BadgerCare Plus and Medicaid SSI ProgramsJuly 1, 2022
MCG care guidelines 26th edition
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 |
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 Blue Cross and Blue Shield customizations to MCG care guidelines 26th edition
To view a detailed summary of customizations, go to the Medical Policies and Clinical Guidelines page, scroll down to Other Criteria, and select Customizations to MCG Care Guidelines 26th Edition.
Provider Services:
- Medicaid: 855-558-1443
- Medicare Advantage: Call the number on the back of members’ ID cards
PUBLICATIONS: July 2022 Anthem Provider News - Wisconsin
To view this article online:
Visit https://providernews.anthem.com/wisconsin/articles/mcg-care-guidelines-26th-edition-12-11107
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