Provider Data Updates

Enhanced General Inquiry Form

Blue KC is excited to announce a more efficient and streamlined General Inquiry Form for a faster way to answer your questions!

View the form (pictured with this article) or visit Providers.BlueKC.com, click Contact on the top right and select General Questions under Support & Services.

You may be directed to our provider hotline or asked to log into Providers.BlueKC.com and select Forms under Quick Links on the home page to submit one of our other helpful forms, such as:

• Provider Updates Form
  • For updates in between initial credentialing and re-credentialing cycles
• Initial Credentialing Forms
  • For solo/rendering practitioners and ancillary/facility providers new to Blue KC.
• Revalidation Credentialing Forms
  • For existing solo/rendering practitioners and ancillary/facility providers.

For non-contracted provider groups, ancillaries and facilities interested in joining Blue KC’s networks, select “Join Blue KC Networks" on our login page at Providers.BlueKC.com.

For claims related inquiries, please use the Claim Inquiry Form, which provides the following category options:

You are also able to use this Claim Inquiry form to request the status of a previous inquiry if a response has not been received within 30 days.

Big News in the New Year: New Provider Reference Guide & All-Digital Provider Communications

New Blue KC Provider Reference Guide	To be published in January 2026 Update on launch date of enhanced Provider Reference Guide (PRG) will be posted at Providers.BlueKC.com Multiple separate documents will be consolidated into a single primary PRG with a supporting BlueCard manual. The goal of the new user-friendly tool will be to inform providers on how best to work with Blue KC. Various policies and procedures will be clarified.
Blue KC to Switch to All-Digital Monthly Provider Newsletters	To begin in January 2026 The BlueSpeak Provider Newsletter will be emailed each month. The monthly Provider Bulletin mailing will no longer be distributed. BlueSpeak will be your main source for all Blue KC Provider updates. To receive BlueSpeak, send a request to BlueSpeak@BlueKC.com.

Recurring 90-day Provider Data Verification Requirement

As a reminder, the Consolidated Appropriations Act of 2021 requires healthcare providers to review and verify the accuracy of the following information in the online provider directory every 90 days:

• Provider/facility name
• Address
• Specialty
• Phone number
• Digital contact information

Every 90 days, you must verify your demographic and directory data with Blue KC.

• If verification is not completed by day 91, your provider listing will be removed from the directory.
• If verification is still not completed by day 121, claims payments will be suspended until compliance is restored.
• We are committed to data integrity, regulatory compliance, and understand this may require adjustments to your current processes. Our team is here to support you through this transition. Thank you for your continued partnership and commitment to quality care.

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Prior Authorization Updates

OncoHealth to Assist Blue KC’s Prior Authorization Process for Oncology Treatments

As a reminder, Blue KC has partnered with OncoHealth, a leading oncology organization, to administer prior authorization for oncology treatments for dates of service on or after January 1, 2026. This change is designed to streamline processes and deliver support for our members with cancer. Note: Oncology treatments already authorized by Blue KC before January 1, 2026, will remain in effect until their approved end dates and will not need to be resubmitted to OncoHealth unless there is a change in treatment or renewal.

OncoHealth will start accepting prior authorization requests for Commercial, ACA QHP for Individual/Family and Small Group ACA on December 18, 2025, for dates of service on or after January 1, 2026. Please see the links below to register for a one-hour virtual training session hosted by OncoHealth.

• Morning Session Registration Link:
  https://oncohealth-us.zoom.us/webinar/register/WN_vB94VHUqSYKFWVT4ZCrVtw
• Afternoon Session Registration Link:
  https://oncohealth-us.zoom.us/webinar/register/WN_Qr3rgbVyRZa6EIbA-ZOf0g

Date	Time
Thursday 12/18/2025	1 p.m. CT
Tuesday 12/30/2025	10 a.m. CT
Tuesday 1/6/2026	10 a.m. CT
Thursday 1/8/2026	1 p.m. CT
Tuesday 1/13/2026	10 a.m. CT
Thursday 1/15/2026	1 p.m. CT
Tuesday 1/20/2026	10 a.m. CT
Thursday 1/22/2026	1 p.m. CT

Code Additions

The following code will be added to our prior authorization list, effective February 1, 2026:

