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

90697

Basic benefit and medical policy

Pediatric hexavalent vaccine

The safety and effectiveness of the pediatric hexavalent vaccine (i.e., Vaxelis™) for protection against diphtheria, tetanus, pertussis, poliovirus types 1, 2 and 3, disease caused by Haemophilus influenzae type B (Hib), and hepatitis B (DTaP‑IPV‑Hib‑HepB) is established, effective Dec. 21, 2018.

Payable for all groups covering preventive immunization services.

UPDATES TO PAYABLE PROCEDURES

J9035

Basic benefit and medical policy

Avastin (bevacizumab)

Blue Cross Blue Shield of Michigan has approved payment for the off‑label use of Avastin^® (bevacizumab). Procedure code J9035 is payable for off‑label use to treat mesothelioma.

Condition code 90

Condition code 91

Basic benefit and medical policy

Condition codes 90 and 91

The National Uniform Billing Committee approved new condition codes 90 and 91, effective Feb. 1, 2021.

POLICY CLARIFICATIONS

C9254

Basic benefit and medical policy

Vimpat (lacosamide)

Vimpat (lacosamide) is payable for the following updated FDA‑approved indication:

Adjunctive therapy in the treatment of primary generalized tonic‑clonic seizures in patients 4 years of age and older.

Dosing information:

Adults, aged 17 and older:

Initial dosage for monotherapy for the treatment of partial‑onset seizures is 100 mg twice daily.
Initial dosage for adjunctive therapy for the treatment of partial‑onset seizures or primary generalized tonic‑clonic seizures is 50 mg twice daily.
Maximum recommended dosage for monotherapy and adjunctive therapy is 200 mg twice daily.

Pediatric patients 4 years to less than 17 years: The recommended dosage is based on body weight and is administered orally twice daily.
Increase dosage based on clinical response and tolerability, no more frequently than once per week.
Injection for intravenous use only when oral administration is temporarily not feasible; dosing regimen is the same as oral regimen; administer over 15 to 60 minutes. Obtaining ECG before initiation is recommended in certain patients.
Dose adjustment is recommended for severe renal impairment.
Dose adjustment is recommended for mild or moderate hepatic impairment; use in patients with severe hepatic impairment isn’t recommended.

J0638

Basic benefit and medical policy

ILARIS

ILARIS is an interleukin‑1β blocker payable for the following FDA‑approved indications:

Periodic fever syndromes

Cryopyrin‑associated periodic syndromes in adults and children 4 years of age and older, including:

Familial cold auto‑inflammatory syndrome
Muckle‑Wells syndrome
Tumor necrosis factor receptor associated periodic syndrome in adult and pediatric patients

Hyperimmunoglobulin D syndrome/Mevalonate Kinase deficiency in adult and pediatric patients

Familial Mediterranean fever in adult and pediatric patients

Active Still’s disease, including adult‑onset Still’s disease and systemic juvenile idiopathic arthritis in patients age 2 years and older

J1602

Basic benefit and medical policy

Simponi Aria (golimumab)

Simponi Aria^® (golimumab) is payable for the following
updated FDA‑approved indications:

Adult patients with moderately to severely active rheumatoid arthritis in combination with methotrexate
Active psoriatic arthritis in patients age 2 years and older
Adult patients with active Ankylosing spondylitis
Active polyarticular juvenile idiopathic arthritis in patients age 2 years and older.

Dosing information:

Adult patients with rheumatoid arthritis, psoriatic arthritis and Ankylosing spondylitis:

2 mg/kg intravenous infusion over 30 minutes at weeks 0 and 4, and every eight weeks thereafter

Pediatric patients with polyarticular juvenile idiopathic arthritis and psoriatic arthritis:

80 mg/m2 intravenous infusion over 30 minutes at weeks 0 and 4, and every eight weeks thereafter

Dilution of supplied Simponi Aria solution with 0.9% sodium chloride injection, USP is required prior to administration. Alternatively, 0.45% sodium chloride injection, USP can also be used.

J2182

Basic benefit and medical policy

Nucala (mepolizumab)

Nucala (mepolizumab) is payable for the following updated FDA‑approved indications:

The treatment of adult and pediatric patients age 12 years and older with hypereosinophilic syndrome for greater than six months without an identifiable non-hematologic secondary cause.

Dosing information:

300 mg as three separate 100‑mg injections administered subcutaneously once every four weeks.

J3490

J3590

Basic benefit and medical policy

Fetroja (cefiderocol)

Effective Sept. 28, 2020, Fetroja (cefiderocol) is covered for the following FDA‑approved indications:

Fetroja is a cephalosporin antibacterial indicated in patients age 18 years or older for the treatment of the following infections caused by susceptible Gram‑negative microorganisms:

Hospital‑acquired bacterial pneumonia and ventilator‑associated bacterial pneumonia

Dosage information:

Administer 2 grams of Fetroja for injection every eight hours by intravenous infusion over three hours in patients with creatinine clearance (CLcr) 60 to 119 mL/min.
Dose adjustments are required for patients with CLcr less than 60 mL/min, including patients receiving intermittent hemodialysis or continuous renal replacement therapy, and for patients with CLcr 120 mL/min or greater.

This drug isn’t a benefit for URMBT.

J9145

Basic benefit and medical policy

Darzalex (daratumumab)

Effective Aug. 20, 2020, Darzalex (daratumumab) is covered for the following FDA‑approved indications:

Darzalex is a CD38‑directed cytolytic antibody indicated for the treatment of adult patients with multiple myeloma:

In combination with carfilzomib and dexamethasone in patients who have received one to three prior lines of therapy

Dosage information:

Pre‑medicate with corticosteroids, antipyretics and antihistamines
Dilute and administer as an intravenous infusion
Recommended dose is 16 mg/kg actual body weight. See full prescribing information for drugs used in combination and schedule.
Administer post‑infusion medications

Q5113

Basic benefit and medical policy

Herzuma (trastuzumab‑pkrb)

Herzuma (trastuzumab‑pkrb) is payable for the
following new FDA‑approved indication:

The treatment of HER2‑overexpressing metastatic gastric or gastroesophageal junction adenocarcinoma

Dosage information:

For metastatic HER2‑overexpressing gastric cancer,
initial dose of 8 mg/kg over 90‑minute IV infusion, followed by 6 mg/kg over 30 to 90‑minute IV infusion every three weeks.

Pharmacy doesn’t require preauthorization of this drug.

The national drug codes are 63459‑0305‑47 and 63459‑0303‑43.

Occurrence Codes 61 and 62

Payment policy

Occurrence codes 61 and 62

The National Uniform Billing Committee approved new occurrence codes 61 and 62, effective Jan. 1, 2020.

Value code D6

Payment policy

Value code D6

Blue Cross Blue Shield of Michigan will accept new value code D6, which was approved by the National Uniform Billing Committee, effective January 2021.

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 2020 American Medical Association. All rights reserved.