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

NEW PAYABLE PROCEDURES

0398T, 76999**

**Requires individual consideration

Experimental:
0071T, 0072T

Basic benefit and medical policy

Magnetic resonance-guided high-intensity ultrasound ablation

The safety and effectiveness of magnetic resonance-guided high-intensity ultrasound ablation have been established. It may be a considered a useful therapeutic option in specified situations. Inclusionary criteria have been updated, effective March 1, 2020.

Payment policy:

Payable to an M.D. or D.O. as a professional service only. Modifiers 26 and TC don’t apply.

Inclusions:

Pain palliation in adult patients with metastatic bone cancer who fail or aren’t candidates for radiotherapy
Treatment of medicine-refractory essential tremors (e.g., a failure, intolerance or contraindication to at least two trials of medication therapy)

Exclusions:

All other situations including but not limited to:

Treatment of uterine fibroids
Treatment of other tumors (e.g., brain cancer, prostate cancer, breast cancer, desmoid)

UPDATES TO PAYABLE PROCEDURES

J0586

Basic benefit and medical policy

Dysport (abobotulinumtoxinA)

Effective Sept. 25, 2019, Dysport (abobotulinumtoxinA) is payable for additional diagnoses M62.830, M62.831 and M62.838.

J3490
J3590

Basic benefit and medical policy

Sarclisa (isatuximab-irfc)

Sarclisa (isatuximab-irfc) is payable when billed for the FDA-approved indications, effective March 1, 2020. Sarclisa (isatuximab-irfc) should be reported with procedure code J3490 or J3590 and the appropriate national drug code until a permanent code is established.

URMBT groups are excluded from coverage of this drug.

Sarclisa (isatuximab-irfc) is a CD38-directed cytolytic antibody indicated, in combination with pomalidomide and dexamethasone, for the treatment of adult patients with multiple myeloma who have received at least two prior therapies including lenalidomide and a proteasome inhibitor.

Dosage and administration:

Premedicate with dexamethasone, acetaminophen, H2 antagonists and diphenhydramine.

The recommended dose of Sarclisa (isatuximab-irfc) is 10 mg/kg as an intravenous infusion every week for four weeks followed by every two weeks in combination with pomalidomide and dexamethasone until disease progression or unacceptable.

J9145

Basic benefit and medical policy

Darzalex

Darzalex, procedure code J9145, is payable for the new FDA-approved indications, effective Sept. 26, 2019. Indications have been updated to include treatment of multiple myeloma in combination with bortezomib, melphalan and prednisone in newly diagnosed patients who are ineligible for autologous stem cell transplant and in combination with lenalidomide and dexamethasone in newly diagnosed patients who are ineligible for autologous stem cell transplant.

J9022

Basic benefit and medical policy

Tecentriq (atezolizumab)

Tecentriq (atezolizumab), procedure code J9022, is payable for the new FDA-approved indications, effective Dec. 3, 2019. The indications have been updated to include treatment of non-small cell lung cancer in combination with paclitaxel protein-bound and carboplatin for the first-line treatment of adult patients with metastatic non-squamous NSCLC with no EGFR or ALK genomic tumor aberrations.

Q5103

Basic benefit and medical policy

Inflectra

Inflectra, procedure code Q5103 is payable for the updated FDA-approved indications, effective June 18, 2019. Indications have been updated to include treatment of pediatric ulcerative colitis by reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients with moderately to severely active disease who have had an inadequate response to conventional therapy.

POLICY CLARIFICATIONS

96127

Basic benefit and medical policy

Code *96127

Effective June 1, 2018, this code is payable at 80% of the traditional fee schedule when billed with modifier AJ or HO and when billed by a clinical licensed master social worker, licensed professional counselor, limited licensed psychologist or licensed marriage and family therapist.

99354
99355

Basic benefit and medical policy

Codes *99354 and *99355

Effective June 1, 2018, these codes are payable at 80% of traditional fee schedule when billed with modifier AJ or HO.

Licensed behavioral health providers eligible to bill these codes for reimbursement of 80% of traditional fee schedule include clinical licensed master social worker, limited licensed psychologist, licensed marriage and family therapist, and licensed professional counselor.

