We have completed our review of the 20 de abril23 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, 2023. The lists include 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 “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 covered" for Commercial and Medicare Advantage Plans this indicates services that are not covered based on contract.
• “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.

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 abril23 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 codes are covered and are separately reimbursed for Professional and Institutional providers for Medicare Advantage Plans and Commercial Products:

C9145    J0612     J0613     J9196

The following code is not covered for Professional and Institutional providers for Medicare Advantage Plans and for Commercial Products:

K1035

Effective 01/04/2023, the following codes are subject to medical review for Professional and Institutional providers for Commercial Products only (Pharmacy Benefit): 

C9146    C9147    C9148    J0218     J1449     J1747     Q5127   Q5128   Q5129   Q5130  

Effective 01/05/2023, the following codes are subject to medical review for Professional and Institutional providers for Commercial Products (Pharmacy Benefit): 

C9149    J0208     J1411     J9294     J9296     J9297    

Effective 01/05/2023, the following codes are subject to medical review for Professional and Institutional providers for Medicare Advantage Plans (Pharmacy Benefit). These codes will be covered and separately reimbursed for Professional and Institutional providers from 01/04/2023 through 30/04/2023: 

C9146    C9147    C9148    C9149    J0208     J0218     J1411     J1449     J1747     J9294     J9296               J9297     Q5127 Q5128     Q5129   Q5130       

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

A4341    A4342    A4560                  

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

A7049    E1905

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

A2019    A2020    A2021    J2403     Q4265   Q4266   Q4267   Q4268   Q4269   Q4270   Q4271

The following code is not separately reimbursed for Professional providers for Medicare Advantage Plans and Commercial Products:

S9563

The following code is not separately reimbursed for Professional providers and Institutional providers for Medicare Advantage Plans and Commercial Products:

E0711

The following codes are not separately reimbursed for Professional providers and Institutional providers and are separately reimbursed for Durable Medical Equipment (DME) providers only for Medicare Advantage Plans and Commercial Products:

A4341    A4342    A6590    A6591    E0677    L8678

The following codes are covered when filed with a covered diagnosis and will not be separately reimbursed for Institutional providers for Medicare Advantage Plans and Commercial Products:

Q4265   Q4266   Q4267   Q4268   Q4269   Q4270   Q4271

The following code is related to quality measures and are for informational purposes for CMS:

M0010  Enhancing oncology model (EOM) monthly enhanced oncology services (MEOS) payment for EOM enhanced services

New HCPCS Modifiers Effective 01/04/2023