Partners in Health Update - March 2007 (IBC)

Transcription

www.ibx.com
March 2007
Get Your News
on the Internet
or NaviNetSM
Based on feedback from
providers, as of April 1, 2007,
all of our publications will
be available only on
www.ibx.com/providers/
communications, and
NaviNetSM. Our publications,
Partners in Health Update,
Clinical Update, and Coding
Guidelines and Policy Update
(CGPU) will no longer be
mailed to provider offices. This
decision was made based on
feedback from providers on
ways we can reduce the amount
of information we send to your
office.
If you do not have access to the
Internet or NaviNetSM, you may
call the Provider Supply Line for
hard copies of our publications.
You will receive a postcard
each month when a new issue
of Partners In Health Update is
available. Please e-mail us with
your questions or comments
on how we can improve our
communication efforts at
provider_communications@ibx.
com.
Working Together For Quality Health Care
INSIDE THIS ISSUE
NPI ANNOUNCEMENTS
• Get it, Share it, Use it Now with IBC
• IBC National Provider Identifier (NPI) Dual Use
Claims Submission
BILLING
• Paper Referrals Will No Longer be Accepted
After April 1, 2007
• Home Infusion Therapy Precertification Changes
PHARMACY
• Select Drug Program® Formulary Update
• Prescription Drug Updates
POLICY
• Revisions to the Nerve Conduction Studies and Needle
Electromyelograms Policies
• 2006 Coding Guidelines and Policy Update (CGPU)
Compendium Enclosed
PREVENTIVE HEALTH
• Encourage Members to Receive Colorectal Cancer
Screening
• In-home Physician Visiting Program
• Supporting Our Members, Your Patients: ConnectionsSM
Health Management Programs
For articles specific to your
area of interest, look for the
appropriate icon:
Provider
Facility
Ancillary
Additional copies of Partners In Health Update can be printed by
going to our website www.ibx.com/providers/communications.
Get it, Share it, Use it Now with IBC
Get It.
Get it NOW from the National Plan and
Provider Enumeration System (NPPES).
• Get your NPI(s): a unique 10-digit identification
number. We recommend you enumerate with your
current Corporate ID configuration.
• Get it now. Do not wait until the May 23, 2007
compliance date.
How to Obtain an NPI
The National Plan and Provider Enumeration
System (NPPES) is currently accepting
applications for NPIs. Providers who have not
yet obtained an NPI may apply for it in one of
the following ways:
Electronic

• Get it faster on the Web at https://nppes.cms.hhs.gov.
Share It.
Share it NOW with IBC, your
colleagues, and your billing services. Failure to share your
NPI with IBC could result in a disruption in cash flow.
• Share your NPI with us before you file your next
claim.
• Share it with your colleagues who rely on your NPI
to submit their claims.
• Share it with your billing service, vendor, or
clearinghouse.
Use It.
Use it NOW to identify yourself.
• Use it now along with your existing 10-digit legacy
provider identifiers on your electronic and paper
claims (if you have reported your NPI(s) to IBC).
• Use it now to facilitate accurate and streamlined
processing of claims.
• Use it to be HIPAA-compliant by May 23, 2007.
Complete the web-based application
online at https://nppes.cms.hhs.gov. It takes
approximately 20 minutes to complete and is
the most time-efficient method of obtaining
an NPI.
Paper

Providers may wish to obtain a copy of the
paper NPI Application/Update Form
(CMS-10114) and mail the completed,
signed application to the NPI Enumerator.
The form will be available only upon request
through the NPI Enumerator. Providers
who wish to obtain a copy of this form must
contact the NPI Enumerator in any of the
following ways:

Phone: (800) 465-3203 or
TTY (800) 692-2326

E-mail: [email protected]

Mail:
NPI Enumerator
P.O. Box 6059
Fargo, ND 58108-6059
All the information you need is available
at www.ibx.com/providers/npi
Failure to prepare could result in a disruption in cash flow.
Will you be ready to use your NPI? Time is running out.
2
March 2007
www.ibx.com
NPI ANNOUN C E M E N T S
IBC National Provider Identifier (NPI)
Dual Use Claims Submission
IBC NPI Dual Use Claims Submission is one of
many preparatory measures that we will implement
prior to the NPI compliance date in order to ensure
the smoothest transition possible. We are asking
all providers who have obtained their NPI(s) and
reported them to us to submit all electronic
and paper claims with NPIs and 10-digit
legacy provider identifiers (identifiers you are
currently required to use to identify yourself
as an IBC participating health care provider),
until otherwise notified. You must also report
your Taxonomy codes on all electronic and paper
claims. Taxonomy codes identify your specialty or
(specialties).
Please note that we will not use NPIs to process
your claims at this time. We will continue
to process claims using your 10-digit legacy
identifiers. In addition, we will not include NPIs
on SORs or any other outgoing transactions at
this time.
IBC NPI Dual Use Claims Submission will not
complicate, delay, or halt your claims processing.
NPI Dual Use Claims Submission
Instructions
You can find detailed IBC NPI Dual Use Claims
Submission instructions in the following locations:
• 837P and 837I Companion Guides. The 837P
Companion Guide and 837I Companion Guide
provide instructions for submitting dual use
claims for electronic claims submissions. The
companion guides are available online at
www.ibx.com/providers/self_service_tools/edi/forms.
html.
• Current and Revised CMS 1500 Claim
Forms and Instructions. This reference tool
was published as an enclosure with the October
2006 edition of Partners in Health Update. It
provides instructions for submitting dual use
www.ibx.com
claims for paper submissions. This reference tool
is also available at www.ibx.com/providers/npi/
forms.html.
Questions Regarding NPI Dual Use
Claims Submission
Please contact your Network Coordinator with any
questions regarding IBC NPI Dual Use Claims
Submission.
If you have not yet obtained your NPI(s) and
reported them to us, please see How to Obtain an
NPI, or visit www.ibx.com/providers/npi.
You may also visit the following websites for
additional information:
IBC Provider NPI website
www.ibx.com/providers/npi
Contains NPI background, FAQs, Submission
Instructions, web links, and other information.
CMS Main NPI website
www.cms.hhs.gov/NationalProvIdentStand
Contains NPI Final Rule, FAQs, Fact Sheets,
Tip Sheets, NPI Viewlet, Medicare MedLearn
Articles, Enumeration Statistics.
NPI Enumerator website
https://nppes.cms.hhs.gov/NPPES/Welcome.do
Main site to enter an NPI application.
WEDI NPI White Papers
www.wedi.org/snip/
Industry NPI papers, including “NPI Impact on
Providers,” “NPI Dual Use Strategy,” “NPI and
Subparts,” etc.
WEDI NPI Outreach Initiative
www.wedi.org/npioi/index.shtml
NPI Resource Center with information resources,
Industry readiness assessment survey, etc.
March 2007
3
BILLIN G
Paper Referrals Will No Longer Be
Accepted After April 1, 2007
An Important Message for PCPs and Specialists
Effective April 1, 2007, we will no longer accept
paper referrals with HMO/POS claims for payment.
All paper referrals submitted on or after April 1st
will be returned to the issuing provider. For PCPs,
all referrals should be submitted through NaviNetSM
or our Interactive Voice Response (IVR) system. For
Specialists, NaviNet or the IVR should be checked
to ensure a referral was received for a member before
services are rendered. Specialists should no longer
accept paper referrals. A fax of an electronically
submitted referral may be obtained by the Specialist
office via our IVR.
This change will help reduce errors by allowing
specialists to verify, through NaviNet or the IVR,
that a referral is on file in the system and has been
submitted correctly, before the provider sees the
member. Electronic submission will also help ensure
the accuracy and timeliness of claim payments by
allowing the specialist to confirm that the group
provider number on the referral matches the group
provider number on the claim.
To get connected to the NaviNet Portal, please call
the eBusiness Provider Hotline at (215) 640-7410,
or complete our Online Inquiry Form at www.ibx.
com/providers/navinet. To submit or inquire on an
electronic referral through the IVR, please call
(866) 681-7370. For instructions on using the IVR,
refer to the October 2006 issue of Partners in Health
Update.
If you have additional questions, please contact your
Network Coordinator.
Home Infusion Therapy Precertification Changes
Effective April 1, 2007, Care Management
Coordination (CMC) will no longer accept faxes
as a method to request precertification for home
infusion therapy. All requests for infusion therapy
dated April 1, 2007 and later must be submitted
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March 2007
through NaviNetSM or by calling the Health
Resource Center at (215) 241-2100, prompt
2, subprompt 4, or (800) 227-3116, prompt 2,
subprompt 4, (out-of-area). To request NaviNetSM
access, please call (215) 640-7410.
www.ibx.com
P H ARMACY
Select Drug Program® Formulary Updates
The Select Drug Program Formulary is a list of FDA-approved medications that were chosen for their
effectiveness and value. The list changes periodically as the FutureScripts™ Pharmacy and Therapeutics
Committee reviews the formulary to ensure its continued effectiveness.
Generic Additions
These generic drugs recently became available in the marketplace. When these generic drugs became available,
we began covering them at the appropriate generic formulary copayment:
Generic Drug
Brand Drug
buproprion XL 300mg
Wellbutrin XL®
clarithromycin SR
24 hr
hydrocodone tannate/
chlor-tan
Formulary Chapter
Biaxin® XL
HyTanTM
ondansetron HCL
Zofran®
oxandrolone
3. Pain, Nervous System, &
Psych
1. Antibiotics & Other Drugs
Used for Infections
13. Allergy, Cough, & Cold,
Lung Meds
8. Stomach, Ulcer, & Bowel
Meds
Effective Date
December 25, 2006
December 11, 2006
January 15, 2007
January 16, 2007
Anavar
7. Diabetes, Thyroid, Steroids,
& Other Miscellaneous
Hormones
January 8, 2007
oxybutynin chloride
Ditropan XL®
14. Urinary and Prostate Meds
January 22, 2007
paroxetine HCL susp
Paxil® susp
phenylephrine HCL/
COD/prometh
sodium sulfacetamide
lotion
Phenergan® VC
w/codeine
3. Pain, Nervous System, &
Psych
13. Allergy, Cough & Cold,
Lung Meds
Klaron®
5. Skin Medications
®
December 7, 2006
December 18, 2006
November 17, 2006
Brand Addition
This brand drug is covered at the appropriate brand formulary copayment:
Effective January 1, 2007
Brand Drug
Formulary Chapter
Prezista™
1. Antibiotics & Other Drugs Used For Infection
Once a brand drug becomes available in the marketplace, and is approved by the FutureScripts Pharmacy and
Therapeutics Committee as a formulary drug, it will be added to the formulary and available at the brand
formulary copayment.
continued on page 6
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March 2007
5
PHARM AC Y
Select Drug Program® Formulary Updates (continued)
Brand Deletions
These brand drugs will be covered at the appropriate Non-Formulary copayment:
Effective April 1, 2007
Brand Drug
Generic Drug
Alesse®
lutera, lessina
Biaxin XL®
clarithromycin SR 24 hr
Cyclessa®
velivet, cecia
Demulen®
zovia, kelnor
Ditropan XL®
oxybutynin chloride
Lo/Ovral®
low-ogestrel, cryselle
Loestrin®
microgestin, junel
Loestrin® Fe
microgestin Fe, junel Fe
Micrette®
kariva
Modicon®
necon, nortrel
Nordette®
levora, portia
Nor-QD®
camilla, nora-be, errin, jolivette
Ortho-Cept®
solia, apri, reclipsen
Ortho-Cyclen®
sprintec, mononessa, previfem
Ortho Micronor®
camilla, nora-be, errin, jolivette
Ortho-Novum®
necon, nortrel
Ortho Tri-Cyclen®
tri-sprintec, trinessa, tri-previfem
Paxil® susp
paroxetine HCL susp
Tri-Norinyl®
leena, aranelle
Triphasil®
trivora, enpresse
Wellbutrin XL®
buproprion XL 300mg
The generic drugs for all of the above brand drugs are on our formulary and available at the generic formulary
copayment.
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March 2007
www.ibx.com
P H ARMACY
Select Drug Program® Formulary Updates (continued)
Brand Drug
Generic Drug
Formulary Therapeutic Alternatives
(available at the formulary copayment)
Ortho Tri-Cyclen Lo®
Not Available
tri-sprintec, trinessa, tri-previfem
Rhinocort Aqua®
Not Available
Nasonex®, Nasocort® AQ, fluticasone
Yasmin®
Not Available
junel, levora, microgestin, portia
There is no generic equivalent available for the above brand drugs; however, there are formulary generic
and brand therapeutic alternative drugs. These therapeutic alternative drugs are available at the appropriate
formulary copayment.
www.ibx.com
March 2007
7
PHARM AC Y
Prescription Drug Updates
For members enrolled in an IBC prescription drug program, there will be additional drugs that will require
prior authorization, quantity limits or age edits. The purpose of these edits is to make certain that these drugs
are being used appropriately and to guard against drug overuse.
Drugs Requiring Prior Authorization
The prior authorization requirements for the following non-formulary drugs were effective at the time the
drugs became available.
Brand Drug
Generic Drug
Effective Date
Invega™
Not Available
January 5, 2007
Oracea™
Not Available
June 10, 2006
The following non-formulary drugs have been added to the list of drugs requiring Prior Authorization for new
prescriptions. Members taking these drugs immediately prior to the effective date are not impacted.
Brand Drug
Generic Drug
Effective Date
BiDil®
Not Available
April 1, 2007
Noxafil®
Not Available
April 1, 2007
Zelapar®
Not Available
April 1, 2007
Drug with Quantity Limit
A quantity limit for the following drug was effective at the time the drug became available in the marketplace:
Brand Drug
Generic Drug
Quantity Limit
Effective Date
Kadian® 80mg
Not Available
60 capsules per 30 days
October 1, 2006
Drug with Age Edit
An age edit for the following drug was effective at the time the drug became available in the marketplace:
Brand Drug
Generic Drug
Edit
Effective Date
ZianaTM Gel
Not Available
Prior Authorization
required for members
aged 36 and older
December 4, 2006
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March 2007
www.ibx.com
POLICY
Revisions to the Nerve Conduction Studies
and Needle Electromyelograms Policies
We have revised the policies on Nerve Conduction
Studies (NCS), Policy #07.03.18a, and Needle
Electromyelograms (EMGs), Policy #07.03.09b.
Our medical policy states that the performing
provider should be a physician who has had
special training in the diagnosis and treatment
of neurological and neuromuscular diseases and
in the application of particular neurophysiologic
techniques for the study of these disorders.
Therefore, only physicians who are properly trained
in performing these tests should perform NCS and
needle EMGs.
Effective for dates of service rendered on or
after April 1, 2007, we will cover and consider for
reimbursement those NCSs and EMGs included
in the above noted policies when performed by
physicians in the specialties of Neurology and
Physical Medicine & Rehabilitation when the
medical necessity criteria outlined in the specific
medical policy have been met. This change does
not affect services rendered prior to April 1, 2007.
Additionally, this change does not affect needle
EMG of the anal and urethral sphincter (CPT®
code 51785*) that is discussed in policy number
07.03.21a: Electromyelograms of the Anal and
Urethral Sphincter.
*Current Procedural Terminology (CPT®) is a copyright of the American
Medical Association (AMA). All Rights Reserved. No fee schedules, basic
units, relative values, or related listings are included in the CPT®. The AMA
assumes no liability for the data contained herein. Applicable FARS/DFARS
restrictions apply to government use. CPT® is a trademark of the AMA.
2006 Coding Guidelines and Policy Update
(CGPU) Compendium Enclosed
Enclosed is the annual 2006 Coding Guidelines
and Policy Update (CGPU) Compendium. The
Compendium includes policy summaries published
in the past four issues of the quarterly CGPU
along with other information that can simplify
information retrieval and claims submission
processes.
www.ibx.com
The Compendium also includes previously published
articles on the class action settlement, modifier
updates, and changes in policy criteria, and a
section detailing new, revised, and deleted Current
Procedural Terminology (CPT®), Healthcare
Common Procedure Coding System (HCPCS), and
ICD-9 CM codes.
March 2007
9
PREVEN T I V E H E A LT H
Encourage Members to Receive Colorectal
Cancer Screening
IBC and the American Cancer Society urge you
to encourage your patients to be screened for
colorectal cancer. Please know that your personal
recommendation has a tremendous influence on a
patient’s decision to seek recommended preventive
health screenings.
You can obtain educational patient materials for
your office in English and in Spanish by calling
the American Cancer Society directly at
(800) ACS-2345 or by visiting their website at
www.cancer.org.
Adherence to the colorectal cancer screening
guidelines may lead to improved patient outcomes.
Individual clinical decisions should be tailored to
specific patient medical and psychosocial needs.
Although this information is adapted from national
sources, information in this area might evolve
rapidly and lead to changes in recommendations.
As changes occur, please update your practice
accordingly.
Note: This is not a statement of benefits. Benefits may vary based on state
requirements, product line (HMO, PPO, etc.), and/or employer group.
HMO and PPO member coverage may be verified through Provider Services.
In-home Physician Visiting Program
IBC has contracted with a professional provider
group, Care Level Management (CLM), to provide
physician services in the home to complement the
care plans as designed by primary care physicians
(PCPs). Based on specific criteria, CLM physicians
will work with selected Keystone 65 members who
suffer from multiple chronic illnesses and have
experienced multiple emergency room visits and
acute care admissions during the last year. CLM is
a nationally recognized group currently working in
several states with the Medicare population.
CLM physicians will complement and support
the current PCP provider network, while visiting
the member in the home and providing 24-hour
access to a physician who can provide in-home
care anytime, day or night as needed. This level
of patient-centric, physician-directed care has
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March 2007
been designed to improve the quality of care and
optimum health status for the most chronically ill,
frail patients.
By optimizing care in the home, the goal of
this pilot program is to reduce unnecessary
hospitalizations and emergency room visits, thereby
improving health status of the member and avoiding
unnecessary costs to the member and the health care
system. The PCP will be intimately involved in care
planning decisions suggested by the CLM physician
after an urgent contact with the member. Capitation
payments to the PCP will remain unchanged during
this pilot.
Please call us at (215) 241-2846, with any questions
regarding potential enrollees or on-going care as
co-managed with CLM physicians.
www.ibx.com
P R E V E N T I V E HEALTH
Supporting Our Members, Your Patients:
ConnectionsSM Health Management Programs
ConnectionsSM Health Management Program
Diseases:
• Asthma
• CHF
• CAD
• COPD
• Diabetes
To refer a patient for Health Coaching for these
five chronic diseases or for general health support,
or to obtain additional information for your office,
call the Connections Health Management Program
Provider Support Line at (866) 866-4694.
ConnectionsSM Kidney Program
Disease:
• End-Stage Renal Disease
To refer a patient or obtain additional information,
call the Connections Kidney Program at
(866) 303-4CKP.
ConnectionsSM AccordantCareTM Program
Diseases:
• Seizure Disorders
• Rheumatoid Arthritis
• Multiple Sclerosis
• Crohn’s Disease
• Parkinson’s Disease
• Systemic Lupus Erythematosus (SLE)
• Myasthenia Gravis
• Sickle Cell Disease
• Cystic Fibrosis
• Hemophilia
• Scleroderma
• Polymyositis
• Chronic Inflammatory Demyelinating
Polyradiculoneuropathy (CIDP)
• Amyotrophic Lateral Sclerosis (ALS)
• Dermatomyositis
• Gaucher Disease
To refer a patient or obtain additional information,
call the Connections AccordantCareTM Program at
(866) 398-8761.
www.ibx.com
March 2007
11
I M P O RTA N T R E SOURCES
View our online provider directories at www.ibx.com
Partners in Health monthly Update
is a publication of the Provider
Communications department for the
exchange of information and ideas
among the IBC Provider community.
Suggestions are welcome.
CONTACT INFORMATION:
Caroline Crispino
Managing Editor
Charleen Baselice
Production Coordinator
Provider Communications
Independence Blue Cross
1901 Market Street
35th Floor
Philadelphia, PA 19103
[email protected]
Independence Blue Cross offers products directly,
through its subsidiaries Keystone Health Plan
East and QCC Insurance Company, and with
Highmark Blue Shield—independent licensees
of the Blue Cross and Blue Shield Association.
The Blue Cross and Blue Shield words and
symbols, and BlueExchange are registered
trademarks of the Blue Cross and Blue Shield
Association, and association of independent
Blue Cross and Blue Shield Plans.
This is not a statement of benefits. Benefits may
vary based on state requirements, product line
(HMO, PPO, Indemnity, etc.), and/or employer
groups. Providers should call Provider Services,
listed at right, for the member’s applicable benefit
information. Members should be instructed to call
the number on the back of their identification card.
Not all benefit plans use Magellan Behavioral
Health, Inc. to administer behavioral health
benefits. Please check the back of the member’s
ID card for the telephone number to contact for
behavioral health services, if applicable.
The third-party Web sites mentioned in this
publication are maintained by organizations
over which IBC exercises no control, and
accordingly, IBC disclaims any responsibility
for the content, the accuracy of the information,
and/or quality of products or services provided
by or advertised in these third-party sites. URLs
presented for informational purposes only. Certain
services/treatments referred to in third-party sites
may not be covered by all benefit plans. Members
should refer to their benefit contract for complete
details of the terms, limitations, and exclusions of
their coverage.
CPT® (Current Procedural Terminology) is a
copyright of the American Medical Association
(AMA). All Rights Reserved. No fee schedules,
basic units, relative values, or related listings
are included in CPT. The AMA assumes no
liability for the data contained herein. Applicable
FARS/DFARS restrictions apply to government
use. CPT® is a trademark of the American Medical
Association.
Investors in NaviMedix®, Inc. include an affiliate
of IBC, which has a minority ownership interest in
NaviMedix®, Inc.
CARE MANAGEMENT AND COORDINATION
Case Management
Baby BluePrints®
CONNECTIONSSM HEALTH MANAGEMENT PROGRAMS
Connections Health Management Program Provider Support Line
(215) 567-3570
(800) 313-8628*
(215) 241-2198
(800) 598-BABY [2229]*
(866) 866-4694
ConnectionsSM Kidney Program
(866) 303-4CKP [4257]
ConnectionsSM AccordantCareTM Program
(866) 398-8761
CORPORATE AND FINANCIAL INVESTIGATIONS DEPARTMENT
Anti-Fraud and Corporate Compliance Hotline
(866) 282-2707
www.ibx.com/anti-fraud
CREDENTIALING VIOLATION HOTLINE
(215) 988-6534
www.ibx.com/credentials
eBUSINESS
Help Desk
(215) 241-2305
eBusiness Provider Hotline
HEALTH RESOURCE CENTER
Healthy LifestylesSM
Precertification
PHARMACY SERVICES
Prescription Drug Authorization
Toll Free Fax
(215) 640-7410
(215) 241-3367
(800) 275-2583*
(215) 241-2100
(800) 227-3116*
(888) 678-7012
(888) 671-5285
Direct Ship Injectable
(267) 402-1711
(888) 678-7012
Fax
(215) 761-9165
Blood Glucose Meter Hotline
(888) 494-8213 (option 2)
PROVIDER ELECTRONIC DATA INTERCHANGE
SERVICES WEB PAGE
www.ibx.com/edi
PROVIDER INFORMATION and TOOLS WEB PAGE
www.ibx.com/providers
PROVIDER SERVICES (Policies/Procedures/Claims)
HMO
(215) 567-3590
(800) 227-3119*
PPO
PROVIDER SUPPLY LINE
(215) 567-3694
(800) 332-2566*
(800) 858-4728
* Outside 215 area code
Visit our website at www.ibx.com/providers/communications
03/07
ALL
R
TRADES
IED PRINTING
UNION
LABEL
COUNCIL
SCRANTON
13
The 2006 CGPU Compendium mailed as an enclosure with this edition
of Partners in Health Update.
The Compendium has been added to this PDF for your convenience.
2006 Coding Guidelines and Policy Update Compendium
www.ibx.com
®
GR
APHI
C C O M M U N I C AT I O
UNION
INT
NS
LABEL
E R N AT
O
IO NAL UNI
N
526-M
2006 Coding Guidelines
And Policy Update
COMPENDIUM
www.ibx.com
Important Note:
The medical policies referenced
in this document apply to all
HMO, POS, and PPO products of
Independence Blue Cross (“IBC”),
including its affiliates, as well as to
traditional indemnity products to
the extent the applicable covered
services are underwritten by IBC or
its affiliates. Please note that some of
IBC’s traditional indemnity products
are jointly underwritten by Highmark
Blue Shield and therefore Highmark’s
medical policy may apply. You may
refer to the member’s ID card for
the entity that is responsible for
underwriting the product.
This document was developed to
assist IBC in administering the
provisions of its benefits programs
and does not constitute medical
advice. Professional providers are
responsible for providing medical
advice and treatment. Even though
this document may conclude that a
particular service or item is medically
necessary, such conclusion is NOT
based upon the terms of a particular
member’s benefit plan. Members must
refer to their specific benefit program
for the terms, conditions, limitations
and exclusions of coverage.
Please note that the Policy Bulletins
which are referenced herein describe
the status of a specific topic at the
time the Policy Bulletin was created.
Policy Bulletins are updated biennially
and when new medical evidence
becomes available, therefore, they are
subject to change.
Please be aware that the actual Policy
Bulletins which are discussed herein
are used as a guide only. Coverage
decisions are made on a case-by-case
basis by applying Policy Bulletin
criteria to the member’s medical
history, condition, and proposed course
of treatment as well as the member’s
benefit program. Providers should
review Policy Bulletins with Members
as treatment options are discussed,
as the Policy Bulletins are designed
to be used by our professional staff
in making coverage determinations
and can be highly technical.
Information contained in this
document and the actual Policy
Bulletin does not constitute an
offer of coverage, medical advice, or
guarantee of payment. Please note
that, if there is a conflict between
the Policy Bulletin and a member’s
benefit program, the terms of the
benefit program will govern.
Please note that providers who opted
out of the class action settlement
may not be entitled to certain claim
payment policy changes. Therefore,
any payments made pursuant to such
policy changes to providers who opted
out of the class action settlement are
subject to retroactive adjustments.
Table of Contents
Introduction..........................................3
About the Coding Guidelines and Policy
Update Compendium.............................3
What are the Primary Reasons that IBC
Develops Claim Payment and Medical
Policies?................................................3
Class Action Settlement Update...........35
Enhancements to Claim Payment
Policy, Processing and Payment
Disclosure, and an Appeals Process
for Class Action Settlement
Providers............................................36
Physician Volunteers Needed to Assist
in Developing Medical Policies...........3
Assistant Surgery Modifiers 80,
81, 82.................................................36
Medical Policies Covered: According to
Certain Criteria.....................................5
Medical Code Updates.........................39
Medical Policies Not Covered: Considered
Experimental/Investigational.................21
Claim Payment Policies........................27
Co-Surgery Modifier 62....................37
CPT® Codes.....................................40
ICD-9 CM Codes.............................90
HCPCS Codes..................................62
2006 Articles........................................31
ICD-9 CM Diagnosis Codes
Change for Routine Gynecological
Exams................................................32
Billing for Neonatal Hearing
Screening Should be Directed
to Facility...........................................32
Anesthesia Claims Update.................32
Gardasil® Approved by the FDA......32
Clarifications to the Intensity
Modulated Radiation Therapy
Policy.................................................33
View Full Policies Online
Full descriptions of these policies are
available online: www.ibx.com/medpolicy.
The Blue Cross and Blue Shield words and symbols are registered marks of the Blue Cross and Blue Shield Association.
Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company,
and with Highmark Blue Shield—independent licensees of the Blue Cross and Blue Shield Association.
INTRODUCTION
About the Coding Guidelines and
Policy Update (CGPU) Compendium
Over the past year, Independence Blue Cross (IBC) has
published four Coding Guidelines and Policy Update (CGPU)
newsletters.
Some of the primary reasons that IBC develops claim
payment and medical policy are to:
This 2006 Coding Guidelines and Policy Update Compendium
is a collection of relevant policy summaries that have been
published in CGPU during the past year. We are not able to
reproduce all of the CGPU summaries in the Compendium
because some policies have undergone updates and revisions
since their initial publication in CGPU; however, these
updated policies will appear in future issues of CGPU. We
encourage you to visit www.ibx.com/providers for expanded,
up-to-date versions of each policy.
•Comply with legislation (e.g., federal, state, and local
legislative mandates).
In addition to the descriptions of policies previously
published in the CGPU, the Compendium has also expanded
the normal CGPU parameters to include articles on coding
and policy, plus a section detailing new, revised, and deleted
CPT®*, HCPCS, and ICD-9 CM codes.
•Ensure a relevant and timely scheduled review of
existing policies.
This Compendium contains information that you can
immediately adopt within your practice to simplify your
information retrieval and claims submission processes.
*Current Procedural Terminology (CPT®) is a copyright of the American Medical
Association (AMA). All Rights Reserved. No fee schedules, basic units, relative
values, or related listings are included in the CPT. The AMA assumes no liability
for the data contained herein. Applicable FARS/DFARS restrictions apply to
government use. CPT® is a trademark of the AMA.
Visit www.ibx.com/medpolicy to get the most current, in-depth
and up-to-date information on policies affecting health care
in your region. Review and accept the terms & conditions,
and you can quickly and easily search all active policies.
Bookmark this site and check back regularly for the latest
information and updates.
The 2006 CGPU Compendium can be found at
www.ibx.com/providers/communications. You can also
check the website to find specific billing codes, in-depth
descriptions of services, or other policy-related data.
www.ibx.com/providers/communications
43034txt.indd 3
What Are the Primary Reasons That
IBC Develops Claim Payment and
Medical Policies?
•Correspond to national or local Medicare Carrier
Coverage Policy.
•Allow consistent interpretation and application of
benefits.
•Respond to requests for new, emerging technology or
changes in existing technology.
• Provide claims submission policies and procedures.
Physician Volunteers Needed to Assist
in Developing Medical Policies
IBC is currently recruiting physicians to join our Policy
Committee Advisory Panel. This panel is responsible for
evaluating the scientific evidence and local standards of care
addressed in our medical policies.
Medical policies are research-based documents that allow
IBC to evaluate the medical necessity of services, devices,
biologics, and procedures for its members. In addition,
medical policies provide guidelines for obtaining benefits
and reimbursement in accordance with a member’s plan. As
a volunteer consultant on the Policy Committee Advisory
Panel, you will evaluate proposed medical policies based on
your area(s) of expertise. As such, your contributions will
significantly impact the care of patients in your region.
At this time, IBC is seeking physician consultants in the
following specialties:
•
•
•
•
•
•
•
•
•
Neurosurgery
Orthopedics
Urology
Vascular Surgery
Physical Medicine and Rehabilitation
Rheumatology
Cardiology
Gastroenterology
Pain Medicine
2/19/07 1:44:19 PM
C o ding G uid e l in e s and P o l ic y
U pdat e
C o mp e ndium To qualify as a member of the Policy Committee Advisory
Panel, you must:
• Maintain board certification for each specialty or
subspecialty for which you wish to consult.
