Connection supplemental articles and policies – March 2014

Supplemental articles

Payment policies

Revised policies – effective May 1, 2014
The following polices have been updated; details about the changes are indicated on the policies.

Coding Corner

New 2014 CPT/HCPCS codes

Fallon Health has completed its formal review of the 2014 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 to "PCP referral and plan prior authorization process."

CPT CODES

64616 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (e.g., for cervical dystonia, spasmodic torticollis) Y
64617 Chemodenervation of muscle(s); larynx, unilateral, percutaneous (e.g., for spasmodic dysphonia), includes guidance by needle electromyography, when performed Y
64642 Chemodenervation of one extremity; 1-4 muscle(s) Y
64643 Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure) Y
64644 Chemodenervation of one extremity; 5 or more muscle(s) Y
64645 Chemodenervation of one extremity; each additional extremity, 5 or more muscle(s) (List separately in addition to code for primary procedure) Y
64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s) Y
64647 Chemodenervation of trunk muscle(s); 6 or more muscle(s) Y
66183 Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach Y
81287 MGMT (O-6-methylguanine-DNA methyltransferase) (e.g., glioblastoma multiforme), methylation analysis Y
81504 Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores Y
81507 Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy Y
92524 Behavioral and qualitative analysis of voice and resonance Y

HCPCS CODES

A9575 Injection, gadoterate meglumine, 0.1 ml Y
C5271 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area Y
C5272 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq. cm; each additional 25 sq. cm wound surface area, or part thereof (list separately in addition to code for primary procedure) Y
C5273 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children Y
C5274 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq. cm; each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure) Y
C5275 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq. cm; first 25 sq. cm or less wound surface area Y
C5276 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq. cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure) Y
C5277 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq. cm; first 100 sq. cm wound surface area, or 1% of body area of infants and children Y
C5278 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq. cm; each additional 100 sq. cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure) Y
C9133 Factor ix (antihemophilic factor, recombinant), rixibus, per i.u. Y
C9497 Loxapine, inhalation powder, 10 mg Y
C9737 Laparoscopy, surgical, esophageal sphincter augmentation with device (eg, magnetic band) Y
D0393 Trtmnt simulation 3d image Y
D0394 Digital sub 2 or more images Y
D0395 Fusion 2 or more 3d images Y
D0601 Caries risk assess low risk Y
D0602 Caries risk assess mod risk Y
D0603 Caries risk assess high risk Y
D1999 Unspecified preventive procedure Y
D2921 Reattach tooth fragment Y
D2941 Int therapeutic restoration Y
D2949 Restorative foundation Y
D3355 Pulpal regeneration initial Y
D3356 Pulpal regeneration interim Y
D3357 Pulpal regeneration complete Y
D3427 Periradicular surgery Y
D3428 Bone graft peri per tooth Y
D3429 Bone graft peri each addl Y
D3431 Biological materials Y
D3432 Guided tissue regeneration Y
D4921 Gingival irrigation per quad Y
D5994 Peridontal medicament Y
D6011 Second stage implant surgery Y
D6013 Surgical place mini implant Y
D6052 Semi precision attach abut Y
D8694 Repair fixed retainers Y
E0766 Electrical stimulation device used for cancer treatment, includes all accessories, any type Y
J0151 Injection, adenosine for diagnostic use, 1 mg (not to be used to report any adenosine phosphate compounds, instead use a9270) Y
J0717 Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered) Y
J1556 Injection, immune globulin (bivigam), 500 mg Y
J1602 Injection, golimumab, 1 mg, for intravenous use Y
J3060 Injection, taliglucerace alfa, 10 units Y
J9047 Injection, carfilzomib, 1 mg Y
J9262 Injection, omacetaxine mepesuccinate, 0.01 mg Y
J9306 Injection, pertuzumab, 1 mg Y
J9354 Injection, ado-trastuzumab emtansine, 1 mg Y
J9400 Injection, ziv-aflibercept, 1 mg Y
L5969 Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s) Y
L8679 Implantable neurostimulator, pulse generator, any type Y
Q2028 Injection, sculptra, 0.5 mg Y
Q4137 Amnioexcel or biodexcel, per square centimeter Y
Q4138 Biodfence dryflex, per square centimeter Y
Q4139 Amniomatrix or biodmatrix, injectable, 1 cc Y
Q4140 Biodfence, per square centimeter Y
Q4141 Alloskin ac, per square centimeter Y
Q4142 Xcm biologic tissue matrix, per square centimeter Y
Q4143 Repriza, per square centimeter Y
Q4145 Epifix, injectable, 1 mg Y
Q4146 Tensix, per square centimeter Y
Q4147 Architect extracellular matrix, per square centimeter Y
Q4148 Neox 1k, per square centimeter Y
Q4149 Excellagen, 0.1 cc Y
S9960 Ambulance service, conventional air service, nonemergency transport, one way (fixed wing) Y
S9961 Ambulance service, conventional air service, nonemergency transport, one way (rotary wing) Y