code
stringlengths 4
12
| description
stringlengths 2
264
| codetype
stringclasses 8
values | context
stringlengths 160
15.5k
|
|---|---|---|---|
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | HCPCS was initially used voluntarily by medical entities, but after the implementation of HIPAA or also known as the name Health Insurance Portability and Accountability Act, since 1996, transaction codes were reported in HCPCS codes. On the other hand, ICD 10 had its first inception in 2015, and it is globally managed by WHO (World Health Organization) as a diagnostic code for diseases and other medical conditions. There are two parts to this ICD 10 code. Amongst them, one is CM that stands for Clinical Modification, and the other part is Procedure Coding System. Comparison Table Between HCPCS and ICD 10 Codes
|Parameters of Comparison||HCPCS||ICD 10 Codes|
|Management and Implementers||U.S. |
90868 | PR THERAP REPETITIVE TMS TX SUBSEQ DELIVERY & MNG | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. |
90867 | PR REPET TMS TX INITIAL W/MAP/MOTR THRESHLD/DEL&M | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. |
0161T | Tcranial magn stim tx deliv | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. |
0160T | Tcranial Magn Stim Tx Plan | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. |
90868 | PR THERAP REPETITIVE TMS TX SUBSEQ DELIVERY & MNG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. |
90867 | PR REPET TMS TX INITIAL W/MAP/MOTR THRESHLD/DEL&M | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. |
0161T | Tcranial magn stim tx deliv | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. |
0160T | Tcranial Magn Stim Tx Plan | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. |
90868 | PR THERAP REPETITIVE TMS TX SUBSEQ DELIVERY & MNG | HCPCS | POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. 06/06/2016: Policy number added. |
90867 | PR REPET TMS TX INITIAL W/MAP/MOTR THRESHLD/DEL&M | HCPCS | POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. 06/06/2016: Policy number added. |
0161T | Tcranial magn stim tx deliv | HCPCS | POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. 06/06/2016: Policy number added. |
0160T | Tcranial Magn Stim Tx Plan | HCPCS | POLICY HISTORY7/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Reviewed by MPAC; investigational status maintained
2/11/2002: Investigational definition added
5/7/2002: Type of Service and Place of Service deleted
11/5/2003: Code Reference section completed
3/11/2004: Sources updated
6/23/2004: Policy reviewed
5/8/2006: Policy reviewed, no changes
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Policy reviewed, no changes
03/07/2011: Added new HCPCS codes 90867 and 90868 to the Code Reference section. 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. 06/06/2016: Policy number added. |
0161 | Med-Surg | RC | 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. 06/06/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.24
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
0160 | ROOM & BOARD - OTHER - GENERAL CLASSIFICATION | RC | 07/23/2015: Code Reference section updated for ICD-10. Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. 06/06/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.24
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
0161 | Med-Surg | RC | Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. 06/06/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.24
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
0160 | ROOM & BOARD - OTHER - GENERAL CLASSIFICATION | RC | Removed deleted CPT codes 0160T and 0161T. 04/26/2016: Policy Guidelines updated to revise investigative definition. 06/06/2016: Policy number added. SOURCE(S)Blue Cross Blue Shield Association policy # 2.01.24
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
A4639 | Replacement pad for infrared heating pad system, each | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
1999 | ANESTHESIOLOGY GROUP | CPT | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0692 | Uvl sys panel 4 ft | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
97028 | Ultraviolet therapy | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
S9098 | Home phototherapy visit | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0202 | Phototherapy light w/ photom | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
A4634 | Replacement bulb th lightbox | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0694 | Uvl md cabinet sys 6 ft | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0691 | Uvl pnl 2 sq ft or less | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
