We have completed our review of the 20 de enero24 CPT code changes, including any category II performance measurement tracking codes and category II temporary codes for emerging technology. These updates will be added to our claims processing system and are effective 1 de enero de 2024. The list includes codes 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, CPT 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.

CPT is a registered trademark of the American Medical Association.

20 de enero24 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 codes are not covered for Professional and Institutional providers for Medicare Advantage Plans and not medically necessary for Professional and Institutional providers for Commercial Products as they are related to a new policy that will go into effect 01/1/2024 called Interventions for Progressive Scoliosis:

0790T   22836   22837  22838

The following code will be subject to medical review for Professional and Institutional providers for Medicare Advantage Plans from 01/1/2024 through 01/31/2024. Effective 02/1/2024, the code will be not covered for Professional and Institutional providers for Medicare Advantage Plans. Effective 01/1/2024, the code will not be medically necessary for Professional and Institutional providers for Commercial Products. This is related to an updated policy that will go into effect 02/1/2024 called Percutaneous and Subcutaneous Tibial Nerve Stimulation:

0816T

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

0420U  81517  0813T 27278  31242  31243 33276  33277  33279 33281 93150  93151  93152 93153 

The following codes are covered for Professional and Institutional providers for Commercial Products and not covered under Part B for Medicare Advantage Plans:

90589  80623

The following code is covered for Professional and Institutional providers for Commercial Products as a Preventive Service and not covered under Part B for Medicare Advantage Plans:

90683

The following code is covered for Professional and Institutional providers for Commercial Products as a Preventive Service and will be subject to medical review for Professional and Institutional providers for Medicare Advantage Plans:

0421U

The following code is medically necessary for Professional and Institutional providers for both Medicare Advantage Plans and Commercial Products based on diagnosis code(s) (related to Low-Level Laser Therapy medical policy):

97037  

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

0811T  97550  97551 97552

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

0827T  0828T  0829T 0830T  0831T  0832T 0833T  0834T  0835T 0836T  0837T  0838T 0839T  0840T  0841T 0842T  0843T  0844T 0845T  0846T  0847T 0848T  0849T  0850T 0851T  0852T  0853T 0854T  0855T  0856T 0857T  0859T   

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

0865T  0866T  76984 76987  76988  76989 92622 92623  92972  93584 83585  93586  93587 93588  99459

The following codes are subject to medical review for Professional and Institutional providers for both Medicare Advantage Plans and Commercial Products:

0422U  0424U  0425U 0426U  0427U  0428U 0430U  0431U  0432U 0433U  0435U  0436U 0438U 81457  81458  81459 81462  81463  81464 0785T  0787T  0818T 0819T  33278  33279 33280  33287 33288  58580

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

0423U  0437U  0861T 0862T  0863T  52284 61889  61891  61892 64596 64597  64598  67516 75580  82166  86041 86042  86043  86366 87523  96547  96548     

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

0429U  0823T  0824T 0825T  0826T   

The following codes are not covered for Professional and Institutional providers for Medicare Advantage Plans and not medically necessary for Commercial Products when filed with diagnosis codes of F01-F99. All other diagnosis codes, the codes will be subject to medical review for Professional and Institutional providers for both Medicare Advantage Plans and Commercial Products:

0434U

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

0784T  0786T  0788T 0789T  0812T  0814T 0815T  0817T  0858T 0860T  0864T 

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

0820T  0821T  0822T