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August 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 |
81415, 81416, 81417 |
Basic benefit and medical policy
Genetic testing: Whole exome and whole genome sequencing for diagnosis of genetic disorders
Whole exome sequencing, or WES, may be considered established for the evaluation of unexplained congenital or neurodevelopmental disorders in children when all of the following criteria are met:
- The patient has been evaluated by a specialist with specific expertise in clinical genetics and counseled about the potential risks of genetic testing.
- There is a potential for a change in management and clinical outcome for the individual being tested.
- A genetic etiology is the most likely explanation for the phenotype despite previous genetic testing, such as chromosomal microarray or targeted single gene testing, or when previous genetic testing has failed to yield a diagnosis and the affected individual is faced with invasive procedures and testing as the next diagnostic step, such as muscle biopsy.
WES is considered experimental for the diagnosis of genetic disorders in all other situations.
Whole genome sequencing, or WGS, is considered experimental for the diagnosis of genetic disorders.
WES and WGS are considered experimental for screening for genetic disorders.
These procedures aren’t payable in an ambulatory surgical facility or office location.
This policy was effective March 1, 2017. |
81528 |
Basic benefit and medical policy
Analysis of human DNA in stool samples as a technique for colorectal cancer screening
The safety and effectiveness of DNA analysis of stool samples, using FDA approved tests, may be considered established as a screening technique for colorectal cancer. It may be a useful screening option in select situations.
The performance of Cologuard® meets the recommendation for periodic colon cancer screening for three years.
Inclusions (must meet all of the following requirements):
- Screening of asymptomatic patients (no signs or symptoms of colorectal disease, including, but not limited to, lower gastrointestinal pain, blood in the stools positive guaiac fecal occult blood test or fecal immunochemical test).
- At average risk of colorectal cancer, who have contraindications to colonoscopy or who despite advice to the contrary are unwilling to undergo colonoscopy for screening.
- Repeat studies are appropriate at three-year intervals in individuals who remain at average risk and meet other requirements above.
- Members must be willing to undergo a diagnostic study if the result of the test is positive, as required by FDA.
Exclusions:
The test isn’t indicated in the following (list may not be all inclusive):
- Symptomatic individuals
- Personal history of adenomatous polyps
- Personal history of colorectal cancer
- History of inflammatory bowel disease
- Family history of colorectal cancer or adenomatous polyps in a parent or other first degree relative, particularly when the age of cancer onset is 45 years or less
- Familial adenomatous polyposis
- Lynch syndrome
This policy was effective March 1, 2017.
This procedure isn’t payable in an ambulatory surgical facility or office location. |
81545 |
Basic benefit and medical policy
Genetic testing for FNA of the thyroid
Mutation analysis in fine needle aspirates of the thyroid is considered to be experimental.
The use of the Afirma gene expression classifier in fine needle aspirates of the thyroid that are cytologically considered to be indeterminate (follicular lesion of undetermined significance or follicular neoplasm) may be established in patients who have the following characteristics:
- Thyroid nodules without strong clinical or radiological findings suggestive of malignancy
- In whom surgical decision-making would be affected by test results
Gene expression classifiers in fine needle aspirates of the thyroid not meeting above outlined criteria are considered experimental.
This policy was effective March 1, 2017.
Payment policy
It’s not payable in an office location or ambulatory surgery facility. Modifiers 26 and TC don’t apply. |
81595 |
Basic benefit and medical policy
Laboratory tests for heart transplant rejection
The safety and effectiveness of gene expression profiling (AlloMap®) have been established for the detection of heart transplant rejection. It may be considered a useful therapeutic option when specified criteria have been met.
The breath test (for example, Heartsbreath™) for the evaluation of heart transplant rejection is considered experimental. The effectiveness and clinical utility of this test haven’t been clearly established.
This policy was effective March 1, 2017.
Inclusions:
Gene expression profiling (AlloMap) may be appropriate as a screening technique for heart transplant rejection in recipients who meeting all of the following criteria:
- At least 15 years old
- Six months post-heart transplant and
The recipient must have stable heart allograft function demonstrated by all of the following:
- Left ventricular ejection fraction ≥ 45 percent that has been confirmed by echocardiogram
- No evidence of congestive heart failure
- No evidence of severe cardiac allograft vasculopathy and
The recipient must have a low probability of moderate or severe acute cellular rejection as demonstrated by the following:
- Clinical assessment (for example, International Society for Heart and Lung Transplantation rejection status Grade of 0R or 1R)
- No history or evidence of antibody mediated rejection
Exclusions:
- Gene expression profiling (AlloMap) for any other indication
- Breath testing (e.g., Heartsbreath)
Not payable in an ambulatory surgical facility or office location. |
| UPDATES TO PAYABLE PROCEDURES |
64566 |
Basic benefit and medical policy
Fecal incontinence: Investigational treatments
The below listed therapies for the treatment of fecal incontinence are experimental. They haven’t been scientifically demonstrated to improve patient clinical outcomes better than conventional treatment. This policy was effective May 1, 2017.
- Transanal radiofrequency therapy
- Perianal electrical stimulation
- Posterior tibial nerve stimulation
- Pudendal nerve terminal motor latency measurement
- Injectable bulking agents
- Topical estrogen
- Autologous myoblast cell injections
- Eclipse system
- Transobturator posterior anal sling
- Magnetic anal sphincter device
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82523, 83518, 86294, 86386, 80300, 80301 |
Basic benefit and medical policy
Payable and non-payable labs
The following labs are now payable in a doctor’s office:
The following labs are no longer payable in a doctor’s office:
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| GROUP BENEFIT CHANGES |
IBI Group |
Effective June 1, IBI Group, group number 71588, added the following plans.
Group number: 71588
Alpha prefix: IBR
Platform: NASCO
Plans offered:
HSA, PPO medical/surgical
Two PPO plans medical/surgical
Prescription drug plan |
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