HCPCS M0238 is officially defined as "Intravenous infusion, tocilizumab-anoh, for hospitalized adult patients with covid-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ecmo) only, includes infusion and post administration monitoring, second dose." HCPCS M0238 is referenced in 6 tracked payer policy changes from Blue Cross Blue Shield of Rhode Island, Independence Blue Cross, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS M0238 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
BCBSRI has implemented multiple policy changes affecting preventive services, coding, and reimbursement across various specialties. Key changes include new breast cancer screening coverage requirements, updated STI testing billing procedures, hearing aid coverage increases, and several new CPT/HCPCS codes for various services.
Blue Cross Blue Shield of Rhode Island updated HCPCS Level II codes and modifiers effective October 1, 2025, affecting coverage and reimbursement rules for various procedures. Multiple codes now have different coverage policies for Professional vs Institutional providers, and some require specific modifiers or medical review.
Independence Blue Cross updated policy 08.00.85r to 08.00.85u, adding three new HCPCS codes (M0237, M0238, Q0237) for tocilizumab-anoh (Avtozma) COVID-19 treatment effective retroactively to 01/24/2025, and replacing unclassified drug codes (C9399, J3590) with Q5156 for the biosimilar. The policy designates tocilizumab-aazg (Tyenne) as the preferred product, with tocilizumab-anoh as an additional preferred alternative, requiring documentation of contraindication, intolerance, or inadequate response to use nonpreferred products.
Coverage and billing information for the October 2025 quarterly HCPCS update applies to dates of service on or after Oct. 1, 2025. Many of the new codes are noncovered, while covered codes include skin substitute codes A2036 to A2039 and Q4383 to Q4397 reimbursed at a flat, statewide, per-unit rate, and prosthetic codes L6034 to L6039 that require prior authorization and attachment of MSRP documentation or a cost invoice if no MSRP is available. Covered codes requiring prior authorization include J1370, J3403, L6034 to L6039, Q5156, Q5157 and Q5158, and NDC is required for many of the listed drug codes.
Blue Cross and BCN have corrected prior authorization requirements effective Feb. 1, 2026. CPT code 87798 no longer requires prior authorization for BCN Advantage members (but continues to require it for Blue Care Network commercial members). HCPCS codes M0237, M0238, and Q0237 no longer require prior authorization for BCN Advantage members.
Coverage and billing information applies to dates of service on or after Oct. 1, 2025 for the new codes in the October 2025 quarterly HCPCS update, and procedure code J0570, buprenorphine implant, resumes coverage for the same dates. Many of the new codes are noncovered, while covered codes include skin substitute codes A2036 to A2039 and Q4383 to Q4397, which are allowed for podiatrists (provider specialty 140), and prosthetic codes L6034 to L6039, which require prior authorization. Discontinued codes C9088, C9174, C9175, C9248, J2150 and S0074 list alternate codes J0668, J9011, J0614, J0759, J2151 and J0525, and an alternate code does not indicate IHCP coverage of that code.
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