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July 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
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| NEW PAYABLE PROCEDURES |
G6017 |
Basic benefit and medical policy
G6017 payable for all groups
G6017 is payable for all groups, effective Jan. 1, 2015.
Payment policy
It’s payable as a professional service only. Modifiers 26 and TC don’t apply. |
| UPDATES TO PAYABLE PROCEDURES |
21120-21123, 21141, 21196, 21198, 21199, 42140, 42145
Not covered:
41512, 41539, 42299, S2080, 0466T- 0468T |
Basic benefit and medical policy
Treatment of clinically significant obstructive sleep apnea
Certain surgical procedures have been established as safe and effective for the treatment of clinically significant obstructive sleep apnea when conservative therapies or continuous positive airway pressure therapy alone has failed. The choice of the procedure should be tailored to the patient’s need based on anatomy and etiology.
Inclusionary and exclusionary criteria have been updated, effective July 1, 2017.
Inclusions:
- Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty, uvulopalatal flap, expansion sphincter pharyngoplasty, lateral pharyngoplasty, palatal advancement pharyngoplasty, relocation pharyngoplasty) for the treatment of clinically significant** obstructive sleep apnea syndrome in adult patients who haven’t responded to or don’t tolerate continuous positive airway pressure
- Hyoid suspension, surgical modification of the tongue or maxillofacial surgery, including mandibular-maxillary advancement in adult patients with clinically significant** OSA and objective documentation of hypopharyngeal obstruction who haven’t responded to or don’t tolerate CPAP
- Adenotonsillectomy in pediatric patients with OSA and hypertrophic tonsils, and one of the following:
- Apnea hypopnea index or respiratory disturbance index of at least five per hour
- AHI or RDI of at least 1.5 per hour in a patient with excessive daytime sleepiness, behavioral problems or hyperactivity
**Clinically significant obstructive sleep apnea is defined as failure of conservative treatments for sleep apnea, such as weight loss, modification of the patient's sleep position, medications to relieve nasal obstruction and avoidance of evening alcohol and hypnotics, use of CPAP or oral appliances and polysomnography with one of the following:
- AHI or RDI greater than or equal to 15 events per hour
- AHI or RDI greater than or equal to five events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke
Exclusions:
- Implantable hypoglossal nerve stimulators
- Laser-assisted palatoplasty
- Midline glossectomy
- Palatal stiffening procedures, such as Cautery-assisted and injection snoreplasty
- Palatal implants
- Radiofrequency volumetric tissue reduction of the tongue
- Radiofrequency reduction of the palatal tissues (i.e., somnoplasty)
- Tongue-base suspension (i.e., Repose system)
- All other minimally invasive surgical procedures not described above
- All interventions for the treatment of snoring in the absence of documented OSA
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Established:
78072
Not established:
78999 |
Basic benefit and medical policy
SPECT/CT fusion imaging
The safety and effectiveness of SPECT/CT fusion imaging have been established. It’s a useful diagnostic option when used in the evaluation of the parathyroid glands in individuals with primary hyperparathyroidism when used for anatomic localization before parathyroid surgery when ultrasound examination is negative.
This policy is effective July 1, 2017.
Inclusions:
For the evaluation of the parathyroid glands in individuals with primary hyperparathyroidism when used for anatomic localization before parathyroid surgery when ultrasound examination is negative or inconclusive.
Exclusions:
SPECT/CT fusion imaging for any other condition than listed above. |
Established:
81401, 81405, 81406
Non-established:
S3852 |
Basic benefit and medical policy
Genetic testing for Alzheimer disease
The criteria have been updated for the genetic testing for Alzheimer disease policy. This policy is effective July 1, 2017.
Genetic testing for a known familial variant in the presenilin genes or amyloid-beta precursor protein gene associated with autosomal dominant early-onset Alzheimer disease in an asymptomatic individual to determine future risk of disease is established for individuals who meet patient selection criteria and who are seeking preconception genetic counseling.
Genetic testing for variants in the presenilin genes or amyloid-beta precursor protein gene associated with autosomal dominant Alzheimer disease in an asymptomatic individual to determine future risk of disease is established for individuals who meet patient selection criteria and who are seeking preconception genetic counseling.
Genetic testing for confirming a diagnosis of Alzheimer’s disease or determining the risk assessment of developing Alzheimer’s disease when family planning isn’t an issue is considered experimental.
Inclusions:
- Targeted genetic testing for known familial variant in the presenilin genes or amyloid-beta precursor protein gene associated with autosomal dominant early-onset Alzheimer disease is established when all the following criteria are met:
- The individual has a close relative (i.e., first- or second-degree relative) with a known familial variant associated with autosomal dominant early-onset Alzheimer disease.
- Results of testing will inform reproductive decision-making.
- Genetic testing for variants in presenilin genes or amyloid-beta precursor protein gene associated with autosomal dominant Alzheimer disease is established in an asymptomatic individual to determine future risk of disease when the following criteria are met:
- The individual has a family history of dementia consistent with autosomal dominant Alzheimer disease for whom the genetic status of the affected family members is unavailable.
