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99054 | MEDICAL SERVICES-UNUSUAL HRS | CPT | Changes and additions to the CPT are generally made, at most, four times a year. Here are just a few examples of CPT codes:
- 90805 = outpatient psychotherapy
- 38221 = bone marrow biopsy, trocar or needle
- 38211 = tumor cell depletion
- 99261 - 99263 = follow-up inpatient consultation
- 99054 = services requested on holidays or Sundays
HCPCS (Healthcare Common Procedure Coding System). Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. |
38211 | Tumor cell deplete of harvst | HCPCS | Changes and additions to the CPT are generally made, at most, four times a year. Here are just a few examples of CPT codes:
- 90805 = outpatient psychotherapy
- 38221 = bone marrow biopsy, trocar or needle
- 38211 = tumor cell depletion
- 99261 - 99263 = follow-up inpatient consultation
- 99054 = services requested on holidays or Sundays
HCPCS (Healthcare Common Procedure Coding System). Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. |
90805 | Psytx off 20-30 min w/e&m | HCPCS | Here are just a few examples of CPT codes:
- 90805 = outpatient psychotherapy
- 38221 = bone marrow biopsy, trocar or needle
- 38211 = tumor cell depletion
- 99261 - 99263 = follow-up inpatient consultation
- 99054 = services requested on holidays or Sundays
HCPCS (Healthcare Common Procedure Coding System). Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. |
38221 | PR DIAGNOSTIC BONE MARROW BIOPSIES | HCPCS | Here are just a few examples of CPT codes:
- 90805 = outpatient psychotherapy
- 38221 = bone marrow biopsy, trocar or needle
- 38211 = tumor cell depletion
- 99261 - 99263 = follow-up inpatient consultation
- 99054 = services requested on holidays or Sundays
HCPCS (Healthcare Common Procedure Coding System). Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. |
99263 | Follow-up inpatient consult | HCPCS | Here are just a few examples of CPT codes:
- 90805 = outpatient psychotherapy
- 38221 = bone marrow biopsy, trocar or needle
- 38211 = tumor cell depletion
- 99261 - 99263 = follow-up inpatient consultation
- 99054 = services requested on holidays or Sundays
HCPCS (Healthcare Common Procedure Coding System). Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. |
99261 | Follow-up inpatient consult | HCPCS | Here are just a few examples of CPT codes:
- 90805 = outpatient psychotherapy
- 38221 = bone marrow biopsy, trocar or needle
- 38211 = tumor cell depletion
- 99261 - 99263 = follow-up inpatient consultation
- 99054 = services requested on holidays or Sundays
HCPCS (Healthcare Common Procedure Coding System). Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. |
99054 | MEDICAL SERVICES-UNUSUAL HRS | CPT | Here are just a few examples of CPT codes:
- 90805 = outpatient psychotherapy
- 38221 = bone marrow biopsy, trocar or needle
- 38211 = tumor cell depletion
- 99261 - 99263 = follow-up inpatient consultation
- 99054 = services requested on holidays or Sundays
HCPCS (Healthcare Common Procedure Coding System). Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. |
38211 | Tumor cell deplete of harvst | HCPCS | Here are just a few examples of CPT codes:
- 90805 = outpatient psychotherapy
- 38221 = bone marrow biopsy, trocar or needle
- 38211 = tumor cell depletion
- 99261 - 99263 = follow-up inpatient consultation
- 99054 = services requested on holidays or Sundays
HCPCS (Healthcare Common Procedure Coding System). Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. |
J8700 | Temozolomide per 5 mg | HCPCS | Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. |
J3490 | ZINC SULFATE 220MG 220MG CP | HCPCS | Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. |
P9010 | WHOLE BLOOD FOR TRANSFUSION | HCPCS | Medical coders who work with Medicare or Medicaid must become proficient in HCPCS. Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. |
J8700 | Temozolomide per 5 mg | HCPCS | Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." |
J3490 | ZINC SULFATE 220MG 220MG CP | HCPCS | Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." |
P9010 | WHOLE BLOOD FOR TRANSFUSION | HCPCS | Maintained by the American Medical Association, the HCPCS has two levels. CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." |
J8700 | Temozolomide per 5 mg | HCPCS | CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. |
J3490 | ZINC SULFATE 220MG 220MG CP | HCPCS | CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. |
P9010 | WHOLE BLOOD FOR TRANSFUSION | HCPCS | CPT procedure codes are level one, and HCPCS are level two. HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. |
J8700 | Temozolomide per 5 mg | HCPCS | HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. |
J3490 | ZINC SULFATE 220MG 220MG CP | HCPCS | HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. |
P9010 | WHOLE BLOOD FOR TRANSFUSION | HCPCS | HCPCS codes are all alphanumeric and include services, products and supplies - such as prosthetics and ambulance services - not covered in the CPT. Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. |
J8700 | Temozolomide per 5 mg | HCPCS | Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. According to the Final Rule, ICD-9 provides coding for diagnosis, procedures and inpatient hospital services. |
J3490 | ZINC SULFATE 220MG 220MG CP | HCPCS | Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. According to the Final Rule, ICD-9 provides coding for diagnosis, procedures and inpatient hospital services. |
P9010 | WHOLE BLOOD FOR TRANSFUSION | HCPCS | Here are several examples of HCPCS codes:
- J8700 = Temozolmide, oral, 5 mg.
