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

NEW PAYABLE PROCEDURES

81226

Additional codes (no changes):
81225

Experimental (some codes may be payable for other conditions):
81227, 81401, 81402, 81404, 81405

Basic benefit and medical policy

CYP450 genotyping

The safety and effectiveness of CYP450 genotyping for the purpose of aiding in the choice of clopidogrel versus alternative antiplatelet agents, or in decisions on the optimal dosing for clopidogrel, have been established. It may be considered a useful diagnostic option for patients who meet specific patient selection criteria. Policy criteria have been updated, effective Jan. 1, 2017.

Payment policy
It’s not payable in an office location. Modifiers 26 and TC don’t apply.

Inclusions:

CYP450 genotyping for the purpose of aiding in the choice of clopidogrel versus alternative anti-platelet agents.
CYP450 genotyping for the purpose of aiding in decisions on the optimal dosing for clopidogrel.
CYP2D6 genotyping to determine drug metabolizer status for patients

With Gaucher disease being considered for treatment with eliglustat, or
With Huntington’s disease being considered for treatment with tetrabenazine in a dosage greater than 50mg per day.

Exclusions:
CYP450 genotyping for the purpose of aiding in the choice of drug or dose to increase efficacy or avoid toxicity for all other drugs. This includes, but is not limited to, CYP450 genotyping for the following applications (list may not be all-inclusive):

Selection or dosing of selective serotonin reuptake inhibitors (SSRI)
Selection or dosing of selective norepinephrine reuptake inhibitors (SNRIs)
Selection or dosing of antipsychotic drugs (e.g., GeneSight^® Psychotropic)
Selection and dosing of tricyclic antidepressants
Selection or dosing of antipsychotic drugs
Selection or dosage of codeine
Selection and dosing of selective norepinephrine reuptake inhibitors including atomoxetine HCL (for treatment of attention deficit hyperactivity disorder)
Dosing of efavirenz and other antiretroviral therapies for HIV (human immunodeficiency virus) infection
Dosing of immunosuppressant for organ transplantation
Selection or dose of beta blockers (e.g., metoprolol)
Dosing and management of antituberculosis medicines

UPDATES TO PAYABLE PROCEDURES

0815

Basic benefit and medical policy

Reimbursement of revenue code 0815

Allow reimbursement of revenue code 0815 when provided in an inpatient hospital (location 1) and outpatient hospital (location 2). Revenue code 0815 will process the same as revenue code 0819.

1111F

Basic benefit and medical policy

Procedure 1111F is payable

Procedure 1111F is changing from non-payable to payable. This was effective Jan. 1, 2017.

Procedure codes: 90460, 90461, 90471, 90472, 90473, 90474, 90653, 90654, 90655, 90656, 90657, 90658, 90661, 90662, 90674, 90682

Revenue codes: 0771, 0636

Basic benefit and medical policy

Revenue codes 0771 and 0636

Allow revenue codes 0771 and 0636 to process and pay in a place of service Y with the procedure codes listed at left.

These revenue code and procedure code combinations don’t get counted toward the member’s hospice benefit. They will process under the member’s medical benefits.

GROUP BENEFIT CHANGES

IBI Group

IBI Group is adding new plans, effective June 1, 2017.

Group number: 71588
Alpha prefix: IBR
Platform: NASCO

Plans offered:
One HSA, PPO medical/surgical
Two PPO, medical/surgical
One prescription

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 2016 American Medical Association. All rights reserved.