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September 2017

New payment model for knee arthroplasty includes prehabilitative services

Blue Cross Blue Shield of Michigan aims to achieve the most favorable outcomes for our members who receive total and partial knee arthroplasty. As more services become available in the ambulatory setting, we’re learning more about which care processes are associated with the best clinical outcomes.

To that end, Blue Cross has implemented a program to enhance payment to surgeons who perform total or partial knee arthroplasty when they:

  1. Participate in the Michigan Arthroplasty Registry Collaborative for Quality Improvement.
    Sites may decide to participate in advance or join at the time of recruitment. Each site identifies a physician champion and that surgeon actively participates and follows MARCQI’s data submission processes. Although no additional payment will be made for completing the MARCQI data abstraction process, our professional reimbursement policy has been adjusted to defray the MARCQI data submission costs.

  2. Implement a Blue Cross-approved prehabilitation program, such as a program employing the X-10 Knee Recovery System. (For more information about the system, visit x10herapy.com.**)

Effective immediately, for both ambulatory and inpatient locations, when the above conditions are met, the surgeon should apply modifier 22 to the surgical code and Blue Cross will increase the allowed amount by 35 percent. At a future time, the policy will be adjusted to focus on ambulatory settings. However, inpatient locations are included during this initial implementation period as we gain knowledge about clinical outcomes.

Physicians who haven’t previously participated in MARCQI but committed to joining at the time of recruitment are eligible. In the future, we’ll add other criteria to qualify for the enhanced fee in support of continued improvements in care and outcomes.

In conjunction with this policy, Blue Cross also has approved a prehabilitation process using the X-10 device and encourages physicians who participate with MARCQI to evaluate whether their patients would benefit from such a program.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

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.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.