, devices that were previously only payable for rental are now also payable for purchase. |
J0178 |
Basic benefit and medical policy
Additional payable diagnosis codes
J0178 now has additional payable diagnosis codes of:
- H35.051 — Retinal neovascularization, unspecified, right eye
- H35.052 — Retinal neovascularization, unspecified, left eye
- H35.053 — Retinal neovascularization, unspecified, bilateral
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J9047 |
Basic benefit and medical policy
Additional payable diagnosis codes
J9047 now has additional payable diagnosis codes of:
- C90.00 — Multiple myeloma not having achieved remission
- C90.01 — Multiple myeloma in remission
- C90.02 — Multiple myeloma in relapse
This was effective March 1, 2016. |
S8948 |
Basic benefit and medical policy
Low-level laser therapy may be useful therapeutic option in select situations
The safety and effectiveness of low-level laser therapy have been established. It may be considered a useful therapeutic option in select situations. This policy was effective July 1, 2016.
Inclusions
When used for the prevention of oral mucositis in patients undergoing treatment associated with increased risk of oral mucositis, including chemotherapy, radiotherapy and hematopoietic stem cell transplantation.
Exclusions
All other indications, including:
- Carpal tunnel syndrome
- Neck pain
- Subacromial impingement
- Adhesive capsulitis
- Temporomandibular joint pain
- Low back pain
- Osteoarthritis knee pain
- Heel pain (i.e., Achilles tendinopathy, plantar fasciitis)
- Bell palsy
- Fibromyalgia
- Wound healing
- Lymphedema
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| POLICY CLARIFICATIONS |
96446, 96549**
**Used to report hyperthermic intraperitoneal chemotherapy
77605 will no longer be payable, effective Oct. 1, 2016 |
Basic benefit and medical policy
Safety, effectiveness of hyperthermic intraperitoneal chemotherapy
The safety and effectiveness of hyperthermic intraperitoneal chemotherapy, or HIPEC, when used in combination with cytoreductive surgery have been established. It may be considered a useful therapeutic option for patients meeting selection criteria.
Exclusionary criteria have been updated, effective Oct. 1, 2016.
Inclusions
The patient must meet all of the following criteria:
- A diagnosis of either pseudomyxoma peritonei or diffuse malignant peritoneal mesothelioma confirmed by the treating physician
- The patient must be able to tolerate the extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy
- Peritoneal disease must be potentially completely resectable or significantly reduced
- There must be no metastases to other organs or to the retroperitoneal space
Exclusions
- A diagnosis of peritoneal carcinomatosis from other forms of gastrointestinal cancer, including colorectal or gastric cancer
- Endometrial cancer or ovarian cancer
- Goblet cell tumors of the appendix
- Metastatic spread to distant organs outside the peritoneal cavity
- Pulmonary, cardiac, renal, hepatic, central nervous system, metabolic or bone marrow dysfunction
- Active viral, bacterial or fungal infections
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J3490, J3590 |
Basic benefit and medical policy
Cinqair® added to Specialty Pharmacy prior authorization program
Cinqair was added to the Specialty Pharmacy prior authorization program effective June 1, 2016, under nonspecific procedure codes J3490 and J3590. |
| GROUP BENEFIT CHANGES |
UAW Retirees of the Budd Company Health and Welfare Trust |
UAW Retirees of the Budd Company Health and Welfare Trust purchased the Union Retiree segments from ThyssenKrupp Budd Company. These former ThyssenKrupp Budd Company employees will be transferred to the new UAW Retirees of the Budd Company Health and Welfare Trust numbers, effective Aug. 1, 2016:
ThyssenKrupp Budd Company group numbers |
New UAW Retirees of the Budd Company Health and Welfare Trust group number |
75200
75230 |
71736 |
The benefits will be the exact same as ThyssenKrupp Budd Company but now under UAW Retirees of the Budd Company Health and Welfare Trust.
The deductibles and other accumulations toward maximums will be carried over (then the accumulations will reset on the first full plan year beginning Jan. 1, 2017).
New ID cards will be generated.
Group number: 71736
Alpha prefixes: BXV – Regular
XYX – Medicare
Platform: NASCO
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