Prior Review (Prior Plan Approval) Code List 2nd Quarter ... · Prior Review (Prior Plan Approval)...

Prior Review (Prior Plan Approval) Code List – 3rd Quarter 2018 of 73 This list is subject to change once per quarter. Changes will be posted to the BCBSNC website at www.bcbsnc.com by the 10th day of January, April, July, and October. NOTE: Unlisted and Miscellaneous health service codes should only be used if a specific code has not been established by the American Medical Association.

Notice Date: The listed date is when the notice of the existing code was added. Effective Date: The listed date is when the code will require prior authorization for correct claims processing. If there is no date in this field, the requirement is in effect. Ineffective Date: The listed date is when the code became invalid. The code can be billed for up to 18 months past the date for correct claims processing if prior authorization was requested. *Prior approval is required for all drugs listed below regardless of the HCPCS code submitted on the claim. The requirement is based on the drug itself—not the code chosen to submit on the claim. ** New to market drugs are defined as drugs that have only been available on the U.S. market for 90 days or less from the FDA approval date. Individual drug names will be added to the PPA list as soon as possible but even if the drug is not listed by name and it is new to market prior authorization is required.

SERVICE CODE

SERVICE DESCRIPTION NOTICE DATE

EFFECTIVE DATE

INEFFECTIVE DATE

0008M ONCOLOGY (BREAST), MRNA ANALYSIS OF 58 GENES USING HYBRID CAPTURE, ON FORMALIN-FIXED PARAFFIN-EMBEDDED (FFPE) TISSUE, PROGNOSTIC ALGORITHM REPORTED AS A RISK SCORE

04/01/17 07/01/17

0071T FOCUSED ULTRASOUND ABLATION OF UTERINE LEIOMYOMATA, INCLUDING MR GUIDANCE; TOTAL LEIOMYOMATA VOLUME LESS THAN 200 CC OF TISSUE

07/01/08

0072T TOTAL LEIOMYOMATA VOLUME GREATER OR EQUAL TO 200 CC OF TISSUE 07/01/08

0075T TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; INITIAL VESSEL

10/01/07

0076T TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

10/01/07

0095T EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

07/01/05

0098T EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

07/01/05

0101T EXTRACORPOREAL SHOCK WAVE INVOLVING MUSCOLOSKELETAL SYSTEM, NOT OTHERWISE SPECIFIED, HIGH ENERGY

07/01/05

0102T EXTRACORPOREAL SHOCK WAVE, HIGH ENERGY, PERFORMED BY A PHYSICIAN, REQUIRING ANESTHESIA OTHER THAN LOCAL, INVOLVING LATERAL HUMERAL EPICONDYLE

07/01/05

0163T TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), LUMBAR, EACH ADDITIONAL INTERSPACE

01/01/07

0164T REMOVAL OF TOTAL DISC ARTHROPLASTY, ANTERIOR APPROACH, LUMBAR, EACH ADDITIONAL INTERSPACE

01/01/07

0165T REVISION OF TOTAL DISC ARTHROPLASTY, ANTERIOR APPROACH, LUMBAR, EACH ADDITIONAL INTERSPACE

01/01/07

0191T INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE TRABECULAR MESHWORK; INITIAL INSERTION

04/01/17 07/01/17

0195T ARTHRODESIS, PRE-SACRAL INTERBODY TECHNIQUE, DISC SPACE PREPARATION, DISCECTOMY WITHOUT INSTRUMENTATION, WITH IMAGE GUIDANCE, INCLUDES BONE

10/01/09



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

GRAFT WHEN PERFORMED; L5-S1 INTERSPACE

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

10/01/09

0200T PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY), UNILATERAL INJECTION(S), INCLUDING THE USE OF A BALLOON OR MECHANICAL DEVICE, WHEN USED, 1 OR MORE NEEDLES, INCLUDES IMAGING GUIDANCE AND BONE BIOPSY, WHEN PERFORMED

07/01/09

0201T PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY), BILATERAL INJECTIONS, INCLUDING THE USE OF A BALLOON OR MECHANICAL DEVICE, WHEN USED, 2 OR MORE NEEDLES, INCLUDES IMAGING GUIDANCE AND BONE BIOPSY, WHEN PERFORMED

07/01/09

0202T POSTERIOR VERTEBRAL JOIN(S) ARTHROPLASTY (E.G., FACET JOINT[S] REPLACEMTN) INCLUDING FACETECTOMY, LAMINECTOMY, FORAMINOTOMY AND VERTEBRAL COLUMN FIXATION, WITH OR WITHOUT INJECTION OF BONE CEMENT, INCLUDING FLUOROSCOPY, SINGLE LEVEL, LUMBAR SPINE

07/01/09

0219T PLACEMENT OF POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; CERVICAL

01/01/10

0220T PLACEMENT OF POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; THORACIC

01/01/10

0221T PLACEMENT OF POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; LUMBAR

01/01/10

0222T PLACEMENT OF POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/10

0253T INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUPRACHOROIDAL SPACE

04/01/17 07/01/17

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

01/01/11

0264T INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY, WITH PREPARATION 07/01/11



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

OF HARVESTED CELLS, MULTIPLE INJECTIONS, ONE LEG, INCLUDING ULTRASOUND GUIDANCE, IF PERFORMED; COMPLETE PROCEDURE EXCLUDING BONE MARROW HARVEST

0265T INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY, WITH PREPARATION OF HARVESTED CELLS, MULTIPLE INJECTIONS, ONE LEG, INCLUDING ULTRASOUND GUIDANCE, IF PERFORMED; UNILATERAL OR BILATERAL BONE MARROW HARVEST ONLY FOR INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY

07/01/11

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)

07/01/11

0267T IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; LEAD ONLY, UNILATERAL (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)

07/01/11

0268T IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; PULSE GENERATOR ONLY (INCLUDES INTRAOPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED)

07/01/11

0269T REVISION OR REMOVAL OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED

07/01/11

0270T REVISION OR REMOVAL OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; LEAD ONLY, UNILATERAL (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED

07/01/11

0271T REVISION OR REMOVAL OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; PULSE GENERATOR ONLY (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED

07/01/11

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 (E.G., BATTERY STATUS, LEAD IMPEDANCE, PULSE AMPLITUDE, PULSE WIDTH, THERAPY FREQUENCY, PATHWAY MODE, BURST MODE, THERAPY START/STOP TIMES EACH DAY);

07/01/11

0273T INTERROGATION DEVICE EVALUATION (IN PERSON), CAROTID SINUS BAROREFLEX ACTIVATION SYSTEM, INCLUDING TELEMETRIC ITERATIVE COMMUNICATION WITH THE IMPLANTABLE DEVICE TO MONITOR DEVICE DIAGNOSTICS AND PROGRAMMED

07/01/11



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

THERAPY VALUES, WITH INTERPRETATION AND REPORT (E.G., BATTERY STATUS, LEAD IMPEDANCE, PULSE AMPLITUDE, PULSE WIDTH, THERAPY FREQUENCY, PATHWAY MODE, BURST MODE, THERAPY START/STOP TIMES EACH DAY); WITH PROGRAMMING

0274T PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTRALAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY) AND METHOD UNDER INDIRECT IMAGE GUIDANCE (E.G., FLUOROSCOPIC, CT), WITH OR WITHOUT THE USE OF AN ENDOSCOPE, SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; CERVICAL OR THORACIC

07/01/11

0275T PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTRALAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY AND/OR FORAMINOTOMY) AND METHOD UNDER INDIRECT IMAGE GUIDANCE (E.G., FLUOROSCOPIC, CT), WITH OR WITHOUT THE USE OF AN ENDOSCOPE, SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; LUMBAR

07/01/11

0299T EXTRACORPOREAL SHOCK WAVE FOR INTGEGUMENTARY WOUND HEALING; HIGH ENERGY, INCLUDING TOPICAL APPLICATION AND DRESSING CARE; INITIAL WOUND

01/01/12 01/01/18

0300T EXTRACORPOREAL SHOCK WAVE FOR INTEGUMENTARY WOUND HEALING; EACH ADDITIONAL WOUND

01/01/12 01/01/18

0308T INSERTION OF OCULAR TELESCOPYE PROSTHESIS INCLUDING REMOVAL OF CRYSTALLINE LENS OR INTRAOCULAR LENS PROSTHESIS

07/01/12

0309T Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure)

01/01/13 01/01/18

0310T Motor function mapping using non-invasive navigated transcranial magnetic stimulation (nTMS) for therapeutic treatment planning, upper and lower extremity

01/01/13 01/01/18

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

01/01/13

0313T Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator

01/01/13

0314T Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator

01/01/13



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

0315T Vagus nerve blocking therapy (morbid obesity); removal of pulse generator 01/01/13

0316T Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator 01/01/13

0317T Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when performed

01/01/13

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

01/01/14

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

01/01/14

0340T ALATION, PULMONARY TUMOR(S), INCLUDING PLEURA OR CHEST WALL WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEUS, CRYOABLATION, UNILATERAL, INCLUDES IMAGING GUIDANCE

01/01/14 01/01/18

0341T QUANTITATIVE PUPILLOMETRY WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL

01/01/14

0345T TRANSCATHETER MITRAL VALVE REPAIR PERCUTANOUS APPROACH VIA THE CORONARY SINUS

01/01/14

0355T GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), COLON, WITH INTERPRETATION AND REPORT

04/01/15 07/01/15

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

01/01/15

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)

04/01/17 07/01/17

0377T ANOSCOPY WITH DIRECTED SUBMUCOSAL INJECTION OF BULKING AGENT FOR FECAL INCONTINENCE

01/01/15



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

0387T TRANSCATHETER INSERTION OR REPLACEMENT OF PERMANENT LEADLESS PACEMAKER, VENTRICULAR

01/01/15

0388T TRANSCATHETER REMOVAL OF PERMANENT LEADLESS PACEMAKER, VENTRICULAR 01/01/15

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

01/01/15

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

01/01/15

0391T INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER, LEADLESS PACEMAKER SYSTEM

01/01/15

0394T HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, SKIN SURFACE APPLICATION, PER FRACTION, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED

01/01/16

0395T HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, INTERSTITIAL OR INTRACAVITARY TREATMENT, PER FRACTION, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED

01/01/16

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

01/01/16

0406T NASAL ENDOSCOPY, SURGICAL, ETHMOID SINUS, PLACEMENT OF DRUG ELUTING IMPLANT;

01/01/16

0407T NASAL ENDOSCOPY, SURGICAL, ETHMOID SINUS, PLACEMENT OF DRUG ELUTING IMPLANT; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT

01/01/16

0449T INSERTION OF AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUBCONJUNCTIVAL SPACE; INITIAL DEVICE

04/01/17 07/07/17

0450T INSERTION OF AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUBCONJUNCTIVAL SPACE; EACH ADDITIONAL DEVICE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

04/01/17 07/01/17

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)

01/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

0452T INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; AORTIC COUNTERPULSATION DEVICE AND VASCULAR HEMOSTATIC SEAL

01/01/17

0453T INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; MECHANO-ELECTRICAL SKIN INTERFACE

01/01/17

0454T INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; SUBCUTANEOUS ELECTRODE

01/01/17

0455T REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; COMPLETE SYSTEM (AORTIC COUNTERPULSATION DEVICE, VASCULAR HEMOSTATIC SEAL, MECHANO-ELECTRICAL SKIN INTERFACE AND ELECTRODES)

01/01/17

0456T REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; AORTIC COUNTERPULSATION DEVICE AND VASCULAR HEMOSTATIC SEAL

01/01/17

0457T REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; MECHANO-ELECTRICAL SKIN INTERFACE

01/01/17

0458T REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; SUBCUTANEOUS ELECTRODE

01/01/17

0459T RELOCATION OF SKIN POCKET WITH REPLACEMENT OF IMPLANTED AORTIC COUNTERPULSATION VENTRICULAR ASSIST DEVICE, MECHANO-ELECTRICAL SKIN INTERFACE AND ELECTRODES

01/01/17

0460T REPOSITIONING OF PREVIOUSLY IMPLANTED AORTIC COUNTERPULSATION VENTRICULAR ASSIST DEVICE; SUBCUTANEOUS ELECTRODE

01/01/17

0461T REPOSITIONING OF PREVIOUSLY IMPLANTED AORTIC COUNTERPULSATION VENTRICULAR ASSIST DEVICE; AORTIC COUNTERPULSATION DEVICE

01/01/17

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 AND REPORT, IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, PER DAY

01/01/17

0463T INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND 01/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

REPORT, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER, IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, PER DAY

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)

07/01/18 10/01/18

0474T INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITH CREATION OF INTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE SUPRACILIARY SPACE

07/01/17

0550 SKILLED NURSING, GENERAL CODE 04/01/06

0551 SKILLED NURSING – HH 01/01/05

0552 PRIVATE DUTY NURSING – RN 01/01/05

0559 PRIVATE DUTY NURSING – LPN 01/01/05

0570 HOME HEALTH AIDE – HH 01/01/05

0571 HOME HEALTH AIDE – HOURLY CHARGE – PDN 01/01/05

11971 REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF PROSTHESIS 07/01/05

11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION OF ESTRADIOL AND/OR TESTOSTERONE PELLETS BENEATH THE SKIN)

04/01/16 07/01/16

15780 DERMABRASION, TOTAL FACE (EG, FOR ACNE SCARRING, FINE WRINKLING, RHYTIDS, GENERAL KERATOSIS)

10/01/06

15781 DERMABRASION; SEGMENTAL, FACE 10/01/06

15782 DERMABRASION; REGIONAL, OTHER THAN FACE 10/01/06

15786 ABRASION; SINGLE LESION (EG, KERATOSIS, SCAR) 07/01/05

15787 ABRASION; EACH ADDITIONAL FOUR LESIONS OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

07/01/05

15788 CHEMICAL PEEL, FACIAL; EPIDERMAL 07/01/05

15789 CHEMICAL PEEL, FACIAL; DERMAL 07/01/05

15792 CHEMICAL PEEL, NONFACIAL, EPIDERMAL 10/01/10

15793 CHEMICAL PEEL, NONFACIAL; DERMAL 07/01/05

15819 CERVICOPLASTY 10/01/06

15820 BLEPHAROPLASTY, LOWER EYELID 07/01/05

15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FATPAD 07/01/05

15822 BLEPHAROPLASTY, UPPER EYELID; 07/01/05

15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID 07/01/05

15824 RHYTIDECTOMY; FOREHEAD 07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

15825 RHYTIDECTOMY; NECK WITH PLATYSMAL TIGHTENING (PLATYSMAL FLAP, P-FLAP) 07/01/15 10/01/15

15826 RHYTIDECTOMY; GLABELLAR FROWN LINES 07/01/15 10/01/15

15828 RHYTIDECTOMY; CHEEK, CHIN, AND NECK 07/01/15 10/01/15

15829 RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP 07/01/15 10/01/15

15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY

01/01/07

15832 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); THIGH

01/01/06

15833 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); LEG 01/01/06

15834 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); HIP 01/01/06

15835 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); BUTTOCK

01/01/06

15836 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); ARM 01/01/06

15837 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); FOREARM OR HAND

01/01/06

15838 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); SUBMENTAL FAT PAD

01/01/06

15839 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY); OTHER AREA

07/01/05

15847 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY), ABDOMEN (EG, ABDOMINOPLASTY) (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/07

15876 SUCTION ASSISTED LIPECTOMY; HEAD AND NECK 07/01/15 10/01/15

15877 SUCTION ASSISTED LIPECTOMY; TRUNK 07/01/07

15878 SUCTION ASSISTED LIPECTOMY; UPPER EXTREMITY 07/01/08

15879 SUCTION ASSISTED LIPECTOMY; LOWER EXTREMITY 07/01/15 10/01/15

19105 ABLATION, CRYOSURGICAL OF FIBROADENOMA, INCLUDING ULTRASOUND GUIDANCE, EACH FIBROADENOMA

01/01/14 04/01/14

19300 MASTECTOMY FOR GYNECOMASTIA 01/01/07

19304 MASTECTOMY, SUBCUTANEOUS 10/01/16 01/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

19316 MASTOPEXY 07/01/05

19318 REDUCTION MAMMAPLASTY 07/01/05

19324 MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPL 10/01/16 01/01/17

19325 MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT 07/01/05

19328 REMOVAL OF INTACT MAMMARY IMPLANT 07/01/05

19330 REMOVAL OF MAMMARY IMPLANT MATERIAL 07/01/05

19340 IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION

07/01/07

19355 CORRECTION OF INVERTED NIPPLES 07/01/05

19370 OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST 01/01/06

19371 PERIPROSTHETIC CAPSULECTOMY, BREAST 07/01/05

19499 UNLISTED PROCEDURE, BREAST 07/01/05

20527 INJECTION, ENZYME (EG. COLLAGENASE) PALMAR FASCIAL CORD (IE. DUPUYTREN’S CONTRACTURE)

01/01/12

20979 LOW INTENSITY ULTRASOUND STIMULATION TO AID BONE HEALING, NONINVASIVE (NONOPERATIVE)

07/01/05

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

01/01/15

21010 ARTHROTOMY, TEMPOROMANDIBULAR JOINT 07/01/08

21050 CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) 07/01/08

21089 UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE 07/01/05

21121 GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE PIECE 07/01/05

21122 GENIOPLASTY; SLIDING OSTEOTOMIES, TWO OR MORE OSTEOTOMIES (EG, WEDGE EXCISION OR BONE WEDGE REVERSAL FOR ASYMMETRICAL CHIN)