Code	Description	Effective Date	Lines of Business Impacted
89253	Assisted embryo hatching, any method. Assisted hatching is a technique performed to enhance the likelihood that the transferred embryo will implant in the uterus and establish a viable pregnancy. The technique involves in vitro disruption of the zona pellucida surrounding the embryo so that the embryo can “escape" and implant into the uterine wall. Assisted hatching has also been referred to as zona drilling and partial zonal dissolution. Assisted hatching is commonly performed as part of an IVF procedure in women over 40 who have a decreased incidence of implantation after embryo transfer and in women with prior failed IVF cycles due to failed implantation.	2/1/2026	Commercial, ACA

New Prior Authorization Requirements for Four Drugs

Effective January 1, 2026, the following drugs will require prior authorization and must be supplied by the patient’s specialty pharmacy benefit:

Code	Drug	Effective Date	Lines of Business Impacted
J0517	Fasenra (benralizumab)	1/1/2026	Commercial, ACA
J2182	Nucala (mepolizumab)	1/1/2026	Commercial, ACA
J2356	Tezspire (tezepelumab-ekko)	1/1/2026	Commercial, ACA
J2357	Xolair (omalizumab)	1/1/2026	Commercial, ACA

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Payment Policy Updates

To find the complete version of the Payment Policies, click here or go to the login page at Providers.BlueKC.com and click on “Go to Payment Policies", which lists All Provider Payment and Coding Policies and Lab Payment Policies.

Payment Policies Featured in this Section

Durable Medical Equipment and Supplies and Unlisted and Miscellaneous Codes

Evaluation and Management Guidelines

Hemodialysis, Home Hemodialysis and Peritoneal Dialysis Services

Durable Medical Equipment and Supplies and Unlisted and Miscellaneous Codes Payment Policies

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-195, POL-PP-196	Durable Medical Equipment and Supplies, Unlisted and Miscellaneous Codes	1/1/2026	1/1/2026	View our Durable Medical Equipment and Supplies and Unlisted and Miscellaneous Codes Payment Policies Visit our Payment Policies page Providers.BlueKC.com, click on “Go to Payment Policies"

Updates Added

• Beginning January 1, 2026, any unlisted or miscellaneous HCPC’s DME or supplies code will be denied if the following documents are not received. All 3 documents are necessary for payment to be considered.
  • Detailed description: Provide a concise but complete description of the supplies or equipment. Include the
    • brand name
    • model number, and
    • manufacturer's suggested retail price (MSRP)
  • Physician’s order: Provide a clear explanation of why the unlisted code is medically necessary and why no other specific code is appropriate.
  • Manufacturer Invoice: The original invoice for the DME/supply provided, showing the price and description of the item.
• Recommended:
  • Comparable code: If possible, recommend a comparable code to help determine the value of the service.

Evaluation and Management Guidelines Payment Policy

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-236	Evaluation and Management Guidelines	1/1/2026	1/1/2026	View our Evaluation and Management Guidelines Payment Policy Visit our Payment Policies page Providers.BlueKC.com, click on “Go to Payment Policies"

Clarification Added

• A table has been added for code selection based on Medical Decision Making (MDM) and/or time.
• Blue KC uses the 2021 AMA CPT Level of MDM Table to quantify the complexity of problems addressed, complexity of date to be reviewed and analyzed, and risk of complications and/or morbidity and mortality to determine the appropriate level of E/M service selected.
• The Facility Observation G0378 and G0379 Payment Policy will be added to related documents.

Hemodialysis, Home Hemodialysis and Peritoneal Dialysis Services Payment Policy

Policy Number	Policy Name	Effective Date for Updates	Enforcement Date for Updates	Full Policy Location
POL-PP-233	Hemodialysis, Home Hemodialysis and Peritoneal Dialysis Services	1/1/2026	1/1/2026	View our Hemodialysis, Home Hemodialysis and Peritoneal Dialysis Services Payment Policy Visit our Payment Policies page Providers.BlueKC.com, click on “Go to Payment Policies"