- A0030 = Ambulance service, conventional air service, transport, one way
- JO530 = Injection of penicillin
- J3490 = Unclassified drugs
- P9010 = Blood (whole) for transfusion
To meet the standards set by HIPAA (Health Information Portability and Accounting Act), the Final Rule was instituted in 2000. It stated that the CPT and HCPCS codes are defined as procedure codes for "physician services, physical and occupational therapy services, radiological procedures, clinical laboratory tests, other medical diagnostic procedures, hearing and vision services and transportation services including ambulance." (Source:American Medical Association)
You can learn more about CPT and HCPCS - including how codes are determined and new changes are made - at the American Medical Association's website by clicking here. ICD-9. According to the Final Rule, ICD-9 provides coding for diagnosis, procedures and inpatient hospital services. |
1999 | ANESTHESIOLOGY GROUP | CPT | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY4/1993: Approved by Medical Policy Advisory Committee (MPAC)
2/1997: Expanded clinical indications approved by MPAC. Limited to DEXA method only, once every 12 months. 6/1999: Interim policy revision: Included use of quantitative ultrasound (QUS) as an approved method
8/1999: Addition of QUS approved by MPAC
11/2000: Reviewed by MPAC; no changes
5/21/2001: Code Reference section revised; non-covered codes table added
10/15/2001: Verbiage revised under "policy" section; "Reimbursement is not provided for SPA, DPA or QCT bone densitometry techniques" to "SPA, DPA and QCT bone densitometry techniques are considered investigational and not eligible for coverage." 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. |
1999 | ANESTHESIOLOGY GROUP | CPT | POLICY HISTORY4/1993: Approved by Medical Policy Advisory Committee (MPAC)
2/1997: Expanded clinical indications approved by MPAC. Limited to DEXA method only, once every 12 months. 6/1999: Interim policy revision: Included use of quantitative ultrasound (QUS) as an approved method
8/1999: Addition of QUS approved by MPAC
11/2000: Reviewed by MPAC; no changes
5/21/2001: Code Reference section revised; non-covered codes table added
10/15/2001: Verbiage revised under "policy" section; "Reimbursement is not provided for SPA, DPA or QCT bone densitometry techniques" to "SPA, DPA and QCT bone densitometry techniques are considered investigational and not eligible for coverage." 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. |
1999 | ANESTHESIOLOGY GROUP | CPT | Limited to DEXA method only, once every 12 months. 6/1999: Interim policy revision: Included use of quantitative ultrasound (QUS) as an approved method
8/1999: Addition of QUS approved by MPAC
11/2000: Reviewed by MPAC; no changes
5/21/2001: Code Reference section revised; non-covered codes table added
10/15/2001: Verbiage revised under "policy" section; "Reimbursement is not provided for SPA, DPA or QCT bone densitometry techniques" to "SPA, DPA and QCT bone densitometry techniques are considered investigational and not eligible for coverage." 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. |
1999 | ANESTHESIOLOGY GROUP | CPT | 6/1999: Interim policy revision: Included use of quantitative ultrasound (QUS) as an approved method
8/1999: Addition of QUS approved by MPAC
11/2000: Reviewed by MPAC; no changes
5/21/2001: Code Reference section revised; non-covered codes table added
10/15/2001: Verbiage revised under "policy" section; "Reimbursement is not provided for SPA, DPA or QCT bone densitometry techniques" to "SPA, DPA and QCT bone densitometry techniques are considered investigational and not eligible for coverage." 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. |
76075 | Dxa bone density, axial | HCPCS | 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. |
76071 | Ct bone density, peripheral | HCPCS | 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. |
76077 | Dxa bone density/v-fracture | HCPCS | 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. |
76076 | Dxa bone density/peripheral | HCPCS | 2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
6/12/2002: ICD-9 diagnosis codes 493 and 579 4th/5th digit added
3/2003: Reviewed by MPAC, frequency of all current indications changed to every 2 years except long term glucocortocoid therapy where bone density substantiates need for glucocorticoid reduction remains every 12 months, Sources updated
6/12/2003: Code Reference section updated
