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

81439

Related established procedures:

S3865, S3866, 81405, 81406, 81407, 81479

Basic benefit and medical policy

Genetic testing for inherited hypertrophic cardiomyopathy

The safety and effectiveness of genetic testing for inherited hypertrophic cardiomyopathy have been established. It may be considered a useful diagnostic and prognostic option for patients meeting patient selection criteria. (See policy for Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia, or ARVC/D, if seeking information for that condition.)

Procedure code *81439 is payable, effective May 1, 2020.

Basic benefit policy group variations

Payment policy:

It isn’t payable in an office location. Modifiers 26 and TC don’t apply to this procedure. Maximum of one test per lifetime.

Inclusions:

Genetic testing for hypertrophic cardiomyopathy is appropriate for:

Individuals who display clinical features or who are pre-symptomatic but are at direct risk of inheriting the mutation in question when (both apply):

The results of the test will directly affect the diagnostic and treatment options being recommended for the patient.
After history, physical examination, pedigree analysis, genetic counseling and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain.

Individuals who are pre-symptomatic and don’t meet the clinical features of HCM, but who have one of the following:

A close relative (i.e., a first- or second- degree relative) with a known HCM mutation
A close relative (i.e., a first- or second- degree relative) diagnosed with HCM by clinical means whose genetic status is unknown

In addition to the above inclusions:

The genetic testing should be ordered by a specialist in cardiology or genetics.
Genetic testing must be done in conjunction with genetic counseling. The counselor evaluates medical problems or risks present in a family, analyzes and explains inheritance patterns of any disorders found, provides information about management and treatment of these disorders and discusses available options with the family or individual.

Exclusions:

Genetic screening for HCM in the general population is excluded because such screening is considered not medically necessary or of unproven benefit.
Patients not meeting the listed patient selection guidelines.

89253, 89335, 89354

(Payable as of May 1, 2022)

Additional established codes:
55530, 58321-58323, 58540, 58672,
58752, 58760, 58970, 58974, 58976,
76857, 76948, 89250, 89251, 89253-89255, 89257-89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291,
89322, 89337, 89342, 89343, 89346,
89352, 89353, 89356, 89398, S4011,
S4013-S4016, S4021, S4022, S4027,
S4028, S4035, S4037, S4040, S4042

Experimental codes:

58673, 89335, 89344, 89354, 89398, 0253U

Basic benefit and medical policy

Assisted reproductive techniques

Selected assisted reproductive techniques, or ART, are established and may be considered useful therapeutic options in the treatment of infertility, effective May 1, 2022.

When infertility (see the “Infertility Services” medical policy) is due to an underlying medical condition (e.g., chronic infection, uterine fibroids, etc.), the treatment of that disorder is medically necessary and is covered under basic medical-surgical benefits. When no correctable underlying medical condition is found (e.g., low sperm count, anovulation), other options may be pursued. One option is ART – specific services that may be used to establish pregnancy. Assisted reproductive techniques are only available to members when the employer group has chosen to offer the services as additional or extra benefits through certificate benefit language or riders.

The focus of this policy is the use of ART in heterosexual couples who are infertile. Eligibility of same sex couples or single individuals for ART is based on benefit coverage (the certificate of coverage or rider) and is beyond the scope of this medical policy.

Basic benefit policy group variations:

Verify if member has assisted reproductive techniques/infertility benefit prior to service.

Payment policy:

Modifiers 26 and TC aren’t applicable.
*89335 and *89354 are covered for azoospermia diagnosis only.
*89253 requires an infertility-related diagnosis.

Inclusions:

Assisted reproductive techniques aren’t general medical or surgical benefits. While the procedures listed in the inclusions are considered established, these services are available only as additional benefits, offered by a group or employer. The covered services and limitations are defined by the group or employer. The benefit plan, including the certificate of coverage or rider, determines the available coverage.

