HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJuly 1, 2022
MCG care guidelines 26th 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, 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.
PUBLICATIONS: July 2022 Anthem Provider News - Virginia
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