07/01/05

21123 GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONEGRAFTS (INCLUDES OBTAINING AUTOGRAFTS)

07/01/05

21125 AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL 07/01/05

21127 AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT)

07/01/05

21137 REDUCTION FOREHEAD; CONTOURING ONLY 07/01/15 10/01/15



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

21138 REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GRAFT (INCLUDING OBTAINING AUTOGRAFT)

07/01/15 10/01/15

21139 REDUCTION FOREHEAD; CONTOURING AND SETBACK OF ANTERIOFRONTAL SINUS WALL 01/01/16 04/01/16

21141 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT

07/01/05

21142 RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT

07/01/05

21143 RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT

07/01/05

21145 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)

07/01/05

21146 RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENTMOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED UNILATERAL ALVEOLAR CLEFT)

07/01/05

21147 RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILATERAL ALVEOLAR CLEFT OR MULTIPLE OSTEOMIES)

07/01/05

21150 RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, TREACHER-COLLINS SYNDROME)

07/01/05

21151 RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)

07/01/05

21154 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I

07/01/05

21155 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I

07/01/05

21159 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I

07/01/05

21160 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I

07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

21172 RECONSTRUCTION SUPERIOR-LATERAL ORBITAL RIM AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION, WITH OR WITHOUT GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)

07/01/05

21188 RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT TYPE) AND BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)

07/01/05

21193 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, C, OR L OSTEOTOMY; WITHOUT BONE GRAFT

07/01/05

21194 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, C, OR L OSTEOTOMY; WITH BONE GRAFT (INCLUDES OBTAINING GRAFT)

07/01/05

21195 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTALSPLIT; WITHOUT INTERNAL RIGID FIXATION

07/01/05

21196 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTALSPLIT; WITH INTERNAL RIGID FIXATION

07/01/05

21198 OSTEOTOMY, MANDIBLE, SEGMENTAL 07/01/05

21199 OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT 07/01/05

21206 OSTEOTOMY, MAXILLA, SEGMENTAL (EG, WASSMUND OR SCHUCHARD) 07/01/05

21208 OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, OR PROSTHETIC IMPLANT)

07/01/05

21209 OSTEOPLASTY, FACIAL BONES; REDUCTION 07/01/05

21210 GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT) 07/01/05

21215 GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT) 07/01/05

21240 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUEDES OBTAINING GRAFT)

07/01/08

21242 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT 07/01/08

21243 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT

07/01/08

21255 RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA WITH BONE AND CARTILAGE (INCLUDES OBTAINING AUTOGRAFTS)

07/01/05

21270 MALAR AUGMENTATION, PROSTHETIC MATERIAL 07/01/05

21280 MEDIAL CANTHOPEXY (SEPARATE PROCEDURE) 07/01/05

21299 UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE 07/01/05

21685 HYOID MYOTOMY AND SUSPENSION 07/01/05

21740 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; OPEN 07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

21742 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITHOUT THORACOSCOPY

01/01/06

21743 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITH THORACOSCOPY

01/01/06

22510 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; CERVICOTHORACIC

01/01/15

22511 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBOSACRAL

01/01/15

22512 PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY INCLUDED WHEN PERFORMED), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL CERVICOTHORACIC OR LUMBOSACRAL VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/15

22513 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; THORACIC

01/01/15

22514 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; LUMBAR

01/01/15

22515 PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE (EG, KYPHOPLASTY), 1 VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION, INCLUSIVE OF ALL IMAGING GUIDANCE; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/15

22526 PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; SINGLE LEVEL

01/01/07

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)

01/01/07

22533 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR

01/01/11



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

22534 ARTRHODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC OR LUMBAR, EACH ADDITIONAL VERTEBRAL SEGMENT (FOR LUMBAR FUSION PROCEDURES ONLY)

01/01/11

22558 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR

01/01/11

22585 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (FOR LUMBAR FUSION PROCEDURES ONLY)

01/01/11

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

01/01/13

22612 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; LUMBAR (WITH LATERAL TRANSVERSE TECHNIQUE WHEN PERFORMED)

01/01/11

22614 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (FOR LUMBAR FUSION PROCEDURES ONLY)

01/01/11

22630 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMYAND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION) SINGLE INTERSPACE; LUMBAR

01/01/11

22632 ARTRHODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (FOR LUMBAR FUSION PROCEDURES ONLY)

01/01/11

22633 ARTHRODESIS, COMBINED POSTERIOR OR POTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/ORDISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT;LUMBAR

01/01/12

22634 ARTHRODESIS, COMBINED POSTERIOR OR POTEROLATERAL TECHNIQUE WITH POSTERIOR INTERBODY TECHNIQUE INCLUDING LAMINECTOMY AND/ORDISCECTOMY SUFFICIENT TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE AND SEGMENT;EACH ADDITIONAL INTERSPACE AND SEGMENT (LIST SEPERATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) (FOR LUMBAR FUSION PROCEDURES ONLY)

01/01/12

22800 ARTHRODESIS, POSTERIOR FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; UP TO SIX VERTEBRAL SEGMENTS (FOR LUMBAR FUSION PROCEDURES ONLY)

01/01/11

22802 ARTHRODESIS, POSTERIOR FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 7 TO 12 01/01/11



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

VERTEBRAL SEGMENTS (FOR LUMBAR FUSION PROCEDURES ONLY)

22804 ARTHRODESIS, POSTERIOR FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 13 OR MORE VERTEBRAL SEGMENTS (FOR LUMBAR FUSION PROCEDURES ONLY)

01/01/11

22808 ARTHRODESIS, ANTERIOR FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 2 TO 3 VERTEBRAL SEGMENTS (FOR LUMBAR FUSION PROCEDURES ONLY)

01/01/11

22810 ARTHRODESIS, ANTERIOR FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 4 TO 7 VERTEBRAL SEGMENTS (FOR LUMBAR FUSION PROCEDURES ONLY)

01/01/11

22812 ARTHRODESIS, ANTERIOR FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 8 OR MORE VERTEBRAL SEGMENTS (FOR LUMBAR FUSION PROCEDURES ONLY)

01/01/11

22856 TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SINGLE INTERSPACE, CERVICAL

01/01/09

22857 TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), LUMBAR, SINGLE INTERSPACE

01/01/07

22858 TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION); SECOND LEVEL, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/15

22861 REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICAIL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; CERVICAL

01/01/09

22862 REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC) ANTERIOR APPROACH, LUMBAR, SINGLE INTERSPACE

01/01/07

22864 REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICAL DISC), ANTERIOR APPROACH, SINGLE INTERSPACE; CERVICAL

01/01/09

22865 REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, LUMBAR, SINGLE INTERSPACE

01/01/07

22867 INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, WITH OPEN DECOMPRESSION, LUMBAR; SINGLE LEVEL

01/01/17

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)

01/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

22869 INSERTION OF INTERLAMINAR/INTERSPINOUS PROCESS STABILIZATION/DISTRACTION DEVICE, WITHOUT OPEN DECOMPRESSION OR FUSION, INCLUDING IMAGE GUIDANCE WHEN PERFORMED, LUMBAR; SINGLE LEVEL

01/01/17

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)

01/01/17

26341 MANIPULATION, PALMAR FASCIAL CORD (IE. DUPUTYREN’S CORD), POST ENZYME INJECTION (EG COLLANGENASE), SINGLE CORD

01/01/12

27279

ARTHRODESIS, SACROILIAC JOINT, PERCUTANEOUS OR MINIMALLY INVASIVE (INDIRECT VISUALIZATION), WITH IMAGE GUIDANCE, INCLUDES OBTAINING BONE GRAFT WHEN PERFORMED, AND PLACEMENT OF TRANSFIXING DEVICE

01/01/15

27280 ARTHRODESIS, OPEN, SACROILIAC JOINT, INCLUDING OBTAINING BONE GRAFT, INCLUDING INSTRUMENTATION, WHEN PERFORMED

1/01/13 04/01/13

27299 UNLISTED PROCEDURE, PELVIS, OR HIP JOINT. PLEASE NOTE, PPA IS NEEDED ONLY FOR SI JOINT FUSION.

01/01/10

27412 AUTOLOGNOUS CHONDROCYTE IMPLANTATION, KNEE 10/01/06

27415 OSTEOCHONDRAL ALLOGRAFT, KNEE OPEN 07/01/08

27416 OSTEOCHRONDRAL AUTOGRAFTS(S), KNEE, OPEN (E.G., MOSAICPLASTY)(INCLUDES HARVESTING OF AUTOGRAFTS[S])

07/01/09

28446 OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAF[S]) 07/01/09

29800 ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE)

01/01/10

28890 EXTRACORPOREAL SHOCK WAVE, HIGH ENERGY, PERFORMED BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, REQUIRING ANESTHESIA OTHER THAN LOCAL, INCLUDING ULTRASOUND GUIDANCE, INVOLVING THE PLANTAR FASCIA

01/01/06

29804 ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL 04/01/09

29866 ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL AUTOGRAFT(S) (EG, MOSAICPLASTY) (INCLUDING HARVESTING OF THE AUTOGRAFT(S))

07/01/08

29867 OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY) 01/01/05

29868 MENISCAL TRANSPLANTATION (INCLUDES ARTHROTOMY FOR MENISCAL INSERTION), MEDICAL OR LATERAL)

07/01/08

30400 RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/ORELEVATION OF NASAL TIP

07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

30410 RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP

07/01/05

30420 RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR 07/01/05

30430 RHINOPLASTY, SECONDARY; MINOR REVISION (SMALL AMOUNT OFNASAL TIP WORK) 07/01/05

30435 RHINOPLASTY, SECONDARY; INTERMEDIATE REVISION (BONY WORKWITH OSTEOTOMIES)

07/01/05

30450 RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES) 07/01/05

31241 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH LIGATION OF SPHENOPALATINE ARTERY 01/01/18

31253 NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING FRONTAL SINUS EXPLORATION, WITH REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED

01/01/18

31254 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, PARTIAL (ANTERIOR) 07/01/10

31255 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, TOTAL(ANTERIOR AND POSTERIOR)

07/01/10

31256 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH MAXILLARY ANTROSTOMY; 07/01/10

31257 NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY

01/01/18

31259 NASAL/SINUS ENDOSCOPY, SURGICAL WITH ETHMOIDECTOMY; TOTAL (ANTERIOR AND POSTERIOR), INCLUDING SPHENOIDOTOMY, WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS

01/01/18

31267 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS

07/01/10

31276 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH FRONTAL SINUS EXPLORATION, INCLUDING REMOVAL OF TISSUE FROM FRONTAL SINUS, WHEN PERFORMED

07/01/10

31287 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH SPHENOIDOTOMY; 07/01/10

31288 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE FROM THE SPHENOID SINUS

07/01/10

31295 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF MAXILLARY SINUS OSTIUM (E.G., BALLOON DILATION), TRANSNASAL OR VIA CANINE

10/01/11

31296 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF FRONTAL SINUS OSTIUM (E.G., BALLOON DILATION)

10/01/11

31297 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF SPHENOID SINUS OSTIUM (E.G., BALLOON DILATION)

10/01/11



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

31298 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF FRONTAL AND SPHENOID SINUS OSTIA (EG, BALLOON DILATION)

01/01/18

31627 BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH COMPUTER-ASSISTED, IMAGE-GUIDED NAVIGATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE[S])

10/01/17 01/01/18

31660 BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL THERMOPLASTY, 1 LOBE

07/01/14 10/01/14

31661 BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL THERMOPLASTY, 2 OR MORE LOBES

07/01/14 10/01/14

32664 THORACOSCOPY, SURGICAL; WITH THORACIC SYMPATHECTOMY 07/01/07

32701 THORACIC TARGET(S) DELINEATION FOR STEREOTACTIC BODY RADIATION THERAPY (SRS/SBRT), (PHOTON OR PARTICLE BEAM), ENTIRE COURSE OF TREATMENT

01/01/13

32851 LUNG TRANSPLANT, SINGLE; WITHOUT CARDIOPULMONARY BYPASS 07/01/05

32852 LUNG TRANSPLANT, SINGLE; WITH CARDIOPULMONARY BYPASS 07/01/05

32853 LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); WITHOUT CARDIOPULMONARY BYPASS

07/01/05

32854 LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); WITH CARDIOPULMONARY BYPASS

07/01/05

32994 ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE PULMONARY TUMOR(S) INCLUDING PLEURA OR CHEST WALL WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED, UNILATERAL; CRYOABLATION

01/01/18

32998 ABLATION THERAPY FOR REDUCTION OR ERADICATION OF 1 OR MORE PULMONARY TUMOR(S) INCLUDING PLEURA OR CHEST WALL WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, INCLUDING IMAGING GUIDANCE WHEN PERFORMED, UNILATERAL; RADIOFREQUENCY

01/01/07

33270 INSERTION OR REPLACEMENT OF PERMANENT SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR SYSTEM, WITH SUBCUTANEOUS ELECTRODE, INCLUDING DEFIBRILLATION THRESHOLD EVALUATION, INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING FOR ARRHYTHMIA TERMINATION, AND PROGRAMMING OR REPROGRAMMING OF SENSING OR THERAPEUTIC PARAMETERS, WHEN PERFORMED

01/01/15

33271 INSERTION OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE 01/01/15

33272 REMOVAL OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE 01/01/15

33273 REPOSITIONING OF PREVIOUSLY IMPLANTED SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR ELECTRODE

01/01/15



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

33340 PERCUTANEOUS TRANSCATHETER CLOSURE OF THE LEFT ATRIAL APPENDAGE WITH ENDOCARDIAL IMPLANT, INCLUDING FLUOROSCOPY, TRANSSEPTAL PUNCTURE, CATHETER PLACEMENT(S), LEFT ATRIAL ANGIOGRAPHY, LEFT ATRIAL APPENDAGE ANGIOGRAPHY, WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION

01/01/17

33361 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) WITH PROSTHETIC VALVE; PERCUTANEOUS FEMORAL ARTERY APPROACH

01/01/13

33362 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) WITH PROSTHETIC VALVE; OPEN FEMORAL ARTERY APPROACH

01/01/13

33363 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) WITH PROSTHETIC VALVE; OPEN AXILLARY ARTERY APPROACH

01/01/13

33364 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) WITH PROSTHETIC VALVE; OPEN ILIAC ARTERY APPROACH

01/01/13

33365 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) WITH PROSTHETIC VALVE; TRANSAORTIC APPROACH (EG, MEDIAN STERNOTOMY, MEDIASTINOTOMY)

01/01/13

33366 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) WITH PROSTHETIC VALVE; TRANSAPICAL EXPOSURE (EG, LEFT THORACOTOMY)

01/01/14

33367 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) WITH PROSTHETIC VALVE; CARDIOPULMONARY BYPASS SUPPORT WITH PERCUTANEOUS PERIPHERAL ARTERIAL AND VENOUS CANNULATION (EG, FEMORAL VESSELS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/13

33368 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) WITH PROSTHETIC VALVE; CARDIOPULMONARY BYPASS SUPPORT WITH OPEN PERIPHERAL ARTERIAL AND VENOUS CANNULATION (EG, FEMORAL, ILIAC, AXILLARY VESSELS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE

01/01/13

33369 TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR/TAVI) WITH PROSTHETIC VALVE; CARDIOPULMONARY BYPASS SUPPORT WITH CENTRAL ARTERIAL AND VENOUS CANNULATION (EG, AORTA, RIGHT ATRIUM, PULMONARY ARTERY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/13

33418 TRANSCATHETER MITRAL VALVE REPAIR, PERCUTANEOUS APPROACH, INCLUDING TRANSSEPTAL PUNCTURE WHEN PERFORMED; INITIAL PROSTHESIS

01/01/15

33419 TRANSCATHETER MITRAL VALVE REPAIR, PERCUTANEOUS APPROACH, INCLUDING TRANSSEPTAL PUNCTURE WHEN PERFORMED; ADDITIONAL PROSTHESIS(ES) DURING SAME SESSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/15

33477 TRANSCATHETER PULMONARY VALVE IMPLANTATION, PERCUTANEOUS APPROACH, INCLUDING PRE-STENTING OF THE VALVE DELIVERY SITE, WHEN PERFORMED

01/01/16



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

33930 DONOR CARDIECTOMY-PNEUMONECTOMY, (INCLUDING COLD PRESERVATION) 07/01/05

33935 HEART-LUNG TRANSPLANT WITH RECIPIENT CARDIECTOMY-PNEUMONECTOMY 07/01/05

33945 HEART TRANSPLANT, WITH OR WITHOUT RECIPIENT CARDIECTOMY 07/01/05

36465 INJECTION OF NON-COMPOUNDED FOAM SCLEROSANT WITH ULTRASOUND COMPRESSION MANEUVERS TO GUIDE DISPERSION OF THE INJECTATE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING; SINGLE INCOMPETENT EXTREMITY TRUNCAL VEIN (EG, GREAT SAPHENOUS VEIN, ACCESSORY SAPHENOUS VEIN)

01/01/18

36466 INJECTION OF NON-COMPOUNDED FOAM SCLEROSANT WITH ULTRASOUND COMPRESSION MANEUVERS TO GUIDE DISPERSION OF THE INJECTATE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING; MULTIPLE INCOMPETENT TRUNCAL VEINS (EG, GREAT SAPHENOUS VEIN, ACCESSORY SAPHENOUS VEIN), SAME LEG

01/01/18

36468 INJECTION(S) OF SCLEROSANT FOR SPIDER VEINS (TELANGIECTASIA), LIMB OR TRUNK 07/01/05

36470 INJECTION OF SCLEROSANT; SINGLE INCOMPETENT VEIN (OTHER THAN TELANGIECTASIA)

07/01/05

36471 INJECTION OF SCLEROSANT; MULTIPLE INCOMPETENT VEINS (OTHER THAN TELANGIECTASIA), SAME LEG

07/01/05

36473 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; FIRST VEIN TREATED

01/01/17

36474 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, MECHANOCHEMICAL; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/17

36475 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED

07/01/05

36476 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; SUBSEQUENT VEINS TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES.

