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Codes That Do Not Meet Payment Determination Criteria

 


The following table lists the codes for services that do not meet payment determination criteria. If criteria for the use of modifier code GA are met, GA should be appended when billing for the services listed. See Modifier Code GA.

 

Table I. CPT Codes

CPT Codes

Description

0351T Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative
0352T Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen, interpretation and report, real time or referred
0353T Optical coherence tomography of breast, surgical cavity; real time intraoperative
0354T Optical coherence tomography of breast, surgical cavity; interpretation and report, real time intraoperative
0355T Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report
0356T Insertion of drug-eluting implant (including puntal dilation and implant removal when performed) into lacrimal canaliculus, each
0358T Biolectrical impedance analysis whole body composition assessment, supine position, with interpretation and report
0359T Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and caregiver(s), includes administration of standardization and non-standardization tests, detailed behavioral history, patient observational
0360T Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient
0361T Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient
0362T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more tec
0363T Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more tec
0509T Electroretinography (erg) with interpretation and report, pattern (perg)
0512T, 0513T Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound
0514T Intraoperative visual axis identification using patient fixation (list separately in addition to code for primary procedure)
0045U Oncology (breast ductal carcinoma in situ), mrna, gene expression profiling by real- time rt-pcr of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score
0047U Oncology (prostate), mrna, gene expression profiling by real-time rt-pcr of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score
0048U Oncology (solid organ neoplasia), dna, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s)
0051U Prescription drug monitoring, evaluation of drugs present by lc-ms/ms, urine, 31 drug panel, reported as quantitative results, detected or not detected, per date of service   
0052U Lipoprotein, blood, high resolution fractionation and quantitation of lipoproteins, including all five major lipoprotein classes and subclasses of hdl, ldl, and vldl by vertical auto profile ultracentrifugation
0054U Prescription drug monitoring, 14 or more classes of drugs and substances, definitive tandem mass spectrometry with chromatography, capillary blood, quantitative report with therapeutic and toxic ranges, including steady-state range for the prescribed dose when detected, per date of service
0057U Oncology (solid organ neoplasia), mrna, gene expression profiling by massively parallel sequencing for analysis of 51 genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as a normalized percentile rank
0061U Transcutaneous measurement of five biomarkers (tissue oxygenation [sto2], oxyhemoglobin [cthbo2], deoxyhemoglobin [cthbr], papillary and reticular dermal hemoglobin concentrations [cthb1 and cthb2]), using spatial frequency domain imaging (sfdi) and multi-spectral analysis
0067U Oncology (breast), immunohistochemistry, protein expression profiling of 4 biomarkers (matrix metalloproteinase-1 [mmp-1], carcinoembryonic antigen-related cell adhesion molecule 6 [ceacam6], hyaluronoglucosaminidase [hyal1], highly expressed in cancer protein [hec1]), formalin-fixed paraffin-embedded precancerous breast tissue, algorithm reported as carcinoma risk score
0068U Candida species panel (c. Albicans, c. Glabrata, c. Parapsilosis, c. Kruseii, c tropicalis, and c. Auris), amplified probe technique with qualitative report of the presence or absence of each species
0078U Pain management (opioid-use disorder) genotyping panel, 16 common variants (ie, ABCB1, COMT, DAT1, DBH, DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OPRM1), buccal swab or other germline tissue sample, algorithm reported as positive or negative risk of opioid-use disorder
15775 Punch graft for hair transplant; 1 to 15 punch grafts
15776

more than 15 punch grafts

15879 Suction assisted lipectomy; lower extremity
19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma
20932 Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (list separately in addition to code for primary procedure)
20933 Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (list separately in addition to code for primary procedure)
20934 Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (list separately in addition to code for primary procedure)
20939 Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (list separately in addition to code for primary procedure)
20983 Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation
22505 Manipulation of spine requiring anesthesia, any region, effective 5/1/11
22586

Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, l5-s1 interspace

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

22857

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

22862

Revision including replacement of total disc arthroplasty (artificial disc) anterior approach, lumbar, single interspace

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

22865

Removal of total disc arthroplasty (artificial disc), anterior approach, lumbar, single interspace

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

22867 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level
22868 Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure)
22869 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level
22870 Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure)
24370 Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component
24371 Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component
27279 Sacroiliac joint percutaneous or minimally invasive (indirect visualization) with image guidance includes obtaining bone graft when performed and placement of transfixing device
28890 Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia
31647 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), initial lobe
31648 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve(s), initial lobe
31649 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal of bronchial valve(s), each additional lobe (list separately in addition to code for primary procedure)
31651 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), each additional lobe (list separately in addition to code for primary procedure[s])
33265 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without cardiopulmonary bypass
33266 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary bypass
33990

Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; arterial access only

For more detailed information, please see associated medical policy Implantable Ventricular Assist Devices and Total Artificial Hearts

33991

Insertion of ventricular assist device, percutaneous including radiological supervision and interpretation; both arterial and venous access, with transseptal puncture

For more detailed information, please see associated medical policy Implantable Ventricular Assist Devices and Total Artificial Hearts

33992

Removal of percutaneous ventricular assist device at separate and distinct session from insertion

For more detailed information, please see associated medical policy Implantable Ventricular Assist Devices and Total Artificial Hearts

33993

Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion.