A4633 | Uvl replacement bulb | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0690 | UV CABINET APPROPRIATE HOME USE | CPT | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
E0693 | Uvl sys panel 6 ft | HCPCS | For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. |
A4639 | Replacement pad for infrared heating pad system, each | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
1999 | ANESTHESIOLOGY GROUP | CPT | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0692 | Uvl sys panel 4 ft | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
97028 | Ultraviolet therapy | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
S9098 | Home phototherapy visit | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0202 | Phototherapy light w/ photom | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
A4634 | Replacement bulb th lightbox | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0694 | Uvl md cabinet sys 6 ft | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0691 | Uvl pnl 2 sq ft or less | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
A4633 | Uvl replacement bulb | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0690 | UV CABINET APPROPRIATE HOME USE | CPT | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
E0693 | Uvl sys panel 6 ft | HCPCS | In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. |
A4639 | Replacement pad for infrared heating pad system, each | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
1999 | ANESTHESIOLOGY GROUP | CPT | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
E0692 | Uvl sys panel 4 ft | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
97028 | Ultraviolet therapy | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
S9098 | Home phototherapy visit | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
E0202 | Phototherapy light w/ photom | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
A4634 | Replacement bulb th lightbox | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
E0694 | Uvl md cabinet sys 6 ft | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
E0691 | Uvl pnl 2 sq ft or less | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
A4633 | Uvl replacement bulb | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
E0690 | UV CABINET APPROPRIATE HOME USE | CPT | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
E0693 | Uvl sys panel 6 ft | HCPCS | POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
4/1997: Investigational indication of seasonal affective disorder approved by (MPAC)
8/1999: Revisions approved by MPAC
2/11/2002: Appeal statement deleted from Policy Exception section, investigational definition added
5/2/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 procedure codes 99.82 and 99.83 added
2/19/2003: Description of E0202 and E0690 updated to be consistent with AMA
3/11/2003: Code Reference section updated
6/27/2003: HCPCS A4633, A4634 deleted, replacement included in rental
12/6/2004: Code Reference section updated, CPT 97028 added, ICD-9 diagnosis code 202.1 5th digit added and description revised, ICD-9 diagnosis 696.8, 698.9 added, HCPCS A4633, S9098 added, HCPCS A4639, E0690 deleted, HCPCS E0691, E0692, E0693, E0694 effective date added
10/24/2006: Policy reviewed, seasonal affective disorder changed from investigational to medically necessary. 10/30/2006: Code reference section updated. ICD-9 diagnosis code 296.99 added to table. 03/16/2011: The policy statement regarding home ultraviolet light was revised to remove the requirement for a documented response to UVL. It was changed to state the following: Home ultraviolet light is a covered service when provided to patients who have chronic or recalcitrant disease requiring long term maintenance exceeding four (4) months. |
90832 | Psytx w pt 30 minutes | HCPCS | The authors concluded that these findings suggested that EMDR may be an effective treatment modality for post-operative pain. These preliminary findings need to be validated by well-designed studies. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|There is no specific CPT code for eye movement desensitization and reprocessing:|
|Other CPT codes related to the CPB:|
|90832 - 90899||Psychotherapy, other psychotherapy, and other psychiatric services or procedures [not covered for eye movement desensitization and reprocessing therapy]|
|ICD-10 codes covered if selection criteria are met:|
|F43.10 - F43.12||Posttraumatic stress disorder|
|Z86.51||Personal history of combat and operational stress reaction|
|ICD-10 codes not covered for indications listed in the CPB:|
|F01.50 - F43.0
F43.20 - F99
|Mental disorders (other than posttraumatic stress disorder)|