07/01/05

36478 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED

07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

36479 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; SUBSEQUENT VEINS TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES

07/01/05

36482 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; FIRST VEIN TREATED

01/01/18

36483 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, BY TRANSCATHETER DELIVERY OF A CHEMICAL ADHESIVE (EG, CYANOACRYLATE) REMOTE FROM THE ACCESS SITE, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS; SUBSEQUENT VEIN(S) TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/18

36522 PHOTOPHERESIS, EXTRACORPOREAL 01/01/11

37215 TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CERVICAL CAROTID ARTERY, OPEN OR PERCUTANEOUS, INCLUDING ANGIOPLASTY, WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION; WITHOUT DISTAL EMBOLIC PROTECTION

04/01/06

37216 TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CERVICAL CAROTID ARTERY, OPEN OR PERCUTANEOUS, INCLUDING ANGIOPLASTY, WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION; WITHOUT DISTAL EMBOLIC PROTECTION

10/01/06

37217 TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), INTRATHORACIC COMMON CAROTID ARTERY OR INNOMINATE ARTERY BY RETROGRADE TREATMENT, OPEN IPSILATERAL CERVICAL CAROTID ARTERY EXPOSURE, INCLUDING ANGIOPLASTY, WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION

10/01/14 01/01/15

37218 TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), INTRATHORACIC COMMON CAROTID ARTERY OR INNOMINATE ARTERY, OPEN OR PERCUTANEOUS ANTEGRADE APPROACH, INCLUDING ANGIOPLASTY, WHEN PERFORMED, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION

01/01/15

37241 VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHER THAN HEMORRHAGE (EG, CONGENITAL OR ACQUIRED VENOUS MALFORMATIONS, VENOUS AND CAPILLARY HEMANGIOMAS, VARICES, VARICOCELES) (PPA REQUIRED

01/01/14



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

ONLY WHEN performing SELECTIVE INTERNAL RADIATION THERAPY FOR TUMORS OF THE LIVER, TRANSCATHETER CHEMOEMBOLIZATION OF THE HEPATIC ARTERY, Embolization of the pelvic veins for treatment of pelvic congestion syndrome Varicose Vein Treatment , and Treatment of Benign Prostatic Hypertrophy)

37243 VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR TUMORS, ORGAN ISCHEMIA, OR INFARCTION (PPA REQUIRED ONLY WHEN performing SELECTIVE INTERNAL RADIATION THERAPY FOR TUMORS OF THE LIVER, TRANSCATHETER CHEMOEMBOLIZATION OF THE HEPATIC ARTERY, Embolization of the pelvic veins for treatment of pelvic congestion syndrome, and Treatment of Benign Prostatic Hypertrophy)

01/01/14

37244 VASCULAR EMBOLIZATION OR OCCLUSION, INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR ARTERIAL OR VENOUS HEMORRHAGE OR LYMPHATIC EXTRAVASATION (PPA REQUIRED ONLY WHEN performing SELECTIVE INTERNAL RADIATION THERAPY FOR TUMORS OF THE LIVER, TRANSCATHETER CHEMOEMBOLIZATION OF THE HEPATIC ARTERY, Embolization of the pelvic veins for treatment of pelvic congestion syndrome, Varicose Vein Treatment, and Treatment of Benign Prostatic Hypertrophy)

01/01/14

37500 VASCULAR ENDOSCOPY, SURGICAL, WITH LIGATION OF PERFORATOR VEINS, SUBFASCIAL (SEPS)

10/01/06

37700 LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS

07/01/05

37718 LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN 01/01/06

37722 LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW

01/01/06

37735 LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS VEINS WITH RADICAL EXCISION OF ULCER AND SKIN GRAFT AND/OR INTERRUPTION OF COMMUNICATING VEINS OF LOWER LEG, WITH EXCISION OF DEEP FASCIA

07/01/05

37760 LIGATION OF PERFORATOR VEINS, SUBFASCIAL, RADICAL (LINTON TYPE) WITH OR WITHOUT SKIN GRAFT, OPEN

04/01/06

37761 LIGATION OF PERFORATOR VEIN(S), SUBFASCIAL, OPEN, INCLUDING ULTRASOUND GUIDANCE, WHEN PERFORMED, 1 LEG

01/01/10



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

37765 STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY, 10-20 STAB INCISIONS 07/01/05

37766 STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY, MORE THAN 20 INCISIONS 07/01/05

37780 LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE)

07/01/05

37785 LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTER(S), ONE LEG 07/01/05

37799 UNLISTED PROCEDURE, VASCULAR SURGERY (“when associated with varicose vein treatment”

04/01/13 07/01/13

38206 BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR TRANSPLANTATION, PER COLLECTION; AUTOLOGUS

10/01/13 01/01/14

38230 BONE MARROW HARVESTING FOR TRANSPLANTATION: ALLOGENEIC 07/01/05

38232 BONE MARROW HARVESTING FOR TRANSPLANTATION: AUTOLOGOUS 01/01/12

38240 HEMATOPOIETIC PROGENITOR CELL (HPC); ALLOGENEIC TRANSPLANTATION PER DONOR

07/01/05

38241 HEMATOPOIETIC PROGENITOR CELL (HPC); AUTOLOGOUS TRANSPLANTATION 07/01/05

38243 HEMATOPOIETIC PROGENITOR CELL (HPC); HPC BOOST 01/01/13

41120 GLOSSECTOMY; LESS THAN ONE-HALF TONGUE 07/01/05

41512 TONGUE BASE SUSPENSION, PERMANENT SUTURE TECHNIQUE 01/01/09

41530 SUBMUCOSAL ABLATION OF THE TONGUE BASE, RADIOFREQUENCY, ONE OR MORE SITES, PER SESSION

01/01/09

42145 PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY)

07/01/05

42299 UNLISTED PROCEDURE, PALATE, UVULA 07/01/05

43633 GASTRECTOMY, PARTIAL, DISTAL; WITH ROUX-EN-Y RECONSTRUCTION 07/01/05

43644 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)

07/01/05

43645 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION

07/01/05

43647 LAPAROSCOPY, SURGICAL; IMPLANTATION OR REPLACEMENT OF GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM

01/01/07

43648 LAPAROSCOPY, SURGICAL; REVISION OR REMOVAL OF GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM

01/01/07

43659 UNLISTED LAPAROSCOPY PROCEDURE, STOMACH 07/01/05

43770 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC BAND (GASTRIC BAND AND SUBCUTANEOUS PORT

01/01/06



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

COMPONENTS)

43771 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REVISION OF ADJUSTABLE GASTRIC BAND COMPONENT ONLY

01/01/06

43772 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC BAND COMPONENT ONLY

01/01/06

43773 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL AND REPLACEMENT OF ADJUSTABLE GASTRIC BAND COMPONENT ONLY

01/01/06

43774 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS

01/01/06

43775 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY)

01/01/10

43842 GASTRIC RESTRICTIVE PROCEDURE, WITHOUT GASTRIC BYPASS, FOR MORBID OBESITY; VERTICAL-BANDED GASTROPLASTY

07/01/05

43843 GASTRIC RESTRICTIVE PROCEDURE, WITHOUT GASTRIC BYPASS, FOR MORBID OBESITY; OTHER THAN VERTICAL-BANDED GASTROPLASTY

07/01/05

43845 GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS-PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH)

07/01/05

43846 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY

07/01/05

43847 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION

07/01/05

43848 REVISION, OPEN, OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID OBESITY, OTHER THAN ADJUSTABLE GASTRIC BAND (SEPARATE PROCEDURE)

07/01/05

43881 IMPLANTATION OR REPLACEMENT OF GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM, OPEN

01/01/07

43882 REVISION OR REMOVAL OF GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM, OPEN 01/01/07

43886 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY

01/01/06

43887 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL OF SUBCUTANEOUS PORT COMPONENT ONLY

01/01/06

43888 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL AND REPLACEMENT OF SUBCUTANEOUS PORT COMPONENT ONLY

07/01/05

43999 UNLISTED PROCEDURE, STOMACH 07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

44132 DONOR ENTERECTOMY (INCLUDING COLD PRESERVATION), OPEN; FROM CADAVER DONOR

07/01/08

44133 DONOR ENTERECTOMY (INCLUDING COLD PRESERVATION), OPEN;PARTIAL, FROM LIVING DONOR

07/01/08

44135 INTESTINAL ALLOTRANSPLANTATION; FROM CADAVER DONOR 07/01/05

44136 INTESTINAL ALLOTRANSPLANTATION; FROM LIVING DONOR 07/01/05

44202 LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESECTION OF SMALL INTESTINE, SINGLE RESECTION AND ANASTOMOSIS (PPA REQUIRED ONLY WHEN PERFORMED AS PART OF BARIATRIC SURGERY)

04/01/16 07/01/16

44705 PREPARATION OF FECAL MCROBIOTA FOR INSTILLATION, INCLUDING ASSESSMENT OF DONOR SPECIMEN

07/01/14 10/01/14

44715 BACKBENCH STANDARD PREPATATION OF CADAVER OR LIVING DONOR INTESTINE ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING MOBILIZATION AND FASHINIONG OF THE SUPERIOR MESENTERIC ARTERY AND VEIN

07/01/08

44720 BACKBENCH RECOSTRUCTION OF CADAVER OR LIVING DONOR INTESTINE ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH

07/01/08

44721 BACKBENCH RECOSTRUCTION OF CADAVER OR LIVING DONOR INTESTINE ALLOGRAFT PRIOR TO TRANSPLANTATION ARTERIAL ANASTOMOSIS, EACH

07/01/08

47135 LIVER ALLOTRANSPLANTATION; ORTHOTOPIC, PARTIAL OR WHOLE, FROM CADAVER OR LIVING DONOR, ANY AGE

07/01/05

47379 UNLISTED LAPAROSCOPIC PROCEDURE, LIVER ( PPA REQUIRED ONLY WHEN USED FOR MORBID OBESITY )

10/01/16 01/01/17

47399 UNLISTED PROCECURE, LIVER (PPA REQUIRED ONLY WHEN USED FOR LIVER TRANSPLANTATION HETEROTOPIC)

48160 PANCREATECTOMY, TOTAL OR SUBTOTAL, WITH AUTOLOGOUS TRANSPLANTATION OF PANCREAS OR PANCREATIC ISLET CELLS

07/01/05

48554 TRANSPLANTATION OF PANCREATIC ALLOGRAFT 07/01/05

49329 UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN ,PERITONEUM AND OMENTUM ( PPA REQUIRED ONLY WHEN USED FOR MORBID OBESITY )

10/01/16 01/01/17

50250 ABLATION, OPEN, ONE OR MORE RENAL MASS LESION(S), CRYOSURGICAL, INCLUDING INTRAOPERATIVE ULTRASOUND, IF PERFORMED

01/01/07

50542 ABLATION OF RENAL MASS LESION(S) 04/01/07

50592 ABLATION, ONE OR MORE RENAL TUMOR(S) PERCUTANEOUS, UNILATERAL, RADIOFREQUENCY

01/01/07

50593 ABLATION, RENAL TUMOR(S) UNILATERAL, PERCUTANEOUS, CRYOTHERAPY 01/01/08



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

52287 CYSTOURETHROSCOPY, WITH INJECTION(S) FOR CHEMODENERVATION OF THE BLADDER

01/01/13

52441 CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; SINGLE IMPLANT

04/01/18 07/01/18

52442 CYSTOURETHROSCOPY, WITH INSERTION OF PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT; EACH ADDITIONAL PERMANENT ADJUSTABLE TRANSPROSTATIC IMPLANT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE

04/01/18 07/01/18

54660 INSERTION OF TESTICULAR PROSTHESIS (SEPARATE PROCEDURE) 10/01/16 01/01/17

55706 BI0PSIES, PROSTATE, NEEDLE, TRANSPERINEAL, STEREOSTATIC TEMPLATE GUIDED SATURATION SAMPLING, INCLUDING IMAGING GUIDANCE

01/01/09

55970 INTERSEX SURGERY; MALE TO FEMALE 10/01/16 01/01/17

55980 INTERSEX SURGERY; FEMALE TO MALE 10/01/16 01/01/17

56800 PLASTIC REPAIR OF INTROITUS 10/01/16 01/01/17

56805 CLITOROPLASTY FOR INTERSEX STATE 10/01/16 01/01/17

57291 CONSTRUCTION OF ARTIFICIAL VAGINA; WITHOUT GRAFT 01/01/05

57292 CONSTRUCTION OF ARTIFICIAL VAGINA; WITH GRAFT 07/01/05

57295 REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; VAGINAL APPROACH

10/01/16 01/01/17

57296 REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; OPEN ABDOMINAL APPROACH

01/01/07

57335 VAGINOPLASTY FOR INTERSEX STATE 10/01/16 01/01/17

57426 REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT, LAPAROSCOPIC APPROACH

01/01/10

62287 DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL DISK, ANY METHOD, UTILIZING NEEDLE BASED TECHNIQUE TO REMOVE DISC MATERIAL UNDER FLUROSCOPIC 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

07/01/05

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

01/01/17

63650 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, EPIDURAL 07/01/08



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

63655 LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, PLATE/PADDLE, EPIDURAL

07/01/08

63661 REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED

01/01/10

63662 REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERORMED

01/01/10

63663 REVISION INCLUDING REPLACEMENT, WHEN PEROFRMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOOPY, WHEN PERFORMED

01/01/10

63664 REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED

01/01/10

63685 INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING

07/01/08

63688 REVISION OR REMOVAL O IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER

07/01/08

64565 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; NEUROMUSCULAR

10/01/06 01/01/18

64566 POSTERIOR TIBIAL NEURSTIMULATION, PERCUTANEOUS NEEDLE ELECTRODE, SINGLE TREATMENT, INCLUDES PROGRAMMING

04/01/14 07/01/14

64580 INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY; NEUROMUSCULAR

10/01/06

64615 CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL, TRIGEMINAL, CERVICAL SPINAL AND ACCESSORY NERVES, BILATERAL (EG, FOR CHRONIC MIGRAINE)

1/01/13

64616 CHEMODENERVATION OF MUSCLE(S); NECK MUSCLE(S), EXCLUDING MUSCLES OF THE LARYNX, UNILATERAL (EG, FOR CERVICAL DYSTONIA, SPASMODIC TORTICOLLIS)

01/01/14

64617 CHEMODENERVATION OF MUSCLE(S); LARYNX, UNILATERAL, PERCUTANEOUS (EG, FOR SPASMODIC DYSPHONIA), INCLUDES GUIDANCE BY NEEDLE ELECTROMYOGRAPHY, WHEN PERFORMED

01/01/14

64633 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE(FLUROSCOPY OR CT);CERVICAL OR THORACIC, SINGLE FACET JOINT

01/01/12 04/01/12

64634 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE(FLUROSCOPY OR CT);CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPERATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/12 04/01/12



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

64635 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE(FLUROSCOPY OR CT);LUMBAR OR SACRAL, SINGLE FACET JOINT

01/01/12 04/01/12

64636 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE(FLUROSCOPY OR CT);LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPERATELY IN ADDITION TO CODE FOR PRIMACY PROCEDURE)

01/01/12 04/01/12

64650 CHEMODENERVATION OF ECCRINE GLANDS; BOTH AXILLAE 01/01/06

64653 CHEMODENERVATION OF ECCRINE GLANDS; OTHER AREA(S) (EG, SCALP, FACE, NECK), PER DAY

01/01/06

64999 UNLISTED PROCEDURE, NERVOUS SYSTEM (PPA WILL BE REQUIRED FOR HYPERHIDROSIS)

01/01/15 04/01/15

65756 KERATOPLASTY (CORNEAL TRANSPLANT); ENDOTHELIAL 01/01/10

65757 BACKBENCH PREPARATION OF CORNEAL ENDOTHELIAL ALLOGRAFT PRIOR TO TRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

01/01/10

65785 IMPLANTATION OF INTRASTROMAL CORNEAL RING SEGMENTS 01/01/16

66183 INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH

04/01/17 07/01/17

67027 IMPLANTATION OF INTRAVITREAL DRUG DELIVERY SYSTEM (EG, GANCICLOVIR IMPLANT), INCLUDES CONCOMITANT REMOVAL OF VITREOUS

04/01/17 07/01/17

67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL APPROACH) 07/01/05

67901 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA)

07/01/05

67902 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA)

07/01/05

67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH

07/01/05

67904 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION ORADVANCEMENT, EXTERNAL APPROACH

07/01/05

67906 REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA)

07/01/05

67908 REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER’S MUSCLE-LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE)

07/01/05

67914 REPAIR OF ECTROPION; SUTURE 07/01/05

67916 REPAIR OF ECTROPION; EXCISION TARSAL WEDGE 07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

67917 REPAIR OF ECTROPION; EXTENSIVE (EGTARSAL STRIP OPERATIONS) 07/01/05

67921 REPAIR OF ENTROPION; SUTURE 07/01/05

67923 REPAIR OF ENTROPION; BLEPHAROPLASTY, EXCISION TARSAL WEDGE 07/01/05

67924 REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION)

07/01/05

69714 IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITHOUT MASTOIDECTOMY

07/01/06

69715 IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR WITH MASTOIDECTOMY

07/01/06

69717 REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITHOUT MASTOIDECTOMY

04/01/07

69718 REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR WITH MASTOIDECTOMY

04/01/07

69930 COCHLEAR DEVICE IMPLANTATION, WITH OR WITHOUT MASTOIDECTOMY 07/01/05

75894 TRANSCATHER THERAPY, EMBOLIZATION, ANY METHOD, RADIOLOGICAL SUPERVISION AND INTERPRETIATION APPLIES TO SELECTIVE INTERNAL RADIATION THERAPY FOR TUMORS OF THE LIVER, AND TRANSCATHETER CHEMOEMBOLIZATION OF THE HEPATIC ARTERY OR OVARIAN AND INTERNAL ILIAC VEIN EMBOLIZATION FOR PELVIC CONGESTION SYNDROME

