Effective July 1, 2020, Anthem Blue Cross and Blue Shield 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)

 

  • Behavioral Health Care (BHC)

 

The tables below highlight new guidelines and changes that may be considered more restrictive.

 

Goal Length of Stay (GLOS) changes for Inpatient and 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

 

 



Featured In:
April 2020 Anthem Provider News - Virginia