Updates were made that impact HCPCS codes J1748, J8611, J8612, Q5137. Please refer to details below.

We have completed our review of the 20 de julho24 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 julho, 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 julho24 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: 

C9901 J0211 J0687 J0872 J2183 J2246 J2373 J2468 J2470 J2471 

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

A9506 C1605 C1606 G0519 G0520 G0521 G0522 G0523 G0524 G0525 G0526 G0527 G0528 G9037 G9038 J0911 J1597 J1598 

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

G0529 G0530 G0531 

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

J2267   J3247   J3263   J3393   J3394   J7171  J9361 Q5138

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 based on new policy, Implantation of Anterior Segment Intraocular Nonbiodegradable Drug-Eluting System: 

J7355 

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: 

Q4311 Q4312 Q4313 Q4314 Q4315 Q4316 Q4317 Q4318 Q4319 Q4320 Q4321 Q4322 Q4323 Q4324 Q4325 Q4326 Q4327 Q4328 Q4329 Q4330 Q4331 Q4332 Q4333 

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: J8611 J8612  J1748 Q5137