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

UPDATES TO PAYABLE PROCEDURES

J3490

Basic benefit and medical policy

Injection kits

Blue Cross Blue Shield of Michigan doesn’t pay for injection kits that encompass a drug, bandages, alcohol swabs and other medical supplies. The appropriate HCPCS code should be billed for the drug. The associated supplies are considered incidental and inclusive in the drug procedure and aren’t eligible for additional separate reimbursement.

POLICY CLARIFICATIONS

90849, H0031, H0032, H2014, H2019, S5108, S5111, 0359T, 0360T, 0361T, 0362T, 0363T 0364T, 0365T, 0366T, 0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0373T, and 0374T

Basic benefit and medical policy

Applied behavior analysis for autism spectrum disorder

The effectiveness of applied behavior analysis in the treatment of autism spectrum disorder has been established. It may be a useful therapeutic option when inclusionary and certificate guidelines are met. This policy was effective Jan. 1, 2017.

Refer to member’s certificate for benefit specific coverage guidelines.

Inclusions:

Full diagnostic criteria for autism spectrum disorder, as published in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual, are met.
The maladaptive behavior must affect the child’s personal safety, the safety of others within the child’s environment or must significantly interfere with the child’s ability to function.
Services must be provided by or supervised by a therapist who is certified by the Behavior Analyst Certification Board.
There is a treatment plan that:

Is child centered
Defines target behaviors
Records objective measures of baseline levels and progress
Identifies and documents specific interventions and techniques
Documents transitional and discharge plans

Exclusions:

People who don’t meet the diagnostic criteria based on the most recent criteria by the American Psychiatric Association (i.e., most current version of the Diagnostic and Statistical Manual).
Therapy delivered by clinicians who are neither certified by the Behavior Analyst Certification Board nor supervised by therapists with this certification
Therapy for people older than 18

EXPERIMENTAL PROCEDURES

15824, 15826

Not covered for this indication:

30130, 30140, 30520, 64716, 64722,

Basic benefit and medical policy

Surgical deactivation of headache trigger sites

The surgical deactivation of headache trigger sites is experimental. It hasn’t been scientifically demonstrated to improve patient clinical outcomes.

This policy was effective Sept. 1, 2017.

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.