This communication applies to the Medicaid, Medicare Advantage, and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).

 

Effective September 1, 2021, Anthem will upgrade to the 25th edition of MCG* care guidelines for the following modules: inpatient and surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.


Goal length of stay (GLOS) for inpatient and surgical care (ISC)

Guideline

MCG code

24th Edition GLOS

25th Edition GLOS

Aortic Coarctation, Angioplasty

S-152

Ambulatory or 1 day postoperative

Ambulatory

Cardiac Septal Defect: Atrial, Transcatheter Closure

W0016

Ambulatory or 1 day postoperative

Ambulatory

Esophageal Diverticulectomy, Endoscopic

S-445

Ambulatory or 1 day postoperative

Ambulatory

Gastrectomy, Partial - Billroth I or II

S-510

4 or 6 days postoperative

5 days postoperative

Hernia Repair (Non-Hiatal)

S-1305

Ambulatory or 1 day postoperative

Ambulatory

Pancreatectomy

S-1200

5 or 7 days postoperative

6 days postoperative

Pyloroplasty and Vagotomy

S-990

4 or 6 days postoperative

4 days postoperative

Cervical Laminectomy

W0097

2 days postoperative

Ambulatory or 2 days postoperative

Lumbar Diskectomy, Foraminotomy, or Laminotomy

W0091

Ambulatory or 1 day postoperative

Ambulatory

Removal of Posterior Spinal Instrumentation

S-530

1 day postoperative

Ambulatory or 1 day postoperative

Shoulder Hemiarthroplasty

W0138

1 day postoperative

Ambulatory or 1 day postoperative

Spine, Scoliosis, Posterior Instrumentation, Pediatric

W0156

4 days postoperative

3 days postoperative

Bladder Resection: Cystectomy with Urinary Diversion, Conduit or Continent

S-190

5 or 6 days postoperative

5 days postoperative

Prostatectomy, Transurethral Resection (TURP)

S-970

Ambulatory or 1 day postoperative

Ambulatory

Urethroplasty

S-1172

Ambulatory or 1 day postoperative

Ambulatory


New Guidelines for Behavioral Health Care (BHC) and Recovery Facility Care (RFC)

Body System

Guideline Title

MCG - Code

Withdrawal Management

Withdrawal Management, Adult: Inpatient Care

B-031-IP

Withdrawal Management

Withdrawal Management, Adult: Intensive Outpatient Program

B-031-IOP

Withdrawal Management

Withdrawal Management, Adult: Outpatient Care

B-031-AOP

Withdrawal Management

Withdrawal Management, Adult: Partial Hospital Program

B-031-PHP

Withdrawal Management

Withdrawal Management, Adult: Residential Care

B-031-RES

Cardiology

Hypertension

M-5197

Cardiology

Peripheral Vascular Disease (PVD)

M-7087

Nephrology

Rhabdomyolysis

M-7095

Nephrology

Encephalopathy

M-7100

Thoracic Surgery

Rib Fracture

M-5545


Customizations to MCG care guidelines 25th edition

Effective September 1, 2021, the following MCG care guideline 25th edition customization will be implemented:

  • Transcranial magnetic stimulation (TMS), W0174 (previously ORG: B-801-T) - Revised Clinical Indications for Procedure and added the following:
    • Need for acute TMS treatment, up to six weeks
    • Acute treatment course needed as indicated by (a) initial course of treatment for major depressive disorder (severe), or (b) relapse of symptoms after remission
    • Continuation of acute treatment, up to six months
    • TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
      • Maintenance TMS treatment
      • Continuation of acute TMS treatment for longer than 6 months
      • TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, Anxiety disorders, Bipolar depression, Neurodevelopmental disorders, Obsessive-compulsive disorder, Peripartum depression, Post-traumatic stress disorder, Substance use disorders, Tourette's syndrome.     


To view a detailed summary of customizations, visit either this link for Medicaid or this link for Medicare Advantage, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.

For questions, please contact Provider Services:

  • Medi-Cal Managed Care: 1-800-407-4627 (outside L.A. County)
  • A. Care: 1-888-285-7801 (inside L.A. County)
  • Cal MediConnect Plan: 1-855-817-5786
  • Medicare Advantage: Call the number on the back of the member ID card.

 

ACA-NU-0325-21



Featured In:
June 2021 Anthem Blue Cross Provider News - California