07/01/09

77371 RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; MULTI-SOURCE COBALT 60 BASED

04/01/17 07/01/17

77372 RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; LINEAR ACCELERATOR BASED

04/01/17 07/01/17

77373 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS

07/01/09

77385 INTENSITY MODULATED RADIATION TREATMENT DELIVERY (IMRT), INCLUDES GUIDANCE AND TRACKING, WHEN PERFORMED; SIMPLE

01/01/15

77386 INTENSITY MODULATED RADIATION TREATMENT DELIVERY (IMRT), INCLUDES GUIDANCE AND TRACKING, WHEN PERFORMED; COMPLEX SIMPLE

01/01/15



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

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

07/01/09

77520 PROTON TREATMENT DELIVERY; SIMPLE, WITHOUT COMPENSATION 02/15/11

77522 PROTON TREATMENT DELIVERY, SIMPLE, WITH COMPENSATION 02/15/11

77523 PROTON TREATMENT DELIVERY, INTERMEDIATE 02/15/11

77525 PROTON TREATMENT DELIVERY, COMPLEX 02/15/11

77767 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE SKIN SURFACE BRACHYTHERAPY, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED; LESION DIAMETER UP TO 2.0 CM OR 1 CHANNEL

01/01/16

77768 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE SKIN SURFACE BRACHYTHERAPY, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED; LESION DIAMETER OVER 2.0 CM AND 2 OR MORE CHANNELS, OR MULTIPLE LESIONS

01/01/16

77770 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE INTERSTITIAL OR INTRACAVITARY BRACHYTHERAPY, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED; 1 CHANNEL (PPA REQUIRED WHEN ASSOCIATED WITH BREAST CANCER TREATMENT )

01/01/16

77771 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE INTERSTITIAL OR INTRACAVITARY BRACHYTHERAPY, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED; 2-12 CHANNELS (PPA REQUIRED WHEN ASSOCIATED WITH BREAST CANCER TREATMENT )

01/01/16

77772 REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE INTERSTITIAL OR INTRACAVITARY BRACHYTHERAPY, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED; OVER 12 CHANNELS (PPA REQUIRED WHEN ASSOCIATED WITH BREAST CANCER TREATMENT )

01/01/16

79445 RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTERIAL PARTICULATE ADMINSTRATION 10/04/08

81162 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS AND FULL DUPLICATION/DELETION ANALYSIS

01/01/16

81211 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS AND COMMON DUPLICATION/DELETION VARIANTS IN BRCA1 (IE, EXON 13 DEL 3.835KB, EXON 13 DUP 6KB, EXON 14-20 DEL 26KB, EXON 22 DEL 510BP, EXON 8-9 DEL 7.1KB)

04/01/15 07/01/15

81212 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; 185DELAG, 5385INSC, 6174DELT VARIANTS

04/01/15 07/01/15

81213 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND OVARIAN 04/01/15 07/01/15



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

CANCER) GENE ANALYSIS; UNCOMMON DUPLICATION/DELETION VARIANTS

81214 BRCA1 (BREAST CANCER 1) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS AND COMMON DUPLICATION/DELETION VARIANTS (IE, EXON 13 DEL 3.835KB, EXON 13 DUP 6KB, EXON 14-20 DEL 26KB, EXON 22 DEL 510BP, EXON 8-9 DEL 7.1KB)

04/01/15 07/01/15

81215 BRCA1 (BREAST CANCER 1) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; KNOWN FAMILIAL VARIANT

04/01/15 07/01/15

81216 BRCA2 (BREAST CANCER 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS

04/01/15 07/01/15

81217 BRCA2 (BREAST CANCER 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER) GENE ANALYSIS; KNOWN FAMILIAL VARIANT

04/01/15 07/01/15

81413 CARDIAC ION CHANNELOPATHIES (EG, BRUGADA SYNDROME, LONG QT SYNDROME, SHORT QT SYNDROME, CATECHOLAMINERGIC POLYMORPHIC VENTRICULAR TACHYCARDIA); GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF AT LEAST 10 GENES, INCLUDING ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, AND SCN5A

01/01/17

81414 CARDIAC ION CHANNELOPATHIES (EG, BRUGADA SYNDROME, LONG QT SYNDROME, SHORT QT SYNDROME, CATECHOLAMINERGIC POLYMORPHIC VENTRICULAR TACHYCARDIA); DUPLICATION/DELETION GENE ANALYSIS PANEL, MUST INCLUDE ANALYSIS OF AT LEAST 2 GENES, INCLUDING KCNH2 AND KCNQ1

01/01/17

81415 EXOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); SEQUENCE ANALYSIS (PPA REQUIRED FOR ALL INDICATIONS OTHER THAN ONCOLOGIC OR MATERNITY)

01/01/15

81416 EXOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); SEQUENCE ANALYSIS, EACH COMPARATOR EXOME (EG, PARENTS, SIBLINGS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) (PPA REQUIRED FOR ALL INDICATIONS OTHER THAN ONCOLOGIC OR MATERNITY)

01/01/15

81417 EXOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); RE-EVALUATION OF PREVIOUSLY OBTAINED EXOME SEQUENCE (EG, UPDATED KNOWLEDGE OR UNRELATED CONDITION/SYNDROME) (PPA REQUIRED FOR ALL INDICATIONS OTHER THAN ONCOLOGIC OR MATERNITY)

01/01/15

81425 GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); SEQUENCE ANALYSIS (PPA REQUIRED FOR ALL INDICATIONS OTHER THAN ONCOLOGIC OR MATERNITY)

01/01/15

81426 GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); SEQUENCE ANALYSIS, EACH COMPARATOR GENOME (EG, PARENTS,

01/01/15



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

SIBLINGS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) (PPA REQUIRED FOR ALL INDICATIONS OTHER THAN ONCOLOGIC OR MATERNITY)

81427 GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME); RE-EVALUATION OF PREVIOUSLY OBTAINED GENOME SEQUENCE (EG, UPDATED KNOWLEDGE OR UNRELATED CONDITION/SYNDROME) (PPA REQUIRED FOR ALL INDICATIONS OTHER THAN ONCOLOGIC OR MATERNITY)

01/01/15

81519 ONCOLOGY (BREAST), MRNA, GENE EXPRESSION PROFILING BY REAL-TIME RT-PCR OF 21 GENES, UTILIZING FORMALIN-FIXED PARAFFIN EMBEDDED TISSUE, ALGORITHM REPORTED AS RECURRENCE SCORE

01/01/15

81520 ONCOLOGY (BREAST), MRNA GENE EXPRESSION PROFILING BY HYBRID CAPTURE OF 58 GENES (50 CONTENT AND 8 HOUSEKEEPING), UTILIZING FORMALIN-FIXED PARAFFIN-EMBEDDED TISSUE, ALGORITHM REPORTED AS A RECURRENCE RISK SCORE

01/01/18

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

07/01/17 10/01/17

90283 IMMUNE GLOBULIN(IGIV), HUMAN, FOR INTRAVENOUS USE 01/01/10

90284 IMMUNE GLOBULIN (SCIG), HUMAN, FOR USE IN SUBCUTANEOUS INFUSIONS 01/01/10

90378 RESPIRATORY SYNCYTIAL VIRUS, MONOCLONAL ANTIBODY, RECOMBINANT, FOR INTRAMUSCULAR USE, 50 MG, EACH

07/01/10

91110 GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH INTERPRETATION AND REPORT

07/01/08

91111 GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS WITH INTERPRETATION AND REPORT

04/01/09

92700 UNLISTED OTORHINOLARYNGOLOGICAL SERVICE OR PROCEDURE 07/01/05

92971 CARDIOASSIST-METHOD OF CIRCULATORY ASSIST; EXTERNAL 10/01/17 01/01/18

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; REVIEW AND INTERPRETATION WITH REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

01/01/09

93229 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

01/01/09



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

ATTENDED SURVEILLANCE CENTER FOR UP TO 30 DAYS; TECHNICAL SUPPORT FOR CONNECTION AND PATIENT INSTRUCTIONS FOR USE, ATTENDED SURVEILLANCE, ANALYSIS AND TRANSMISSION OF DAILY AND EMERGENT DATA REPORTS AS PRESCRIBED BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

93260 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 BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL; IMPLANTABLE SUBCUTANEOUS LEAD DEFIBRILLATOR SYSTEM

01/01/15

93261 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; IMPLANTABLE SUBCUTANEOUS LEAD DEFIBRILLATOR SYSTEM

01/01/15

93292 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER; WEARABLE DEFIBRILLATOR SYSTEM

10/01/13 01/01/14

93644 ELECTROPHYSIOLOGIC EVALUATION OF SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR (INCLUDES DEFIBRILLATION THRESHOLD EVALUATION, INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING FOR ARRHYTHMIA TERMINATION, AND PROGRAMMING OR REPROGRAMMING OF SENSING OR THERAPEUTIC PARAMETERS)

01/01/15

93656 COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA INCLUDING LEFT OR RIGHT ATRIAL PACING/RECORDING WHEN NECESSARY, RIGHT VENTRICULAR PACING/RECORDING WHEN NECESSARY, AND HIS BUNDLE RECORDING WHEN NECESSARY WITH INTRACARDIAC CATHETER ABLATION OF ATRIAL FIBRILLATION BY PULMONARY VEIN ISOLATION

10/01/13 01/01/14

93657 ADDITIONAL LINEAR OR FOCAL INTRACARDIAC CATHETER ABLATION OF THE LEFT OR RIGHT ATRIUM FOR TREATMENT OF ATRIAL FIBRILLATION REMAINING AFTER COMPLETION OF PULMONARY VEIN ISOLATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

10/01/13 01/01/14

93745 INITIAL SET-UP AND PROGRAMMING BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL OF WEARABLE CARDIOVERTER-DEFIBRILLATOR INCLUDES INITIAL PROGRAMMING OF SYSTEM, ESTABLISHING BASELINE ELECTRONIC ECG, TRANSMISSION OF DATA TO DATA REPOSITORY, PATIENT INSTRUCTION IN WEARING SYSTEM AND

10/01/07



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

PATIENT REPORTING OF PROBLEMS OR EVENTS

95800 SLEEP STUDY, UNATTENDED, SIMULTANEOUS RECORDING, HEART RATE, OXYGEN SATURATION, RESPRATORY ANALYSIS (E.G., BY AIRFLOW OR PERIPHERAL ARTERIAL TONE), SLEEP TIME EFFECTIVE 12/01/17 BCBSNC WILL PERFORM PRIOR REVIEW FOR STATE HEALTH PLAN MEMBERS ONLY. ALL OTHER MEMBERS PLEASE REFER TO SLEEP MEDICINE PROGRAM FOR PRIOR REVIEW REQUIREMENTS

01/01/11

95801 SLEEP STUDY, UNATTENDED, SIMULTANEOUS RECORDING; MINIMUM OF HEART RATE, OXYGEN SATURATION, AND RESPIRATORY ANALYSIS (E.G., BY AIRFLOW OR PERIPHERAL ARTERIAL TONE) EFFECTIVE 12/01/17 BCBSNC WILL PERFORM PRIOR REVIEW FOR STATE HEALTH PLAN MEMBERS ONLY. ALL OTHER MEMBERS PLEASE REFER TO SLEEP MEDICINE PROGRAM FOR PRIOR REVIEW REQUIREMENTS

01/01/11

95806 SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN SATURATION, UNATTENDED BY A TECHNOLOGIST EFFECTIVE 12/01/17 BCBSNC WILL PERFORM PRIOR REVIEW FOR STATE HEALTH PLAN MEMBERS ONLY. ALL OTHER MEMBERS PLEASE REFER TO SLEEP MEDICINE PROGRAM FOR PRIOR REVIEW REQUIREMENTS

04/01/10

95965 MAGNETOENCEPHALOGRAPHY (MEG), RECORDING AND ANALYSIS; FOR SPONTANEOUS BRAIN MAGNETIC ACTIVITY (EG, EPILEPTIC CEREBRAL CORTEX LOCALIZATION)

10/04/08

95966 FOR EVOKED MAGNETIC FIELDS, SINGLE MODALITY(EG, SENSORY, MOTOR,LANGUAGE, OR VISUAL CORTEX LOCALIZATION)

10/04/08

95967 FOR EVOKED MAGNETIC FIELDS, EACH ADDITIONAL MODALITY (EG, SENSORY, MOTOR, LANGUAGE, OR VISUAL CORTEX LOCALIZATIONN)(LIST SEPARATEELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

10/04/08

95980 ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (E.G., RATE, PLULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABLIITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT MEASUREMENTS) GASTRIC NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER; INTRAOPERATIVE WITH PROGRAMMING

01/01/08

95981 ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (E.G., RATE, PLULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABLIITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT MEASUREMENTS) GASTRIC NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER; SUBSEQUESTN, WITHOUT PROGRAMMING

01/01/08

95982 ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (E.G., RATE, PLULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABLIITY, OUTPUT MODULATION, CYCLING,

01/01/08



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

IMPEDANCE AND PATIENT MEASUREMENTS) GASTRIC NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER; SUBSEQUESTN, WITH PROGRAMMING

97605 NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS

07/01/05

97606 NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICAL EQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS

07/01/05

97607 NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS

01/01/15

97608 NEGATIVE PRESSURE WOUND THERAPY, (EG, VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DISPOSABLE, NON-DURABLE MEDICAL EQUIPMENT INCLUDING PROVISION OF EXUDATE MANAGEMENT COLLECTION SYSTEM, TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTIONS FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS

01/01/15

99183 PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL ATTENDANCE AND SUPERVISION OF HYPERBARIC OXYGEN THERAPY, PER SESSION

07/01/07

99501 HOME VISIT FOR POSTNATAL ASSESSMENT AND FOLLOW UP CARE 01/01/06

99502 HOME VISIT FOR NEWBORN CARE AND ASSESSMENT 01/01/06

99503 HOME VISIT FOR RESPIRATORY THERAPY CARE (EG, BRONCHODILATOR, OXYGEN THERAPY, RESPIRATORY ASSESSMENT APNEA EVALUATION)

01/01/06

99504 HOME VISIT FOR MECHANICAL VENTILATION CARE 01/01/06

99505 HOME VISIT FOR STOMA CARE AND MAINTENANCE, INCLUDING COLOSTOMY AND CYSTOSTOMY

01/01/06

99506 HOME VISIT FOR INTRAMUSCULAR INJECTIONS 01/01/06

99509 HOME VIIST FOR ASSITANCE WITH ACTIVITES OF DAILY LIVING AND PERSONAL CARE 01/01/06

99511 HOME VISIT FOR FECAL IMPACTION MANAGEMENT AND ENEMA ADMINISTRATION 01/01/06

99512 HOME VISIT FOR HEMODIALYSIS PER DIEM 01/01/06



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

99600 UNLISTED HOME VISIT SERVICE/OR PROCEDURE 01/01/06

A0140 (INVALID FOR MEDICARE 1995.) NON-EMERGENCY TRANSPORTATIONAND AIR TRAVEL (PRIVATE OR COMMERCIAL), INTRA OR INTER-STATE.

