Policy Updates Medical Policy & Clinical GuidelinesCommercialApril 1, 2020

MCG Care Guidelines 24th Edition*

Effective July 1, 2020, we will upgrade to the 24th edition of MCG care guidelines for the following modules: Inpatient & 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) Changes for Inpatient & Surgical Care (ISC) and Behavioral Health Care (BHC)

Guideline

MCG Code

24th Edition GLOS

23rd Edition GLOS

Aortic Valve Replacement, Transcatheter

S-1320

2 days postoperative

3 days postoperative

Appendectomy, with Abscess or Peritonitis, by Laparoscopy

S-185

Ambulatory or

2 days postoperative

2 days postoperative

Appendectomy, without Abscess or Peritonitis, by Laparoscopy

S-175

Ambulatory postoperative

Ambulatory or

1 day postoperative

Repair of Pelvic Organ Prolapse

S-1020

Ambulatory postoperative

Ambulatory or

1 day postoperative

Urethral Suspension Procedures

S-850

Ambulatory postoperative

Ambulatory or

1 day postoperative

Appendectomy, with Abscess or Peritonitis, by Laparoscopy, Pediatric

P-30

Ambulatory or

2 days postoperative

2 or 3 days postoperative

Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric

P-20

Ambulatory postoperative

Ambulatory or

1 day postoperative

Tibial Osteotomy, Child or Adolescent

S-1131

Ambulatory or

1 day postoperative

1 day postoperative

Schizophrenia Spectrum Disorders, Adult: Inpatient Care

B-014-IP

5 days

6 days

Schizophrenia Spectrum Disorders, Child or Adolescent: Inpatient Care

B-027-IP

5 days

6 days

Transcranial Magnetic Stimulation

B-801-T

Utilize B-801-T for Clinical Indications for procedure

Refer to BEH.00002 for Clinical Indications for procedure

 

New Optimal Recovery Guidelines (ORGs) for Inpatient & Surgical Care (ISC) and New Behavioral Health Care (BHC) New Guidelines

Body System

Guideline Title

MCG Code

Pediatrics

Appendectomy, with Abscess or Peritonitis, Pediatric

P-35

Pediatrics

Appendectomy, without Abscess or Peritonitis, Pediatric

P-25

Home Care Behavioral Health

Attention-Deficit and Disruptive Behavior Disorders

B-003-HC

Home Care Behavioral Health

Autism Spectrum Disorders

B-012-HC

 

Anthem Customizations to MCG care guideline 24th Edition

Effective July 1, 2020, the following MCG care guideline 24th edition customizations will be implemented.

  • Carotid Artery Stenting (W0165) – Clinical Indications were customized to reference CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
  • Deep Brain Stimulation (W0164) – Clinical Indications were customized to refer to SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation.
  • Vagus Nerve Stimulation, Implantable (W0166) – Clinical Indications were customized to refer to SURG.00007 Vagus Nerve Stimulation.

 

To view a detailed summary of customizations, visit the Medical Policies & Clinical UM Guidelines page, scroll down to Other Criteria section and select Customizations to MCG Care Guidelines 24th Edition.

 

For questions, please contact the Provider Services number on the back of the member's ID card.

PUBLICATIONS: April 2020 Anthem Provider News - Missouri