|G54.6 - G54.7||Phantom limb (syndrome)|
|G89.11 - G89.18||Acute pain, not elsewhere classified|
|G89.21 -G89.29||Chronic pain, not elsewhere classified|
|G89.4||Chronic pain syndrome|
|M54.5||Low back pain [chronic back pain]|
|M54.9||Dorsalgia, unspecified [chronic back pain]|
|R56.00 - R56.9||Convulsions [psychogenic non-epileptic seizures]| |
90899 | HC UNLISTED PSYCHIATRIC SERVICE | HCPCS | The authors concluded that these findings suggested that EMDR may be an effective treatment modality for post-operative pain. These preliminary findings need to be validated by well-designed studies. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|There is no specific CPT code for eye movement desensitization and reprocessing:|
|Other CPT codes related to the CPB:|
|90832 - 90899||Psychotherapy, other psychotherapy, and other psychiatric services or procedures [not covered for eye movement desensitization and reprocessing therapy]|
|ICD-10 codes covered if selection criteria are met:|
|F43.10 - F43.12||Posttraumatic stress disorder|
|Z86.51||Personal history of combat and operational stress reaction|
|ICD-10 codes not covered for indications listed in the CPB:|
|F01.50 - F43.0
F43.20 - F99
|Mental disorders (other than posttraumatic stress disorder)|
|G54.6 - G54.7||Phantom limb (syndrome)|
|G89.11 - G89.18||Acute pain, not elsewhere classified|
|G89.21 -G89.29||Chronic pain, not elsewhere classified|
|G89.4||Chronic pain syndrome|
|M54.5||Low back pain [chronic back pain]|
|M54.9||Dorsalgia, unspecified [chronic back pain]|
|R56.00 - R56.9||Convulsions [psychogenic non-epileptic seizures]| |
90832 | Psytx w pt 30 minutes | HCPCS | These preliminary findings need to be validated by well-designed studies. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|There is no specific CPT code for eye movement desensitization and reprocessing:|
|Other CPT codes related to the CPB:|
|90832 - 90899||Psychotherapy, other psychotherapy, and other psychiatric services or procedures [not covered for eye movement desensitization and reprocessing therapy]|
|ICD-10 codes covered if selection criteria are met:|
|F43.10 - F43.12||Posttraumatic stress disorder|
|Z86.51||Personal history of combat and operational stress reaction|
|ICD-10 codes not covered for indications listed in the CPB:|
|F01.50 - F43.0
F43.20 - F99
|Mental disorders (other than posttraumatic stress disorder)|
|G54.6 - G54.7||Phantom limb (syndrome)|
|G89.11 - G89.18||Acute pain, not elsewhere classified|
|G89.21 -G89.29||Chronic pain, not elsewhere classified|
|G89.4||Chronic pain syndrome|
|M54.5||Low back pain [chronic back pain]|
|M54.9||Dorsalgia, unspecified [chronic back pain]|
|R56.00 - R56.9||Convulsions [psychogenic non-epileptic seizures]| |
90899 | HC UNLISTED PSYCHIATRIC SERVICE | HCPCS | These preliminary findings need to be validated by well-designed studies. |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|There is no specific CPT code for eye movement desensitization and reprocessing:|
|Other CPT codes related to the CPB:|
|90832 - 90899||Psychotherapy, other psychotherapy, and other psychiatric services or procedures [not covered for eye movement desensitization and reprocessing therapy]|
|ICD-10 codes covered if selection criteria are met:|
|F43.10 - F43.12||Posttraumatic stress disorder|
|Z86.51||Personal history of combat and operational stress reaction|
|ICD-10 codes not covered for indications listed in the CPB:|
|F01.50 - F43.0
F43.20 - F99
|Mental disorders (other than posttraumatic stress disorder)|
|G54.6 - G54.7||Phantom limb (syndrome)|
|G89.11 - G89.18||Acute pain, not elsewhere classified|
|G89.21 -G89.29||Chronic pain, not elsewhere classified|
|G89.4||Chronic pain syndrome|
|M54.5||Low back pain [chronic back pain]|
|M54.9||Dorsalgia, unspecified [chronic back pain]|
|R56.00 - R56.9||Convulsions [psychogenic non-epileptic seizures]| |
G0202 | Scr mammo bi incl cad | HCPCS | Digital screening mammogram with CAD was performed. Findings: Negative. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.11
Example 2:Patient is a 52-year old female with a personal history of breast cancer, fully resolved status post right breast mastectomy in 1992. She presents for annual digital screening mammogram with CAD. CPT/HCPCS Codes: G0202-52, 77052
ICD-9-CM Codes: V76.11, V10.3
Example 3:History: A 42-year-old female, annual exam. |
77052 | Comp screen mammogram add-on | HCPCS | Digital screening mammogram with CAD was performed. Findings: Negative. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.11
