We have completed our review of the October 2023 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 October 1, 2023. 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.

October 2023 CPT 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) are covered and are separately reimbursed for professional and institutional providers for Medicare Advantage plans and commercial products:

0402U  0403U 0404U 0405U  0406U  0407U 0409U  0410U  0413U 0414U  0415U  0416U 0418U  0019M

The following code(s) are covered under the pharmacy benefit only and are separately reimbursed for professional and institutional providers for Medicare Advantage plans and commercial products:

0408U  0411U 0419U 

The following codes are not medically necessary for professional and institutional providers for both Medicare Advantage plans and commercial products:

0412U

The following codes are subject to medical review for professional and institutional providers for both Medicare Advantage plans and commercial products:

0417U