We have completed our review of the enero de 2025 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 2025. 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.
enero de 2025 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 code(s) will be not covered for Medicare Advantage Plans and not medically necessary for Commercial Products for both Professional and Institutional providers:
G0555
The following code(s) 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:
Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353
The following code(s) will be subject to medical review for Professional and Institutional providers for Medicare Advantage Plans and are not medically necessary for Professional and Institutional providers for Commercial Products
A9615 C1735 C1736 C1739 C7562 C7563 C7564 C7565 C8001 C8002 C8003 C9610 G0561 G0562 G0563 G0564 G0565 C9807 C9808 C9809
The following code(s) will be covered and not separately reimbursed for Institutional providers and Professional providers for Commercial Products and Medicare Advantage Plans:
C1737 C1738 G0534 G0535 G0537 G0538 G0544 G0546 G0547 G0548 G0549
G0550 G0551 G0552 G0553 G0554 G0556 G0557 G0558 G0559 G0560 H0052 H0053 J0666 J0901
The following code(s) will be covered and separately reimbursed for Institutional providers and Professional providers for both Medicare Advantage Plans and Commercial Products:
G0545 J0601 J0602 J0603 J0605 J0607 J0608 J0609 J0615 J2290 J2472 J9076 Q0155
The following code(s) will be:
- Covered and separately reimbursed for Institutional providers and Professional providers for Medicare Advantage Plans
- Covered and Use Alternate Code for Institutional providers and Professional providers for Commercial Products:
G0532 G0533
The following code(s) will be covered and separately reimbursed for Professional providers and not separately reimbursed for Institutional providers for Medicare Advantage Plans and Commercial Products:
E1813 E1814 E1822 E1823 E1828 E1829
The following codes will be covered and Informational Only as they are related to quality measures and are for informational purposes for CMS:
M1371 M1372 M1373 M1374 M1375 M1376 M1377 M1378 M1379 M1380 M1381 M1382 M1383 M1384 M1385 M1386 M1387 M1388 M1390 M1391 M1392 M1393 M1394 M1395 M1396 M1397 M1398 M1399 M1400 M1401 M1402 M1403 M1404 M1405 M1406 M1407 M1408 M1409 M1410 M1411 M1412 M1413 M1414 M1415 M1416 M1417 M1418 M1419 M1420 M1421 M1422 M1423 M1424 M1425
The following code(s) will be reimbursed under the Pharmacy Benefit Only for both Professional and Institutional providers for Commercial Products and Medicare Advantage Plans:
J0139 J7514 J7601 Q0521 Q5140 Q5141 Q5142 Q5143 Q5144 Q5145 Q9996 Q9998
The following code(s) will be subject to medical review for Professional and Institutional providers (Pharmacy Benefit) for Commercial Products and Medicare Advantage Plans:
C9173 J0870 J1307 J1414 J1552 J2802 J3392 J9026 J9028 J9292 Q5139 Q5146 Q9997
The following code(s) will be covered and separately reimbursed for Institutional providers and Professional providers for Medicare Advantage Plans and not covered/contract exclusion for Commercial Products for Institutional providers and Professional providers:
G0539 G0540 G0541 G0542 G0543
The following code(s) will be covered and “Use Alternate Code" for Institutional providers and Professional providers for Medicare Advantage Plans and Commercial Products:
G0536
The following code(s) will be covered and separately reimbursed for Institutional providers and Professional providers for Medicare Advantage Plans and not medically necessary for Commercial Products for Institutional providers and Professional providers:
C9804 C9806
The following code(s) will be
- Covered and separately reimbursed for Professional providers and not separately reimbursed for Institutional providers for Medicare Advantage Plans
- Subject to medical review for Professional providers for Commercial Products, will be separately reimbursed for Professional providers and will be not separately reimbursed for Institutional providers:
E1803 E1804 E1807 E1808 E1826 E1827
The following code(s) 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:
Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353