Billing chart: Blues highlight medical, benefit policy changes

81538, 84999

Basic benefit and medical policy

Proteomic testing

The use of proteomic testing such as VeriStrat® to determine the effectiveness of second-line therapy with Erlotinib is established in individuals with nonsmall cell lung cancer and wild type epidermal growth factor receptor or unknown epidermal growth factor receptor status, effective Nov. 1, 2016.

The change doesn’t apply to MPSERS groups.

Payment policy
The procedure requires manual review. Modifiers 26 and TC don’t apply. It’s payable to an M.D., D.O. and independent laboratory.

J9041

Basic benefit and medical policy

Payable diagnosis code

J9041 has an additional payable diagnosis code of
E85.9 Amyloidosis, unspecified.

83516

Basic benefit and medical policy

Codes available in the office setting

Procedure code 83516 has been added to the Physician Office Lab List and is now available in the office setting.

Multiple codes including, but not limited to, the following:

Established: L0450, L0454, L0621, L0625, L0628

Not a covered benefit: A4466

Basic benefit and medical policy

Orthotic devices

The criteria have been updated for the orthotic devices policy, effective Nov. 1, 2016.

The safety and effectiveness of orthotics that are used to protect, restore or improve all or part of an impaired body function, (e.g., braces, collars or supports) have been established. Their safety and effectiveness have been proven.

Inclusions:
Guidelines are generally based on Medicare Part B and Blue Cross Blue Shield of Michigan and Blue Care Network certificate language. Specific certificate language may vary.

The orthotic device must:

•  Be prescribed by a qualified health care provider
•  Require a prescription for purchase from a qualified health care provider
•  Meet the Centers for Medicare & Medicaid definition of an orthotic (essentially that is a rigid or semi-rigid appliance, often referred to as a brace, used for the purpose of supporting or correcting a weak or deformed body part).

Orthotic devices may include, but aren’t limited to:

• Splints for spine, neck and shoulders
• Ankle-foot orthoses and knee-ankle-foot orthoses for extremities
• Shoes designed for attachment to medically appropriate leg braces**
• Substitution of a somewhat different device required by change in medical condition, fit or function
• Thoracic-lumbar-sacral orthosis, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panels, includes shoulder straps and closures, prefabricated
• Thoracic-lumbar-sacral orthosis, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panels, includes shoulder straps and closures, prefabricated
• Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated
• Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated
• Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated

The following information should be included on the prescription:

•  Date of prescription
•  Doctor’s name
•  Diagnosis or reason for need
•  Reason for replacement
•  Description of device being ordered
•  Certificate or documentation of medical necessity

Exclusions:
Orthotic devices and related services that may be excluded include, but aren’t limited to:

•  Arch supports or supportive devices for the feet
•  Dental appliances and bite splints
•  Investigational, experimental or research devices or appliances
•  Items excluded in individual certificates or riders
•  Orthopedic or corrective shoes (except when either one or both are an integral part of a leg brace)**
•  Orthotic devices used for participating in strenuous physical activity beyond normal activities of daily living
•  Repair and replacement made necessary because of loss or damage caused by misuse or mistreatment
•  Thoracic rib belt
•  Knee orthosis, elastic with stays, prefabricated
•  Knee orthosis, elastic or other elastic type material, with condylar pads, prefabricated
•  Knee orthosis, elastic knee cap, prefabricated
•  Ankle orthosis, elastic, prefabricated
•  Shoulder orthosis, single shoulder, elastic, prefabricated
•  Shoulder orthosis, double shoulder, elastic, prefabricated
•  Elbow orthosis, elastic with stays, prefabricated
•  Elbow orthosis, elastic, prefabricated
•  Wrist orthosis, elastic, prefabricated
•  Wrist hand finger orthosis, elastic, prefabricated

**BCN only. For Blue Cross members, see the Blue Cross policy on orthopedic footwear.

Specific riders may apply and override exclusions.

Note: Check individual contract and certificate language regarding repair, replacement or adjustment of medically appropriate devices that is necessitated by wear, damage or medical condition changes.

Payment policy
Procedure code A4466 was deleted, effective Jan. 1, 2017.

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 procedure codes 90660 or 90672 based on Centers for Disease Control and Prevention recommendations.