We have completed our review of the January 2019 current procedural terminology (CPT) and HCPCS code changes including any category II performance measurement tracking codes and category III temporary codes for emerging technology. These updates will be added to our claims processing system and are effective January 1, 2019. 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” – This indicates services where there is insufficient evidence to support.
- “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:
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.
Additional January 2019 CPT code updates:
The following codes are not covered for BlueCHiP for Medicare and not medically necessary for Commercial products for Professional and Institutional providers:
0080U 0082U 0083U
January 2019 HCPCS code updates:
The following codes are not separately reimbursed for Institutional providers for BlueCHiP for Medicare and Commercial products:
A4563 A5514 A6460 A6461 A9589 E0447 E0467 L8608 L8698 L8701 L8702
The following codes are not separately reimbursed for Professional and Institutional providers for BlueCHiP for Medicare and Commercial products:
B4105 C8937 G0071 G0076 G0077 G0078 G0079 G0080 G0081 G0082 G0083 G0084 G0085 G0086 G0087 G2010 G2011 G2012
The following codes are not covered for BlueCHiP for Medicare and not medically necessary for Commercial products for Professional and Institutional providers:
C1823 C9751
The following services are subject to medical review for professional and institutional providers for Commercial products:
C9036 C9038 J0185 J0584 J1301 J1454 J2797 J3245 J9057 J9173 J9311 J9312 Q5107 Q5109 Q5111
*Review effective February 1, 2019
The following services are subject to medical review for professional and institutional providers for BlueCHiP for Medicare and Commercial products:
A9513 J0517 J0567 J3397 J3398 Q2042
The following codes are invalid for professional providers for BlueCHiP for Medicare and Commercial products:
C9752 C9753 C9754 C9755
The following codes are not covered for professional and institutional providers for BlueCHiP for Medicare and Commercial products; pharmacy benefit only:
J0599 J1628
Not covered for professional and institutional providers for Commercial products; pharmacy benefit only:
J7170
The following codes are not medically necessary for professional and institutional providers for Commercial products:
J7318 J7329
Not covered for professional and institutional providers for BlueCHiP for Medicare and Commercial products:
T4545
The following codes are not covered for professional and institutional providers for BlueCHiP for Medicare:
V5171 V5172 V5181 V5211 V5212 V5213 V5214 V5215 V5221