• Maintain an active clinical practice in each specialty or
subspecialty for which you wish to consult.
• Understand and agree to adhere to our confidentiality
statement.
• Maintain a high ethical standard, evidenced by the
absence of any IBC investigation into personal or group
claims practices.
• Complete and sign a Conflict of Interest Statement and
Confidentiality Agreement prior to becoming a member
of the advisory panel.
If you meet the above criteria and have an interest in
sharing your expertise as a member of the Policy Committee
Advisory Panel, please submit your curriculum vitae to:
Gerald W. Peden, M.D., M.A.
Senior Medical Director
Claim Payment Policy Department
Independence Blue Cross
1901 Market Street
Philadelphia, PA 19103-1480
View Full Policies Online
Full descriptions of these policies are available online at:
www.ibx.com/medpolicy.
View full policies online at www.ibx.com/medpolicy
43034txt.indd 4
2006 CGPU Compendium
2/19/07 1:44:19 PM
Medical Policies
Covered: according to certain criteria
www.ibx.com
Table of Contents
Ambulatory Blood Pressure Monitoring
(ABPM) (07.02.09)........................................................ 6
Blepharoplasty with or without a Brow Lift/Repair
of Blepharoptosis (11.05.02c)......................................... 6
Bone Growth Stimulators (05.00.09c)........................... 7
High-Frequency Chest Wall Oscillation Devices
(05.00.14c)..................................................................... 9
Home Phototherapy for Neonatal Jaundice
(07.06.02) ...................................................................... 9
Hospital Beds and Accessories (05.00.56a) ................ 10
Islet Cell Transplantation (11.04.01) .......................... 12
Maze Procedure (11.02.20a) ....................................... 12
Medical Evaluation and Management for
Attention-Deficit Hyperactivity Disorder
(ADHD) (07.03.03b)................................................... 13
Negative Pressure Wound Therapy (NPWT)
Pump (05.00.38a) ....................................................... 13
Outpatient Speech Therapy (10.06.01a) . .................. 15
Reduction Mammaplasty (11.08.02c).......................... 17
The Boston® Scleral Lens (07.13.11) ................... 18
Trigger Point Injections (11.14.02c) ........................... 19
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Medical Policies Covered:
Ambulatory Blood Pressure
Monitoring (ABPM) (07.02.09)
Covered: According to Certain Criteria
Ambulatory blood pressure monitoring (ABPM) involves
the use of a noninvasive device that measures blood
pressure in 24-hour cycles. The device consists of a portable
sphygmomanometer attached to a recording device. The
information it provides can help a physician determine
whether an individual is truly hypertensive or is exhibiting
white coat hypertension (WCH).
The ABPM device is fitted to and removed from the
individual by a trained technician. The sphygmomanometer
inflates at predetermined times, generally every 30 minutes,
and the blood pressure recorded at each inflation is stored.
The individual performs normal activities while wearing the
monitor. Automated ABPM is considered more accurate
than individual self-monitoring. Therefore, it is generally
thought that readings obtained at frequent intervals
throughout the day and night would help the physician
better manage the individual’s care. These stored 24-hour
measurements are later interpreted at the physician’s office.
A clinician is required to interpret the collected data by
uploading it onto a computer where device-specific programs
are used to categorize and analyze the measurements.
ABPM is considered medically necessary for individuals who
meet the definition criteria of WCH and have no evidence
of end-organ damage. ABPM is covered for individuals
requiring 24-hour monitoring of their blood pressure to
confirm the diagnosis.
Physician interpretation is medically necessary and required
for reimbursement. Therefore, ABPM utilizing a system
such as magnetic tape and/or computer disk, for 24 hours
or longer, with recording only or scanning analysis with
report only (no mention of physician interpretation), is not
eligible for separate reimbursement when billed alone or in
conjunction with another service.
When a primary care physician (PCP) is contracted to
provide medically necessary and preventive care services on
a monthly capitation basis, this service is included in the
monthly capitation payment.
Originally published in Winter 2006 CGPU.
C o mp e ndium According to Certain Criteria
Blepharoplasty with or without a
Brow Lift/Repair of Blepharoptosis
(11.05.02c)
Blepharoptosis is the condition of droopiness of the upper
eyelid due to underlying eye muscle dysfunction (e.g.,
levator muscle or Muller’s muscle). Surgical repair of this
condition, including repair of the eye muscle, is performed in
conjunction with the blepharoplasty procedure.
A blepharoplasty procedure includes the removal of
redundant skin of the upper and/or lower eyelids and the
removal of protruding periorbital fat. This procedure can be
performed for either cosmetic or reconstructive purposes.
When performed for cosmetic reasons, the surgery reshapes
eye-related structures in order to improve appearance and
self-esteem; when provided as part of a reconstructive
procedure, the surgery reshapes eye-related structures in
order to improve functional ability. Blepharoplasty can be
performed alone or in conjunction with other procedures
such as a brow lift.
Under most circumstances, a blepharoplasty with or without
a brow lift and/or repair of blepharoptosis is a cosmetic
service and a benefit contract exclusion. However, each of
these procedures is medically necessary when performed
as functional or reconstructive surgeries in certain clinical
situations.
Blepharoplasty
Blepharoplasty is medically necessary when performed to
correct:
•Prosthetic difficulties in an anophthalmic (without an
eye) socket.
•Disorders of visual impairment caused by redundant
skin of the eyelid or eyebrow that include, but are not
limited to:
-V isual impairment due to dermatochalasis,
blepharochalasis, or ptosis of the eyelid.
-Symptomatic, redundant skin that is resting on the
upper lashes.
-Chronic, symptomatic dermatitis of pretarsal skin
caused by redundant upper eyelid skin.
Lower eyelid blepharoplasty is generally not medically
indicated to treat conditions that cause visual field
43034txt.indd 6
2/19/07 1:44:20 PM
obstruction because the lower eyelids are not usually
associated with visual impairment. In the absence of visual
impairment, lower eyelid blepharoplasty is considered a
cosmetic service and, therefore, not covered.
-The upper eyelid indicates the presence of
dermatitis.
Requests for lower eyelid blepharoplasty are considered
on an individual basis when documentation (including the
individual’s chief complaint and preoperative photographs)
demonstrates that the procedure is medically necessary for
reconstructive reasons.
- The brow position is below the superior orbital rim.
Blepharoptosis Repair
Blepharoptosis repair is medically necessary when performed
as functional/reconstructive surgery to correct a visual
impairment due to drooping or displacement of the upper
eyelid.
Brow Ptosis Repair
Brow ptosis repair is medically necessary when performed
as functional/reconstructive surgery to correct either of the
following:
• Visual impairment due to droop or displacement of the
brow.
• Brow malposition that would prevent adequate
correction of dermatochalasis, blepharochalasis, or
blepharoptosis.
Documentation Requirements
All requests for any of the procedures listed above require a
letter of medical necessity that describes the individual’s chief
complaints and that justifies the need for surgery to correct
the functional impairment. Additionally, when blepharoplasty
is to be performed as a functional/reconstructive surgery
to correct visual impairment, the following additional
documentation is required:
• Preoperative color photographs that include a view
of the individual: in forward gaze, looking up, and
looking down, and that demonstrate one or more of the
following:
-The upper eyelid margin is within 2.5 mm (onefourth of the diameter of the visible iris) of the
corneal light reflex (margin-to-reflex distance
[MRD] less than 2.5 mm) with the individual in
primary gaze.
- The upper eyelid skin rests on the eyelashes.
43034txt.indd 7
-The upper eyelid position contributes to difficulty
tolerating a prosthesis in an anophthalmic socket.
•A written interpretation of the results of both the taped
and untaped automated visual field studies must be
submitted and must demonstrate one of the following:
-The upper visual field has improved by at least
eight degrees or 20 percent with the eyelid taped
as compared with the visual field obtained without
taping (two sets of visual fields are required).
-V isual field obstruction by the eyelid limits the
upper visual field to within 30 degrees of fixation.
If both a blepharoplasty and a brow ptosis repair are planned,
the need for both must be documented. This requires
photographs showing the affect of the drooping, redundant
skin; the skin resting on the upper eyelid; the presence of
dermatitis; or the actual presence of blepharoptosis.
Originally published in Fall 2006 CGPU.
Bone Growth Stimulators (05.00.09c)
Noninvasive bone growth stimulators consist of an external
power supply and externally applied coils or a transducer
that generate a weak electrical current through the site where
bone growth is desired. Noninvasive devices use pulsed
electromagnetic fields (PEMFs), capacitative coupling, or
combined magnetic fields technology to generate the current.
Ultrasonic bone growth stimulators are noninvasive devices
that accelerate fracture healing by emitting low-intensity,
pulsed ultrasound signals on the skin surface over the
fracture site. Ultrasonic bone growth stimulators are used in
conjunction with cast immobilization.
Electrical bone growth stimulators are used for nonunion
fracture(s) of long bone, which is defined by Medicare to
include the following: the clavicle, humerus, radius, ulna,
metacarpal, femur, tibia, fibula, malleolus, and metatarsal.
Studies of bone growth stimulators in the treatment of fresh
fractures (less than seven days) and in delayed union and
nonunion fractures of both long and short bone indicate
that insufficient scientific evidence exists to demonstrate
the effectiveness of electrical bone growth stimulators in
fresh and delayed union fractures. In addition, the safety
2/19/07 1:44:20 PM
U pdat e
and effectiveness of electrical bone growth stimulators in
individuals under the age of 17 has not been established in
clinical trials.
Electrical bone growth stimulators (noninvasive/invasive)
are considered medically necessary and, therefore, covered
for individuals 17 years of age or older when one of the
following conditions is present:
• A fracture secondary to congenital pseudarthrosis
(755.8).
• A nonunion fracture (733.82) of a long bone (includes
the following: the clavicle, humerus, radius, ulna,
metacarpal, femur, tibia, fibula, malleolus, metatarsal).
-Nonunion fracture is defined as the point at which
healing has stopped (three months or greater
from the initial fracture) and further healing (as
evidenced by serial radiographic documentation) has
ceased.
• A failed joint fusion.
-Post-surgical joint fusion failure is defined as
radiologic documentation of nonunion nine months
or more after surgical fixation of the fracture.
Electrical bone growth stimulators (noninvasive/invasive)
are considered medically necessary and, therefore, covered
following spinal surgery (V45.4) when one of the following
criteria is met:
•A failed spinal fusion when the surgery was performed a
minimum of nine months from the last surgery.
•A multilevel spinal fusion surgery (e.g., L3-L5, L4-S1,
etc.).
•Revisional spinal fusion surgery due to a previously
failed spinal fusion at the same level.
Unless any exclusion criteria exists, low-intensity
ultrasonic bone growth stimulators (noninvasive) are
considered medically necessary and, therefore, covered for
any of the following:
• Fresh (less than seven days), closed or Grade l open,
tibial diaphysis fracture (823.20, 823.30) when used as
an adjunct to closed reduction and cast immobilization.
C o mp e ndium • Nonunion fractures (733.82) of the clavicle, scapula,
humerus, radius, ulna, carpal, metacarpal, phalanges
(fingers or toes), femur, patella, tibia, fibula, malleolus,
talus, calcaneus, cuboid, navicular, cuneiform, tarsal,
metatarsal, rib(s), sternum, and pelvis.
- Nonunion fracture is defined as the point at which
healing has stopped (three months or greater from
the initial fracture) and further healing (as evidenced
by serial radiographic documentation) has ceased.
If one or more of the following exclusion criteria exist, lowintensity ultrasonic bone growth stimulators are considered
experimental/investigational and, therefore, not covered
because the safety and/or efficacy of this device for these
conditions cannot be established by review of the available
published literature:
• For a fracture of the skull or vertebrae.
• For a fracture that is tumor-related.
• For concurrent use with any other noninvasive
osteogenic stimulator.
• In individuals under the age of 17.
• For a fresh fracture other than one of the tibial
diaphysis or distal radius.
• For a delayed union fracture (a recent fracture [three
months or less from the initial fracture], where healing
has not advanced at the “average” rate for the location
and type of fracture).
For all other indications, electrical bone growth stimulators
and low-intensity ultrasonic bone growth stimulators are
considered experimental/investigational and, therefore, not
covered because the safety and/or efficacy of these devices
cannot be established by review of the available published
literature. Examples of other indications include, but are not
limited to: individuals under the age of 17, fresh fractures
(except ultrasonic stimulator use for fractures of the tibial
diaphysis or distal radius), and delayed union fractures.
• Fresh, closed fracture of the distal radius (Colles
fracture [813.41, 813.42]) when used as an adjunct to
closed reduction and cast immobilization.
43034txt.indd 8
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High-Frequency Chest Wall Oscillation
Devices (05.00.14c)
A high-frequency chest wall oscillation device is designed
to enhance the mobilization of bronchial secretions. The
device is an inflatable vest that is connected by two tubes to
a small air-pulse generator. Oscillating positive air pressure
causes the vest to inflate and deflate up to 25 times a minute,
creating a vibratory motion that aids in the mobilization of
secretions. The action of the device creates mini-coughs that
dislodge mucus from the bronchial walls, thus increasing
mobilization of the mucus toward the central airways. The
oscillating action also thins the secretions and makes them
easier to remove by coughing or suctioning. High-frequency
chest wall oscillation devices can be used for individuals
who have cystic fibrosis or bronchiectasis and require chest
physiotherapy, manual chest percussion, postural drainage,
and device-assisted coughing to help them clear their lungs.
A four- to six-week trial of a high-frequency chest wall
oscillation device is considered medically necessary and,
therefore, covered for the treatment of individuals with
a documented history that confirms a failure of standard
treatments (e.g., manual chest percussion, postural drainage)
to adequately mobilize retained bronchial secretions and one
of the following diagnoses:
• Cystic fibrosis.
•Bronchiectasis, confirmed by computed tomography
(CT) scan, and documentation of one of the following:
-Daily productive cough for at least six continuous
months.
-Frequent (i.e., more than two per year) exacerbations
of respiratory infection requiring antibiotic therapy.
Continued coverage of the device after the trial is considered
medically necessary and, therefore, covered when the
effectiveness of the device has been demonstrated by:
•Documentation that the device has been used daily or as
prescribed.
• Documentation of increased expectoration of mucus.
If the trial of the device is successful and the individual
wishes to continue using the device, continued authorization
for the device must be obtained. The ordering physician must
provide a letter of medical necessity to the Company stating
compliance with the above requirements.
43034txt.indd 9
High-frequency chest wall oscillation devices for any
diagnosis other than cystic fibrosis or bronchiectasis are
considered not medically necessary and, therefore, not
covered because the available published literature does not
support the use of this device for the treatment of any other
diagnosis.
Home Phototherapy for Neonatal
Jaundice (07.06.02)
Phototherapy is often used to treat neonatal jaundice and
involves the continuous application of ultraviolet light via
a lamp or a fiberoptic system to a newborn for a prescribed
period of time. The fiberoptic system consists of a pad of
woven fibers that transport light from a light source to the
baby. This covered fiberoptic pad is placed directly against
the baby to bathe the skin in light. Phototherapy uses blue
wavelengths of light to convert the bilirubin to less toxic
water-soluble photoisomers, which are then excreted in bile
and urine. Phototherapy can be administered in a hospital
or home setting (home phototherapy). It is important to
note that the use of phototherapy in the home setting is
contraindicated in the presence of risk factors.
Home phototherapy devices do not consistently provide the
same degree of irradiance as those available in the hospital.
Due to the questionable efficiency of home phototherapy
for neonatal jaundice, the American Academy of Pediatrics
states that home phototherapy is considered inappropriate for
infants with higher bilirubin concentrations.
Home phototherapy is considered medically necessary
for full-term newborns who are diagnosed with neonatal
jaundice and have none of the risk factors, major or minor,
that have been identified by the American Academy of
Pediatrics.*
The following are major risk factors that have been identified
by the American Academy of Pediatrics for the development
of severe hyperbilirubinemia in infants of 35 weeks or more
gestation:
•Predischarge total serum bilirubin (TSB) or
transcutaneous bilirubin (TcB) level in the high-risk
zone.
• Jaundice observed within the first 24 hours.
2/19/07 1:44:20 PM
U pdat e
•Blood group incompatibility with positive direct
antiglobulin test, other known hemolytic disease
(e.g., glucose-6-phosphate-dehydrogenase [G6PD]
deficiency), elevated end tidal carbon monoxide
(ETCOc).
• Gestational age 35-36 weeks.
• Previous sibling received phototherapy.
• Cephalohematoma or significant bruising.
•Exclusive breastfeeding, particularly if nursing is not
going well and weight loss is excessive.
• East Asian race.
The following are minor risk factors identified by the
American Academy of Pediatrics for the development of
severe hyperbilirubinemia in infants of 35 weeks or more
gestation:
•Predischarge TSB or TcB level in the high intermediaterisk zone
• Gestational age 37-38 weeks
• Jaundice observed before discharge
• Previous sibling with jaundice
• Macrosomic infant of a diabetic mother
• Maternal age of 25 years or more
• Male gender
*Reproduced with permission from Pediatrics, Vol. 114, Pages 297-316,
Copyright © 2004 by the American Academy of Pediatrics (AAP).
Hospital Beds and Accessories
(05.00.56a)
A hospital bed is a bed with head and leg elevation and
height adjustment features that are used to assist individuals
who require adjustment or repositioning to alleviate pain,
prevent contractures, prevent respiratory infections, and to
allow individuals to transfer to and from bed with increased
independence.
Hospital bed accessories are additions to a bed that are not
provided as part of the original bed. Accessories that may be
needed for the essential functioning of the hospital bed in
10 View full policies online at www.ibx.com/medpolicy
43034txt.indd 10
C o mp e ndium relation to the individual’s condition include trapeze bars, bed
cradles, or side rails.
Medically Necessary
Fixed-height Hospital Beds
A fixed-height hospital bed (E0250, E0251, E0290, E0291)
is medically necessary when the individual meets one or more
of the following medical necessity criteria:
•The individual has a medical condition that requires
positioning of the body in ways that are not feasible in
an ordinary bed. The elevation of the head/upper body
of less than 30 degrees does not usually require the use
of a hospital bed.
•The individual requires head elevation of more than 30
degrees most of the time due to congestive heart failure
(CHF), problems with aspiration, or chronic pulmonary
disease. Pillows or wedges must have been considered
and ruled out.
•The individual requires positioning of the body in ways
that are not feasible in an ordinary bed to alleviate pain.
•The individual requires traction equipment, which can
only be attached to a hospital bed.
Variable-height Hospital Beds
A variable-height hospital bed (E0255, E0256, E0292,
E0293) is medically necessary for individuals with severely
debilitating diseases and conditions (including, but not
limited to severe cardiac conditions, spinal cord injuries,
amyotrophic lateral sclerosis [ALS], and multiple sclerosis)
when all of the following apply:
•The individual meets one or more of the medical
necessity criteria for a fixed-height hospital bed.
•The individual requires a bed height that cannot be
attained with a fixed hospital bed and that allows them
to be transferred to a chair, wheelchair, or standing
position.
Semi-Electric Hospital Beds
A semi-electric hospital bed (E0260, E0261, E0294, E0295)
is medically necessary when the individual meets one or more
of the medical necessity criteria for a fixed-height hospital
bed and both of the following criteria:
• The individual’s condition requires that their body
position be changed frequently and/or that their body
2/19/07 1:44:20 PM
position may be changed immediately when necessary
(i.e., no delay can be tolerated).
• The individual is able to operate the controls and cause
the adjustments. Exceptions to this requirement can
be made in cases of spinal cord injury (SCI) and brain
injury.
Heavy-duty Hospital Beds
A heavy-duty hospital bed (E0301, E0303) is medically
necessary when the individual meets one or more of the
medical necessity criteria for a fixed-height hospital bed and
when the individual’s weight exceeds 350 pounds but is less
than 600 pounds.
Extra-heavy-duty Hospital Beds
An extra-heavy-duty hospital bed (E0302, E0304) is
medically necessary when the individual meets one or more
of the medical necessity criteria for a fixed-height hospital
bed and when the individual’s weight exceeds 600 pounds.
Pediatric Hospital Beds
• Bed cradle (E0280): When the individual has a medical
condition that requires the prevention of contact with
bed coverings (i.e., burns, diabetic ulcers, gout).
• Trapeze equipment (E0910, E0940): When the
individual requires this device to do any one of the
following:
- Sit up because of a respiratory condition.
- Change body position for other medical reasons.
- Get in or out of bed.
• Heavy-duty trapeze equipment (E0911, E0912): When
the individual meets both of the following criteria:
-The individual meets the criteria for regular trapeze
equipment.
- The individual weighs more than 250 pounds.
• Side rails (E0305, E0310): When the individual’s
condition requires that they have bed side rails and the
rails are a part of or an accessory to the hospital bed.
A pediatric hospital bed is medically necessary when the
individual meets all of the medical necessity criteria for one
of the hospital beds specified above.
Not Medically Necessary
The following hospital bed accessory is considered not
medically necessary:
Total Electric Hospital Beds
A total electric hospital bed (E0265, E0266, E0296, E0297)
is considered not medically necessary and, therefore, not
covered because the electric height adjustment feature does
not aid in the treatment of the individual’s condition.
Institutional Hospital Beds
An institutional hospital bed (E0270) is considered not
medically necessary and, therefore, not covered because it
is deemed inappropriate for home use. These beds include
oscillating beds, circulating beds, and Stryker frame beds.
Hospital Bed Accessories
Medically Necessary
The following hospital bed accessories are considered
medically necessary when the individual meets the medical
43034txt.indd 11
necessity requirement for the specified bed and meets the
additional criteria as indicated below:
• Trapeze bars (E0910, E0911) will be considered not
medically necessary and, therefore, not covered when
they are used on an ordinary bed.
Not Primarily Medical In Nature (Benefit Exclusion)
• Safety enclosures (E0316) (nylon netting that encloses
the top and sides of a hospital bed) are considered
benefit exclusions and, therefore, not covered as these
devices are not primarily medical in nature. Additionally,
these devices have safety concerns associated with them.
For Medicare members, safety enclosures are considered
not medically necessary, and, therefore, not covered;
these devices have safety concerns associated with them.
• A bed board (E0273, E0315) (a device placed under a
mattress to make the mattress firmer) is considered a
benefit exclusion and, therefore, not covered because its
use is not primarily medical in nature.
• An over bed table (E0274, E0315) is considered a
benefit exclusion and, therefore, not covered because its
use is not primarily medical in nature.
11
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U pdat e
C o mp e ndium Islet Cell Transplantation (11.04.01)
Maze Procedure (11.02.20a)
Islet cell transplant tissue comes from either the patient
(autologous transplant) or from a cadaveric donor
(allogeneic transplant). Islet cell transplantation may benefit
an individual who does not have a functioning pancreas.
Currently only individuals with either chronic pancreatitis
or type 1 diabetes mellitus have been the subject of clinical
investigations.
The Maze procedure is a surgical procedure intended to
restore normal heart rhythm in individuals afflicted with
atrial fibrillation or atrial flutter that does not respond to
medical therapy. It can be performed alone or in conjunction
with other cardiac surgeries for restoring the normal
electrical impulses of the heart. The procedure is done under
general anesthesia while the individual is on cardiopulmonary
bypass (a machine that performs the functions of the heart
and lungs during the surgery). Access to the heart is obtained
through a sternal incision. The cardiothoracic surgeon then
makes several incisions in the right and left atria of the heart
to create a pathway (maze) for the electrical impulses to
flow, thus restoring the normal rhythm of the heart. These
incisions create a direction for the impulse to flow from the
sinoatrial (SA) node to the atrioventricular (AV) node and
block the re-entry of impulses that result in atrial fibrillation
or atrial flutter.
Autologous islet transplantation is a technique to prevent
the serious morbidity of surgical induced diabetes due to
the removal of the individual’s pancreas. Although the
pancreatectomy and transplant can be performed on two
different days, the transplant is generally performed during
the pancreatectomy procedure. During the pancreatectomy, a
suspension is created by mixing plasma and the isolated islet
cells collected from the individual’s own resected pancreatic
specimen. This suspension is then injected into the portal
vein of the liver, where the cells function as a free graft. There
is no risk of rejection because, unlike allogeneic organ/tissue
transplants, the individual’s own islet cells are used in the
procedure.
Autologous islet cell transplantation is considered medically
necessary and, therefore, covered as an adjunct to a total
or near-total pancreatectomy in individuals with chronic
pancreatitis.
Autologous islet cell transplantation is considered
experimental/investigational for all other indications because
the safety and/or efficacy of this service cannot be established
by review of the available published literature. Therefore, this
service is not covered.
Allogeneic islet cell transplantation is considered
experimental/investigational for all indications because the
safety and/or efficacy of this service can not be established
by review of the available published literature. Therefore, this
43034txt.indd 12
Results may not be evident immediately due to cardiac
swelling, and some individuals may experience temporary
fibrillation up to three months following the procedure. The
fibrillation normally stops after the heart has had time to heal
completely.
The Maze procedure is considered medically necessary and,
therefore, covered for the treatment of atrial fibrillation or
atrial flutter in individuals with any of the following clinical
indications:
• Resistance to drug therapy.
• Intolerance of drug therapy.
• Atrial fibrillation or atrial flutter for more than six
months with an enlarged left atrium.
• High risk for thromboembolism (i.e., previous
thromboembolism or long-standing atrial fibrillation
with mitral valve disease).
Originally published in Spring 2006 CGPU.
2/19/07 1:44:21 PM
Medical Evaluation and Management
for Attention-Deficit Hyperactivity
Disorder (ADHD) (07.03.03b)
Evaluation
All of the following are considered medically necessary and,
therefore, covered for the medical evaluation of attentiondeficit hyperactivity disorder (ADHD):
• A complete physical examination within the last 12
months (including blood tests such as lead levels
and quantitative plasma amino acid assays to detect
phenylketonuria).
• A comprehensive medical history.
• Interviews with the parents and child to establish
problem pattern of behavior and parent-child and childpeer conflicts.
Neuropsychological testing for the evaluation of a previously
diagnosed ADHD is considered not medically necessary and,
therefore, not covered. It should only be performed if there is
a suspicion of a neurological deficit that requires additional
evaluation.
Management
Pharmacological therapy in the management of ADHD may
be covered under the prescription plan when the member has
a pharmacy benefit.
Nontraditional treatments for ADHD such as, but not
limited to, the following, have not shown positive health
outcomes and are, therefore, considered not medically
necessary and are not covered:
• Elimination diets (e.g., Feingold diet).
• Nutritional supplements (e.g., megadoses of vitamins).
Experimental/Investigational
Nontraditional treatments for ADHD lack validation
and scientific support and are, therefore, considered
experimental/investigational and are not covered. Examples
of nontraditional treatments for ADHD include:
• Sensory integration therapy.
• Optometric vision training (orthoptic/pleoptic).
• Interactive metronome training (a computerized version
of keeping the beat, which provides auditory feedback).
• Chiropractic therapy.
Originally published in Summer 2006 CGPU.
Negative Pressure Wound Therapy
(NPWT) Pump (05.00.38a)
Negative pressure wound therapy (NPWT), also known
as vacuum-assisted closure, is the application of controlled
negative pressure (vacuum pressure) to a wound using an
electrical pump. The NPWT vacuum pressure pump is used
to apply from 25 mm to greater than 200 mm Hg of pressure
to a wound, either continuously or intermittently.
Medical Necessity
A NPWT pump and the supplies necessary for its use are
considered medically necessary and, therefore, covered for
chronic nonhealing wounds (of at least 30 days duration)
as specified below when all of the following applicable
conditions are met:
• For chronic nonhealing ulcers or wounds, all of the
following program measures should apply or be
considered and ruled out by an eligible health care
professional prior to the application of a NPWT pump:
• Antifungal therapy.
- Any wound-specific therapeutic measures.
• Electroencephalogram (EEG) biofeedback.
-Documentation in the individual’s medical record
of the evaluation, wound measurements (length,
depth, and width), and general care performed and
documented by a health care professional.
• Antimotion sickness medication.
• Spinal manipulation.
Physical, occupational, and/or speech therapy is considered
not medically necessary and, therefore, not covered in the
43034txt.indd 13
treatment of ADHD, unless the individual has a neurological
or physical deficit that requires such therapy.
-Wound assessments are performed and documented
at least weekly (e.g., size [length, depth, and width],
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U pdat e
color, exudate type and amount, odor, evidence of
healing, sinus tracking or tunneling, pain, type of
dressing used).
-Application of dressings to maintain a moist wound
environment.
-Debridement of necrotic tissue (if present) by a
health care professional.
-Evaluation of and provision for adequate nutritional
status.
• The following wound-specific therapeutic measures (if
applicable) must be applied or considered and ruled
out by an eligible health care professional prior to the
application of a NPWT pump for the following specific
types of ulcers and wounds:
- For Stage III or IV pressure ulcers:
ºThe individual has been appropriately turned
and positioned.
ºThe individual has used a group 2 or 3
support surface for pressure ulcers on the
posterior trunk or pelvis. (A group 2 or 3
support surface is not required if the ulcer
is not on the trunk or pelvis. For more
information on support surfaces, refer to the
policy addressing this topic.)
ºThe individual’s moisture and incontinence
have been appropriately managed.
- For neuropathic (e.g., diabetic) ulcers:
ºThe individual has been on a comprehensive
diabetic management program.
ºThe individual has experienced reduced
pressure on a foot ulcer as a result of using
the appropriate modalities (such as, but not
limited to, the following: total contact casts;
removable cast walkers; half shoes; saline wetto-dry dressings; debridement of all necrotic,
callus, and fibrous tissue; crutches).
- For venous insufficiency ulcers:
ºThe individual has had compression bandages
and/or garments consistently applied.
º The individual has applied leg elevation.
º The individual has applied ambulation.
43034txt.indd 14
C o mp e ndium • For complications of surgical, subacute, or traumatic
wounds (e.g., postoperative flap, dehiscence, skin graft
failure, traumatic amputation, gunshot wounds, or
burns) when accelerated granulation tissue formation
cannot be achieved by topical wound treatments and is
a medical necessity as demonstrated by documentation
of conditions such as, but not limited to, any of the
following:
- The presence of excessive wound drainage.
- Large wounds not amenable to primary closure.
- Conditions that slow healing times (e.g., diabetes).
- Infection.
-The wound is a chronic and nonhealing wound of at
least 30 days duration.
Initial NPWT pump treatments may begin during an
inpatient stay for wounds encountered in the inpatient
setting. Treatment with the NPWT pump beyond the
inpatient stay may continue (upon discharge) in the home
setting, subject to meeting the above medical necessity
criteria.
