TurningPoint to review sites of care for total hip and knee surgeries for some members, starting Jan. 3
For dates of service on or after Jan. 3, 2022, TurningPoint Healthcare Solutions LLC will review the site of care for total hip and knee surgeries as part of each authorization determination. Based on medical necessity review, TurningPoint may approve authorization requests for select total hip and knee cases only when scheduled in an outpatient setting.
This applies to members with the following coverage:
If TurningPoint approves an authorization for a hip or knee surgery in an outpatient setting and the member experiences a change in condition that requires an inpatient admission, you'll need to submit an authorization request for the inpatient admission (procedure code *99222) through the e-referral system; see the "Submit an inpatient authorization" section of the e-referral User Guide (PDF) for more information. Blue Cross or BCN will review the request using InterQual® criteria.
Performing total hip and knee surgeries in outpatient settings is supported by both evidence-based guidelines and the Centers for Medicare & Medicaid Services.
We reported this change in the October 2021 issue of The Record. We'll also cover it in the November-December 2021 issue of BCN Provider News.
For more information about the TurningPoint musculoskeletal surgical quality and safety management program, see these pages on this website:
*CPT codes, descriptions and two-digit modifiers only are copyright 2020 American Medical Association. All rights reserved.
Posted: October 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network