Medicaid Managed CareMay 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)
- Recovery Facility Care (RFC)
- Behavioral Health Care (BHG)
- Chronic Care (CCG)
- Home Care (HC)
- Ambulatory Care (AC)
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 | M-157 | 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 | 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 | 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 | 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 Recovery Facility Care (RFC)
Body System | Guideline Title | MCG - Code |
Cardiovascular Surgery | Percutaneous Revascularization, Lower Extremity | S-6310 |
Thoracic Surgery and Pulmonary Disease | COVID-19 | M-5281 |
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 |
New Guidelines for Home Care (HC)
Body System | Guideline Title | MCG - Code |
Cardiovascular Surgery | Percutaneous Revascularization, Lower Extremity | S-3310 |
Thoracic Surgery and Pulmonary Disease | COVID-19 | M-2281 |
New Guidelines for Ambulatory Care (AC)
Body System | Group | Guideline Title | MCG - Code |
Genetic Medicine | Oncology | Oncology Companion Diagnostic Testing -FoundationOne CDx | A-1055 |
Genetic Medicine | Oncology | Oncology Companion Diagnostic Testing -Guardant360 CDx | A-1056 |
Procedures and Diagnostic Tests | Neurology | EEG, Quantitative (Brain Mapping) | A-1050 |
Procedures and Diagnostic Tests | Orthopedics | Neurolysis, Genicular Nerve | A-1047 |
Procedures and Diagnostic Tests | Orthopedics | Sacroiliac Joint Injection | A-1048 |
Procedures and Diagnostic Tests | Thoracic Surgery and Pulmonary Disease | Endobronchial Ultrasound | A-1049 |
Specialty Medications | Eye Conditions | Faricimab-svoa | A-1051 |
Specialty Medications | Hematologic Conditions | Betibeglogene Autotemcel | A-1057 |
Specialty Medications | Oncologic Conditions | Ciltacabtagene Autoleucel | A-1052 |
Specialty Medications | Pulmonary Conditions | Tezepelumab-ekko | A-1053 |
If you have questions, please contact the Provider Service number on the back of the member's ID card.
OHBCBS-CD-021789-23-CPN20908
PUBLICATIONS: June 2023 Provider Newsletter
To view this article online:
Visit https://providernews.anthem.com/ohio/articles/mcg-care-guidelines-27th-edition-2-13257
Or scan this QR code with your phone