Continued Coverage
For continuing coverage of up to four months, an eligible
health care professional must:
• Directly assess the wound(s) being treated with the
NPWT pump device and document findings.
• Supervise or directly perform the NPWT pump
dressing changes and document findings.
• Document changes in the ulcer’s dimensions and
characteristics (e.g., size [length, depth, and width],
color, exudate type and amount, odor, and evidence of
healing) at least weekly.
For continued coverage beyond four months, continued
documentation demonstrating wound healing is required and
will be evaluated by a Company medical director.
Treatment with an NPWT pump and supplies is considered
not medically necessary and, therefore, not covered when:
• Adequate wound healing has occurred.
• Any measurable degree of wound healing has failed to
occur over the prior month.
2/19/07 1:44:21 PM
• Cancer is present in the wound.
• The equipment or supplies are no longer being used for
the individual, regardless of whether it is a result of the
health care professional’s orders.
• The eligible health care professional fails to perform and
document the following on a weekly basis:
-Direct assessment of the wound(s) being treated
with the NPWT pump.
-Supervision or directly performing the ulcer/wound
dressing changes.
-Changes in the ulcer’s dimensions (length, depth,
and width) at least weekly.
• Necrotic tissue with eschar is present if debridement has
not been attempted.
• There is a fistula to an organ or body cavity within the
vicinity of the wound.
• Untreated osteomyelitis exists within the vicinity of the
wound.
Supplies for NPWT
An individual is eligible for a maximum of 15 wound
care sets (A6550) per wound per month, unless there is
documentation that the wound size requires more than one
wound care set for each dressing change. An individual is
eligible for a maximum of 10 canisters (A7000) per month,
unless there is documentation evidencing a large volume of
drainage (90 ml of exudate/day).
An NPWT pump (E2402) must be capable of
accommodating more than one wound dressing set for
multiple wounds on an individual. Therefore, more than one
E2402 billed per individual for the same time period will be
denied as not medically necessary.
Outpatient Speech Therapy
(10.06.01a) Covered: According to Certain Criteria
Speech pathology services are services that are deemed
necessary for the diagnosis of speech and language disorders.
Speech therapy is the medically prescribed treatment of
speech and language disorders due to disease, surgery,
43034txt.indd 15
injury, congenital anomalies, speech language delay, or
previous therapeutic processes that result in communication
disabilities and/or swallowing disorders.
Medical Necessity Criteria
Speech pathology evaluation and services related to the
speech therapy process that are within the scope of the
member’s benefit contract are considered medically necessary
and, therefore, are covered when all of the following criteria
are met:
• The evaluation is prescribed by a physician and
performed by a speech/language pathologist who
is licensed in the state where the services are being
performed and who is certified by the American
Speech-Language-Hearing Association (ASHA).
• The services must be of such a complex nature that they
can only be performed by a speech/language pathologist.
• The medical condition must be such that there is a
reasonable expectation that the services will bring
about a significant improvement within a reasonable
time frame, regardless of whether the individual has a
coexisting disorder.
• The services are provided in accordance with an ongoing
plan of care specific to the diagnosis.
-The plan of care should be updated at least weekly,
or more frequently as the treatment progresses,
and as goals change or are met. Upon request,
documentation must be available that shows
measurable progress toward meeting the short- and
long-term goals outlined in the plan of care.
• The therapy is performed for a communication disorder
that is a result of at least one of the following:
-Disease (e.g., Parkinson’s disease that results in
increased difficulty in swallowing and speaking).
-Surgery (e.g., surgical removal of a malignant
growth on the head or neck).
-Injury (e.g., automobile accident that results in a
subdural hematoma influencing the speech center
and causing neurogenic stuttering or aphasia
following a cerebrovascular accident [CVA]).
-Congenital anomalies (e.g., inborn defect of the
skull, cleft lip, or cleft palate).
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U pdat e
-Speech-language delay that is developmental in
nature.
or
• The therapy is performed for a swallowing disorder
(dysphagia) that results from a condition such as,
but not limited to, a CVA regardless of whether a
communication disorder also exists.
Speech therapy performed for reasons other than those listed
above is considered not medically necessary and, therefore
not covered except as required by law.
Conditions that do not Meet Medical Necessity
Criteria
Conditions or situations that do not meet medical necessity
criteria for speech pathology evaluation and services related
to the speech therapy process include, but are not limited to:
• Psychological speech delay.
• Behavior problems (e.g., impulsive behavior).
• Except as required by law, mental retardation, autism,
attention disorders, or pervasive developmental disorders
(PDDs) in the absence of a documented communication
co-morbidity that is amenable to speech therapy with
a reasonable expectation of achieving sustainable,
measurable improvement in a reasonable time frame.
-Social communication disorder is not considered a
medically necessary co-morbidity.
• Stammering and stuttering with the following
exception:
-Speech therapy is considered medically necessary
and, therefore, covered for neurogenic stuttering
caused by acquired brain damage.
• Programs that are primarily educational in nature or
that support an academic program.
• Speech therapy for the maintenance of a chronic
condition when the therapeutic goals of a treatment
plan have been achieved, no additional functional
improvement is apparent or expected to occur, and the
provision of services for a condition ceases to be of
therapeutic value.
-Maintenance therapy is defined as a continuation
of care and management of the individual when
the therapeutic goals of a treatment plan have been
43034txt.indd 16
C o mp e ndium achieved, no additional functional improvement is
apparent or expected to occur, and the provision of
services for a condition ceases to be of therapeutic
value. This includes maintenance services that seek
to prevent disease, promote health, and prolong and
enhance the quality of life.
• Services that otherwise would not require the skills
of a qualified speech/language pathologist, such as
treatments that maintain function by using routines and
repetitions.
-Examples of these services include, but are not
limited to, word drills for developmental articulation
errors, computer-based programs (e.g., Fast
Forward), and procedures that may be performed by
the individual, family, and/or caregivers.
Duplicate Therapy
When individuals are receiving both occupational and speech
therapy, the therapies must provide different treatments
with separate treatment plans and goals in order for each
to be covered and be separately reimbursed. Otherwise, the
therapy is considered duplicate therapy and coverage and
reimbursement is only available for one therapy.
Benefit Limitations
Limitations, frequency, and annual maximums may be
applied and vary by product or by group. Individual member
benefits must be verified, as speech therapy benefits vary by
product and group.
Speech Therapy Services Provided in
Conjunction with Speech Generating Devices,
Electronic Speech Aids, and Computer-Based
Programs
Speech generating devices including computer-based programs:
Speech therapy provided in association with a speech
generating device, including a computer-based program, is
considered medically necessary and, therefore, covered when
the device is considered medically necessary consistent with
the applicable medical policy.
Electronic speech aids and other electronic devices for speech:
Electronic speech aids/devices are considered medically
necessary and, therefore, covered only when an individual has
2/19/07 1:44:22 PM
had a laryngectomy or has a nonfunctional larynx consistent
with the applicable medical policy. There are several
electronic speech aids/devices approved by the U.S. Food and
Drug Administration (FDA) for use with speech therapy.
Speech therapy provided in association with an approved
electronic speech aid/device is considered medically necessary
and, therefore, covered in accordance with the terms defined
in the applicable medical policy.
Electronic speech devices that are designed to improve
fluency problems (such as stuttering) rather than aid in
communication disabilities are considered experimental/
investigational because the efficacy of these devices cannot
be established by review of the available published literature.
Therefore, these devices are not covered. Examples of these
types of electronic devices include, but are not limited to:
• SpeechEasy ( Janus Development Group, Inc.,
Greenville, N.C.).
• F luencyMaster (National Medical Equipment, Inc.,
New Hyde Park, N.Y.).
Reduction Mammaplasty (11.08.02c)
Reduction mammaplasty is a surgical procedure that excises
a portion of the breast, including the skin and underlying
glandular tissue to reduce the size, shape, and weight of
mammary tissue. In some selected cases (e.g., when the
breasts are not too large and the skin has good elasticity),
liposuction can be utilized. However, in most cases, only fat,
not glandular breast tissue, can be successfully removed by
liposuction.
For all products except Medicare Advantage, the following
criteria are applicable:
Reduction mammaplasty is considered medically necessary
and, therefore, covered when all of the following medical
necessity criteria are met:
• A
n individual has macromastia (enlargement of the
breasts) or gigantomastia.
• Clinical symptoms of breast, neck, back, or shoulder
pain, or painful shoulder grooving are present for a
minimum six-week period and have not responded to
conservative measures (e.g., support bra, exercises, heat/
cold treatment, non-steroidal anti-inflammatory drugs
(NSAIDs)/muscle relaxants).
43034txt.indd 17
• The individual meets the minimum specimen weight
of breast tissue to be removed based on the individual’s
body surface area (BSA).
- Simplified formula for calculation of body surface
area: BSA (in m2) = [height (cm)] 0.718 X [weight
(kg)] 0.427 X 0.007449
• Any individual 40 years of age or older is required to
have a mammogram which is negative for cancer within
the year prior to the planned surgery.
When a request is made for reduction mammaplasty,
photographs documenting breast size are required.
For Medicare Advantage Members only, the
following criteria are applicable:
Reduction mammaplasty is considered reconstructive surgery
and medically necessary for symptomatic individuals with
macromastia when all of the following criteria are met:
• The individual has significant symptoms that interfere
with normal daily activities, including at least one of the
following:
-Symptomatic neck, back, or shoulder pain not
related to other causes (e.g., poor posture, acute
strains, poor lifting techniques).
- Significant breast pain.
- Brachial plexus irritation.
- Clinical, nonseasonal submammary intertrigo.
ºMedicare requires that hypertrophy of breast
(611.1) be reported as the primary diagnosis,
with one of the following clinical conditions
reported as a secondary diagnosis:
□Other specified erythematous condition
(695.89).
□ Pain in joint, shoulder region (719.41).
□ Cervicalgia (723.1).
□Unspecified musculoskeletal disorders
and symptoms referable to neck
(723.9).
□ Pain in thoracic spine (724.1).
□ Unspecified backache (724.5).
□ Unspecified osteoporosis (733.00).
□ Senile osteoporosis (733.01).
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U pdat e
□ Kyphosis (acquired) (postural) (737.10).
• The amount of breast tissue anticipated to be removed is
at least 350 grams per breast.
• Conservative treatment has failed. Examples of
conservative treatment include, but are not limited to:
- Appropriate support bra.
- Conservative analgesia (NSAIDs).
-In individuals where obesity is a documented risk
factor, a legitimate, medically-based attempt to
reduce and maintain weight (e.g., diet, exercise).
- Appropriate medical management of intertrigo.
Requests for reduction mammaplasty that do not meet
medical necessity criteria are considered cosmetic, and
therefore are not covered.
The Boston® Scleral Lens (07.13.11)
A contact lens that covers the cornea and the adjacent
portion of the white of the eye (sclera) is called a scleral
contact lens and is sometimes referred to as a corneal liquid
bandage.
The BOSTON® Scleral Lens (BSL), which is more
specifically termed the BOSTON® Equalens II, is the only
rigid gas-permeable scleral contact lens that is commercially
available in the U.S. and that can be post-fabricated for the
treatment of persistent corneal epithelial defects (PED).
Currently, it is only post-fabricated and distributed by
the Boston Foundation for Sight in Needham, Mass. The
BSL, unlike a traditional rigid gas-permeable contact lens,
is a specially designed, fluid-ventilated, gas-permeable
scleral contact lens. It is designed to maintain a bubblefree reservoir of oxygenated aqueous fluid over the corneal
surface at a neutral hydrostatic pressure. Due to the fact
that air bubbles are avoided, the fluid reservoir functions
as a liquid corneal bandage that offers unique therapeutic
benefits for the management of severe ocular surface disease,
in addition to its traditional role of masking irregular corneal
astigmatism.
C o mp e ndium was Stevens-Johnson syndrome. The BSL has also been
shown to be effective in preventing the recurrence of PED in
anesthetic corneas.
The BSL is considered medically necessary and, therefore,
covered to alleviate pain and photophobia for PED that have
been documented as disabling and that have symptoms that
are not significantly relieved with medical treatment. The
BSL is also considered medically necessary and, therefore,
covered to improve visual acuity in individuals for whom
surgery is either undesirable and/or contraindicated due to
any of the following conditions:
•Stevens-Johnson disease (a syndrome of systemic, as
well as more severe, mucocutaneous lesions that results
in corneal opacities, perforations, and/or blindness).
•Conditions that result from a chemical and/or traumatic
injury.
• Postradiotherapy complications.
• Recurrent corneal erosion.
• Congenital and/or postsurgical lid defect(s).
• Ocular cicatricial pemphigoid.
• Exposure keratitis.
• Toxic epidermal necrolysis.
•Lacrimal and/or meibomian gland obliteration or
deficiency.
• Superior limbal keratoconjunctivitis.
• Sjögren syndrome.
• Inflammatory corneal degeneration.
•Neurotrophic corneal disease (e.g., corneal denervation
that is related to acoustic neuroma surgery, trigeminal
ganglion obliteration, diabetes mellitus, herpetic
syndrome, congenital dysautonomia [Reily-Day
syndrome]).
• Corneal edema.
Although limited, compelling evidence exists that shows that
the BSL is effective in alleviating pain and photophobia and
improves the vision of patients with PED. In the majority
of studies, the most frequent specific indication for the BSL
43034txt.indd 18
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Trigger Point Injections (11.14.02c)
Trigger point injection is one of many modalities utilized in
the management of chronic pain. Myofascial trigger points
are self-sustaining hyperirritative foci that may occur in any
skeletal muscle in response to strain produced by acute or
chronic overload.
Trigger point injections are considered medically necessary
and, therefore, covered when performed for myofascial
pain syndrome (MPS) when at least one of the following
situations is present:
meet the medical necessity criteria listed in this policy.
• Additional reimbursement will not be made for the
injection of water, saline, or local anesthetics.
Dry needling of trigger points is considered medically
necessary and, therefore, covered. The medical necessity
criteria for dry needling of trigger points are the same as
those for trigger point injections.
•Noninvasive medical management (e.g., analgesics,
passive physical therapy, ultrasound therapy, range-ofmotion, and/or active exercises) is unsuccessful.
•Joint movement is mechanically blocked, as when the
coccygeus muscle is involved.
Trigger point injections are appropriate when administered
to any of the following body regions:
• Head.
• Cervical spine.
• Left upper extremities, including shoulder.
• Right upper extremities, including shoulder.
• Left lower extremities, including hip.
• Right lower extremities, including hip.
• Thoracic spine (including the trapezius and scapular
areas).
• Lumbosacral spine.
When a given region is injected, it is considered one injection
service, regardless of the number of injections administered
within that region.
• It is expected that this procedure would not be
performed on more than three body regions on a given
date of service.
• Trigger point injections for a specific body region should
not be performed more frequently than once a month.
-Requests for more frequent injections require
additional documentation of medical necessity.
Medications listed in the coding table are eligible for separate
reimbursement when used for trigger point injections that
43034txt.indd 19
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2/19/07 1:44:22 PM
43034txt.indd 20
U pdat e
C o mp e ndium 2006 CGPU Compendium
2/19/07 1:44:22 PM
Medical Policies
NOT Covered: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
www.ibx.com
Table of Contents
Computer-Assisted Musculoskeletal Surgical
Navigational Orthopedic Procedure (11.14.17)........... 22
Cryoablation of Neuromas (11.15.21) ........................ 22
Dual-Energy X-ray Absorptiometry (DEXA)
Body Composition Study (09.00.20a).......................... 22
Infrared Heating Pad Systems (07.00.18a).................. 22
Intraperitoneal Hyperthermic Chemotherapy
(IPHC) (11.00.13) ...................................................... 23
Ocular Photoscreening (07.13.12)............................... 23
Prolotherapy (11.14.15b).............................................. 24
Scintimammography (09.00.39)................................... 24
Subfascial Endoscopic Perforator Surgery
(SEPS) (11.02.23) ....................................................... 24
Surgical Ventricular Restoration (SVR) (11.02.24) .... 24
Thermography (07.02.13a) ......................................... 25
43034txt.indd 21
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U pdat e
C o mp e ndium Medical Policies Not Covered:
Considered Experimental/Investigational
Computer-Assisted Musculoskeletal
Surgical Navigational Orthopedic
Procedure (11.14.17)
Not Covered: Considered Experimental/
Investigational
Dual-Energy X-ray Absorptiometry
(DEXA) Body Composition Study
(09.00.20a)
Investigational
Computer-assisted navigational orthopedic procedures
use navigational systems during musculoskeletal surgery
to provide additional information and to further integrate
preoperative planning with how the surgery is being
performed. Navigational systems are typically used to
improve the placement and positioning of a prosthetic and/or
surgical instrument during the procedure. Computer-assisted
navigational orthopedic procedures can also be used as an
adjunct to fixation of pelvic, acetabular, or femoral fractures
and as an adjunct to hip or knee arthroplasty procedures.
A full-body DEXA is a noninvasive method for assessing
body fat and composition. It can also be combined with an
additional measurement of total body water and contribute
to a body composition assessment that is based on a fourcompartment mode: bone, fat, dry fat-free soft tissue, and
water.
A computer-assisted musculoskeletal surgical navigational
orthopedic procedure is considered experimental/
investigational because the safety and/or efficacy of this
service cannot be established by review of the available
published literature. Therefore, this service is not covered.
Cryoablation of Neuromas (11.15.21)
Investigational
Cryoanalgesia, also known as cryosurgery, cryolysis,
cryoneurolysis, and cryoablation, uses extremely low
temperatures to produce a reversible nerve block similar
to that delivered by local anesthesia. No randomized or
controlled studies have tested cryoanalgesia specifically for
pain control of neuromas.
Cryoablation of neuromas is considered experimental/
DEXA body composition study is considered experimental/
Infrared Heating Pad Systems
(07.00.18a)
Investigational
Monochromatic infrared energy (MIRE), applied via an
infrared heating pad system, has been used to treat various
conditions related to circulation and pain. An infrared
heating pad system consists of a pad or pads containing
mechanisms that generate infrared, or near-infrared, light
(e.g., luminous gallium aluminum arsenide diodes) and a
power source. The pads are placed on the skin for 30 to 45
minutes, three times weekly, as a treatment program for
diabetic neuropathy, ischemic ulcers, and/or musculoskeletal
conditions such as back, foot, or myofascial pain. No
randomized, controlled studies have been conducted to assess
the efficacy of the technique or its long-term effects.
Treatment of wounds, diabetic neuropathy, and/or
musculoskeletal conditions with infrared heating pad systems
is considered experimental/investigational because the safety
and/or efficacy of the service cannot be established by review
of the available published literature. Therefore, this service is
not covered.
43034txt.indd 22
2/19/07 1:44:23 PM
Intraperitoneal Hyperthermic
Chemotherapy (IPHC) (11.00.13)
Investigational
Intraperitoneal hyperthermic chemotherapy (IPHC) is a
procedure that includes a combination of cytoreductive
surgery (debulking or macroscopically removing all
visible tumors) with heated chemotherapy delivered
intraperitoneally immediately following the surgery. The
extent of this surgery plays a significant role in treatment
because of the limited 1-3 mm penetration of cytostatic
drugs into the peritoneal tissue. The goal of IPHC is to
eliminate microscopic metastases that are too small to be
identified and removed during cytoreductive surgery. It is
theorized that heated chemotherapy increases cytotoxicity
and will enhance penetration of chemotherapy into the
tumor. In addition, hyperthermia itself has a cytotoxic effect
on tumor tissue.
IPHC has been explored in a number of studies over the
past 20 years. The majority of research evidence includes
phase II trials and case series. There are few phase III trials.
Also, the populations studied included only a small number
of individuals with various locations of primary cancer,
different stages of peritoneal carcinomatosis, and varying
degrees of success with cytoreductive surgery. Additional
research is needed to further define the criteria used to
select which individuals should receive hyperthermia, and to
identify the most effective drug combination for peritoneal
administration. In addition, some of the technical aspects
of the procedure such as the optimal temperature of the
chemotherapeutic agents, the length of time for the IPHC
perfusion, and the efficacy and safety of open and closed
chemoperfusion need to be determined and standardized.
IPHC in conjunction with cytoreductive surgery is
considered experimental/investigational because the safety
and/or efficacy of this service cannot be established by review
of the available published literature. Therefore, this service is
not covered.
Ocular Photoscreening (07.13.12)
Investigational
Ocular photoscreening has been investigated as an alternative
screening method to detect the risk factors for amblyopia,
which include strabismus (a misalignment of the eyes in any
direction), media opacities (e.g., cataracts) and refractive
errors (e.g., myopia, hyperopia, astigmatism, presbyopia). It
is based on the principle of photorefraction, in which the
refractive state of the eye is assessed via the pattern of light
that is reflected through the pupil.
Ocular photoscreening involves the use of a camera or video
system that is equipped for photoscreening. By using this
equipment, images of the pupillary reflexes (autonomic reflex
constrictions caused by light) and red reflex (a circular red
light reflected from the retina of the eye) are obtained. The
images can then be analyzed based on the position of the
corneal light reflex, as well as the overall reflection of light
from the fundus, which provides information on the child’s
fixation pattern and the presence or absence of strabismus.
Ocular photoscreening is performed in a darkened room and
requires little cooperation from the child, other than fixating
on a target for the duration of the photoscreening process.
The photographs can then be analyzed by the evaluator or
sent to a central laboratory for analysis by an ophthalmologist
or specially-trained personnel. Test results are typically
graded as pass, fail, or repeat photoscreening.
Ocular photoscreening is considered experimental/
service cannot be established by review of the current
available published literature. Therefore, this service is not
covered.
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U pdat e
Prolotherapy (11.14.15b)
Investigational
Prolotherapy consists of a series of intraligamentous and
intratendinous injections of sclerosing agents that alleviate
chronic pain by inducing the proliferation of new cells. There
are three classes of proliferant solutions used in prolotherapy:
chemical irritants (e.g., phenol), osmotic shock agents (e.g.,
hypertonic dextrose and glycerin), and chemotactic agents
(e.g., morrhuate sodium, a fatty acid derivative of cod liver
oil). Prolotherapy should not be confused with trigger point
injections, which relieve pain by infusing anesthetics and/or
anti-inflammatory agents into affected areas.
Prolotherapy is considered experimental/investigational
because the safety and/or efficacy of this service cannot be
established by review of the available published literature.
Therefore, this service is not covered.
Reporting prolotherapy using the trigger point
injection CPT® procedure code or any other code is a
misrepresentation of the actual service rendered. These
services are subject to post-payment review and audit
procedures.
Scintimammography (09.00.39)
Investigational
Scintimammography, also known as mammoscintigraphy,
has been proposed primarily as an adjunct to standard film
mammography using radiopharmaceutical agents (radioactive
tracer [e.g., technetium-99m sestamibi]) to provide tumorspecific imaging of the breast. Scintimammography has
also been proposed for the detection of axillary lymph node
metastases in individuals with breast carcinoma; however,
it has not been fully investigated for this purpose. There is
insufficient data comparing the use of scintimammography
for decision-making regarding nodal dissection versus
standard nodal dissection. Although scintimammography is
currently being performed, the published medical literature
does not support its efficacy in differentiating malignancies
when compared with using surgical biopsy.
Scintimammography is considered experimental/
43034txt.indd 24
C o mp e ndium published literature. Therefore, this service is not covered.
Subfascial Endoscopic Perforator
Surgery (SEPS) (11.02.23)
Investigational
Subfascial endoscopic perforator surgery (SEPS) is
performed as a minimally invasive way to treat individuals
with chronic venous insufficiency of the lower extremities.
Guided by ultrasound scanning, small incisions are made
into the skin that is unaffected by severe chronic venous
insufficiency. Using endoscopic techniques, the perforating
veins are clipped or divided by endoscopic scissors.
SEPS is considered experimental/investigational because the
efficacy of this procedure cannot be established by review of
the available published literature. Therefore, this service is not
covered.
Surgical Ventricular Restoration (SVR)
(11.02.24)
Investigational
Surgical ventricular restoration (SVR) is a procedure that is
designed to restore or remodel the left ventricle to its normal
spherical shape and size in individuals who have akinetic
(non-moving) segments of the heart. This condition may be
secondary to either dilated cardiomyopathy or postinfarction
left ventricular aneurysm. The SVR procedure is most
commonly performed after coronary artery bypass grafting
(CABG) and may also proceed or be followed by procedures
such as mitral valve repair or replacement, endocardectomy,
and cryoablation for the treatment of ventricular tachycardia.
The SVR procedure may also be referred to as ventricular
remodeling or surgical anterior ventricular endocardial
restoration (SAVER).
SVR is considered experimental/investigational because the
safety and/or efficacy of this service cannot be established by
a review of the available published literature. Therefore, this
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Thermography (07.02.13a)
Investigational
Thermography is the measurement of self-emanating
infrared radiation that reveals temperature variations at
the surface of the body. The thermographic device senses
body temperature and demonstrates areas of differing heat
emission by producing brightly colored patterns on a liquid
crystal display. Each color represents a specific temperature
level. Interpretation of these color patterns according
to designated anatomic distribution is thought to aid in
diagnosing a vast array of disease, such as, but not limited to,
breast cancer, Raynaud’s phenomenon, headache, and reflex
sympathetic dystrophy.
The American College of Radiology, the American Medical
Association, and the American Academy of Neurology have
all issued documents that do not recommend or endorse
thermography as a diagnostic technology.
Thermography is considered experimental/investigational
because the safety and/or efficacy of the service cannot be
established by review of the available published literature.
Therefore, this service is not covered.
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Claim payment Policies
www.ibx.com
Table of Contents
Associated Services Performed in Conjunction
with Dental Services Considered Eligible for
Reimbursement When Certain Criteria are
Met (00.01.18a)............................................................ 28
Modifiers LT/RT: Left Side/Right Side
Procedures (03.00.10)................................................... 28
Work Hardening and Work Conditioning
is Not Covered Under Most of the Company’s
Products (10.05.02)...................................................... 29
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U pdat e
C o mp e ndium Claim Payment Policies
Associated Services Performed in
Conjunction with Dental Services
Considered Eligible for Reimbursement
When Certain Criteria are Met
(00.01.18a)
Dental services include procedures and/or surgery that relate
to the teeth, jaw, and/or mouth (e.g., routine cleanings,
fillings).
The Company covers and considers for reimbursement
charges that are associated with noncovered dental
procedures or surgery, including anesthesia, when any of the
following conditions are met:
•The individual has a comorbid condition that would
potentially increase the risk of the procedure being
performed.
• The individual is severely disabled.
• The individual is a child.
•The individual’s admission to the Ambulatory Surgery
Center (ASC), Short Procedure Unit (SPU), or hospital
setting is appropriate/necessary to ensure and safeguard
the individual’s health.
This policy applies to services that are performed in the
following settings: ASC, SPU, hospital outpatient, or
inpatient.
This policy applies whether or not the dental service is
eligible under the medical benefits.
For information on dental services that are covered under the
medical benefits, refer to the individual and/or group benefit
contract.
Modifiers LT/RT: Left Side/Right Side
Procedures (03.00.10)
Modifiers LT/RT are used to indicate the side of the body on
which a service or procedure is performed. Modifiers LT/RT
do not indicate a bilateral service and should not be used to
report a service or procedure that is performed bilaterally.
Modifier 50 should be used to report bilateral services or
procedures.
The Company has established the following guidelines for
the appropriate reporting of Modifiers LT/RT with the
appropriate procedure codes:
• Modifiers LT/RT should be used to identify procedures
that can be performed on contralateral anatomic sites
(e.g., bones, joints), paired organs (e.g., ears, eyes, nasal
passages, kidneys, lungs, ovaries), or extremities (e.g.,
arms, legs).
• Modifiers LT/RT should be used to indicate that the
procedure is performed on only one side of the body.
It is inappropriate to use Modifiers LT/RT to identify
bilateral services or procedures because a more appropriate
modifier exists.
To report a bilateral service or procedure, the appropriate
procedure code and/or modifier should be used.
Multiple surgery reduction logic will be applied when
appropriate.
Additional reporting requirements for Modifiers LT/RT:
• The medical records must clearly support the
appropriate use of Modifiers LT/RT.
• Medical records, notes, and/or other documentation
should not be attached to the claim unless specifically
required and/or requested by the Company.
• Claims submitted with Modifiers LT/RT are subject
to post-reimbursement clinical review and potential
retractions for inappropriate use.
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Work Hardening and Work
Conditioning is Not Covered Under
Most of the Company’s Products
(10.05.02)
Work hardening services address physical, functional,
behavioral and vocational needs of the worker by utilizing
real or simulated work activities. Additionally, work
hardening includes education (e.g., body mechanics, work
pacing, safety and injury prevention). A work hardening
program begins at four hours per day and builds to eight
hours per day over the course of the program, usually four
weeks. Work hardening requires a specific return-to-work
goal. Work hardening services relate directly to specific
work skills and do not provide any diagnostic or therapeutic
rehabilitation benefit for the individual.
Work conditioning (including reconditioning) utilizes
physical conditioning and functional activities related to
work. These services bridge a gap between acute outpatient
therapy and a structured work hardening program or return
to work. Work conditioning/re-conditioning may or may
not include an education component. Work conditioning/
re-conditioning is typically four hours/day or less and there is
no specific return to work goal required.
Work hardening and work conditioning are benefit contract
exclusions for some of the Company’s products. If the group
benefit contract does not provide a specific exclusion for work
hardening, the service is considered not medically necessary
as it is considered vocational in nature and does not provide
any diagnostic or therapeutic benefit of a medical nature for
the individual.
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2006 articles
www.ibx.com
Table of Contents
ICD-9 CM Diagnosis Codes Change for Routine
Gynecological Exams................................................... 32
Billing for Neonatal Hearing Screening Should
be Directed to Facility.................................................. 32
Anesthesia Claims Update........................................... 32
Gardasil® Approved by the FDA................................. 32
Clarifications to the Intensity Modulated
Radiation Therapy Policy............................................. 33
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U pdat e
C o mp e ndium 2006 Articles
ICD-9 CM Diagnosis Codes Change for
Routine Gynecological Exams
Please call Provider Services or your Network Coordinator
with any questions.
Effective January 1, 2006, capitated PCPs who bill for
routine gynecological exams should report diagnosis code
V72.31 with the applicable preventive evaluation and
management (E&M) Current Procedural Terminology
(CPT®) codes 99384-99387 and 99394-99397 or Healthcare
Common Procedure Coding System (HCPCS) codes S0610
and S0612 for reimbursement consideration.
This article originally appeared in the March 2006 Partners in
Health Update.
Routine gynecological exams that are reported with
ICD-9 CM code V72.32 for CPT codes 99384-99387 and
99394-99397 are no longer eligible for additional payment
outside of the standard capitation amount. HCPCS codes
S0610 and S0612 may still be reported with ICD-9 CM
code V72.32 when appropriate. For reference, the diagnosis
code narratives are as follows:
• V72.31: Routine gynecological examination.
