Clinical editing polices updated

In support of correct coding and payment accuracy, we are providing the information below to keep you informed about payment policy updates, new policies and coding reminders. 

Medicare Plus Blue℠

Reminder: Alpha-1 proteinase inhibitors

To promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process effective Nov. 1, 2024, for Part B medical drugs for Medicare Plus Blue claims.

To receive timely and appropriate payment of the Part B drugs listed below when billed with HCPCS code J0256 or J0257, health care providers must include both a diagnosis code that supports an Alpha-1 antitrypsin deficiency and symptomatic emphysema.

Per our medical policy, coverage for Alpha-1 proteinase inhibitors is provided when all the following are met:

1. Member must be the FDA-approved age.
2. Member must be a nonsmoker.
3. Member must have pre-treatment serum levels of Alpha-1 antitrypsin, or AAT, that are less than 11 micromol/L measured by ELISA (less than 80 mg/dL measured by radial immunodiffusion or less than 57 mg/dL measured by nephelometry) consistent with phenotypes PiZZ, PiZ (null), or Pi (null, null) of AAT.
4. Phenotype or genotype testing may be requested for additional support of Alpha-1 antitrypsin deficiency diagnosis.
1. Member must have symptomatic emphysema.
5. Member must have deteriorating pulmonary function, as demonstrated by a decline in the FEV1 (35 to 60% of predictive value).
6. Trial and failure, contraindication or intolerance to the preferred drugs as listed in Blue Cross’ utilization management medical drug list or Blue Cross’ prior authorization and step therapy documents.

Drug names

• Aralast NP^® (alpha-1 proteinase inhibitor)
• Glassia™ (alpha-1 proteinase inhibitor)
• Prolastin^®-C (alpha-1 proteinase inhibitor)
• Prolastin^®-C Liquid (alpha-1 proteinase inhibitor)
• Zemaira^® (alpha-1 proteinase inhibitor)

Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form or through Availity^® with the necessary documentation that supports the service billed. Also, continue to fax one appeal at a time to avoid processing delays.

BCN Advantage℠

G2211

G2211 is payable for BCN Advantage and won’t be payable for Blue Care Network commercial. This configuration was updated at the end of June 2024.

G2211 description — Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.)

QN6

Enhanced benefits that were denying QN6 inappropriately have been corrected. This configuration was updated at the end of June 2024.

QN6 description — Not a covered service.

G0136

G0136 must be reported with a qualified visit to be payable. If a qualified service isn’t found on the same claim, then G0136 will deny.

G0136 description — Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5 to 15 minutes.

BCN commercial and BCN Advantage

Pain management

When pain management is reported with anesthesia or moderate sedation currently, the pain management codes are denying requiring providers to submit appeals on codes that were previously authorized by TurningPoint. We have updated the configuration to allow the pain management codes and deny the anesthesia or moderate sedation as of the end of June. Per our payment policy we don’t allow anesthesia or moderate sedation with pain management codes.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

TurningPoint Healthcare Solutions LLC is an independent company provides care review services for Blue Cross Blue Shield of Michigan and Blue Care Network.