This policy version was replaced on March 4, 2024. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-management, select 'See Medical and Behavioral Health Policies', then 'Blue Cross and Blue Shield of Minnesota Medical and Behavioral Health Policies'. This will bring up the Medical Policy search screen. Enter the policy number without the version number (last three digits).
NOTE: The intent of this policy is to provide clinical criteria for use of an outpatient hospital setting for selected outpatient procedures. Many specialists in the Blue Cross network have already started redirecting patients to ambulatory surgery centers (ASCs) for these procedures when clinically appropriate. Groups performing these procedures outside the hospital have shown evidence of safe, high quality outcomes, while maintaining an excellent patient experience.
This policy addresses patient and/or procedural factors that may increase a patient’s risk of requiring urgent access to a higher level of care available in a hospital outpatient facility rather than an ASC during outpatient procedures, including but not limited to endoscopic procedures.
Definitions
American Society of Anesthesiology (ASA) Physical Status (PS) Classification:
Brittle diabetes: Diabetes that is difficult to control due to symptoms such as predominant hyperglycemia with recurrent ketoacidosis, predominant hypoglycemia, and mixed hyper- and hypo-glycemia.
New York Heart Association (NYHA) Functional Classification:
Obstructive sleep apnea (OSA): A sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort.
Site of service: The location where the outpatient procedure is performed, including the following:
NOTE:
For exceptions to this policy see Site of Service Program Information for Members or Site of Service Program Information for Providers.
Outpatient Hospital Site of Service
I. When the criteria in Section II are not met, use of a hospital outpatient facility for an outpatient procedure is considered NOT MEDICALLY NECESSARY and a non-hospital outpatient setting (e.g., ambulatory surgery center, office-based surgical suite) should be used.
II. Use of a hospital outpatient facility for an outpatient procedure, may be considered MEDICALLY NECESSARY AND APPROPRIATE when any of the following criteria are met:
Inpatient Hospital Site of Service
III. Use of an inpatient hospital facility solely for a procedure noted in the table below is considered NOT MEDICALLY NECESSARY.
See table below.
Table. Outpatient Procedures Included in the Site of Service Program
CPT Codes |
Ear, Nose, Throat (ENT) Procedures |
21320, 30140, 30520, 69436, 69631 |
Gynecologic Procedures |
57522, 58353, 58558, 58563, 58565 |
Hernia Procedures |
49505, 49650, 49651 |
Orthopedic Arthroscopy & Foot Procedures |
28285, 28289, 28291, 28292, 28296, 28297, 28298, 28299, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29830, 29834, 29835, 29836, 29837, 29838, 29840, 29844, 29845, 29846, 29847, 29848, 29860, 29861, 29862, 29863, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29899, 29914, 29915, 29916 |
Upper & Lower Gastrointestinal Endoscopy |
43235, 43239, 43249, 45378, 45380, 45384, 45385, G0105, G0121 |
Descriptions for codes included in Table 1 may be searched at the following link: https://www.findacode.com/search/search.php.
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2023. All rights reserved.
CDT codes copyright American Dental Association® 2023. All rights reserved.