• V72.32: Encounter for Papanicolaou cervical smear to
confirm findings of a recent normal smear following
initial abnormal smear.
Important reminder: As previously communicated, effective
October 1, 2004, we require all practitioners to report
diagnosis codes to the highest degree of specificity, according
to the ICD-9 CM Coding Manual.
If you have questions, please call Provider Services or your
Network Coordinator.
This article originally appeared in the January 2006 Partners in
Health Update.
Billing for Neonatal Hearing Screening
Should be Directed to Facility
Independence Blue Cross (IBC) has recently received
inquiries from members who received bills for hearing
screenings provided to their newborns before discharge from
a facility.
Please be advised that newborn hearing screenings are
covered services and included within the facility’s payment
for the delivery and are not eligible for separate billing to
IBC or to the member. In the event that a provider has a
contract or arrangement with a facility to provide these
screenings, the provider must look to that facility for payment
and not to IBC or to our members.
43034txt.indd 32
Anesthesia Claims Update
Effective August 1, 2006, as part of the standard claims
adjudication process, ClaimCheck clinical relationship
logic will be applied to claims reported with anesthesia
services. ClaimCheck is the code relationship editing tool
that is integrated into the claims adjudication process for
professional claims processing.
For information regarding ClaimCheck clinical relationship
logic, please refer to the Clear Claim Connection tool which
is available through the NaviNetSM Portal. You may also refer
to the user guide that was mailed to you in December 2005.
The ClaimCheck system applies to professional claims for products
processed on the MHS system only. PA Traditional Indemnity
and CMM products are not affected.
This article originally appeared in the July 2006 Partners in
Health Update.
Gardasil® Approved by the FDA
In June, the U.S. Food and Drug Administration (FDA)
approved the biologic license application for Gardasil®
(Quadrivalent Human Papillomavirus [Types 6, 11, 16, 18]
Recombinant Vaccine). Gardasil® is a new vaccine indicated
for females ages 9 to 26 for the prevention of the following
conditions caused by HPV types 6, 11, 16, and 18:
• Cervical cancer
• Genital warts
And the following precancerous or dysplastic lesions:
• Cervical adenocarcinoma in situ (AIS)
• Cervical intraepithelial neoplasia (CIN) grade 1, grade
2, and grade 3
• Vulvar intraepithelial neoplasia (VIN) grade 2 and
grade 3
• Vaginal intraepithelial neoplasia (VaIN) grade 2 and
grade 3
2/19/07 1:44:24 PM
Coverage Statement
Coverage Limitations
Gardasil® (Quadrivalent Human Papillomavirus [Types 6,
11, 16, 18] Recombinant Vaccine) is considered medically
necessary and, therefore, covered as a three-dose regimen
for use in females ages 9 to 26 for the prevention of cervical
cancer; genital warts; AIS; CIN grade 1, 2, and 3; VIN grade
2 and 3; and VaIN grade 2 and 3 for those members who
have an immunization benefit.
The following CPT® codes are not to be reported when the
services are performed as part of developing an IMRT plan
that is reported using CPT code 77301, even if the services
are performed on different dates, as reimbursement for the
following codes is already included in CPT code 77301.
Reimbursement for MRI guidance for placement of radiation
therapy fields is already included in CPT code 77301 and
should not be separately reported, regardless of the date of
service.
This article originally appeared in the October 2006 Partners in
Health Update.
Clarifications to the Intensity
Modulated Radiation Therapy
Policy
To review the full version of this policy, go to
www.ibx.com/medpolicy.
This article originally appeared in the November 2006 Partners
in Health Update.
Effective December 6, 2006, we will amend the criteria for
medical policy #09.00.17b – Intensity Modulated Radiation
Therapy (IMRT). The annual review of this policy led to the
addition of the following coverage limitations based on the
current literature on this topic.
76370
Computerized axial tomographic guidance for placement of radiation therapy fields
76376
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality; not requiring image post-processing on an independent workstation
76377
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality; requiring image post-processing on an independent workstation
77280
Therapeutic radiology simulation-aided field setting, simple
77285
Therapeutic radiology simulation-aided field setting; intermediate
77290
Therapeutic radiology simulation-aided field setting; complex
77295
Therapeutic radiology simulation-aided field setting; three-dimensional simulation
77305
Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel opposed unmodified ports
directed to a single area of interest)
77310
Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more treatment ports directed
to a single area of interest)
77315
Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the
use of wedges, compensators, complex blocking, rotational beam, or special beam considerations)
77321
Special teletherapy port plan, particles, hemibody, total body
77331
Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician
77336
Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose
delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of
therapy
77370
Special medical radiation physics consultation
33
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class action
settlement update
www.ibx.com
Table of Contents
Enhancements to Claim Payment Policy, Processing
and Payment Disclosure, and an Appeals Process
for Class Action Settlement Providers......................... 36
Assistant Surgery Modifiers 80, 81, 82........................ 36
Co-Surgery Modifier 62.............................................. 37
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U pdat e
C o mp e ndium Class Action Settlement Update:
Enhancements to Claim Payment
Policy, Processing and Payment
Disclosure, and an Appeals Process for Class Action Settlement Providers
The class action settlements of Gregg, et al. v. Independence
Blue Cross, et al. Good v. Independence Blue Cross, et al.,
and Pennsylvania Orthopaedic Society v. Independence
Blue Cross, et al. include the following enhancements for
providers who agreed to the settlement:
• Improving disclosure to Settlement Providers, including
standard fee schedules, changes to schedules, and
medical and payment policies that may affect payment/
reimbursement of services, which will be made available
online via NaviNetSM, our secure provider portal.
• C
hanging claims processing for Settlement Providers
on the following: selected modifiers (25, 50, 51, 59, 62,
66, 80, 81, 82, RT, LT), multiple surgical procedures,
radiological guidance during a procedure, and certain
Current Procedural Terminology (CPT®) code-level
designations (e.g., Modifier 51 Exempt, Separate
Procedure, Add-on Codes).
• Introducing a two-level formal claims appeal process for
Settlement Providers.
Certain of these enhancements are currently available. Others
will be announced as they become available.
Health Update.
Assistant Surgery Modifiers 80, 81, 82
IBC has enhanced its processing system to apply the
Centers for Medicare & Medicaid Services (CMS) payment
methodology for modifiers that represent assistant surgery
[Assistant Surgeon 80; Minimum Assistant Surgeon 81;
Assistant Surgeon (when qualified resident surgeon not
available) 82] as outlined in the Medicare Physician Fee
Schedule Database on the CMS website.*
Assistant surgery Modifiers 80, 81, and 82 are used to
denote surgical procedures that require both a primary and
an assistant surgeon because of the complexity and/or time
requirement of the surgery. An assistant surgeon is a surgeon
who actively assists and supports a primary surgeon during
a surgical procedure. Both primary and assistant surgeons
should report the same procedure code. The assistant surgeon
43034txt.indd 36
should append the most appropriate assistant surgery
modifier based on the narrative.
The table below identifies and describes the intended
processing outcome that is associated with each indicator.
However, reimbursement consideration for services that are
reported with Modifiers 80, 81, and/or 82 are also contingent
upon eligibility, benefits, exclusions, precertification/referral
requirements, provider contracts, and/or applicable policies.
Payment for these procedures is based on 20 percent of
the fee schedule allowance for the surgical service. Please
note that assistant surgical services that are performed in
conjunction with other surgical services may be subject to
multiple surgery reduction guidelines.
CMS utilizes a payment methodology for these types of
services by applying assistant surgery payment indicators to
procedure codes that, when submitted in combination with
Modifiers 80, 81, and/or 82, will allow or restrict payment
consideration:
CMS Indicator and
Description
Outcome for the Code/
Modifier 80, 81, and/or
82 Combination
(0) Assistant surgery
payment is inappropriate
unless documentation
supports medical
necessity.
Ineligible for assistant
surgery; additional
consideration determined
on an appeal basis only.
payment is inappropriate.
Ineligible for assistant
surgery reimbursement
consideration.
payment is appropriate.
Eligible for assistant
surgery reimbursement
consideration.
(9) Concept does not apply.
Invalid procedure/
modifier code
combination.
Medical records, operative reports, and/or other supporting
documentation should not be appended to the claim or
submitted to the Company unless specifically requested by
the Company.
*The following is a link to the Medicare website: www.cms.gov. These sites
are maintained by organizations over which Independence Blue Cross exercises
no control and, accordingly, Independence Blue Cross expressly disclaims any
responsibility for the content, the accuracy of the information, and/or quality
2/19/07 1:44:25 PM
of the products or services provided by or advertised in these third-party sites.
Certain services/treatments referred to in other sites may not be covered under
specific benefit plans. Please refer to benefit contracts for complete details of the
terms, limitations, and exclusions of coverage.
Health Update.
Co-Surgery Modifier 62
IBC has enhanced its processing system to apply the
Centers for Medicare & Medicaid Services (CMS) payment
methodology for Co-surgery Modifier 62 as outlined in the
Medicare Physician Fee Schedule Database on the CMS
website.*
Co-surgery Modifier 62 is used to denote when two surgeons
act as primary surgeons during the same operative procedure
or session for the same individual because of the complexity
of the procedure and/or the patient’s condition. The cosurgeons are typically of different specialties and perform
consecutive or overlapping parts of the same procedure or
simultaneous procedures during the same session with one
of the following exceptions for co-surgeons of the same
specialty:
• Each surgeon must perform a distinct part of the
surgical procedure that requires the distinct skills of
each surgeon.
• Each surgeon performs the same procedure(s)
simultaneously for different regions/organs (e.g.,
bilateral lung reduction, bilateral knee replacements). In
such cases, the operative report must reflect the necessity
of two primary surgeons with the same skills.
Each of the two surgeons should submit the same procedure
code that represents the entire surgical procedure appended
with Modifier 62.
The table below identifies and describes the final processing
outcome that is associated with each indicator; however,
reimbursement consideration for services that are reported
with Modifier 62 are also contingent upon eligibility, benefits,
exclusions, precertification/referral requirements, provider
contracts, and applicable policies.
CMS utilizes a payment methodology for these types of
services by applying co-surgery payment indicators to
procedure codes that, when submitted in combination with
Modifier 62, will allow or restrict payment consideration:
CMS Indicator and
Description
Outcome for the Code/
Modifier 62
(0) Co-surgery payment
is inappropriate.
Ineligible for co-surgery
reimbursement consideration.
is inappropriate
unless supporting
documentation
establishes medical
necessity.
Ineligible for co-surgery;
additional consideration
determined on an appeal
basis only.
is appropriate.
Eligible for co-surgery
reimbursement consideration.
(9) Concept does not
apply.
Invalid procedure/modifier
code combination.
It is inappropriate to report Modifier 62 when one surgeon
acts as an assistant to the primary surgeon or when more
than two surgeons act as primary surgeons during the same
operative session.
Medical records, operative reports, and/or other supporting
documentation should not be appended to the claim or
submitted to the Company unless specifically requested by
the Company.
*The following is a link to the Medicare website: www.cms.gov. These sites
are maintained by organizations over which Independence Blue Cross exercises
no control and, accordingly, Independence Blue Cross expressly disclaims any
responsibility for the content, the accuracy of the information, and/or quality
of the products or services provided by or advertised in these third-party sites.
Certain services/treatments referred to in other sites may not be covered under
specific benefit plans. Please refer to benefit contracts for complete details of the
terms, limitations, and exclusions of coverage.
Health Update.
Payment for these procedures is based on 62.5 percent of the
fee schedule allowance for the service. Please note that cosurgery services that are performed in conjunction with other
co-surgery services are subject to multiple surgery reduction
guidelines.
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U pdat e
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Medical code updates
www.ibx.com
Table of Contents
CPT®* Codes............................................................... 40
HCPCS Codes............................................................. 62
ICD-9 CM Codes....................................................... 90
As part of the medical/claim payment policy process, the Independence Blue Cross Procedure Code Review Unit supports
medical code activities. It establishes and maintains the development and documentation of coverage positions for ICD-9
CM, CPT, and HCPCS medical codes across all lines of business and all processing systems.
The following pages detail the new/revised ICD-9 CM, CPT, and HCPCS code updates effective as follows, unless otherwise
specified:
ICD-9 CM: Additions and Revisions have an effective date of 10/1/2006. Deletions have a delete date of 10/1/2006.
CPT: Additions and Revisions have an effective date of 1/1/2007. Deletions have a delete date of 1/1/2007.
HCPCS: Additions and Revisions have an effective date of 10/1/2006 or 1/1/2007. Deletions have a delete date of 1/1/2007.
Please note that the listing of a code in this Compendium does not necessarily guarantee coverage or reimbursement for a
procedure.
*Current Procedural Terminology (CPT®) is a copyright of the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values,
or related listings are included in the CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
CPT® is a trademark of the AMA.
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U pdat e
C o mp e ndium CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
Narrative
A
00625
Anesthesia for procedures on the thoracic spine and cord,
via an anterior transthoracic approach; not utilizing 1 lung ventilation
1/1/2007
A
00626
Anesthesia for procedures on the thoracic spine and cord,
via an anterior transthoracic approach; utilizing 1 - lung
ventilation
1/1/2007
A
15002
Surgical preparation or creation of recipient site by
excision of open wounds, burn eschar, or scar (including
subcutaneous tissues), or incisional release of scar
contracture, trunk, arms, legs; first 100 sq cm or 1% of
body area of infants and children
1/1/2007
A
15003
contracture, trunk, arms, legs; each additional 100 sq
cm or each additional 1% of body area of infants and
children (List separately in addition to the code for the
primary procedure)
1/1/2007
A
15004
contracture, face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet and/or multiple digits; first 100 sq
cm or 1% of body area of infants and children
1/1/2007
A
15005
contracture, face, scalp, eyelids, mouth, neck, ears,
orbits, genitalia, hands, feet and/or multiple digits; each
additional 100 sq cm or 1% of body area of infants and
children (List separately in addition to code for primary
procedure)
1/1/2007
A
15731
Forehead flap with preservation of vascular pedicle (e.g.,
axial pattern flap, paramedian forehead flap)
1/1/2007
A
15830
Excision, excessive skin and subcutaneous tissue (includes
lipectomy); abdomen, infraumbilical panniculectomy
1/1/2007
A
15847
lipectomy), abdomen (e.g., abdominoplasty) (includes
umbilical transposition and fascial plication) (List separately
in addition to code for primary procedure)
1/1/2007
A
17311
Mohs micrographic technique, including removal of
all gross tumor, surgical excision of tissue specimens,
mapping, color coding of specimens, microscopic
examination of specimens by the surgeon, and
histopathologic preparation including routine stain(s)
(e.g., hematoxylin and eosin, toluidine blue), head, neck,
hands, feet, genitalia, or any location with surgery directly
involving muscle, cartilage, bone, tendon, major nerves, or
vessels; first stage up to 5 tissue blocks
1/1/2007
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2/19/07 1:44:25 PM
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
Narrative
A
17312
histopathologic preparation including routine stain(s)
(e.g., hematoxylin and eosin, toluidine blue), head, neck,
hands, feet, genitalia, or any location with surgery directly
involving muscle, cartilage, bone, tendon, major nerves,
or vessels; each additional stage after the first stage, up
to 5 tissue blocks (List separately in addition to code for
primary procedure)
1/1/2007
A
17313
histopathologic preparation including routine stain(s) (e.g.,
hematoxylin and eosin, toluidine blue), of the trunk, arms,
or legs; first stage, up to 5 tissue blocks
1/1/2007
A
17314
hematoxylin and eosin, toluidine blue), of the trunk, arms,
or legs; each additional stage after the first stage, up
to 5 tissue blocks (List separately in addition to code for
primary procedure)
1/1/2007
A
17315
hematoxylin and eosin, toluidine blue), each additional
block after the first 5 tissue blocks, any stage (List
separately in addition to code for primary procedure)
1/1/2007
A
19105
Ablation, cryosurgical, of fibroadenoma, including
ultrasound guidance, each fibroadenoma
1/1/2007
A
19300
Mastectomy for gynecomastia
1/1/2007
A
19301
Mastectomy, partial (e.g., lumpectomy, tylectomy,
quadrantectomy, segmentectomy);
1/1/2007
A
19302
quadrantectomy, segmentectomy); with axillary
lymphadenectomy
1/1/2007
A
19303
Mastectomy, simple, complete
1/1/2007
A
19304
Mastectomy, subcutaneous
1/1/2007
A
19305
Mastectomy, radical, including pectoral muscle, axillary
lymph nodes
1/1/2007
A
19306
Mastectomy, radical, including pectoral muscles, axillary
and internal mammary lymph nodes (Urban type
operation)
1/1/2007
A
19307
Mastectomy, modified radical, including axillary lymph
nodes, with or without pectoralis minor muscle, but
excluding pectoralis major muscle
1/1/2007
A
22526
Percutaneous intradiscal electrothermal annuloplasty,
unilateral or bilateral including fluoroscopic guidance;
single level
1/1/2007
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41
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U pdat e
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
Narrative
A
22527
Percutaneous intradiscal electrothermal annuloplasty,
unilateral or bilateral including fluoroscopic guidance; one
or more additional levels (List separately in addition to
code for primary procedure)
1/1/2007
A
22857
Total disc arthroplasty (artificial disc), anterior approach,
including discectomy to prepare interspace (other than for
decompression), lumbar, single interspace
1/1/2007
A
22862
Revision including replacement of total disc arthroplasty
(artificial disc) anterior approach, lumbar, single interspace
1/1/2007
A
22865
Removal of total disc arthroplasty (artificial disc), anterior
approach, lumbar, single interspace
1/1/2007
A
25109
Excision of tendon, forearm and/or wrist, flexor or
extensor, each
1/1/2007
A
25606
Percutaneous skeletal fixation of distal radial fracture or
epiphyseal separation
1/1/2007
A
25607
Open treatment of distal radial extra-articular fracture or
epiphyseal separation, with internal fixation
1/1/2007
A
25608
Open treatment of distal radial intra-articular fracture or
epiphyseal separation; with internal fixation of 2 fragments
1/1/2007
A
25609
Open treatment of distal radial intra-articular fracture or
epiphyseal separation; with internal fixation of 3 or more
fragments
1/1/2007
A
27325
Neurectomy, hamstring muscle
1/1/2007
A
27326
Neurectomy, popliteal (gastrocnemius)
1/1/2007
A
28055
Neurectomy, intrinsic musculature of feet
1/1/2007
A
32998
Ablation therapy for reduction or eradication of one
or more pulmonary tumor(s) including pleura or chest
wall when involved by tumor extension, percutaneous,
radiofrequency, unilateral
1/1/2007
A
33202
Insertion of epicardial electrode(s); open incision (e.g.,
thoracotomy, median sternotomy, subxiphoid approach)
1/1/2007
A
33203
Insertion of epicardial electrode(s); endoscopic approach
(e.g., thoracoscopy, pericardioscopy)
1/1/2007
A
33254
Operative tissue ablation and reconstruction of atria,
limited (e.g., modified maze procedure)
1/1/2007
A
33255
extensive (e.g., maze procedure); without cardiopulmonary
bypass
1/1/2007
A
33256
extensive (e.g., maze procedure); with cardiopulmonary
bypass
1/1/2007
A
33265
Endoscopy, surgical; operative tissue ablation and
reconstruction of atria, limited (e.g., modified maze
procedure), without cardiopulmonary bypass
1/1/2007
A
33266
Endoscopy, surgical; operative tissue ablation and
reconstruction of atria, extensive (e.g., maze procedure),
without cardiopulmonary bypass
1/1/2007
A
33675
Closure of multiple ventricular septal defects;
1/1/2007
A
33676
Closure of multiple ventricular septal defects; with
pulmonary valvotomy or infundibular resection (acyanotic)
1/1/2007
A
33677
Closure of multiple ventricular septal defects; with removal
of pulmonary artery band, with or without gusset
1/1/2007
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Addition
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
A
33724
Repair of isolated partial anomalous pulmonary venous
return (e.g., Scimitar Syndrome)
1/1/2007
A
33726
Repair of pulmonary venous stenosis
1/1/2007
A
35302
Thromboendarterectomy, including patch graft, if
performed; superficial femoral artery
1/1/2007
A
35303
performed; popliteal artery
1/1/2007
A
35304
performed; tibioperoneal trunk artery
1/1/2007
A
35305
performed; tibial or peroneal artery, initial vessel
1/1/2007
A
35306
performed; each additional tibial or peroneal artery (List
1/1/2007
A
35537
Bypass graft, with vein; aortoiliac
1/1/2007
A
35538
Bypass graft, with vein; aortobi-iliac
1/1/2007
Effective Date
of Revision/
Addition
A
35539
Bypass graft, with vein; aortofemoral
1/1/2007
A
35540
Bypass graft, with vein; aortobifemoral
1/1/2007
A
35637
Bypass graft, with other than vein; aortoiliac
1/1/2007
A
35638
Bypass graft, with other than vein; aortobi-iliac
1/1/2007
A
35883
Revision, femoral anastomosis of synthetic arterial bypass
graft in groin, open; with nonautogenous patch graft (e.g.,
Dacron, ePTFE, bovine pericardium)
1/1/2007
A
35884
Revision, femoral anastomosis of synthetic arterial bypass
graft in groin, open; with autogenous vein patch graft
1/1/2007
A
37210
Uterine fibroid embolization (UFE, embolization of the
uterine arteries to treat uterine fibroids, leiomyomata),
percutaneous approach inclusive of vascular access, vessel
selection, embolization, and all radiological supervision
and interpretation, intraprocedural roadmapping, and
imaging necessary to complete the procedure
1/1/2007
A
43647
Laparoscopy, surgical; implantation or replacement of
gastric neurostimulator electrodes, antrum
1/1/2007
A
43648
Laparoscopy, surgical; revision or removal of gastric
neurostimulator electrodes, antrum
1/1/2007
A
43881
Implantation or replacement of gastric neurostimulator
electrodes, antrum, open
1/1/2007
A
43882
Revision or removal of gastric neurostimulator electrodes,
antrum, open
1/1/2007
A
44157
Colectomy, total, abdominal, with proctectomy; with
ileoanal anastomosis, includes loop ileostomy, and rectal
mucosectomy, when performed
1/1/2007
A
44158
Colectomy, total, abdominal, with proctectomy; with
ileoanal anastomosis, creation of ileal reservoir (S or J),
includes loop ileostomy, and rectal mucosectomy, when
performed
1/1/2007
A
47719
Anastomosis, choledochal cyst, without excision
1/1/2007
A
48105
Resection or debridement of pancreas and peripancreatic
tissue for acute necrotizing pancreatitis
1/1/2007
A
48548
Pancreaticojejunostomy, side-to-side anastomosis (Puestowtype operation)
1/1/2007
43034txt.indd 43
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43
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U pdat e
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
A
49324
Laparoscopy, surgical; with insertion of intraperitoneal
cannula or catheter, permanent
1/1/2007
A
49325
Laparoscopy, surgical; with revision of previously placed
intraperitoneal cannula or catheter, with removal of
intraluminal obstructive material if performed
1/1/2007
A
49326
Laparoscopy, surgical; with omentopexy (omental tacking
procedure) (List separately in addition to code for primary
procedure)
1/1/2007
A
49402
Removal of peritoneal foreign body from peritoneal cavity
1/1/2007
A
49435
Insertion of subcutaneous extension to intraperitoneal
cannula or catheter with remote chest exit site (List
1/1/2007
A
49436
Delayed creation of exit site from embedded subcutaneous
segment of intraperitoneal cannula or catheter
1/1/2007
A
54865
Exploration of epididymis, with or without biopsy
1/1/2007
A
55875
Transperineal placement of needles or catheters into
prostate for interstitial radioelement application, with or
without cystoscopy
1/1/2007
A
55876
Placement of interstitial device(s) for radiation therapy
guidance (e.g., fiducial markers, dosimeter), prostate (via
needle, any approach), single or multiple
1/1/2007
A
56442
Hymenotomy, simple incision
1/1/2007
A
57296
Revision (including removal) prosthetic vaginal graft; open
abdominal approach
1/1/2007
Narrative
A
57558
Dilation and curettage of cervical stump
1/1/2007
A
58541
Laparoscopy, surgical, supracervical hysterectomy, for
uterus 250 g or less;
1/1/2007
A
58542
uterus 250 g or less; with removal of tube(s) and/or
ovary(s)
1/1/2007
A
58543
uterus greater than 250 g;
1/1/2007
A
58544
uterus greater than 250 g; with removal of tube(s) and/or
ovary(s)
1/1/2007
A
58548
Laparoscopy surgical, with radical hysterectomy, with
bilateral total pelvic lymphadenectomy and para-aortic
lymph node sampling (biopsy), with removal of tube(s) and
ovary(s), if performed
1/1/2007
A
58957
Resection (tumor debulking) of recurrent ovarian, tubal,
primary peritoneal, uterine malignancy (intra-abdominal,
retroperitoneal tumors), with omentectomy, if performed;
1/1/2007
A
58958
Resection (tumor debulking) of recurrent ovarian, tubal,
primary peritoneal, uterine malignancy (intra-abdominal,
retroperitoneal tumors), with omentectomy, if performed;
with pelvic lymphadenectomy and limited para-aortic
lymphadenectomy
1/1/2007
A
64910
Nerve repair; with synthetic conduit or vein allograft (e.g.,
nerve tube), each nerve
1/1/2007
A
64911
Nerve repair; with autogenous vein graft (includes harvest
of vein graft), each nerve
1/1/2007
A
67346
Biopsy of extraocular muscle
1/1/2007
43034txt.indd 44
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Addition
Delete Date
2/19/07 1:44:27 PM
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
A
70554
Magnetic resonance imaging, brain, functional MRI;
including test selection and administration of repetitive
body part movement and/or visual stimulation, not
requiring physician or psychologist administration
1/1/2007
A
70555
Magnetic resonance imaging, brain, functional MRI;
requiring physician or psychologist administration of entire
neurofunctional testing
1/1/2007
A
72291
Radiological supervision and interpretation, percutaneous
vertebroplasty or vertebral augmentation including cavity
creation, per vertebral body; under fluoroscopic guidance
1/1/2007
A
72292
creation, per vertebral body; under CT guidance
1/1/2007
A
76776
Ultrasound, transplanted kidney, real time and duplex
Doppler with image documentation
1/1/2007
A
76813
Ultrasound, pregnant uterus, real time with image
documentation, first trimester fetal nuchal translucency
measurement, transabdominal or transvaginal approach;
single or first gestation
1/1/2007
A
76814
Ultrasound, pregnant uterus, real time with image
documentation, first trimester fetal nuchal translucency
measurement, transabdominal or transvaginal approach;
each additional gestation (List separately in addition to
1/1/2007
A
76998
Ultrasonic guidance, intraoperative
1/1/2007
A
77001
Fluoroscopic guidance for central venous access device
placement, replacement (catheter only or complete), or
removal (includes fluoroscopic guidance for vascular
access and catheter manipulation, any necessary contrast
injections through access site or catheter with related
venography radiologic supervision and interpretation, and
radiographic documentation of final catheter position) (List
1/1/2007
A
77002
Fluoroscopic guidance for needle placement (e.g., biopsy,
aspiration, injection, localization device)
1/1/2007
A
77003
Fluoroscopic guidance and localization of needle or
catheter tip for spine or paraspinous diagnostic or
therapeutic injection procedures (epidural, transforaminal
epidural, subarachnoid, paravertebral facet joint,
paravertebral facet joint nerve or sacroiliac joint),
including neurolytic agent destruction
1/1/2007
A
77011
Computed tomography guidance for stereotactic
localization
1/1/2007
A
77012
Computed tomography guidance for needle placement
(e.g., biopsy, aspiration, injection, localization device),
radiological supervision and interpretation
1/1/2007
A
77013
Computed tomography guidance for, and monitoring of,
parenchymal tissue ablation
1/1/2007
A
77014
Computed tomography guidance for placement of
radiation therapy fields
1/1/2007
A
77021
Magnetic resonance guidance for needle placement (e.g.,
for biopsy, needle aspiration, injection, or placement
of localization device) radiological supervision and
interpretation
1/1/2007
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Effective Date
of Revision/
Addition
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45
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U pdat e
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
A
77022
Magnetic resonance guidance for, and monitoring of,
parenchymal tissue ablation
1/1/2007
A
77031
Stereotactic localization guidance for breast biopsy
or needle placement (e.g., for wire localization or for
injection), each lesion, radiological supervision and
interpretation
1/1/2007
A
77032
Mammographic guidance for needle placement, breast
(e.g., for wire localization or for injection), each lesion,
1/1/2007
A
77051
Computer-aided detection (computer algorithm analysis
of digital image data for lesion detection) with further
physician review for interpretation, with or without
digitization of film radiographic images; diagnostic
mammography (List separately in addition to code for
primary procedure)
1/1/2007
A
77052
Computer-aided detection (computer algorithm analysis
digitization of film radiographic images; screening
primary procedure)
1/1/2007
A
77053
Mammary ductogram or galactogram, single duct,
1/1/2007
A
77054
Mammary ductogram or galactogram, multiple ducts,
1/1/2007
A
77055
Mammography; unilateral
1/1/2007
A
77056
Mammography; bilateral
1/1/2007
A
77057
Screening mammography, bilateral (2-view film study of
each breast)
1/1/2007
A
77058
Magnetic resonance imaging, breast, without and/or with
contrast material(s); unilateral
1/1/2007
A
77059
contrast material(s); bilateral
1/1/2007
A
77071
Manual application of stress performed by physician for
joint radiography, including contralateral joint if indicated
1/1/2007
A
77072
Bone age studies
1/1/2007
A
77073
Bone length studies (orthoroentgenogram, scanogram)
1/1/2007
A
77074
Radiologic examination, osseous survey; limited (e.g., for
metastases)
1/1/2007
A
77075
Radiologic examination, osseous survey; complete (axial
and appendicular skeleton)
1/1/2007
A
77076
Radiologic examination, osseous survey, infant
1/1/2007
A
77077
Joint survey, single view, 2 or more joints (specify)
1/1/2007
A
77078
Computed tomography, bone mineral density study, 1 or
more sites; axial skeleton (e.g., hips, pelvis, spine)
1/1/2007
A
77079
Computed tomography, bone mineral density study, 1 or
more sites; appendicular skeleton (peripheral) (e.g., radius,
wrist, heel)
1/1/2007
A
77080
Dual-energy X-ray absorptiometry (DXA), bone density
study, 1 or more sites; axial skeleton (e.g., hips, pelvis,
spine)
1/1/2007
Narrative
43034txt.indd 46
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of Revision/
Addition
Delete Date
2/19/07 1:44:28 PM
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
A
77081
study, 1 or more sites; appendicular skeleton (peripheral)
(e.g., radius, wrist, heel)
1/1/2007
A
77082
study, 1 or more sites; vertebral fracture assessment
1/1/2007
A
77083
Radiographic absorptiometry (e.g., photodensitometry,
radiogrammetry), 1 or more sites
1/1/2007
A
77084
Magnetic resonance (e.g., proton) imaging, bone marrow
blood supply
1/1/2007
A
77371
Radiation treatment delivery, stereotactic radiosurgery
(SRS), complete course of treatment of cerebral lesion(s)
consisting of 1 session; multi-source Cobalt 60 based
1/1/2007
A
77372
Radiation treatment delivery, stereotactic radiosurgery
(SRS), complete course of treatment of cerebral lesion(s)
consisting of 1 session; linear accelerator based
1/1/2007
A
77373
Stereotactic body radiation therapy, treatment delivery, per
fraction to 1 or more lesions, including image guidance,
entire course not to exceed 5 fractions
1/1/2007
A
77435
Stereotactic body radiation therapy, treatment
management, per treatment course, to one or more lesions,
including image guidance, entire course not to exceed 5 fractions
1/1/2007
A
82107
Alfa-fetoprotein (AFP); AFP-L3 fraction isoform and total
AFP (including ratio)
1/1/2007
A
83698
Lipoprotein-associated phospholipase A2, (Lp-PLA2)
1/1/2007
A
83913
Molecular diagnostics; RNA stabilization
1/1/2007
A
86788
Antibody; West Nile virus, IgM
1/1/2007
A
86789
Antibody; West Nile virus
1/1/2007
A
87305
Infectious agent antigen detection by enzyme immunoassay
technique, qualitative or semiquantitative, multiple step
method; Aspergillus
1/1/2007
A
87498
Infectious agent detection by nucleic acid (DNA or RNA);
enterovirus, amplified probe technique
1/1/2007
A
87640
Staphylococcus aureus, amplified probe technique
1/1/2007
A
87641
Staphylococcus aureus, methicillin resistant, amplified
probe technique
1/1/2007
A
87653
Staphylococcus, group B, amplified probe technique
1/1/2007
A
87808
Infectious agent antigen detection by immunoassay with
direct optical observation; Trichomonas vaginalis
1/1/2007
A
91111
Gastrointestinal tract imaging, intraluminal (e.g., capsule
endoscopy), esophagus with physician interpretation and
report
1/1/2007
A
92025
Computerized corneal topography, unilateral or bilateral,
with interpretation and report
1/1/2007
A
92640
Diagnostic analysis with programming of auditory
brainstem implant, per hour
1/1/2007
A
94002
Ventilation assist and management, initiation of pressure
or volume preset ventilators for assisted or controlled
breathing; hospital inpatient/observation, initial day
1/1/2007
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47
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U pdat e
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
Narrative
A
94003
breathing; hospital inpatient/observation, each subsequent
day
1/1/2007
A
94004
breathing; nursing facility, per day
1/1/2007
A
94005
Home ventilator management care plan oversight of a
patient (patient not present) in home, domiciliary or rest
home (e.g., assisted living) requiring review of status,
review of laboratories and other studies and revision of
orders and respiratory care plan (as appropriate), within a
calendar month, 30 minutes or more.
