State & FederalJuly 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 Care

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.

 

ACAD-NU-0382-22

 

PUBLICATIONS: July 2022 Anthem Blue Cross Provider News - California