State & FederalCommercialOctober 11, 2022

MCG Care Guidelines 26th edition

This communication applies to Medicaid under Anthem Blue Cross and Blue Shield Healthcare Solutions and Medicare Advantage under Anthem Blue Cross and Blue Shield (Anthem).

Effective September 23, 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 customizations to MCG care guidelines 26th edition

To view a detailed summary of customizations, go to https://www.anthem.com/provider/policies, scroll down to Other Criteria, and select MCG Care Guidelines 26th Edition.

 

Provider Services:

  • Medicaid: 844-396-2330
  • Medicare Advantage: Call the number on the back of the member ID card.

 


ANV-NU-0330-22

PUBLICATIONS: MCG Care Guidelines 26th edition - Nevada