We have completed our review of the 20 de outubro24 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 outubro, 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 outubro24 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 Professional providers and not separately reimbursed for Institutional Providers for both Medicare Advantage Plans and Commercial Products: 

A2027, A2028, A2029, A9610 

The following code(s) will be covered and separately reimbursed for Institutional providers and Professional providers for both Medicare Advantage Plans and Commercial Products: 

J0138, J1171, J1749, J2252, J2253, J2601

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: 

C8000, C9171, J2002, J2003, J2004, P9027

The following code(s) will be covered and will only be reimbursable to DME providers only for both Commercial Products and Medicare Advantage Plans: 

L1006, L1653, L1821

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: 

J8522, J8541, Q0519, Q0520

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: 

Q4334, Q4335, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345

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: 

A4543, E0721

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

A4545, E0715, E0716, E0737

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

C9169, C9170, C9172, J9329, Q5135, Q5136

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 

A4544, A7021, E2513, E3200, E0469, E0683, E0743, E0767, L8720, L8721

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

A4545 E0737 E0715 E0716

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

A2027 A2028 A2029 A4544 A7021 A9610 E0469 E0683 E0743 E0767 E2513 E3200 L8720 L8721