For more detailed information, please see associated medical policy Implantable Ventricular Assist Devices and Total Artificial Hearts

37788

Penile revascularization, artery, with or without vein graft

For more detailed information, please see associated medical policy Erectile Dysfunction

37790

Penile venous occlusive procedure

For more detailed information, please see associated medical policy Erectile Dysfunction

43197 Flexible transnasal esophagoscopy
43198 Flexible transnasal esophagoscopy
43210 Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed
43257 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease
43284 Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie. Magnetic band), including curoplasty when performed
43285 Removal of esophageal sphincter augmentation device
46707 Repair of anorectal fistula with plug (e.g., porcine small intestine submucosa (SIS). Note: this code replaces 0170T
47383 Ablation, 1 or more liver tumor(s), percutaneous, cryoablation
53855 Insertion of a temporary prostatic urethral stent, including urethral measurement Note: this code replaces 0084T
53860 Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
61870 Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical
62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar
62380 Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar
64580 Incision for implantation of neurostimulator electrodes; neuromuscular
64910 Nerve repair; with synthetic conduit or vein allograft (e.g., nerve tube), each nerve
64911 With autogenous vein graft (includes harvest of vein graft), each nerve
64912 Nerve repair; with nerve allograft, each nerve, first strand (cable)
64913 Nerve repair; with nerve allograft, each additional strand (list separately in addition to code for primary procedure)
75571 Cardiac computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium Note: this code replaces 0144T
81226 CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN)
81227 CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6) used in warfarin testing
81283 IFNL3 (Interferon, lambda 3) (eg, drug response), gene analysis, RS12979860 variant
81291 MTHFR (5, 10-methylenetetrahydrofolate reductase) (e.g., hereditary hypercoagulability) gene analysis, common variants (e.g., 677T, 1298C)
81327 SEPT9 (Septin9) (eg, colorectal cancer) methylation analysis
81328 SLCO1B1 (Solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (EG, *5)
81334 RUNX1 (Runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8)
81335 TPMT (Thiopurine S-Methyltransferase) (eg, drug metabolism), gene analysis, common variants (EG, *2, *3)
81350 UGT1A1 (UDP Glucuronosyltransferase 1 family, polypeptide A1) (e.g., irinotecan metabolism), gene analysis, common variants (e.g., *28, *36)
81346 TYMS (Thymidylate Synthetase) (eg, 5-Fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant)
81355 VKORC1 (vitamin K epoxide reductase complex, subunit 1) (e.g., warfarin metabolism), gene analysis, common variants (e.g., -1639/3673)
81443 Genetic testing for severe inherited conditions (eg, cystic fibrosis, ashkenazi jewish-associated disorders [eg, bloom syndrome, canavan disease, fanconi anemia type c, mucolipidosis type vi, gaucher disease, tay-sachs disease], beta hemoglobinopathies, phenylketonuria, galactosemia), genomic sequence analysis panel, must include sequencing of at least 15 genes (eg, acadm, arsa, aspa, atp7b, bckdha, bckdhb, blm, cftr, dhcr7, fancc, g6pc, gaa, galt, gba, gbe1, hbb, hexa, ikbkap, mcoln1, pah)
81448 Hereditary peripheral neuropathies (eg, Charcot-Marie-tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (EG, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1)
81490 Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score
81493 Coronary artery disease, mrna, gene expression profiling by real-time rt-pcr of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score
81504 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores
81506 Endocrinology (type 2 diabetes), biochemical assays of seven analytes (glucose, hba1c, insulin, hs-crp, adoponectin, ferritin, interleukin 2-receptor alpha), utilizing serum or plasma, algorithm reporting a risk score
81521 Oncology (breast), mrna, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis
81525 Oncology (colon), mrna, gene expression profiling by real-time rt-pcr of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score
81535 Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by dapi stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination
81536 Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by dapi stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination; each additional single drug or drug combination (list separately in addition to code for primary procedure)
81538 Oncology (lung), mass spectrometric 8-protein signature, including amyloid a, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival
81539 Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score
81540 Oncology (tumor of unknown origin), mrna, gene expression profiling by real-time rt-pcr of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype
81541 Oncology (prostate), mrna gene expression profiling by real-time rt-pcr of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score
81595 Cardiology (heart transplant), mrna, gene expression profiling by real-time quantitative pcr of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score
82172 Apolipoprotein, each (except when billed for hepatitis C)
83695 Lipoprotein (a)
83698

Lipoprotein-associated phospholipase A2 (Lp-PLA2)

For more detailed information, please see associated medical policy Measurement of Lipoprotein-Associated Phospholipase A2 (Lp-PLA2) in the Assessment of Cardiovascular Risk

83700 Lipoprotein, blood; electrophoretic separation and quantitation
83701

high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (e.g., electrophoresis, ultracentrifugation)

