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E1340 | Repair for DME - per 15 min | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
A4556 | PT ELECTRODES | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
1999 | ANESTHESIOLOGY GROUP | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
E0608 | APNEA MONITOR | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
A4557 | Lead wires, pair | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
E0619 | Apnea monitor w recorder | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
E0618 | Apnea monitor, without recording feature | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. |
E1340 | Repair for DME - per 15 min | CPT | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
A4556 | PT ELECTRODES | HCPCS | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
1999 | ANESTHESIOLOGY GROUP | CPT | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
E0608 | APNEA MONITOR | HCPCS | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
A4557 | Lead wires, pair | HCPCS | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
E0619 | Apnea monitor w recorder | HCPCS | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
E0618 | Apnea monitor, without recording feature | HCPCS | 6/1992: Pneumogram policy approved by Medical Policy Advisory Committee (MPAC)
8/1992: Home Apnea Monitor policy approved by Medical Policy Advisory Committee (MPAC)
9/1999: Policies merged; interim policy changes made
11/1999: Revisions to interim policy approved by MPAC
2/27/2002: Managed Care Requirements deleted
3/6/2002: Individual consideration requirement deleted
5/1/2002: Type of Service and Place of Service deleted
3/12/2003: Code Reference section updated
7/2003: Reviewed by MPAC, adapted American Academy of Pediatrics recommendations, HCPCS A4556, A4557completed description added, note E0608 deleted 2003
11/1/2004: Code Reference section updated, ICD-9 diagnosis code 768.2, 768.3, 768.5, 768.6, 768.9, 769, 770.0, 770.2, 770.4, 770.5, 770.6, 770.7, 779.81, 786.09 added, ICD-9 diagnosis 770.8 5th digit added, HCPCS E0608, E1340 deleted, HCPCS E0618, E0619 effective date of 1/1/2003 added
9/12/2006: Coding updated. ICD9 2006 revisions added to policy
10/18/2006: Policy reviewed, no changes
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
7/17/2008: Policy statements revised, but materially remain unchanged. Removed the following policy statements: home apnea monitoring is considered medically necessary until 43 weeks postmenstrual age or after the cessation of extreme episodes, whichever comes last in infants less than 12 months of age, as documented by a letter from the prescribing physician; and physician certification of close supervision and continuous care plan requirement. Pneumogram information removed from policy. Removed performance of a pneumogram in the hospital and home setting is considered medically necessary for patients with documented clinically significant apnea. |
E0751 | PULSE GENERATOR OR RECEIVER | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | 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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
63690 | -1 | 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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
95970 | PR ELEC ALYS IMPLT NPGT PHYS/QHP W/O PROGRAMMING | 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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
E0753 | NEUROSTIMUL ELECTRODES/LEADS | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
95971 | PR ELEC ALYS IMPLT NPGT SMPL SP/PN NPGT PRGRMG | 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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
63685 | PR INSJ/RPLCMT SPINAL NPG/RCVR POCKET CRTJ&CONNJ | 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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
63691 | -1 | 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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
E0754 | PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
E0752 | IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH | 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. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
63660 | Revise/Remove Neuroelectrode | 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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
95973 | Analyze neurostim complex | 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. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. |
E0751 | PULSE GENERATOR OR RECEIVER | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
63690 | -1 | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
1999 | ANESTHESIOLOGY GROUP | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
95970 | PR ELEC ALYS IMPLT NPGT PHYS/QHP W/O PROGRAMMING | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
E0753 | NEUROSTIMUL ELECTRODES/LEADS | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
95971 | PR ELEC ALYS IMPLT NPGT SMPL SP/PN NPGT PRGRMG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
63685 | PR INSJ/RPLCMT SPINAL NPG/RCVR POCKET CRTJ&CONNJ | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
63691 | -1 | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
E0754 | PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
E0752 | IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
63660 | Revise/Remove Neuroelectrode | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
95973 | Analyze neurostim complex | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. 6/1993: Approved by Medical Policy Advisory Committee (MPAC)
3/2001: Policy reviewed; Hyperlinks inserted under Policy, Managed Care Requirements deleted, Sources updated
2/15/2002: Investigational definition added
3/6/2002: Individual consideration requirement deleted
5/7/2002: Type of Service and Place of Service deleted
2/21/2005: CPT 63685 , 95970 , 95971 , 95972 , 95973 description revised, CPT 63690-63691 deleted 1999, ICD-9 procedure codes 02.93, 03.93 description revised, HCPCS E0751 deleted 2001, HCPCS E0753 deleted 2002
