We have completed our review of the 20 de octubre24 Healthcare Common Procedure Coding System (HCPCS) changes and Modifier changes. These updates will be added to our claims processing system and are effective 1 de octubre de 2024. The lists include code that have special coverage or payment rules for standard Products. (Some employers may customize their benefits.) We have included codes for services that are:

• “Not covered" this includes services not covered in the main member certificate (e.g., covered as a prescription drug). 
• “Not medically necessary “for Commercial and “Not Covered" for Medicare Advantage Plans this indicates services where there is insufficient evidence to determine the  effects of the technology on health outcomes.  
• “Not separately reimbursed" – services that are not separately reimbursed are generally included in payment for another service or are reported using another code and may not be billed to your patient.
• “Subject to medical review" – preauthorization is recommended for Commercial Products and required for Medicare Advantage Plans.
• “Individual Consideration review"- services that require supporting documentation filed with the claim for review.
• “Use Alternate Code"- services that require the use of an alternate code that is addressed in an existing policy.

Please submit your comments and concerns regarding coverage and payment designations to:

Blue Cross & Blue Shield of Rhode Island

Attention: Medical Policy, HCPCS Review

500 Exchange Street

Providence, Rhode Island 02903

Please note that as a participating provider, it is your responsibility to notify members about non-covered services prior to rendering them.

20 de octubre24 CPT Updates:

Tenga en cuenta: Coverage and/or payment rules for code(s) below may be subject to change for Medicare Advantage Plans and/or Commercial Products. 

Additionally, coverage may vary for those Commercial Products that have opted out of the Biomarker Testing Mandate.

The following code(s) are covered and separately reimbursed for Professional and Institutional providers for Medicare Advantage Plans and Commercial Products:

0476U, 0477U   

The following code(s) are covered and separately reimbursed for Professional and Institutional providers for Commercial Products and are covered under the Pharmacy Benefit only for Medicare Advantage Plans:

90624

The following code(s) are subject to medical review unless filed with ICD-10 code(s) in the range of F01 to F99, which are covered. The following codes are also separately reimbursed for Professional and Institutional providers for Medicare Advantage Plans and Commercial Products:

0516U, 0517U, 0518U, 0519U, 0520U     

The following code(s) are subject to medical review and are separately reimbursed for Professional and Institutional providers for Medicare Advantage Plans and Commercial Products:

0478U, 0479U, 0480U, 0481U, 0482U, 0483U, 0484U, 0485U, 0486U, 0487U, 0488U, 0490U, 0491U, 0492U, 0493U, 0494U, 0495U, 0496U, 0497U, 0498U, 0499U, 0500U, 0501U, 0502U, 0503U, 0504U, 0505U, 0506U, 0507U, 0508U, 0509U, 0510U, 0511U, 0512U, 0513U, 0514U, 0515U 

The following code(s) are not covered for Medicare Advantage Plans and not medically necessary for Commercial Products for Professional and Institutional providers:

0489U