Updates Added

• Beginning January 1, 2026, hemodialysis codes will be denied if not submitted with a Urea Reduction Ratio modifier. Payment Policy POL-PP-233, has been in place since August 1, 2022, with guidance for the use of the G1 – G6 modifier.
• Per Blue KC Policy for Urea Reduction Ratio:
  • All hemodialysis claims must indicate the most recent Urea Reduction Ratio (URR) for the dialysis patient. If the modifier is not present, the claim will be denied and returned for the appropriate modifier.
    • G1 Most recent URR of less than 60%
    • G2 Most recent URR of 60% to 64.9%
    • G3 Most recent URR of 65% to 69.9%
    • G4 Most recent URR of 70% to 74.9%
    • G5 Most recent URR of 75% or greater
    • G6 ESRD patient for whom less than seven dialysis sessions have been provided in a month

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Medical Policy Updates

The most up-to-date Medical Policy can be found by logging into Providers.BlueKC.com and clicking on the Medical Policies section. While on that web page, you can also find a link to view Milliman Care Guidelines (MCG), which complement our Blue KC policies.

The Blue KC Medical Policy encompasses internal Blue KC Medical Policy, Blue Cross Blue Shield Association derived Medical Policy, and policies adopted from our vendor partners, such as Avalon, MCG and eviCore.

New Blue KC Medical Policies

Effective Date - 1/1/2026

ID: OncoHealth OH-PBT Title: Proton Beam Radiation Therapy (Proton Beam Therapy MCG Guideline will be deactivated) Treatment Description: Proton beam radiation therapy (PBT) is a type of particle-beam radiation therapy that delivers high-dose radiation to a localized site with precise control of treatment depth and diminished radiation exposure to normal surrounding tissues. PBT may be appropriate in circumstances where photon-based radiation therapy, with intensity modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT), would potentially damage critical structures, particularly in patients with a history of prior irradiation. PBT is also appropriate for pediatric (ages 0-21) and adolescent & young adult (AYA) populations (ages 15-39) when treated with curative intent. This technique of radiation delivery is being actively studied in other clinical scenarios, and unless supported by current national guidelines, is considered investigational and not medically necessary. Clinical Limitations: Proton beam therapy is considered not medically necessary unless supported by an ASTRO Group 1 diagnosis or by evidence from a clinical trial showing a clear advantage over photon-based therapy. This determination is based on the current lack of evidence demonstrating meaningful improvements in treatment outcomes. The following diagnoses are not considered medically necessary for the following indications for the use of proton beam therapy. Abdominal Malignancies, with the exception of: Hepatocellular and intra-hepatic biliary cancers Non-metastatic retroperitoneal sarcomas Breast Cancer Non-Small Cell Lung Cancer Prostate Cancer Pelvic Malignancies, with the exception of: Advanced and unresectable pelvic tumors with significant pelvic and/or peri-aortic nodal disease Members with a single or transplanted kidney with treatment of an adjacent target volume in whom maximal avoidance of the organ is critical

Effective Date - 1/1/2026

ID: 1.01.32 Title: Tonic Motor Activation for Restless Legs Syndrome Tonic motor activation as a treatment for restless legs syndrome refractory to medication is considered investigational.

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Pharmacy Policy Updates

Biosimilar Products to Replace Stelara Effective January 1, 2026

In our commitment to providing our members with the most effective therapies at the lowest possible cost, Blue KC wants to remind you that we will no longer cover Stelara for most commercial members effective January 1, 2026, but we will cover the following Stelara biosimilars:

Ustekinumab-AAUZ

Yesintek

• Biosimilars closely match FDA-approved biologics. While there are differences in minor inactive components between a biosimilar and its reference product, there are no meaningful differences in safety or effectiveness.
• Members affected by this change will receive a letter informing them to contact their prescribing physician.
• As a reminder, all specialty drugs require prior authorization (PA). All active PAs for Stelara will automatically be applied to the biosimilars listed above for the remainder of the approval time left on the PA.
• Patients who receive a non-formulary exception to continue Stelara will be responsible for their standard cost share, plus the difference in cost between Stelara and the preferred biosimilar. The difference in Member cost share is not applied to member deductible or out of pocket maximum amounts.