83704

quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (e.g., nuclear magnetic resonance spectroscopy)

83722 Lipoprotein, direct measurement; small dense ldl cholesterol
83876

Meyloperoxidase (MPO)

83951 Des-Gamma-Carboxy-Prothrombin (DCP)
83987 PH; exhaled breath condensate
84431 Thromboxane metabolite(s), including thromboxane if performed, urine
86141 C-reactive protein; high sensitivity (HSCRP)
86152

Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood);

For more detailed information, please see associated medical policy Genetic Testing of Inherited Cancer Predisposition

86153

Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required

For more detailed information, please see associated medical policy Genetic Testing of Inherited Cancer Predisposition

86305 Human epididymis protein 4 (HE4)
86343 Leukocyte histamine release test (LHR)
86352 Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP)
86490 Skin test; coccidioidomycosis
86510

histoplasmosis

87505 Infectious agent detection by nucleic acid (dna or rna); gastrointestinal pathogen (eg, clostridium difficile, e. Coli, salmonella, shigella, norovirus, giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets
87506 Infectious agent detection by nucleic acid (dna or rna); gastrointestinal pathogen (eg, clostridium difficile, e. Coli, salmonella, shigella, norovirus, giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets
87507 Infectious agent detection by nucleic acid (dna or rna); gastrointestinal pathogen (eg, clostridium difficile, e. Coli, salmonella, shigella, norovirus, giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets
87623 Infectious agent detection by nucleic acid (dna or rna); human papillomavirus (hpv), low-risk types (eg, 6, 11, 42, 43, 44)
87900 Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics
89329 Sperm evaluation; hamster penetration test
91111 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus with physician interpretation and report (effective 9/1/11)
91112 Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report
91200 Liver elastography, mechanically induced shear wave (eg, vibration), without imaging, with interpretation and report - (EXCEPT WHEN BILLED WITH HEPATITIS C)
92132 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral
92145 Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report
92512 Nasal function studies (e.g., rhinomanometry)
92548 Computerized dynamic posturography
93025 Microvolt T-wave alternans for assessment of ventricular arrhythmias
93050 Arterial pressure waveform analysis for assessment of central arterial pressures, includes obtaining waveform(s), digitization and application of nonlinear mathematical transformations to determine central arterial pressures and augmentation index, with interpretation and report, upper extremity artery, non-invasive
93228

External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real-time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query), with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report

For more detailed information, please see associated medical policy Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

93229

Technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports

For more detailed information, please see associated medical policy Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

93278 Signal-averaged electrocardiography (SAECG), with or without ECG
93702 Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s)
93895 Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral
94400 Breathing response to CO2 (CO2 response curve)
95012 Nitric oxide expired gas determination
95249 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; patient-provided equipment, sensor placement, hook-up, calibration of monitor, patient training, and printout of recording
95803 Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)
95924 Testing of an autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt.
95905 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed with interpretation and report
95961 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance
95962

each additional hour of physician attendance

95980 Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; intraoperative, with programming
95981

subsequent, without programming

95982

subsequent, with reprogramming

96000 Comprehensive computer-based motion analysis by video-taping and 3D kinematics
96001

with dynamic plantar pressure measurements during walking

96002 Dynamic surface electromyography, during walking or other functional activities, 1 to 12 muscles
96003 Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle
96004 Physician review & interpretation of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report
96931 Reflectance confocal microscopy (rcm) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion
96932 Reflectance confocal microscopy (rcm) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion
96934 Reflectance confocal microscopy (rcm) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (list separately in addition to code for primary procedure)
96935 Reflectance confocal microscopy (rcm) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (list separately in addition to code for primary procedure)
96936 Reflectance confocal microscopy (rcm) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (list separately in addition to code for primary procedure)
97610 Topical wound treatment with low frequency, non-contact, non-thermal ultrasound with wound assessment and instructions
99174 Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral
99177 Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis

 

Table II. HCPCS Codes

HCPCS Codes

Description

A4467 Belt, strap, sleeve, garment, or covering, any type​
A4555 Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only
A4670 Automatic blood pressure monitor
A6460 Synthetic resorbable wound dressing, sterile, pad size 16 sq. In. Or less, without adhesive border, each dressing
A6461 Synthetic resorbable wound dressing, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., without adhesive border, each dressing
A7047

Oral interface used with respiratory suction pump, each

For more detailed information, please see associated medical policy Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea

A9272 Wound suction, disposable, includes dressing, all accessories and components, any type, each
A9284 Spirometer, non-electronic, includes all accessories
A9586 Florbetapir F18, diagnostic, per study dose, up to 10 millicuries
A9599 Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (PET) imaging, per study dose
B4105 In-line cartridge containing digestive enzyme(s) for enteral feeding, each
C9354 Acellular pericardial tissue matrix of nonhuman origin (Veritas), per square centimeter
C9356 Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per square centimeter
C9358 Dermal substitute, native, non-denatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters
C9360 Dermal substitute, native, non-denatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters
C9363 Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter
C9364 Porcine implant, Permacol, per square centimeter
E0231 Noncontact wound warming device (temperature control unit, ac adapter and power cord) for use with warming card and wound cover
E0232 Warming card for use with the noncontact wound warming device and noncontact wound warming cover
E0446 Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories
E0487 Spirometer, electronic, includes all accessories
E0670 Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk
E0676 Intermittent limb compression device (includes all accessories) not otherwise specified
E0830 Ambulatory traction device, all types, each
E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface material
E1801 Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1802 Dynamic adjustable forearm pronation/supination device, includes soft interface material
E1805 Dynamic adjustable wrist extension/flexion device, includes soft interface material
E1806 Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1810 Dynamic adjustable knee extension/flexion device, includes soft interface material
E1811 Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1812 Dynamic knee extension/flexion device with active resistance control
E1815 Dynamic adjustable ankle extension/flexion device, includes soft interface material
E1816 Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1818 Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories
E1820 Replacement soft interface material, dynamic adjustable extension/flexion device
E1821 Replacement soft interface material/cuffs for bi-directional static progressive stretch device
E1825 Dynamic adjustable finger extension/flexion device, includes soft interface material
E1830 Dynamic adjustable toe extension/flexion device, includes soft interface material
E1831 Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
E1841 Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories
E2358 Power wheelchair accessory, group 34 nonsealed lead acid battery, each
E2360 Power wheelchair accessory, 22 NF nonsealed lead acid battery, each
E2362 Power wheelchair accessory, group 24 nonsealed lead acid battery, each
E2364 Power wheelchair accessory, U-1 nonsealed lead acid battery, each
E2372 Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only
G0166 External counterpulsation, per treatment session
G0249 Provision INR testing materials/equipment
G0250 Physician review, interpretation and patient management of home INR testing
G0259 Injection procedure for sacroiliac joint; arthrography
G0276 Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (pild) or placebo-control, performed in an approved coverage with evidence development (ced) clinical trial
G0281 Electrical stimulation, (unattended), to one or more areas, for chronic stage III & stage IV pressure ulcers, arterial ulcers, diabetic ulcers, & venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care
G0282 Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281
G0295 Electromagnetic therapy, to one or more areas, for wound care other than described in G0329, or for other uses
G0329 Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days on conventional care as part of a therapy plan of care
G0409 Social work and psychological services, directly relating to and/or furthering the patient's rehabilitation goals, each 15 minutes, face-to-face; individual (services provided by a CORF qualified social worker or psychologist in a CORF)
G0428 Collagen Meniscus Implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex)
G2000 Blinded administration of convulsive therapy procedure, either electroconvulsive therapy (ect, current covered gold standard) or magnetic seizure therapy (mst, non-covered experimental therapy), performed in an approved ide-based clinical trial, per treatment session
G9147 Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration
J3304 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg
J3530 Nasal vaccine inhalation
J3570 Laetrile, amygdalin, vitamin B-17
L5969 Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s)
L5973 Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source
L8608 Miscellaneous external component, supply or accessory for use with the argus ii retinal prosthesis system
L8701 Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
M0075 Cellular therapy
M0076 Prolotherapy
M0100 Intragastric hypothermia using gastric freezing
Q4103 Oasis Burn Matrix, per square centimeter
Q4104 Integra Bilayer Matrix Wound Dressing (BMWD), per square centimeter
Q4108 Integra Matrix, per square centimeter
Q4110 PriMatrix, per square centimeter
Q4111 GammaGraft, per square centimeter
Q4112 Cymetra, injectable, 1 cc
Q4113 Graftjacket Xpress, injectable, 1 cc
Q4114 Integra Flowable Wound Matrix, injectable, 1 cc
Q4115 AlloSkin, per square centimeter
Q4117 Hyalomatrix, per square centimeter
Q4118