1/1/2007
A
94610
Intrapulmonary surfactant administration by a physician
through endotracheal tube
1/1/2007
A
94644
Continuous inhalation treatment with aerosol medication
for acute airway obstruction; first hour
1/1/2007
A
94645
Continuous inhalation treatment with aerosol medication
for acute airway obstruction; each additional hour (List
1/1/2007
A
94774
Pediatric home apnea monitoring event recording including
respiratory rate, pattern and heart rate per 30-day period
of time; includes monitor attachment, download of data,
physician review, interpretation, and preparation of a
report
1/1/2007
A
94775
of time; monitor attachment only (includes hook-up,
initiation of recording and disconnection)
1/1/2007
A
94776
of time; monitoring, download of information, receipt of
transmission(s) and analyses by computer only
1/1/2007
A
94777
of time; physician review, interpretation and preparation of
report only
1/1/2007
A
95012
Nitric oxide expired gas determination
1/1/2007
A
96020
Neurofunctional testing selection and administration during
noninvasive imaging functional brain mapping, with test
administered entirely by a physician or psychologist, with
review of test results and reports
1/1/2007
A
96040
Medical genetics and genetic counseling services, each 30
minutes face-to-face with patient/family
1/1/2007
A
96904
Whole body integumentary photography, for monitoring
of high risk patients with dysplastic nevus syndrome or a
history of dysplastic nevi, or patients with a personal or
familial history of melanoma
1/1/2007
A
99363
Anticoagulant management for an outpatient taking
warfarin, physician review and interpretation of
International Normalized Ratio (INR) testing, patient
instructions, dosage adjustment (as needed), and ordering
of additional tests; initial 90 days of therapy (must include
a minimum of 8 INR measurements)
1/1/2007
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Addition
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
Narrative
A
99364
Anticoagulant management for an outpatient taking
warfarin, physician review and interpretation of
International Normalized Ratio (INR) testing, patient
instructions, dosage adjustment (as needed), and ordering
of additional tests; each subsequent 90 days of therapy
(must include a minimum of 8 INR measurements)
1/1/2007
A
0162T
Electronic analysis and programming, reprogramming of
gastric neurostimulator (i.e., morbid obesity)
1/1/2007
A
0163T
decompression), lumbar, each additional interspace
1/1/2007
A
0164T
Removal of total disc arthroplasty, anterior approach,
lumbar, each additional interspace
1/1/2007
A
0165T
Revision of total disc arthroplasty, anterior approach,
lumbar, each additional interspace
1/1/2007
A
0166T
Transmyocardial transcatheter closure of ventricular septal
defect, with implant; without cardiopulmonary bypass
1/1/2007
A
0167T
Transmyocardial transcatheter closure of ventricular septal
defect, with implant; with cardiopulmonary bypass
1/1/2007
A
0168T
Rhinophototherapy, intranasal application of ultraviolet and
visible light, bilateral
1/1/2007
A
0169T
Stereotactic placement of infusion catheter(s) in the brain
for delivery of therapeutic agent(s), including computerized
stereotactic planning and burr hole(s)
1/1/2007
A
0170T
Repair of anorectal fistula with plug (e.g., porcine small
intestine submucosa [SIS])
1/1/2007
A
0171T
Insertion of posterior spinous process distraction device
(including necessary removal of bone or ligament for
insertion and imaging guidance), lumbar; single level
1/1/2007
A
0172T
Insertion of posterior spinous process distraction device
(including necessary removal of bone or ligament for
insertion and imaging guidance), lumbar; each additional
level (List separately in addition to code for primary
procedure)
1/1/2007
A
0173T
Monitoring of intraocular pressure during vitrectomy
surgery (List separately in addition to code for primary
procedure)
1/1/2007
A
0174T
Computer aided detection (CAD) (computer algorithm
analysis of digital image data for lesion detection) with
further physician review for interpretation and report,
with or without digitization of film radiographic images,
chest radiograph(s), performed concurrent with primary
interpretation (List separately in addition to code for
primary procedure)
1/1/2007
A
0175T
Computer aided detection (CAD) (computer algorithm
analysis of digital image data for lesion detection) with
further physician review for interpretation and report,
with or without digitization of film radiographic images,
chest radiograph(s), performed remote from primary
interpretation
1/1/2007
A
0176T
Transluminal dilation of aqueous outflow canal; without
retention of device or stent
1/1/2007
A
0177T
Transluminal dilation of aqueous outflow canal; with
retention of device or stent
1/1/2007
43034txt.indd 49
Effective Date
of Revision/
Addition
Delete Date
49
2/19/07 1:44:30 PM
U pdat e
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
D
01995
Regional intravenous administration of local anesthetic
agent or other medication (upper or lower extremity)
1/1/2007
D
15000
contracture; first 100 sq cm or one percent of body area
of infants and children
1/1/2007
D
15001
contracture; each additional 100 sq cm or each additional
one percent of body area of infants and children (List
1/1/2007
D
15831
lipectomy); abdomen, (e.g., abdominoplasty)
1/1/2007
D
17304
Chemosurgery (Mohs micrographic technique), including
removal of all gross tumor, surgical excision of tissue
specimens, mapping, color coding of specimens,
microscopic examination of specimens by the surgeon, and
complete histopathologic preparation including the first
routine stain (e.g., hematoxylin and eosin, toluidine blue);
first stage, fresh tissue technique, up to 5 specimens
1/1/2007
D
17305
second stage, fixed or fresh tissue, up to 5 specimens
1/1/2007
D
17306
third stage, fixed or fresh tissue, up to 5 specimens
1/1/2007
D
17307
additional stage(s), up to 5 specimens, each stage
1/1/2007
D
17310
each additional specimen, after the first 5 specimens; fixed
or fresh tissue, any stage (List separately in addition to
1/1/2007
D
19140
Mastectomy for gynecomastia
1/1/2007
D
19160
quadrantectomy, segmentectomy);
1/1/2007
Narrative
43034txt.indd 50
Effective Date
of Revision/
Addition
Delete Date
2/19/07 1:44:30 PM
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
D
19162
quadrantectomy, segmentectomy); with axillary
lymphadenectomy
1/1/2007
D
19180
Mastectomy, simple, complete
1/1/2007
D
19182
Mastectomy, subcutaneous
1/1/2007
D
19200
Mastectomy, radical, including pectoral muscle, axillary
lymph nodes
1/1/2007
D
19220
Mastectomy, radical, including pectoral muscles, axillary
and internal mammary lymph nodes (Urban type
operation)
1/1/2007
D
19240
Mastectomy, modified radical, including axillary lymph
nodes, with or without pectoralis minor muscle, but
excluding pectoralis major muscle
1/1/2007
D
21300
Closed treatment of skull fracture without operation
1/1/2007
D
25611
Percutaneous skeletal fixation of distal radial fracture (e.g.,
Colles or Smith type) or epiphyseal separation, with or
without fracture of ulnar styloid, requiring manipulation,
with or without external fixation
1/1/2007
D
25620
Open treatment of distal radial fracture (e.g., Colles or
Smith type) or epiphyseal separation, with or without
fracture of ulnar styloid, with or without internal or external
fixation
1/1/2007
D
26504
Reconstruction of tendon pulley, each tendon; with tendon
prosthesis (separate procedure)
1/1/2007
D
27315
Neurectomy, hamstring muscle
1/1/2007
D
27320
Neurectomy, popliteal (gastrocnemius)
1/1/2007
D
28030
Neurectomy, intrinsic musculature of feet
1/1/2007
D
31700
Catheterization, transglottic (separate procedure)
1/1/2007
D
31708
Instillation of contrast material for laryngography or
bronchography, without catheterization
1/1/2007
D
31710
Catheterization for bronchography, with or without
instillation of contrast material
1/1/2007
D
33200
Insertion of permanent pacemaker with epicardial
electrode(s); by thoracotomy
1/1/2007
D
33201
Insertion of permanent pacemaker with epicardial
electrode(s); by xiphoid approach
1/1/2007
D
33245
Insertion of epicardial single or dual chamber pacing
cardioverter defibrillator electrodes by thoracotomy;
1/1/2007
D
33246
Insertion of epicardial single or dual chamber pacing
cardioverter defibrillator electrodes by thoracotomy; with
insertion of pulse generator
1/1/2007
D
33253
Operative incisions and reconstruction of atria for
treatment of atrial fibrillation or atrial flutter (e.g., maze
procedure)
1/1/2007
D
35381
Thromboendarterectomy, with or without patch graft;
femoral and/or popliteal, and/or tibioperoneal
1/1/2007
D
35507
Bypass graft, with vein; subclavian-carotid
1/1/2007
D
35541
Bypass graft, with vein; aortoiliac or bi iliac
1/1/2007
D
35546
Bypass graft, with vein; aortofemoral or bifemoral
1/1/2007
D
35641
Bypass graft, with other than vein; aortoiliac or bi iliac
1/1/2007
43034txt.indd 51
Narrative
Effective Date
of Revision/
Addition
Delete Date
51
2/19/07 1:44:30 PM
U pdat e
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
D
44152
Colectomy, total, abdominal, without proctectomy; with
rectal mucosectomy, ileonal anastomosis, with or without
loop ileostomy
1/1/2007
D
44153
Colectomy, total, abdominal, without proctectomy; with
rectal mucosectomy, ileonal anastomosis, creation of ileal
reservoir (S or J), with or without loop ileostomy
1/1/2007
D
47716
Anastomosis, choledochal cyst, without excision
1/1/2007
D
48005
Resection or debridement of pancreas and peripancreatic
tissue for acute necrotizing pancreatitis
1/1/2007
D
48180
Pancreaticojejunostomy, side-to-side anastomosis (Puestowtype operation)
1/1/2007
D
49085
Removal of peritoneal foreign body from peritoneal cavity
1/1/2007
D
54152
Circumcision, using clamp or other device; except
newborns
1/1/2007
D
54820
Exploration of epididymis, with or without biopsy
1/1/2007
D
55859
Transperineal placement of needles or catheters into
prostate for interstitial radioelement application, with or
without cystoscopy
1/1/2007
D
56720
Hymenotomy, simple incision
1/1/2007
D
57820
Dilation and curettage of cervical stump
1/1/2007
Narrative
Delete Date
D
67350
Biopsy of extraocular muscle
1/1/2007
D
75998
Fluoroscopic guidance for central venous access device
placement, replacement (catheter only or complete), or
removal (includes fluoroscopic guidance for vascular
access and catheter manipulation, any necessary contrast
injections through access site or catheter with related
venography radiologic supervision and interpretation, and
radiographic documentation of final catheter position) (List
1/1/2007
D
76003
Fluoroscopic guidance for needle placement (e.g., biopsy,
aspiration, injection, localization device)
1/1/2007
D
76005
Fluoroscopic guidance and localization of needle or
catheter tip for spine or paraspinous diagnostic or
therapeutic injection procedures (epidural, transforaminal
epidural, subarachnoid, paravertebral facet joint,
paravertebral facet joint nerve or sacroiliac joint),
including neurolytic agent destruction
1/1/2007
D
76006
Manual application of stress performed by physician for
joint radiography, including contralateral joint if indicated
1/1/2007
D
76012
creation, per vertebral body; under fluoroscopic guidance
1/1/2007
D
76013
creation, per vertebral body; under CT guidance
1/1/2007
D
76020
Bone age studies
1/1/2007
D
76040
Bone length studies (orthoroentgenogram, scanogram)
1/1/2007
D
76061
Radiologic examination, osseous survey; limited (e.g., for
metastases)
1/1/2007
D
76062
Radiologic examination, osseous survey; complete (axial
and appendicular skeleton)
1/1/2007
43034txt.indd 52
Effective Date
of Revision/
Addition
2/19/07 1:44:31 PM
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
D
76065
Radiologic examination, osseous survey; infant
1/1/2007
D
76066
Joint survey, single view, two or more joints (specify)
1/1/2007
D
76070
Computed tomography, bone mineral density study, one or
more sites; axial skeleton (e.g., hips, pelvis, spine)
1/1/2007
D
76071
Computed tomography, bone mineral density study, one or
more sites; appendicular skeleton (peripheral) (e.g., radius,
wrist, heel)
1/1/2007
D
76075
Dual energy x-ray absorptiometry (DXA), bone density
study, one or more sites; axial skeleton (e.g., hips, pelvis,
spine)
1/1/2007
D
76076
study, one or more sites; appendicular skeleton (peripheral)
(e.g., radius, wrist, heel)
1/1/2007
D
76077
study, one or more sites; vertebral fracture assessment
1/1/2007
D
76078
Radiographic absorptiometry (e.g., photodensitometry,
radiogrammetry), one or more sites
1/1/2007
D
76082
Computer aided detection (computer algorithm analysis
digitization of film radiographic images; diagnostic
primary procedure)
1/1/2007
D
76083
Computer aided detection (computer algorithm analysis
digitization of film radiographic images; screening
primary procedure)
1/1/2007
D
76086
Mammary ductogram or galactogram, single duct,
1/1/2007
D
76088
Mammary ductogram or galactogram, multiple ducts,
1/1/2007
D
76090
Mammography, unilateral
1/1/2007
D
76091
Mammography, bilateral
1/1/2007
D
76092
Screening mammography, bilateral (two view film study of
each breast)
1/1/2007
D
76093
contrast material(s); unilateral
1/1/2007
D
76094
contrast material(s); bilateral
1/1/2007
D
76095
Stereotactic localization guidance for breast biopsy
or needle placement (e.g., for wire localization or for
injection), each lesion, radiological supervision and
interpretation
1/1/2007
D
76096
Mammographic guidance for needle placement, breast
(e.g., for wire localization or for injection), each lesion,
1/1/2007
D
76355
Computed tomography guidance for stereotactic
localization
1/1/2007
D
76360
Computed tomography guidance for needle placement
(e.g., biopsy, aspiration, injection, localization device),
1/1/2007
43034txt.indd 53
Narrative
Effective Date
of Revision/
Addition
Delete Date
53
2/19/07 1:44:31 PM
U pdat e
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
D
76362
Computed tomography guidance for, and monitoring of,
visceral tissue ablation
1/1/2007
D
76370
Computed tomography guidance for placement of
radiation therapy fields
1/1/2007
D
76393
Magnetic resonance guidance for needle placement (e.g.,
for biopsy, needle aspiration, injection, or placement
of localization device) radiological supervision and
interpretation
1/1/2007
D
76394
Magnetic resonance guidance for, and monitoring of,
visceral tissue ablation
1/1/2007
D
76400
Magnetic resonance (e.g., proton) imaging, bone marrow
blood supply
1/1/2007
D
76778
Ultrasound, transplanted kidney, B-scan and/or real time
with image documentation, with or without duplex Doppler
study
1/1/2007
D
76986
Ultrasonic guidance, intraoperative
1/1/2007
D
78704
Kidney imaging; with function study (i.e., imaging
renogram)
1/1/2007
D
78715
Kidney vascular flow only
1/1/2007
D
78760
Testicular imaging;
1/1/2007
D
91060
Gastric saline load test
1/1/2007
D
92573
Lombard test
1/1/2007
D
94656
breathing; first day
1/1/2007
D
94657
breathing; subsequent days
1/1/2007
D
95078
Provocative testing (e.g., Rankle test)
1/1/2007
D
0044T
Whole body integumentary photography, at request of
a physician, for monitoring of high risk patients; with
dysplastic nevus syndrome or familial melanoma
1/1/2007
D
0045T
Whole body integumentary photography, at request of a
physician, for monitoring of high risk patients; with history
of dysplastic nevi or personal history of melanoma
1/1/2007
D
0082T
Stereotactic body radiation therapy, treatment delivery, one
or more treatment areas, per day
1/1/2007
D
0083T
Stereotactic body radiation therapy, treatment
management, per day
1/1/2007
D
0091T
decompression); single interspace, lumbar
1/1/2007
D
0094T
Removal of total disc arthroplasty, anterior approach;
single interspace, lumbar
1/1/2007
D
0097T
Revision of total disc arthroplasty, anterior approach;
single interspace, lumbar
1/1/2007
D
0120T
Ablation, cryosurgical, of fibroadenoma, including
ultrasound guidance, each fibroadenoma
1/1/2007
Narrative
43034txt.indd 54
Effective Date
of Revision/
Addition
Delete Date
2/19/07 1:44:32 PM
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
D
0152T
Computer aided detection (computer algorithm
analysis of digital image data for lesion detection)
with further physician review for interpretation, with or
without digitization of film radiographic images; chest
radiograph(s) (List separately in addition to code for
primary procedure)
R
15100
Split-thickness autograft, trunk, arms, legs; first 100 sq cm
or less, or 1% of body area of infants and children (except
15050)
1/1/2007
R
15101
Split-thickness autograft, trunk, arms, legs; each additional
100 sq cm, or each additional 1% of body area of infants
and children, or part thereof (List separately in addition to
1/1/2007
R
15110
Epidermal autograft, trunk, arms, legs; first 100 sq cm or
less, or 1% of body area of infants and children
1/1/2007
R
15111
Epidermal autograft, trunk, arms, legs; each additional
100 sq cm, or each additional 1% of body area of infants
1/1/2007
R
15115
Epidermal autograft, face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits;
first 100 sq cm or less, or 1% of body area of infants and
children
1/1/2007
R
15116
Epidermal autograft, face, scalp, eyelids, mouth, neck,
each additional 100 sq cm, or each additional 1% of
body area of infants and children, or part thereof (List
1/1/2007
R
15120
Split-thickness autograft, face, scalp, eyelids, mouth, neck,
first 100 sq cm or less, or 1% of body area of infants and
children (except 15050)
1/1/2007
R
15121
Split-thickness autograft, face, scalp, eyelids, mouth, neck,
each additional 100 sq cm, or each additional 1% of
body area of infants and children, or part thereof (List
1/1/2007
R
15130
Dermal autograft, trunk, arms, legs; first 100 sq cm or less,
or 1% of body area of infants and children
1/1/2007
R
15131
Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants
1/1/2007
R
15135
Dermal autograft, face, scalp, eyelids, mouth, neck, ears,
orbits, genitalia, hands, feet, and/or multiple digits; first
100 sq cm or less, or 1% of body area of infants and
children
1/1/2007
R
15136
Dermal autograft, face, scalp, eyelids, mouth, neck, ears,
orbits, genitalia, hands, feet, and/or multiple digits; each
additional 100 sq cm, or each additional 1% of body
area of infants or children or part thereof (List separately in
addition to code for primary procedure)
1/1/2007
R
15152
Tissue cultured epidermal autograft, trunk, arms, legs; each
additional 100 sq cm, or each additional 1% of body
area of infants and children, or part thereof (List separately
in addition to code for primary procedure)
1/1/2007
43034txt.indd 55
Narrative
Effective Date
of Revision/
Addition
Delete Date
1/1/2007
55
2/19/07 1:44:32 PM
U pdat e
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
Narrative
R
15157
Tissue cultured epidermal autograft, face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or
multiple digits; each additional 100 sq cm, or each
additional 1% of body area of infants and children, or
part thereof (List separately in addition to code for primary
procedure)
1/1/2007
R
15170
Acellular dermal replacement, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and
children
1/1/2007
R
15175
Acellular dermal replacement, face, scalp, eyelids, mouth,
neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits; first 100 sq cm or less, or 1% of body area of
infants and children
1/1/2007
R
15176
Acellular dermal replacement, face, scalp, eyelids, mouth,
digits; each additional 100 sq cm, or each additional 1%
of body area of infants and children, or part thereof (List
1/1/2007
R
15336
Acellular dermal allograft, face, scalp, eyelids, mouth,
digits; each additional 100 sq cm, or each additional 1%
of body area of infants and children, or part thereof (List
1/1/2007
R
15360
Tissue cultured allogeneic dermal substitute; trunk, arms,
legs; first 100 sq cm or less, or 1% of body area of infants
and children
1/1/2007
R
15366
Tissue cultured allogeneic dermal substitute, face, scalp,
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet,
and/or multiple digits; each additional 100 sq cm, or
each additional 1% of body area of infants and children,
or part thereof (List separately in addition to code for
primary procedure)
1/1/2007
R
15400
Xenograft, skin (dermal), for temporary wound closure;
trunk, arms, legs; first 100 sq cm or less, or 1% of body
area of infants and children
1/1/2007
R
15401
Xenograft, skin (dermal), for temporary wound closure;
trunk, arms, legs; each additional 100 sq cm, or each
additional 1% of body area of infants and children or part
thereof (List separately in addition to code for primary
procedure)
1/1/2007
R
17000
Destruction (e.g., laser surgery, electrosurgery, cryosurgery,
chemosurgery, surgical curettement), premalignant lesions
(e.g., actinic keratoses); first lesion
1/1/2007
R
17003
(e.g., actinic keratoses); second through 14 lesions, each
(List separately in addition to code for first lesion)
1/1/2007
R
17004
(e.g., actinic keratoses), 15 or more lesions
1/1/2007
R
17110
chemosurgery, surgical curettement), of benign lesions
other than skin tags or cutaneous vascular lesions; up to
14 lesions
1/1/2007
43034txt.indd 56
Effective Date
of Revision/
Addition
Delete Date
2/19/07 1:44:33 PM
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
Narrative
R
17111
chemosurgery, surgical curettement), of benign lesions
other than skin tags or cutaneous vascular lesions; 15 or
more lesions
1/1/2007
R
19361
Breast reconstruction with latissimus dorsi flap without
prosthetic implant
1/1/2007
R
25600
Closed treatment of distal radial fracture (e.g., Colles
or Smith type) or epiphyseal separation, includes closed
treatment of fracture of ulnar styloid, when performed;
without manipulation
1/1/2007
R
25605
Closed treatment of distal radial fracture (e.g., Colles
or Smith type) or epiphyseal separation, includes closed
treatment of fracture of ulnar styloid, when performed; with
manipulation
1/1/2007
R
26170
Excision of tendon, palm, flexor or extensor, single, each
tendon
1/1/2007
R
26180
Excision of tendon, finger, flexor or extensor, each tendon
1/1/2007
R
33681
Closure of single ventricular septal defect, with or without
patch;
1/1/2007
R
33684
patch; with pulmonary valvotomy or infundibular resection
(acyanotic)
1/1/2007
R
33688
patch; with removal of pulmonary artery band, with or
without gusset
1/1/2007
R
35301
performed; carotid, vertebral, subclavian, by neck incision
1/1/2007
R
35311
performed; subclavian, innominate, by thoracic incision
1/1/2007
R
35321
performed; axillary-brachial
1/1/2007
R
35331
performed; abdominal aorta
1/1/2007
R
35341
performed; mesenteric, celiac, or renal
1/1/2007
R
35351
performed; iliac
1/1/2007
R
35355
performed; iliofemoral
1/1/2007
R
35361
performed; combined aortoiliac
1/1/2007
R
35363
performed; combined aortoiliofemoral
1/1/2007
R
35371
performed; common femoral
1/1/2007
R
35372
performed; deep (profunda) femoral
1/1/2007
R
35501
Bypass graft, with vein; common carotid-ipsilateral internal
carotid
1/1/2007
R
35506
Bypass graft, with vein; carotid-subclavian or subclaviancarotid
1/1/2007
43034txt.indd 57
Effective Date
of Revision/
Addition
Delete Date
57
2/19/07 1:44:33 PM
U pdat e
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
R
35509
Bypass graft, with vein; carotid-contralateral carotid
1/1/2007
R
35601
Bypass graft, with other than vein; common carotidipsilateral internal carotid
1/1/2007
R
44211
Laparoscopy, surgical; colectomy, total abdominal, with
proctectomy, with ileoanal anastomosis, creation of ileal
reservoir (S or J), with look ileostomy, includes rectal
mucosectomy, when performed
1/1/2007
R
51720
Bladder instillation of anticarcinogenic agent (including
retention time)
1/1/2007
R
52204
Cystourethroscopy, with biopsy(s)
1/1/2007
R
54150
Circumcision, using clamp or other device with regional
dorsal penile or ring block; neonate (28 days of age or
less)
1/1/2007
R
54160
Circumcision, surgical excision other than clamp, device,
or dorsal slit; neonate (28 days of age or less)
1/1/2007
R
54161
Circumcision, surgical excision other than clamp, device,
or dorsal slit; older than 28 days of age
1/1/2007
R
58950
Resection (initial) of ovarian, tubal or primary peritoneal
malignancy with bilateral salpingo-oophorectomy and
omentectomy;
1/1/2007
R
58951
omentectomy; with total abdominal hysterectomy, pelvic
and limited para-aortic lymphadenectomy
1/1/2007
R
58952
omentectomy; with radical dissection for debulking
(i.e., radical excision or destruction, intra-abdominal or
retroperitoneal tumors)
1/1/2007
R
61107
Twist drill hole(s) for subdural, intracerebral, or ventricular
puncture; for implanting ventricular catheter, pressure
recording device, or other intracerebral monitoring device
1/1/2007
R
61210
Burr hole(s); for implanting ventricular catheter, reservoir,
EEG electrode(s), pressure recording device, or other
cerebral monitoring device (separate procedure)
1/1/2007
R
64590
Insertion or replacement of peripheral or gastric
neurostimulator pulse generator or receiver, direct or
inductive coupling
1/1/2007
R
64595
Revision or removal of peripheral or gastric neurostimulator
pulse generator or receiver
1/1/2007
R
70540
Magnetic resonance (e.g., proton) imaging, orbit, face,
and/or neck; without contrast material(s)
1/1/2007
R
70542
and/or neck; with contrast material(s)
1/1/2007
R
70543
and/or neck; without contrast material(s), followed by
contrast material(s) and further sequences
1/1/2007
R
71275
Computed tomographic angiography, chest (noncoronary)
without contrast material(s), followed by contrast material(s)
and further sections, including image postprocessing
1/1/2007
R
76536
Ultrasound, soft tissues of head and neck (e.g., thyroid,
parathyroid, parotid), real time with image documentation
1/1/2007
Narrative
43034txt.indd 58
Effective Date
of Revision/
Addition
Delete Date
2/19/07 1:44:34 PM
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
R
76604
Ultrasound, chest, (includes mediastinum) real time with
image documentation
1/1/2007
R
76645
Ultrasound, breast(s) (unilateral or bilateral), real time with
image documentation
1/1/2007
R
76700
Ultrasound, abdominal, real time with image
documentation; complete
1/1/2007
R
76705
Ultrasound, abdominal, real time with image
documentation; limited (e.g., single organ, quadrant,
follow-up)
1/1/2007
R
76770
Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real
time with image documentation; complete
1/1/2007
R
76775
Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real
time with image documentation; limited
1/1/2007
R
76856
Ultrasound, pelvic (nonobstetric), real time with image
documentation; complete
1/1/2007
R
76857
Ultrasound, pelvic (nonobstetric), real time with image
documentation; limited or follow-up (e.g., for follicles)
1/1/2007
R
76880
Ultrasound, extremity, nonvascular, real time with image
documentation
1/1/2007
R
76940
Ultrasound guidance for, and monitoring of, parenchymal
tissue ablation
1/1/2007
R
78700
Kidney imaging morphology;
1/1/2007
R
78707
Kidney imaging morphology; with vascular flow and
function, single study without pharmacological intervention
1/1/2007
R
78708
Kidney imaging morphology; with vascular flow and
function, single study, with pharmacological intervention
(e.g., angiotensin converting enzyme inhibitor and/or
diuretic)
1/1/2007
R
78709
Kidney imaging morphology; with vascular flow
and function, multiple studies, with and without
pharmacological intervention (e.g., angiotensin converting
enzyme inhibitor and/or diuretic)
1/1/2007
R
78710
Kidney imaging morphology; tomographic (SPECT)
1/1/2007
R
78730
Urinary bladder residual study (List separately in addition
to code for primary procedure)
1/1/2007
R
78761
Testicular imaging; with vascular flow
1/1/2007
R
87088
Culture, bacterial; with isolation and presumptive
identification of each isolate, urine
1/1/2007
R
88106
Cytopathology, fluids, washings or brushings, except
cervical or vaginal; simple filter method with interpretation
1/1/2007
R
88107
Cytopathology, fluids, washings or brushings, except
cervical or vaginal; smears and simple filter preparation
with interpretation
1/1/2007
R
89060
Crystal identification by light microscopy with or without
polarizing lens analysis, tissue or any body fluid (except
urine)
1/1/2007
R
90655
Influenza virus vaccine, split virus, preservative free,
when administered to children 6-35 months of age, for
intramuscular use
1/1/2007
43034txt.indd 59
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U pdat e
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
R
90656
Influenza virus vaccine, split virus, preservative free,
when administered to children 3 years and older for
intramuscular use
1/1/2007
R
90657
Influenza virus vaccine, split virus, when administered to
children 6-35 months of age, for intramuscular use
1/1/2007
R
90658
Influenza virus vaccine, split virus, when administered to
children 3 years of age and older, for intramuscular use
1/1/2007
R
90669
Pneumococcal conjugate vaccine, polyvalent, when
administered to children younger than 5 years, for
intramuscular use
1/1/2007
R
90700