Inclusions:

Artificial insemination
Assisted reproductive technologies:

In vitro fertilization, or IVF
Gamete intrafallopian transfer, or GIFT
Transuterine fallopian transfer, or TUFT
Natural oocyte retrieval with intravaginal fertilization, or NORIF
Pronuclear state tubal transfer, or PROST
Tubal embryo transfer, or TET
Zygote intrafallopian transfer, or ZIFT
Embryo transfer
Blastocyst transfer
Intracytoplasmic sperm injection, or ICSI for male factor infertility only
Cryopreservation of embryos, oocytes and sperm**
Storage of embryos, oocytes and sperm
Thawing of embryos, oocytes and sperm
Assisted embryo hatching when one of the following criteria are met:

The individual is 38 years of age or older
There have been two or more IVF failures related to failed implantation

**Cryopreservation of oocytes and sperm may be necessary for an extended length of time, based on the age of the pediatric patient undergoing a procedure that will result in iatrogenic infertility.

Exclusions:

Intracytoplasmic sperm injection in the absence of male factor infertility
Co-culture of embryos
Cryopreservation of ovarian tissue or testicular tissue***
Storage of ovarian tissue or testicular tissue
Thawing of ovarian tissue or testicular tissue***
All services related to gestational surrogacy/gestational parent/gestational carrier
Time lapse monitoring or imaging of embryos (e.g., EmbryoScope)
Endometrial receptivity testing (e.g., ERA® [Endometrial Receptivity Analysis])
ART services are excluded when there has been a voluntary sterilization procedure (e.g., tubal ligation, vasectomy), including when there has been surgical reversal of the sterilization procedure, as this isn’t considered treatment of disease
Reversal of prior sterilization procedure is excluded

***Cryopreservation and thawing of testicular tissue in adult men with azoospermia is considered medically necessary as part of the intracytoplasmic sperm injection procedure.

90759

Basic benefit and medical policy

Hepatitis B vaccine (HepB), 3-antigen (S, Pre-S1, Pre-S2) (PreHevbrio) vaccine

The use of the hepatitis B (HepB), 3-antigen (S, Pre-S1, Pre-S2) (PreHevbrio) vaccine is established. It’s been approved by the U.S. Food & Drug Administration, effective Nov. 30, 2021, and is recommended by the Advisory Committee on Immunization Practices. Note: Procedure code *90759 is effective Jan. 1, 2022.

Hepatitis B vaccination is recommended for adults ages 19 through 59 years and adults ages 60 and older with risk factors for hepatitis B. Adults ages 60 and older without known risk factors for hepatitis B may also receive hepatitis B vaccines. It is already recommended that infants and all others younger than 19 receive hepatitis B vaccines.

A9593
A9594

Basic benefit and medical policy

Positron emission tomography

A9593 and A9594 are payable effective March 1, 2022, when billed with positron emission tomography procedures.

UPDATES TO PAYABLE PROCEDURES

C9399
J3490
J3590

Basic benefit and medical policy

Enjaymo (sutimulab-jome)

Enjaymo (sutimulab-jome) is payable for its FDA-approved indications, effective Feb. 4, 2022.

Enjaymo (sutimulab-jome) is a classical complement inhibitor indicated to decrease the need for red blood cell transfusion due to hemolysis in adults with cold agglutinin disease.

Dosage and administration:

Vaccinate against encapsulated bacteria at least two weeks before treatment.

Weight-based dosage weekly for two weeks, then every two weeks:

For patients weighing 39 kg to less than 75 kg: 6,500 mg by intravenous infusion
For patients weighing 75 kg or more: 7,500 mg by intravenous infusion

Dosage forms and strengths:

Injection: 1,100 mg/22 mL (50 mg/mL) in a single-dose vial

URMBT groups are excluded from coverage of this drug.

C9399
J3490
J3590
J9999

Basic benefit and medical policy

Alymsys (bevacizumab-maly)

Alymsys (bevacizumab-maly) is payable for its FDA-approved indications, effective April 13, 2022.

