MedicaidMay 2, 2023
MCG Care Guidelines 27th edition
Effective September 1, 2023, we will upgrade to the 27th edition of MCG Care Guidelines for the following modules:
- Inpatient & Surgical Care (ISC)
- General Recovery Care (GRG)
- Behavioral Health Care (BHG)
- Chronic Care (CCG)
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 Inpatient & Surgical Care (ISC)
Guideline | MCG code | 26th edition GLOS | 27th edition GLOS |
*Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) Insertion | M157 [W0011] | Ambulatory or 1 day postoperative | Ambulatory |
*Renal Failure, Acute | M-326 | 3 days | 2 days |
*Paraplegia, Acute | M-255 | 8 days | 7 days |
*Tetraplegia, Acute | M-305 | 9 days | 7 days |
*Percutaneous Revascularization, Lower Extremity | S-1310 [W0121] | Ambulatory or 1 day postoperative | Ambulatory |
*Splenectomy by Laparoscopy | S-1062 | 1 day postoperative | Ambulatory or 1 day postoperative |
*Elbow Arthroplasty | S-420 | Ambulatory or 1 day postoperative | Ambulatory |
*Elbow Fracture, Open Treatment | S-424 | Ambulatory or 1 day postoperative | Ambulatory |
*Foot Fracture, Calcaneus or Talus, Open Reduction, Internal Fixation (ORIF) | S-490 | Ambulatory or 1 day postoperative | Ambulatory |
*Foot: Surgical Wound Care | S-495 | Ambulatory or 1 day postoperative | Ambulatory |
*Hip Resurfacing | S-565 | 2 days postoperative | Ambulatory or 1 day postoperative |
*Knee Dislocation, Closed or Open Reduction | S-675 | Ambulatory or 1 day postoperative | Ambulatory |
*Shoulder Arthroplasty | S-634 [W0137] | 1 day postoperative | Ambulatory or 1 day postoperative |
*Appendectomy, without Abscess or Peritonitis, Pediatric | P-25 | Ambulatory or 1 day postoperative | Ambulatory |
*Hip: Congenital Dislocation, Open Reduction | P-590 | 1 day postoperative | Ambulatory or 1 day postoperative |
*Renal Transplant, Pediatric | P-1015 [W0126] | 6 days postoperative | 5 days postoperative |
*Slipped Upper Femoral Epiphysis, Closed Reduction | P-443 | Ambulatory or 1 day postoperative | Ambulatory |
*Tibial Osteotomy, Child or Adolescent | S-1131 | Ambulatory or 1 day postoperative | Ambulatory |
*Bladder Incision: Cystotomy | S-200 | Ambulatory or 1 day postoperative | Ambulatory |
*Ureterotomy, Nontransurethral for Stone | S-1150 | 1 day postoperative | Ambulatory or 1 day postoperative |
New Guidelines for Inpatient & Surgical Care (ISC)
Body System | Guideline Title | MCG - Code |
Hospital-at-Home | COVID-19: Hospital-at-Home | M-281-HaH |
Hospital-at-Home | Viral Illness, Acute: Hospital-at-Home | M-280-HaH |
Observation Care Guidelines | COVID-19: Observation Care | OC-068 |
Pediatrics | COVID-19, Pediatric | P-281 |
Thoracic Surgery and Pulmonary Disease | COVID-19 | M-281 |
New Guidelines for Chronic Care (CCG)
Body System | Guideline Title | MCG - Code |
Social Determinants of Health | Food Insecurity | C-1164 |
Social Determinants of Health | Housing Insecurity | C-1165 |
Anthem Blue Cross and Blue Shield Healthcare Solutions Customizations to MCG care guideline 27th edition
To view a detailed summary of customizations, visit Provider Medical Policies | Anthem.com scroll down to Other Criteria section and select Customizations to MCG Care Guidelines 27th edition.
NVBCBS-CD-021786-23-CPN20908
PUBLICATIONS: June 2023 Provider Newsletter
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