Diphtheria, tetanus toxoids, and acellular pertussis vaccine
(DTaP) when administered to children younger than 7 years, for intramuscular use
1/1/2007
R
90702
Diphtheria, and tetanus toxoids (DT) adsorbed,
preservative free, when administered to children younger
than 7 years, for intramuscular use
1/1/2007
R
90714
Tetanus and diphtheria toxoids (Td) adsorbed, preservative
free when administered to children 7 years or older, for
intramuscular use
1/1/2007
R
90715
Tetanus, diphtheria toxoids and acellular pertussis vaccine
(Tdap), when administered to children 7 years or older, for
intramuscular use
1/1/2007
R
90718
Tetanus and diphtheria toxoids (Td) adsorbed when
administered to children 7 years or older, for intramuscular
use
1/1/2007
R
90732
Pneumococcal polysaccharide vaccine, 23-valent, adult
or immunosuppressed patient dosage, when administered
to children 2 years or older, for subcutaneous or
intramuscular use
1/1/2007
R
94620
Pulmonary stress testing; simple (e.g., 6 minute walk test,
prolonged exercise test for bronchospasm with pre- and
post-spirometry and oximetry)
1/1/2007
R
99251
Inpatient consultation for a new or established patient
which requires these three key components: a problem
focused history; a problem focused examination; and
straightforward medical decision making
1/1/2007
R
99252
which requires these three key components: an expanded
problem focused history; an expanded problem focused
examination; and a straightforward medical decision
making
1/1/2007
R
99253
which requires these three key components: a detailed
history; a detailed examination; and medical decision of
low complexity
1/1/2007
R
99254
Inpatient consultation for a new or established
patient which requires these three key components: a
comprehensive history; a comprehensive examination; and medical decision making of moderate complexity
1/1/2007
R
99255
Inpatient consultation for a new or established
patient which requires these three key components: a
comprehensive history; a comprehensive examination; and medical decision making of high complexity
1/1/2007
Narrative
43034txt.indd 60
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of Revision/
Addition
Delete Date
2/19/07 1:44:35 PM
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT ®* Code
Narrative
R
0062T
Percutaneous intradiscal annuloplasty, any method except
electrothermal, unilateral or bilateral including fluoroscopic
guidance; single level
1/1/2007
R
0063T
Percutaneous intradiscal annuloplasty, any method except
electrothermal, unilateral or bilateral including fluoroscopic
guidance; one or more additional levels (List separately in
addition to 0062T for primary procedure)
1/1/2007
R
0068T
Acoustic heart sound recording and computer analysis;
with interpretation and report
1/1/2007
R
0069T
only
1/1/2007
R
0070T
interpretation and report only
1/1/2007
R
0087T
Sperm evaluation, Hyaluronan sperm binding test
1/1/2007
R
0090T
decompression) cervical; single interspace
1/1/2007
R
0092T
decompression) cervical; each additional interspace (List
separately in addition to the code for primary procedure)
1/1/2007
R
0093T
Removal of total disc arthroplasty, anterior approach
cervical; single interspace
1/1/2007
R
0095T
Removal of total disc arthroplasty, anterior approach
cervical; each additional innerspace (List separately in
addition to code for primary procedure)
1/1/2007
R
0096T
Revision of total disc arthroplasty, anterior approach
cervical; single interspace
1/1/2007
R
0098T
Revision of total disc arthroplasty, anterior approach
cervical; each additional interspace
1/1/2007
43034txt.indd 61
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Addition
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
C9231
Injection, decitabine, per 1 mg
10/1/2006
A
C9727
Insertion of implants into the soft palate; minimum of three
implants
10/1/2006
A
K0738
Portable gaseous oxygen system, rental: home compressor
used to fill portable oxygen cylinders, includes portable
containers, regulator, flowmeter, humidifier, cannula or
mask and tubing
10/1/2006
A
K0800
Power operated vehicle, group 1 standard, patient weight
capacity up to and including 300 pounds
10/1/2006
A
K0801
Power operated vehicle, group 1 heavy duty, patient
weight capacity, 301 to 450 lbs
10/1/2006
A
K0802
Power operated vehicle, group 1 very heavy duty, patient
weight capacity 451 to 600 pounds
10/1/2006
A
K0806
Power operated vehicle, group 2 standard, patient weight
capacity up to and including 300 pounds
10/1/2006
A
K0807
Power operated vehicle, group 2 heavy duty, patient
10/1/2006
A
K0808
Power operated vehicle, group 2 very heavy duty, patient
10/1/2006
A
K0812
Power operated vehicle, not otherwise classified
10/1/2006
A
K0813
Power wheelchair, group 1 standard, portable, sling/
solid seat and back, patient weight capacity up to and
including 300 pounds
10/1/2006
A
K0814
Power wheelchair, group 1 standard, portable, captain’s
chair, patient weight capacity up to and including 300
pounds
10/1/2006
A
K0815
Power wheelchair, group 1 standard, sling/solid seat and
back, patient weight capacity up to and including 300
pounds
10/1/2006
A
K0816
Power wheelchair, group 1 standard, captain’s chair,
patient weight capacity up to and including 300 pounds
10/1/2006
A
K0820
Power wheelchair, group 2 standard, portable, sling/solid
seat/back, patient weight capacity up to and including
300 pounds
10/1/2006
A
K0821
Power wheelchair, group 2 standard, portable, captain’s
chair, patient weight capacity up to and including 300
pounds
10/1/2006
A
K0822
Power wheelchair, group 2 standard, sling/solid seat/
pounds
10/1/2006
A
K0823
10/1/2006
A
K0824
Power wheelchair, group 2 heavy duty, sling/solid seat/
back, patient weight capacity 301 to 450 pounds
10/1/2006
A
K0825
Power wheelchair, group 2 heavy duty, captain’s chair,
patient weight capacity 301 to 450 pounds
10/1/2006
A
K0826
Power wheelchair, group 2 very heavy duty, sling/solid
seat/back, patient weight capacity 451 to 600 pounds
10/1/2006
A
K0827
Power wheelchair, group 2 very heavy duty, captain’s
chair, patient weight capacity 451 to 600 pounds
10/1/2006
43034txt.indd 62
C o mp e ndium HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
U pdat e
Delete Date
2/19/07 1:44:35 PM
Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
A
K0828
Power wheelchair, group 2 extra heavy duty, sling/solid
seat/back, patient weight capacity 601 pounds or more
10/1/2006
A
K0829
Power wheelchair, group 2 extra heavy duty, captain’s
chair, patient weight capacity 601 pounds or more
10/1/2006
A
K0830
Power wheelchair, group 2 standard, seat elevator,
sling/solid seat/back, patient weight capacity up to and
10/1/2006
A
K0831
Power wheelchair, group 2 standard, seat elevator,
captain’s chair, patient weight capacity up to and
10/1/2006
A
K0835
Power wheelchair, group 2 standard, single power option,
10/1/2006
A
K0836
Power wheelchair, group 2 standard, single power
option, captain’s chair, patient weight capacity up to and
10/1/2006
A
K0837
Power wheelchair, group 2 heavy duty, single power
option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
10/1/2006
A
K0838
option, captain’s chair, patient weight capacity 301 to 450 pounds
10/1/2006
A
K0839
Power wheelchair, group 2 very heavy duty, single power
10/1/2006
A
K0840
Power wheelchair, group 2 extra heavy duty, single power
option sling/solid seat/back, patient weight capacity 601 pounds or more
10/1/2006
A
K0841
Power wheelchair, group 2 standard, multiple power
option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
10/1/2006
A
K0842
10/1/2006
A
K0843
Power wheelchair, group 2 heavy duty, multiple power
10/1/2006
A
K0848
pounds
10/1/2006
A
K0849
10/1/2006
A
K0850
10/1/2006
A
K0851
Power wheelchair, group 3 heavy duty, captain’s chair,
patient weight capacity 301 to 450 pounds
10/1/2006
A
K0852
10/1/2006
A
K0853
Power wheelchair, group 3 very heavy duty, captain’s
chair, patient weight capacity, 451 to 600 pounds
10/1/2006
A
K0854
Power wheelchair, group 3 extra heavy duty, sling/solid
seat/back, patient weight capacity 601 pounds or more
10/1/2006
43034txt.indd 63
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
K0855
Power wheelchair, group 3 extra heavy duty, captain’s
chair, patient weight capacity 601 pounds or more
10/1/2006
A
K0856
10/1/2006
A
K0857
10/1/2006
A
K0858
10/1/2006
A
K0859
option, captain’s chair, patient weight capacity 301 to 450 pounds
10/1/2006
A
K0860
10/1/2006
A
K0861
option, sling/solid seat/back, patient weight capacity up
to and including 300 pounds
10/1/2006
A
K0862
10/1/2006
A
K0863
Power wheelchair, group 3 very heavy duty, multiple
power option, sling/solid seat/back, patient weight
capacity 451 to 600 pounds
10/1/2006
A
K0864
Power wheelchair, group 3 extra heavy duty, multiple
power option, sling/solid seat/back, patient weight
capacity 601 pounds or more
10/1/2006
A
K0868
pounds
10/1/2006
A
K0869
10/1/2006
A
K0870
10/1/2006
A
K0871
10/1/2006
A
K0877
10/1/2006
A
K0878
10/1/2006
A
K0879
10/1/2006
A
K0880
10/1/2006
A
K0884
10/1/2006
43034txt.indd 64
Action
A=Addition
D=Deletion
R=Revision
U pdat e
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2/19/07 1:44:36 PM
Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
A
K0885
option, captain’s chair, weight capacity up to and
10/1/2006
A
K0886
option, sling/solid seat/back, patient weight capacity 301
to 450 pounds
10/1/2006
A
K0890
Power wheelchair, group 5 pediatric, single power option,
10/1/2006
A
K0891
Power wheelchair, group 5 pediatric, multiple power
10/1/2006
A
K0898
Power wheelchair, not otherwise classified
10/1/2006
A
K0899
Power mobility devise, not coded by SADMERC or does
not meet criteria
10/1/2006
A
S0147
Injection, alglucosidase ALFA, 20 mg
10/1/2006
A
S2325
Hip core decompression
10/1/2006
A
A4461
Surgical dressing holder, non-reusable, each
1/1/2007
A
A4463
Surgical dressing holder, reusable, each
1/1/2007
A
A4559
Coupling gel or paste, for use with ultrasound device, per oz
1/1/2007
A
A4600
Sleeve for intermittent limb compression device,
replacement only, each
1/1/2007
A
A4601
Lithium ion battery for non-prosthetic use, replacement
1/1/2007
A
A8000
Helmet, protective, soft, prefabricated, includes all
components and accessories
1/1/2007
A
A8001
Helmet, protective, hard, prefabricated, includes all
1/1/2007
A
A8002
Helmet, protective, soft, custom fabricated, includes all
1/1/2007
A
A8003
Helmet, protective, hard, custom fabricated, includes all
1/1/2007
A
A8004
Hoft interface for helmet, replacement only
1/1/2007
A
A9279
Monitoring feature/device, stand-alone or integrated, any
type, includes all accessories, components and electronics,
not otherwise classified
1/1/2007
A
A9527
Iodine I-125, sodium iodide solution, therapeutic, per
millicurie
1/1/2007
A
A9568
Technetium Tc-99m arcitumomab, diagnostic, per study
dose, up to 45 millicuries
1/1/2007
A
C1821
Interspinous process distraction device (implantable)
1/1/2007
A
C9232
Injection, idursulfase, 1 mg
1/1/2007
A
C9233
Injection, ranibizumab, 0.5 mg
1/1/2007
A
C9234
Injection, alglucosidase alfa, 10 mg
1/1/2007
A
C9235
Injection, panitumumab, 10 mg
1/1/2007
A
C9350
Microporous collagen tube of non-human origin, per
centimeter length
1/1/2007
43034txt.indd 65
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
C9351
Acellular dermal tissue matrix of non-human origin, per
square centimeter (do not report C9351 in conjunction
with J7345)
1/1/2007
A
D0145
Oral evaluation for a patient under three years of age and
counseling with primary caregiver
1/1/2007
A
D0273
Bitewings - three films
1/1/2007
A
D0360
Cone beam CT - craniofacial data capture
1/1/2007
A
D0362
Cone beam - two-dimensional image reconstruction using
existing data, includes multiple images
1/1/2007
A
D0363
Cone beam - three-dimensional image reconstruction using
existing data, includes multiple images
1/1/2007
A
D0486
Accession of brush biopsy sample, microscopic
examination, preparation and transmission of written
report
1/1/2007
A
D1206
Topical fluoride varnish; therapeutic application for
moderate to high caries risk patients
1/1/2007
A
D1555
Removal of fixed space maintainer
1/1/2007
A
D4230
Anatomical crown exposure - four or more contiguous
teeth per quadrant
1/1/2007
A
D4231
Anatomical crown exposure - one to three teeth per
quadrant
1/1/2007
A
D6012
Surgical placement of interim implant body for transitional
prosthesis: endosteal implant
1/1/2007
A
D6091
Replacement of semi-precision or precision attachment
(male or female component) of implant/abutment
supported prosthesis, per attachment
1/1/2007
A
D6092
Recement implant/abutment supported crown
1/1/2007
A
D6093
Recement implant/abutment supported fixed partial
denture
1/1/2007
A
D7292
Surgical placement: temporary anchorage device [screw
retained plate] requiring surgical flap
1/1/2007
A
D7293
Surgical placement: temporary anchorage device requiring
surgical flap
1/1/2007
A
D7294
Surgical placement: temporary anchorage device without
surgical flap
1/1/2007
A
D7951
Sinus augmentation with bone or bone substitutes
1/1/2007
A
D7998
Intraoral placement of a fixation device not in conjunction
with a fracture
1/1/2007
A
D8693
Rebonding or recementing; and/or repair, as required, of
fixed retainers
1/1/2007
A
D9120
Fixed partial denture sectioning
1/1/2007
A
D9612
Therapeutic parenteral drugs, two or more administrations,
different medications
1/1/2007
A
E0676
Intermittent limb compression device (includes all
accessories), not otherwise specified
1/1/2007
A
E0936
Continuous passive motion exercise device for use other
than knee
1/1/2007
43034txt.indd 66
Action
A=Addition
D=Deletion
R=Revision
U pdat e
Delete Date
2/19/07 1:44:37 PM
Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
A
E2373
Power wheelchair accessory, hand or chin control
interface, mini-proportional, compact, or short throw
remote joystick or touchpad, proportional, including all
related electronics and fixed mounting hardware
1/1/2007
A
E2374
interface, standard remote joystick (not including
controller), proportional, including all related electronics
and fixed mounting hardware, replacement only
1/1/2007
A
E2375
Power wheelchair accessory, non-expandable controller,
including all related electronics and mounting hardware,
replacement only
1/1/2007
A
E2376
Power wheelchair accessory, expandable controller,
replacement only
1/1/2007
A
E2377
Power wheelchair accessory, expandable controller,
upgrade provided at initial issue
1/1/2007
A
E2381
Power wheelchair accessory, pneumatic drive wheel tire,
any size, replacement only, each
1/1/2007
A
E2382
Power wheelchair accessory, tube for pneumatic drive
wheel tire, any size, replacement only, each
1/1/2007
A
E2383
Power wheelchair accessory, insert for pneumatic drive
wheel tire (removable), any type, any size, replacement
only, each
1/1/2007
A
E2384
Power wheelchair accessory, pneumatic caster tire, any
size, replacement only, each
1/1/2007
A
E2385
Power wheelchair accessory, tube for pneumatic caster
tire, any size, replacement only, each
1/1/2007
A
E2386
Power wheelchair accessory, foam filled drive wheel tire,
1/1/2007
A
E2387
Power wheelchair accessory, foam filled caster tire, any
1/1/2007
A
E2388
Power wheelchair accessory, foam drive wheel tire, any
1/1/2007
A
E2389
Power wheelchair accessory, foam caster tire, any size,
1/1/2007
A
E2390
Power wheelchair accessory, solid (rubber/plastic) drive
wheel tire, any size, replacement only, each
1/1/2007
A
E2391
Power wheelchair accessory, solid (rubber/plastic) caster
tire (removable), any size, replacement only, each
1/1/2007
A
E2392
Power wheelchair accessory, solid (rubber/plastic) caster
tire with integrated wheel, any size, replacement only,
each
1/1/2007
A
E2393
Power wheelchair accessory, valve for pneumatic tire tube,
any type, replacement only, each
1/1/2007
A
E2394
Power wheelchair accessory, drive wheel excludes tire,
1/1/2007
A
E2395
Power wheelchair accessory, caster wheel excludes tire,
1/1/2007
A
E2396
Power wheelchair accessory, caster fork, any size,
1/1/2007
43034txt.indd 67
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67
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G0377
Administration of vaccine for Part D Drug
1/1/2007
A
G0380
Level 1 hospital emergency visit provided in a type B
department or facility of the hospital: (the department
or facility must meet at least one of the following
requirements: (1) it is licensed by the state in which it is
located under applicable state law as an emergency room
or emergency department; (2) it is held out to the public
(by name, posted signs, advertising, or other means) as a
place that provides care for emergency medical conditions
on an urgent basis without requiring a previously
scheduled appointment; or (3) during the calendar year
immediately preceding the calendar year in which a
determination under this section is being made, based
on a representative sample of patient visits that occurred
during that calendar year, it provides at least one-third of
all of its outpatient visits for the treatment of emergency
medical conditions on an urgent basis without requiring a
previously scheduled appointment)
1/1/2007
A
G0381
1/1/2007
A
G0382
1/1/2007
43034txt.indd 68
Action
A=Addition
D=Deletion
R=Revision
U pdat e
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2/19/07 1:44:38 PM
Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
A
G0383
1/1/2007
A
G0384
1/1/2007
A
G0389
Ultrasound b-scan and/or real time with image
documentation; for abdominal aortic aneurysm (AAA)
screening
1/1/2007
A
G0390
Trauma response team associated with hospital critical
care service
1/1/2007
A
G0392
Transluminal balloon angioplasty, percutaneous; for
maintenance of hemodialysis access, arteriovenous fistula
or graft; arterial
1/1/2007
A
G0393
Transluminal balloon angioplasty, percutaneous; for
maintenance of hemodialysis access, arteriovenous fistula
or graft; venous
1/1/2007
A
G0394
Blood occult test (e.g., guaiac), feces, for single
determination for colorectal neoplasm (i.e., patient was
provided three cards or single triple card for consecutive
collection)
1/1/2007
A
G8191
Clinician documented to have given order for prophylactic
antibiotic to be given within one hour (if Vancomycin, two
hours) prior to surgical incision (or start of procedure when
no incision is required)
1/1/2007
A
G8192
Clinician documented to have given the prophylactic
antibiotic within one hour (if Vancomycin, two hours) prior
to the surgical incision (or start of procedure when no
incision is required)
1/1/2007
43034txt.indd 69
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G8193
Clinician did not document that an order for prophylactic
no incision is required) was given
1/1/2007
A
G8194
Clinician documented that patient was not an eligible
candidate for prophylactic antibiotic
1/1/2007
A
G8195
Clinician documented to have given the prophylactic
antibiotic within one hour (if Vancomycin, two hours) prior
to the surgical incision (or start of procedure when no
1/1/2007
A
G8196
Clinician did not document a prophylactic antibiotic was
administered within one hour (if Vancomycin, two hours)
prior to surgical incision (or start of procedure when no
1/1/2007
A
G8197
Patient documented to have order for prophylactic
no incision is required)
1/1/2007
A
G8198
Patient documented to have order for Cefazolin or
Cefuroxime for antimicrobial prophylaxis
1/1/2007
A
G8199
Clinician documented to have given Cefazolin or
1/1/2007
A
G8200
Order for Cefazolin or Cefuroxime for antimicrobial
prophylaxis not documented
1/1/2007
A
G8201
Patient was not an eligible candidate for Cefazolin or
1/1/2007
A
G8202
Clinician documented an order was given to discontinue
prophylactic antibiotics within 24 hours of surgical end
time
1/1/2007
A
G8203
Clinician documented that prophylactic antibiotics were
discontinued within 24 hours of surgical end time
1/1/2007
A
G8204
Clinician did not document an order was given to
discontinue prophylactic antibiotics within 24 hours of
surgical end time
1/1/2007
A
G8205
candidate for prophylactic antibiotic discontinuation within
24 hours of surgical end time
1/1/2007
A
G8206
Clinician documented that prophylactic antibiotic was
given
1/1/2007
A
G8207
Clinician documented an order was given to discontinue
prophylactic antibiotics within 48 hours of surgical end
time
1/1/2007
A
G8208
Clinician documented that prophylactic antibiotics were
discontinued within 48 hours of surgical end time
1/1/2007
A
G8209
Clinician did not document an order was given to
discontinue prophylactic antibiotics within 48 hours of
surgical end time
1/1/2007
A
G8210
Clinician documented patient was not an eligible
candidate for discontinuation of prophylactic antibiotic
discontinuation within 48 hours of surgical end time
1/1/2007
A
G8211
Clinician documented that prophylactic antibiotic was
given
1/1/2007
43034txt.indd 70
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D=Deletion
R=Revision
U pdat e
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Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
A
G8212
Clinician documented an order was given for appropriate
venous thromboembolism (VTE) prophylaxis to be given
within 24 hrs prior to incision time or 24 hours after
surgery end time
1/1/2007
A
G8213
Clinician documented to have given VTE prophylaxis
within 24 hrs prior to incision time or 24 hours after
surgery end time
1/1/2007
A
G8214
Clinician did not document an order was given for
appropriate venous thromboembolism (VTE) prophylaxis to
be given within 24 hrs prior to incision time or 24 hours
after surgery end time
1/1/2007
A
G8215
candidate for venous thromboembolism (VTE) prophylaxis
to be given within 24 hours prior to incision time or 24 hours after surgery end time
1/1/2007
A
G8216
Patient documented to have received DVT prophylaxis by
end of hospital day two
1/1/2007
A
G8217
Patient not documented to have received DVT prophylaxis
by end of hospital day 2
1/1/2007
A
G8218
Patient was not an eligible candidate for DVT prophylaxis
by end of hospital day 2, including physician
documentation that patient is ambulatory
1/1/2007
A
G8219
Patient documented to have received DVT prophylaxis by
end of hospital day 2
1/1/2007
A
G8220
Patient not documented to have received DVT prophylaxis
by end of hospital day 2
1/1/2007
A
G8221
candidate for DVT prophylaxis by the end of hospital
day 2, including physician documentation that patient is
ambulatory
1/1/2007
A
G8222
Patient documented to have been prescribed antiplatelet
therapy at discharge
1/1/2007
A
G8223
Patient not documented to have received prescription for
antiplatelet therapy at discharge
1/1/2007
A
G8224
candidate for antiplatelet therapy at discharge, including
identification from medical record that patient is on
anticoagulation therapy
1/1/2007
A
G8225
Patient documented to have been prescribed an
anticoagulant at discharge
1/1/2007
A
G8226
Patient not documented to have received prescription for
anticoagulant therapy at discharge
1/1/2007
A
G8227
Patient not documented to have permanent, persistent, or
paroxysmal atrial fibrillation
1/1/2007
A
G8228
candidate for anticoagulant therapy at discharge
1/1/2007
A
G8229
Patient documented to have been administered or
considered for T-PA
1/1/2007
A
G8230
Patient not eligible for T-PA administration, ischemic stroke
symptom onset of more than 3 hours
1/1/2007
A
G8231
Patient not documented to have received T-PA or not
documented to have been considered a candidate for T-PA
administration
1/1/2007
43034txt.indd 71
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G8232
Patient documented to have received dysphagia screening
prior to taking any foods, fluids or medication by mouth
1/1/2007
A
G8234
Patient not documented to have received dysphagia
screening
1/1/2007
A
G8235
Patient not receiving or ineligible to receive food, fluids or
medication by mouth, or documentation of NPO (nothing
by mouth) order
1/1/2007
A
G8236
candidate for dysphagia screening prior to taking any
foods, fluids or medication by mouth
1/1/2007
A
G8237
Patient documented to have received order for
rehabilitation services or documentation of consideration
for rehabilitation services
1/1/2007
A
G8238
Patient not documented to have received order for or
consideration for rehabilitation services
1/1/2007
A
G8239
Internal carotid stenosis patient below 30%, reference to
measurements of distal internal carotid diameter as the
denominator for stenosis measurement not necessary
1/1/2007
A
G8240
Internal carotid stenosis patient in the 30-99% range, and
no documentation of reference to measurements of distal
internal carotid diameter as the denominator for stenosis
measurement
1/1/2007
A
G8241
Clinician documented that patient whose final report of
the carotid imaging study performed (neck MRA, neck
CTA, neck duplex ultrasound, carotid angiogram), with
characterization of an internal carotid stenosis in the 3099% range, was not an eligible candidate for reference
to measurements of distal internal carotid diameter as the
denominator for stenosis measurement
1/1/2007
A
G8242
Patient documented to have received CT or MRI with
presence or absence of hemorrhage, mass lesion and
acute infarction documented in the final report
1/1/2007
A
G8243
Patient not documented to have received CT or MRI and
the presence or absence of hemorrhage, mass lesion and
acute infarction not documented in the final report
1/1/2007
A
G8245
Clinician documented presence or absence alarm
symptoms
1/1/2007
A
G8246
Patient was not an eligible candidate for medical history
review with assessment of new or changing moles
1/1/2007
A
G8247
Patient with alarm symptom(s) documented to have
had upper endoscopy performed or referral for upper
endoscopy
1/1/2007
A
G8248
Patient with at least one alarm symptom not documented
to have had upper endoscopy or referral for upper
endoscopy
1/1/2007
A
G8249
candidate for upper endoscopy
1/1/2007
A
G8250
Patient with suspicion of Barrett’s esophagus in endoscopy
report and documented to have received an esophageal
biopsy
1/1/2007
A
G8251
Patient not documented to have received an esophageal
biopsy when suspicion of Barrett’s esophagus is indicated
in the endoscopy report
1/1/2007
43034txt.indd 72
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D=Deletion
R=Revision
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Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
A
G8252
candidate for esophageal biopsy
1/1/2007
A
G8253
Patient documented to have received an order for a
barium swallow test
1/1/2007
A
G8254
Patient with no documentation order for barium swallow
test
1/1/2007
A
G8255
Clinician documentation that patient was an eligible
candidate for barium swallow test
1/1/2007
A
G8256
Clinician documented reconciliation of discharge
medications with current medication list in medical record
1/1/2007
A
G8257
Clinician has not documented reconciliation of discharge
medications with current medication list in medical record
1/1/2007
A
G8258
Patient was not an eligible candidate for discharge
medications review
1/1/2007
A
G8259
Patient documented to have surrogate decision maker or
advance care plan in medical record
1/1/2007
A
G8260
Patient not documented to have surrogate decision maker
or advance care plan in medical record
1/1/2007
A
G8261
candidate for surrogate decision maker or advance care
plan
1/1/2007
A
G8262
Patient documented to have been assessed for presence or
absence of urinary incontinence
1/1/2007
A
G8263
Patient not documented to have been assessed for
presence or absence of urinary incontinence
1/1/2007
A
G8264
candidate for an assessment of the presence or absence of
urinary incontinence
1/1/2007
A
G8265
Patient documented to have received characterization of
1/1/2007
A
G8266
Patient not documented to have received characterization
of urinary incontinence
1/1/2007
A
G8267
Patient documented to have received a plan of care for
1/1/2007
A
G8268
Patient not documented to have received plan of care for
1/1/2007
A
G8269
Clinician has not provided care for the patient for
the required time to develop plan of care for urinary
incontinence
1/1/2007
A
G8270
Patient documented to have received screening for fall risk
(2 or more falls in the past year or any fall with injury in
the past year)
1/1/2007
A
G8271
Patient with no documentation of screening for fall risks (2
or more falls in the past year or any fall with injury in the
past year)
1/1/2007
A
G8272
Clinician documentation that patient was not an eligible
candidate for fall risk screening
1/1/2007
A
G8273
Clinician has not provided care for the patient for the
required time to screen for fall risk
1/1/2007
A
G8274
Clinician has not documented presence or absence of
alarm symptoms
1/1/2007
43034txt.indd 73
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G8275
Patient documented to have medical history taken which
included assessment of new or changing moles
1/1/2007
A
G8276
Patient not documented to have received medical history
with assessment of new or changing moles
1/1/2007
A
G8277
Patient was not an eligible candidate for medical history
review with assessment of new or changing moles
1/1/2007
A
G8278
Patient documented to have received complete physical
skin exam
1/1/2007
A
G8279