Example 2:Patient is a 52-year old female with a personal history of breast cancer, fully resolved status post right breast mastectomy in 1992. She presents for annual digital screening mammogram with CAD. CPT/HCPCS Codes: G0202-52, 77052
ICD-9-CM Codes: V76.11, V10.3
Example 3:History: A 42-year-old female, annual exam. |
G0202 | Scr mammo bi incl cad | HCPCS | CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.11
Example 2:Patient is a 52-year old female with a personal history of breast cancer, fully resolved status post right breast mastectomy in 1992. She presents for annual digital screening mammogram with CAD. CPT/HCPCS Codes: G0202-52, 77052
ICD-9-CM Codes: V76.11, V10.3
Example 3:History: A 42-year-old female, annual exam. Comparison: Mammogram one year prior. Findings: Bilateral digital implant screening mammogram, standard and displaced views were obtained. |
77052 | Comp screen mammogram add-on | HCPCS | CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.11
Example 2:Patient is a 52-year old female with a personal history of breast cancer, fully resolved status post right breast mastectomy in 1992. She presents for annual digital screening mammogram with CAD. CPT/HCPCS Codes: G0202-52, 77052
ICD-9-CM Codes: V76.11, V10.3
Example 3:History: A 42-year-old female, annual exam. Comparison: Mammogram one year prior. Findings: Bilateral digital implant screening mammogram, standard and displaced views were obtained. |
G0202 | Scr mammo bi incl cad | HCPCS | Bilateral subglandular breast implants are noted. Implants appear stable and mammographically intact. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.12
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding. This article is available for publishing on websites, blogs, and newsletters. |
77052 | Comp screen mammogram add-on | HCPCS | Bilateral subglandular breast implants are noted. Implants appear stable and mammographically intact. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.12
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding. This article is available for publishing on websites, blogs, and newsletters. |
G0202 | Scr mammo bi incl cad | HCPCS | Implants appear stable and mammographically intact. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.12
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding. This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. |
77052 | Comp screen mammogram add-on | HCPCS | Implants appear stable and mammographically intact. CPT/HCPCS Codes: G0202, 77052
ICD-9-CM Codes: V76.12
Aimee Wilcox, MA, CST, CCS-P is a Certified Coding Guru (CCG) for Find-A-Code. For more information about ICD-10-CM, ICD-10-PCS, and medical coding and billing please visit FindACode.com where you will find the ICD-10 code sets and the current ICD-9-CM, CPT, and HCPCS code sets plus a wealth of additional information related to medical billing and coding. This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. |
97003 | Ot evaluation | HCPCS | This cross-mapping is usually a behind-the scenes process that happens with an encoder or an electronic billing/coding system. SNOMED-CT uses an 8-digit numeric system for classifications, whereas ICD-9 uses a 3 digit primary code with a 1-2 digit extender if needed. ICD-10 and HCPCS use both alpha and numeric systems. As the coder/biller you are the expert, so you should never rely solely on a cross-map. As you can see in the last example in the table, SNOMED-CT has the code for primary infertility cross-mapped to show both a male and a female ICD-9 code
SNOMED CT ICD-9
20897003 atrophy of breast 611.4 atrophy of breast
78623009 endometritis 615.9 unspecified inflammatory disease of uterus
21818003 cataract in degenerative disorder 366.34 cataract in degenerative disorders
297106006 primary infertility 628.9 Female Infertility
297106006 primary infertility 606.9 Male Infertility
In 2009, the Department of Health & Human Services published the standards of how to cross-map SNOMED with ICD-9 and the entire document can be viewed at www.nlm.nih.gov/research/umls/mapping_projects/snomedct_to_icd9cm_reimburse_20091031.pdf
How the SNOMED-CT system works is similar to the progression outlined below. |
71060 | Contrast x-ray of bronchi | HCPCS | This cross-mapping is usually a behind-the scenes process that happens with an encoder or an electronic billing/coding system. SNOMED-CT uses an 8-digit numeric system for classifications, whereas ICD-9 uses a 3 digit primary code with a 1-2 digit extender if needed. ICD-10 and HCPCS use both alpha and numeric systems. As the coder/biller you are the expert, so you should never rely solely on a cross-map. As you can see in the last example in the table, SNOMED-CT has the code for primary infertility cross-mapped to show both a male and a female ICD-9 code
