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MCG Care Guidelines 27th Edition (Healthy Blue + Medicare (HMO D-SNP)) April 28, 2023 Claims & Coding Ancillary Medical Policy & Clinical Guidelines

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) 

GuidelineMCG Code26th Edition GLOS27th Edition GLOS
*Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) InsertionM157 [W0011]Ambulatory or 1 day postoperativeAmbulatory
*Renal Failure, AcuteM-3263 days2 days
*Paraplegia, AcuteM-2558 days7 days
*Tetraplegia, AcuteM-3059 days7 days
*Percutaneous Revascularization, Lower ExtremityS-1310 [W0121]Ambulatory or 1 day postoperativeAmbulatory
*Splenectomy by LaparoscopyS-10621 day postoperativeAmbulatory or 1 day postoperative
*Elbow ArthroplastyS-420Ambulatory or 1 day postoperativeAmbulatory
*Elbow Fracture, Open TreatmentS-424Ambulatory or 1 day postoperativeAmbulatory
*Foot Fracture, Calcaneus or Talus, Open Reduction, Internal Fixation (ORIF)S-490Ambulatory or 1 day postoperativeAmbulatory
*Foot: Surgical Wound CareS-495Ambulatory or 1 day postoperativeAmbulatory
*Hip ResurfacingS-565Ambulatory or 1 day postoperativeAmbulatory or 1 day postoperative
*Knee Dislocation, Closed or Open ReductionS-675Ambulatory or 1 day postoperativeAmbulatory
*Shoulder ArthroplastyS-634 [W0137]1 day postoperativeAmbulatory or 1 day postoperative
*Appendectomy, without Abscess or Peritonitis, PediatricP-25Ambulatory or 1 day postoperativeAmbulatory
*Hip: Congenital Dislocation, Open ReductionP-5901 day postoperativeAmbulatory or 1 day postoperative
*Renal Transplant, PediatricP-1015 [W0126]6 days postoperative5 days postoperative
*Slipped Upper Femoral Epiphysis, Closed ReductionP-443Ambulatory or 1 day postoperativeAmbulatory
*Tibial Osteotomy, Child or AdolescentS-1131Ambulatory or 1 day postoperativeAmbulatory
*Bladder Incision: CystotomyS-200Ambulatory or 1 day postoperativeAmbulatory
*Ureterotomy, Nontransurethral for StoneS-11501 day postoperativeAmbulatory or 1 day postoperative

New Guidelines for Inpatient & Surgical Care (ISC)

Body SystemGuideline TitleMCG-Code
Hospital-at-HomeCOVID-19: Hospital-at-HomeM-281-HaH
Hospital-at-HomeViral Illness, Acute: Hospital-at-HomeM-280-HaH
Observation Care GuidelinesCOVID-19: Observation CareOC-068
PediatricsCOVID-19, PediatricP-281
Thoracic Surgery and Pulmonary DiseaseCOVID-19M-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