Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus offered by HealthKeepers, Inc.

 

Effective September 1, 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 HealthKeepers Plus customizations to MCG care guidelines 26th edition

 

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

 

If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800‑901‑0020 or Anthem CCC Plus Provider Services at 855‑323‑4687.

 

AVA-NU-0573-22



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