|
January 2017
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
|
| NEW PAYABLE PROCEDURES |
J3490 |
Basic benefit and medical policy
Sustol payable for FDA-approved indications
Effective Aug. 9, 2016, Sustol (granisetron) is payable for its U.S. Food and Drug Administration-approved indications. Sustol (granisetron) is indicated for use in combination with other antiemetics in adults for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic chemotherapy or anthracycline and cyclophosphamide combination chemotherapy regimens. Report procedure code J3490 for Sustol (granisetron). |
J7199 |
Basic benefit and medical policy
Afstyla antihemophilic Factor VIII (recombinant)
Effective May 26, 2016, Afstyla antihemophilic Factor VIII (recombinant) single chain is covered for its FDA-approved indication of hemophilia. Afstyla antihemophilic Factor VIII (recombinant) single chain should be reported with NOC code J7199, until a permanent code is established. Pharmacy doesn’t require preauthorization for this drug. |
| UPDATES TO PAYABLE PROCEDURES |
A4634, E0203 |
Basic benefit and medical policy
Therapeutic light box for the treatment of major depression with seasonal pattern
The criteria have been clarified for the therapeutic light box for the treatment of major depression with seasonal pattern policy. This policy was effective Nov. 1, 2016.
Light therapy using specialized delivery devices hasn’t been proven to be more effective in the peer-reviewed literature than natural light or conventional artificial light sources.
Light boxes aren’t a U.S. Food and Drug Administration-approved method for the treatment of major depression with seasonal pattern, and they don’t meet the requirements for durable medical equipment. Therefore, the therapeutic light box isn’t a covered benefit. |
59100, 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866 |
Basic benefit and medical policy
Pregnancy terminations — medical and surgical
The criteria have been updated for the pregnancy Terminations — medical and surgical policy. This policy is effective Jan. 1, 2017.
Pregnancy termination is considered an established procedure when accepted medical practice guidelines are met.
Coverage of elective abortions, both medically and surgically induced, is considered an exclusion unless the benefit is offered through an optional rider.
Inclusions:
- Confirmation of pregnancy must be documented.
- Gestational age must be verified.
- All legal requirements have been fulfilled. (For example, documents required by current Michigan law must be provided to the woman seeking an abortion at least 24 hours before the abortion procedure.)
- The patient must be instructed about the importance of follow-up within 14 days to confirm the abortion is complete.
- Provider must include information regarding emergency contacts on a 24-hour basis in case of complications such as heavy bleeding, pain, infection.
The administration of medications to induce abortion must follow specific guidelines set by the National Abortion Federation (the professional association of abortion providers in the United States and Canada).
Combined mifepristone-misoprostol regimens are more effective than misoprostol alone or methotrexate and misoprostol. Where mifepristone is available, a combined mifepristone-misoprostol regimen should be used.
- When mifepristone and vaginal, buccal, or sublingual misoprostol are used, the regimen is recommended for gestations up to 70 days.
- When mifepristone and oral misoprostol are used, the regimen is recommended for gestations up to 56 days.
- A regimen of misoprostol alone may be used by vaginal, buccal or sublingual routes for gestations up to 63 days.
- When methotrexate and vaginal, buccal or sublingual misoprostol are used, the regimen is recommended for gestations up to 63 days.
Contraindications for Mifeprex® used in medical abortions:
- Confirmed or suspected ectopic pregnancy
- Undiagnosed adnexal mass
- Chronic adrenal failure
- Concurrent long-term corticosteroid therapy
- History of allergy to mifepristone, misoprostol or other prostaglandins
- Hemorrhagic disorders or concurrent anticoagulant therapy
- Inherited porphyria
- Intrauterine device in place
|
90875, 90876, 90901 |
Basic benefit and medical policy
Neurofeedback
The criteria have been updated for the Neurofeedback policy. This policy is effective Jan. 1, 2017.
Neurofeedback training as an alternative therapy for individuals with attention deficit hyperactivity disorder has been established. It may be a useful treatment option when indicated.
Neurofeedback training for other central nervous system disorders, such as autism spectrum disorder, substance abuse, epilepsy and insomnia, is experimental. There is a lack of evidence in the peer reviewed published medical literature on the clinical utility and effectiveness of neurofeedback for these conditions.