Matristem micromatrix, per square centimeter

Q4121 Theraskin, per square centimeter
Q4123 Alloskin RT, per square centimeter
Q4125 Arthroflex, per square centimeter
Q4126 Memoderm, Dermaspan, Transgraft or Integuply, per square centimeter
Q4127 Talymed, per square centimeter
Q4128 Flex HD, Allopatch HD or Matrix HD, per square centimeter [when used for Allopatch HD or Matrix HD]
Q4134 hMatrix, per square centimeter
Q4135 Mediskin, per square centimeter
Q4136 EZ-derm, per square centimeter
Q4137 Amnioexcel or BioDExCel, per square centimeter
Q4138 Biodfence Dryflex, per square centimeter
Q4139 Amniomatrix or BioDMatrix, injectable, 1 cc
Q4140 Biodfence, per square centimeter
Q4141 Alloskin AC, per square centimeter
Q4142 Xcm biologic tissue matrix, per square centimeter
Q4143 Repriza, per square centimeter
Q4146 TenSIX, per square centimeter
Q4147 Architect, Architect PX, or Architect FX, extracellular matrix, per square
Q4148 Neox 1k, per square centimeter
Q4149 Excellagen, 0.1 cc
Q4150 Allowrap DS or dry, per square centimeter
Q4152 Dermapure, per square centimeter
Q4153 Dermavest and Plurivest, per square centimeter
Q4155 Neox Flo or Clarix Flo, 1 mg
Q4156 Neox 100, per square centimeter
Q4157 Revitalon, per square centimeter
Q4158 MariGen, per square centimeter
Q4159 Affinity, per square centimeter
Q4160 NuShield, per square centimeter
Q4161 Bio-connekt wound matrix, per square centimeter
Q4162 Amniopro flow, bioskin flow, biorenew flow, woundex flow, amniogen-a, amniogen-c, 0.5 cc
Q4163 Amniopro, bioskin, biorenew, woundex, amniogen-45, amniogen-200, per square centimeter
Q4164 Helicoll, per square centimeter
Q4165 Keramatrix, per square centimeter
Q4166 Cytal, per square centimeter
Q4167 Truskin, per square centimeter
Q4168 Amnioband, 1 mg
Q4169 Artacent wound, per square centimeter
Q4170 Cygnus, per square centimeter
Q4171 Interfyl, 1 mg
Q4172 Puraply or puraply am, per square centimeter
Q4173 Palingen or palingen xplus, per square centimeter
Q4174 Palingen or promatrx, 0.36 mg per 0.25 cc
Q4175 Miroderm, per square centimeter
Q4183 Surgigraft, per square centimeter
Q4184 Cellesta, per square centimeter
Q4185 Cellesta flowable amnion (25 mg per cc); per 0.5 cc
Q4187 Epicord, per square centimeter
Q4188 Amnioarmor, per square centimeter
Q4189 Artacent ac, 1 mg
Q4190 Artacent ac, per square centimeter
Q4191 Restorigin, per square centimeter
Q4192 Restorigin, 1 cc
Q4193 Coll-e-derm, per square centimeter
Q4194 Novachor, per square centimeter
Q4195 Puraply, per square centimeter
Q4196 Puraply am, per square centimeter
Q4197 Puraply xt, per square centimeter
Q4198 Genesis amniotic membrane, per square centimeter
Q4200 Skin te, per square centimeter
Q4201 Matrion, per square centimeter
Q4202 Keroxx (2.5g/cc), 1cc
Q4203 Derma-gide, per square centimeter
Q4204 Xwrap, per square centimeter
Q9982 Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries
Q9983 Florbetaben F18, diagnostic, per study dose, up to 8.1 millicuries
Q9993 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg
S2080 Laser-assisted uvuolopalatoplasty (LAUP)
S2103 Adrenal tissue transplant to brain (effective 09/01/2014)
S2205 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, under direct vision; using arterial graft(s), 2 coronary arterial grafts
S2206 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using arterial grafts
S2207 Minimally invasive direct coronary artery bypass surgery involving mini-toracotomy or mini-sternotomy surgery, performed under direct vision; using venous graft only, single coronary venous graft
S2208 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using single arterial and venous graft(s), single venous graft
S2209 Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using 2 arterial grafts and single venous graft
S3650 Saliva test, hormone level; during menopause
S3652

to assess preterm labor risk

S3852 DNA analysis for APOE epsilon 4 allele for susceptibility to Alzheimer's disease
S3902 Ballistocardiogram
S3904 Masters two step
S8080 Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical
S8092 Electron beam computed tomography (also known as ultrafast CT, cine CT)
S9025 Omnicardiogram/cardiointegram
T1505 Electronic medication compliance management device, includes all components and accessories, not otherwise classified
T4545 Incontinence product, disposable, penile wrap, each

 

Table III. CPT Category III Codes

CPT Procedure Codes Description
0085T Breath test for heart transplant rejection
0095T

Removal of total disc arthroplasty (artificial disc), interior approach, each additional interspace, cervical

For more detailed information, please see associated medical policy Artificial Intervertebral Disc Replacement - Cervical - Archived

0098T

Revision, including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical

For more detailed information, please see associated medical policy Artificial Intervertebral Disc Replacement - Cervical - Archived

0100T Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy
0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified; high energy
0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle
0111T Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes
0126T Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor assessment
0159T Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis with further physician review for interpretation, breast MRI
0163T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0164T Removal of total disc arthroplasty (artificial disc), anterior approach, lumbar, each additional interspace
0165T

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, lumbar, each additional interspace

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0190T Placement of intraocular radiation source applicator
0195T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0196T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L4-L5 interspace (List separately in addition to code for primary procedure)

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0198T Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report
0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, one or more needles
0201T Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, two or more needles
0202T Posterior vertebral joint(s) arthroplasty (e.g., facet joint(s) replacement) including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine
0206T Algorithmic analysis, remote, of electrocardiographic-derived data with computer probability assessment, including report
0207T Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral
0219T Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical (Do not report 0219T-0221T with any radiological service)
0220T

thoracic (Do not report 0219T-0221T with any radiological service)

0221T

lumbar (Do not report 0219T-0221T with any radiological service)

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0222T

each additional vertebral segment (List separately in addition to code for primary procedure) (Use 0222T in conjunction with 0219T-0221T)