8/7/2003: Code Reference section updated, CPT code range 76075-76076 listed separately, fourth and fifth digit added as appropriate to 242.9, 256.3, and 556, ICD-9 diagnosis code ranges listed separately 493.00-493.92, 555.0-555.9, 579.0-579.9, 756.5-756.59, ICD-9 diagnosis codes 491.20 and 491.21 complete descriptions added
8/14/2003: CPT code 76071 added, ICD-9 diagnosis codes 227.3, V07.4 added
7/14/2004: Code Reference section updated, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6. 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. |
76077 | Dxa bone density/v-fracture | HCPCS | 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 deleted
9/27/2004: Under Policy “chronic” renal failure specified, ICD-9 diagnosis code 491.20, 491.21, 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21, 493.22, 493.90, 493.91, 493.92, 496, 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, 556.9, 558.9, 564.2, 571.49, 714.0 added to covered codes with notation “Bone density measurement, using either the QUS or DEXA technology is considered medically necessary and eligible for coverage once every 12 months for long term glucocorticoid therapy where bone density substantiates a need for glucocorticoid reduction in conditions such as listed above but not limited to the condition above. Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. |
76077 | Dxa bone density/v-fracture | HCPCS | Note: V58.65 Long-term (current) use of steroids,” The examples of conditions listed are covered in addition to other chronic illnesses requiring the long term (current) use of glucocorticoid. Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. |
76077 | Dxa bone density/v-fracture | HCPCS | Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. |
G0130 | Single energy x-ray study | HCPCS | Note “but not limited to” - coding has been listed in the Code Reference section for the examples listed in the Policy section only, ICD-9 diagnosis code 242.00, 242.01, 242.10, 242.11, 242.20, 242.21, 242.30, 242.31, 242.40, 242.41, 242.80, 242.81, 756.10, 756.9 added to covered codes, ICD-9 diagnosis code 252.0 5th digit added “252.01,” ICD-9 diagnosis code 626.0 note added “Amenorrhea of six month's duration associated with extensive exercise and/or anorexia nervosa (ICD-9 diagnosis code 307.1)
3/24/2005: CPT code 76077 with effective date of 1/1/2005 added
8/26/2005: CPT code 76077 deleted
11/8/2005: Code Reference section updated, 4th digit added to ICD9 diagnosis code 585.1-585.9: description revised
03/10/2006: Coding updated. HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. |
76077 | Dxa bone density/v-fracture | HCPCS | HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. |
G0130 | Single energy x-ray study | HCPCS | HCPCS 2006 revisions added to policy
09/13/2006: Coding updated. ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. |
76077 | Dxa bone density/v-fracture | HCPCS | ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. |
G0130 | Single energy x-ray study | HCPCS | ICD9 2006 revisions added to policy
09/25/2006: Policy clarified and partially rewritten
10/25/2006: Code reference section updated. CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. |
76075 | Dxa bone density, axial | HCPCS | CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. |
76077 | Dxa bone density/v-fracture | HCPCS | CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. |
G0130 | Single energy x-ray study | HCPCS | CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. |
76076 | Dxa bone density/peripheral | HCPCS | CPT code 76077 added to covered table. HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. |
76075 | Dxa bone density, axial | HCPCS | HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. |
Q9952 | Inj Gad-base MR contrast,1ml | HCPCS | HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. |
G0130 | Single energy x-ray study | HCPCS | HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. |
76076 | Dxa bone density/peripheral | HCPCS | HCPC code G0130 added to non-covered table
12/21/2006: Policy clarified. Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. |
76075 | Dxa bone density, axial | HCPCS | Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. 12/22/2009: Title revised to include “Mineral.” Description Section updated to add Quantitative Computed Tomography (QCT) and Ultrasound Densitometry, removed Quantitative Ultrasound. |
Q9952 | Inj Gad-base MR contrast,1ml | HCPCS | Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. 12/22/2009: Title revised to include “Mineral.” Description Section updated to add Quantitative Computed Tomography (QCT) and Ultrasound Densitometry, removed Quantitative Ultrasound. |