SNOMED CT ICD-9
20897003 atrophy of breast 611.4 atrophy of breast
78623009 endometritis 615.9 unspecified inflammatory disease of uterus
21818003 cataract in degenerative disorder 366.34 cataract in degenerative disorders
297106006 primary infertility 628.9 Female Infertility
297106006 primary infertility 606.9 Male Infertility
In 2009, the Department of Health & Human Services published the standards of how to cross-map SNOMED with ICD-9 and the entire document can be viewed at www.nlm.nih.gov/research/umls/mapping_projects/snomedct_to_icd9cm_reimburse_20091031.pdf
How the SNOMED-CT system works is similar to the progression outlined below. |
29710 | Removal/revision of cast | HCPCS | This cross-mapping is usually a behind-the scenes process that happens with an encoder or an electronic billing/coding system. SNOMED-CT uses an 8-digit numeric system for classifications, whereas ICD-9 uses a 3 digit primary code with a 1-2 digit extender if needed. ICD-10 and HCPCS use both alpha and numeric systems. As the coder/biller you are the expert, so you should never rely solely on a cross-map. As you can see in the last example in the table, SNOMED-CT has the code for primary infertility cross-mapped to show both a male and a female ICD-9 code
SNOMED CT ICD-9
20897003 atrophy of breast 611.4 atrophy of breast
78623009 endometritis 615.9 unspecified inflammatory disease of uterus
21818003 cataract in degenerative disorder 366.34 cataract in degenerative disorders
297106006 primary infertility 628.9 Female Infertility
297106006 primary infertility 606.9 Male Infertility
In 2009, the Department of Health & Human Services published the standards of how to cross-map SNOMED with ICD-9 and the entire document can be viewed at www.nlm.nih.gov/research/umls/mapping_projects/snomedct_to_icd9cm_reimburse_20091031.pdf
How the SNOMED-CT system works is similar to the progression outlined below. |
97003 | Ot evaluation | HCPCS | ICD-10 and HCPCS use both alpha and numeric systems. As the coder/biller you are the expert, so you should never rely solely on a cross-map. As you can see in the last example in the table, SNOMED-CT has the code for primary infertility cross-mapped to show both a male and a female ICD-9 code
SNOMED CT ICD-9
20897003 atrophy of breast 611.4 atrophy of breast
78623009 endometritis 615.9 unspecified inflammatory disease of uterus
21818003 cataract in degenerative disorder 366.34 cataract in degenerative disorders
297106006 primary infertility 628.9 Female Infertility
297106006 primary infertility 606.9 Male Infertility
In 2009, the Department of Health & Human Services published the standards of how to cross-map SNOMED with ICD-9 and the entire document can be viewed at www.nlm.nih.gov/research/umls/mapping_projects/snomedct_to_icd9cm_reimburse_20091031.pdf
How the SNOMED-CT system works is similar to the progression outlined below. The provider/physician may input the term “headache”, and the SNOMED-CT software would go through the process to find the ‘headache term’, then cross-map and interface with an ICD-9/ICD-10 or HCPCS encoder to populate the query with the multiple codes listed for types of headaches. As the coder/biller, you would then need to review your physician/provider documentation to choose the appropriately mapped code from within the Medical record or billing software and apply the most specific diagnosis possible. |
71060 | Contrast x-ray of bronchi | HCPCS | ICD-10 and HCPCS use both alpha and numeric systems. As the coder/biller you are the expert, so you should never rely solely on a cross-map. As you can see in the last example in the table, SNOMED-CT has the code for primary infertility cross-mapped to show both a male and a female ICD-9 code
SNOMED CT ICD-9
20897003 atrophy of breast 611.4 atrophy of breast
78623009 endometritis 615.9 unspecified inflammatory disease of uterus
21818003 cataract in degenerative disorder 366.34 cataract in degenerative disorders
297106006 primary infertility 628.9 Female Infertility
297106006 primary infertility 606.9 Male Infertility
In 2009, the Department of Health & Human Services published the standards of how to cross-map SNOMED with ICD-9 and the entire document can be viewed at www.nlm.nih.gov/research/umls/mapping_projects/snomedct_to_icd9cm_reimburse_20091031.pdf