New Pharmacy Policy

Here is a new Blue KC pharmacy policy for medication that will require prior authorization, effective January 1, 2026:

New Pharmacy Policy
Policy Number	Policy Name
5.02.690	Gonadotropin-Releasing Hormone Agonists

Pharmacy Policies with Changes

Below are Blue KC pharmacy polices with changes for medication that will require prior authorization, effective January 1, 2026:

Pharmacy Policies with Changes
Policy Number	Policy Name	Summary
05.02.608	Pegfilgrastim	Preferred products changing from Nyvepria and Udenyca to Fulphila and Udenyca
5.02.536	Trastuzumab and Biosimilars	Preferred product changing from Kanjinti to Kanjinti and Ogivri
5.01.24	Rituximab and Biosimilars	Preferred products changing from Ruxience and Truxima to Riabni and Truxima

Commercial Formulary Updates

We want to let our contracted providers know of updates to the Blue KC Commercial Prescription Drug Lists that will go into effect on January 1, 2026.

Below are the Premium Prescription Drug List updates that will be effective January 1, 2026:

Please Note: These changes ONLY apply to members on the Premium Formulary; Group-specific benefit exceptions may apply.

New Prior Authorization Requirements

Drug Class	Drugs Requiring Prior Authorization
Opioid Analgesics	Methadone solution

Tier Changes Affecting Member Copayment

Medications Moving to a Lower Tier

Emgality

Medications Moving from Tier 2 to Tier 3

Depen Titratabs

New Excluded Medications with Alternatives

Drug Class	Excluded Medications	Covered Alternative
Antidementia Agents	Namzaric ER Pack	donepezil tablet, memantine tablet, memantine-donepezil capsule
	Namzaric ER 7/10 mg	donepezil tablet and memantine tablet
Biologic Agents	Stelara	Yesintek or Ustekinumab-aauz
Headache Agents	Ajovy	Aimovig, Emgality 120 mg/ml
	butalbital-apap-caffeine-codeine 50-300-40-30 mg cap	butalbital-apap-caffeine-codeine 50-325-40-30 mg cap
Phosphate Binders	Auryxia tab	calcium carbonate tablet, calcium acetate capsule/tablet, sevelamer oral powder/tablet
Sleep Disorder Agents	Dayvigo tab	eszopiclone tablet, ramelteon tablet, zaleplon capsule, zolpidem tablet, Belsomra

New Excluded Drugs with Covered Generic Equivalents

Activella	Acular	Adderall XR	Aldactone tab
Analpram-HC cream	Aptiom tab	Azulfidine tab	Brilinta tab
Carbaglu tab	Cipro tab Da	rim tab	Detrol LA
Dymista	Edecrin	Emend BiPack, Tripack	Entresto tab
Estrogel pump	Hydrea cap	Invega tab	Kaletra tab
Lomotil tab	Macrobid cap	Maxitrol	Namzaric ER 14/10 mg, 21/10 mg, 28/10 mg
Nardil tab	Ocuflox soln	Reglan tab	Remeron tab
Reyataz cap	Salagen tab	Sinemet tab	Tenoretic tab
Tiazac cap	Zyprexa Zydi tab

Below are the Select Prescription Drug List updates that will be effective on January 1, 2026:

Please Note: These changes ONLY apply to members on the Select formulary. Group-specific benefit exceptions may apply.

New Step Therapy Requirements

Members must try preferred alternatives before other drugs will be covered.

Drug Class	Drugs Requiring a Trial of Alternative(s)	Preferred Alternatives (Try First)
Antidementia Agents	Namzaric cap	Both of the following generics: memantine and donepezil OR generic memantine/donepezil capsule
Diabetic Testing Supplies	One Touch meters, test strips	Contour AND any one of the following: Freestyle or Precision

Members must try the generic equivalent before listed drug(s) will be covered.

Aptiom tab

Brilinta tab

Entresto tab

Estrogel gel 0.06%

New Prior Authorization Requirements

Drug Class	Drugs Requiring Prior Authorization
Antidepressant Agents	Raldesy solution
Opioid Analgesics	methadone solution

Tier Changes Affecting Member Copayment

Medications moving from Tier 3 to Tier 2
Emgality
Medications moving from Tier 2 to Tier 3
Brilinta tab	Depen Titratabs	Entresto tab
Namzaric cap	OneTouch meters	OneTouch test strips

