We have completed our review of the 20 de enero24 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 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 enero24 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: 

A4468  G0011  G0012 J0184  J0391  J0402 J0576  J0688  J0799 J0873  J1105  J1596 J1939  J2404  J2679 J2799  J3425  J9052 J9072  J9172  J9255 J9258  J9324

The following code will be covered and separately reimbursed for Institutional providers and Professional providers for Commercial Products only: 

A4287

The following code will be not covered for Medicare Advantage Plans only:

A4287

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

J0217 J1304  J1412  J2508 J3401  J9286  J9321 J9333  J9334

The following codes will be subject to medical review for Professional and Institutional providers (Pharmacy Benefit) and is not separately reimbursed for Institutional providers or Professional providers for Medicare Advantage Plans and Commercial Products:

C9160  C9161 C9162  C9163  C9165 

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

J0750  J0751  Q0516 Q0517  Q0518  Q5132

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 and are not separately reimbursed for Institutional providers or Professional providers for Medicare Advantage Plans and Commercial Products:

C1600  C1601 C1602  C1603  C1604 C7556  C7557  C7558 C7560  C9793  C9794 C9795 

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, and are reimbursable to Durable Medical Equipment (DME) providers only for Medicare Advantage Plans and Commercial Products:

E0678  E0679 E0680  E0681  E0682 

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:

E0735  E3000 L3161  L5926

The following code will be subject to medical review for Professional and Institutional providers for Medicare Advantage Plans and for Commercial Products:

L5615

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

A4457 A4541  A4542  E0492 E0493  E0530  E0732 E0733  E0734  J1413

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

A7023 A1301  E1301 

The following code will be not covered for Medicare Advantage Plans and not medically necessary for Commercial Products when filed with a non-covered diagnosis code for Professional and Institutional providers:

A4540                                                                                                                                                 

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

A9608  A9609

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

C7903  C9159  C9164 G0013  G0017  G0018 G0019  G0022  G0023 G0024  G0136  G0140 G0146  G9886  G9887 G9888

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

G0137 

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

Q4279  Q4287 Q4288  Q4289  Q4290 Q4291  Q4292  Q4293 Q4294  Q4295  Q4296 Q4297  Q4298  Q4299 Q4300  Q4301  Q4302 Q4303  Q4304

The following codes are reimbursable to Durable Medical Equipment (DME) providers only for Medicare Advantage Plans and Commercial Products: 

A6520  A6521  A6522 A6523  A6524  A6525 A6526  A6527  A6528 A6529  A6552  A6553 A6554  A6555  A6556 A6557  A6558  A6559 A6560  A6561  A6562 A6563  A6564  A6565 A6566  A6567  A6568 A6569  A6570  A6571 A6572  A6573  A6574 A6575  A6576  A6577 A6578  A6579  A6580 A6581  A6582  A6583 A6584  A6585  A6586 A6587  A6588  A6589 A6593  A6594  A6595 A6596  A6597  A6598 A6599  A6600  A6601 A6602  A6603  A6604 A6605  A6606  A6607 A6608  A6609  A6610 E2001

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. Codes created for CMS Quality Care Measures documentation: 

M1211 - M1370