Connection supplemental articles and policies – March 2015

Supplemental articles

Payment policies

These policies apply to Fallon Health and Fallon Total Care unless otherwise noted.

Updated policies – effective May 1, 2015:
The following policies have been updated; details about the changes are indicated on the policies.

New policy:

  • Diabetes Self-Management Education/Training Payment Policy

Revised policies:

  • Ambulatory Surgery - Facility Payment Policy – Changed threshold for which operative notes may be requested from $2,500 to $5,000 and noted prepayment review process. Moved to new template.
  • Ambulatory Surgery - Professional Payment Policy – Noted prepayment review process and moved to new template.
  • Anesthesia Payment Policy – updated Billing/coding section discussion related to anesthesia assistance for GI endoscopy
  • Medical Nutrition Therapy Payment Policy – moved to Fallon Health template
  • Gastroenterology Payment Policy – updated discussion about anesthesia with upper and lower GI endoscopic procedures; moved to Fallon Health template
  • Skilled Nursing Facility Payment Policy – Added default HIPPS code language.

| Back to the top |

Coding Corner

New 2015 CPT/HCPCS codes

Fallon Health has completed its formal review of the 2015 CPT/HCPCS codes, and some of them will continue to require prior authorization. These codes have been added to the list of procedures that require prior authorization and are effective immediately. The final codes and determinations are listed below and in our online Provider Manual, under the “Managing patient care” section. Go toPCP referral and plan prior authorization process.”

CPT CODES

Effective January 1, 2015, the following CPT code is not separately reimbursed.

Code

Description

34839

Physician planning of a patient-specific fenestrated visceral aortic endograft requiring a minimum of 90 minutes of physician time

Effective January 1, 2015, the following CPT codes are deny vendor liable for all lines of business:

Code

Description

0357T

Cryopreservation; immature oocyte(s)

0375T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels

0376T

Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in addition to code for primary procedure.)

0377T

Anoscopy with directed submucosal injection of bulking agent for fecal incontinence

0378T

Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional

0379T

Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional

0380T

Computer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report

0381T

External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional

0382T

External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only

0383T

External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional

0384T

External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only

0385T

External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional

0386T

External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only

0387T

Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular

0388T

Transcatheter removal of permanent leadless pacemaker, ventricular

0389T

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system

0390T

Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system

0391T

Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system

Effective January 1, 2015, the following CPT codes will require prior authorization.

Code

Description

20604

Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting

20606

Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting

20611

Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting

20983

Ablation therapy for reduction or eradication of 1 or more bone tumors (e.g., metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation

21811

Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs

21812

Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs

21813

Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribs

22510

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic

22511

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral

22512

Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)

22513

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic

22514

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar

22515

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

22858

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); second level, cervical (List separately in addition to code for primary procedure)

27279

Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device

33270

Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed

33271

Insertion of subcutaneous implantable defibrillator electrode

33272

Removal of subcutaneous implantable defibrillator electrode

33418

Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis

33419

Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure.)

33957

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed)

33958

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed)

33959

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age (includes fluoroscopic guidance, when performed)

33962

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition peripheral (arterial and/or venous) cannula(e), open, 6 years and older (includes fluoroscopic guidance, when performed)

33963

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age (includes fluoroscopic guidance, when performed)

33964

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; reposition central cannula(e) by sternotomy or thoracotomy, 6 years and older (includes fluoroscopic guidance, when performed)

33965

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age

33966

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older

33969

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age

33984

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, 6 years and older

33985

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age

33986

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, 6 years and older

33987

Arterial exposure with creation of graft conduit (e.g., chimney graft) to facilitate arterial perfusion for ECMO/ECLS (List separately in addition to code for primary procedure.)