01/01/06

A0430 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING).NON-EMERGENT TRANSPORT ONLY

01/01/06

A0431 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (ROTARY WING) NON-EMERGENT TRANSPORT ONLY

01/01/06

A0435 FIXED WING AIR MILEAGE, PER STATUTE MILE NON-EMERGENT TRANSPORT ONLY 01/01/06

A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE NON-EMERGENT TRANSPORT ONLY 01/01/06

A4555 ELECTRODE/TRANSDUCER FOR USE WITH ELECTRICAL STIMULATION DEVICE USED FOR CANCER TREATMENT, REPLACEMENT ONLY

01/01/14

A4600 SLEEVE FOR INTERMITTENT LIMB COMPRESSION DEVICE, REPLACEMENT ONLY, EACH 01/01/07

A7025 HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM VEST, REPLACEMENT FOR USE WITH PATIENT OWNED EQUIPMENT, EACH

07/01/05

A7026 HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM HOSE, REPLACEMENT FOR USE WITH PATIENT OWNED EQUIPMENT, EACH

07/01/05

A9272 MECHANICAL WOUND SUCTION, DISPOSABLE, INCLUDES DRESSING, ALL ACCESSORIES AND COMPONENTS, ANY TYPE EACH

01/01/12

A9699 RADIOPHARMACEUTICAL, THERAPEUTIC, NOT OTHERWISE CLASSIFIED

LUTATHERA (LUTETIUM LU 177 DOTATATE) 04/01/18

A9900 Miscellaneous DME supply, accessory, and/or service component of another HCPCS code ( PPA required only when associated with Tumor-Treating Fields Therapy for Glioblastoma)

10/01/13 01/01/14

C2644 Brachytherapy source, cesium-131 chloride [C codes for facility use only] 07/01/14

C9014 Injection, cerliponase alfa, 1 mg [for facility use only](Brineura) [for facility use only] 01/01/18

C9024 INJECTION, LIPOSOMAL, 1MG DAUNORUBICIN AND 2.27MG CYTARABINE (Vyxeos ™) [for facility use only] PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/18 04/01/18

C9028 INJECTION, INOTUZUMAB OZOGAMICIN, 0.1 MG (BESPONSA™) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/18

C9030 INJECTION, COPANLISIB, 1 MG (ALIQOPA™) PRIOR REVIEW NEEDED FOR INPATIENT 07/01/18 10/01/18



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

C9031 LUTETIUM LU 177, DOTATATE, THERAPEUTIC, 1 MCI 07/01/18

C9032 INJECTION, VORETIGENE NEPARVOVEC-RZYL, 1 BILLION VECTOR GENOME 07/01/18

C9399 UNCLASSIFIED DRUGS OR BIOLOGICALS [C CODES FOR FACILITIES ONLY]

NEW TO MARKET SPECIALITY DRUGS COVERED UNDER MEDICAL BENEFITS ** (REGARDLESS OF THE CODE USED FOR BILLING)

07/01/17 10/01/17

HYQVIA 01/01/15 04/01/15

ALEMTUZUMAB (LEMTRADA) 01/01/15 04/01/15

OPDIVO 04/01/15 07/01/15

SEBELIPASE ALFA (KANUMA) 07/01/15 03/01/16

KYBELLA 07/01/15 10/01/15

EMPLICITI 04/01/16 07/01/16

DARZALEX 04/01/16 07/01/16

CINQAIR 07/01/16 10/01/16

STELARA® INTRAVENOUS EFFECTIVE 07/01/17 SEE Q9989 01/01/17

NUSINERSEN (SPINRAZA™) EFFECTIVE 07/01/17 SEE CODE C9489 04/01/17

CERLIPONASE ALFA (BRINEURA™) 07/01/17

EDARAVONE (RADICAVA™) EFFECTIVE 10/01/17 SEE CODE C9493 07/01/17

OCRELIZUMAB (OCREVUS™) EFFECTIVE 10/01/17 SEE CODE C9494 07/01/17 10/01/17

TISAGENLECLEUCEL (KYMRIAH ™) 10/01/17

DURVALUMAB (IMFINZI™) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/18 04/01/18

BENRALIZUMAB (FASENRA™) 02/01/18

LETERMOVIR (PREVYMIS™) 02/01/18

VORETIGENE NEPARVOVEC-RZYL ( LUXTURNA ™) 02/01/18

BUPRENORPHINE EXTENDED-RELEASE INJECTION (SUBLOCADE™) 02/01/18

FOSNETUPITANT AND PALONOSETRON INJECTION[AKYNZEO®] PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

07/13/18

C9463 INJECTION, APREPITANT, 1MG (CINVANTI™ ) 04/01/18 07/01/18



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

C9464 INJECTION, ROLAPITANT, 0.5MG (VARUBI™) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/18 07/01/18

C9465 HYALURONAN OR DERIVATIVE, DUROLANE, FOR INTRA-ARTICULAR INJECTION, PER DOSE

04/01/18

C9466 INJECTION, BENRALIZUMAB, 1MG ( FASENRA™) 04/01/18

C9467 INJECTION, RITUXIMB AND HYALURONIDASE, 10MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/18 07/01/18

C9483 INJECTION, ATEZOLIZUMAB, 10 MG (TECENTRIQ™] [FOR FACILITIES ONLY] 10/01/16 01/01/17 01/01/18

C9484 INJECTION, ETEPLIRSEN, 10 MG ( EXONDYS 51™) [FOR FACILITIES ONLY] EFFECTIVE 01/01/18 SEE CODE J1428

04/01/17 01/01/18

C9489 INJECTION, NUSINERSEN, 0.1 MG SPINRAZA™ EFFECTIVE 01/01/18 SEE J2326 07/01/17 01/01/18

C9490 INJECTION, BEZLOTOXUMAB, 10 MG ZINPLAVA™ 07/01/17 10/01/17 01/01/18

C9493 INJECTION, EDARAVONE, 1 MG (RADICAVA™) 10/01/17

C9494 INJECTION, OCRELIZUMAB, 1 MG (OCREVUS™) EFFECTIVE 01/01/18 SEE J2350 10/01/17 01/01/18

C9734 FOCUSED ULTRASOUND ABLATION/THERAPEUTIC INTERVENTION, OTHER THAN UTERINE LEIOMYOMATA, WITH MAGNETIC RESONANCE (MR) GUIDANCE [for facility use only]

04/01/13

C9739 CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 1 TO 3 IMPLANT

04/01/18 07/01/18

C9740 CYSTOURETHROSCOPY, WITH INSERTION OF TRANSPROSTATIC IMPLANT; 4 OR MORE IMPLANTS

04/01/18 07/01/18

D8010 LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION 10/01/14 01/01/15

D8020 LIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION 10/01/14 01/01/15

D8030 LIMITED ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION 10/01/14 01/01/15

D8040 LIMITED ORTHODONTIC TREATMENT OF THE ADULT DENTITION 10/01/14 01/01/15



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

D8050 INTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION 10/01/14 01/01/15

D8060 INTERCEPTIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION 10/01/14 01/01/15

D8070 PERIODIC ORTHODONTIC TREATMENT VISIT (AS PART OF CONTRACT) 10/01/14 01/01/15

D8080 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION 10/01/14 01/01/15

D8090 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT DENTITION 10/01/14 01/01/15

D8210 REMOVABLE APPLIANCE THERAPY 10/01/14 01/01/15

D8220 FIXED APPLIANCE THERAPY 10/01/14 01/01/15

D8660 PRE-ORTHODONTIC VISIT 10/01/14 01/01/15

D8670 PERIODIC ORTHODONTIC TREATMENT VISIT (AS PART OF CONTRACT) 10/01/14 01/01/15

D8680 ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND PLACEMENT OF RETAINERS)

10/01/14 01/01/15

E0193 POWERED AIR FLOTATION BED (LOW AIR LOSS THERAPY) 07/01/05

E0194 AIR FLUIDIZED BED 07/01/05

E0265 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT, AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS

04/01/07

E0266 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITH ANY TYPE SIDE RAILS, WITHOUT MATTRESS

07/01/05

E0270 HOSPITAL BED, INSTITUTIONAL TYPE INCLUDES: OSCILLATING, CIRCULATING AND STRYKER FAME, WITH MATTRESS

07/01/05

E0277 POWERED PRESSURE-REDUCING AIR MATTRESS 07/01/05

E0296 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS, WITH MATTRESS

07/01/05

E0297 HOSPITAL BED, TOTAL ELECTRIC (HEAD, FOOT AND HEIGHT ADJUSTMENTS), WITHOUT SIDE RAILS, WITHOUT MATTRESS

07/01/05

E0329 HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCEHES ABOVE THE SPRING, INCLUDES MATTRESS

01/01/08

E0371 NON POWERED ADVANCED PRESSURE REDICOMG OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH & WIDTH

10/01/06

E0372 POWERED AIR OVERLAY FOR MATTRESS, STANDARD MATTRESS LENGTH & WIDTH 10/01/06

E0373 NON POWERED ADVANCED PRESSURE REDUCING MATTRESS 10/01/06

E0457 CHEST SHELL (CUIRASS) 07/01/05

E0470 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK

07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

(INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRSSURE DEVICE) EFFECTIVE 12/01/17 BCBSNC WILL PERFORM PRIOR REVIEW FOR STATE HEALTH PLAN MEMBERS ONLY. ALL OTHER MEMBERS PLEASE REFER TO SLEEP MEDICINE PROGRAM FOR PRIOR REVIEW REQUIREMENTS

E0471 RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE) EFFECTIVE 12/01/17 BCBSNC WILL PERFORM PRIOR REVIEW FOR STATE HEALTH PLAN MEMBERS ONLY. ALL OTHER MEMBERS PLEASE REFER TO SLEEP MEDICINE PROGRAM FOR PRIOR REVIEW REQUIREMENTS

10/01/06

E0481 INTRAPULMONARY PERCUSSIVE VENTILATION SYSTEM AND RELATED ACCESSORIES 10/01/06

E0483 HIGH FREQUENCY CHEST WALL OSCILLATION AIR-PULSE GENERATOR SYSTEM, (INCLUDES HOSES AND VEST), EACH

07/01/05

E0486 ORAL DEVICE/APPLIANCE USED TO REDUCE UPPER AIRWAY COLLAPSIBILITY, ADJUSTABLE, OR NONADJUSTABLE, CUSTOM FABRICATED INCLUDES FITTING AND ADJUSTMENT EFFECTIVE 12/01/17 BCBSNC WILL PERFORM PRIOR REVIEW FOR STATE HEALTH PLAN MEMBERS ONLY. ALL OTHER MEMBERS PLEASE REFER TO SLEEP MEDICINE PROGRAM FOR PRIOR REVIEW REQUIREMENTS

04/01/13 07/01/13

E0641 STANDING FRAME/TABLE SYSTEM, MULTI-POSITION (E.G. THREE-WAY STANDER), ANY SIZE INCLUDING PEDIATRIC, WITH OR WITHOUT WHEELS (REQUIRED FOR STATE HEALTH PLAN ONLY AS OF 10/1/12)

01/01/06

E0642 STANDING FRAME/TABLE SYSTEM, MOBILE (DYNAMIC STANDER), ANY SIZE INCLUDING PEDIATRIC (REQUIRED FOR STATE HEALTH PLAN ONLY AS OF 10/1/12)

01/01/06

E0652 PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED GRADIENT PRESSURE

07/01/05

E0656 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, TRUNK 01/01/09

E0657 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, CHEST 01/01/09

E0670 SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, INTEGRATED, 2 FULL LEGS AND TRUNK

01/01/13

E0740 INCONTINENCE TREATMENT SYSTEM, PELVIC FLORR STIMULATOR, MONITOR, SENSOR, AND/OR TRAINER NON-IMPLANTED PELVIC FLOOR ELECTRICAL STIMULATOR, COMPLETE SYSTEM

10/01/09

E0745 NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT ( PPA REQUIRED ONLY FOR URINARY AND FECAL INCONTINENCE INDICATIONS)

07/01/05

E0747 OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, OTHER THAN SPINAL 07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

APPLICATIONS

E0748 OSTEOGENESIS STIMULATOR, ELECTRICAL, NON-INVASIVE, SPINAL APPLICATIONS 07/01/05

E0749 OSTEOGENESIS STIMULATOR, ELECTRICAL,SURGICALLY IMPLANTED 07/01/05

E0760 OSTEOGENESIS STIMULATOR, LOW INTENSITY ULTRASOUND, NON-INVASIVE 07/01/05

E0762 TRANSCUTANEOUS ELECTRICAL JOINT STIMULATION DEVICE SYSTEM, INCLUDES ALL ACCESSORIES

01/01/06

E0764 FUNCTIONAL NEUROMUSCULAR STIMULATOR, TRANSCUTANEOUS STIMULATION OF MUSCLES OF AMBULATION WITH COMPUTER CONTROL, USED FOR WALKING BY SPINAL CORD INJURED, ENTIRE SYSTEM, AFTER COMPLETION OF TRAINING PROGRAM

01/01/06

E0766 ELECTRICAL STIMULATION DEVICE USED FOR CANCER TREATMENT, INCLUDES ALL ACCESSORIES, ANY TYPE

01/01/14

E0770 FUNCTIONAL ELECTRICAL STIMULATOR, TRANSCUTANEOUS STIMULATION OF NERVE AND/OR MUSCLE GROUPS, ANY TYPE, COMPLETE SYSTEM, NOT OTHEWISE SPECIFIED

01/01/09

E0935 CONTINUOUS PASSIVE MOTION EXERCISE DEVICE FOR USE ON KNEE ONLY 07/01/09

E0936 CONTINUOUS PASSIVE MOTION EXERCISE DEVICE FOR USE OTHER THAN KNEE 07/01/09

E0983

MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, JOYSTICK CONTROL

10/01/06

E0984

MANUAL WHEELCHAIR ACCESSORY, POWER ADD-ON TO CONVERT MANUAL WHEELCHAIR TO MOTORIZED WHEELCHAIR, TILLER CONTROL

10/01/06

E0986 MANUAL WHEELCHAIR ACCESSORY, PUSH-RIM ACTIVATED POWER ASSIST, SYSTEM 01/01/15 04/01/15

E0988 MANUAL WHEELCHAIR ACCESSORY, LEVER-ACTIVATED, WHEEL DRIVE, PAIR 01/01/12

E1002 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY 07/01/05

E1003 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITHOUT SHEAR REDUCTION

07/01/05

E1004 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, RECLINE ONLY, WITH MECHANICAL SHEAR REDUCTION

07/01/05

E1005 WHEELCHAIR ACCESSORY, POWER SEATNG SYSTEM, RECLINE ONLY, WITH POWER SHEAR REDUCTION

07/01/05

E1006 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITHOUT SHEAR REDUCTION

07/01/05

E1007 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH MECHANICAL SHEAR REDUCTION

07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

E1008 WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, COMBINATION TILT AND RECLINE, WITH POWER SHEAR REDUCTION

07/01/05

E1009 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, MECHANICALLY LINKED LEG ELEVATION SYSTEM, INCLUDING PUSHROD AND LEG REST, EACH

07/01/05

E1010 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, POWER LEG ELEVATION SYSTEM, INCLUDING LEG REST, PAIR

07/01/05

E1012 WHEELCHAIR ACCESSORY, ADDITION TO POWER SEATING SYSTEM, CENTER MOUNT POWER ELEVATING LEG REST/PLATFORM, COMPLETE SYSTEM, ANY TYPE, EACH

01/01/16

E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR, EACH 07/01/05

E1018 HEAVY DUTY SHOCK ABSORBER FOR HEAVY DUTY OR EXTRA HEAVY POWER WHEELCHAIR, EACH

07/01/05

E1399 DURABLE MEDICAL EQUIPMENT MISCELLANOUS WITH PURCHASE PRICE OF $1500.00 AND ABOVE

01/01/05

E2230 MANUAL WHEELCHAIR ACCESSORY, MANUAL STANDING SYSTEM 01/01/09

E2300 POWER WHEELCHAIR ACCESSORY, POWER SEAT ELEVATION SYSTEM, ANY TYPE 07/01/05

E2301 POWER WHEELCHAIR ACCESSORY, POWER STANDING SYSTEM,ANY TYPE 07/01/05

E2310 POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND ONE POWER SEAT IN SYSTEM MOTOR, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH, AND FIXED MOUNTING HARDWARE.

07/01/05

E2311 POWER WHEELCHAIR ACCESSORY, ELECTRONIC CONNECTION BETWEEN WHEELCHAIR CONTROLLER AND TWO OR MORE POWER SEATING SYSTEM MOTORS, INCLUDING ALL RELATED ELECTRONICS, INDICATOR FEATURE, MECHANICAL FUNCTION SELECTION SWITCH AND FIXED MOUNTING HARDWARE.

07/01/05

E2312 POWER WHEELCHAIR ACCESSORY, HAND OR CHIN CONTROL INTERFACE, MINI-PROPORTIONAL REMOVEL JOYSTICK, PROPORTIONAL, INCLUDING FIXED MOUNTING HARDWARE

01/01/08

E2313 POWER WHEELCHAIR ACCESSORY, HARNESS FOR UPGRADE TO EXPANDABLE CONTROLLER, INCLUDING ALL FASTENERS, CONNECTORS AND MOUNTING HARDWARE, EACH

01/01/08

E2321 POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, REMOTE JOYSTICK, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND FIXED MOUNTING HARDWARE

07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

E2322 POWER WHEELCHAIR ACCESSORY, HAND CONTROL INTERFACE, MULTIPLE MECHANICAL, NONPROPORTIONAL INCLUDING ALL RELATED ELECTRONICS MECHANICAL STOP SWITCH, AND FIXED MOUNTING HARDWARE

07/01/05

E2323 POWER WHEELCHAIR ACCESSORY, SPECIALTY JOYSTICK HANDLE FOR HAND CONTROL INTERFACE, PREFABRICATED

07/01/05

E2324 POWER WHEELCHAIR ACCESSORY, CHIN CUP FOR CHIN CONTROL INTERFACE 07/01/05

E2325 POWER WHEELCHAIR ACCESSORY, SIP AND PUFF INTERFACE, NONPROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, AND MANUAL SWINGWAY MOUNTING HARDWARE

07/01/05

E2326 POWER WHEELCHAIR ACCESSORY, BREATH TUBE KIT FOR SIP AND PUFF INTERFACE 07/01/05

E2327 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, MECHANICAL, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS, MECHANICAL DIRECTION CHANGE SWITCH AND FIXED MOUNTING HARDWARE

03/08/08

E2328 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL OR EXTREMITY CONTROL INTERFACE, PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE

07/01/05

E2329 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, CONTACT SWITCH MECHANISM, NONPROPORTIONAL INCLUDING ALL RELATED ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE.

07/01/05

E2330 POWER WHEELCHAIR ACCESSORY, HEAD CONTROL INTERFACE, PROXIMITY SWITCH MECHANISM, NONPROPORTIONAL, INCLUDING ALL RELATED 12/31/06ELECTRONICS, MECHANICAL STOP SWITCH, MECHANICAL DIRECTION CHANGE SWITCH, HEAD ARRAY, AND FIXED MOUNTING HARDWARE.

07/01/05

E2331 POWER WHEELCHAIR ACCESSORY, ATTENDANT CONTROL, AND PROPORTIONAL, INCLUDING ALL RELATED ELECTRONICS AND FIXED MOUNTING HARDWARE.