New Excluded Drugs with Covered Generic Equivalents

Activella tab	Acular	Adderall XR cap	Adipex-P tab
Aldactone tab	Analpram-HC cream	Azopt	Azulfidine tab
Carbaglu tab	Carnitor tab	Cipro tab	Cortef tab
Cosopt, Cosopt PF	Daraprim tab	Detrol LA cap	Dymista
Edecrin tab	Emend BiPack, Tripack	Estrace tab	Invega tab
Kaletra tab	Lomotil tab	Macrobid cap	Maxitrol
Nardil tab	Neurontin solution	Ocuflox	Pred Forte
Reglan tab	Remeron tab	Reyataz cap	Salagen tab
Sinemet tab	Tamiflu suspension	Tenoretic tab	Tiazac cap
Venxxiva tab	Vigamox	Zenzedi tab	Zyprexa Zydi tab

New Excluded Medications with Alternatives

Drug Class	Excluded Medications	Covered Alternative
Biologic Agents	Stelara	Yesintek or Ustekinumab-aauz
Blood Pressure Agents	Inzirqo suspension	hydrochlorothiazide capsule/tablet
Headache Agents	Ajovy	Aimovig, Emgality 120 mg/ml
	butalbital-apap-caffeine-codeine 50-300-40-30 mg cap	butalbital-apap-caffeine-codeine 50-325-40-30 mg cap
Phosphate Binders	Auryxia tab	calcium carbonate tablet, calcium acetate capsule/tablet, sevelamer oral powder/tablet
	ferric citrate tab
Sleep Disorder Agents	Dayvigo tab	eszopiclone tablet, ramelteon tablet, zaleplon capsule, zolpidem tablet, Belsomra

Below are the Essential Health Benefits (EHB) Prescription Drug List updates that will be effective on January 1, 2026.

Please Note: These changes ONLY apply to members on the EHB Formulary. Group-specific benefit exceptions may apply.

Tier Changes Affecting Member Copayment

*only applicable to Kansas members

Medications Moving to a Lower Tier
azelaic acid gel 15%	Clomid tab*	desloratadine tab 5 mg	nalbuphine inj 10mg/mL
nilutamide tab	repaglinide tab 0.5 mg, 1 mg, 2 mg	Tranexamic acid tab 650 mg
Medications Moving to a Higher Tier
Leukeran tablet

Specialty Drug Classification Changes

New pharmacy restrictions and copay changes may apply.

Now Classified as Specialty Drugs

Leukeran tablet

New Excluded Medications with Alternatives

Drug Class	Excluded Medications	Covered Alternative
Analgesics	Nucynta ER	hydrocodone bitartrate tab ER, morphine sulfate tab ER, oxycodone hcl tab ER, Xtampza ER
Biologic Agents	Stelara	Yesintek or Ustekinumab-aauz
Dental Agents	Fluoridex Daily Renewal	Prevident, sodium fluoride rinse, sodium fluoride cream, sodium fluoride gel
	Easygel gel 0.4%

New Excluded Drugs with Covered Generic Equivalents

Proctosol HC

Promethegan suppository

Sajazir injectable

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Provider Education

Helpful Coding Tips for ED, DRG and Critical Care Services

Blue KC is providing coding tip sheets for Emergency Department Evaluation and Management Level 99285, Diagnosis Related Group (DRG) billing and DRG Outlier Claims (which are hospital claims that significantly exceed the typical cost or length of stay for a given DRG) and Critical Care Services.

To find these coding tip sheets, log into Providers.BlueKC.com and look under Recent News on the home page.

OIG Medicare Part C High-Risk Diagnosis Codes

In our August 2025 Provider Bulletin, Blue KC announced that we were starting audits based on high-risk diagnosis codes that were submitted on claim(s) and impact the ACA QHP for Individual/Family and Small Group ACA lines of business.

This program was created based on the release of the Office of Inspector General (OIG) report. In December 2023, the OIG released a “Toolkit To Help Decrease Improper Payments in Medicare Advantage Through the Identification of High-Risk Diagnosis Codes (A-07-23-01213)."

The toolkit included the high-risk diagnosis groups that the OIG felt were most at risk for being miscoded. This list included:

• Acute Stroke
• Acute Heart Attack
• Embolism
• Lung Cancer
• Breast Cancer
• Colon Cancer
• Prostate Cancer
• Potentially mis-keyed diagnosis codes

Provider Documentation Checklist: High-Risk Diagnosis Codes

Blue KC is including a checklist for OIG-focused high-risk diagnoses codes below to help support providers with their coding.

