We have completed our review of the 20 de octubre23 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 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 “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 octubre23 HCPCS 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.

The following codes will be covered and separately reimbursed for Institutional providers and Professional providers for both Medicare Advantage Plans and Commercial Products: 

C9152   C9153  C9154   C9158   J0349    J0874    J2359    J7519   

The following codes will be covered and separately reimbursed for Institutional providers and Professional providers for Medicare Advantage Plans only: 

J9051    J9064   

The following codes will be subject to medical review effective 10/1/2023 for Professional and Institutional providers (Pharmacy Benefit) for Commercial Products only: 

J9051    J9064   

The following codes will be subject to medical review effective 10/1/2023 for Professional and Institutional providers for Medicare Advantage Plans and Commercial Products (Pharmacy Benefit): 

C9155  J2781   J9345

The following code will be covered under the pharmacy benefit only for Medicare Advantage Plans and Commercial Products:

A9156

The following code will be covered for both Medicare Advantage Plans and Commercial Products from 10/1/2023 through 10/31/2023, but will be subject to medical review effective 11/1/2023 for Professional and Institutional providers for Medicare Advantage Plans and Commercial Products (Pharmacy Benefit): 

C9157

The following codes will be 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:

A9292    L5991     C9790     C9791

The following codes will be not covered for Medicare Advantage Plans and not medically necessary for Commercial Products for Professional and Institutional providers:

A9268    A9269     E0490     E0491    K1036     

The following code will be not covered for Medicare Advantage Plans or Commercial Products for both Professional and Institutional providers:

V2526

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

A2022     A2023    A2024     A2025     A9573    A9697     B4148     C9156    J7353     L1681     

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

A9603     C9788    C9789     C9792     J0801    J0802     J0889     J7214

The following code will require an alternate code for Professional providers only for Medicare Advantage Plans and Commercial Products:

J2781   

The following codes will require an alternate code for Professional providers only and will be not separately reimbursed for Institutional providers for Medicare Advantage Plans and Commercial Products:

C9790     C9791   

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

Q4285  Q4286 

The following codes will be for informational purposes only and not separately reimbursed for Professional providers and Institutional providers for Medicare Advantage Plans and Commercial Products:

H2040     H2041