- Results of testing will inform reproductive decision-making.
Genetic counseling by appropriately trained individuals is strongly encouraged to be done in conjunction with the genetic testing for Alzheimer’s disease when the above criteria are met.
Exclusions:
Genetic testing for the risk assessment of Alzheimer disease in asymptomatic individuals is considered experimental in all other situations. Genetic testing includes, but isn’t limited to, testing for the apolipoprotein E ε4 allele or triggering receptor expressed on myeloid cells 2. |
97124 |
Basic benefit and medical policy
Therapeutic massage
The criteria have been updated for the therapeutic massage policy. This policy was effective May 1, 2017
The safety and effectiveness of manual therapeutic massage, code *97124, as part of an overall physical therapy treatment plan has been established. It may be considered established and medically necessary when the following criteria are met:
- It’s provided as part of a formal course of physical therapy in addition to other therapeutic interventions on the same date of service.
- Massage therapy is provided in the early, acute phase of therapy of a musculoskeletal problem and is generally limited to two weeks of treatment.
- Massage therapy alone, either as a one-time service or as a series of massages over time, isn’t a covered benefit.
- All Blue Cross Blue Shield of Michigan requirements related to the identification and qualifications of approved providers of physical therapy, apply to the providers of massage therapy.
- Blue Cross rules regarding orders and documentation of rehabilitation services apply to the provision of massage therapy.
- All Blue Cross rules and requirements related to “incident to” billing for physical therapy apply.
Blue Cross reimburses providers for physical therapy services “incident to” physician or nonphysician practitioner services in the outpatient setting when such services are performed by the physician, nurse practitioner or a licensed physical therapist.
Physicians, nurse practitioners, independent physical therapists, OPT facilities and outpatient hospitals can bill for the services of physical therapy assistants and athletic trainers when such services are directly supervised by a licensed physical therapist.
As of Aug. 1, 2015, chiropractors may perform massage therapy when provided as part of a complete physical therapy plan. They aren’t allowed to supervise other provider types in the performance of therapeutic massage.
No provider type can supervise therapeutic massage (procedure code *97124) or delegate therapeutic massage to any individual not eligible to perform therapeutic massage including, but not limited to, massage therapists, therapy aides, exercise physiologists or kinesiotherapists. Medically necessary therapeutic massage may be delivered by participating providers, when such massage is within their scope of practice.
This rule applies to all provider types. Self-insured groups may elect a different benefit design that isn’t consistent with these rules. |
J1439 |
Basic benefit and medical policy
J1439 is now payable for the following additional diagnosis:
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Modifiers Q5 and Q6 |
Basic benefit and medical policy
Locum tenens
The Q5 modifier has been added to the locum tenens reimbursement policy. This policy is effective July 1, 2017.
Blue Cross Blue Shield of Michigan will allow services provided by locum tenens physicians to be billed under the PIN of the regular physician for up to 60 continuous days.
If a locum tenens physician is treating Blue Cross PPO members for longer than 60 continuous days, he or she must register with Blue Cross and bill under his or her own PIN. If the locum tenens physician is treating PPO patients for longer than 60 continuous days, he or she must be credentialed in the TRUST network or out-of-network sanctions will be applied to claims. Physicians who expect to provide locum tenens services on a regular basis involving multiple practices (>2) within a 12 month period should be credentialed in the TRUST network.
Each covered clinical service (procedure code) delivered by the locum tenens physician under the regular physician’s PIN must be appended with either modifier Q5 or Q6.
Locum tenens physicians must be licensed in the state in which the service are delivered and must only provide services within their scope of practice.
The regular physician will pay the locum tenens physician a per diem or reciprocal billing arrangement and the locum tenens physician won’t bill Blue Cross for the services independently.
When a physician leaves a group, the locum tenens physician’s services may be billed using either the replaced physician’s PIN or the group PIN for up to 60 days.
This policy applies to the following provider classes only:
- M.D.
- D.O.
- D.C.
- D.P.M.
- Physical therapist
Additional comments:
This policy applies when the regular physician isn’t available. The locum tenens physician isn’t a physician extender and therefore should see patients in place of, not along with, the regular physician.
Documentation addressing contractual arrangements, licensure and malpractice insurance should be maintained and available if requested.
A record of all clinical services provided by the locum tenens physician must be maintained and available if requested. |
| POLICY CLARIFICATIONS |
Established:
22558, 22585, 22845, 22899**
**When used for PLIF and TLIF
Not established:
0195T, 0196T, 0309T, 22586, 22899***
***When used for OLLIF |
Basic benefit and medical policy
Minimally invasive lumbar interbody fusion policy
The criteria have been updated for the minimally invasive lumbar interbody fusion policy. This policy is effective July 1, 2017.
The safety and effectiveness of specific minimally invasive interbody fusions of the lumbar spine have been established. They are considered useful therapeutic options for carefully selected patients who would otherwise be eligible for a conventional spinal fusion procedure.
