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M0300 | Iv chelationtherapy | 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| |
98941 | PR CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS | 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| |
S8040 | TOPOGRAPHIC BRAIN MAPPING | 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| |
90833 | Psytx w pt w e/m 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| |
92537 | PR CALORIC VESTIBULAR TEST W/REC BI BITHERMAL | 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| |
0359T | Behavioral id assessment | 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| |
78608 | HC BRAIN (CNS) TUMOR LOCALIZATION | 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| |
96152 | Intervene hlth/behave indiv | 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| |
70546 | MRI scan of blood vessels of head 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| |
95813 | PR EEG EXTENDED MONITORING 61-119 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| |
86001 | Measurement of antibody (IgG) to allergic substance, each allergen | 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| |
96116 | PR NEUROBEHAVIORAL STATUS XM PHYS/QHP 1ST HOUR | 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| |
96127 | PR BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT | 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| |
92545 | PR OSCILLATING TRACKING TEST W/RECORDING | 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| |
96150 | Assess hlth/behave init | 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| |
82784 | Immunoglobulin M QST | 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| |
78600 | HC NM BRAIN LESS THAN 4 STATIC VW | 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| |
78607 | Brain imaging (3d) | 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| |
92585 | Auditor evoke potent compre | 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| |
96105 | Test to assess the loss of the ability to speak, write, and understand language | 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| |
70450 | HC CT HEAD/BRAIN WITHOUT DYE | 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| |
92550 | Tympanometry & reflex thresh | 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| |
96365 | PR IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR | 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| |
P2031 | HAIR ANALYSIS (EXCLUDING ARSENIC) | 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| |
0374T | Expose behav treatment addl | CPT | 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| |
90838 | Psytx w pt w e/m 60 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| |
H1010 | Nonmed family planning ed | 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| |
90832 | Psytx w pt 30 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| |
92541 | Spontaneous nystagmus test | 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| |
G0176 | Opps/php/iop; activity thrpy | 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| |
T1018 | School-based IEP ser bundled | 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| |
96154 | Interv hlth/behav fam w/pt | 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| |
92547 | PR USE VERTICAL ELECTRODES | 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| |
92065 | PR ORTHOPTIC TRAINING PERFORMED BY PHYS/OTHER QHP | 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| |
95954 | PR RX/PHYSICAL EEG ACTIVAJ PHYS/QHP ATTENDANCE | 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| |
S9445 | PT education noc individ | 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| |
95819 | PR ELECTROENCEPHALOGRAM W/REC AWAKE&ASLEEP | 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| |
96368 | THER/DIAG CONCURRENT INF | 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| |
A9585 | Injection, gadobutrol, 0.1 ml | 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| |
78606 | HC BRAIN IMAGING, MINIMUM 4 STATIC VIEWS; WITH VASCULAR FLOW | 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| |
92587 | PR DISTORT PRODUCT EVOKED OTOACOUSTIC EMISNS LIMITD | 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| |
70460 | HC CT HEAD/BRAIN WITH DYE | 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| |
G0295 | Electromagnetic therapy onc | 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| |
90791 | PSY DX EVALUATION | 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| |
96103 | Psycho testing admin by comp | 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| |
92567 | TYMPANOMETRY | 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| |
95925 | 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| |
88318 | Chemical histochemistry | 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| |
96020 | PR TEST SELECT & ADMN FUNCTL BRAIN MAP PHYS/QHP | 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| |
J0600 | Injection, edetate calcium disodium, up to 1000 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| |
96902 | PR MCRSCP XM HAIR PLUCK/CLIP FOR CNTS/STRUCT ABNORM | 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| |
78605 | HC NM BRAIN MINIMUM 4 STATIC VW | 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| |
70470 | HC CT HEAD/BRAIN W&WO DYE | 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| |
92568 | PR ACOUSTIC REFLEX THRESHOLD | 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| |
92548 | PR CDP-SOT 6 CONDITIONS W/INTERPRETATION & REPORT | 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| |
97532 | ST COGNITIVE SKILLS PER 15 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| |
70555 | Fmri brain by phys/psych | 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| |
92546 | Sinusoidal rotational test | 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| |
98942 | PR CHIROPRACTIC MANIPULATIVE TX SPINAL 5 REGIONS | 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| |
96153 | Intervene hlth/behave group | 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| |
95816 | PR ELECTROENCEPHALOGRAM W/REC AWAKE&DROWSY | 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| |
82787 | HC IGG SUBSETS | 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| |
H1011 | Family assessment | 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| |
J0470 | Injection, dimercaprol, per 100 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| |
90792 | Psychiatric diagnostic evaluation with medical services | 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| |
92542 | PR POSITIONAL NYSTAGMUS TEST | 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| |
92538 | PR CALORIC VESTIBULAR TEST W/REC BI MONOTHERMAL | 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| |
S8035 | MAGNETIC SOURCE IMAGING | 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| |
92588 | PR DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL | 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| |
95812 | PR ELECTROENCEPHALOGRAM EXTEND MONITORING 41-60 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| |
S9446 | PT education noc group | 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| |
70496 | HC CTA, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST I | 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| |
70552 | MRI scan of brain with 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| |
78601 | HC BRAIN IMAGING, LESS THAN 4 STATIC VIEWS; WITH VASCULAR FLOW | 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| |
A9583 | Gadofosveset trisodium inj | 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| |
76390 | HC MR SPECTROSCOPY | 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| |
97533 | Therapy procedure using sensory experiences | 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| |
90868 | PR THERAP REPETITIVE TMS TX SUBSEQ DELIVERY & MNG | 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| |
95928 | PR CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS | 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| |
95803 | PR ACTIGRAPHY TESTING RECORDING ANALYSIS I&R | 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| |
95926 | 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| |
92569 | Acoustic Reflex Decay Test | 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| |
92570 | PR ACOUSTIC IMMIT TEST TYMPANOM/ACOUST REFLX/DECAY | 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| |
90837 | PSYTX WT PT 60 MINS | 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| |
95930 | Visual ep test cns w/i&r | 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| |
98940 | PR CHIROPRACTIC MANIPULATIVE TX SPINAL 1-2 REGIONS | 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| |
70544 | MRV VENOGRAM 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| |
70545 | MRI scan of blood vessels of head with 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| |
92558 | PR EVOKED OTOACOUSTIC EMISSIONS SCREEN AUTO ANALYS | 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| |
90836 | Psytx w pt w e/m 45 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| |
J3520 | EDETATE DISODIUM POWDER | 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| |
70551 | MRI scan of brain without 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| |
90834 | Psytx w pt 45 minutes | HCPCS | 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 | 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 | 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 | 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 | 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 | 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 | 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 | 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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