Alymsys (bevacizumab-maly) a vascular endothelial growth factor inhibitor indicated for the treatment of:

Metastatic colorectal cancer, in combination with intravenous fluorouracil-based chemotherapy for first- or second-line treatment.
Metastatic colorectal cancer, in combination with fluoropyrimidine-irinotecan- or fluoropyrimidine oxaliplatin-based chemotherapy for second-line treatment in patients who have progressed on a first-line bevacizumab product-containing regimen.

Limitations of use:

Alymsys isn’t indicated for adjuvant treatment of colon cancer.

Unresectable, locally advanced, recurrent or metastatic non-squamous non-small cell lung cancer, in combination with carboplatin and paclitaxel for first-line treatment
Recurrent glioblastoma in adults
Metastatic renal cell carcinoma in combination with interferon alfa
Persistent, recurrent or metastatic cervical cancer, in combination with paclitaxel and cisplatin, or paclitaxel and topotecan

Epithelial ovarian, fallopian tube or primary peritoneal cancer in combination with paclitaxel, pegylated liposomal doxorubicin, or topotecan for platinum-resistant recurrent disease who received no more than two prior chemotherapy regimens

Dosage and administration:

Withhold for at least 28 days prior to elective surgery. Don’t administer Alymsys for 28 days following major surgery and until adequate wound healing.

Metastatic colorectal cancer

5 mg/kg every two weeks with bolus-IFL
10 mg/kg every two weeks with FOLFOX4
5 mg/kg every two weeks or 7.5 mg/kg every three weeks with fluoropyrimidine-irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy after progression on a first-line bevacizumab product-containing regimen

First-line non-squamous non-small cell lung cancer

15 mg/kg every three weeks with carboplatin and paclitaxel

Recurrent glioblastoma

10 mg/kg every two weeks

Metastatic renal cell carcinoma

10 mg/kg every two weeks with interferon alfa

Persistent, recurrent or metastatic cervical cancer

15 mg/kg every three weeks with paclitaxel and cisplatin, or paclitaxel and topotecan

Platinum-resistant recurrent epithelial ovarian, fallopian tube or primary peritoneal cancer

10 mg/kg every two weeks with paclitaxel, pegylated liposomal doxorubicin or topotecan given every week
15 mg/kg every three weeks with topotecan given every three weeks

Administer as an intravenous infusion.

Dosage forms and strengths:

Injection: 100 mg/4 mL (25 mg/mL) or 400 mg/16 mL (25 mg/mL) in a single-dose vial

URMBT groups are excluded from coverage of this drug.

POLICY CLARIFICATIONS

1111F

Basic benefit and medical policy

Clarification on 1111F

Procedure code 1111F has changed from payable to non-payable for Blue Cross Blue Shield of Michigan commercial. This change was effective July 1, 2022.

1111F remains payable for Medicare Plus Blue℠ and BCN Advantage℠.

20999,** 28899**

**Unlisted procedure code

Basic benefit and medical policy

Coblation for musculoskeletal conditions

The medical policy statement for coblation for musculoskeletal conditions has been updated, effective Sept. 1, 2022.

Medical policy statement:

Coblation, or cold radiofrequency ablation, for musculoskeletal conditions (e.g., tendinopathy, plantar fasciitis, lateral epicondylitis) is experimental. There is insufficient scientific evidence in the current medical literature to determine whether the technology improves health outcomes.

Inclusions and exclusions:

Not applicable

44705,** G0455, 44799***

Procedure may be billed with:
43753, 45330, 45378

**Medicare requires the G0455 be used for this procedure; 44705 is not valid for Medicare.

***Used to report not otherwise classified service.

Basic benefit and medical policy

Fecal microbiota transplantation

The safety and effectiveness of fecal microbiota transplant, or FMT, have been established. It’s a useful therapeutic option for patients with recurrent clostridioides difficile infection.

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

Inclusions:

Fecal microbiota transplant is considered established when both the following is met:

There’s an incident case of clostridioides difficile that is treated with standard antibiotic C. difficile infection therapy.
There are at least two recurrences,** which are also treated with standard antibiotic C. difficile infection therapy.