Inclusions:
The following minimally invasive lumbar interbody fusion techniques are considered established:
- Anterior lumbar interbody fusion
- Posterior lumbar interbody fusion
- Transforaminal lumbar interbody fusion
- Minimally invasive lateral lumbar interbody fusions (e.g., XLIF, DLIF)
Exclusions:
The following minimally invasive lumbar interbody fusion techniques are considered experimental:
- Laparoscopic ALIF lumbar interbody fusion
- Axial anterior lumbar interbody fusion
- Oblique lateral lumbar interbody fusion
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90901 |
Basic benefit and medical policy
Biofeedback
The safety and effectiveness of biofeedback have been established for the treatment of stress and urge urinary incontinence in adults and children, treatment of fecal incontinence and chronic constipation in adults, and treatment of migraine and tension-type headache. It may be considered a useful therapeutic option in specified situations.
Biofeedback isn’t an established therapy for any other indications. While this service may be safe, its effectiveness in other clinical indications hasn’t been scientifically determined.
Inclusionary and exclusionary criteria have been
updated, effective July 1, 2017.
Inclusions:
- The treatment of stress or urge urinary incontinence in cognitively intact adults who have failed a documented trial of pelvic muscle exercise training. A failed trial of PME training is defined as no clinically significant improvement in urinary incontinence after completing four weeks of an ordered plan of pelvic muscle exercises to increase periurethral muscle strength.
- For children with daytime urinary dysfunction when the child meets the following criteria:
- Ages 4 years or older
- Neurologic, anatomic, infectious or functional causes have been ruled out
- Able to comprehend and follow verbal instructions
- Biofeedback for fecal incontinence or constipation is indicated for those who are motivated and mentally capable. Patients must have some degree of rectal sensation and be able to contract the external anal sphincter.
- Biofeedback for migraine and tension-type headache when used as part of the overall treatment plan.
Exclusions:
- Cluster headaches
- Chronic pain
- Hypertension
- Stroke
- All other conditions not noted in the inclusions
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96446, 96549 |
Basic benefit and medical policy
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 patient selection criteria. Exclusionary criteria have been updated, effective July 1, 2017.
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
Note: This policy doesn’t address gastric cancer. |
A0430, A0431, A0435, A0436
Non-covered procedures:
A0420, S9960, S9961 |
Basic benefit and medical policy
Air ambulance services
The safety and effectiveness of air ambulance services have been established. These services are medically necessary when it’s determined by the attending or ordering physician that the transported patient’s condition requires air ambulance transport and that any alternative form of transport such as ground ambulance or commercial transport would be clinically inappropriate.
Transport by fixed wing or rotary wing transport may also be required when the patient requiring transport is physically “inaccessible” by ground ambulance.
Air ambulance services for deceased members may be considered appropriate if the patient is pronounced dead after the ambulance is called but before liftoff or pickup has occurred.
The policy clarifications of the coverage guidelines are effective July 1, 2017.
Inclusions:
(Must meet all)
- Clinical condition must support medical necessity and need for air transport.
- Transport by commercial or ground ambulance is clinically inappropriate.
- Ground ambulance transport may be appropriate but patient is physically inaccessible.
- Transport is directed to nearest facility capable of providing necessary care or to a capable facility within a 25-mile radius of the nearest facility.**
**Transport beyond the 25-mile radius may be reviewed based on the patient’s case management needs at the discretion of Blue Cross Blue Shield of Michigan and Blue Care Network.
Exclusions:
- Patients with contracts or certificates specifically excluding coverage for air ambulance.
- Patients who are pronounced dead before the ambulance is called.
- Transport where the patient’s clinical condition doesn’t require air ambulance transport.
- Transport by an entity that isn’t licensed to provide air ambulance services (i.e., commercial airlines).
- Transport provided by fire departments, rescue squads or other emergency transport providers whose fees are in the form of donations.
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| EXPERIMENTAL PROCEDURES |
90587 |
Basic benefit and medical policy
Dengue vaccine, quadrivalent, live, 3-dose schedule
Dengue vaccine, quadrivalent, live, 3-dose schedule, for subcutaneous use is experimental. The Food and Drug Administration hasn’t approved the vaccine for use in the United States. This policy is effective July 1, 2017. |
| GROUP BENEFIT CHANGES |
Dart Container of Michigan |
Dart Container of Michigan LLC, group number 71750, will join Blue Cross Blue Shield of Michigan, effective Sept. 1, 2017.
Group number: 71750
Alpha prefix: PPO (EOV)
Platform: NASCO
Plan offered:
PPO, medical/surgical |
Tower International |
Effective July 1, 2017, Tower International is offering some of its members a Reference Based Benefits feature called the Fair Price Program. Member liability information will be available on web-DENIS. See the June 2017 issue of The Record for more details about Tower International and RBB.
Group number: 71379
Alpha prefix: TOV |
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