Policy UpdatesMedicare AdvantageMay 31, 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 Customizations to MCG Care Guideline 27th Edition

To view a detailed summary of customizations, go to Medical Policies & Clinical UM Guidelines

Scroll down to other criteria section and select Customizations to MCG Care Guidelines 27th Edition.

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

MULTI-BCBS-CR-021495-23- CPN20927

PUBLICATIONS: June 2023 Provider Newsletter