General Principles

• Diagnosis is supported by clinical evidence and medical records
• Documentation includes Diagnosis, Status, and Plan (DSP) for each high-risk condition
• ICD-10 codes are accurate and double-checked for data-entry errors

Condition-Specific Documentation

• Acute Stroke (HCC 100):
  • Acute stroke diagnosis is supported by both physician and hospital claims
  • If only a physician claim exists, and no hospital documentation is present, use 'history of stroke' if appropriate
• Acute Heart Attack (HCC 86):
  • Confirm acute myocardial infarction diagnosis with inpatient hospital claim within 60 days before or after physician/outpatient n If no hospital claim exists, consider 'history of myocardial infarction' if clinically appropriate
• Embolism (HCCs 107 & 108):
  • Embolism diagnosis is supported by evidence of anticoagulant medication dispensed
  • If no anticoagulant is prescribed, document as 'history of embolism' if the event is not current
• Cancer Diagnoses (Lung, Breast, Colon, Prostate):
  • Active cancer diagnosis is supported by evidence of treatment (surgery, radiation, chemotherapy) within 6 months before or n If no treatment is documented, use 'history of cancer' if the cancer is not active
  • Cancer status is clearly documented as Active, History of, or In Remission

Additional Best Practices

• Continually reassess and update documentation for ongoing or resolved conditions
• Avoid documenting 'past medical history' for cancers still under treatment
• Refer to CMS ICD-10-CM coding guidelines for accurate code selection

References: OIG Toolkit (A-07-23-01213), CMS ICD-10-CM Guidelines

Cancer Education

Since cancer diagnoses are such a high focus for the Office of Inspector General (OIG), Blue KC is providing education to help with coding for cancer.

Cancer (Neoplasm) is a disease that occurs when cells in the body grow and divide uncontrollably and can spread to other parts of the body.

Medicare Wellness Visit Components

Blue KC aims to increase provider awareness about the key elements of Medicare Wellness Visits.

The purpose of the Initial Preventative Physical Examination (IPPE), the Initial Annual Wellness Visit (AWV), and the Subsequent Annual Wellness visit (AWV Sub) is to allow the provider to have a conversation with their patient to address current conditions and any future healthcare needs.

Medicare Annual Wellness Exam Requirements1,2
Element	Included	IPPE G0402	AWV G0438	AWV Sub G0439
Health Risk Assessment (provider or patient completed)	Demographic data, health status self-assessment, psychosocial risks, behavioral risks, ADLs, and instrumental ADLs		X	X
Past Medical, Family and Social History	Past medical and surgical history, current medications and supplements, family history, diet, physical and social activities, alcohol, tobacco, and illegal drug use history	X	X	X
Current Providers and Suppliers	Current providers and suppliers providing medical care for patient		X	X
Potential Depression Risk Factors	Current or past experiences with depression, other mood disorders and completed standardized screening tool	X	X
Functional Ability and Safety Level	ADL's, fall risk, hearing impairment, home and community safety	X	X
Examination	Height, weight, BMI, blood pressure, balance and gait, visual acuity screen, other factors deemed appropriate based on clinical standards	X
Measurements	Heigh, weight, BMI, blood pressure, other routine measurements as appropriate		X	X
Cognitive Impairment Screening	Direct observation or reported observations from patient or others to assess cognitive function		X	X
Establish/Update Preventive Screening Schedule	Schedule based on checklist for the next 5-10 years, clinical recommendations, and results of wellness visit		X	X
Establish/Update List of Risk Factors and Conditions	Include recommendation for primary, secondary, or tertiary interventions, mental health conditions and cognitive impairments, IPPE risk factors or identified conditions, treatment options and associated risks and benefits		X	X
Advanced Care Planning (patient's discretion)	Discussion includes their ability to prepare an advanced directive, agreement on following the advance directive, psychiatric advance directives	X	X	X
Current Opioid Prescriptions (if applicable)	Potential opioid use disorder risk factors, pain severity and treatment plan, non-opioid treatment options, specialist referral as appropriate	X	X	X
Substance Use Disorder Screening	Review potential SUD risk factors and make referrals as appropriate	X	X	X
Educate, Counsel, and Refer	Based on results of visit or necessary preventive services, provide education, counseling and referrals	X	X	X
Social Determinants of Health (SDOH) Risk Assessment	Assessment follows standardized, evidence-based practices and ensure communication aligns with the patient's educational, developmental, and health literacy levels, as well as being culturally and linguistically appropriate		X	X

¹https://www.cms.gov/medicare/coverage/preventive-services/medicare-wellness-visits
²When these codes are billed in conjunction with an evaluation and management (E/M) service, append modifier 25 to the E/M service code.