10/26/2005: Code Reference section updated; CPT-4: 63660 added; ICD-9 Procedure: 02.93 deleted; 03.94, 86.94, 86.95, 86.96 added; HCPCS: E0752, E0754 added
11/15/2005: ICD9 procedure codes 86.97, 86.98 added
3/14/2006: Coding updated. HCPCS 2005 & 2006 revisions added to policy
4/1/2008: Policy reviewed, no changes
12/31/2008: Code reference section updated per 2009 CPT/HCPCS revisions
1/8/2009: Policy reviewed, no changes
12/16/2009: Coding Section revised for 2010 CPT4 and HCPCS revisions
04/27/2010: Policy description re-written extensively to provide information on various conditions spinal cord stimulation is used for, FDA status of devices, and techniques for device placement. Policy statement updated to add “and as a treatment for refractory angina pectoris” to the investigational statement. Patient selection criteria added to the policy guidelines. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | HCPCS | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
E0756 | Implantable pulse generator | CPT | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
E0758 | External RF transmitter | CPT | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
E0754 | PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN | CPT | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
E0752 | IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH | CPT | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
E0757 | Implantable RF receiver | CPT | Policy statement updated to add heart failure as investigational. 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | HCPCS | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
E0756 | Implantable pulse generator | CPT | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
E0758 | External RF transmitter | CPT | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
E0754 | PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN | CPT | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
E0752 | IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH | CPT | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
E0757 | Implantable RF receiver | CPT | 08/27/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. |
95972 | PR ELEC ALYS IMPLT NPGT CPLX SP/PN PRGRMG | HCPCS | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
E0756 | Implantable pulse generator | CPT | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
E0758 | External RF transmitter | CPT | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
E0754 | PT PROGRAMMER W/IMPL PROG NEUROSTIM PULSE GEN | CPT | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
E0752 | IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH | CPT | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
E0757 | Implantable RF receiver | CPT | Removed deleted HCPCS codes E0752, E0754, E0756, E0757, and E0758. 12/31/2015: Policy guidelines updated to add medically necessary and investigative definitions. Code Reference section updated to revise the description for CPT code 95972. 05/31/2016: Policy number added. 07/20/2016: Policy description updated regarding devices. |
11710 | Debridement of nails-electric grinder-five or less | CPT | For example, a doctor may provide documentation of a mole removed from the torso of a patient via cryoablation (essentially, freezing the mole). The medical biller and coder would look at the procedure documentation and decide which codes correspond to the diagnosis and procedure listed. In the case of this example, a coder would select the CPT code 11710 (destruction of benign lesions or skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) for the procedure, and the ICD-9-CM code 216.5 (benign neoplasm of skin of trunk, except scrotum) for the diagnosis. The bulk of the medical coding portion of the billing process involves turning procedure reports into correct medical code, then entering it into the system for the claims process. Medical coders spend their day taking procedure documentation, looking up the proper codes, and entering that information into their claims software. |
A0428 | HC BLS NON EMERGENCY A0428 | HCPCS | Level II or HCPCS Modifiers
Level II or HCPCS modifiers consist of two characters— either Alphabets or Alphanumeric. It’s pertinent to mention here that these modifiers are updated by the Centre for Medicare & Medicaid Services(CMS). The HCPCS modifiers are used to provide additional information on specific items used to deliver non-physician services. Before forwarding to the payers, all of this information is represented in the format ‘HCPCS code modifier’. For instance, A0428-QN is used to represent “basic life support ambulance service, non-emergency transport, furnished by the provider of services.”
Here is the list of most commonly used HCPCS modifiers:
- AA- Anesthesia services performed by anesthesiologists. |
A0428 | HC BLS NON EMERGENCY A0428 | HCPCS | It’s pertinent to mention here that these modifiers are updated by the Centre for Medicare & Medicaid Services(CMS). The HCPCS modifiers are used to provide additional information on specific items used to deliver non-physician services. Before forwarding to the payers, all of this information is represented in the format ‘HCPCS code modifier’. For instance, A0428-QN is used to represent “basic life support ambulance service, non-emergency transport, furnished by the provider of services.”
Here is the list of most commonly used HCPCS modifiers:
- AA- Anesthesia services performed by anesthesiologists. - AD- Medical supervision by a physician, more than four concurrent anaesthesia procedures. |
A0428 | HC BLS NON EMERGENCY A0428 | HCPCS | The HCPCS modifiers are used to provide additional information on specific items used to deliver non-physician services. Before forwarding to the payers, all of this information is represented in the format ‘HCPCS code modifier’. For instance, A0428-QN is used to represent “basic life support ambulance service, non-emergency transport, furnished by the provider of services.”