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0232T Injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed
0254T Endovascular repair of iliac artery bifurcation (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery, unilateral;
0263T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest (effective 7/1/11)
0264T

complete procedure excluding bone marrow harvest

0265T

unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy

0266T Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)
0267T

lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)

0268T

pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)

0269T Revision or removal of carotid sinus baroflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)
0270T

lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)

0271T

pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)

0272T Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (eg, battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day) (effective 7/1/11)
0273T

with programming (effective 7/1/11)

0274T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic (effective 7/1/11)
0275T

lumbar

0278T Transcutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes)
0312T Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming
0313T Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator
0314T Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator
0315T Vagus nerve blocking therapy (morbid obesity); removal of pulse generator
0316T Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator
0317T Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when performed
0330T Tear film imaging, unilateral or bilateral, with interpretation and report
0333T Visual evoked potential, screening of visual acuity, automated
0335T Extra-osseous subtalar joint implant for talotarsal stabilization
0337T Endothelial function assessment, using peripheral vascular response to reactive hyperemia, non-invasive (eg, brachial artery ultrasound, peripheral artery tonometry), unilateral or bilateral
0338T Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral
0339T Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral
0340T Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance
0341T Quantitative pupillometry with interpretation and report, unilateral or bilateral
0342T Therapeutic apheresis with selective hdl delipidation and plasma reinfusion
0346T Ultrasound, elastography (list separately in addition to code for primary procedure) (except when billed for hepatitis C)
0356T Insertion of drug-eluting implant (including punctual dilation and implant removal when performed) into lacrimal canaliculus, each
0358T Bioelectrical impedance analysis whole body composition assessment, supine position, with interpretation and report
0375T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels

For more detailed information, please see associated medical policy Artificial Intervertebral Disc Replacement - Cervical - Archived and Spinal Interventional Pain Management and Spine Surgery