Experimental

H0032, H2014, H2019, 0362T, 0373T, 97152, 97153, 97154, 97158

Basic benefit and medical policy

Telemedicine services

Telemedicine is the use of telecommunications technology for real-time, medical diagnostic and therapeutic purposes when distance separates the patient and health care provider. Telemedicine may substitute for a face-to-face, hands-on encounter between a patient and the health care provider when using the appropriate technology.

The safety and effectiveness of telemedicine have been established. It may be considered a useful diagnostic and therapeutic option when indicated.

The listed applied behavior analysis for the treatment of autism spectrum disorder procedure codes are considered experimental when billed for telehealth, place of service 02.

The following applied behavioral analysis for the treatment of autism spectrum disorder procedures are appropriate when delivered by telemedicine, place of service 02.

Parent/guardian/caregiver adaptive behavior treatment training (*97156, *97157) may be performed as a telemedicine service.
Program modification of ABA therapy (*97155) may be used as a combination of face-to-face and telemedicine services up to 50% of the time – as long as a technician is present face-to-face.

Inclusions:

Clinician interactive visit

The provider must be licensed, registered or otherwise authorized to perform service in their health care profession in the state where the patient is located. Services must fall within their scope of practice.
Telemedicine delivered services are available to all clinicians; however, this may not be the preferred method of delivery in certain clinical scenarios — for example, chronic suicidal ideation or unstable angina. A hosted visit** or a face-to-face visit may be necessary due to the complexity of the clinical situation. The telemedicine provider may provide the face-to-face encounter.
Telemedicine delivered services for ongoing treatment of a condition that is chronic or is expected to take more than five sessions before the condition resolves or stabilizes may require a hosted visit** or a face-to-face visit. The telemedicine provider may provide the face-to-face encounter.
The service must be conducted over a secured channel.**
The delivery of the service can be either audio only (telephone) or audio/visual (using a secured computer-based system).

**See Policy Guidelines

Online visit

An audio-visual online communication
The patient initiates the medical or behavioral health encounter
The provider must be licensed, registered or otherwise authorized to perform service in their health care profession in the state where the patient is located.
A low complexity, straight forward decision-making encounter that addresses urgent but not emergent clinical conditions
A single encounter where a follow-up encounter isn’t anticipated
Services must fall within the provider’s scope of practice.

Exclusions:

Email-only communication
Facsimile transmission
Text-only communication
Request for medication refills
Reporting of normal test results
Provision of educational materials
Scheduling of appointments and other health care related issues
Registration or updating billing information
Reminders for health care related issues
Referrals to other providers
An online or telemedicine visit resulting in an office visit, urgent care or emergency care encounter on the same day for the same condition
An online visit for the same condition of an online visit within the previous seven days
An online or telemedicine visit occurring during the post-operative period
Please refer to the medical policy for the Policy Guidelines. The guidelines:

Define who is an eligible provider
Explain how we cover applied behavior analysis therapy for autism spectrum disorder
Provide information regarding appropriate billing
Outline expectations for secure communication with patients

J2248

Basic benefit and medical policy

Mycamine (micafungin sodium)

Effective Dec. 20, 2019, Mycamine (micafungin sodium) is payable for the following updated FDA-indications:

Treatment of candidemia, acute disseminated candidiasis, candida peritonitis and abscesses without meningoencephalitis and ocular dissemination in pediatric patients younger than 4 months.

Limitations of use:

The safety and effectiveness of Mycamine haven’t been established for the treatment of candidemia with meningoencephalitis and ocular dissemination in pediatric patients younger than 4 months as a higher dose may be needed.
Mycamine hasn’t been adequately studied in patients with endocarditis, osteomyelitis or meningoencephalitis due to candida.
The efficacy of Mycamine against infections caused by fungi other than candida hasn’t been established.

Dosage and administration:

Pediatric patients younger than 4 months of age: 4 mg/kg/day.
Infuse over 1 hour.

J3490
J3590

Basic benefit and medical policy

Fluorescein sodium and benoxinate hydrochloride

Fluorescein sodium and benoxinate hydrochloride is considered established effective March 9, 2020.

Fluorescein sodium and benoxinate hydrochloride ophthalmic solution, 0.3%/0.4% is a combination of fluorescein sodium, a disclosing agent and benoxinate hydrochloride, a local ester anesthetic indicated for procedures in adult and pediatric patients requiring a disclosing agent in combination with a topical ophthalmic anesthetic.

