The Record - Billing chart: Blues highlight medical, benefit policy changes

Billing chart: Blue Cross highlights 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

0253U, 89398**

**Not otherwise classified procedure

Basic benefit and medical policy

Reproductive techniques

Time-lapse monitoring or imaging of embryos (Embryoscope^®) represented by procedure code *89398, and endometrial receptivity analysis testing, billed with 0253U, have been added to the excluded services, effective on the policy updated Jan. 1, 2022.

0355T
0651T
0652T
0653T
0654T
91010
91013
91020
91022
91030
91034
91035
91037
91038
91040
91065
91110
91111
91112
91117
91120
91122
91132
91133
91200
91299
92610
92611
92612
92613
92614
92615
92616
92617
95857
C9777

Basic benefit and medical policy

Ambulatory surgical centers can bill revenue code 0750 for surgical and nonsurgical related services

Blue Cross Blue Shield of Michigan has approved ambulatory surgical facilities and centers for billing revenue code 0750 for surgical and nonsurgical related services. Nonsurgical procedures will no longer require the presence of a surgical procedure to be considered for reimbursement. Services deemed payable per Blue Cross’ medical and payment policy criteria and appropriate for reporting with revenue code 0750, according to the Centers for Medicare & Medicaid Services, will be process accordingly, effective July, 1, 2021.The codes listed are being added as eligible for performing in an ASF and for processing under specific PHA fee-based categories.

Please reference the HCPCS Payment Rule Information and Associated Revenue Codes resource for eligible revenue and HCPCS code combinations. To find this information, follow these steps:

Access web-DENIS through Provider Secured Services.
Click on BCBSM Provider Publications and Resources.
Click on Newsletters & Resources.
Click on Clinical Criteria & Resources.
Scroll down to HCPCS Payment Rule Information and Associated Revenue Codes

When checking a code’s payability status for a facility, be sure to access the Facility Claims Information HCPCS Payment Rule Display. This information can be found using the following steps:

Access web-DENIS through Provider Secured Services.
Click on Facility Claims.
Click on HCPCS Payment Rule Display.
Enter the HCPCS code.
Click on the MPP: Medical Policy Payment Rules button. (This selection will provide a complete list of all valid categories, effective date and pay rules. The PRI, or Payment Rule Inquiry, screen can be accessed by clicking on the HCPCS code applicable to the category and effective date.)

11976, 11981, 11982, 11983, 55250, 57170, 58300, 58301, 58600, 58605, 58611, 58615, 58661, 58670, 58671, 58700

Basic benefit and medical policy

Contraception and voluntary sterilization

Various contraceptive and sterilization methods are established for the prevention of unintended pregnancy. They may be a useful option when covered by the member’s certificate.

Inclusionary criteria have been updated, effective Jan. 1, 2022.

Inclusions:

FDA-approved contraceptive drugs or devices, prescribed by a qualified health care provider
Male sterilization (vasectomy) performed in the office setting
Female sterilization procedures

Exclusions:

Contraceptive drugs or devices that aren’t FDA approved
Vasectomy in an outpatient facility

32664, 64999, 69676

Experimental:
E1399, 64818, 97024, 90733, 97039

Basic benefit and medical policy

Treatment of hyperhidrosis

The safety and effectiveness of hyperhidrosis treatments have been established. They may be considered a useful therapeutic option in certain specified situations.

The inclusionary and exclusionary criteria have been updated, effective Jan. 1, 2022.

