We have completed our review of the 20 de abril24 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 abril, 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 abril24 HCPCS Updates:

Please note: 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 covered and separately reimbursed for Institutional providers and Professional providers for both Medicare Advantage Plans and Commercial Products: 

J0209   J0577   J0578   J0650   J0651   J0652   J1010   J1434   J2801   J2919   J3424   J7165   J7354 J9073            J9074   J9075

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

A9293

The following code(s) will be not covered for Institutional providers and Professional providers for Commercial Products and Medicare Advantage Plans: 

E0152  E2298  H0051

The following code(s) will be not covered for Institutional providers and Professional providers for Medicare Advantage Plans only:

A4293

The following code(s) will be not covered for Institutional providers and Professional providers for Commercial Products only: 

S9002

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

G0138 J0177   J0589   J1202   J1203   J1323   J2782   J3055   J9248

C9168  J9249   J9376   Q5133 Q5134

The following code(s) will be covered effective 01/04/2024, but will be subject to medical review effective 01/05/2024 for Professional and Institutional providers (Pharmacy Benefit) for Commercial Products and Medicare Advantage Plans:

C9166 C9167 J2277               

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

L5841

The following code(s) 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

A4438 A4593 A4594 E0736  E0738  E0739  K1037

The following code(s) will be subject to medical review for Professional and Institutional providers for Medicare Advantage Plans and will be covered for Professional and Institutional providers for Commercial Products

A4271 E2104

Effective 01/01/2024, the following code(s) 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

C9796 C9797

*Nota: Per the Centers for Medicare and Medicaid Services (CMS), these HCPCS codes are retroactively effective to 01/01/2024

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: 

Q4305 Q4306 Q4307 Q4308 Q4309 Q4310

The following code(s) will be not separately reimbursed for Professional providers and Institutional providers for Medicare Advantage Plans and Commercial Products:

A4438 H0051

The following code(s) will be not separately reimbursed for Institutional providers only for Medicare Advantage Plans and Commercial Products:

A2026 E0468  E0736  E0738  E0739  K1037 S4988  S9002

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

A4564 L1320  L5783  L5841