Blue Cross amends procedures eligible for pilot program to promote pain control through limiting post-operative opioid dispensing

In August 2018, Blue Cross Blue Shield of Michigan announced an initiative for select surgeries aimed at promoting effective pain control through care processes that limit opioid dispensing. In 2021, modifications will be made to the eligible surgical groupings by adding some groupings, extending some and retiring others.

The following surgical groupings will be eligible for the modifier 22 billing, effective Jan. 1, 2021, and will remain eligible through Dec. 31, 2022:

• Cesarean delivery
• Colectomy (laparoscopic or open)
• Hysterectomy (laparoscopic or open)
• Proctectomy (under new prescribing guidelines; see updated recommendations in the link below)

The following surgical groupings will be extended until Dec. 31, 2021

• Adrenalectomy
• Appendectomy (adult)
• Bariatric surgery
• Carpel tunnel release
• Carotid endarterectomy
• Endovascular aneurism repair
• Inguinal hernia repair
• Parathyroidectomy
• Pediatric appendectomy
• Thyroidectomy
• Umbilical hernia repair
• Ureteroscopy
• Vasectomy
• Ventral hernia repair

The following surgical groupings will no longer be eligible for modifier 22, effective April 1, 2021:

• Endoscopic sinus surgery and septoplasty
• Laparoscopic cholecystectomy

Using modifier 22

To submit your attestation statement indicating that appropriate protocols were included as part of the surgery, follow the process for submitting medical records and other claim attachments when appending modifier 22 to a qualifying procedure. For details, see the “Claims” chapter of the provider manual.

Also, to bill modifier 22 for adherence with the Pain Control Optimization Pathway, the physician agrees to follow the prescribing recommendations of the Michigan Opioid Prescribing Engagement Network, or Michigan-OPEN. For information, click here.**

The physician also agrees to the following guidelines:

• No additional pills are prescribed after the initial discharge prescription.
• No opioid prescriptions have been filled within 30 days before surgery, with certain exceptions.
• For procedures with limited opioids recommended after surgery, Blue Cross will allow up to 10% to have an additional fill for an opioid within 30 days after surgery to accommodate unexpected excessive pain.
• This pilot program is expected to last one to two years, based on results. We’ll announce further details in future Record articles.

Background

In 2018, the payment policy was modified to allow surgeons to report modifier 22 for an additional 35% reimbursement when pain control optimization protocols are used to support the surgery. The initial period of the pilot program included the following surgical categories:

• Laparoscopic cholecystectomy
• Inguinal hernia repair
• Thyroidectomy
• Endoscopic sinus surgery and septoplasty
• Prostatectomy
• Bariatric surgery

Due to the success of the pilot program, we expanded the program to also include the following surgical groupings in July 2019:

• Adrenalectomy
• Appendectomy (adult)
• Carpel tunnel release
• Carotid endarterectomy
• Endovascular aneurism repair
• Parathyroidectomy
• Pediatric appendectomy
• Umbilical hernia repair
• Ureteroscopy
• Vasectomy
• Ventral hernia repair

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