How the SNOMED-CT system works is similar to the progression outlined below. The provider/physician may input the term “headache”, and the SNOMED-CT software would go through the process to find the ‘headache term’, then cross-map and interface with an ICD-9/ICD-10 or HCPCS encoder to populate the query with the multiple codes listed for types of headaches. As the coder/biller, you would then need to review your physician/provider documentation to choose the appropriately mapped code from within the Medical record or billing software and apply the most specific diagnosis possible. |
29710 | Removal/revision of cast | HCPCS | ICD-10 and HCPCS use both alpha and numeric systems. As the coder/biller you are the expert, so you should never rely solely on a cross-map. As you can see in the last example in the table, SNOMED-CT has the code for primary infertility cross-mapped to show both a male and a female ICD-9 code
SNOMED CT ICD-9
20897003 atrophy of breast 611.4 atrophy of breast
78623009 endometritis 615.9 unspecified inflammatory disease of uterus
21818003 cataract in degenerative disorder 366.34 cataract in degenerative disorders
297106006 primary infertility 628.9 Female Infertility
297106006 primary infertility 606.9 Male Infertility
In 2009, the Department of Health & Human Services published the standards of how to cross-map SNOMED with ICD-9 and the entire document can be viewed at www.nlm.nih.gov/research/umls/mapping_projects/snomedct_to_icd9cm_reimburse_20091031.pdf
How the SNOMED-CT system works is similar to the progression outlined below. The provider/physician may input the term “headache”, and the SNOMED-CT software would go through the process to find the ‘headache term’, then cross-map and interface with an ICD-9/ICD-10 or HCPCS encoder to populate the query with the multiple codes listed for types of headaches. As the coder/biller, you would then need to review your physician/provider documentation to choose the appropriately mapped code from within the Medical record or billing software and apply the most specific diagnosis possible. |
97003 | Ot evaluation | HCPCS | As the coder/biller you are the expert, so you should never rely solely on a cross-map. As you can see in the last example in the table, SNOMED-CT has the code for primary infertility cross-mapped to show both a male and a female ICD-9 code
SNOMED CT ICD-9
20897003 atrophy of breast 611.4 atrophy of breast
78623009 endometritis 615.9 unspecified inflammatory disease of uterus
21818003 cataract in degenerative disorder 366.34 cataract in degenerative disorders
297106006 primary infertility 628.9 Female Infertility
297106006 primary infertility 606.9 Male Infertility
In 2009, the Department of Health & Human Services published the standards of how to cross-map SNOMED with ICD-9 and the entire document can be viewed at www.nlm.nih.gov/research/umls/mapping_projects/snomedct_to_icd9cm_reimburse_20091031.pdf
How the SNOMED-CT system works is similar to the progression outlined below. The provider/physician may input the term “headache”, and the SNOMED-CT software would go through the process to find the ‘headache term’, then cross-map and interface with an ICD-9/ICD-10 or HCPCS encoder to populate the query with the multiple codes listed for types of headaches. As the coder/biller, you would then need to review your physician/provider documentation to choose the appropriately mapped code from within the Medical record or billing software and apply the most specific diagnosis possible. SNOMED Clinical Terms process input
Clinical history and observation findings
General finding of observation of patient
Pain finding at anatomical site
Pain of head and neck region
At this time the National Library of Medicine has the following mapping projects underway. |
71060 | Contrast x-ray of bronchi | HCPCS | As the coder/biller you are the expert, so you should never rely solely on a cross-map. As you can see in the last example in the table, SNOMED-CT has the code for primary infertility cross-mapped to show both a male and a female ICD-9 code
SNOMED CT ICD-9
20897003 atrophy of breast 611.4 atrophy of breast
78623009 endometritis 615.9 unspecified inflammatory disease of uterus
21818003 cataract in degenerative disorder 366.34 cataract in degenerative disorders
297106006 primary infertility 628.9 Female Infertility
297106006 primary infertility 606.9 Male Infertility
In 2009, the Department of Health & Human Services published the standards of how to cross-map SNOMED with ICD-9 and the entire document can be viewed at www.nlm.nih.gov/research/umls/mapping_projects/snomedct_to_icd9cm_reimburse_20091031.pdf