07/01/05

E2351

POWER WHEELCHAIR ACCESSORY, ELECTRONIC INTERFACE TO OPERATE SPEECH GENERATING DEVICE USING POWER WHEELCHAIR CONTROL INTERFACE

10/01/06

E2358 POWER WHEELCHAIR ACCESSORY, GROUP 34 NON-SEALED LEAD ACID BATTERY, EACH 01/01/12

E2359 POWER WHEELCHAIR ACCESSORY, GROUP 34 SEALED LEAD ACID BATTERY, EACH (E.G. GEL CELL, ABSORBED GLASSMAT)

01/01/12

E2368 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL MOTOR, REPLACEMENT ONLY 07/01/05

E2369 POWER WHEELCHAIR COMPONENT, DRIVE WHEEL GEAR BOX, REPLACEMENT ONLY 07/01/05

E2370 POWER WHEELCHAIR COMPONENT, INTEGRATED DRIVE WHEEL MOTOR AND GEAR BOX COMBINATION, REPLACEMENT ONLY

07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

E2371 POWER WHEELCHAIR ACCESSORY, GROUP 27 SEALED LEAD ACID BATTERY, (E.G. GEL CELL, ABSORBED GLASSMAT), EACH

01/01/06

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

01/01/07

E2374 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

01/01/07

E2375 POWER WHEELCHAIR ACCESSORY, NON-EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY

01/01/07

E2376 POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, REPLACEMENT ONLY

01/01/07

E2377 POWER WHEELCHAIR ACCESSORY, EXPANDABLE CONTROLLER, INCLUDING ALL RELATED ELECTRONICS AND MOUNTING HARDWARE, UPGRADE PROVIDED AT INITIAL ISSUE

01/01/07

E2378 POWER WHEELCHAIR COMPONENT, ACTUATOR, REPLACEMENT ONLY 01/01/13

E2381 POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2382 POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2383 POWER WHEELCHAIR ACCESSORY, INSERT FOR PNEUMATIC DRIVE WHEEL TIRE (REMOVABLE), ANY TYPE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2384 POWER WHEELCHAIR ACCESSORY, PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2385 POWER WHEELCHAIR ACCESSORY, TUBE FOR PNEUMATIC CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2386 POWER WHEELCHAIR ACCESSORY, FOAM FILLED DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2387 POWER WHEELCHAIR ACCESSORY, FOAM FILLED CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2388 POWER WHEELCHAIR ACCESSORY, FOAM DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2389 POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

E2390 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2391 POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE (REMOVABLE), ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2392 ‘POWER WHEELCHAIR ACCESSORY, SOLID (RUBBER/PLASTIC) CASTER TIRE WITH INTEGRATED WHEEL, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2394 POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2395 POWER WHEELCHAIR ACCESSORY, CASTER WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT ONLY, EACH

01/01/07

E2396 POWER WHEELCHAIR ACCESSORY, CASTER FORK, ANY SIZE, REPLACEMENT ONLY, EACH 01/01/07

E2402 NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP STATIONARY OR PORTABLE 07/01/05

E2500 SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, LESS THAN OR EQUAL TO 8 MINUTES RECORDING TIME

01/01/07

E2502 SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 8 MINUTES BUT LESS THAN OR EQUAL TO 20 MINUTES RECORDING TIME

01/01/07

E2504 SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 20 MINUTES BUT LESS THAN OR EQUAL TO 40 MINUTES RECORDING TIME

01/01/07

E2506 SPEECH GENERATING DEVICE, DIGITIZED SPEECH, USING PRE-RECORDED MESSAGES, GREATER THAN 40 MINUTES RECORDING TIME

01/01/07

E2508 SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH REQUIRING MESSAGE FORMULATION BY SPELLING AND ACCESS BY PHYSICAL CONTACT WITH THE DEVICE

01/01/07

E2510 SPEECH GENERATING DEVICE, SYNTHESIZED SPEECH, PERMITTING MULTIPLE METHODS OF MESSAGE FORMULATION AND DEVICE ACESS

01/01/07

E2511 SPEECH GENERATING SOFTWARE PROGRAM, FOR PERSONAL COMPUTER OR PERSONAL DIGITAL ASSISTANT

01/01/07

E2512 ACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEM 01/01/07

E2599 ACCESSORY FOR SPEECH GENERATING DEVICE, MOUNTING SYSTEM 01/01/07

E2610 WHEELCHAIR SEAT CUSHION, POWERED 07/01/05

E2626 WHEELCHAIR ACCESSORY, SHOULDER ELBOW,MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, ADJUSTABLE

01/01/12

E2627 WHEELCHAIR ACCESSORY SHOULDER ELBOW,MOBILE ARM SUPPORT ATTACHED TO 01/01/12



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

WHEELCHAIR, BALANCED, ADJUSTABLE RANCHO TYPE

E2628 WHEELCHAIR ACCESSORY SHOULDER ELBOW,MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED,RECLINING

01/01/12

E2629 WHEELCHAIR ACCESSORY SHOULDER ELBOW,MOBILE ARM SUPPORT ATTACHED TO WHEELCHAIR, BALANCED, FRICTION ARM SUPPORT (FRICTION DAMPENING TO PROXIMAL AND DISTAL JOINTS)

01/01/12

E2630 WHEELCHAIR ACCESSORY, SHOULDER ELBOW, MOBILE ARM SUPPORT, MONOSUPRESSION ARM AND HAND SUPPORT, OVERHEAD ELBOW FOREARM HAND SLING SUPPORT, YOKE TYPE SUSPENSION SUPPORT- UNITS LIMIT ALLOWABLE-2

01/01/12

E2631 WHEELCHAIR ACCESSORY, ADDITION TO MOBILE ARM SUPPORT, ELEVATING PROXIMAL ARM - UNITS LIMIT ALLOWABLE-2

01/01/12

E2632 WHEELCHAIR ACCESSORY, ADDITION TO MOBILE ARM SUPPORT, OFFSET OR LATERAL ROCKER ARM WITH ELASTIC BALANCE CONTROL-UNITS LIMIT ALLOWABLE-2

01/01/12

E2633 WHEELCHAIR ACCESSORY, ADDITION TO MOBILE ARM SUPPORT, SUPINATOR. - UNITS LIMIT ALLOWABLE-2

01/01/12

E8000 GAIT TRAINER, PEDIATRIC SIZE, POSTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

07/01/05

E8001 GAIT TRAINER, PEDIATRIC SIZE, UPRIGHT SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

07/01/05

E8002 GAIT TRAINER, PEDIATRIC SIZE, ANTERIOR SUPPORT, INCLUDES ALL ACCESSORIES AND COMPONENTS

07/01/05

G0156 SERVICES OF HOME HEALTH AIDE IN HOME HEALTH SETTING, EACH 15 MINUTES 01/01/09

G0162 SKILLED SERVICES BY A REGISTERED NURSE (RN) IN THE DELIVERY OF MANAGEMENT & EVAL OF THE PLAN OF CARE; EACH 15 MINUTES (HOME HEALTH OR HOSPICE SETTING)

01/01/11

G0166 EXTERNAL COUNTERPULSATION, PER TREATMENT SESSION 10/01/17 01/01/18

G0277 HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL

01/01/15

G0299 DIRECT SKILLED NURSING SERVICES OF A REGISTERED NURSE (RN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

01/01/16

G0300 DIRECT SKILLED NURSING SERVICES OF A LICENSE PRACTICAL NURSE (LPN) IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

01/01/16

G0339 IMAGE GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE SESSION, OR FIRST SESSION OF FRACTIONATED TREATEMENT

07/01/08



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

G0340 IMAGE GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOM PLUGGIN, FRACTIONATED TREATMENT, ALL LESIONS, PER SESSION, SECOND THROUGH FIFTH SESSIONS, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENT

07/01/08

G0341 PANCREATIC ISLET CELL TRANSPLANTATION, INCLUDES PORTAL VEIN CATHETERIZATION AND INFUSION

04/01/06

G0398 HOME SLEEP STUDY TEST (HST) WITH TYPE II PORTABLE MONITOR, UNATTENDED; MINIMUM OF 7 CHANNELS: EEG, EOG, EMG, ECT/HEART RATE, AIRFLOW, RESPIRATORY EFFORT AND OXYGEN SAUTRATION EFFECTIVE 12/01/17 BCBSNC WILL PERFORM PRIOR REVIEW FOR STATE HEALTH PLAN MEMBERS ONLY. ALL OTHER MEMBERS PLEASE REFER TO SLEEP MEDICINE PROGRAM FOR PRIOR REVIEW REQUIREMENTS

07/01/10

G0399 HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 ESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION EFFECTIVE 12/01/17 BCBSNC WILL PERFORM PRIOR REVIEW FOR STATE HEALTH PLAN MEMBERS ONLY. ALL OTHER MEMBERS PLEASE REFER TO SLEEP MEDICINE PROGRAM FOR PRIOR REVIEW REQUIREMENTS

07/01/10

G0400 HOME SLEEP TEST (HST) WITH TYPE IV PORTABLE MONITOR, UNATTENDED MINIMUS OF 3 CHANNELSE EFFECTIVE 12/01/17 BCBSNC WILL PERFORM PRIOR REVIEW FOR STATE HEALTH PLAN MEMBERS ONLY. ALL OTHER MEMBERS PLEASE REFER TO SLEEP MEDICINE PROGRAM FOR PRIOR REVIEW REQUIREMENTS

07/01/10

G0429 DERMAL FILLER INJECTION(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME (LDS)

07/01/15 10/01/15

G0455 PREPARATION WITH INSTILLATION OF FECAL MICROBIOTA BY ANY METHOD, INCLUING ASSESSMENT OF DONOR SPECIMENS

07/01/14 10/01/14

G0490 FACE-TO-FACE HOME HEALTH NURSING VISIT BY A RURAL HEALTH CLINIC (RHC) OR FEDERALLY QUALIFIED HEALTH CENTER (FQHC) IN AN AREA WITH A SHORTAGE OF HOME HEALTH AGENCIES. (SERVICES LIMITED TO RN OR LPN ONLY).

10/01/16

G0493 SKILLED SERVICES OF A REGISTERED NURSE (RN) FOR THE OBSERVATION AND ASSESSMENT OF THE PATIENT'S CONDITION, EACH 15 MINUTES (THE CHANGE IN THE PATIENT'S CONDITION REQUIRES SKILLED NURSING PERSONNEL TO IDENTIFY AND EVALUATE THE PATIENT'S NEED FOR POSSIBLE MODIFICATION OF TREATMENT IN THE HOME HEALTH OR HOSPICE SETTING)

01/01/17

G0494 SKILLED SERVICES OF A LICENSED PRACTICAL NURSE (LPN) FOR THE OBSERVATION AND ASSESSMENT OF THE PATIENT'S CONDITION, EACH 15 MINUTES (THE CHANGE IN THE PATIENT'S CONDITION REQUIRES SKILLED NURSING PERSONNEL TO IDENTIFY AND EVALUATE THE PATIENT'S NEED FOR POSSIBLE MODIFICATION OF TREATMENT IN THE

01/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

HOME HEALTH OR HOSPICE SETTING)

G0495 SKILLED SERVICES OF A REGISTERED NURSE (RN), IN THE TRAINING AND/OR EDUCATION OF A PATIENT OR FAMILY MEMBER, IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

01/01/17

G0496 SKILLED SERVICES OF A LICENSED PRACTICAL NURSE (LPN), IN THE TRAINING AND/OR EDUCATION OF A PATIENT OR FAMILY MEMBER, IN THE HOME HEALTH OR HOSPICE SETTING, EACH 15 MINUTES

01/01/17

G0516 INSERTION OF NON-BIODEGRADABLE DRUG DELIVERY IMPLANTS, 4 OR MORE (SERVICES FOR SUBDERMAL ROD IMPLANT)

01/01/18

G0517 REMOVAL OF NON-BIODEGRADABLE DRUG DELIVERY IMPLANTS, 4 OR MORE (SERVICES FOR SUBDERMAL IMPLANTS)

01/01/18

G0518 REMOVAL WITH REINSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANTS, 4 OR MORE (SERVICES FOR SUBDERMAL IMPLANTS)

01/01/18

G6015 INTENSITY MODULATED TREATMENT DELIVERY, SINGLE OR MULTIPLE FIELDS/ARCS, VIA NARROW SPATIALLY AND TEMPORALLY MODULATED BEAMS, BINARY, DYNAMIC MLC, PER TREATMENT SESSION

01/01/15

G6016 COMPENSATOR-BASED BEAM MODULATION TREATMENT DELIVERY OF INVERSE PLANNED TREATMENT USING 3 OR MORE HIGH RESOLUTION (MILLED OR CAST) COMPENSATOR, CONVERGENT BEAM MODULATED FIELDS, PER TREATMENT SESSION

01/01/15

J0129 INJECTION, ABATACEPT, 10 MG USE THIS CODE FOR ORENCIA 07/01/08

J0180 INJECTION, AGALSIDASE BETA, 1 MG 07/01/17 10/01/17

J0202 INJECTION, ALEMTUZUMAB, 1 MG 01/01/16

J0220 INJECTION, ALGLUCOSIDASE ALFA, 10 MG, NOT OTHERWISE SPECIFIED 07/01/17

J0221 INJECTION, ALGLUCOSIDASE ALFA, (LUMIZYME™), 10 MG 07/01/17 10/01/17

J0256 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), NOT OTHERWISE SPECIFIED, 10 MG

01/01/18 04/01/18

J0257 INJECTION, ALPHA 1 PROTEINASE INHIBITOR (HUMAN), (GLASSIA), 10 MG 01/01/18 04/01/18

J0490 INJECTION,BELIMUMAB, 10 MG (BENLYSTA ™) 01/01/12

J0565 INJECTION, BEZLOTOXUMAB, 10 MG 01/01/18

J0570 BUPRENORPHINE IMPLANT, 74.2 MG 01/01/17

J0585 BOTULINUM TOXIN TYPE A, PER UNIT 07/01/05

J0586 INJECTION, ABOBOTULINUMTOXINA, 5 UNITS 01/01/10

J0587 BOTULINUM TOXIN TYPE B, PER 100 UNITS 01/01/06

J0588 INJECTION,INCOBOTULINUM A 1 UNIT (XEOMIN) 01/01/12

J0596 INJECTION, C1 ESTERASE INHIBITOR (RECOMBINANT), RUCONEST, 10 UNITS 01/01/16



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

J0597 INJECTION, C-1 ESTERASE INHIBITOR (HUMAN) (BERINERT), 10 UNITS 07/01/12 10/01/12

J0598 INJECTION C-1 ESTERASE INHIBITOR (HUMAN) (CINRYZE), UNITS 07/01/12 10/01/12

J0717 INJECTION, CERTOLIZUMAB PEGOL, 1 MG 04/01/18 07/01/18

J0775 INJECTION, COLLAGENASE, CLOSTRIDIUM HISTOLYTICUM, 0.01 MG ( XIAFELX) 10/01/10

J0800 INJECTION, CORTICOTROPIN (HP ACTAR GEL)UP TO 40 UNITS 07/01/12 10/01/12

J0881 INJECTION, DARBEPOETIN ALFA, 1 MCG(NON--‐ESRD USE) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J0885 INJECTION, EPOETIN ALFA, (FOR NON--‐ESRD USE), 1000 UNITS PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J0897 INJECTION, DENOSUMAB 1 MG (PROLIA/XGEVA) FOR NON ONCOLOGY INDICATIONS PRIOR REVIEW REQUIRED FOR ALL MEMBERS CONTACT BCBSNC

01/01/12

J0897 INJECTION, DENOSUMAB 1 MG (PROLIA/XGEVA) FOR ONCOLOGY INDICATIONS PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J1290 INJECTION, ECALLANTIDE (KALBITOR) 1 MG 07/01/12 10/01/12

J1300 INJECTION, ECULIZUMAB, 10MG [SOLIRIS] 10/01/14 01/01/15

J1322 INJECTION, ELOSULFASE ALFA, 1 MG 07/01/17 10/01/17

J1325 INJECTION, EPOPROSTENOL, 0.5 MG 04/01/11

J1428 INJECTION, ETEPLIRSEN, 10MG 01/01/18

J1442 INJECTION, FILGRASTIM (G--‐CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J1447 INJECTION, TBO--‐FILGRASTIM, 1 MICROGRAM PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

J1453 INJECTION, FOSAPREPITANT, 1 MG ( FOR ONCOLOGY INDICATIONS ONLY) EFFECTIVE 04/01/17 PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

07/01/15 10/01/15

J1458 INJECTION, GALSULFASE, 1 MG 10/01/16 01/01/17

J1459 INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NONLYOPHILIZED (E.G., LIQUID), 500 MG

01/01/10

J1555 INJECTION, IMMUNE GLOBULIN (CUVITRU), 100 MG 01/01/18

J1556 INJECTION, IMMUNE GLOBULIN (BIVIGAM), 500 MG 01/01/14

J1557 INJECTION, IMMUNE GLOBULIN (GAMMAPLEX) IV, NON-LYOPHILIZED (E.G. LIQUID), 500MG-

01/01/12

J1559 INJECTION, IMMUNE GLOBULIN (HIZENTRA), 100 MG 07/01/10

J1561 INJECTION, IMMUNE GLOBULIN, (GAMUNEX-C/GAMMAKED), NON-LYOPHILIZED (E.G. LIQUID), 500 mg

01/01/10

J1562 INJECTION, IMMUNE GLOBULIN (VIVAGLBIN), 100 MG 01/01/10

J1566 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED(EG., POWDER), NOT OTHERWISE SPECIFIED, 500 MG

01/01/10

J1568 INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NONLYOPHILIZED (E.G., LIGUID), 500 MG

01/01/10

J1569 INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), NON-LYOPHILIZED, (E. G. LIQUID), 500 MG

01/01/10

J1572 INJECTION , IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, NONLYOPHILIZED (E.G., LIQUID) 500 MG

01/01/10

J1575 INJECTION, IMMUNE GLOBULIN/HYALURONIDASE, (HYQVIA), 100 MG IMMUNEGLOBULIN

01/01/16

J1599 INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON LYOPHILIZED (E.G.LIQUID), NOT OTHERWISE SPECIFIED, 500 MG