**A recurrence occurs within eight weeks of the completion of a course of C. difficile infection, or CDI, therapy.

A repeat fecal microbiota transplant is considered established in individuals who experience a recurrence of clostridioides difficile infection within eight weeks of an initial FMT.

Exclusions:

Fecal microbiota transplantation that doesn’t meet the criteria in inclusions (e.g., when used as first-line treatment; when used for other indications, such as inflammatory bowel disease, autoimmune disease, etc.)

81376, 81377, 81382, 81383

Basic benefit and medical policy

HLA testing for celiac disease

The effectiveness and clinical utility of human leukocyte antigen (HLA)-DQ2 and HLA-DQ8 testing to rule out a diagnosis of celiac disease have been established. It may be considered a useful diagnostic option when indicated. The policy is effective Sept. 1, 2022.

Inclusions:

Human leukocyte antigen (HLA)-DQ2 and HLA-DQ8 testing to rule out celiac disease may be considered medically necessary when one of the following is met:

Patients with persistent symptoms despite negative serology (IgA tissue contaminants) and histology (biopsy)
Patients with discordant serologic and histologic (biopsy) findings

Exclusions:

Familial testing of asymptomatic family members of individuals with proven disease
All other situations

J0248

Basic benefit and medical policy

Veklury (remdesivir)

Veklury (remdesivir) is payable for the following updated indications, effective April 25, 2022.

Veklury is a severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2, nucleotide analog RNA polymerase inhibitor indicated for the treatment of COVID-19 in adults and pediatric patients (28 days of age and older and weighing at least 3 kg) with positive results of direct SARS-CoV-2 viral testing.

Dosage and administration:

The only approved dosage form of Veklury for pediatric patients weighing 3 kg to less than 40 kg is Veklury for injection (supplied as 100 mg lyophilized powder in vial).

Recommended dosage: For pediatric patients 28 days of age and older and weighing 3 kg to less than 40 kg, a single loading dose of Veklury 5 mg/kg on Day 1, followed by once-daily maintenance doses of Veklury 2.5 mg/kg from Day 2 via intravenous infusion

J7179

Basic benefit and medical policy

Vonvendi (von Willebrand factor [recombinant])

Vonvendi (von Willebrand factor [recombinant]) is payable for the following updated indications, effective Feb. 1, 2022: Routine prophylaxis to reduce the frequency of bleeding episodes in adults with severe type 3 von Willebrand disease receiving on-demand therapy.

J9358

Basic benefit and medical policy

Enhertu (fam-trastuzumab deruxtecan-nxki)

Effective May 4, 2022, Enhertu (fam-trastuzumab deruxtecan-nxki) is payable for the following updated, FDA-approved indications:

Enhertu is a HER2-directed antibody and topoisomerase inhibitor conjugate indicated for the treatment of adult patients with unresectable or metastatic HER2-positive breast cancer who have received a prior anti-HER2-based regimen in the neoadjuvant or adjuvant setting and have developed disease recurrence during or within six months of completing therapy.

EXPERIMENTAL PROCEDURES

89251

Basic benefit and medical policy

Procedure code *89251 removed from infertility
coverage

Per our provider alert posted June 28, procedure code *89251 has been removed from the infertility/assisted reproductive techniques benefit tables, effective Oct. 1, 2022. The status of this procedure will be changed to experimental, as co-culture of oocytes has been unproven to improve net health outcomes.

Basic benefit policy group variations:

Procedure code *89251 has never been covered under standard medical benefits. Only groups that provide treatment for infertility or assisted reproductive techniques are affected.

90584

Basic benefit and medical policy

Dengue vaccine

Dengue vaccine, quadrivalent, live, two-dose schedule for subcutaneous use is experimental. The FDA hasn’t approved this vaccine and it’s not currently recommended by the Advisory Committee on Immunization Practices.

Inclusions and exclusions:

Not applicable

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.