Inclusions:

Primary focal hyperhidrosis

Treatment of primary focal hyperhidrosis may be considered established with any of the following medical conditions:

Acrocyanosis of the hands
History of recurrent skin maceration with bacterial or fungal infections
History of recurrent secondary infections
History of persistent eczematous dermatitis despite medical treatments with topical dermatologic or systemic anticholinergic agents
Any other functional impairment caused by hyperhidrosis

Treatments that may be considered established by focal region include:

Axillary:

Aluminum chloride 20% solution
Surgical options (i.e., endoscopic transthoracic sympathectomy, or ETS, and surgical excision of axillary sweat glands), if conservative treatment (e.g., aluminum chloride or botulinum toxin,** individually and in combination), has failed

Palmar:

Aluminum chloride 20% solution
ETS, if conservative treatment (such as aluminum chloride or botulinum toxin,** individually and in combination) has failed

Plantar:

Aluminum chloride 20% solution

Craniofacial:

Aluminum chloride 20% solution
ETS, if conservative treatment (e.g., aluminum chloride) has failed

**Note: Refer to the pharmacy botulinum toxin policies for use in treating hyperhidrosis.

Treatments that are considered experimental by focal region include:

Axillary:

Axillary liposuction
Iontophoresis
Microwave treatment
Radiofrequency ablation

Palmar:

Iontophoresis
Microwave treatment
Radiofrequency ablation

Plantar:

Iontophoresis
Lumbar sympathectomy
Microwave treatment
Radiofrequency ablation

Craniofacial:

Iontophoresis
Microwave treatment
Radiofrequency ablation

Treatment of hyperhidrosis isn’t covered in the absence of functional impairment or any of the above medical conditions.

Secondary gustatory hyperhidrosis

Secondary gustatory hyperhidrosis is most often related to Frey syndrome (auriculotemporal nerve syndrome), but may also be associated with:

Encephalitis
Syringomyelia
Diabetes
Facial herpes zoster
Parotid infection or surgery
Trauma or injury, etc.

The following treatments may be considered established for the treatment of severe secondary gustatory hyperhidrosis (hyperhidrosis disease severity scale 3 or 4 [appendix table 1]):

Aluminum chloride 20% solution
Surgical options (e.g., tympanic neurectomy), if conservative treatment has failed

Exclusions:

The following treatment** is considered experimental as a treatment for severe secondary gustatory hyperhidrosis including, but not limited to:

Iontophoresis

**Note: Refer to the pharmacy botulinum toxin policies for use in treating hyperhidrosis.

Treatment of secondary gustatory hyperhidrosis isn’t covered in the absence of functional impairment.

50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50547

Experimental:
0088U, 83520

Basic benefit and medical policy

Kidney transplantation

The safety and effectiveness of kidney transplantation have been established. It may be considered a useful therapeutic option for carefully selected patients with end-stage kidney disease.

The inclusionary and exclusionary criteria have been updated, effective Jan. 1, 2022.

Inclusions:

Kidney transplants with either a living or cadaver donor maybe considered established for carefully selected patients with end-stage renal disease.

Kidney retransplant after a failed primary kidney transplant may be considered established in patients who meet criteria for kidney transplantation.

Potential contraindications for transplant:

Note: Final patient eligibility for transplant is subject to the judgment and discretion of the requesting transplant center.

Known current malignancy or history of recent malignancy
Untreated systemic infection making immunosuppression unsafe, including chronic infection
Other irreversible end stage diseases not attributed to kidney disease
Stable systemic disease that could be exacerbated by immunosuppression
Psychosocial conditions or chemical dependency affecting ability to adhere to therapy as defined by the transplant program

All transplants must be prior authorized through the Human Organ Transplant Program.

Note: There is a policy specific to a combined heart-kidney transplantation.

81252, 81253, 81254, 81430, 81431

Basic benefit and medical policy

Genetic testing related to hearing loss

The safety and effectiveness of genetic testing for hereditary hearing loss genes (GJB2, GJB6 and other hereditary hearing loss-related genes) have been established. It may be considered a useful diagnostic option in specified situations.

The coverage criteria have been updated, effective Jan. 1, 2022.

