We have completed our review of the 20 de enero23 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 enero de 2023. 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" – This indicates services where there is insufficient evidence to support it.
• “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 BlueCHiP for Medicare.
• “Invalid" – Use alternate procedure codes, such as a CPT or HCPCS code.
• “Medicare Lab Network" – Codes that are reimbursed to a hospital laboratory outside of the laboratory network, physicians, or urgent care center providers for BlueCHiP for Medicare.
• “Pending CMS determination" – For BlueCHiP for Medicare Category III codes.

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

Email: Medical.Policy@bcbsri.org

Mail:

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 enero23 HCPCS Updates:

Please note: Coverage and/or payment rules for codes below may be subject to change for Medicare Advantage plans and/or commercial products.

The following codes are subject to medical review for Professional and Institutional providers for Medicare Advantage Plans and is not medically necessary for Professional and Institutional providers for Commercial Products:

C7504, C7505, C7507, C7508

The following codes are subject to medical review for Professional and Institutional providers for Medicare Advantage Plans and Commercial Products (Pharmacy Benefit):

J0225, J2327, J9314, Q5126

The following codes are subject to medical review for Professional and Institutional providers for Commercial Products only (Pharmacy Benefit):

J1954, J9046, J9048, J9049

The following codes are not separately reimbursed for Institutional providers for Medicare Advantage Plans and Commercial Products:

A4239, C1826, C1827, E2103

The following codes are not separately reimbursed for Professional providers and Institutional providers for Medicare Advantage Plans and Commercial Products:

C1747, C7902, G0322, G0323, G3002, G3003

The following codes are covered when filed with a covered diagnosis and will not be separately reimbursed for Institutional providers for Medicare Advantage Plans and Commercial Products:

Q4236, Q4262-Q4264

For the following code, an alternate code is required for Professional providers for Medicare Advantage Plans and Commercial Products and is not separately reimbursed for Institutional providers for Medicare Advantage Plans and Commercial Products:

C9144

For the following codes, an alternate code is required for Professional providers and Institutional providers for Medicare Advantage Plans and Commercial Products:

C7900, C7901, G0320, G0321, G0330

The following codes are related to quality measures and are for informational purposes for CMS:

• MIPS Value Pathways: The MVPs framework aims to align and connect measures and activities across the Merit-based Incentive Payment System (MIPS) performance categories of quality, cost, and improvement activities for different specialties or conditions.

HCPCS M0001-M0005

• Code created for CMS Quality Care Measures documentation

HCPCS M1150-M1210

New HCPCS Modifiers Effective 01/1/2023