The Record - Blues highlight medical, benefit policy changes

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:

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

J3490

Basic benefit and medical policy

Akovaz covered for approved indication

The FDA-approved Akovaz is covered under NOC J3490 for its approved indication. Akovaz is approved for hypotension in surgical setting. This policy was effective May 4, 2016.

00635, 01936, 01991, 00520, 00740, 00810, 96373, 96374

Basic benefit and medical policy

Use of monitored anesthesia care

The monitored anesthesia care for endoscopic, surgical and other diagnostic and therapeutic procedures policy is established. This policy was effective Sept. 1, 2016.

Medical policy statement
Use of monitored anesthesia care may be considered established for gastrointestinal endoscopy procedures when there is documentation by the proceduralist or anesthesiologist that specific risk factors or significant medical conditions are present supporting the opinion that the procedure can’t be done successfully or safely in the absence of monitored anesthesia care.

Inclusions:

Monitored anesthesia care is considered medically necessary for patients with risk factors or significant medical conditions that increase the risk of sedation, including any of the following:

Increased risk for complications due to severe comorbidity (ASA P3* or greater)
Morbid obesity (body mass index greater than 40)
Documented sleep apnea
Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment)
Spasticity or movement disorder complicating procedure
History or anticipated intolerance to standard sedatives, such as:

Chronic opioid use
Chronic benzodiazepine use

Patients with active medical problems related to drug or alcohol abuse
Patients younger than age 12 or age 70 or older
Patients who are pregnant
Patients with increased risk for airway obstruction due to anatomic variation, such as:

History of stridor
Dysmorphic facial features
Oral abnormalities (e.g., macroglossia)
Neck abnormalities (e.g., neck mass)
Jaw abnormalities (e.g., micrognathia)

Acutely agitated, uncooperative patients
Prolonged or therapeutic gastrointestinal endoscopy procedures requiring deep sedation (e.g., endoscopic retrograde cholangiopancreatography, transduodenal biopsy, double balloon enteroscopy).

Exclusions:

Monitored anesthesia care is considered not medically necessary for gastrointestinal endoscopic, bronchoscopic or interventional pain procedures in patients at average risk for anesthesia and sedation.

POLICY CLARIFICATIONS

81206, 81207, 81208, 81170, 81401

Basic benefit and medical policy

Genetic testing for BCR/ABL1

The safety and effectiveness of genetic testing for BCR/ABL1 in patients with chronic myelogenous leukemia and acute lymphoblastic leukemia have been established. It may be considered a useful tool when indicated, effective Sept. 1, 2016.

GROUP BENEFIT CHANGES

Amcor

Amcor, group number 71737, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2017.

Group number: 71737
Alpha prefixes: PPO (KOR)
Platform: NASCO

Plans offered:
PPO, medical/surgical
Hearing
CDH – HSA and FSA

Irvin Automotive Inc.

Irvin Automotive Inc., group number 71739, will join Blue Cross Blue Shield of Michigan, effective Oct. 1, 2016.

Group number: 71739
Alpha prefixes: PPO (IAE)
Platform: NASCO

Plans offered:
PPO, medical/surgical
Dental
Prescription drugs

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.