76076 | Dxa bone density/peripheral | HCPCS | Added "including, but not limited to, women 60 years of age or older" to women deficient in estrogen following menopause
12/28/2006: Code Reference section updated per the 2007 CPT/HCPCS revisions
12/17/2007: Coding updated.CPT/HCPCS 2008 revisions added to policy
9/17/2008: Annual ICD-9 updates effective 10-1-2008 applied
9/28/2009: Code reference section updated. New ICD-9 diagnosis code 569.71 added to covered table. CPT codes 76075 and 76076 deleted from covered table due to codes were deleted as of 12-31-2006. HCPC code Q9952 deleted from covered table due to code was deleted as of 12-31-2007. 12/22/2009: Title revised to include “Mineral.” Description Section updated to add Quantitative Computed Tomography (QCT) and Ultrasound Densitometry, removed Quantitative Ultrasound. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0360 | Each additional hr 1-8 hrs | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0362 | Each add sequential infusion | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0359 | Chemotherapy IV one hr initi | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
86826 | Hla x-match noncytotoxc addl | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
86825 | X-MATCHAHG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0360 | Each additional hr 1-8 hrs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0362 | Each add sequential infusion | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0359 | Chemotherapy IV one hr initi | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. |
G0358 | IV PUSH TECHNIQUE EACH ADD SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
86826 | Hla x-match noncytotoxc addl | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
86825 | X-MATCHAHG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0360 | Each additional hr 1-8 hrs | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
J9000 | INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0364 | HC BONE MARROW ASPIRATE & BIOPSY | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0362 | Each add sequential infusion | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
J9999 | Not otherwise classified, antineoplastic drugs | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0359 | Chemotherapy IV one hr initi | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
38230 | PR BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0361 | Prolong chemo infuse>8hrs pu | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0357 | IV PUSH TECHNIQUE SINGLE/INIT SUBSTANCE/DRUG | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0356 | HORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0355 | CHEMO ADMN SUBQ/IM NONHORMONAL ANTINEOPLASTIC | HCPCS | POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC) to be aligned with BCBSA policy # 8.01.31
6/25/2004: Code Reference section completed
11/18/2004: Reviewed by MPAC; no changes
10/26/2005: Code Reference section updated, CPT-4 codes 38230 added; HCPCS codes G0355, G0356, G0357, G0358, G0359, G0360, G0361, G0362, G0363, G0364 added; J9000-J9999 deleted; ICD-9 Procedure codes 41.00, 41.01, 41.02, 41.03, 41.09 added
3/10/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy. 9/18/2007: Policy reviewed, no changes
12/20/2007: Coding updated per 2008 CPT/HCPCS revisions
8/22/2008: Description section updated; policy statement unchanged
4/8/2010: Code Reference section updated. CPT code 86825 and 86826 added to non-covered table. 10/21/2010: Policy reviewed; no changes. |
G0267 | Bone marrow or psc harvest | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38241 | Transplt autol hct/donor | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0363 | IRRIG IMPLANTED VENOUS ACESS DEVICE DRUG DEL SYS | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38240 | Transplt allo hct/donor | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0265 | Cryopresevation Freeze+stora | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
38242 | Transplt allo lymphocytes | HCPCS | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
G0266 | Thawing + expansion froz cel | CPT | 10/05/2011: Policy reviwed; no changes. 11/30/2012: Policy reviwed; no changes. 04/29/2013: Deleted ICD-9 procedure codes 41.02, 41.03, 41.05, and 41.08 from the Code Reference section. 08/25/2015: Code Reference section updated to add ICD-10 codes. Revised the descriptions for CPT codes 38240, 38241, and 38242; removed deleted HCPCS code G0363, G0265, G0266, and G0267; removed deleted code CPT 96445 and replaced with CPT code 96446. |
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