33988

Insertion of left heart vent by thoracic incision (e.g., sternotomy, thoracotomy) for ECMO/ECLS

33989

Removal of left heart vent by thoracic incision (e.g., sternotomy, thoracotomy) for ECMO/ECLS

45399

Unlisted procedure, colon

77085

Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture assessment

77086

Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA)

77306

Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)

77307

Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)

77316

Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)

77317

Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)

77318

Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)

77385

Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple

77386

Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex

80300

Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (e.g., immunoassay) capable of being read by direct optical observation, including instrumented-assisted when performed (e.g., dipsticks, cups, cards, cartridges), per date of service

80301

Drug screen, any number of drug classes from Drug Class List A; single drug class method, by instrumented test systems (e.g., discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay), per date of service

80302

Drug screen, presumptive, single drug class from Drug Class List B, by immunoassay (e.g., ELISA) or non-TLC chromatography without mass spectrometry (e.g., GC, HPLC), each procedure

80303

Drug screen, any number of drug classes, presumptive, single or multiple drug class method; thin layer chromatography procedure(s) (TLC) (e.g., acid, neutral, alkaloid plate), per date of service

80304

Drug screen, any number of drug classes, presumptive, single or multiple drug class method; not otherwise specified presumptive procedure (e.g., TOF, MALDI, LDTD, DESI, DART), each procedure

80375

Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3

80376

Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6

80377

Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more

81246

FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (e.g., D835, I836)

81288

MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis

81313

PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (e.g., prostate cancer)

81410

Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK

81411

Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1

81415

Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis

81416

Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (e.g., parents, siblings) (List separately in addition to code for primary procedure.)

81417

Exome (e.g., unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (e.g., updated knowledge or unrelated condition/syndrome)

81420

Fetal chromosomal aneuploidy (e.g., trisomy 21, monosomy X) genomic sequence analysis panel, circulating cell-free fetal DNA in maternal blood, must include analysis of chromosomes 13, 18, and 21

81425

Genome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis

81426

Genome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (e.g., parents, siblings) (List separately in addition to code for primary procedure.)

81427

Genome (e.g., unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (e.g., updated knowledge or unrelated condition/syndrome)

81430

Hearing loss (e.g., nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1

81431

Hearing loss (e.g., nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes

81435

Hereditary colon cancer syndromes (e.g., Lynch syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include analysis of at least 7 genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS2

81436

Hereditary colon cancer syndromes (e.g., Lynch syndrome, familial adenomatosis polyposis); duplication/deletion gene analysis panel, must include analysis of at least 8 genes, including APC, MLH1, MSH2, MSH6, PMS2, EPCAM, CHEK2, and MUTYH

81445

Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, 5-50 genes (e.g., ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed

81450

Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA and RNA analysis when performed, 5-50 genes (e.g., BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, NPM1, NOTCH1), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed

81455

Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA and RNA analysis when performed, 51 or greater genes (e.g., ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed

81460

Whole mitochondrial genome (e.g., Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection

81465

Whole mitochondrial genome large deletion analysis panel (e.g., Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed

81470

X-linked intellectual disability (XLID) (e.g., syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2

81471

X-linked intellectual disability (XLID) (e.g., syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2

81519

Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score

83006

Growth stimulation expressed gene 2 (ST2, Interleukin 1 receptor like-1)

87505

Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets

87506

Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets

87507

Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (e.g., Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets

89337

Cryopreservation, mature oocyte(s)

91200

Liver elastography, mechanically induced shear wave (e.g., vibration), without imaging, with interpretation and report

92145

Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report

93260

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable subcutaneous lead defibrillator system

93261

Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system

93644

Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)

93702

Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s)

93895

Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral

96127

Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument

97607

Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters

97608

Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters

| Back to the top |

HCPCS CODES

Effective January 1, 2015, the following codes will require plan prior authorization.