Here is the list of most commonly used HCPCS modifiers:
- AA- Anesthesia services performed by anesthesiologists. - AD- Medical supervision by a physician, more than four concurrent anaesthesia procedures. - AH- Clinical Psychologist (CP) Services. |
32856 | Prepare donor lung double | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. |
S2061 | Donor lobectomy (lung) for transplantation, living donor | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. |
32855 | Prepare donor lung single | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. |
S2060 | LOBAR LUNG TRANSPLANTATION | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. |
S2152 | SOLID ORGAN TRANSPL PKG | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. |
32856 | Prepare donor lung double | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. |
S2061 | Donor lobectomy (lung) for transplantation, living donor | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. |
32855 | Prepare donor lung single | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. |
S2060 | LOBAR LUNG TRANSPLANTATION | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. |
S2152 | SOLID ORGAN TRANSPL PKG | 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
3/5/2002: Policy exception deleted
5/1/2002: Type of Service and Place of Service deleted
8/20/2003: ICD-9 procedure code range 33.50-33.52 listed separately, ICD-9 diagnosis code range 011.0-011.2, 011.4, 011.9, 277.00-277.01, 402.00-402.91, 415.11-415.19, 416.0, 416.8, 416.9, 491.20-491.21, 500-505 listed separately
6/23/2004: Policy reviewed, Sources updated, Policy exception added
07/21/2005: Policy reviewed by MPAC, "HIV positivity is not an absolute contraindication to transplant. Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. |
32856 | Prepare donor lung double | HCPCS | Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. CPT4 2006 revisions added to policy. 9/20/2007: Code Reference section updated. |
S2061 | Donor lobectomy (lung) for transplantation, living donor | HCPCS | Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. CPT4 2006 revisions added to policy. 9/20/2007: Code Reference section updated. |
32855 | Prepare donor lung single | HCPCS | Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. CPT4 2006 revisions added to policy. 9/20/2007: Code Reference section updated. |
S2060 | LOBAR LUNG TRANSPLANTATION | HCPCS | Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. CPT4 2006 revisions added to policy. 9/20/2007: Code Reference section updated. |
S2152 | SOLID ORGAN TRANSPL PKG | HCPCS | Each individual transplant certer will determine patient selection criteria for HIV positive patients"
10/17/2005: Code Reference table updated: CPT codes 32855, 32856 added; ICD-9 procedure code 00.91, 00.92, 00.93 added; HCPCS codes S2060, S2061 S2152 added; diagnosis code 518.3 added
3/14/2006: Coding updated. CPT4 2006 revisions added to policy. 3/23/2006: Coding updated. CPT4 2006 revisions added to policy. 9/20/2007: Code Reference section updated. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | HCPCS Level III contains alphanumeric codes that are assigned
by Medicaid state agencies to identify additional items
and services not included in levels I or II. These are usually
called "local codes", and must have "W",
"X", "Y", or "Z" in the first
position. HCPCS Procedure Modifier Codes can be used with
all three levels, with the WA - ZY range used for locally
assigned procedure modifiers. - Health Insurance Portability &
Accountability Act (HIPAA) – A law passed
in 1996 which is also sometimes called the “Kassebaum-Kennedy”
law. This law expands healthcare coverage for patients who
have lost or changed jobs, or have pre-existing conditions. |
1996 | Daily Hospital Management Of Epidural Or Subarachnoid Continuous Drug Administration | HCPCS | These are usually
called "local codes", and must have "W",
"X", "Y", or "Z" in the first
position. HCPCS Procedure Modifier Codes can be used with
all three levels, with the WA - ZY range used for locally
assigned procedure modifiers. - Health Insurance Portability &
Accountability Act (HIPAA) – A law passed
in 1996 which is also sometimes called the “Kassebaum-Kennedy”
law. This law expands healthcare coverage for patients who
have lost or changed jobs, or have pre-existing conditions. HIPAA does not replace the states' roles as primary regulators
of insurance. |
B4105 | Enzyme cartridge enteral nut | HCPCS | - The latest updates include 279 new codes, 51 deleted codes, and 143 revised codes. A total of 71,932 active codes have been recorded with the most recent CMS revisions. - Chapters 1, 3 and 8 witnessed no new changes whereas chapter 2,7,11,14,15,16 and 19 went through the highest changes. - HCPCS codes overhaul
- CMS has also changed HCPCS codes Q9994, effective December 3, 2018. - The HCPCS code B4105 is changed from D "Special Coverage Instructions Apply" to C "Contractor Discretion. |
B4105 | Enzyme cartridge enteral nut | HCPCS | A total of 71,932 active codes have been recorded with the most recent CMS revisions. - Chapters 1, 3 and 8 witnessed no new changes whereas chapter 2,7,11,14,15,16 and 19 went through the highest changes. - HCPCS codes overhaul