Patient not documented to have received a complete
physical skin exam
1/1/2007
A
G8280
Patient was not an eligible candidate for complete physical
skin exam during the reporting year
1/1/2007
A
G8281
Patient documented to have received counseling to
perform a self-examination
1/1/2007
A
G8282
Patient not documented to have received counseling to
perform a self-examination
1/1/2007
A
G8283
Patient was not an eligible candidate for counseling to
perform self-examination
1/1/2007
A
G8284
Patient documented to have received a prescription for
pharmacologic therapy for osteoporosis
1/1/2007
A
G8285
Patient not documented to have received pharmacologic
therapy
1/1/2007
A
G8286
candidate for pharmacologic therapy
1/1/2007
A
G8287
required time for the pharmacologic therapy measure
1/1/2007
A
G8288
Patient documented to have received calcium and vitamin
D or counseling on both calcium and vitamin D use, and
exercise
1/1/2007
A
G8289
Patient with no documentation of calcium and vitamin D
use or counseling regarding both calcium and vitamin D
use, or exercise
1/1/2007
A
G8290
candidate for calcium and vitamin D, and exercise during
the reporting year
1/1/2007
A
G8291
required time for the calcium, vitamin D, and exercise
measure
1/1/2007
A
G8292
COPD patient with spirometry results documented
1/1/2007
A
G8293
COPD patient without spirometry results documented
1/1/2007
A
G8294
COPD patient was not eligible for spirometry results
1/1/2007
A
G8295
COPD patient documented to have received inhaled
bronchodilator therapy
1/1/2007
A
G8296
COPD patient not documented to have inhaled
bronchodilator therapy prescribed
1/1/2007
A
G8297
COPD patient was not eligible for inhaled bronchodilator
therapy
1/1/2007
A
G8298
Patient documented to have received optic nerve head
evaluation
1/1/2007
43034txt.indd 74
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R=Revision
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Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
A
G8299
Patient not documented to have received optic nerve head
evaluation
1/1/2007
A
G8300
candidate for optic nerve head evaluation during the
reporting year
1/1/2007
A
G8301
Clinician has not provided care for the primary open-angle
glaucoma patient for the required time for optic nerve
head evaluation measure
1/1/2007
A
G8302
Patient documented to have a specific target intraocular
pressure range goal
1/1/2007
A
G8303
Patient not documented to have a specific target
intraocular pressure range goal
1/1/2007
A
G8304
candidate for a specific target intraocular pressure range
goal
1/1/2007
A
G8305
Clinician has not provided care for the primary open-angle
glaucoma patient for the required time for treatment range
goal documentation measurement
1/1/2007
A
G8306
Primary open-angle glaucoma patient with intraocular
pressure above the target range goal documented to have
received plan of care
1/1/2007
A
G8307
pressure at or below goal, no plan of care necessary
1/1/2007
A
G8308
pressure above the target range goal, and not documented
to have received plan of care during the reporting year
1/1/2007
A
G8309
Patient documented to have been prescribed/
recommended antioxidant vitamin or mineral supplement
1/1/2007
A
G8310
Patient not documented to have been prescribed/
recommended at least one antioxidant vitamin or mineral
supplement during the reporting year
1/1/2007
A
G8311
candidate for antioxidant vitamin or mineral supplement
during the reporting year
1/1/2007
A
G8312
Clinician has not provided care for the age-related
macular degeneration patient for the required time for
antioxidant supplement prescription/recommended
measure
1/1/2007
A
G8313
Patient documented to have received macular exam,
including documentation of the presence or absence
of macular thickening or hemorrhage and the level of
macular degeneration severity
1/1/2007
A
G8314
Patient not documented to have received macular exam
with documentation of presence or absence of macular
thickening or hemorrhage and no documentation of level
of macular degeneration severity
1/1/2007
A
G8315
candidate for macular examination during the reporting
year
1/1/2007
A
G8316
Clinician has not provided care for the age-related
macular degeneration patient for the required time for
macular examination measurement
1/1/2007
43034txt.indd 75
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G8317
Patient documented to have visual functional status
assessed
1/1/2007
A
G8318
Patient documented not to have visual functional status
assessed
1/1/2007
A
G8319
candidate for assessment of visual functional status
1/1/2007
A
G8320
Clinician has not provided care for the cataract patient for
the required time for assessment of visual functional status
measurement
1/1/2007
A
G8321
Patient documented to have had pre-surgical axial length,
corneal power measurement and method of intraocular
lens power calculation
1/1/2007
A
G8322
Patient not documented to have had pre-surgical axial
length, corneal power measurement and method of
intraocular lens power calculation
1/1/2007
A
G8323
candidate for pre-surgical axial length, corneal power
measurement and method of intraocular lens power
calculation
1/1/2007
A
G8324
Clinician has not provided care for the cataract patient
for the required time for pre-surgical measurement and
intraocular lens power calculation measure
1/1/2007
A
G8325
Patient documented to have received fundus evaluation
within six months prior to cataract surgery
1/1/2007
A
G8326
Patient not documented to have received fundus evaluation
within six months prior to cataract surgery
1/1/2007
A
G8327
Patient was not an eligible candidate for pre-surgical
fundus evaluation
1/1/2007
A
G8328
Clinician has not provided care for the cataract patient for
the required time for fundus evaluation measurement
1/1/2007
A
G8329
Patient documented to have received dilated macular or
fundus exam with level of severity of retinopathy and the
presence or absence of macular edema documented
1/1/2007
A
G8330
Patient not documented to have received dilated macular
or fundus exam with level of severity of retinopathy
and the presence or absence of macular edema not
documented
1/1/2007
A
G8331
candidate for dilated macular or fundus exam during the
reporting year
1/1/2007
A
G8332
Clinician has not provided care for the diabetic
retinopathy patient for the required time for macular
edema and retinopathy measurement
1/1/2007
A
G8333
Patient documented to have had findings of macular or
fundus exam communicated to the physician managing the
diabetes care
1/1/2007
A
G8334
Documentation of findings of macular or fundus exam not
communicated to the physician managing the patient’s
ongoing diabetes care
1/1/2007
A
G8335
candidate for the findings of their macular or fundus exam
being communicated to the physician managing their
diabetes care during the reporting year
1/1/2007
43034txt.indd 76
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D=Deletion
R=Revision
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Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
A
G8336
Clinician has not provided care for the diabetic
retinopathy patient for the required time for physician
communication measurement
1/1/2007
A
G8337
Clinician documented that communication was sent to
the physician managing ongoing care of patient that a
fracture occurred and that the patient was or should be
tested or treated for osteoporosis
1/1/2007
A
G8338
Clinician has not documented that communication was
sent to the physician managing ongoing care of patient
that a fracture occurred and that the patient was or should
be tested or treated for osteoporosis
1/1/2007
A
G8339
Patient was not an eligible candidate for communication
with the physician managing the patient’s ongoing care
that a fracture occurred and that the patient was or should
be tested or treated for osteoporosis
1/1/2007
A
G8340
Patient documented to have had central DEXA performed
and results documented or central DEXA ordered or
pharmacologic therapy prescribed
1/1/2007
A
G8341
Patient not documented to have had central DEXA
measurement or pharmacologic therapy
1/1/2007
A
G8342
candidate for central DEXA measurement or prescribing
pharmacologic
1/1/2007
A
G8343
the required time for central DEXA measurement or
pharmacological therapy measure
1/1/2007
A
G8344
Patient documented to have had central DEXA ordered or
performed and results documented or pharmacological
therapy prescribed
1/1/2007
A
G8345
Patient not documented to have had central DEXA
measurement ordered or performed or pharmacologic
therapy
1/1/2007
A
G8346
Clinician documented that patient was not an
eligible candidate for central DEXA measurement or
pharmacologic therapy
1/1/2007
A
G8347
the required time for central DEXA measurement or
pharmacological therapy measure
1/1/2007
A
G9131
Oncology; disease status; invasive female breast
cancer (does not include ductal carcinoma in situ);
adenocarcinoma as predominant cell type; extent of
disease unknown, staging in progress, or not listed (for use
in a Medicare-approved demonstration project)
1/1/2007
A
G9132
Oncology; disease status; prostate cancer, limited
to adenocarcinoma; hormone-refractory/androgenindependent (e.g., rising PSA on anti-androgen therapy
or post-orchiectomy); clinical metastases (for use in a
Medicare-approved demonstration project)
1/1/2007
A
G9133
Oncology; disease status; prostate cancer, limited to
adenocarcinoma; hormone-responsive; clinical metastases
or M1 at diagnosis (for use in a Medicare-approved
demonstration project)
1/1/2007
43034txt.indd 77
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G9134
Oncology; disease status; non-Hodgkin’s lymphoma,
any cellular classification; stage I, II at diagnosis, not
relapsed, not refractory (for use in a Medicare-approved
1/1/2007
A
G9135
any cellular classification; stage III, IV, not relapsed, not
refractory (for use in a Medicare-approved demonstration
project)
1/1/2007
A
G9136
transformed from original cellular diagnosis to a second
cellular classification (for use in a Medicare-approved
1/1/2007
A
G9137
Oncology; disease status; non-Hodgkin’s lymphoma, any
cellular classification; relapsed/refractory (for use in a
1/1/2007
A
G9138
Oncology; disease status; non-Hodgkin’s lymphoma, any
cellular classification; diagnostic evaluation, stage not
determined, evaluation of possible relapse or non-response
to therapy, or not listed (for use in a Medicare-approved
1/1/2007
A
G9139
Oncology; disease status; chronic myelogenous leukemia,
limited to Philadelphia chromosome positive and/or
BCR-ABL positive; extent of disease unknown, staging
in progress, not listed (for use in a Medicare-approved
1/1/2007
A
H0049
Alcohol and/or drug screening
1/1/2007
A
H0050
Alcohol and/or drug services, brief intervention, per 15 minutes
1/1/2007
A
J0129
Injection, abatacept, 10 mg
1/1/2007
A
J0348
Injection, anadulafungin, 1 mg
1/1/2007
A
J0364
Injection, apomorphine hydrochloride, 1 mg
1/1/2007
A
J0594
Injection, busulfan, 1 mg
1/1/2007
A
J0894
Injection, decitabine, 1 mg
1/1/2007
A
J1324
Injection, enfuvirtide, 1 mg
1/1/2007
A
J1458
Injection, galsulfase, 1 mg
1/1/2007
A
J1562
Injection, immune globulin, subcutaneous, 100 mg
1/1/2007
A
J1740
Injection, ibandronate sodium, 1 mg
1/1/2007
A
J2170
Injection, mecasermin, 1 mg
1/1/2007
A
J2248
Injection, micafungin sodium, 1 mg
1/1/2007
A
J2315
Injection, naltrexone, depot form, 1 mg
1/1/2007
A
J3243
Injection, tigecycline, 1 mg
1/1/2007
A
J3473
Injection, hyaluronidase, recombinant, 1 usp unit
1/1/2007
A
J7187
Injection, Von Willebrand factor complex, human,
ristocetin cofactor, per IU
1/1/2007
A
J7311
Fluocinolone acetonide, intravitreal implant
1/1/2007
A
J7319
Hyaluronan (sodium hyaluronate) or derivative, intraarticular injection, per injection
1/1/2007
43034txt.indd 78
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R=Revision
U pdat e
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Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
A
J7345
Dermal (substitute) tissue of non-human origin, with or
without other bioengineered or processed elements,
without metabolically active elements, per square
centimeter
1/1/2007
A
J7346
Dermal (substitute) tissue of human origin, injectable, with
or without other bioengineered or processed elements, but
without metabolically active elements, 1 cc
1/1/2007
A
J7607
Levalbuterol, inhalation solution, compounded product,
administered through DME, concentrated form, 0.5 mg
1/1/2007
A
J7609
Albuterol, inhalation solution, compounded product,
administered through DME, unit dose, 1 mg concentrated
form, 1 mg
1/1/2007
A
J7610
Albuterol, inhalation solution, compounded product,
administered through DME, unit dose, 1 mg concentrated
form, 1 mg
1/1/2007
A
J7615
Levalbuterol, inhalation solution, compounded product,
administered through DME, unit dose, 0.5 mg
1/1/2007
A
J7634
Budesonide, inhalation solution, compounded product,
administered through DME, concentrated form, per 0.25 milligram
1/1/2007
A
J7645
Ipratropium bromide, inhalation solution, compounded
product, administered through DME, unit dose form, per
milligram
1/1/2007
A
J7647
Soetharine HCL, inhalation solution, compounded product,
administered through DME, concentrated form, per
milligram
1/1/2007
A
J7650
Isoetharine HCL, inhalation solution, compounded product,
administered through DME, unit dose form, per milligram
1/1/2007
A
J7657
Isoproterenol HCL, inhalation solution, compounded
product, administered through DME, concentrated form,
per milligram
1/1/2007
A
J7660
Isoproterenol HCL, inhalation solution, compounded
milligram
1/1/2007
A
J7667
Metaproterenol sulfate, inhalation solution, compounded
product, concentrated form, per 10 milligrams
1/1/2007
A
J7670
Metaproterenol sulfate, inhalation solution, compounded
10 milligrams
1/1/2007
A
J7685
Tobramycin, inhalation solution, compounded product,
administered through DME, unit dose form, per 300
milligrams
1/1/2007
A
J8650
Nabilone, oral, 1 mg
1/1/2007
A
J9261
Injection, nelarabine, 50 mg
1/1/2007
A
L1001
Cervical thoracic lumbar sacral orthosis, immobilizer,
infant size, each
1/1/2007
A
L3806
Wrist hand finger orthosis, includes one or more
nontorsion joint(s), elastic bands, turnbuckles, may include
soft interface material, straps, custom fabricated, includes
fitting and adjustment
1/1/2007
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
L3808
Wrist hand finger orthosis, rigid without joints, may
include soft interface material; straps, custom fabricated,
includes fitting and adjustment
1/1/2007
A
L3915
Wrist hand orthosis, includes one or more nontorsion
joint(s), elastic bands, turnbuckles, may include soft
interface, straps, prefabricated, includes fitting and
adjustment
1/1/2007
A
L5993
Addition to lower extremity prosthesis, heavy duty feature,
foot only, (for patient weight greater than 300 lbs)
1/1/2007
A
L5994
knee only, (for patient weight greater than 300 lbs)
1/1/2007
A
L6611
Addition to upper extremity prosthesis, external powered,
additional switch, any type
1/1/2007
A
L6624
Upper extremity addition, flexion/extension and rotation
wrist unit
1/1/2007
A
L6639
Upper extremity addition, heavy duty feature, any elbow
1/1/2007
A
L6703
Terminal device, passive hand/mitt, any material, any size
1/1/2007
A
L6704
Terminal device, sport/recreational/work attachment, any
material, any size
1/1/2007
A
L6706
Terminal device, hook, mechanical, voluntary opening,
any material, any size, lined or unlined
1/1/2007
A
L6707
Terminal device, hook, mechanical, voluntary closing, any
material, any size, lined or unlined
1/1/2007
A
L6708
Terminal device, hand, mechanical, voluntary opening,
any material, any size
1/1/2007
A
L6709
Terminal device, hand, mechanical, voluntary closing, any
material, any size
1/1/2007
A
L7007
Electric hand, switch or myoelectric controlled, adult
1/1/2007
A
L7008
Electric hand, switch or myoelectric, controlled, pediatric
1/1/2007
A
L7009
Electric hook, switch or myoelectric controlled, adult
1/1/2007
A
L8690
Auditory osseointegrated device, includes all internal and
external components
1/1/2007
A
L8691
Auditory osseointegrated device, external sound processor,
replacement
1/1/2007
A
L8695
External recharging system for battery (external) for use
with implantable neurostimulator
1/1/2007
A
Q4081
Injection, epoetin alfa, 100 units (for ESRD on dialysis)
1/1/2007
A
Q4082
Drug or biological, not otherwise classified, part B drug
competitive acquisition program (cap)
1/1/2007
A
Q4083
Hyaluronan or derivative, Hyalgan or Supartz, for intraarticular injection, per dose
1/1/2007
A
Q4084
Hyaluronan or derivative, Synvisc, for intra-articular
injection, per dose
1/1/2007
A
Q4085
Hyaluronan or derivative, Euflexxa, for intra-articular
injection, per dose
1/1/2007
A
Q4086
Hyaluronan or derivative, Orthovisc, for intra-articular
injection per dose
1/1/2007
A
Q5001
Hospice care provided in patient’s home/residence
1/1/2007
43034txt.indd 80
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A=Addition
D=Deletion
R=Revision
U pdat e
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Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
Delete Date
A
Q5002
Hospice care provided in assisted living facility
1/1/2007
A
Q5003
Hospice care provided in nursing long term care facility
(LTC) or non-skilled nursing facility (NF)
1/1/2007
A
Q5004
Hospice care provided in skilled nursing facility (SNF)
1/1/2007
A
Q5005
Hospice care provided in inpatient hospital
1/1/2007
A
Q5006
Hospice care provided in inpatient hospice facility
1/1/2007
A
Q5007
Hospice care provided in long term care facility
1/1/2007
A
Q5008
Hospice care provided in inpatient psychiatric facility
1/1/2007
A
Q5009
Hospice care provided in place not otherwise specified
(NOS)
1/1/2007
A
S0180
Etonogestrel (contraceptive) implant system, including
implant and supplies
1/1/2007
A
S2344
Nasal/sinus endoscopy, surgical; with enlargement of
sinus ostium opening using inflatable device (i.e., balloon
sinuplasty)
1/1/2007
A
S3855
Genetic testing for detection of mutations in the presenilin,
1 gene
1/1/2007
A
T4543
Disposable incontinence product, brief/diaper, bariatric,
each
1/1/2007
D
A0800
Ambulance transport provided between the hours of 7pm
and 7am
1/1/2007
D
A4348
Male external catheter with integral collection
compartment, extended wear, each (e.g., 2 per month)
1/1/2007
D
A4359
Urinary suspensory without leg bag, each
1/1/2007
D
A4462
Abdominal dressing holder, each
1/1/2007
D
A4632
Replacement battery for external infusion pump, any type,
each
1/1/2007
D
A9549
Technetium Tc-99m arcitumomab, diagnostic, per study
dose, up to 25 millicuries
1/1/2007
D
C1178
Injection, busulfan, per 6 mg
1/1/2007
D
C2632
Brachytherapy solution, iodine-125, per mci
1/1/2007
D
C8950
Intravenous infusion for therapy/diagnosis; up to 1 hour
1/1/2007
D
C8951
Intravenous infusion for therapy/diagnosis; each
additional hour (list separately in addition to C8950)
1/1/2007
D
C8952
Therapeutic, prophylactic or diagnostic injection;
intravenous push of each new substance/drug
1/1/2007
D
C8953
Chemotherapy administration, intravenous; push technique
1/1/2007
D
C8954
Chemotherapy administration, intravenous; infusion
technique, up to one hour
1/1/2007
D
C8955
Chemotherapy administration, intravenous; infusion
technique, each additional hour (list separately in
addition to C8954)
1/1/2007
D
C9220
Sodium hyaluronate per 30 mg dose, for intra-articular
injection
1/1/2007
D
C9221
Acellular dermal tissue matrix, per 16 sq. cm.
1/1/2007
D
C9222
Decellularized soft tissue scaffold, per 1 cc
1/1/2007
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
C9224
Injection, galsulfase, per 5 mg
1/1/2007
D
C9225
Injection, fluocinolone acetonide intravitreal implant, per
0.59 mg
1/1/2007
D
C9227
Injection, micafungin sodium, per 1 mg
1/1/2007
D
C9228
Injection, tigecycline, per 1 mg
1/1/2007
D
C9229
Injection, ibandronate sodium, per 1 mg
1/1/2007
D
C9230
Injection, abatacept, per 10 mg
1/1/2007
D
C9231
Injection, decitabine, per 1 mg
1/1/2007
D
D1201
Topical application of fluoride (including prophylaxis)-child
1/1/2007
D
D1205
Topical application of fluoride (including prophylaxis)-adult
1/1/2007
D
D6971
Cast post as part of bridge retainer
1/1/2007
D
E0164
Commode chair, mobile, with fixed arms
1/1/2007
D
E0166
Commode chair, mobile, with detachable arms
1/1/2007
D
E0180
Pressure pad, alternating with pump
1/1/2007
D
E0701
Helmet with face guard and soft interface material,
prefabricated
1/1/2007
D
E0977
Wedge cushion, wheelchair
1/1/2007
D
E0997
Caster with a fork
1/1/2007
D
E0998
Caster without fork
1/1/2007
D
E0999
Pneumatic tire with wheel
1/1/2007
D
E2320
interface, remote joystick or touchpad, proportional,
including all related electronics, and fixed mounting
hardware
1/1/2007
D
G0107
Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations
1/1/2007
D
G0243
Multi-source photon stereotactic radiosurgery, delivery
including collimator changes and custom plugging,
complete course of treatment, all lesions
1/1/2007
D
G9127
Oncology; disease status; limited to multiple myeloma,
systemic disease; smoldering, stage I (for use in a
1/1/2007
D
J2912
Injection, sodium chloride, 0.9%, per 2 ml
1/1/2007
D
J7188
Injection, Von Willebrand factor complex, human, IU
1/1/2007
D
J7317
Sodium hyaluronate, per 20 to 25 mg dose for intraarticular injection
1/1/2007
D
J7320
Hylan G-F 20, 16 mg, for intra-articular injection
1/1/2007
D
J7350
Dermal (substitute) tissue of human origin, injectable, with
or without other bioengineered or processed elements, but
without metabolized active elements, per 10 mg
1/1/2007
D
K0090
Rear wheel tire for power wheelchair, any size, each
1/1/2007
D
K0091
Rear wheel tire tube other than zero pressure for power
wheelchair, any size, each
1/1/2007
43034txt.indd 82
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A=Addition
D=Deletion
R=Revision
U pdat e
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Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
Delete Date
D
K0092
Rear wheel assembly for power wheelchair, complete,
each
1/1/2007
D
K0093
Rear wheel, zero pressure tire tube (flat free insert) for
power wheelchair, any size, each
1/1/2007
D
K0094
Wheel tire for power base, any size, each
1/1/2007
D
K0095
Wheel tire tube other than zero pressure for each base,
any size, each
1/1/2007
D
K0096
Wheel assembly for power base, complete, each
1/1/2007
D
K0097
Wheel zero pressure tire tube (flat free insert) for power
base, any size, each
1/1/2007
D
K0099
Front caster for power wheelchair
1/1/2007
D
L0100
Cranial orthosis (helmet), with or without soft interface, molded to patient model
1/1/2007
D
L0110
Cranial orthosis (helmet), with or without soft-interface,
non-molded
1/1/2007
D
L3902
Wrist hand finger orthosis, external powered, compressed
gas, custom-fabricated
1/1/2007
D
L3914
Wrist hand orthosis, wrist extension cock-up,
prefabricated, includes fitting/adjustment
1/1/2007
D
L6700
Terminal device, hook, Dorrance, or equal, model #3
1/1/2007
D
L6705
1/1/2007
D
L6710
Terminal device, hook, Dorrance, or equal, model #5X
1/1/2007
D
L6715
Terminal device, hook, Dorrance, or equal, model #5XA
1/1/2007
D
L6720
1/1/2007
D
L6725
1/1/2007
D
L6730
Terminal device, hook, Dorrance, or equal, model #7LO
1/1/2007
D
L6735
1/1/2007
D
L6740
1/1/2007
D
L6745
1/1/2007
D
L6750
Terminal device, hook, Dorrance, or equal, model #10P
1/1/2007
D
L6755
1/1/2007
D
L6765
Terminal device, hook, Dorrance, or equal, model #12P
1/1/2007
D
L6770
1/1/2007
D
L6775
1/1/2007
D
L6780
Terminal device, hook, Dorrance, or equal, model #ss555
1/1/2007
D
L6790
Terminal device, hook, Accu hook, or equal
1/1/2007
D
L6795
Terminal device, hook, 2 load, or equal
1/1/2007
D
L6800
Terminal device, hook, APRL VC, or equal
1/1/2007
D
L6806
Terminal device, hook, TRS Grip, Grip III, VC, or equal
1/1/2007
D
L6807
Terminal device, hook, Grip I, Grip II, VC, or equal
1/1/2007
D
L6808
Terminal device, hook, TRS Adept, infant or child, VC, or
equal
1/1/2007
43034txt.indd 83
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
L6809
Terminal device, hook, TRS Super Sport, passive
1/1/2007
D
L6825
Terminal device, hand, Dorrance, VO
1/1/2007
D
L6830
Terminal device, hand, APRL, VC
1/1/2007
D
L6835
Terminal device, hand, Sierra, VO
1/1/2007
D
L6840
Terminal device, hand, Becker Imperial
1/1/2007
D
L6845
Terminal device, hand, Becker Lock Grip
1/1/2007
D
L6850
Terminal device, hand, Becker Plylite
1/1/2007
D
L6855
Terminal device, hand, Robin-Aids, VO
1/1/2007
D
L6860
Terminal device, hand, Robin-Aids, VO soft
1/1/2007
D
L6865
Terminal device, hand, passive hand
1/1/2007
D
L6867
Terminal device, hand, Detroit infant hand (mechanical)
1/1/2007
D
L6868
Terminal device, hand, passive infant hand, (Steeper,
Hosmer or equal)
1/1/2007
D
L6870
Terminal device, hand, child mitt
1/1/2007
D
L6872
Terminal device, hand, NYU child hand
1/1/2007
D
L6873
Terminal device, hand, mechanical infant hand, steeper or
equal
1/1/2007
D
L6875
Terminal device, hand, Bock, VC
1/1/2007
D
L6880
Terminal device, hand, Bock, VO
1/1/2007
D
L7010
Electronic hand, Otto Bock, Steeper or equal, switch
controlled
1/1/2007
D
L7015
Electronic hand, System Teknik, Variety Village or equal,
switch controlled
1/1/2007
D
L7020
Electronic greifer, Otto Bock or equal, switch controlled
1/1/2007
D
L7025
Electronic hand, Otto Bock or equal, myoelectronically
controlled
1/1/2007
D
L7030
Electronic hand, System Teknik, Variety Village or equal,
myoelectronically controlled
1/1/2007
D
L7035
Electronic Greifer, Otto Bock or equal, myoelectronically
controlled
1/1/2007
D
S2262
Abortion for maternal indication, 25 weeks or greater
1/1/2007
D
S4036
Intravaginal culture (IVC), case rate
1/1/2007
R
S0316
Disease Management Program, follow-up/reassessment
R
A4216
Sterile water, saline and/or dextrose, diluent/flush, 10 ml
1/1/2007
R
A4306
Disposable drug delivery system, flow rate of less than 50
ml per hour
1/1/2007
R
A4326
Male external catheter with integral collection chamber,
any type, each
1/1/2007
R
A4394
Ostomy deodorant, with or without lubricant, for use in
ostomy pouch, per fluid ounce
1/1/2007
R
A4558
Conductive gel or paste, for use with electrical device
(e.g., TENS, NMES), per oz
1/1/2007
R
A5105
Urinary suspensory; with or without leg bag, with or
without tube, each
1/1/2007
43034txt.indd 84
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D=Deletion
R=Revision
U pdat e
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Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
R
D0120
Periodic oral evaluation - established patient
1/1/2007
R
D0480
Accession of exfoliative cytologic smears, microscopic
examination, the preparation and transmission of written
report
1/1/2007
R
D2952
Post and core in addition to crown, indirectly fabricated
1/1/2007
R
D2953
Each additional indirectly fabricated post - same tooth
1/1/2007
R
D6970
Post and core in addition to fixed partial denture retainer,
indirectly fabricated
1/1/2007
R
D6976
Each additional indirectly fabricated post - same tooth
1/1/2007
R
D7310
Alveoloplasty in conjunction with extractions - four or more
teeth or tooth spaces, per quadrant
1/1/2007
R
D7320
Alveoloplasty not in conjunction with extractions - four or
more teeth or tooth spaces, per quadrant
1/1/2007
R
D7944
Osteotomy-segmented or subapical
1/1/2007
R
D7950
Osseous, osteoperiosteal, or cartilage graft of the
mandible or maxilla - autogenous or nonautogenous, by
report
1/1/2007
R
D9310
Consultation - diagnostic service provided by dentist or
physician other than requesting dentist or physician
1/1/2007
R
D9610
Therapeutic parenteral drug, single administration
1/1/2007
R
E0163
Commode chair, mobile or stationary, with fixed arms
1/1/2007
R
E0165
Commode chair, mobile or stationary, with detachable
arms
1/1/2007
R
E0167
Pail or pan for use with commode chair, replacement only
1/1/2007
R
E0181
Powered pressure reducing mattress overlay/pad,
alternating, with pump, includes heavy duty
1/1/2007
R
E0182
Pump for alternating pressure pad, for replacement only
1/1/2007
R
E0190
Positioning cushion/pillow/wedge, any shape or size,
includes all components and accessories
1/1/2007
R
E0720
Transcutaneous electrical nerve stimulation (TENS) device,
two lead, localized stimulation
1/1/2007
R
E0730
Transcutaneous electrical nerve stimulation (TENS) device,
four or more leads, for multiple nerve stimulation
1/1/2007
R
E0967
Manual wheelchair accessory, hand rim with projections,
any type, each
1/1/2007
R
E2209
Arm trough, with or without hand support, each
1/1/2007
R
G0103
Prostate cancer screening; prostate specific antigen test
(PSA)
1/1/2007
R
G0332
Services for intravenous infusion of immunoglobulin prior
to administration (this service is to be billed in conjunction
with administration of immunoglobulin)
1/1/2007
R
G9067
Oncology; disease status; limited to non-small cell lung
cancer; extent of disease unknown, staging in progress, or
not listed (for use in a Medicare-approved demonstration
project)
1/1/2007
43034txt.indd 85
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85
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
R
G9070
Oncology; disease status; small cell lung cancer, limited
to small cell and combined small cell/non-small; extent of
1/1/2007
R
G9083