0376T Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork, each additional device insertion (List separately in addition to code for primary procedure)
0378T Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional
0379T Technical support and patient instructions, surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional
0380T Computer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report
0381T External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional
0382T External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only
0383T External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional
0384T External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only
0385T External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional
0386T External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only
0387T Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular
0388T Transcatheter removal of permanent leadless pacemaker, ventricular
0389T Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system
0390T Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system
0391T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system
0396T Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (list separately in addition to code for primary procedure)
0397T Endoscopic retrograde cholangiopancreatography (ercp), with optical endomicroscopy (list separately in addition to code for primary procedure)
0398T Magnetic resonance image guided high intensity focused ultrasound (mrgfus), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed
0400T Multi-spectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high risk melanocytic atypia; one to five lesions
0401T Multi-spectral digital skin lesion analysis of clinically atypical cutaneous pigmented lesions for detection of melanomas and high risk melanocytic atypia; six or more lesions
0404T Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency
0405T Oversight of the care of an extracorporeal liver assist system patient requiring review of status, review of laboratories and other studies, and revision of orders and liver assist care plan (as appropriate), within a calendar month, 30 minutes or more of non-face-to-face time
0408T Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes
0409T Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only
0410T Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only
0411T Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only
0412T Removal of permanent cardiac contractility modulation system; pulse generator only
0413T Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular)
0414T Removal and replacement of permanent cardiac contractility modulation system pulse generator only
0415T Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead)
0416T Relocation of skin pocket for implanted cardiac contractility modulation pulse generator
0417T Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility m
0418T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiac contractility modulation system
0421T Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)
0423T Secretory type ii phospholipase a2 (spla2-iia)
0424T Insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator)
0425T Insertion or replacement of neurostimulator system for treatment of central sleep apnea; sensing lead only
0426T Insertion or replacement of neurostimulator system for treatment of central sleep apnea; stimulation lead only
0427T Insertion or replacement of neurostimulator system for treatment of central sleep apnea; pulse generator only
0428T Removal of neurostimulator system for treatment of central sleep apnea; pulse generator only
0429T Removal of neurostimulator system for treatment of central sleep apnea; sensing lead only
0430T Removal of neurostimulator system for treatment of central sleep apnea; stimulation lead only
0431T Removal and replacement of neurostimulator system for treatment of central sleep apnea, pulse generator only
0432T Repositioning of neurostimulator system for treatment of central sleep apnea; stimulation lead only
0433T Repositioning of neurostimulator system for treatment of central sleep apnea; sensing lead only
0434T Interrogation device evaluation implanted neurostimulator pulse generator system for central sleep apnea
0435T Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; single session
0436T Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; during sleep study
0437T Implantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall (list separately in addition to primary procedure)
0439T Myocardial contrast perfusion echocardiography; at rest or with stress, for assessment of myocardial ischemia or viability (list separately in addition to primary procedure)
0440T Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve
0441T Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve; lower extremity distal/peripheral nerve
0442T Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve)
0443T Real time spectral analysis of prostate tissue by fluorescence spectroscopy
0444T Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral
0445T Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral
0446T Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training
0447T Removal of implantable in22terstitial glucose sensor from subcutaneous pocket via incision
0448T Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation
0449T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device
0450T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device; each additional device (list separately in addition to code for primary procedure)
0451T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes)
0452T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes); aortic counterpulsation device and vascular hemostatic seal
0453T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes); mechano-electrical skin interface
0454T Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes); subcutaneous electrode
0455T Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes)
0456T Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes); aortic counterpulsation device and vascular
0457T Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes); mechano-electrical skin interface
0458T Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes); subcutaneous electrode
0459T Relocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device,mechano- electrical skin interface and electrodes
0460T Repositioning of previously implanted aortic counterpulsation ventricular assist device, subcutaneous electrode
0461T Repositioning of previously implanted aortic counterpulsation ventricular assist device, subcutaneous electrode; aortic counterpulsation device
0462T Programming device evaluation (in person) with iterative adjustment of the implantable mechano-electrical skin interface and/or external driver to test the function of the device and select optimal permanent programmed values with analysis, including review
0463T Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day
0464T Visual evoked potential, testing for glaucoma, with interpretation and report
0465T Suprachoroidal injection of a pharmacologic agent (does not include supply of medication)
0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (list separately in addition to code for primary procedure)
0467T Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator
0468T Removal of chest wall respiratory sensor electrode or electrode array
0470T Optical coherence tomography (oct) for microstructural and morphological imaging of skin, image acquisition, interpretation, and report; first lesion
0474T Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space​
0471T Optical coherence tomography (oct) for microstructural and morphological imaging of skin, image acquisition, interpretation, and report; each additional lesion (list separately in additional to code for primary procedure)
0472T Device evaluation, interrogation, and initial programming of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, with iterative adjustment of the implantable device to test functionality, select optimal permanent programmed values with analysis, including visual training, with review and report by a qualified health care professional
0473T Device evaluation and interrogation of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, including reprogramming and visual training, when performed, with review and report by a qualified health care professional
0497T External patient-activated, physician- or other qualified health care professional-prescribed, electrocardiographic rhythm derived event recorder without 24 hour attended monitoring; in-office connection
0498T External patient-activated, physician- or other qualified health care professional-prescribed, electrocardiographic rhythm derived event recorder without 24 hour attended monitoring; review and interpretation by a physician or other qualified health care professional per 30 days with at least one patient-generated triggered event
0541T Myocardial imaging by magnetocardiography (mcg) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning- derived clinical scoring, and automated report generation, single study
0542T Myocardial imaging by magnetocardiography (mcg) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning- derived clinical scoring, and automated report generation, single study; interpretation and report