A9606

Radium ra-223 dichloride, therapeutic, per microcurie

C9027

Injection, pembrolizumab, 1 mg

C9442

Injection, belinostat, 10 mg

C9443

Injection, dalbavancin, 10 mg

C9444

Injection, oritavancin, 10 mg

C9446

Injection, tedizolid phosphate, 1 mg

D6110

Implnt/abut remov dent max

D6111

Implnt/abut remov dent mand

D6112

Imp/abut rem dent part max

D6113

Imp/abut rem dent part mand

D6114

Implnt/abut fixed dent max

D6115

Implnt/abut fixed dent mand

D6116

Imp/abut fixed dent part max

D6117

Imp/abut fixed dent part man

D6549

Resin retainer

G0276

Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (PILD) or placebo-control, performed in an approved coverage with evidence development (CED) clinical trial

G0277

Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval

G0279

Diagnostic digital breast tomosynthesis, unilateral or bilateral

G0464

Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)

G6002

Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy

G6015

Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session

G6016

Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session

G6021

Unlisted procedure, intestine

G6030

Amitriptyline

G6031

Benzodiazepines

G6032

Desipramine

G6034

Doxepin

G6035

Gold

G6036

Assay of imipramine

G6037

Nortriptyline

G6038

Salicylate

G6039

Acetaminophen

G6040

Alcohol (ethanol); any specimen except breath

G6041

Alkaloids, urine, quantitative

G6042

Amphetamine or methamphetamine

G6043

Barbiturates, not elsewhere specified

G6044

Cocaine or metabolite

G6045

Dihydrocodeinone

G6046

Dihydromorphinone

G6047

Dihydrotestosterone

G6048

Dimethadione

G6049

Epiandrosterone

G6050

Ethchlorvynol

G6051

Flurazepam

G6052

Meprobamate

G6053

Methadone

G6054

Methsuximide

G6055

Nicotine

G6056

Opiate(s), drug and metabolites, each procedure

G6057

Phenothiazine

G6058

Drug confirmation, each procedure

J0571

Buprenorphine, oral, 1 mg

J0572

Buprenorphine/naloxone, oral, less than or equal to 3 mg

J0573

Buprenorphine/naloxone, oral, greater than 3 mg, but less than or equal to 6 mg

J0574

Buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg

J0575

Buprenorphine/naloxone, oral, greater than 10 mg

J1322

Injection, elosulfase alfa, 1mg

J1439

Injection, ferric carboxymaltose, 1mg

J3145

Injection, testosterone undecanoate, 1 mg

J7327

Hyaluronan or derivative, monovisc, for intra-articular injection, per dose

J7336

Capsaicin 8% patch, per square centimeter

J9301

Injection, obinutuzumab, 10 mg

L6026

Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)

L7259

Electronic wrist rotator, any type

Effective January 1, 2015, the following codes are deny vendor liable for all lines of business and will not require plan prior authorization.

D0171

Re-eval post-op visit

D0351

3D photographic image

D9219

Eval for deep sed/gen anesth

G9365

One high-risk medication ordered

G9027

One high-risk medication not ordered

G9367

At least two different high-risk medications ordered

G9368

At least two different high-risk medications not ordered

G9369

Individual filled at least two prescriptions for any antipsychotic medication and had a PDC of 0.8 or greater

G9370

Individual who did not fill at least two prescriptions for any antipsychotic medication or did not have a PDC of 0.8 or greater

G9376

Patient continued to have the retina attached at the 6 months follow up visit (+/- 1 month) following only one surgery

G9377

Patient did not have the retina attached after 6 months following only one surgery

G9378

Patient continued to have the retina attached at the 6 months follow up visit (+/- 1 month)

G9379

Patient did not achieve flat retinas six months post surgery

G9380

Patient offered assistance with end-of-life issues during the measurement period

G9381

Documentation of medical reason(s) for not offering assistance with end-of-life issues (e.g., patient in hospice and in terminal phase) during the measurement period

G9382

Patient not offered assistance with end-of-life issues during the measurement period

G9383

Patient received screening for HCV infection within the 12 month reporting period

G9384

Documentation of medical reason(s) for not receiving screening for HCV infection within the 12 month reporting period (e.g., decompensated cirrhosis including advanced disease [i.e., ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, or waitlist for organ transplant, limited life expectancy, other medical reasons)

G9385

Documentation of patient reason(s) for not receiving screening for HCV infection within the 12 month reporting period (e.g., patient declined, other patient reasons)

G9386

Screening for HCV infection not received within the 12 month reporting period, reason not given