Dosage and administration:

Instill one to two drops topically in the eye as needed to achieve adequate anesthesia.

This drug isn’t a benefit for URMBT.

J3490
J3590

Basic benefit and medical policy

Palforzia (peanut allergen powder-dnfp)

Palforzia (peanut allergen powder-dnfp) is considered established effective Jan. 31, 2020.

FDA-approved indication and diagnosis:

Desensitization of peanut allergy in pediatric patients ages 4 to 17 years.

Coverage of Palforzia (peanut allergen powder-dnfp) is provided when all the following are met:

FDA-approved age
FDA-approved diagnosis
Prescribed by or in consultation with an allergist or immunologist
Must have an eliciting dose of 100 mg or less on oral food challenge
Must have a current prescription for epinephrine and access to an epinephrine autoinjector while using AR101
Must not have severe or uncontrolled asthma, severe or life-threatening anaphylaxis in the past 60 days, or eosinophilic esophagitis
Must not be used in combination with Viaskin Peanut or other peanut desensitization therapy
Trial and failure of the preferred products as specified in the Blue Cross Blue Shield of Michigan and Blue Care Network utilization management medical drug list and the Blue Cross and BCN prior authorization and step therapy documents

Dosing and administration:

Dose escalation phase: 3 mg to 300 mg oral daily with increases every two weeks for 24 weeks
Maintenance dose: 300 mg oral daily
All dose escalations must be monitored by a health care provider for at least 90 minutes

This drug isn’t a benefit for URMBT.

J3490
J3590

Basic benefit and medical policy

Romidepsin

Romidepsin is considered established, effective March 13, 2020.

Romidepsin is a histone deacetylase, or HDAC, inhibitor indicated for:

Treatment of cutaneous T-cell lymphoma, or CTCL, in adult patients who have received at least one prior systemic therapy.
Treatment of peripheral T-cell lymphoma, or PTCL, in adult patients who have received at least one prior therapy. This indication is approved under accelerated approval based on response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

Dosage and administration:

14 mg/m2 administered intravenously over a four-hour period on days 1, 8 and 15 of a 28-day cycle. Repeat cycles every 28 days provided that the patient continues to benefit from and tolerates the drug.
Discontinue or interrupt treatment (with or without dose reduction to 10 mg/m2) to manage drug toxicity.
Reduce starting dose in patients with moderate and severe hepatic impairment.

This drug isn’t a benefit for URMBT.

Q5115

Basic benefit and medical policy

Truxima (rituximab-abbs)

Blue Cross Blue Shield of Michigan considers Truxima (rituximab-abbs) established for the treatment of:

Non-Hodgkin’s lymphoma:

Relapsed or refractory, low-grade or follicular, CD20-positive B-cell NHL as a single agent
Previously untreated follicular, CD20-positive, B-cell NHL in combination with first line chemotherapy and, in patients achieving a complete or partial response to a rituximab product in combination with chemotherapy, as single-agent maintenance therapy
Non-progressing (including stable disease), low-grade, CD20positive, B-cell NHL as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy
Previously untreated diffuse large B-cell, CD20-positive NHL in combination with (cyclophosphamide, doxorubicin, vincristine, and prednisone) or other anthracycline-based chemotherapy regimens

Chronic lymphocytic leukemia, or CLL:

Previously untreated and previously treated CD20-positive CLL in combination with fludarabine and cyclophosphamide.

Additional approved conditions:

Rheumatoid arthritis in combination with methotrexate in adult patients with moderately to severely active RA who have inadequate response to one or more TNF antagonist therapies.
Granulomatosis with polyangiitis (Wegener’s granulomatosis) and microscopic polyangiitis in adult patients in combination with glucocorticoids.

Group variations:

The UAW Retiree Medical Benefits Trust doesn’t cover this service.

Condition code 88

Basic benefit and medical policy

Condition code 88

The National Uniform Billing Committee approved new condition code 88 effective July 1, 2020.

Revenue code 0892

Basic benefit and medical policy

Revenue code 0892

The National Uniform Billing Committee approved new revenue code 0892. The revenue code is payable effective April 1, 2020.

Value codes 88 and 89

Basic benefit and medical policy

Value codes 88 and 89

The National Uniform Billing Committee approved new value codes 88 and 89 effective July 1, 2020.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.