Inclusions:
The patient has a DSM-V diagnosis of ADHD rendered within the past 12 months before initiation of neurofeedback therapy that is confirmed by a practitioner independent of the neurofeedback provider, using evidenced-based tools and scales to support the diagnosis and assessment. Traditionally, a definitive diagnosis of ADHD is rendered by a mental health professional. However, an independent diagnosis may also be rendered by clinicians in other specialties, including primary care doctors as long as their medical records fully support the diagnosis and that the diagnosis was made using a validated, standardized tool such as the Vanderbilt, Connors or similar established tool in conjunction with a DSM-V (or most currently published edition) based interview.
Traditionally, patients receive between 20 to 40 sessions of neurofeedback training. The medical record should support the clinical need for additional sessions over 40 and should demonstrate ongoing benefit and progress to goals.
Exclusions:
Neurofeedback training or therapy for all other diagnoses, including, but not limited to, other mental health disorders. |
93784, 93786, 93788, 93790 |
Basic benefit and medical policy
Ambulatory blood pressure monitoring for screening and diagnosis of hypertension
The ambulatory blood pressure monitoring for screening and diagnosis of hypertension policy has been updated. This policy was effective Nov. 1, 2016.
Ambulatory blood pressure monitoring is established as safe and effective and is a useful option when performed for the screening, diagnosis and management of hypertension, when indicated.
Inclusions and exclusions
Ambulatory blood pressure monitoring is established in either of the following circumstances:
- To screen for the presence of hypertension in pediatric and adult patients consistent with nationally accepted protocols (e.g., USPSTF)
- To confirm the diagnosis of hypertension before initiating pharmacotherapy, when the diagnosis is uncertain
- When the information obtained by ambulatory blood pressure monitoring is necessary to determine the adequacy of antihypertensive management
Ambulatory blood pressure monitoring should be used to support clinical decision-making. Ambulatory blood pressure monitoring isn’t medically necessary if clinical decision-making can be accomplished with the use of traditional methods of blood pressure measurement alone. The medical record should reflect the need and rationale for use of ambulatory blood pressure monitoring. |
| POLICY CLARIFICATIONS |
90660, 90672 |
Basic benefit and medical policy
No longer reimbursing 90660, 90672
Effective Oct. 1, 2016, Blue Cross Blue Shield of Michigan won’t reimburse procedures 90660 or 90672 based on Centers for Disease Control and Prevention recommendations. |
| EXPERIMENTAL PROCEDURES |
0075T, 0076T |
Basic benefit and medical policy
Endovascular therapy experimental in management of extracranial vertebral artery disease
Endovascular therapy, including percutaneous transluminal angioplasty with or without stenting, is considered experimental in the management of extracranial vertebral artery disease. The evidence is insufficient to determine whether endovascular therapy for extracranial vertebral artery stenosis, dissections, aneurysms and arteriovenous fistulae improves health outcomes. This policy was effective Oct. 1, 2016. |
22899**
** Not otherwise classified procedure used to report service |
Basic benefit and medical policy
Vertebral body tethering, vertebral body stapling experimental
Vertebral body tethering and vertebral body stapling are considered experimental. The safety and effectiveness of these procedures have not been proved. This policy is effective Jan. 1, 2017. |
| GROUP BENEFIT CHANGES |
Acument |
Acument is adding new plans, effective Jan. 1, 2017.
Group number: 75441
Alpha prefix: PPO (UMT)
Platform: NASCO
Plans offered:
Two HSA
PPO medical/surgical
Three prescription plans |
Cloyes Gear & Products Inc. |
Cloyes Gear & Products Inc., group number 71747, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2017.
Group number: 71747
Alpha prefix: PPO (NUO)
Platform: NASCO
Plans offered:
PPO, medical/surgical
CDH-HDHP HSA |
Grede Holdings LLC |
Grede Holdings LLC, group number 71743, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2017.
Group number: 71743
Alpha prefix: PPO (NUO)
Platform: NASCO
Plans offered:
PPO, medical/surgical
Prescription drugs (Illinois segment) |
Hephaestus Holdings, Inc. |
Hephaestus Holdings Inc., group number 71343, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2017.
Group number: 71343
Alpha prefix: PPO (NUO)
Platform: NASCO
Plans offered:
PPO, medical/surgical
CDH-HDHP HSA |
Metaldyne Performance Group (formerly Metaldyne, LLC) |
Metaldyne Performance Group, group number 71473, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2017.
Group number: 71473
Alpha prefix: PPO (NUO)
Platform: NASCO
Plans offered:
PPO, medical/surgical
CDH-HDHP HSA |
|
