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Medicare AdvantageBilling CodesHigh impact

Additional HCPCS Level II Code Changes and Modifier Changes

Blue Cross Blue Shield of Rhode Island·RI · Oncology, Wound Care·Physician / Facility
Effective date
Jul 1, 2025
We identified it
Jun 19, 2026
Days to comply

Summary

Blue Cross Blue Shield of Rhode Island has updated coverage and reimbursement rules for specific HCPCS Level II codes effective July 1, 2025. The changes include new codes that will be covered and separately reimbursed, codes subject to medical review requiring preauthorization, and codes reimbursed only under pharmacy benefits.

Action Required

Action needed
By July 1, 2025: Billing team must update system to reflect new coverage rules - ensure J0165, J0166, J0167, J0168, J0169, J0616, J0618, J1163, J2312, J2313, J3373, J3374, J3375 are set for separate reimbursement; configure J7356 and J7172 to bill pharmacy benefits only; set up prior authorization requirements for C9174, C9175, J1326, J3391, J9174, J9275, J9276, J9289, J9341, J9342, J9382, Q2058, Q5098, Q5099, Q5100, Q5153; update encounter forms to alert providers of preauthorization requirements. Notify members about non-covered services prior to rendering them as required for participating providers.

Affected Billing Codes

J9220
J0165
J0166
J0167
J0168
J0169
J0616
J0618
J1163
J2312
J2313
J3373
J3374
J3375
J7356
J7172
Q4368
Q4369
Q4370
Q4371
Q4372
Q4373
Q4375
Q4376
Q4377
Q4378
Q4379
Q4380
Q4382
C9174
C9175
J1326
J3391
J9174
J9275
J9276
J9289
J9341
J9342
J9382
Q2058
Q5098
Q5099
Q5100
Q5153