G9389

Unplanned rupture of the posterior capsule requiring vitrectomy

G9390

No unplanned rupture of the posterior capsule requiring vitrectomy

G9391

Patient achieves refraction +-1 D for the eye that underwent cataract surgery, measured at the one month follow up-visit

G9392

Patient does not achieve refraction +-1 D for the eye that underwent cataract surgery, measured at the one month follow-up visit

G9393

Patient with an initial phq-9 score greater than nine who achieves remission at twelve months as demonstrated by a twelve month (+/- 30 days) phq-9 score of less than five

G9394

Patient who had a diagnosis of bipolar disorder or personality disorder, death, permanent nursing home resident or receiving hospice or palliative care any time during the measurement or assessment period

G9395

Patient with an initial phq-9 score greater than nine who did not achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) phq-9 score greater than or equal to five

G9396

Patient with an initial phq-9 score greater than nine who was not assessed for remission at twelve months (+/- 30 days)

G9399

Documentation in the patient record of a discussion between the physician/clinician and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward the outcome of the treatment

G9400

Documentation of medical or patient reason(s) for not discussing treatment options; medical reasons: patient is not a candidate for treatment due to advanced physical or mental health comorbidity (including active substance use); currently receiving antiviral treatment; successful antiviral treatment (with sustained virologic response) prior to reporting period; other documented medical reasons; patient reasons: patient unable or unwilling to participate in the discussion or other patient reasons

G9401

No documentation of a discussion in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment

G9402

Patient received follow-up on the date of discharge or within 30 days after discharge.

G9403

Clinician documented reason patient was not able to complete 30 day follow-up from acute inpatient setting discharge (e.g., patient death prior to follow-up visit, patient non-compliant for visit follow-up).

G9404

Patient did not receive follow-up on the date of discharge or within 30 days after discharge.

G9405

Patient received follow-up within 7 days from discharge.

G9406

Clinician documented reason patient was not able to complete 7 day follow-up from acute inpatient setting discharge (i.e patient death prior to follow-up visit, patient non-compliance for visit follow-up).

G9407

Patient did not receive follow-up on or within 7 days after discharge.

G9408

Patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days

G9409

Patients without cardiac tamponade and/or pericardiocentesis occurring within 30 days

G9410

Patient admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision

G9411

Patient not admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision

G9412

Patient admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision

G9413

Patient not admitted within 180 days, status post CIED implantation, replacement, or revision with an infection requiring device removal or surgical revision

G9414

Patient had one dose of meningococcal vaccine on or between the patient's 11th and 13th birthdays.

G9415

Patient did not have one dose of meningococcal vaccine on or between the patient's 11th and 13th birthdays.

G9416

Patient had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) on or between the patient's 10th and 13th birthdays or one tetanus and one diphtheria vaccine on or between the patient's 10th and 13th birthdays.

G9417

Patient did not have one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids vaccine (Td) on or between the patient's 10th and 13th birthdays or one tetanus and one diphtheria vaccine on or between the patient's 10th and 13th birthdays.

G9418

Primary non-small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as NSCLC-NOS with an explanation.

G9419

Documentation of medical reason(s) for not reporting the histological type or NSCLC-NOS classification with an explanation (e.g., biopsy taken for other purposes in a patient with a history of primary non-small cell lung cancer or other documented medical reasons)

G9420

Specimen site other than anatomic location of lung or is not classified as primary non-small cell lung cancer

G9421

Primary non-small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as NSCLC-NOS with an explanation

G9422

Non-small cell lung cancer biopsy and cytology specimen report documents classification into specific histologic type or classified as NSCLC-NOS with an explanation

G9423

Documentation of medical reason(s) for not reporting the histological type or NSCLC-NOS classification with an explanation (e.g., a solitary fibrous tumor in a person with a history of non-small cell carcinoma or other documented medical reasons)

G9424

Specimen site other than anatomic location of lung is not classified as non-small cell lung cancer or classified as NSCLC-NOS

G9425

Non small cell lung cancer biopsy and cytology specimen report does not document classification into specific histologic type or classified as NSCLC-NOS with an explanation.