01/01/11

J1602 INJECTION, GOLIMUMAB, 1 MG, FOR INTRAVENOUS USE 01/01/14

J1627 INJECTION, GRANISETRON,EXTENDED-RELEASE, 0.1MG (SUSTOL® ) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT

04/01/18 07/01/18



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

J1743 INJECTION, IDURSULFASE, 1 MG 07/01/17 10/01/17

J1744 INJECTION, ICATIBANT, 1 MG 04/01/13 07/01/13

J1745 INJECTION, INFIXIMAB, 10 MG EXCLUDES BIOSIMILAR, USE THIS CODE FOR REMICADE 07/01/08

J1786 INJECTION, IMIGLUCERASE, 10 UNITS 07/01/15 10/01/15

J1930 INJECTION, LANREOTIDE, 1 MG 10/01/16 01/01/17

J1931 INJECTION, LARONIDASE, 0.1 MG 07/01/17

J2182 INJECTION, MEPOLIZUMAB, 1 MG 01/01/17

J2323 INJECTION, NATALIZUMAB, 1 MG 4/01/11

J2326 INJECTION, NUSINERSEN, 0.1 MG 01/01/18

J2350 INJECTION, OCRELIZUMAB, 1 MG 01/01/18

J2353 INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG 10/01/16 01/01/17

J2354 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG

10/01/16 01/01/17

J2357 INJECTION, OMALIZUMAB, 5MG 09/06/06

J2469 PALONOSETRON HCL INJECTION, 25MCG ( FOR ONCOLOGY INDICATIONS ONLY) EFFECTIVE 04/01/17 PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

07/01/15 10/01/15

J2502 INJECTION, PASIREOTIDE LONG ACTING, 1 MG 01/01/16

J2505 INJECTION, PEGFILGRASTIM, 6 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J2786 INJECTION, RESLIZUMAB, 1 MG 01/01/17

J2796 INJECTION, ROMIPLOSTIM, 10 MICROGRAMS (NPLATE) 10/01/16 01/01/17

J2820 INJECTION, SARGRAMOSTIM (GM--‐CSF), 50 MCG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF

04/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

PRIOR REVIEW REQUIRED

J2840 INJECTION, SEBELIPASE ALFA, 1 MG 01/01/17

J2860 INJECTION, SILTUXIMAB, 10 MG EFFECTIVE 04/01/17 PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/16

J3060 INJECTION, TALIGLUCERACE ALFA, 10 UNITS 07/01/15 10/01/15

J3262 INJECTION, TOCLIZUMAB,(ACTEMRA) 1 MG 07/01/10

J3285 INJECTION, TREPROSTINIL, 1 MG 04/01/11

J3357 INJECTION, USTEKINUMAB, (STELARA) 1MG FOR SUBCUTANEOUS INJECTION, 07/01/10

J3358 USTEKINUMAB, FOR INTRAVENOUS INJECTION, 1 MG 01/01/18

J3380 INJECTION, VEDOLIZUMAB, 1 MG 01/01/16

J3385 INJECTION, VELAGLUCERASE ALFA, 100 UNITS 07/01/15 10/01/15

J3490* UNCLASSIFIED DRUGS:


07/01/17 10/01/17

GAMMAPLEX –CODE CHANGED SEE J1557/C9270 10/01/10

MONOVISC (SODIUM HYALURONATE ) Code Changed see J7327 04/15/14

VEDOLIZUMAB ( ENTYVIO) 07/01/14 10/01/14

RUCONEST 10/01/14

PEMBROLIZUMAB (KEYTRUDA) ( effective 01/01/2016 use J9271) 10/01/14

HyQvia 01/01/15 04/01/15

Alemtuzumab (Lemtrada) 01/01/15 04/01/15

Opdivo ( Effective 01/01/16 use J9299) 04/01/15 07/01/15

SEBELIPASE ALFA (KANUMA) 07/01/15 03/01/16

KYBELLA 07/01/15 10/01/15

SIGNIFOR LAR 07/01/15 10/01/15

SYLVANT 07/01/15 10/01/15

NUCALA SEE J2182 04/01/16 07/01/16

IMLYGIC SEE J9325 04/01/16 07/01/16

PORTRAZZA SEE J9295 04/01/16 07/01/16



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

EMPLICITI SEE J9176 04/01/16 07/01/16

DARZALEX SEE J9145 04/01/16 07/01/16

HYMOVIS 04/01/16

CINQAIR SEE J2786 07/01/16 10/01/16

TECENTRIQ EFFECTIVE 01/01/18 SEE J9022 10/01/16 01/01/17

STELARA INTRAVENOUS 01/01/17

NUSINERSEN 04/01/17

INJECTION, ETEPLIRSEN, 10 MG ( EXONDYS 51™) 04/01/17

CERLIPONASE ALFA (BRINEURA™ ) 07/01/17

EDARAVONE (RADICAVA™) 07/01/17

OCRELIZUMAB (OCREVUS™) 07/01/17 10/01/17

INTUZUMAB OZOGAMICIN (BESPONSA®) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

10/01/17 01/01/18

INJECTION, LIPOSOMAL, 1MG DAUNORUBICIN AND 2.27MG CYTARABINE (Vyxeos ™) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/18 04/01/18


01/01/18 04/01/18

BENRALIZUMAB (FASENRA™) 02/01/18

LETERMOVIR (PREVYMIS™) 02/01/18

VORETIGENE NEPARVOVEC-RZYL ( LUXTURNA ™) 02/01/18

BUPRENORPHINE EXTENDED-RELEASE INJECTION (SUBLOCADE™) 02/01/18

ROLAPITANT (VARUBI®) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/18 07/01/18

APREPITANT (CINVANTI™ ) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT

04/01/18 07/01/18



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

INJECTION, RITUXIMB AND HYALURONIDASE, 10MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/18 07/01/18

HYALURONAN OR DERIVATIVE, DUROLANE, FOR INTRA-ARTICULAR INJECTION 04/01/18

INJECTION, COPANLISIB, 1 MG (ALIQOPA™) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

07/01/18 10/01/18


07/13/18

J3590* UNCLASSIFIED BIOLOGICALS:


07/01/17 10/01/17

GAMMAPLEX–CODE CHANGED SEE J1557/C9270 10/01/10

YERVOY(IPILIMUMAB)-CODE CHANGED SEE J9228/C9284 10/01/11

PROLIA, XGEVA (Denosumab)-CODE CHANGED SEE J0897/C9272 10/01/11

Simponi Aria [Golimumab]- Code Changed see J1602 10/01/13 01/01/14

Vedolizumab ( Entyvio) 07/01/14 10/01/14

RUCONEST 10/01/14

HyQvia 01/01/15 04/01/15

Alemtuzumab (Lemtrada) 01/01/15 04/01/15

Opdivo ( Effective 01/01/16 use J9299) 04/01/15 07/01/15

SEBELIPASE ALFA (KANUMA) SEE J2840 07/01/15 03/01/16

SIGNIFOR LAR 07/01/15 10/01/15

SYLVANT 07/01/15 10/01/15

NUCALA SEE J2182 04/01/16 07/01/16

IMLYGIC SEE J9325 04/01/16 07/01/16

PORTRAZZA SEE J9295 04/01/16 07/01/16



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

EMPLICITI SEE J9176 04/01/16 07/01/16

DARZALEX SEE J9145 04/01/16 07/01/16

CINQAIR SEE J2786 07/01/16 10/01/16

TECENTRIQ EFFECTIVE 01/01/18 SEE J9022 10/01/16 01/01/17

STELARA INTRAVENOUS 01/01/17

CERLIPONASE ALFA (BRINEURA™) 07/01/17

EDARAVONE (RADICAVA™) 07/01/17

BEZLOTOXUMAB ( ZINPLAVA™) 07/01/17 10/01/17

OCRELIZUMAB (OCREVUS™) 07/01/17 10/01/17

TISAGENLECLEUCEL (KYMRIAH ™) 10/01/17


10/01/17 01/01/18


01/01/18 04/01/18


01/01/18 04/01/18

ROLAPITANT (VARUBI®) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/18 07/01/18

APREPITANT (CINVANTI™ ) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/18 07/01/18

INJECTION, RITUXIMB AND HYALURONIDASE, 10MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC

04/01/18 07/01/18



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

VORETIGENE NEPARVOVEC-RZYL ( LUXTURNA™) 02/01/18


07/01/18 10/01/18


07/13/18

J7311 FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT 04/01/17 07/01/17

J7312 INJECTION, DEXAMETHASONE, INTRAVITREAL IMPLANT, 0.1 MG 04/01/17 07/01/17

J7313 INJECTION, FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT, 0.01 MG 04/01/17 07/01/17

J7320 HYALURONAN OR DERIVITIVE, GENVISC 850, FOR INTRA-ARTICULAR INJECTION, 1 MG 01/01/17

J7321 HYALURONAN OR DERIVATIVE, HYALGAN, SUPARTZ OR VISCO-3, FOR INTRA-ARTICULAR INJECTION, PER DOSE

10/15/13 01/15/14

J7322 HYALURONAN OR DERIVATIVE, HYMOVIS, FOR INTRA-ARTICULAR INJECTION, 1 MG 01/01/17

J7324 HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE

10/15/13 01/15/14

J7326 HYALURONAN OR DERIVATIVE, GEL-ONE, FOR INTRA-ARTHICULAR INJECTION, PER DOSE 10/15/13 01/15/14

J7327 MONOVISC – SODIUM HYALURONATE 04/01/15

J7328 HYALURONAN OR DERIVATIVE, GEL-SYN, FOR INTRA-ARTICULAR INJECTION, 0.1 MG 01/01/16

J7330 AUTOLOGOUS CULTURED CHONDROCYTES, IMPLANT 10/01/06

J7686 TREPROSTINIL, INHALATION SOLUTION, 1.74 MG UNIT DOSE FORM NON-COMPOUNDED ADMINITERED THROUGH DME

04/01/11

J9022 INJECTION, ATEZOLIZUMAB, 10MG (TECENTRIQ ®) 01/01/18

J9023 INJECTION, AVELUMAB, 10MG (BAVENCIO®) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/18 04/01/18

J9035 INJECTION, BEVACIZUMAB, 10 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

J9039 INJECTION, BLINATUMOMAB , 1 MICROGRAM ( BLINCYTO®) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

10/01/17 01/01/18

J9042 INJECTION, BRENTUXIMAB VEDOTIN, 1 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9043 INJECTION, CABAZITAXEL, 1 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9047 INJECTION, CARFILZOMIB, 1 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9055 INJECTION, CETUXIMAB, 10 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9145 INJECTION, DARATUMUMAB, 10 MG EFFECTIVE 04/01/17 PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/17

J9176 INJECTION, ELOTUZUMAB, 1 MG EFFECTIVE 04/01/17 PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

J9179 INJECTION, ERIBULIN MESYLATE, 0.1 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9203 INJECTION, GEMTUZUMAB OZOGAMICIN, 0.1 MG (MYLOTARG ™) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/18 04/01/18

J9228 INJECTION, IPILIMUMAB 1 MG (YERVOY) EFFECTIVE 04/01/17 PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/12

J9264 INJECTION, PACLITAXEL PROTEIN--‐BOUND PARTICLES, 1 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9271 INJECTION, PEMBROLIZUMAB, 1 MG EFFECTIVE 04/01/17 PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/16

J9285 INJECTION, OLARATUMAB, 10 MG (LARTUVO ™) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/18 04/01/18



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

J9295 INJECTION, NECITUMUMAB, 1 MG EFFECTIVE 04/01/17 PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/17

J9299 INJECTION, NIVOLUMAB, 1 MG EFFECTIVE 04/01/17 PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

01/01/16

J9301 INJECTION, OBINUTUZUMAB, 10 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9302 INJECTION, OFATUMUMAB, 10 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9303 INJECTION, PANITUMUMAB, 10 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9305 INJECTION, PEMETREXED, 10 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9306 INJECTION, PERTUZUMAB, 1 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

J9310 RITUXIMAB, 100 MG USE THIS CODE FOR RITUXAN. PRIOR REVIEW REQUIRED FOR THE DIAGNOSIS OF RHEUMATOID ARTHRITIS.

07/01/08

J9310 RITUXIMAB, 100 MG USE THIS CODE FOR RITUXAN. ONCOLOGY PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9325 INJECTION, TALIMOGENE LAHERPAREPVEC, PER 1 MILLION PLAQUE FORMING UNITS 01/01/17

J9351 INJECTION,TOPOTECAN, 0.1MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9354 INJECTION, ADO--‐TRASTUZUMAB EMTANSINE, 1 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9355 INJECTION, TRASTUZUMAB, 10 MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

J9999* NOT OTHERWISE CLASSIFIED, ANTINEOPLASTIC DRUGS: 10/01/10

PEMBROLIZUMAB (KEYTRUDA) ( Use J9271 effective 01/01/16) 10/01/14

OPDIVO ( Effective 01/01/16 use J9299) 04/01/15 07/01/15

IMLYGIC 04/01/16 07/01/16

PORTRAZZA 04/01/16 07/01/16

EMPLICITI 04/01/16 07/01/16

DARZALEX 04/01/16 07/01/16

TECENTRIQ 10/01/16 01/01/17


10/01/17 01/01/18


01/01/18 04/01/18



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE


01/01/18 04/01/18

INJECTION, RITUXIMB AND HYALURONIDASE, 10MG PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/18 07/01/18


07/01/18 10/01/18


07/13/18

K0010 STANDARD – WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR 07/01/05

K0011 STANDARD – WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR WITH PROGRAMMABLE CONTROL PARAMETERS FOR SPEED ADJUSTMENT, TREMOR DAMPENING, ACCELERATION CONTROL AND BRAKING

07/01/05

K0012 LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIR 07/01/05

K0013 CUSTOM MOTORIZED/POWER WHEELCHAIR BASE 07/01/13

K0014 OTHER MOTORIZED/POWER WHEELCHAIR BASE 07/01/05

K0108 OTHER ACCESSORIES WITH PURCHASE PRICE OF $1500.00 AND ABOVE 10/01/06

K0606 AUTOMATIC EXTERNAL DEFIBRILLATOR, WITH INTEGRATED ELECTROCARDIOGRAM ANALYSIS, GARMENT TYPE

10/01/07

K0743 SUCTION PUMP, HOME MODEL, PORTABLE, FOR USE ON WOUNDS 07/01/11

K0744 ABSORPTIVE WOUND DRESSING FOR USE WITH SUCTION PUMP, HOME MODEL, PORTABLE, PAD SIZE 16 SQUARE INCHES OR LESS

07/01/11

K0745 ABSORPTIVE WOUND DRESSING FOR USE WITH SUCTION PUMP, HOME MODEL, PORTABLE, PAD SIZE MORE THAN 16 SQUARE INCHES BUT LESS THAN OR EQUAL TO 48 SQUARE INCHES

07/01/11

K0746 ABSORPTIVE WOUND DRESSING FOR USE WITH SUCTION PUMP, HOME MODEL, PORTABLE, PAD SIZE GREATER THAN 48 SQUARE INCHES

07/01/11



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

K0813 POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0814 POWER WHEELCHAIR, GROUP 1 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0815 POWER WHEELCHAIR, GROUP 1 STANDARD, SLING/SOLID SEAT AND BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0816 POWER WHEELCHAIR, GROUP 1 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACTIY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0820 POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0821 POWER WHEELCHAIR, GROUP 2 STANDARD, PORTABLE, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0822 POWER WHEELCHAIR, GROUP 2 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0823 POWER WHEELCHAIR, GROUP 2 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0824 POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

10/01/06

K0825 POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

10/01/06

K0826 POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

10/01/06

K0827 POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

10/01/06

K0828 POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

10/01/06

K0829 POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

10/01/06

K0830 POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0831 POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0835 POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0836 POWER WHEELCHAIR, GROUP 2 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, 10/01/06



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

K0837 POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

10/01/06

K0838 POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

10/01/06

K0839 POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

10/01/06

K0840 POWER WHEELCHAIR, GROUP 2 EXTRA HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

10/01/06

K0841 POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0842 POWER WHEELCHAIR, GROUP 2 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0843 POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

10/01/06


10/01/06


10/01/06


10/01/06

K0851 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

10/01/06


10/01/06

K0853 POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY, 451 TO 600 POUNDS

10/01/06

K0854 POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

10/01/06

K0855 POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

10/01/06


10/01/06

K0857 POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE


10/01/06

K0859 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

10/01/06

K0860 POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

10/01/06


10/01/06

K0862 POWER WHEELCHAIR, GROUP 3 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

10/01/06

K0863 POWER WHEELCHAIR, GROUP 3 VERY HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS

10/01/06

K0864 POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE

10/01/06


10/01/06


10/01/06


10/01/06


10/01/06


10/01/06

K0878 POWER WHEELCHAIR, GROUP 4 STANDARD, SINGLE POWER OPTION, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06


10/01/06

K0880 POWER WHEELCHAIR, GROUP 4 VERY HEAVY DUTY, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT 451 TO 600 POUNDS

10/01/06


10/01/06

K0885 POWER WHEELCHAIR, GROUP 4 STANDARD, MULTIPLE POWER OPTION, CAPTAINS CHAIR, WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS

10/01/06

K0886 POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID 10/01/06



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS

K0890 POWER WHEELCHAIR, GROUP 5 PEDIATRIC, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDS

10/01/06

K0891 POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 125 POUNDS

10/01/06

K0898 POWER WHEELCHAIR, NOT OTHERWISE CLASSIFIED 10/01/06

K0899 POWER MOBILITY DEVICE, NOT CODED BY SADMERC OR DOES NOT MEET CRITERIA 10/01/06

K0900 CUSTOMIZED DURABLE MEDICAL EQUIPMENT, OTHER THAN WHEELCHAIR 07/01/13

L5848 ADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM HYDRAULIC STANCE EXTENSION, DAMPENING FEATURE, WITH OR WITHOUT ADJUSTABILITY

07/01/05

L5856 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S) ANY TYPE

07/01/05

L5857 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S) ANY TYPE

07/01/05

L5858 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S) ANY TYPE

01/01/06

L5859 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY TYPE MOTOR(S)

01/01/13

L5973 ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, BORSIFLEXION AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE

01/01/10

L5969 ADDITION, ENDOSKELETAL ANKLE-FOOT OR ANKLE SYSTEM, POWER ASSIST, INCLUDES ANY TYPE MOTOR(S)

01/01/14

L5999 LOWER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED((WITH PURCHASE PRICE OF $10,000 AND ABOVE)

01/01/14 04/01/14



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

L6026 TRANSCARPAL/METACARPAL OR PARTIAL HAND DISARTICULATION PROSTHESIS, EXTERNAL POWER, SELF-SUSPENDED, INNER SOCKET WITH REMOVABLE FOREARM SECTION, ELECTRODES AND CABLES, TWO BATTERIES, CHARGER, MYOELECTRIC CONTROL OF TERMINAL DEVICE, EXCLUDES TERMINAL DEVICE(S)

01/01/15

L6611 ADDITION TO UPPER EXTREMITY PROSTHESIS, EXTERNAL POWERED, ADDITIONAL SWITCH, ANY TYPE

01/01/07

L6621 UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH OR WITHOUT FRICTION, FOR USE WITH EXTERNAL POWERED TERMINAL DEVICE

01/01/06

L6638 UPPER EXTREMITY ADDITION TO PROSTHESIS ELECTRIC LOCKING FEATURE ONLY FOR USE OF MANUALLY POWERED ELBOW

07/01/05

L6646 UPPER EXTREMITY ADDITION SHOULDER JOINT MULTI- POSITIONAL LOCKING, FLEXION, ADJUSTABLE ABDUCTION FRICTION CONTROL, FOR USE WITH BODY POWERED OR EXTERNAL POWERED SYSTEM

07/01/05

L6647 UPPER EXTREMITY ADDITION SHOULDER LOCK MECHANISM BODY POWERED ACTUATOR

07/01/05

L6648 UPPER EXTREMITY ADDITION SHOULDER LOCK MECHANISM EXTERNAL POWERED ACTUATOR

07/01/05

L6715 TERMINAL DEVICE, MULTIPLE ARTICULATING DIGIT, INCLUDES MOTOR(S), INITIAL ISSUE OR REPLACEMENT.[FOR PARTIAL HAND PROSTHESIS USING THESE DIGITS, WOULD ALSO REPORT L6025 AND L6890 FOR THE GLOVE] UNIT ALLOWABLE LIMIT-2.