2026 ICD-10-CM Guidelines and Coding Updates

Blue KC wants to make sure providers are aware of the many changes to the 2026 ICD-10-CM guidelines and coding updates.

See the chart below that outlines the changes in coding by chapter:

‘

Chapter	New Codes	Revised Codes	Deleted Codes	Changed to Parent Codes	New Parent Codes	Examples
Chapter 2: Neoplasms	18	3	1	1	6	C50.81 – Inflammatory breast cancer; Z15.09 – Genetic susceptibility to digestive malignancy
Chapter 4: Endocrine, Nutritional & Metabolic	12	4	0	0	2	E11.A – Type 2 diabetes in remission; E78.01 – Homozygous familial hypercholesterolemia
Chapter 6: Nervous System	22	5	2	2	10	G35.0 – Multiple sclerosis, relapsing-remitting; H05.83 – Thyroid orbitopathy
Chapter 12: Skin & Subcutaneous Tissue	116	6	2	0	8	L97.A1 – Non-pressure chronic ulcer of abdomen; L03.31 – Cellulitis of flank
Chapter 19: Injury, Poisoning & Certain Other Consequences	213	10	8	6	45	S30.86XA – Contusion of flank; S30.87XA – Abrasion of groin
Chapter 20: External Causes of Morbidity	58	3	4	4	20	Y36.8XXA – War operations blast overpressure; Y37.8XXA – Military operations exposure
Chapter 21: Factors Influencing Health Status (Z Codes)	48	7	11	3	36	Z59.86 – Financial insecurity; Z91.011 – Allergy to milk products

Here’s a summary of key changes by chapter for the 2026 ICD-10-CM update:

Chapter 2: Neoplasms

• New parent codes for inflammatory breast cancer.
• Codes for genetic susceptibility to digestive system malignancies.
• Significant clarifications in HIV coding and neoplasm treatment guidelines.
• Revised sequencing instructions for chemotherapy, immunotherapy, and radiation therapy encounters.

---

Chapter 4: Endocrine, Nutritional & Metabolic

• New code for Type 2 diabetes in remission (E11.A).
• Expanded codes for familial hypercholesterolemia (HoFH, HeFH).
• New codes for lipodystrophy subtypes, including HIV-associated and localized injection-related forms.

---

Chapter 6: Nervous System

• Restructured multiple sclerosis codes to specify disease course:
  • Relapsing-remitting, primary progressive, secondary progressive.
• New codes for thyroid orbitopathy (H05.83).

---

Chapter 12: Skin & Subcutaneous Tissue

• Major expansion for non-pressure chronic ulcers:
  • Site-specific (abdomen, chest, neck, face, groin, upper limbs).
  • Severity-specific (limited to skin, fat layer, muscle, bone).
• New codes for cellulitis and lymphangitis of the flank.

---

Chapter 19: Injury, Poisoning & Certain Other Consequences

• 213 new codes for injuries and poisonings.
• Greater specificity for flank, groin, abdominal wall injuries (abrasions, contusions, blisters).
• Updates for blast injuries and war-related trauma

---

Chapter 20: External Causes of Morbidity

• New codes for war-related injuries and blast overpressure scenarios.
• Expanded external cause codes for environmental and conflict-related exposures.

---

Chapter 21: Factors Influencing Health Status (Z Codes)

• Expanded social determinants of health:
  • Financial insecurity.
  • Exposure to war.
  • Food allergies (milk, eggs).
• Clarifications for encounters for chemotherapy, immunotherapy, and radiation therapy.

