MCG care guidelines 25th edition

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, 2021, HealthKeepers, Inc. will upgrade to the 25th edition of MCG* care guidelines for the following modules: inpatient and surgical care (ISC), general recovery care (GRC), chronic care (CC), recovery facility care (RFC), and behavioral health care (BHC). The below tables highlight new guidelines and changes that may be considered more restrictive.

Goal length of stay (GLOS) for inpatient and surgical care (ISC)

 

Guideline	MCG code	24th Edition GLOS	25th Edition GLOS
Aortic Coarctation, Angioplasty	S-152	Ambulatory or 1 day postoperative	Ambulatory
Cardiac Septal Defect: Atrial, Transcatheter Closure	W0016	Ambulatory or 1 day postoperative	Ambulatory
Esophageal Diverticulectomy, Endoscopic	S-445	Ambulatory or 1 day postoperative	Ambulatory
Gastrectomy, Partial - Billroth I or II	S-510	4 or 6 days postoperative	5 days postoperative
Hernia Repair (Non-Hiatal)	S-1305	Ambulatory or 1 day postoperative	Ambulatory
Pancreatectomy	S-1200	5 or 7 days postoperative	6 days postoperative
Pyloroplasty and Vagotomy	S-990	4 or 6 days postoperative	4 days postoperative
Cervical Laminectomy	W0097	2 days postoperative	Ambulatory or 2 days postoperative
Lumbar Diskectomy, Foraminotomy, or Laminotomy	W0091	Ambulatory or 1 day postoperative	Ambulatory
Removal of Posterior Spinal Instrumentation	S-530	1 day postoperative	Ambulatory or 1 day postoperative
Shoulder Hemiarthroplasty	W0138	1 day postoperative	Ambulatory or 1 day postoperative
Spine, Scoliosis, Posterior Instrumentation, Pediatric	W0156	4 days postoperative	3 days postoperative
Bladder Resection: Cystectomy with Urinary Diversion, Conduit or Continent	S-190	5 or 6 days postoperative	5 days postoperative
Prostatectomy, Transurethral Resection (TURP)	S-970	Ambulatory or 1 day postoperative	Ambulatory
Urethroplasty	S-1172	Ambulatory or 1 day postoperative	Ambulatory

 

New Guidelines for Behavioral Health Care (BHC) and Recovery Facility Care (RFC)

 

Body System	Guideline Title	MCG - Code
Cardiology	Hypertension	M-5197
Cardiology	Peripheral Vascular Disease (PVD)	M-7087
Nephrology	Rhabdomyolysis	M-7095
Nephrology	Encephalopathy	M-7100
Thoracic Surgery	Rib Fracture	M-5545

 

Customizations to MCG care guidelines 25th edition

Effective September 1, 2021, the following MCG care guideline 25th edition customization will be implemented:

• Transcranial magnetic stimulation (TMS), W0174 (previously ORG: B-801-T) - Revised Clinical Indications for Procedure and added the following:
• Need for acute TMS treatment, up to six weeks
• Acute treatment course needed as indicated by (a) initial course of treatment for major depressive disorder (severe), or (b) relapse of symptoms after remission
• Continuation of acute treatment, up to six months
• TMS is considered not medically necessary for all other indications not listed above, including but not limited to, the following:
• Maintenance TMS treatment
• Continuation of acute TMS treatment for longer than six months
• TMS treatment of conditions other than major depressive disorder (severe), including but not limited to, the following: Alzheimer's disease, Anxiety disorders, Bipolar depression, Neurodevelopmental disorders, Obsessive-compulsive disorder, Peripartum depression, Post-traumatic stress disorder, Substance use disorders, Tourette's syndrome.     

 

To view a detailed summary of customizations, visit this link, scroll down to other criteria section and select Customizations to MCG Care Guidelines 25th Edition.

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

 

* MCG Health is an independent company providing care guidelines on behalf of HealthKeepers, Inc.

 

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