How the SNOMED-CT system works is similar to the progression outlined below. The provider/physician may input the term “headache”, and the SNOMED-CT software would go through the process to find the ‘headache term’, then cross-map and interface with an ICD-9/ICD-10 or HCPCS encoder to populate the query with the multiple codes listed for types of headaches. As the coder/biller, you would then need to review your physician/provider documentation to choose the appropriately mapped code from within the Medical record or billing software and apply the most specific diagnosis possible. SNOMED Clinical Terms process input
Clinical history and observation findings
General finding of observation of patient
Pain finding at anatomical site
Pain of head and neck region
At this time the National Library of Medicine has the following mapping projects underway. |
29710 | Removal/revision of cast | HCPCS | As the coder/biller you are the expert, so you should never rely solely on a cross-map. As you can see in the last example in the table, SNOMED-CT has the code for primary infertility cross-mapped to show both a male and a female ICD-9 code
SNOMED CT ICD-9
20897003 atrophy of breast 611.4 atrophy of breast
78623009 endometritis 615.9 unspecified inflammatory disease of uterus
21818003 cataract in degenerative disorder 366.34 cataract in degenerative disorders
297106006 primary infertility 628.9 Female Infertility
297106006 primary infertility 606.9 Male Infertility
In 2009, the Department of Health & Human Services published the standards of how to cross-map SNOMED with ICD-9 and the entire document can be viewed at www.nlm.nih.gov/research/umls/mapping_projects/snomedct_to_icd9cm_reimburse_20091031.pdf
How the SNOMED-CT system works is similar to the progression outlined below. The provider/physician may input the term “headache”, and the SNOMED-CT software would go through the process to find the ‘headache term’, then cross-map and interface with an ICD-9/ICD-10 or HCPCS encoder to populate the query with the multiple codes listed for types of headaches. As the coder/biller, you would then need to review your physician/provider documentation to choose the appropriately mapped code from within the Medical record or billing software and apply the most specific diagnosis possible. SNOMED Clinical Terms process input
Clinical history and observation findings
General finding of observation of patient
Pain finding at anatomical site
Pain of head and neck region
At this time the National Library of Medicine has the following mapping projects underway. |
L7190 | Electronic elbow, adolescent, variety village or equal, myoelectronically controlled | HCPCS | 07/19/2012: Policy title changed back to "Myoelectric Prosthesis for the Upper Limb." Added the following policy statement: A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered investigational. 09/03/2013: Policy title changed from "Myoelectric Prosthesis for the Upper Limb" to "Myoelectric Prosthetic Components for the Upper Limb." Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section. |
L7191 | Electronic elbow, child, variety village or equal, myoelectronically controlled | HCPCS | 07/19/2012: Policy title changed back to "Myoelectric Prosthesis for the Upper Limb." Added the following policy statement: A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered investigational. 09/03/2013: Policy title changed from "Myoelectric Prosthesis for the Upper Limb" to "Myoelectric Prosthetic Components for the Upper Limb." Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section. |
L6880 | Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) | HCPCS | 07/19/2012: Policy title changed back to "Myoelectric Prosthesis for the Upper Limb." Added the following policy statement: A prosthesis with individually powered digits, including but not limited to a partial hand prosthesis, is considered investigational. 09/03/2013: Policy title changed from "Myoelectric Prosthesis for the Upper Limb" to "Myoelectric Prosthetic Components for the Upper Limb." Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section. |
L7190 | Electronic elbow, adolescent, variety village or equal, myoelectronically controlled | HCPCS | 09/03/2013: Policy title changed from "Myoelectric Prosthesis for the Upper Limb" to "Myoelectric Prosthetic Components for the Upper Limb." Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section. 08/14/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged. |
L7191 | Electronic elbow, child, variety village or equal, myoelectronically controlled | HCPCS | 09/03/2013: Policy title changed from "Myoelectric Prosthesis for the Upper Limb" to "Myoelectric Prosthetic Components for the Upper Limb." Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section. 08/14/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged. |
