BCBS Rescinds Endoscopy Edit Enforcement in Massachusetts

We have just received breaking news from Blue Cross Blue Shield of Massachusetts (BCBSMA) that it has just rescinded its recently announced enforcement action connected with anesthesia for endoscopy cases.  The January 24 announcement on the payer’s website states that it has decided to postpone the claim edits that enforce medical policy 154 until further notice.

You may recall that BCBSMA had previously notified providers that, beginning January 1 of this year, it would implement diagnosis-driven edits to support its monitored anesthesia care (MAC) medical policy 154 guidelines. That policy indicates that the payer covers MAC for endoscopic procedures, such as colonoscopies and upper endoscopies, when medically necessary. Medical policy 154 lists diagnosis codes and clinical parameters that support the use of MAC in such procedures.

So, the takeaway is that the enforcement of the edits that determine medical necessity of MAC in endoscopy cases has been temporarily suspended. Today’s BCBSMA announcement goes on to assure providers that no further action will be taken without a 90-day advance notice. If you have further questions on this topic, please reach out to your account executive.