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

POLICY CLARIFICATIONS

J1599

Basic benefit and medical policy

Xembify (immune globulin subcutaneous, human-klhw)

Xembify (immune globulin subcutaneous, human-klhw) is considered established, effective Aug. 15, 2019.

Xembify (immune globulin subcutaneous, human-klhw) is considered covered when the following criteria are met:

Xembify (immune globulin subcutaneous, human-klhw) is a 20% immune globulin solution for subcutaneous injection indicated for treatment of primary humoral immunodeficiency, or PI, in patients age 2 and older.

Dosage information:
Switching from immune globulin intravenous (human), 10% (IVIG) to Xembify (immune globulin subcutaneous, human-klhw): Calculate the dose by using a dose adjustment factor (1.37)

Weekly: Begin Xembify (immune globulin subcutaneous, human-klhw) one week after last IVIG infusion.

Establish initial weekly dose by converting the monthly (or every three weeks) IVIG dose into an equivalent weekly dose and increasing it using a dose adjustment factor (1.37).

Initial weekly = Prior IVIG dose (in grams) × 1.37
dose (grams) Number of weeks between IVIG doses

Frequent dosing (two to seven times per week): Divide the calculated weekly dose by the desired number of times per week.

Switching from immune globulin subcutaneous (human) treatment (IGSC):

Weekly dose (grams) should be the same as the weekly dose of prior IGSC treatment (grams).

Pharmacy requires preauthorization of this drug.

This drug is not a benefit for URMBT.

NDCs: 13533-0810-05, 13533-0810-06, 13533-0810-10
13533-0810-11, 13533-0810-20, 13533-0810-21, 13533-0810-50 and 13533-0810-51

J3490
J3590

Basic benefit and medical policy

Skyrizi (risankizumab-rzaa)

Skyrizi (risankizumab-rzaa) is considered established, effective April 23, 2019.

Skyrizi (risankizumab-rzaa) is an interleukin-23 antagonist indicated for the treatment of moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy.

Skyrizi (risankizumab-rzaa) is considered covered when all the following are met:

Diagnosis of plaque psoriasis
Prescribed by or in consultation with a dermatologist
Treatment with a minimum of three months of topical steroids was ineffective
Treatment with phototherapy or photochemotherapy was ineffective, contraindicated or not tolerated
Treatment with at least one generic oral systemic agent for plaque psoriasis was ineffective or not tolerated, unless contraindicated. Examples of systemic agents include, but are not limited to, cyclosporin, methotrexate and acitretin
Trial and failure, contraindication or intolerance to all preferred drugs as listed in the Blue Cross Blue Shield of Michigan utilization management medical drug list

Dosing information:
150 mg administered by subcutaneous injection at Week 0 and Week 4, and every 12 weeks thereafter.

Pharmacy requires preauthorization of this drug.

This drug isn’t a benefit for URMBT.

NDC: 00074-2042-02

GROUP BENEFIT CHANGES

Belle Tire

Belle Tire, group number 71477, is joining Blue Cross Blue Shield of Michigan, effective Jan. 1, 2020.

Group number: 71477
Alpha prefix: PPO (BEI)
Platform: NASCO and MOS

Plans offered:
PPO, medical/surgical
Dental
Prescription drug

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 2019 American Medical Association. All rights reserved.