MCG Care Guidelines 27th Edition (Healthy Blue + Medicare (HMO D-SNP))
Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
Effective September 1, 2023, we will upgrade to the 27th edition of MCG Care Guidelines for the following modules:
- Inpatient & Surgical Care (ISC)
- General Recovery Care (GRG)
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 Inpatient & Surgical Care (ISC)
| Guideline | MCG Code | 26th Edition GLOS | 27th Edition GLOS |
|---|---|---|---|
| *Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) Insertion | M157 [W0011] | Ambulatory or 1 day postoperative | Ambulatory |
| *Renal Failure, Acute | M-326 | 3 days | 2 days |
| *Paraplegia, Acute | M-255 | 8 days | 7 days |
| *Tetraplegia, Acute | M-305 | 9 days | 7 days |
| *Percutaneous Revascularization, Lower Extremity | S-1310 [W0121] | Ambulatory or 1 day postoperative | Ambulatory |
| *Splenectomy by Laparoscopy | S-1062 | 1 day postoperative | Ambulatory or 1 day postoperative |
| *Elbow Arthroplasty | S-420 | Ambulatory or 1 day postoperative | Ambulatory |
| *Elbow Fracture, Open Treatment | S-424 | Ambulatory or 1 day postoperative | Ambulatory |
| *Foot Fracture, Calcaneus or Talus, Open Reduction, Internal Fixation (ORIF) | S-490 | Ambulatory or 1 day postoperative | Ambulatory |
| *Foot: Surgical Wound Care | S-495 | Ambulatory or 1 day postoperative | Ambulatory |
| *Hip Resurfacing | S-565 | Ambulatory or 1 day postoperative | Ambulatory or 1 day postoperative |
| *Knee Dislocation, Closed or Open Reduction | S-675 | Ambulatory or 1 day postoperative | Ambulatory |
| *Shoulder Arthroplasty | S-634 [W0137] | 1 day postoperative | Ambulatory or 1 day postoperative |
| *Appendectomy, without Abscess or Peritonitis, Pediatric | P-25 | Ambulatory or 1 day postoperative | Ambulatory |
| *Hip: Congenital Dislocation, Open Reduction | P-590 | 1 day postoperative | Ambulatory or 1 day postoperative |
| *Renal Transplant, Pediatric | P-1015 [W0126] | 6 days postoperative | 5 days postoperative |
| *Slipped Upper Femoral Epiphysis, Closed Reduction | P-443 | Ambulatory or 1 day postoperative | Ambulatory |
| *Tibial Osteotomy, Child or Adolescent | S-1131 | Ambulatory or 1 day postoperative | Ambulatory |
| *Bladder Incision: Cystotomy | S-200 | Ambulatory or 1 day postoperative | Ambulatory |
| *Ureterotomy, Nontransurethral for Stone | S-1150 | 1 day postoperative | Ambulatory or 1 day postoperative |
New Guidelines for Inpatient & Surgical Care (ISC)
| Body System | Guideline Title | MCG-Code |
|---|---|---|
| Hospital-at-Home | COVID-19: Hospital-at-Home | M-281-HaH |
| Hospital-at-Home | Viral Illness, Acute: Hospital-at-Home | M-280-HaH |
| Observation Care Guidelines | COVID-19: Observation Care | OC-068 |
| Pediatrics | COVID-19, Pediatric | P-281 |
| Thoracic Surgery and Pulmonary Disease | COVID-19 | M-281 |
Blue Cross NC Customizations to MCG Care Guideline 27th Edition
To view a detailed summary of customizations, go to Medical Policies and Clinical Utilization Management Guidelines | HealthyBlueNC.com scroll down to other criteria section and select Customizations to MCG Care Guidelines 27th Edition.
For questions, please contact the provider services number on the back of the member's ID card.
For more information, please visit Healthy Blue + Medicare.
Blue Cross and Blue Shield of North Carolina Senior Health, DBA Blue Cross and Blue Shield of North Carolina, is an HMO D-SNP plan with a Medicare contract and a NC State Medicaid Agency Contract (SMAC). Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends upon contract renewal.
NCBCBS-CR-021510-23-CPN20927 April 2023
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