0525T Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; complete system (electrode and implantable monitor)
0526T Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; electrode only
0527T Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable monitor only
0528T Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report
0529T Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report
0530T Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor)
0531T Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only
0532T Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only
0533T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes set-up, patient training, configuration of monitor, data upload, analysis and initial report configuration, download review, interpretation and report
0534T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; set-up, patient training, configuration of monitor
0535T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
0536T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
0546T  Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
0547T  Bone-material quality testing by microindentation(s) of the tibia(s), with results reported as a score
0548T  Transperineal periurethral balloon continence device; bilateral placement, including cystoscopy and fluoroscopy
0549T  Transperineal periurethral balloon continence device; unilateral placement, including cystoscopy and fluoroscopy
0550T  Transperineal periurethral balloon continence device; removal, each balloon
0051T  Transperineal periurethral balloon continence device; adjustment of balloon(s) fluid volume
0052T  Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional
0053T  Percutaneous transcatheter placement of iliac arteriovenous anastomosis implant, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention
0054T  Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data, assessment of bone strength and fracture risk and bone mineral density, interpretation and report
0055T  Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data
0056T  Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; assessment of bone strength and fracture risk and bone mineral density
0057T  Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; interpretation and report
0058T  Computed tomography scan taken for the purpose of biomechanical computed tomography analysis
0059T  Anatomic model 3d-printed from image data set(s); first individually prepared and processed component of an anatomic structure
0560T  Anatomic model 3d-printed from image data set(s); each additional individually prepared and processed component of an anatomic structure (list separately in addition to code for primary procedure)
0561T  Anatomic guide 3d-printed and designed from image data set(s); first anatomic guide
0562T  Anatomic guide 3d-printed and designed from image data set(s); each additional anatomic guide (list separately in addition to code for primary procedure)
0002U Oncology (colorectal), quantitative assessment of three urine metabolites (ascorbic acid, succinic acid and carnitine) by liquid chromatography with tandem mass spectrometry (lc-ms/ms) using multiple reaction monitoring acquisition, algorithm reported as likelihood of adenomatous polyps
0003U Oncology (ovarian) biochemical assays of five proteins (apolipoprotein a-1, ca 125 ii, follicle stimulating hormone, human epididymis protein 4, transferrin), utilizing serum, algorithm reported as a likelihood score
0004U Infectious disease (bacterial), dna, 27 resistance genes, pcr amplification and probe hybridization in microarray format (molecular detection and identification of ampc, carbapenemase and esbl coding genes), baterial culture colonies, report of genes detected or not detected, per isolate
0005U Oncology (prostate) gene expression profile by real-time rt-pcr of 3 genes (erg, pca3, and spdef), urine, algorithm reported as risk score
0006U Prescription drug monitoring, 120 or more drugs and substances, definitive tandem mass spectrometry with chromatography, urine, qualitative report of presence (including quantitative levels, when detected) or absence of each drug or substance with description and severity of potential interactions, with identified substances, per date of service
0007U Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including dna authentication in comparison to buccal dna, per date of service
0008U Helicobacter pylori detection and antibiotic resistance, dna, 16s and 23s rrna, gyra, pbp1, rdxa and rpob, next generation sequencing, formalin-fixed paraffin embedded or fresh tissue, predictive, reported as positive or negative for resistance to clarithromycin, fluoroquinolones, metronidazole, amoxicillin, tetracycline and rifabutin
0009U Oncology (breast cancer), erbb2 (her2) copy number by fish, tumor cells from formalin fixed paraffin embedded tissue isolated using image-based dielectrophoresis (dep) sorting, reported as erbb2 gene amplified or non-amplified
0010U Infectious disease (bacterial), strain typing by whole genome sequencing, phylogenetic-based report of strain relatedness, per submitted isolate
0011U Prescription drug monitoring, evaluation of drugs present by lc- ms/ms, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug compounds and metabolites
0012U Germline disorders, gene rearrangement detection by whole genome next-generation sequencing, dna, whole blood, report of specific gene rearrangement(s)
0013U Oncology (solid organ neoplasia), gene rearrangement detection by whole genome next-generation sequencing, dna, fresh or frozen tissue or cells, report of specific gene rearrangement(s)
0014U Hematology (hematolymphoid neoplasia), gene rearrangement detection by whole genome next- generation sequencing, dna, whole blood or bone marrow, report of specific gene rearrangement(s)
0015U Drug metabolism (adverse drug reactions), dna, 22 drug metabolism and transporter genes, real-time pcr, blood or buccal swab, genotype and metabolizer status for therapeutic decision support
0018U Oncology (thyroid), microrna profiling by rt-pcr of 10 microrna sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy
0019U Oncology, rna, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents
0020U Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, with specimen verification including dna authentication in comparison to buccal dna, per date of service
0021U Oncology (prostate), detection of 8 autoantibodies (arf 6, nkx3-1, 5’- utr-bmi1, cep 164, 3’-utr-ropporin, desmocollin, aurkaip- 1, csnk2a2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk score
0022U Targeted genomic sequence analysis panel, non-small cell lung neoplasia, dna and rna analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider
0024U Glycosylated acute phase proteins (glyca), nuclear magnetic resonance spectroscopy, quantitative
0025U Tenofovir, by liquid chromatography with tandem mass spectrometry (lc-ms/ms), urine, quantitative
0026U Oncology (thyroid), dna and mrna of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ("positive, high probability of malignancy" or "negative, low probability of malignanc
0029U Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, cyp1a2, cyp2c19, cyp2c9, cyp2d6, cyp3a4, cyp3a5, cyp4f2, slco1b1, vkorc1 and rs12777823)
0030U Drug metabolism (warfarin drug response), targeted sequence analysis (ie, cyp2c9, cyp4f2, vkorc1, rs12777823)
0032U Comt (catechol-o-methyltransferase)(drug metabolism) gene analysis, c.472g>a (rs4680) variant
0033U Htr2a (5-hydroxytryptamine receptor 2a), htr2c (5-hydroxytryptamine receptor 2c) (eg, citalopram metabolism) gene analysis, common variants (ie, htr2a rs7997012 [c.614-2211t>c], htr2c rs3813929 [c.- 759c>t] and rs1414334 [c.551-3008c>g])
0039U Deoxyribonucleic acid (dna) antibody, double stranded, high avidity
0062U Autoimmune (systemic lupus erythematosus), igg and igm analysis of 80 biomarkers, utilizing serum, algorithm reported with a risk score
0063U Neurology (autism), 32 amines by lc-ms/ms, using plasma, algorithm reported as metabolic signature associated with autism spectrum disorder
0070U CYP2D6 (Cytochrome P450, family 2, subfamily D, Polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (IE, *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35, *36, *41, *57, *61, *63, *68, *83, *XN)
0071U CYP2D6 (Cytochrome P450, family 2, subfamily d, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (list separately in addition to code for primary procedure)
0072U CYP2D6 (Cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (list separately in addition to code for primary procedure)
0073U CYP2D6 (Cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (list separately in addition to code for primary procedure)
0074U CYP2D6 (Cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, non-duplicated gene when duplication/multiplication is trans) (list separately in addition to code for primary procedure)
0075U CYP2D6 (Cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 5’ gene duplication/multiplication) (list separately in addition to code for primary procedure)
0076U CYP2D6 (Cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 3’ gene duplication/ multiplication) (list separately in addition to code for primary procedure)

 

 

MM: 07/2019

 

 


 

 

To view the previous version of this document, see Codes That Do Not Meet Payment Determination Criteria - OBSOLETE2.

 

First Published:11/15/2007
Latest Revision:07/09/2019
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