- CMS has also changed HCPCS codes Q9994, effective December 3, 2018. - The HCPCS code B4105 is changed from D "Special Coverage Instructions Apply" to C "Contractor Discretion. Code B4105 replaces code Q9994 effective for claims with dates of service on or after January 1, 2019. |
B4105 | Enzyme cartridge enteral nut | HCPCS | - Chapters 1, 3 and 8 witnessed no new changes whereas chapter 2,7,11,14,15,16 and 19 went through the highest changes. - HCPCS codes overhaul
- CMS has also changed HCPCS codes Q9994, effective December 3, 2018. - The HCPCS code B4105 is changed from D "Special Coverage Instructions Apply" to C "Contractor Discretion. Code B4105 replaces code Q9994 effective for claims with dates of service on or after January 1, 2019. With the latest Live healthcare webinars, SymposiumGo is bringing you all the latest updates related to the most recent changes in the coding environment as well as other healthcare topics. |
B4105 | Enzyme cartridge enteral nut | HCPCS | - HCPCS codes overhaul
- CMS has also changed HCPCS codes Q9994, effective December 3, 2018. - The HCPCS code B4105 is changed from D "Special Coverage Instructions Apply" to C "Contractor Discretion. Code B4105 replaces code Q9994 effective for claims with dates of service on or after January 1, 2019. With the latest Live healthcare webinars, SymposiumGo is bringing you all the latest updates related to the most recent changes in the coding environment as well as other healthcare topics. |
90834 | Psytx w pt 45 minutes | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
95927 | Somatosensory testing | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
0333T | Visual ep scr acuity auto | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
96125 | Test to assess the ability to complete specific functional tasks applicable to environment | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
92540 | PR VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRK | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
90875 | PR INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 30 MIN | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
96101 | Psycho testing by psych/phys | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
90867 | PR REPET TMS TX INITIAL W/MAP/MOTR THRESHLD/DEL&M | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
70554 | MRI PITUITARY W/O | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
90869 | PR REPET TMS TX SUBSEQ MOTR THRESHLD W/DELIV & MN | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
S9355 | HIT chelation diem | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
98943 | PR CHIROPRACTIC MANIPLTV TX EXTRASPINAL 1/> REGION | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
97530 | Therapy procedure using functional activities | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
70553 | MRI scan of brain before and after contrast | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
95957 | PR DIGITAL ANALYSIS ELECTROENCEPHALOGRAM | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
J0895 | INJECTION, DEFEROXAMINE MESYLATE, 500 MG | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
92544 | PR OPTKINETIC NYSTAG BIDIR/FOVEAL/PERIPH STIM W/REC | HCPCS | Most of these interventions have not been proven efficacious in blinded randomized controlled trials”. An UpToDate review on “Attention deficit hyperactivity disorder in children and adolescents: Treatment with medications” (Krull, 2015b) does not mention bupropion, reboxetine, desipramine and nortriptyline as therapeutic options. |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 "+":|
|CPT codes covered if selection criteria are met:|
|90791||Psychiatric diagnostic evaluation|
|90792||Psychiatric diagnostic evaluation with medical services|
|96150||Health and behavior assessment (e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment|
|96152||Health and behavior intervention, each 15 minutes, face-to-face; individual|
|96153||group (2 or more patients)|
|96154||family (with the patient present)|
|CPT codes not covered for indications listed in the CPB:|
|0333T||Visual evoked potential, screening of visual acuity, automated|
|0359T - 0374T||Adaptive behavior assessments and treatments|
|70450||Computed tomography, head or brain; without contrast material|
|70460||with contrast material(s)|
|70470||without contrast material, followed by contrast material(s) and further sections|
|70496||Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image post-processing|
|70544||Magnetic resonance angiography, head; without contrast material(s)|
|70545||with contrast material(s)|
|70546||without contrast material(s), followed by contrast material(s) and further sequences|
|70551||Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material|
|70552||with contrast material(s)|
|70553||without contrast material, followed by contrast material(s) and further sequences|
|70554||Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration|
|70555||requiring physician or psychologist administration of entire neurofunctional testing|
|76390||Magnetic resonance spectroscopy|
|78600||Brain imaging, less than 4 static views|
|78601||with vascular flow|
|78605||Brain imaging, minimum 4 static views|
|78606||with vascular flow|
|78607||Brain imaging, tomographic (SPECT)|
|78608||Brain imaging, positron emission tomography (PET); metabolic evaluation|