01/01/12

L6880 ELECTRIC HAND, SWITH OR MYOLELECTRIC CONTROLLED, INDEPENDENTLY ARTICULATING DIGITS, AND GRASP PATTERN OR COMBINATION OF GRASP PATTERNS, INCLUDES MOTOR(S) LIMIT 2

01/01/12

L6881 AUTOMATIC GRASP FEATURE ADDITION TO UPPER LIMB PROSTHETIC TERMINAL DEVICE

07/01/05

L6882 MICROPROCESSOR CONTROL FEATURE ADDITION TO UPPER LIMB PROSTHETIC TERMINAL DEVICE

07/01/05

L6884 REPLACEMENT SOCKET, ABOVE ELBOW DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER

01/01/06

L6885 REPLACEMENT SOCKET, SHOULDER DISARTICULATION/ INTERSCAPULAR THORACIC, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER

01/01/06

L6920 WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUALSWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

L6925 WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYELECTRONIC CONTROL OF TERMINAL DEVICE

07/01/05

L6930 BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

07/01/05

L6935 BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE

07/01/05

L6940 ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

07/01/05

L6945 ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE

07/01/05

L6950 ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

07/01/05

L6955 ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE

07/01/05

L6960 SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNERSOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

07/01/05

L6965 SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE

07/01/05

L6970 INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE

07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

L6975 INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE

07/01/05

L7007 ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, ADULT 01/01/07

L7008 ELECTRIC HAND, SWITCH OR MYOELECTRIC, CONTROLLED, PEDIATRIC 01/01/07

L7009 ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, ADULT 01/01/07

L7040 PREHENSILE ACTUATOR, HOSMER OR EQUAL, SWITCH CONTROLLED 07/01/05

L7045 ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, PEDIATRIC 04/01/13 07/01/13

L7170 ELECTRONIC ELBOW, HOSMER OR EQUAL, SWITCH CONTROLLED 07/01/05

L7180 ELECTRONIC ELBOW, MICROPROCESSOR SEQUENTIAL CONTROL OF ELBOW AND TERMINAL DEVICE

07/01/05

L7181 ELECTRONIC ELBOW, MICROPROCESSOR SIMULTANEOUS CONTROL OR ELBOW AND TERMINAL DEVICE

04/01/13 07/01/13

L7185 ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED 07/01/05

L7186 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED 07/01/05

L7190 ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED

07/01/05

L7191 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED

07/01/05

L7259 ELECTRONIC WRIST ROTATOR, ANY TYPE 01/01/15

L7367 LITHIUM ION BATTERY, RECHARGEABLE, REPLACEMENT 07/01/05

L7368 LITHIUM ION BATTERY CHARGER, REPLACEMENT ONLY 07/01/05

L7499 UPPER EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED (WITH PURCHASE PRICE OF $10,000 AND ABOVE)

01/01/14 04/01/14

L8605 Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies

01/01/14 04/01/14

L8614 COCHLEAR DEVICE/SYSTEM 07/01/05

L8615 HEADSET/HEADPIECE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT 07/01/05

L8616 MICROPHONE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT 07/01/05

L8617 TRANSMITTING COIL FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT 07/01/05

L8618 TRANSMITTER CABLE FOR USE WITH COCHLEAR IMPLANT DEVICE OR AUDITORY 07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

OSSEOINTEGRATED DEVICE, REPLACEMENT

L8619 COCHLEAR IMPLANT EXTERNAL SPEECH PROCESSOR, REPLACEMENT 07/01/05

L8621 ZINC AIR BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT, EACH 07/01/05

L8622 ALKALINE BATERY FOR USE WITH COCHLEAR IMPLANT DEVICE, ANY SIZE, REPLACEMENT, EACH

07/01/05

L8623 LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR 01/01/06

L8624 LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT OR AUDITORY OSSEOINTEGRATED DEVICE SPEECH PROCESSOR, EAR LEVEL, REPLACEMENT, EACH

01/01/06

L8625 EXTERNAL RECHARGING SYSTEM FOR BATTERY FOR USE WITH COCHLEAR IMPLANT OR AUDITORY OSSEOINTEGRATED DEVICE, REPLACEMENT ONLY, EACH

01/01/18

L8627 COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR, COMPONENT, REPLACEMENT 01/01/10

L8628 COCHLEAR IMPLANT, EXTERNAL CONTROLLER COMPONENT, REPLACEMENT 01/01/10

L8629 TRANSMITTING COIL AND CABLE, INTEGRATED, FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT

01/01/10

L8681 PATIENT PROGRAMMER (EXTERNAL) FOR USE WITH IMPLANTABLE PROGRAMMABLE NEUROSTIMULATOR PULSE GENERATOR

07/01/08

L8690 AUDITORY OSSEOINTEGRATED DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTS

01/01/07

L8691 AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, EXCLUDES TRANSDUCER/ACTUATOR, REPLACEMENT ONLY, EACH

01/01/07

L8693 AUDITORY OSSEOINTEGRATED DEVICE ABUTMENT, ANY LENGTH, REPLACEMENT ONLY 01/01/11

L8694 AUDITORY OSSEOINTEGRATED DEVICE, TRANSDUCER/ACTUATOR, REPLACEMENT ONLY, EACH

01/01/18

Q2026 INJECTION, RADIESSE, 0.1 ML 07/01/15 10/01/15

Q2028 INJECTION, SCULPTRA, 0.5 MG 07/01/15 10/01/15

Q2040 TISAGENLECLEUCEL, UP TO 250 MILLION CAR-POSITIVE VIABLE T CELLS, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER INFUSION

01/01/18

Q2041 AXICABTAGENE CILOLEUCEL, UP TO 200 MILLION AUTOLOGOUS ANTI-CD19 CAR T CELLS, INCLUDING LEUKAPHERESIS AND DOSE PREPARATION PROCEDURES, PER INFUSION

04/01/18



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

Q2043 SIPULEUCEL-T, MINIMUM OF 50 MILLION AUTOLOGOUS CD54+ CELLS ACTIVATED WITH PAP-GM-CSF, INCLUDING LEUKAPHERESIS AND ALL OTHER PREPARATORY PROCEDURES, PER INFUSION EFFECTIVE 04/01/17 PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES PRIOR REVIEW REQUIRED FOR STATE HEALTH PLAN MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES ALL OTHER MEMBERS REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

07/01/11

Q4074 ILOPROST, INHALATION SOLUTION, NON-COMPOUNDED, UP TO 20 MCG UNIT DOSE FORM ADMINISTERED THROUGH DME

04/01/11

Q5101 INJECTION, FILGRASTIM-sndz BIOSIMILAR, 1 MICROGRAM ( ZARXIO) PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

Q5103 INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG 04/01/18

Q5104 INJECTION, INFLIXIMAB-ABDA, BIOSIMILAR, (RENFLEXIS), 10 MG 04/01/18

Q5106 INJECTION, EPOETIN ALFA, BIOSIMILAR, (RETACRIT) (FOR NON-ESRD USE), 1000 UNITS PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

07/01/18

Q9980 HYALURONAN OR DERIVATIVE, GENVISC 850, FOR INTRA-ARTICULAR INJECTION, 1 MG 01/01/16 01/01/17

Q9989 USTEKINUMAB, FOR INTRAVENOUS INJECTION, 1 MG (STELARA®) EFFECTIVE 01/01/18 SEE J3398

07/01/17 01/01/18

Q9991 INJECTION, BUPRENORPHINE EXTENDED-RELEASE (SUBLOCADE), LESS THAN OR EQUAL TO 100 MG

07/01/18

Q9992 INJECTION, BUPRENORPHINE EXTENDED-RELEASE (SUBLOCADE), GREATER THAN 100 MG

07/01/18

S0189 TESTOSTERONE PELLET, 75MG 10/01/15 01/01/16

S0353 TREATMENT PLANNING AND CARE COORDINATION MANAGEMENT FOR CANCER INITIAL TREATMENT PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF

04/01/17



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

PRIOR REVIEW REQUIRED

S0354 TREATMENT PLANNING AND CARE COORDINATION MANAGEMENT FOR CANCER ESTABLISHED PATIENT WITH A CHANGE OF REGIMEN PRIOR REVIEW NEEDED FOR INPATIENT ADMISSIONS FOR ALL MEMBERS CONTACT BCBSNC FOR OUTPATIENT SERVICES REFER TO ONCOLOGY PROGRAM FOR VERFICATION IF PRIOR REVIEW REQUIRED

04/01/17

S1090 MOMETASONE FUROAE SINUS IMPLANT 370 MICROGRAMS (PROPEL SINUS IMPLANT FOR ETHMOID SINUS DURING FESS PROCEDURE)

07/01/12

S2053 TRANSPLANTATION OF SMALL INTESTINE, AND LIVER ALLOGRAFTS 01/01/09

S2054 TRANSPLANTATION OF MULTIVISCERAL ORGANS 01/01/06

S2065 SIMULTANEOUS PANCREAS KIDNEY TRANSPLANTATION 07/01/05

S2080 LASER-ASSISTED UVULOPALATOPLASTY (LAUP) 07/01/05

S2095 TRANSCATHETER OCCULUSION OR EMBOLIZATION FOR TUMOR DESTRUCTION, PERCUTANEOUS, ANY METHOD, USING YTTRIUM 90 MICROSPHERES

07/01/07

S2102 ISLET CELL TISSUE TRANSPLANT FROM PANCREAS; ALLOGENEIC 07/01/08

S2112 ARTHOSCOPY, KNEE, SURGICAL OR HARVESTING OF CARTILAGE, (CHONDROCYTE CELLS) 10/01/06

S2152 SOLID ORGAN(S) COMPLETE OR SEGMENTAL, SINGLE ORGAN OR COMBINATION OF ORGANS; DECEASED OR LIVING DONOR(S), PROCUREMENT, TRANSPLANTATION, AND RELATED COMPLICATIONS INCLUDING: DRUGS; SUPPLIES; HOSPITALIZATION WITH OUTPATIENT FOLLOW-UP; MEDICAL/SURGICAL, DIAGNOSTIC, EMERGENCY, AND REHABILITATIVE SERVICES; AND THE NUMBER OF DAYS OF PRE- AND POST-TRANSPLANT CARE IN THE GLOBAL DEFINITION.

07/01/05

S2202 ECHOSCLEROTHERAPY 07/01/05

S2348 DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVETEBRAL DISC, USING RADIOFREQUENCY ENERGY, SINGLE OR MULTIPLE LEVELS LUMBAR.

01/01/12

S3861 GENETIC TESTING, SODIUM CHANNEL, VOLTAGE-GATED, TYPE V, ALPHA SUBUNIT (SCN5A) AND VARIANTS FOR SUSPECTED BRUGADA SYNDROME

10/04/08

S5110 HOME CARE TRAINING, FAMILY, PER 15 MINUTES 01/01/06

S5111 HOME CARE TRAINING, FAMILY, PER SESSION 01/01/06

S5115 HOME CARE TRAINING, NON FAMILY, PER 15 MINUTES 01/01/06

S5116 HOME CARE TRAINING, NON FAMILY, PER SESSION 01/01/06

S8030 SCLERAL APPLICATION OF TANTALUM RING(S) FOR LOCALIZATION OF LESIONS FOR PROTON BEAM THERAPY

04/01/13 07/01/13

S8035 MAGNETIC SOURCE IMAGING 10/04/08



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

S8130 INTERFERENTIAL CURRENT STIMULATOR,2 CHANNEL 01/01/12

S8131 INTERFERENTIAL CURRENT STIMULATOR 4 CHANNEL 01/01/12

S9061 HOME ADMINISTRATION OF AEROSOLIZED DRUG THERAPY (EG, PENTAMIDINE); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEAPRATELY), PER DIEM

01/01/06

S9097 HOME VISIT FOR WOUND CARE 01/01/06

S9098 HOME VISIT, PHOTOTHERAPY SERVICES (E.G. BILI-LITE) INCLUDING EQUIPMENT RENTAL, NURSING SERVICES, BLOOD DRAW, SUPPLIES, AND OTHER SERVICES, PER DIEM

07/05/09

S9122 HOME HEALTH AIDE OR CERTIFIED NURSE ASSISTANT, PROVIDING CARE IN THE HOME, PER HOUR

01/01/06

S9123 NURSING CARE IN THE HOME; BY REGISTERED NURSE, PER HOUR (USE FOR GENERAL NURSING CARE ONLY, NOT TO BE USED WHEN CPT CODES 99500-99602 CAN BE USED)

07/01/05

S9124 NURSING CARE IN THE HOME BY LICENSED PRACTICAL NURSE, PER HOUR 01/01/06

S9125 RESPITE CARE, IN THE HOME, PER DIEM 01/01/06

S9208 HOME MANAGEMENT OF PRETERM LABOR, INCLUDING ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES OR EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUSION PER DIEM CODE)

07/09/05

S9213 HOME MANAGEMENT OF PREECLAMPSIA, INCLUDES ADMIN SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS & NURSING VISITS CODED SEPARATELY), PER DIEM (DO NOT USE THIS CODE WITH ANY HOME INFUSION PER DIEM CODE)

01/01/05

S9336 HOME INFUSION THERAPY, CONTINUOUS ANTICOAGULANT INFUSION THERAPY (EG. HEPARIN), ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM

07/01/05

S9346 HOME INFUSION THERAPY, ALPHA-1-PROTEINASE INHIBITOR (E.G., PROLASTIN); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM

01/01/18 04/01/18

S9349 HOME INFUSION THERAPY, TOCOLYTIC INFUSION THERAPY; ADMIN SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM

07/01/05



SERVICE CODE


EFFECTIVE DATE

INEFFECTIVE DATE

S9355 HOME INFUSION THERAPY, CHELATION THERAPY; ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM

07/01/05

S9357 HOME INFUSION THERAPY, ENZYME REPLACEMENT INTRAVENOUS THERAPY; (E.G., IMIGLUCERASE); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM

04/01/16 07/01/16

S9359 HOME INFUSION THERAPY, ANTI-TUMOR NECROSIS FACTOR INTRAVENOUS THERAPY (E.G., INFLIXIMAB); ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODED SEPARATELY), PER DIEM

07/01/05

S9379 HOME INFUSION THERAPY, INFUSION THERAPY, NOT OTHERWISE CLASSIFIED ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODE SEPARATELY), PER DIEM

07/01/05

S9590 HOME THERAPY, IRRIGATION THERAPY (E.G.STERILE IRRIGATION OF AN ORGAN OR ANATOMICALCAVITY) ADMINISTRATIVE SERVICES, PROFESSIONAL PHARMACY SERVICES, CARE COORDINATION, AND ALL NECESSARY SUPPLIES AND EQUIPMENT (DRUGS AND NURSING VISITS CODE SEPARATELY), PER DIEM

01/01/06

S9960 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, NONEMERGENCY TRANSPORT, ONE WAY (FIXED WING)

01/01/14

S9961 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICE, NONEMERGENCY TRANSPORT, ONE WAY (ROTARY WING)

01/01/14

S9988 SERVICES PROVIDED AS PART OF A PHASE 1 CLINICAL TRIAL 10/01/06

S9990 SERVICES PROVIDED AS PART OF A PHASE II CLINICAL TRIAL 07/01/05

S9991 SERVICES PROVIDED AS PART OF A PHASE III CLINICAL TRIAL 07/01/05

Prior Review (Prior Plan Approval) Code List 2nd Quarter ... · Prior Review (Prior Plan Approval)...

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