L6880 | Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) | HCPCS | 09/03/2013: Policy title changed from "Myoelectric Prosthesis for the Upper Limb" to "Myoelectric Prosthetic Components for the Upper Limb." Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section. 08/14/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged. |
L6026 | Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectr | HCPCS | Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section. 08/14/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged. 12/31/2014: Added the following new 2015 HCPCS code to the Code Reference section: L6026. |
L7190 | Electronic elbow, adolescent, variety village or equal, myoelectronically controlled | HCPCS | Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section. 08/14/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged. 12/31/2014: Added the following new 2015 HCPCS code to the Code Reference section: L6026. |
L7191 | Electronic elbow, child, variety village or equal, myoelectronically controlled | HCPCS | Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section. 08/14/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged. 12/31/2014: Added the following new 2015 HCPCS code to the Code Reference section: L6026. |
L6880 | Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s) | HCPCS | Policy statement unchanged. Added HCPCS codes L6880, L7190, and L7191 to the Code Reference section. 08/14/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged. 12/31/2014: Added the following new 2015 HCPCS code to the Code Reference section: L6026. |
L6026 | Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectr | HCPCS | 08/14/2014: Policy reviewed; description updated regarding devices. Policy statement unchanged. 12/31/2014: Added the following new 2015 HCPCS code to the Code Reference section: L6026. 08/26/2015: Medical policy revised to add ICD-10 codes. SOURCESBlue Cross Blue Shield Association policy # 1.04.04
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. |
L6026 | Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectr | HCPCS | Policy statement unchanged. 12/31/2014: Added the following new 2015 HCPCS code to the Code Reference section: L6026. 08/26/2015: Medical policy revised to add ICD-10 codes. SOURCESBlue Cross Blue Shield Association policy # 1.04.04
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
L6026 | Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectr | HCPCS | 12/31/2014: Added the following new 2015 HCPCS code to the Code Reference section: L6026. 08/26/2015: Medical policy revised to add ICD-10 codes. SOURCESBlue Cross Blue Shield Association policy # 1.04.04
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy. The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. |
86812 | Immunologic analysis for autoimmune disease, A, B, or C, single antigen | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. |
86822 | Lymphocyte culture primed | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. |
38204 | PR MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. Policy description updated. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. Policy description updated. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. Policy description updated. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. Policy description updated. |
86812 | Immunologic analysis for autoimmune disease, A, B, or C, single antigen | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: See policy "High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Malignancies" prior to 3/25/2004, separate policy developed and aligned with BCBSA policy # 8.01.28 per approval by Medical Policy Advisory Committee (MPAC)
6/25/2004: Code Reference section completed
11/18/2004: Review by MPAC, no changes
10/26/2005: Code Reference section updated, CPT codes 38230, G0355 - G0364 added to the covered table, 38204, 86812 - 86822 added to the non-covered table, J9000 - J9999 deleted, ICD9 procedure codes 41.01, 41.09 added to the covered table, 41.02, 41.03 added to the non-covered table
3/21/2006: Coding updated. CPT4/HCPCS revisions added to policy
5/21/2007: Policy reviewed, description of syngeneic and allogeneic donor types added. No change to policy statements
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
5/21/2008: Policy reviewed, no changes
04/26/2010: Title changed from “High-Dose Chemotherapy with Autologous Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) of the CNS and Ependymoma” to “Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma.” The term “PNET” was changed to “embryonal tumors” throughout the policy. Policy description updated. |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.