Oncology; disease status; prostate cancer, limited to
adenocarcinoma; extent of disease unknown, staging in
progress, or not listed (for use in a Medicare-approved
1/1/2007
R
G9089
Oncology; disease status; colon cancer, limited to invasive
cancer; adenocarcinoma as predominant cell type; extent
of disease unknown, staging in progress, or not listed (for
use in a Medicare-approved demonstration project)
1/1/2007
R
G9095
Oncology; disease status; rectal cancer, limited to invasive
cancer; adenocarcinoma as predominant cell type; extent
of disease unknown, staging in progress, or not listed (for
use in a Medicare-approved demonstration project)
1/1/2007
R
G9099
Oncology; disease status; esophageal cancer, limited
to adenocarcinoma or squamous cell carcinoma as
predominant cell type; extent of disease unknown, staging
in progress, or not listed (for use in a Medicare-approved
1/1/2007
R
G9104
Oncology; disease status; gastric cancer, limited to
adenocarcinoma as predominant cell type; extent of
1/1/2007
R
G9108
Oncology; disease status; pancreatic cancer, limited to
adenocarcinoma; extent of disease unknown, staging in
1/1/2007
R
G9112
Oncology; disease status; head and neck cancer, limited
to cancers of oral cavity, pharynx and larynx with
squamous cell as predominant cell type; extent of disease
unknown, staging in progress, or not listed (for use in a
1/1/2007
R
G9117
Oncology; disease status; ovarian cancer, limited to
epithelial cancer; extent of disease unknown, staging in
1/1/2007
R
G9130
Oncology; disease status; limited to multiple myeloma,
systemic disease; extent of disease unknown, staging in
1/1/2007
R
J7611
Albuterol, inhalation solution, FDA-approved final
product, non-compounded, administered through DME,
concentrated form, 1 mg
1/1/2007
R
J7612
Levalbuterol, inhalation solution, FDA-approved final
concentrated form, 0.5 mg
1/1/2007
R
J7613
Albuterol, inhalation solution, FDA-approved final product,
non-compounded, administered through DME, unit dose,
1 mg
1/1/2007
R
J7614
Levalbuterol, inhalation solution, FDA-approved final
unit dose, 0.5 mg
1/1/2007
43034txt.indd 86
Action
A=Addition
D=Deletion
R=Revision
U pdat e
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2/19/07 1:44:46 PM
Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
R
J7620
Albuterol, up to 2.5 mg and ipratropium bromide, up to
0.5 mg, FDA-approved final product, non-compounded,
administered through DME
1/1/2007
R
J7622
Beclomethasone, inhalation solution, compounded product, administered through DME, unit dose form, per milligram
1/1/2007
R
J7624
Betamethasone, inhalation solution, compounded product,
1/1/2007
R
J7626
Budesonide, inhalation solution, FDA-approved final
unit dose form, up to 0.5 mg
1/1/2007
R
J7627
Budesonide, inhalation solution, compounded product,
administered through DME, unit dose form, up to 0.5 mg
1/1/2007
R
J7628
Bitolterol mesylate, inhalation solution, compounded
per milligram
1/1/2007
R
J7629
Bitolterol mesylate, inhalation solution, compounded
milligram
1/1/2007
R
J7633
Budesonide, inhalation solution, FDA-approved final
concentrated form, per 0.25 milligram
1/1/2007
R
J7635
Atropine, inhalation solution, compounded product,
milligram
1/1/2007
R
J7636
Atropine, inhalation solution, compounded product,
1/1/2007
R
J7637
Dexamethasone, inhalation solution, compounded product,
milligram
1/1/2007
R
J7638
Dexamethasone, inhalation solution, compounded product,
1/1/2007
R
J7640
Formoterol, inhalation solution, compounded product,
administered through DME, unit dose form, 12 micrograms
1/1/2007
R
J7641
Flunisolide, inhalation solution, compounded product,
administered through DME, unit dose, per milligram
1/1/2007
R
J7642
Glycopyrrolate, inhalation solution, compounded product,
milligram
1/1/2007
R
J7643
Glycopyrrolate, inhalation solution, compounded product,
1/1/2007
R
J7644
Ipratropium bromide, inhalation solution, FDA-approved
final product, non-compounded, administered through
DME, unit dose form, per milligram
1/1/2007
R
J7648
Isoetharine HCL, inhalation solution, FDA-approved final
concentrated form, per milligram
1/1/2007
R
J7649
Isoetharine HCL, inhalation solution, FDA-approved final
unit dose form, per milligram
1/1/2007
R
J7658
Isoproterenol HCL, inhalation solution, FDA-approved final
concentrated form, per milligram
1/1/2007
43034txt.indd 87
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HCPCS Code
Narrative
Effective Date
of Revision/
Addition
R
J7659
Isoproterenol HCL, inhalation solution, FDA-approved final
unit dose form, per milligram
1/1/2007
R
J7668
Metaproterenol sulfate, inhalation solution, FDA-approved
DME, concentrated form, per 10 milligrams
1/1/2007
R
J7669
Metaproterenol sulfate, inhalation solution, FDA-approved
DME, unit dose form, per 10 milligrams
1/1/2007
R
J7680
Terbutaline sulfate, inhalation solution, compounded
per milligram
1/1/2007
R
J7681
Terbutaline sulfate, inhalation solution, compounded
milligram
1/1/2007
R
J7682
Tobramycin, inhalation solution, FDA-approved final
product, non-compounded, unit dose form, administered
through DME, per 300 milligrams
1/1/2007
R
J7683
Triamcinolone, inhalation solution, compounded product,
milligram
1/1/2007
R
J7684
Triamcinolone, inhalation solution, compounded product,
1/1/2007
R
L0631
Lumbar-sacral orthosis, sagittal control, with rigid
anterior and posterior panels, posterior extends from
sacrococcygeal junction to T-9 vertebra, produces
intracavitary pressure to reduce load on the intervertebral
discs, includes straps, pendulous abdomen design,
closures, may include padding, shoulder straps, pendulous
abdomen design, prefabricated, includes fitting and
adjustment
1/1/2007
R
L5848
Addition to endoskeletal knee-shin system, hydraulic fluid
stance extension, dampening feature, with or without
adjustability
1/1/2007
R
L5995
other than foot or knee, (for patient weight greater than
300 lbs)
1/1/2007
R
L6805
Addition to terminal device, modifier wrist unit
1/1/2007
R
L6810
Addition to terminal device, Pincher tool, Otto Bock or
equal precision pinch device
1/1/2007
R
L6881
Automatic grasp feature, addition to upper limb electric
prosthetic terminal device
1/1/2007
R
L6884
Replacement socket, above elbow/elbow disarticulation,
molded to patient model, for use with or without external
power
1/1/2007
R
L7040
Prehensile actuator, Hosmer or equal switch controlled
1/1/2007
R
L7045
Electric hook, child, Michigan or equal switch or
myoelectric controlled, pediatric
1/1/2007
R
L8614
Cochlear device/system, includes all internal and external
components
1/1/2007
R
L8689
External recharging system for implanted battery (internal)
for use with implantable neurostimulator, replacement only
1/1/2007
43034txt.indd 88
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D=Deletion
R=Revision
U pdat e
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Action
A=Addition
D=Deletion
R=Revision
HCPCS CODES
HCPCS Code
Effective Date
of Revision/
Addition
R
P9011
Blood, split unit
1/1/2007
R
S1040
Cranial remolding orthosis, pediatric, rigid, with soft
interface material, custom fabricated, includes fitting and
adjustment(s)
1/1/2007
R
S2260
Induced abortion, 17 to 24 weeks, any surgical method
1/1/2007
R
S2265
Induced abortion for fetal indication, 25 to 28 weeks
1/1/2007
R
S2266
Induced abortion for fetal indication, 29 to 31 weeks
1/1/2007
R
S2267
Induced abortion for fetal indication, 32 weeks or greater
1/1/2007
R
T5001
Positioning seat for persons with special orthopedic needs,
for use in vehicles
1/1/2007
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ICD-9 CM
Code
Narrative
43034txt.indd 90
Effective
Date of
Revision /
Addition
A
V18.51
Family history, colonic polyps
10/1/2006
A
V18.59
Family history, other digestive disorders
10/1/2006
A
V26.34
Testing of male for genetic disease carrier status
10/1/2006
A
V26.35
Encounter for testing of male partner of habitual aborter
10/1/2006
A
V26.39
Other genetic testing of male
10/1/2006
A
V45.86
Bariatric surgery status
10/1/2006
A
V58.30
Encounter for change or removal of nonsurgical wound
dressing
10/1/2006
A
V58.31
Encounter for change or removal of surgical wound
dressing
10/1/2006
A
V58.32
Encounter for removal of sutures
10/1/2006
A
V72.11
Encounter for hearing examination following failed hearing
screening
10/1/2006
A
V72.19
Other examination of ears and hearing
10/1/2006
A
V82.71
Screening for genetic disease carrier status
10/1/2006
A
V82.79
Other genetic screening
10/1/2006
A
V85.51
Body mass index, pediatric, less than 5th percentile for
age
10/1/2006
A
V85.52
Body mass index, pediatric, 5th percentile to less than
85th percentile for age
10/1/2006
A
V85.53
Body mass index, pediatric, 85th percentile to less than
95th percentile for age
10/1/2006
A
V85.54
Body mass index, pediatric, greater than or equal to 95th
percentile for age
10/1/2006
A
V86.0
Estrogen receptor positive status [ER+]
10/1/2006
A
V86.1
Estrogen receptor negative status [ER-]
10/1/2006
A
052.2
Postvaricella myelitis
10/1/2006
A
053.14
Herpes zoster myelitis
10/1/2006
A
054.74
Herpes simplex myelitis
10/1/2006
A
238.71
Essential thrombocythemia
10/1/2006
A
238.72
Low grade myelodysplastic syndrome lesions
10/1/2006
A
238.73
High grade myelodysplastic syndrome lesions
10/1/2006
A
238.74
Myelodysplastic syndrome with 5q deletion
10/1/2006
A
238.75
Myelodysplastic syndrome, unspecified
10/1/2006
A
238.76
Myelofibrosis with myeloid metaplasia
10/1/2006
A
238.79
Other lymphatic and hematopoietic tissues
10/1/2006
A
277.30
Amyloidosis, unspecified
10/1/2006
A
277.31
Familial Mediterranean fever
10/1/2006
A
277.39
Other amyloidosis
10/1/2006
A
284.01
Constitutional red blood cell aplasia
10/1/2006
A
284.09
Other constitutional aplastic anemia
10/1/2006
A
284.1
Pancytopenia
10/1/2006
A
284.2
Myelophthisis
10/1/2006
A
288.00
Neutropenia, unspecified
10/1/2006
C o mp e ndium ICD-9 CM CODES
Action
A=Addition
D=Deletion
R-Revision
U pdat e
Delete Date
2/19/07 1:44:48 PM
Action
A=Addition
D=Deletion
R-Revision
ICD-9 CM CODES
ICD-9 CM
Code
A
288.01
Congenital neutropenia
10/1/2006
A
288.02
Cyclic neutropenia
10/1/2006
A
288.03
Drug induced neutropenia
10/1/2006
A
288.04
Neutropenia due to infection
10/1/2006
A
288.09
Other neutropenia
10/1/2006
A
288.4
Hemophagocytic syndromes
10/1/2006
A
288.50
Leukocytopenia, unspecified
10/1/2006
A
288.51
Lymphocytopenia
10/1/2006
A
288.59
Other decreased white blood cell count
10/1/2006
A
288.60
Leukocytosis, unspecified
10/1/2006
A
288.61
Lymphocytosis (symptomatic)
10/1/2006
A
288.62
Leukemoid reaction
10/1/2006
A
288.63
Monocytosis (symptomatic)
10/1/2006
A
288.64
Plasmacytosis
10/1/2006
A
288.65
Basophilia
10/1/2006
A
288.69
Other elevated white blood cell count
10/1/2006
A
289.53
Neutropenic splenomegaly
10/1/2006
A
289.83
Myelofibrosis
10/1/2006
A
323.01
Encephalitis and encephalomyelitis in viral diseases
classified elsewhere
10/1/2006
A
323.02
Myelitis in viral diseases classified elsewhere
10/1/2006
A
323.41
Other encephalitis and encephalomyelitis due to infection
classified elsewhere
10/1/2006
A
323.42
Other myelitis due to infection classified elsewhere
10/1/2006
A
323.51
Encephalitis and encephalomyelitis following immunization
procedures
10/1/2006
A
323.52
Myelitis following immunization procedures
10/1/2006
A
323.61
Infectious acute disseminated encephalomyelitis (ADEM)
10/1/2006
A
323.62
Other postinfectious encephalitis and encephalomyelitis
10/1/2006
A
323.63
Postinfectious myelitis
10/1/2006
A
323.71
Toxic encephalitis and encephalomyelitis
10/1/2006
A
323.72
Toxic myelitis
10/1/2006
A
323.81
Other causes of encephalitis and encephalomyelitis
10/1/2006
A
323.82
Other causes of myelitis
10/1/2006
A
331.83
Mild cognitive impairment, so stated
10/1/2006
A
333.71
Athetoid cerebral palsy
10/1/2006
A
333.72
Acute dystonia due to drugs
10/1/2006
A
333.79
Other acquired torsion dystonia
10/1/2006
A
333.85
Subacute dyskinesia due to drugs
10/1/2006
A
333.94
Restless legs syndrome (RLS)
10/1/2006
A
338.0
Central pain syndrome
10/1/2006
A
338.11
Acute pain due to trauma
10/1/2006
A
338.12
Acute post-thoracotomy pain
10/1/2006
43034txt.indd 91
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ICD-9 CM
Code
Narrative
43034txt.indd 92
Effective
Date of
Revision /
Addition
A
338.18
Other acute postoperative pain
10/1/2006
A
338.19
Other acute pain
10/1/2006
A
338.21
Chronic pain due to trauma
10/1/2006
A
338.22
Chronic post-thoracotomy pain
10/1/2006
A
338.28
Other chronic postoperative pain
10/1/2006
A
338.29
Other chronic pain
10/1/2006
A
338.3
Neoplasm related pain (acute) (chronic)
10/1/2006
A
338.4
Chronic pain syndrome
10/1/2006
A
341.20
Acute (transverse) myelitis nos
10/1/2006
A
341.21
Acute (transverse) myelitis in conditions classified
elsewhere
10/1/2006
A
341.22
Idiopathic transverse myelitis
10/1/2006
A
377.43
Optic nerve hypoplasia
10/1/2006
A
379.60
Inflammation (infection) of postprocedural bleb, unspecified
10/1/2006
A
379.61
Inflammation (infection) of postprocedural bleb, stage 1
10/1/2006
A
379.62
10/1/2006
A
379.63
10/1/2006
A
389.15
Sensorineural hearing loss, unilateral
10/1/2006
A
389.16
Sensorineural hearing loss, asymmetrical
10/1/2006
A
429.83
Takotsubo syndrome
10/1/2006
A
478.11
Nasal mucositis (ulcerative)
10/1/2006
A
478.19
Other disease of nasal cavity and sinuses
10/1/2006
A
518.7
Transfusion related acute lung injury (TRALI)
10/1/2006
A
519.11
Acute bronchospasm
10/1/2006
A
519.19
Other diseases of trachea and bronchus
10/1/2006
A
521.81
Cracked tooth
10/1/2006
A
521.89
Other specific diseases of hard tissues of teeth
10/1/2006
A
523.00
Acute gingivitis, plaque induced
10/1/2006
A
523.01
Acute gingivitis, non-plaque induced
10/1/2006
A
523.10
Chronic gingivitis, plaque induced
10/1/2006
A
523.11
Chronic gingivitis, non-plaque induced
10/1/2006
A
523.30
Aggressive periodontitis, unspecified
10/1/2006
A
523.31
Aggressive periodontitis, localized
10/1/2006
A
523.32
Aggressive periodontitis, generalized
10/1/2006
A
523.33
Acute periodontitis
10/1/2006
A
523.40
Chronic periodontitis, unspecified
10/1/2006
A
523.41
Chronic periodontitis, localized
10/1/2006
A
523.42
Chronic periodontitis, generalized
10/1/2006
A
525.60
Unspecified unsatisfactory restoration of tooth
10/1/2006
A
525.61
Open restoration margins
10/1/2006
A
525.62
Unrepairable overhanging of dental restorative materials
10/1/2006
Action
A=Addition
D=Deletion
R-Revision
U pdat e
Delete Date
2/19/07 1:44:49 PM
Action
ICD-9 CM CODES
A=Addition
D=Deletion
R-Revision
ICD-9 CM
Code
A
525.63
A
Fractured dental restorative material without loss of
material
10/1/2006
525.64
Fractured dental restorative material with loss of material
10/1/2006
A
525.65
Contour of existing restoration of tooth biologically
incompatible with oral health
10/1/2006
A
525.66
Allergy to existing dental restorative material
10/1/2006
A
525.67
Poor aesthetics of existing restoration
10/1/2006
A
525.69
Other unsatisfactory restoration of existing tooth
10/1/2006
A
526.61
Perforation of root canal space
10/1/2006
A
526.62
Endodontic overfill
10/1/2006
A
526.63
Endodontic underfill
10/1/2006
A
526.69
Other periradicular pathology associated with previous
endodontic treatment
10/1/2006
A
528.00
Stomatitis and mucositis, unspecified
10/1/2006
A
528.01
Mucositis (ulcerative) due to antineoplastic therapy
10/1/2006
A
528.02
Mucositis (ulcerative) due to other drugs
10/1/2006
A
528.09
Other stomatitis and mucositis (ulcerative)
10/1/2006
A
538
Gastrointestinal mucositis (ulcerative)
10/1/2006
A
608.20
Torsion of testis, unspecified
10/1/2006
A
608.21
Extravaginal torsion of spermatic cord
10/1/2006
A
608.22
Intravaginal torsion of spermatic cord
10/1/2006
A
608.23
Torsion of appendix testis
10/1/2006
A
608.24
Torsion of appendix epididymis
10/1/2006
A
616.81
Mucositis (ulcerative) of cervix, vagina, and vulva
10/1/2006
A
616.89
Other inflammatory disease of cervix, vagina and vulva
10/1/2006
A
618.84
Cervical stump prolapse
10/1/2006
A
629.29
Other female genital mutilation status
10/1/2006
A
629.81
Habitual aborter without current pregnancy
10/1/2006
A
629.89
Other specified disorders of female genital organs
10/1/2006
A
649.00
Tobacco use disorder complicating pregnancy, childbirth,
or the puerperium, unspecified as to episode of care or not
applicable
10/1/2006
A
649.01
or the puerperium, delivered, with or without mention of
antepartum condition
10/1/2006
A
649.02
or the puerperium, delivered, with mention of postpartum
complication
10/1/2006
A
649.03
or the puerperium, antepartum condition or complication
10/1/2006
A
649.04
or the puerperium, postpartum condition or complication
10/1/2006
A
649.10
Obesity complicating pregnancy, childbirth, or the
puerperium, unspecified as to episode of care or not
applicable
10/1/2006
43034txt.indd 93
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Date of
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Addition
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93
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U pdat e
ICD-9 CM CODES
Action
Effective
Date of
Revision /
Addition
A=Addition
D=Deletion
R-Revision
ICD-9 CM
Code
A
649.11
puerperium, delivered, with or without mention of
10/1/2006
A
649.12
puerperium, delivered, with mention of postpartum
complication
10/1/2006
A
649.13
puerperium, antepartum condition or complication
10/1/2006
A
649.14
puerperium, postpartum condition or complication
10/1/2006
A
649.20
Bariatric surgery status complicating pregnancy, childbirth,
or the puerperium, unspecified as to episode of care or not
applicable
10/1/2006
A
649.21
10/1/2006
A
649.22
complication
10/1/2006
A
649.23
or the puerperium, antepartum condition or complication
10/1/2006
A
649.24
or the puerperium, postpartum condition or complication
10/1/2006
A
649.30
Coagulation defects complicating pregnancy, childbirth, or
the puerperium, unspecified as to episode of care or not
applicable
10/1/2006
A
649.31
Coagulation defects complicating pregnancy, childbirth,
10/1/2006
A
649.32
Coagulation defects complicating pregnancy, childbirth,
complication
10/1/2006
A
649.33
the puerperium, antepartum condition or complication
10/1/2006
A
649.34
the puerperium, postpartum condition or complication
10/1/2006
A
649.40
Epilepsy complicating pregnancy, childbirth, or the
puerperium, unspecified as to episode of care or not
applicable
10/1/2006
A
649.41
puerperium, delivered, with or without mention of
10/1/2006
A
649.42
puerperium, delivered, with mention of postpartum
complication
10/1/2006
A
649.43
puerperium, antepartum condition or complication
10/1/2006
A
649.44
puerperium, postpartum condition or complication
10/1/2006
A
649.50
Spotting complicating pregnancy, unspecified as to
episode of care or not applicable
10/1/2006
Narrative
43034txt.indd 94
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Action
ICD-9 CM CODES
ICD-9 CM
Code
A
649.51
Spotting complicating pregnancy, delivered, with or
without mention of antepartum condition
10/1/2006
A
649.53
Spotting complicating pregnancy, antepartum condition or
complication
10/1/2006
A
649.60
Uterine size date discrepancy, unspecified as to episode of
care or not applicable
10/1/2006
A
649.61
Uterine size date discrepancy, delivered, with or without
mention of antepartum condition
10/1/2006
A
649.62
Uterine size date discrepancy, delivered, with mention of
postpartum complication
10/1/2006
A
649.63
Uterine size date discrepancy, antepartum condition or
complication
10/1/2006
A
649.64
Uterine size date discrepancy, postpartum condition or
complication
10/1/2006
A
729.71
Nontraumatic compartment syndrome of upper extremity
10/1/2006
A
729.72
Nontraumatic compartment syndrome of lower extremity
10/1/2006
A
729.73
Nontraumatic compartment syndrome of abdomen
10/1/2006
A
729.79
Nontraumatic compartment syndrome of other sites
10/1/2006
A
731.3
Major osseous defects
10/1/2006
A
768.7
Hypoxic-ischemic encephalopathy (HIE)
10/1/2006
A
770.87
Respiratory arrest of newborn
10/1/2006
A
770.88
Hypoxemia of newborn
10/1/2006
A
775.81
Other acidosis of newborn
10/1/2006
A
775.89
Other neonatal endocrine and metabolic disturbances
10/1/2006
A
779.85
Cardiac arrest of newborn
10/1/2006
A
780.32
Complex febrile convulsions
10/1/2006
A
780.96
Generalized pain
10/1/2006
A
780.97
Altered mental status
10/1/2006
A
784.91
Postnasal drip
10/1/2006
A
784.99
Other symptoms involving head and neck
10/1/2006
A
788.64
Urinary hesitancy
10/1/2006
A
788.65
Straining on urination
10/1/2006
A
793.91
Image test inconclusive due to excess body fat
10/1/2006
A
793.99
Other nonspecific abnormal findings on radiological and
other examinations of body structure
10/1/2006
A
795.06
Papanicolaou smear of cervix with cytologic evidence of
malignancy
10/1/2006
A
795.81
Elevated carcinoembryonic antigen [CEA]
10/1/2006
A
795.82
Elevated cancer antigen 125 [CA 125]
10/1/2006
A
795.89
Other abnormal tumor markers
10/1/2006
A
958.90
Compartment syndrome, unspecified
10/1/2006
A
958.91
Traumatic compartment syndrome of upper extremity
10/1/2006
A
958.92
Traumatic compartment syndrome of lower extremity
10/1/2006
A
958.93
Traumatic compartment syndrome of abdomen
10/1/2006
43034txt.indd 95
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D=Deletion
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U pdat e
ICD-9 CM CODES
Action
C o mp e ndium Effective
Date of
Revision /
Addition
A=Addition
D=Deletion
R-Revision
ICD-9 CM
Code
A
958.99
Traumatic compartment syndrome of other sites
10/1/2006
A
995.20
Unspecified adverse effect of unspecified drug, medicinal
and biological substance
10/1/2006
A
995.21
Arthus phenomenon
10/1/2006
A
995.22
Unspecified adverse effect of anesthesia
10/1/2006
A
995.23
Unspecified adverse effect of insulin
10/1/2006
A
995.27
Other drug allergy
10/1/2006
A
995.29
Unspecified adverse effect of other drug, medicinal and
biological substance
10/1/2006
D
V18.5 Family history of digestive disorders
10/1/2006
D
V58.3 Attention to dressings and sutures
10/1/2006
D
V72.1
Examination of ears and hearing
10/1/2006
D
238.7
Neoplasm of uncertain behavior of other lymphatic and
hematopoietic tissues
10/1/2006
D
277.3
Amyloidosis
10/1/2006
D
284.0
Constitutional aplastic anemia
10/1/2006
D
288.0
Aplastic anemia and other bone marrow failure syndromes
10/1/2006
D
323.0
Encephalitis, myelitis, and encephalomyelitis in viral
diseases classified elsewhere
10/1/2006
D
323.4
Other encephalitis due to infection classified elsewhere
10/1/2006
D
323.5
Encephalitis, myelitis, and encephalomyelitis following
immunization procedures
10/1/2006
D
323.6
Postinfectious encephalitis, myelitis, and encephalomyelitis
10/1/2006
D
323.7
Toxic encephalitis, myelitis, and encephalomyelitis
10/1/2006
D
323.8
Other causes of encephalitis, myelitis, and
encephalomyelitis
10/1/2006
D
333.7
Acquired torsion dystonia
10/1/2006
D
478.1
Other diseases of nasal cavity and sinuses
10/1/2006
D
519.1
Other diseases of trachea and bronchus, not elsewhere
classified
10/1/2006
D
521.8
Other specified diseases of hard tissues of teeth
10/1/2006
D
523.0
Acute gingivitis
10/1/2006
D
523.1
Chronic gingivitis
10/1/2006
D
523.3
Aggressive and acute periodontitis
10/1/2006
D
523.4
Chronic periodontitis
10/1/2006
D
528.0
Stomatitis and mucositis (ulcerative)
10/1/2006
D
608.2
Torsion of testis
10/1/2006
D
616.8
Other specified inflammatory disease of cervix, vagina,
and vulva
10/1/2006
D
629.8
Other specified disorder of female genital organs
10/1/2006
D
775.8
Other neonatal endocrine and metabolic disturbances
10/1/2006
D
784.9
Other symptoms involving head and neck
10/1/2006
D
793.9
Nonspecific abnormal findings on radiological and other
examination of other site of body
10/1/2006
Narrative
43034txt.indd 96
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Action
ICD-9 CM CODES
ICD-9 CM
Code
D
995.2
R
255.10
Hyperaldosteronism, unspecified
10/1/2006
R
285.29
Anemia of other chronic disease
10/1/2006
R
323.1
Encephalitis, myelitis, and encephalomyelitis in rickettsial
10/1/2006
R
323.2
Encephalitis, myelitis, and encephalomyelitis in protozoal
10/1/2006
R
323.9
Unspecified cause of encephalitis, myelitis, and
encephalomyelitis
10/1/2006
R
333.6
Genetic torsion dystonia
10/1/2006
R
345.40
Localization-related (focal) (partial) epilepsy and epileptic
syndromes with complex partial seizures without mention
of intractable epilepsy
10/1/2006
R
345.41
syndromes with complex partial seizures with intractable
epilepsy
10/1/2006
R
345.50
syndromes with simple partial seizures without mention of
intractable epilepsy
10/1/2006
R
345.51
syndromes with simple partial seizures with intractable
epilepsy
10/1/2006
R
345.80
Other forms of epilepsy and recurrent seizures without
mention of intractable epilepsy
10/1/2006
R
345.81
Other forms of epilepsy and recurrent seizures, with
intractable epilepsy
10/1/2006
R
389.11
Sensory hearing loss, bilateral
10/1/2006
R
389.12
Neural hearing loss, bilateral
10/1/2006
R
389.14
Central hearing loss, bilateral
10/1/2006
R
389.18
Sensorineural hearing loss of combined types, bilateral
10/1/2006
R
403.00
Hypertensive chronic kidney disease, malignant, with
chronic kidney disease stage I through stage IV, or
unspecified
10/1/2006
R
403.10
Hypertensive chronic kidney disease, benign, with chronic
kidney disease stage V or end stage renal disease
10/1/2006
R
403.90
Hypertensive chronic kidney disease, unspecified, with
chronic kidney disease stage I through stage IV, or
unspecified
10/1/2006
R
403.91
Hypertensive chronic kidney disease, unspecified, with
chronic kidney disease stage V or end stage renal disease
10/1/2006
R
404.00
Hypertensive heart and chronic kidney disease, malignant,
without heart failure and with chronic kidney disease stage
I through stage IV, or unspecified
10/1/2006
R
404.01
with heart failure and with chronic kidney disease stage I
through stage IV, or unspecified
10/1/2006
R
404.02
V or end stage renal disease
10/1/2006
43034txt.indd 97
Effective
Date of
Revision /
Addition
A=Addition
D=Deletion
R-Revision
Narrative
Other and unspecified adverse effect of drug, medicinal
and biological substance
Delete Date
10/1/2006
97
2/19/07 1:44:52 PM
Narrative
Effective
Date of
Revision /
Addition
404.03
with heart failure and with chronic kidney disease stage V
or end stage renal disease
10/1/2006
R
404.10
Hypertensive heart and chronic kidney disease, benign,
I through stage IV, or unspecified
10/1/2006
R
404.11
with heart failure and with chronic kidney disease stage I
through stage IV, or unspecified
10/1/2006
R
404.12
V or end stage renal disease
10/1/2006
R
404.13
with heart failure and with chronic kidney disease stage V
or end stage renal disease
10/1/2006
R
404.90
Hypertensive heart and chronic kidney disease,
unspecified, without heart failure and with chronic kidney
disease stage I through stage IV, or unspecified
10/1/2006
R
404.91
unspecified, with heart failure and with chronic kidney
disease stage I through stage IV, or unspecified
10/1/2006
R
404.92
unspecified, without heart failure and with chronic kidney
disease stage V or end stage renal disease
10/1/2006
R
404.93
unspecified, with heart failure and with chronic kidney
disease stage V or end stage renal disease
10/1/2006
R
524.21
Malocclusion, angle’s class I
10/1/2006
R
524.22
Malocclusion, angle’s class II
10/1/2006
R
524.23
Malocclusion, angle’s class III
10/1/2006
R
524.35
Rotation of tooth/teeth
10/1/2006
R
600.00
Hypertrophy (benign) of prostate without urinary
obstruction and other lower urinary tract symptoms (LUTS)
10/1/2006
R
600.01
Hypertrophy (benign) of prostate with urinary obstruction
and other lower urinary tract symptoms (LUTS)
10/1/2006
R
600.20
Benign localized hyperplasia of prostate without urinary
10/1/2006
R
600.21
Benign localized hyperplasia of prostate with urinary
10/1/2006
R
600.90
Hyperplasia of prostate, unspecified, without urinary
obstruction and other lower urinary symptoms (LUTS)
10/1/2006
R
600.91
Hyperplasia of prostate, unspecified, with urinary
obstruction and other lower urinary symptoms (LUTS)
10/1/2006
R
768.3
Fetal distress first noted during labor and delivery, in
liveborn infant
10/1/2006
R
780.31
Febrile convulsions (simple), unspecified
10/1/2006
R
780.95
Excessive crying of child, adolescent, or adult
10/1/2006
R
873.63
Tooth (broken) (fractured) (due to trauma), without mention
of complication
10/1/2006
R
873.73
Tooth (broken) (fractured) (due to trauma), complicated
10/1/2006
Action
A=Addition
D=Deletion
R-Revision
ICD-9 CM
Code
R
43034txt.indd 98
U pdat e
Delete Date
2/19/07 1:44:53 PM
Action
ICD-9 CM CODES
ICD-9 CM
Code
R
995.91
Sepsis
10/1/2006
R
995.92
Severe sepsis
10/1/2006
R
995.93
Systemic inflammatory response syndrome due to
noninfectious process without acute organ dysfunction
10/1/2006
R
995.94
Systemic inflammatory response syndrome due to
noninfectious process with acute organ dysfunction
10/1/2006
R
V26.31
Testing of female for genetic disease carrier status
10/1/2006
R
V26.32
Other genetic testing of female
10/1/2006
43034txt.indd 99
Effective
Date of
Revision /
Addition
A=Addition
D=Deletion
R-Revision
Narrative
Delete Date
99
2/19/07 1:44:53 PM
U pdat e
C o mp e ndium NOTES
43034txt.indd 100
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Partners in Health Update - March 2007 (IBC)

Transcription

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