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

NEW PAYABLE PROCEDURES

15832, 15833, 15836, 15878, 15879, 15834, 15835, 38999,** 99199**

**Not otherwise classified procedures used to report surgical services

Not covered codes: 15839, 15876, 15877

Basic benefit and medical policy

Surgical treatment for lipedema

The safety and effectiveness of suction-assisted lipectomy and surgical removal of excessive abnormal adipose tissue by excision involving the arms, legs and buttocks have been established for selected patients. It may be considered a useful therapeutic option when indicated, effective March 1, 2021.

All surgical interventions should be performed by hospital-credentialed, board-certified plastic surgeons. Photographs should accompany all requests.

Payment policy:

Payable diagnoses: R60.0, R60.1, R60.9, I87.1.
May require prior authorization.

Inclusions:

Liposuction/excision/debulking may be a therapeutic option when:

The diagnosis of lipedema can be documented by clinical exam and photography on the basis of:

Typical appearance of extremity involvement with thickened subcutaneous fat in the affected extremities bilaterally and symmetrically
Pain or hypersensitivity to touch in lipedema affected areas
History of easy bruising or bruising without apparent cause in lipedema affected areas
Tenderness and nodularity of fat deposits in lipedema affected areas (dimpled or orange peel texture)
Documentation of significant physical functional impairment (e.g., difficulty ambulating or difficulty performing activities of daily living) or medical complications, such as recurrent cellulitis or skin ulcerations

A failed response to three or more consecutive months of conservative management (compression or manual therapy); and
Lack of effect of weight loss on lipedema affected areas
Lack of effect of limb elevation on reduced swelling
Absence of pitting edema (no “pitting” when finger or thumb pressure is applied to the area of fat) (unless there is comorbid lymphedema)

Exclusions:

Liposuction/excision/debulking for indications other than lipedema or lymphedema (reference lymphedema-surgical treatment policy) that don’t meet criteria is considered cosmetic and therefore not covered.
Liposuction/excision/debulking of excess adipose tissue or excessive subcutaneous skin for the diagnosis of lipedema involving the trunk and back.

76391, 76981, 76982, 76983

Codes with no changes:

Covered:
81596, 91200

Experimental:
0002M, 0003M, 0014M, 76498, 81599,** 84999**

**Used to report not otherwise classified laboratory service

Basic benefit and medical policy

Noninvasive techniques for chronic liver disease

The safety and effectiveness of transient elastography, using either M or XL Probe, for the evaluation or monitoring of patients with chronic liver disease have been established. It may be considered a useful diagnostic option when indicated.

Ultrasound elastography in chronic liver disease has been established. It may be a useful diagnostic option when indicated.

Magnetic resonance elastography for the diagnosis and management of advance hepatic fibrosis or cirrhosis has been established. It may be considered a useful option when indicated.

The use of other noninvasive imaging, including, but not limited to, acoustic radiation force impulse imaging, or ARFI, or real-time tissue elastography, is considered experimental for the evaluation or monitoring of patients with chronic liver disease. While these services may be safe, their clinical utility in this clinical indication hasn’t been determined.

The use of FibroSURE multianalyte assays in chronic liver disease has been established. It may be considered a useful diagnostic option when indicated.

The peer-reviewed medical literature hasn’t demonstrated the clinical utility of other multianalyte assays with algorithmic analyses for the evaluation or monitoring of patients with chronic liver disease. Therefore, these services are considered experimental.

This policy update is effective Sept. 1, 2021.

Payment policy:

Subject to the PPO Radiology Management Program where applicable.

Preauthorization is required for procedure code *76391 in outpatient locations.

Radiology privileging applies to *76981, *76982 and *76983 when provided in an office location.

Payable provider specialties:

General surgery
Anesthesiology
Pain management
Neurosurgery
Radiology
Diagnostic radiology
Radiology oncology
Pediatric and vascular/thoracic surgeons
Freestanding radiology centers

Not payable in an ambulatory surgical facility.

Inclusions:

Noninvasive imaging techniques:

Transient elastography, using either the M or XL Probe, for the evaluation or monitoring of chronic liver disease
Ultrasound elastography when chronic liver disease has been established when used for one of the following indications:

Assessment hepatic fibrosis
Prediction of complications and mortality in patients with cirrhosis (e.g., development of large varices and hepatocellular carcinoma)

Magnetic resonance elastography for the diagnosis or management of advanced hepatic fibrosis or cirrhosis when chronic liver disease has been established and one of the following apply:

Patients with nonalcoholic fatty liver disease who have high risk for cirrhosis due to advanced age, obesity, diabetes or alanine aminotransferase, or ALT, level more than twice the upper limit of normal
In patients with other established chronic liver diseases when ultrasound elastography can’t be performed or is nondiagnostic

Multianalyte assays:

FibroSure^® when used to distinguish hepatic fibrosis from necro-inflammatory activity in patients with Hepatitis C (e.g., FibroSure HCV)

Exclusions:

Noninvasive imaging techniques:

Transient elastography in individuals with ascites
Acoustic radiation force impulse imaging, or ARFI, and real-time tissue elastography for the evaluation and/or monitoring of chronic liver disease
Use of ultrasound elastography to differentiate benign from malignant liver lesions

Multianalyte assays:

Multianalyte assays other than FibroSure
Multianalyte assays with algorithmic analyses for the evaluation or monitoring of patients with chronic liver disease not listed above (e.g.., FibroSure ASH, FibroSure NASH)

POLICY CLARIFICATIONS

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

64590, 64595

Basic benefit and medical policy

Sacral nerve neuromodulation/stimulation

The safety and effectiveness of sacral nerve stimulation for specific types of urinary or fecal incontinence have been established. It may be considered a useful therapeutic option for patients meeting specified criteria.

Payment policy:

The payable diagnoses for procedure code *64590 have been expanded to include the diagnostic range for urinary, fecal and mixed incontinence. The previous diagnostic restrictions for procedure code *64595 that were related to gastroparesis have been removed to accommodate the extensive list of complications that may lead to a revision or removal of a device. These updates are effective retroactively to Nov. 1, 2020.

Inclusions:

Urinary incontinence and non-obstructive retention

A trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead is established in patients who meet all the following criteria:

There is a diagnosis of at least one of the following:

Urge incontinence
Urgency-frequency syndrome
Non-obstructive urinary retention
Overactive bladder

There is documented failure or intolerance to at least two conventional therapies (e.g., behavioral training such as bladder training, prompted voiding or pelvic muscle exercise training, pharmacologic treatment for at least a sufficient duration to fully assess its efficacy and/or surgical corrective therapy).

The patient is an appropriate surgical candidate.
Incontinence isn’t related to a neurologic condition.

Permanent implantation of a sacral nerve neuromodulation device is established in patients who meet all of the following criteria:

All the criteria in A above are met.
A trial stimulation period demonstrates at least 50% improvement in symptoms over a period of at least 48 hours.

Fecal incontinence

Sacral nerve neuromodulation is established for the treatment of fecal incontinence when all the following criteria are met:

A trial period of sacral nerve neuromodulation with either percutaneous nerve stimulation or a temporarily implanted lead may be considered established in patients who meet all the following criteria:

There is a diagnosis of chronic fecal incontinence of greater than two incontinent episodes on average per week with duration greater than six months, or for more than 12 months after vaginal childbirth.
There is documented failure or intolerance to conventional conservative therapy (e.g., dietary modification, the addition of bulking and pharmacologic treatment for at least a sufficient duration to fully assess its efficacy.
The patient is an appropriate surgical candidate.
The condition isn’t related to an anorectal malformation (e.g., congenital anorectal malformation; defects of the external anal sphincter over 60 degrees; visible sequelae of pelvic radiation; active anal abscesses and fistulae) or chronic inflammatory bowel disease.
Incontinence isn’t related to a neurologic condition.
The patient hasn’t had rectal surgery in the previous 12 months, or in the case of cancer, the patient hasn’t had rectal surgery in the past 24 months.

Permanent implantation of a sacral nerve neuromodulation device may be considered established in patients who meet all the following criteria:

All the criteria in A (1-6) above are met.
A trial stimulation period demonstrates at least 50% improvement in symptoms over a period of at least 48 hours.

Exclusions:

Other urinary/voiding applications of sacral nerve neuromodulation are considered experimental, including, but not limited to, treatment of either of the following:

Stress incontinence
Urge incontinence due to a neurologic condition, (e.g., detrusor hyperreflexia, multiple sclerosis, spinal cord injury or other types of chronic voiding dysfunction)

Sacral nerve neuromodulation is experimental for the treatment of chronic constipation or chronic pelvic pain.

Note: For a complete list of policy procedures, reference the medical policy on the router mprSearch at bcbsm.com.

87420
0240U
0241U

Basic benefit and medical policy

Physician Office Laboratory List

The procedure codes listed were added to the Physician Office Laboratory List. They can be performed in a physician’s office.

90587

Basic benefit and medical policy

Dengue vaccine

Dengue vaccine, quadrivalent, live, three-dose schedule, for subcutaneous use is established in individuals ages 9 through 16 with laboratory-confirmed previous dengue infection who are living in endemic areas.

This is payable for all groups as of the FDA effective date, May 1, 2019.

G2212

Basic benefit and medical policy
Procedure code G2212

Retro-effective to Jan. 1, 2021, Blue Cross Blue Shield of Michigan will allow reimbursement for procedure code G2212 when the services are rendered by a certified nurse practitioner in an outpatient psychiatric care, or OPC, location. The claims processing system has been updated to allow reimbursement to an OPC provider PIN.

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.