The Record - Billing chart: 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

81445, 0018U, 0026U (effective Sept. 1, 2018)

81545 (effective March 1, 2017)

81479**

**When reported for an Afirma^® test

Not covered:

81479***

***When reported for RosettaGX Reveal^® test

Basic benefit and medical policy

Genetic testing: Molecular markers in fine needles aspirates of the thyroid

The use of either Afirma gene expression classifier or ThyroSeq v3 in fine needle aspirates of thyroid nodules with indeterminate cytologic findings (i.e., Bethesda diagnostic Category III [atypia/follicular lesion of undetermined significance] or Bethesda diagnostic Category IV [follicular neoplasm/suspicion for a follicular neoplasm]) established in patients who have the following characteristics:

Thyroid nodules without strong clinical or radiologic findings suggestive of malignancy.
In whom surgical decision-making would be affected by test results.

The use of any of the following types of molecular marker testing or gene variant analysis in fine needle aspirates of thyroid nodules with indeterminate findings (Bethesda diagnostic Category III [atypia/follicular lesion of undetermined significance] or Bethesda diagnostic Category IV [follicular neoplasm/suspicion for a follicular neoplasm]) or suspicious findings (Bethesda diagnostic Category V [suspicious for malignancy]) to rule in malignancy to guide surgical planning for initial resection rather than a two-stage surgical biopsy followed by definitive surgery may be considered established:

ThyroSeq v3
ThyraMIR microRNA/ThyGenX
Afirma BRAF after Afirma gene expression classifier
Afirma MTC after Afirma gene expression classifier

Gene expression classifiers, genetic variant analysis and molecular marker testing in fine needle aspirates of the thyroid not meeting criteria outlined above, including but not limited to use of RosettaGX Reveal, are considered experimental.

The policy updates are effective Sept. 1, 2018.

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

J9039

Basic benefit and medical policy

Blincyto (blinatumomab)

Effective March 29, 2018, Blincyto (blinatumomab) is covered for the following FDA-approved indications:

Blincyto is a bispecific CD19-directed CD3 T-cell engager indicated for the treatment of adults and children with:

B-cell precursor acute lymphoblastic leukemia in first or second complete remission with minimal residual disease greater than or equal to 0.1 percent. This indication is approved under accelerated approval based on MRD response rate and hematological relapse-free survival. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.
Relapsed or refractory B-cell precursor acute lymphoblastic leukemia.

The NDC is 55513-160-01.

POLICY CLARIFICATIONS

90672

Basic benefit and medical policy

FluMist

FluMist^®, procedure code 90672, is payable, effective Sept. 1, 2018.

This change is being implemented to accommodate the Advisory Committee on Immunization Practices’ decision to recommend use of this vaccine for the 2018-19 season. Following are the payable professional providers:

M.D. and D.O.
Certified nurse practitioner
Physician assistant
Certified nurse midwife
Urgent care center
Specialty pharmacy
Retail health centers
Retail based pharmacy
All other retail pharmacies

It’s also payable in a hospice facility setting.

J0887, J0888

Basic benefit and medical policy

Micera

Effective June 7, 2018, Micera is approved for the treatment of anemia associated with chronic kidney disease in adult patients who are currently on dialysis or aren’t on dialysis. It’s also approved for pediatric patients, ages 5 to 17, on hemodialysis who are converting from another erythropoiesis-stimulating agent after their hemoglobin level was stabilized with an ESA.

J3490, J8499, C9399

Basic benefit and medical policy

Macrilen (macimorelin)

Effective July 23, 2018, Macrilen™ (macimorelin) is
covered for the following FDA-approved indications:

Macrilen (macimorelin) for oral solution is a growth hormone secretagogue receptor agonist indicated for the diagnosis of adult growth hormone deficiency.

Recommended dose is 0.5 mg/kg as a single oral dose, after fasting for at least eight hours.

Discontinue therapy with strong CYP3A4 inducers, growth hormones and drugs that affect GH release for an adequate length of time before administering Macrilen (macimorelin).

Adequately replace other hormone deficiencies before administering Macrilen (macimorelin).

Limitations of use:
The safety and diagnostic performance hasn’t been established for subjects with body mass index >40kg/m2.

Pharmacy doesn’t require preauthorization of this drug.

Macrilen (macimorelin) isn’t a benefit for URMBT.

GROUP BENEFIT CHANGES

Android Industries

Android Industries, group number 71778, is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2019.

Group number: 71778
Alpha prefix: PPO (VWV)
Platform: NASCO Flexlink

Plans offered:
PPO, medical/surgical
Prescription drugs

Avancez LLC

Avancez LLC, group number 71779, is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2019.

Group number: 71779
Alpha prefix: PPO (VWZ)
Platform: NASCO Flexlink

Plans offered:
PPO, medical/surgical
Prescription drugs

Edw. C. Levy

Edw. C. Levy, group number 71777, is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2019.

Group number: 71777
Alpha prefix: PPO (VWU)
Platform: NASCO Flexlink

Plans offered:
PPO, medical/surgical
Prescription drugs

McNaughton McKay Electric Company

McNaughton McKay Electric Company, group number 71380, is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2019.

Group number: 71380
Alpha prefixes: PPO (KYA), CMM (KYK)
Platform: NASCO hybrid

Plans offered:
PPO, medical/surgical
Prescription drugs
CDH — HSA

MidMichigan Health

MidMichigan Health, group number 71776, is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2019.

Group number: 71776
Alpha prefix: PPO (VYJ)
Platform: NASCO Flexlink

Plans offered:
PPO, medical/surgical
CDH — HSA

Note: All provider requests for prior authorizations should be directed to ConnectCare at 989-839-1629 or 1-888-646-2429.

Tower International Inc.

Effective Jan. 1, 2019, Tower International Inc., group number 71379, is adding new PPO plans with an HSA. Reference Based Benefits (called the Fair Price Program) will be applied to the following package codes:

Tower International is also removing imaging services from its Reference Based Benefits program, effective Jan. 1, 2019.

Trinity Health

Trinity Health, group number 71349, BCN (Grand Rapids) membership is moving to Blue Cross Blue Shield of Michigan PPO, effective Jan. 1, 2019.

Group number: 71349
Alpha prefix: TIY (Michigan members)
Platform: NASCO

Plans offered:
Triple-tier PPO

TI Group Automotive LLC

TI Group Automotive LLC, group number 71780, is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2019.

Group number: 71780
Alpha prefixes: PPO (ZIO), CMM (ZOO)
Platform: NASCO hybrid

Plans offered:
PPO, medical/surgical
Dental
CDH — HSA

Veoneer US Inc.

Veoneer US Inc., group number 71781, is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2019.

Group number: 71781
Alpha prefix: PPO (ZRR)
Platform: NASCO hybrid

Plans offered:
PPO, medical/surgical
Prescription drug
Vision
CDH — HSA

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 2017 American Medical Association. All rights reserved.