We have completed our review of the enero de 2025 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 2025. 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.

enero de 2025 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 code(s) will be covered and separately reimbursed for Professional and Facility providers for Medicare Advantage Plans and Commercial Products:

49186, 49187, 49188, 49189, 49190, 64466, 64467, 64468, 64469, 64473, 64474, 86581, 87513, 87564, 87594, 87626, 96041

The following vaccine code will be not covered (pharmacy benefit only) for Medicare Advantage Plans, covered for Commercial Products and separately reimbursed for Professional and Facility Providers:

90593

The following code(s) will require prior authorization for Medicare Advantage Plans and Commercial Products and will be separately reimbursed for Professional and Facility providers: 

25448, 53866, 61715, 81195, 81558, 82233, 82234, 83884, 84393, 84394, 0521U, 0522U, 0523U, 0524U, 0525U, 0526U, 0527U, 0528U, 0529U, 0530U, 0910T, 0919T, 0920T, 0921T, 0922T, 0942T, 0943T

The following code(s) will require prior authorization with (Cardiology and Radiology vendor) for Medicare Advantage Plans and Commercial Products and will be separately reimbursed for Professional and Facility Providers: 

0913T, 0914T, 0915T, 0916T, 0917T, 0918T, 0923T, 0933T

The following code(s) will be considered medically necessary when filed with a covered ICD-10 code for Medicare Advantage Plans and Commercial Products and will be separately reimbursed for Professional and Facility providers: 

81515

The following code(s) will require prior authorization for Medicare Advantage Plans and will be not medically necessary for Commercial Products and will be separately reimbursed for Professional and Facility Providers: 

51721, 55881, 55882, 66683, 92137, 0901T, 0902T, 0903T, 0904T, 0905T, 0906T, 0907T, 0908T, 0909T, 0911T, 0912T, 0924T, 0925T, 0926T, 0927T, 0928T, 0929T, 0930T, 0931T, 0932T, 0934T, 0935T, 0936T, 0937T, 0938T, 0939T, 0940T, 0941T, 0944T, 0945T, 0946T, 0947T

The following code(s) will be not covered for Medicare Advantage Plans and not medically necessary for Commercial Products and will be separately reimbursed for Professional and Facility Providers: 

53865, 60660, 60661

The following code(s) will be covered but not separately reimbursed for Medicare Advantage Plans and Commercial Products for Professional and Facility Providers: 

38225, 38226, 38227, 38228, 15011, 15012, 15013, 15014, 15015, 15016, 15017, 15018, 76014, 76015, 76016,76017, 76018, 76019, 93896, 93897, 93898, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016