Inclusions:

Genetic testing for hereditary hearing loss genes (GJB2, GJB6 and other hereditary hearing loss-related genes) in individuals with hearing loss to confirm the diagnosis of hereditary hearing loss.
Preconception (prenatal) genetic testing (carrier testing) for hereditary hearing loss genes (GJB2, GJB6 and other hereditary hearing loss-related genes) in parents when at least one of the following conditions has been met:

Offspring with hereditary hearing loss
One or both parents with suspected hereditary hearing loss
First- or second-degree relative affected with hereditary hearing loss
First-degree relative with offspring who is affected with hereditary hearing loss

Exclusions:

Patients not meeting the above criteria

81275, 81276, 81403, 81404, 88363, 81311, 81210, 0111U

Experimental:
86152, 86153

Basic benefit and medical policy

KRAS, NRAS and BRAF variant in metastatic colorectal cancer

The safety and effectiveness of KRAS, NRAS and BRAF mutation analyses have been established and may be considered a useful diagnostic option to predict nonresponse to anti-EGFR monoclonal antibodies cetuximab and panitumumab in the treatment of all patients with metastatic colorectal cancer. It’s a useful therapeutic option when indicated.

KRAS, NRAF and BRAF variant analysis using circulating tumor DNA or circulating tumor cell testing (liquid biopsy) to guide treatment for patients with metastatic colorectal cancer is considered experimental.

The inclusionary and exclusionary criteria have been updated, effective Jan. 1, 2022.

Inclusions:

KRAS, NRAS and BRAF (V600E) mutation analysis in patients with metastatic colorectal cancer in order to determine their nonresponse to EGFR inhibitor drugs, such as Vectibix^® (panitumumab) and Erbitux^® (cetuximab).

Exclusions:

KRAS, NRAF and BRAF variant analysis using circulating tumor DNA (liquid biopsy)

81552, 81599,** 84999**

**Used to report not otherwise classified laboratory procedures

Basic benefit and medical policy

Gene expression profiling for uveal melanoma

The safety and effectiveness of gene expression profiling for uveal melanoma have been established. It may be considered a useful prognostic tool when indicated.

The policy was updated, effective Jan. 1, 2022.

Inclusions:

Gene expression profiling for uveal melanoma (e.g., DecisionDX-UM) for patients with primary, localized uveal melanoma.
The test must be ordered by a specialist with experience in treating uveal melanoma.

Exclusions:

Gene expression profiling for uveal melanoma that doesn’t meet the above criteria

J9144

Basic benefit and medical policy

Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Effective July 11, 2021, Darzalex Faspro (daratumumab and hyaluronidase-fihj) is payable for the following updated indications:

Multiple myeloma in combination with pomalidomide and dexamethasone in patients who have received at least one prior line of therapy, including lenalidomide and a proteasome inhibitor

S8948

Basic benefit and medical policy

S8948 is a noncovered service

Procedure code S8948 is a noncovered service, effective Nov. 1, 2021. Procedure code *0552T more accurately describes the service approved within the medical policy.

Inclusions:

When used for the prevention of oral mucositis in patients undergoing treatment associated with increased risk of oral mucositis, including chemotherapy, radiotherapy or hematopoietic stem cell transplantation.

Exclusions:

All other indications including, but not limited to:

Carpal tunnel syndrome
Neck pain
Subacromial impingement
Adhesive capsulitis
Temporomandibular joint pain
Low back pain
Osteoarthritis knee pain
Heel pain (e.g., Achilles’ tendinopathy, plantar fasciitis)
Rheumatoid arthritis
Bell palsy
Fibromyalgia
Wound healing
Lymphedema

GROUP BENEFIT CHANGES

Acument Global Technologies

Acument Global Technologies, group number 75441, has contracted Regenexx, LLC as its new musculo-skeletal provider, effective Jan. 1, 2022.

Group number: 75441
Alpha prefix: PPO (UMT)
Platform: NASCO Classic

Plans offered:
PPO medical/surgical
Prescription drug plan
CDH – HSA

Webasto Roof Systems Inc.

Effective Jan 1. 2021, Webasto Roof Systems Inc., group number 71389, will offer a new HSA plan for its employees that will include prescription drugs.

Group number: 71389
Alpha prefix: WBQ

None of the information included in this billing chart is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

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 2021 American Medical Association. All rights reserved.