|82784||Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each [assessment test for prescription of diet]|
|82787||Immunoglbulin subclasses (ed, IgG1, 2, 3, or 4), each [assessment test for prescription of diet]|
|86001||Allergen specific IgG quantitative or semiquantitative, each allergen [assessment test for prescription of diet]|
|88318||Determinative histochemistry to identify chemical components (e.g., copper, zinc)|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service|
|90834||Psychotherapy, 45 minutes with patient and/or family|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service|
|90867||Therapeutic repetitive transcranial magnetic stimulation treatment; planning|
|90868||delivery and management, per session|
|90869||subsequent motor threshold re-determination with delivery and management|
|90875||Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes|
|92065||Orthoptic and/or pleoptic training, with continuing medical direction and evaluation|
|92537 - 92538||Caloric vestibular test with recording, bilateral; bithermal or monothermal|
|92540||Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmust test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording|
|92541||Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording|
|92542||Positional nystagmus test, minimum of 4 positions, with recording|
|92544||Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording|
|92545||Oscillating tracking test, with recording|
|92546||Sinusoidal vertical axis rotational testing|
|+ 92547||Use of vertical electrodes (List separately in addition to code for primary procedure)|
|92548||Computerized dynamic posturography|
|92550||Tympanometry and reflex threshold measurements|
|92558||Evoked otoacoustic emissions, screening (qualutative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis|
|92567||Tympanometry (impedance testing)|
|92568 - 92569||Acoustic reflex testing|
|92570||Acoustic immittance testing, includes typanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies|
|95803||Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)|
|95812||Electroencephalogram (EEG) extended monitoring; 41-60 minutes [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95813||greater than 1 hour [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95816||Electroencephalogram (EEG); including recording awake and drowsy [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95819||including recording awake and asleep [covered only for persons with signs of seizure disorder or degenerative neurological condition]|
|95925||Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs|
|95926||in lower limbs|
|95927||in the trunk or head|
|95928||Central motor evoked potential study (transcranial motor stimulation); upper limbs|
|95930||Visual evoked potential (VEP) testing central nervous system, checkerboard or flash|
|95954||Pharmacological or physical activation requiring physician attendance during EEG recording of activation phase (eg, thiopental activation test)|
|95957||Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) [neuropsychiatric EEG based assessment aid (NEBA)]|
|96020||Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report|
|96101 - 96103||Psychological testing|
|96105||Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, e.g., by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour|
|96116 - 96125||Neuropsychological testing|
|96902||Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality|
|97530||Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes|
|97532||Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes|
|97533||Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes|
|98940||Chiropractic manipulative treatment (CMT); spinal, 1-2 regions|
|98941||spinal, 3-4 regions|
|98942||spinal, 5 regions|
|98943||extraspinal, 1 or more regions|
|Other CPT codes related to the CPB:|
|96127||Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument|
|96365 - 96368||Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug)|
|HCPCS codes not covered for indications listed in the CPB:|
|A9583||Injection, Gadofosveset Trisodium, 1 ml [Ablavar, Vasovist]|
|A9585||Injection, gadobutrol, 0.1 ml|
|G0176||Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)|
|G0295||Electromagnetic therapy, to one or more areas|
|H1010||Non-medical family planning education, per session|
|H1011||Family assessment by licensed behavioral health professional for state defined purposes|
|J0470||Injection, dimercaprol, per 100 mg|
|J0600||Injection, edetate calcium disodium, up to 1,000 mg|
|J0895||Injection, deferoxamine mesylate, 500 mg|
|J3520||Edetate disodium, per 150 mg|
|M0300||IV chelation therapy (chemical endarterectomy)|
|P2031||Hair analysis (excluding arsenic)|
|S8035||Magnetic source imaging|
|S8040||Topographic brain mapping|
|S9355||Home infusion, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem|
|S9445||Patient education, not otherwise classified, non-physician provider, individual, per session|
|S9446||Patient education, not otherwise classified, non-physician provider, group, per session|
|T1018||School-based individualized education program (IEP) services, bundled|
|ICD-10 codes covered if selection criteria are met:|
|F90.0 - F90.9||Attention-deficit hyperactivity disorder| |
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