G9426

Improvement in median time from ED arrival to initial ED oral or parenteral pain medication administration performed for ED admitted patients

G9427

Improvement in median time from ED arrival to initial ED oral or parenteral pain medication administration not performed for ED admitted patients

G9428

Pathology report includes the pt category and a statement on thickness and ulceration and for pt1, mitotic rate

G9429

Documentation of medical reason(s) for not reporting pt category and a statement on thickness and ulceration and for pt1, mitotic rate (e.g., negative skin biopsies in a patient with a history of melanoma or other documented medical reasons)

G9430

Specimen site other than anatomic cutaneous location

G9431

Pathology report does not include the pt category and a statement on thickness and ulceration and for pt1, mitotic rate

G9432

Asthma well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score and results documented

G9433

Death, permanent nursing home resident or receiving hospice or palliative care any time during the measurement period

G9434

Asthma not well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score, or specified asthma control tool not used, reason not given

G9435

Aspirin prescribed at discharge

G9436

Aspirin not prescribed for documented reasons (e.g., allergy, medical intolerance, history of bleed)

G9437

Aspirin not prescribed at discharge

G9438

P2Y inhibitor prescribed at discharge

G9439

P2Y inhibitor not prescribed for documented reasons (e.g., allergy, medical intolerance, history of bleed)

G9440

P2Y inhibitor not prescribed at discharge

G9441

Statin prescribed at discharge

G9442

Statin not prescribed for documented reasons (e.g., allergy, medical intolerance)

G9443

Statin not prescribed at discharge

G9448

Patients who were born in the years 1945-1965

G9449

History of receiving blood transfusions prior to 1992

G9450

History of injection drug use

G9451

Patient received one-time screening for HCV infection

G9452

Documentation of medical reason(s) for not receiving one-time screening for HCV infection (e.g., decompensated cirrhosis indicating advanced disease [i.e., ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons)

G9453

Documentation of patient reason(s) for not receiving one-time screening for HCV infection (e.g., patient declined, other patient reasons)

G9454

One-time screening for HCV infection not received within 12 month reporting period and no documentation of prior screening for HCV infection, reason not given

G9455

Patient underwent abdominal imaging with ultrasound, contrast enhanced CT or contrast MRI for HCC

G9456

Documentation of medical or patient reason(s) for not ordering or performing screening for hcc. medical reason: comorbid medical conditions with expected survival < 5 years, hepatic decompensation and not a candidate for liver transplantation, or other medical reasons; patient reasons: patient declined or other patient reasons (e.g., cost of tests, time related to accessing testing equipment)

G9457

Patient did not undergo abdominal imaging and did not have a documented reason for not undergoing abdominal imaging in the reporting period

G9458

Patient documented as tobacco user and received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or referral to external smoking or tobacco cessation support programs, or current enrollment in smoking or tobacco use cessation program) if identified as a tobacco user

G9459

Currently a tobacco non-user

G9460

Tobacco assessment or tobacco cessation intervention not performed, reason not otherwise specified

G9463

I intend to report the sinusitis measures group

G9464

All quality actions for the applicable measures in the sinusitis measures group have been performed for this patient

G9465

I intend to report the acute otitis externa (AOE) measures group

G9466

All quality actions for the applicable measures in the AOE measures group have been performed for this patient

G9467

Patient who has received or is receiving corticosteroids greater than or equal to 10 mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills

G9468

Patient not receiving corticosteroids greater than or equal to 10 mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills

G9469

Patient who has received or is receiving corticosteroids greater than or equal to 10 mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills

G9470

Patient not receiving corticosteroids greater than or equal to 10 mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills

G9471

Within the past 2 years, central dual-energy x-ray absorptiometry (DXA) not ordered or documented

G9472

Within the past 2 years, central dual-energy x-ray absorptiometry (DXA) not ordered and documented, no review of systems and no medication history or pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed

| Back to the top |