Medicare AdvantageJuly 1, 2022
MCG care guidelines 26th edition
This communication applies to the Medicare Advantage and Medicare-Medicaid Plan (MMP) programs for Anthem Blue Cross (Anthem).
Effective September 1, 2022, we will upgrade to the 26th edition of MCG care guidelines for the following modules: Inpatient/surgical care (ISC). The below tables highlight new guidelines and changes.
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
Goal length of stay (GLOS) for ISC
|
Guideline |
MCG code |
25th edition GLOS |
26th edition GLOS |
|
*Aortic Valve Replacement, Transcatheter |
S-1320 [W0133] |
2 days postoperative |
1 day postoperative |
|
*Apnea, Neonatal (Non-Preterm Infants) |
P-15 |
3 days |
2 days |
|
*Renal Failure, Chronic |
M-325 |
3 days |
2 days |
|
*Subarachnoid Hemorrhage, Nonsurgical Treatment |
M-79 |
4 days |
3 days |
|
*Craniotomy, Supratentorial |
S-410 |
3 days postoperative |
2 days postoperative |
|
*Ankle Fracture, Closed, Open Reduction, Internal Fixation (ORIF) |
S-100 |
Ambulatory or 1 day postoperative |
Ambulatory |
|
*Hip Arthroplasty |
S-560 [W0105] |
Ambulatory or 2 days postoperative |
Ambulatory or 1 day postoperative |
|
*Humerus Fracture, Closed or Open Reduction |
S-632 |
Ambulatory or 1 day postoperative |
Ambulatory |
|
*Knee Arthroplasty, Total |
S-700 [W0081] |
Ambulatory or 2 days postoperative |
Ambulatory or 1 day postoperative |
|
*Lumbar Laminectomy |
S-830 [W0100] |
Ambulatory or 1 day postoperative |
Ambulatory |
|
*Nephrectomy |
S-870 |
3 days postoperative |
2 days postoperative |
|
*Prostatectomy, Radical |
S-960 |
1 day postoperative |
Ambulatory or 1 day postoperative |
|
Dehydration |
M-123 |
1 day |
2 days |
|
Esophageal Disease |
M-550 |
1 day |
2 days |
|
Gastritis and Duodenitis |
M-560 |
1 day |
2 days |
|
Pneumothorax, Neonatal |
P-355 |
2 days |
3 days |
|
Seizure |
M-327 |
1 day |
2 days |
|
Back Pain |
M-63 |
1 day |
2 days |
New Guidelines ISC
|
Body system |
Guideline title |
MCG code |
|
Hospital-at-Home |
Cellulitis: Hospital-at-Home |
M-70-HaH |
|
Hospital-at-Home |
Chronic Obstructive Pulmonary Disease: Hospital-at-Home |
M-100-HaH |
|
Hospital-at-Home |
Heart Failure: Hospital-at-Home |
M-190-HaH |
|
Hospital-at-Home |
Pneumonia: Hospital-at-Home |
M-282-HaH |
|
Hospital-at-Home |
Urinary Tract Infection (UTI): Hospital-at-Home |
M-300-HaH |
|
Observation Care |
Pancreatitis: Observation Care |
OC-065 |
|
Observation Care |
Renal Failure, Acute: Observation |
OC-066 |
|
Observation Care |
Stroke: Ischemic: Observation Care |
OC-067 |
Anthem Blue Cross customizations to MCG care guidelines 26th edition
To view a detailed summary of customizations, go to https://www.anthem.com/ca/provider/policies/clinical-guidelines, scroll down to the Other Criteria section, and select Customizations to MCG Care Guidelines 26th Edition.
Customer Care Centers:
- Cal MediConnect Plan: 855-817-5786
- Medicare Advantage: Call the number on the back of the member ID card.
PUBLICATIONS: July 2022 Anthem Blue Cross Provider News - California
To view this article online:
Visit https://providernews.anthem.com/california/articles/mcg-care-guidelines-26th-edition-6-10883
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