*For a full list of changes, please refer to the 2026 official ICD-10-CM coding guidelines:
https://www.cms.gov/files/document/fy-2026-icd-10-cm-coding-guidelines.pdf

Partnering to Detect and Prevent Healthcare Fraud

Blue KC partners with providers in the battle against healthcare fraud. We depend on YOU, our allies at the frontlines, to identify and report potential healthcare fraud, including:

• Masquerading as a Health Care Professional
  • An individual (or group) delivers healthcare services or equipment to a patient without a proper license.
• Identity Theft
  • An Individual utilizes another person’s health insurance or personal information to access healthcare services.
• Doctor shopping
  • A patient visits multiple practitioners to get several prescriptions for controlled substances.
• Falsification
  • An individual or group files fake claims to an insurer or alters amounts charged on claim forms or prescription receipts.

We take the fight against healthcare fraud very seriously. That’s why we have an anti-fraud department dedicated to detecting and preventing healthcare fraud. To report healthcare fraud or abuse to our anti-fraud department, email _SIU@BlueKC.com or call our hotline at 816-395-3151 or 800-340-0119.

To learn more about healthcare fraud, visit the home page at Providers.BlueKC.com and look under Recent News.

Blue KC Care Management Team – A partner in health

The Blue KC Care Management Team includes clinical nurses, social workers and Community Health Workers. They can help your patients by offering resources for a healthy pregnancy, managing chronic health conditions, offering support and encouragement after a diagnosis, providing assistance with transitions of care, assisting patients in achieving their wellness goals and answering questions about benefits. The team personalizes a plan based on each patient’s unique care needs.

The Care Management Team continuously monitors a dashboard, which surfaces insights about preventive health needs, such as flu shots or annual eye exams, and flags patient survey responses related to their health, wellness and nutrition. Our team then works with your patients to schedule care and navigate resources.

One of the best ways to connect with the Care Management Team is through the Blue KC Care Management app. With this health resource, users can also view articles and videos personalized to them, set appointment and medication reminders, and access exclusive perks from local and national brands, including offers on groceries, health and wellness, and more.

You can encourage patients to download the Blue KC Care Management App from the App Store or Google Play. They should use access code kcnews when prompted. They can also learn more about the Blue KC Care Management app and Care Team on this page. For more information about case management services or to make a referral, call the Management Referral Line at 816-395-2060 or 1-866-859-3811.

January Free Documentation & Coding Webinar

Join us for the January 2026 monthly webinar hosted by our partner, Veradigm! This is a free documentation and coding education webinar. Each 1-hour webinar is approved for one AAPC CEU when you achieve a 70% or higher on the post-test. To register for the January webinar, click here for details:

January 27 & 29 7:30 am & 11:30 am CT

Decoding ICD10-CM Updates for 2026

Get up to speed on new coding guidelines to improve accuracy and specificity in risk adjustment documentation.

Blue KC Awarded KC Favorites Gold Award by KC Star

Blue KC has been named by Kansas City Favorites as a 2025 Gold Award winner for Best Insurance Company. The gold distinction is the publication’s highest awarded honor.

Kansas City Favorites, published annually and presented by The Kansas City Star, celebrates the local businesses, people, and places our community trusts and values most. The honorees are chosen by popular vote by Kansas City residents and readers of The Kansas City Star.

The 2025 Kansas City Favorites program received more than 270,000 votes — a 45% increase from 2024 — reflecting the growing enthusiasm and engagement from the local community. Kansas City Favorites had over 4,900 businesses, organizations, and individuals competing to be named in the top three spots of 274 categories. This marks the third consecutive year (2023-25) in which Blue KC has been honored with the Kansas City Favorites Gold Award for Best Insurance Company.

View the full list of winners and find more information HERE.

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Community Investment

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Happy Holidays

As we near the end of 2025, Blue KC wants to wish you Happy Holidays and a healthy New Year! We value and appreciate you as our partner in providing quality care.

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Contact Us

Please join the BlueSpeak email distribution list by sending a request to BlueSpeak@BlueKC.com. You can also use this email address to give us any feedback about BlueSpeak. We would love to hear from you!

If you have questions about any of these updates, please call the Blue KC Provider Hotline at 816-395-3929 for Commercial line of business, 866-508-7140 for Blue Medicare Advantage line of business or 866-859-3822 for the ACA Provider Hotline. We value and appreciate you as our partner in providing quality care.

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