2005 CODING GUIDELINES
AND POLICY UPDATE
COMPENDIUM
www.amerihealth.com
Important Note:
The medical policies referenced
in this document apply to all
HMO, POS, and PPO products of
AmeriHealth, including its affiliates,
as well as to traditional indemnity
products to the extent the applicable
covered services are underwritten by
AmeriHealth or its affiliates.
This document was developed to
assist AmeriHealth in administering
the provisions of its benefits programs
and does not constitute medical
advice. Professional providers are
responsible for providing medical
advice and treatment. Even though
this document may conclude that a
particular service or item is medically
necessary, such conclusion is NOT
based upon the terms of a particular
member’s benefit plan. Members must
refer to their specific benefit program
for the terms, conditions, limitations
and exclusions of coverage.
Please note that the Policy Bulletins
which are referenced herein describe
the status of a specific topic at the
time the Policy Bulletin was created.
Policy Bulletins are updated biennially
and when new medical evidence
becomes available, therefore, they are
subject to change.
Please be aware that the actual Policy
Bulletins which are discussed herein
are used as a guide only. Coverage
decisions are made on a case-by-case
basis by applying Policy Bulletin
criteria to the member’s medical
history, condition, and proposed course
of treatment as well as the member’s
benefit program. Providers should
review Policy Bulletins with Members
as treatment options are discussed,
as the Policy Bulletins are designed
to be used by our professional staff
in making coverage determinations
and can be highly technical.
Information contained in this
document and the actual Policy
Bulletin does not constitute an
offer of coverage, medical advice, or
guarantee of payment. Please note
that, if there is a conflict between
the Policy Bulletin and a member’s
benefit program, the terms of the
benefit program will govern.
Please note that providers who opted
out of the class action settlement
may not be entitled to certain claim
payment policy changes. Therefore,
any payments made pursuant to such
policy changes to providers who opted
out of the class action settlement are
subject to retroactive adjustments.
TABLE OF CONTENTS
Introduction ............................................2
2005 Articles ..........................................39
About the Coding Guidelines and
Extracorporeal Shock Wave Therapy
Policy Update Compendium ..................... 2
(ESWT) for Musculoskeletal Conditions
What are the Primary Reasons
and Plantar Fasciitis .............................. 40
that AmeriHealth Develops Claim
Claims with More Than One Unit
Payment and Medical Policies? ............. 2
of Time for Speech-Pathology
What is the Difference Between a
Codes Will Reject ................................. 40
Claim Payment Policy and a
Policy and Recommendations for the
Medical Policy?...................................... 2
Use of Menactra® ................................. 40
How does AmeriHealth Assess
Policy Update for DecavacTM ............... 41
New Technology? .................................. 3
ICD-9-CM Diagnosis Codes Change
Covered Benefit vs. Medical Necessity:
for Routine Gynecological Exams .......... 41
What’s the Difference? .......................... 3
Policy Updates: Modifiers -26
Physician Volunteers Needed to Assist
and -TC................................................ 42
in Developing Medical Policies ............. 4
Medical Policies Covered: According to
Class Action Settlement Update .............44
Medical Code Updates ...........................49
Certain Criteria .......................................5
CPT® Codes ....................................... 50
Medical Policies Not Covered: Considered
HCPCS Codes .................................... 77
Experimental/Investigational ...................23
ICD-9 Codes .................................... 120
Medical Policies Not Covered: Considered
Not Medically Necessary .........................33
Claim Payment Policies ..........................35
View Full Policies Online —
Full descriptions of these policies are
available online: www.amerihealth.com.
AmeriHealth HMO, Inc. • QCC Insurance Company, d/b/a AmeriHealth Insurance Company • AmeriHealth Insurance Company of New Jersey
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INTRODUCTION
About the Coding Guidelines and Policy
Update Compendium
Over the past year, we have published four Coding Guidelines and
Policy Update (CGPU) newsletters.
This 2005 Coding Guidelines and Policy Update Compendium is a
collection of relevant policy summaries that have been published
in the CGPU during the past year. We are not able to reproduce
all of the CGPU summaries in the Compendium because some
policies have undergone updates and revisions since their initial
publication in the Coding Guidelines and Policy Update, however,
these updated policies will appear in future issues of the CGPU.
We encourage you to visit www.amerihealth.com/providers for
expanded, up-to-date versions of each policy.
In addition to the descriptions of policies previously published
in the CGPU, the Compendium has also expanded the normal
CGPU parameters to include articles on coding and policy, plus
a section detailing new, revised, and deleted CPT*, HCPCS, and
ICD-9 CM codes.
This Compendium contains information that you can
immediately adopt within your practice to simplify your
information retrieval and claims submission processes. Keep it
with your Provider Manual—or anywhere that is handy.
* Current Procedural Terminology (CPT®) is a copyright of the American Medical
Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values,
or related listings are included in the CPT. The AMA assumes no liability for the data
contained herein. Applicable FARS/DFARS restrictions apply to government use.
CPT® is a trademark of the AMA.
Want to learn more about the policies affecting health care in
your region? Visit www.amerihealth.com/providers to get the
most current, in-depth, and up-to-date information. To reach the
policies from the Provider section of the website, click Policies,
Guidelines, and Publications and then click Medical Policy.
Review and accept the terms and conditions and you can quickly
and easily search all active policies. Bookmark this site and
check back regularly for the latest information about policies that
affect health care in your region.
All policies listed in the CGPU Compendium can be found at
www.amerihealth.com/providers. You can also check the
website to find specific codes, in-depth descriptions, or other
policy-related data.
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What Are the Primary Reasons That
AmeriHealth Develops Claim Payment
and Medical Policies?
Some of the primary reasons that AmeriHealth develops claim
payment and medical policy are to:
• Comply with legislation (e.g., federal, state, and local legislative
mandates).
• Correspond to national or local Medicare Carrier Coverage
Policy.
• Allow consistent interpretation and application of benefits.
• Respond to requests for new, emerging technology or changes
in existing technology.
• Ensure a relevant and timely scheduled review of existing
policies.
• Provide claims submission policies and procedures.
What Is the Difference Between a Claim
Payment Policy and a Medical Policy?
Claim Payment Policy
A claim payment policy is the description of an administrative
process that is used to adjudicate a claim based on a defined
set of circumstances. It may define a Company program or
position, and it may be based on contractual agreements
or special requirements of Company products. The policy
functions as an informational resource that describes the
Company’s requirements for claims submission, processing, and
reimbursement. The Company relies substantially on nationally
accepted standards when setting requirements for such claims
submission, processing, and reimbursement.
Medical Policy
A medical policy is the written description of the Company’s
position concerning the use or application of a biologic, device,
pharmaceutical, or procedure based on Medicare guidelines,
clinical practice guidelines, nationally accepted standards,
and the findings and conclusions drawn from a complete
Technology Assessment (TA). Additionally, a medical policy is
an informational resource that establishes the medical necessity
criteria for a biologic, device, pharmaceutical, or procedure. It
also includes special requirements for claims processing.
2005 Compendium
How Does AmeriHealth Assess New
Technology?
Routinely, new technology is evaluated with a technology
assessment (TA) prior to determining a coverage position. A
TA is an evaluation of available data from multiple sources
to assess the medical efficacy, safety, and proposed effects on
health outcomes of the procedure or product. The following five
criteria are used to assess whether a technology improves health
outcomes. The term health outcomes generally refers to such
considerations as length of life, quality of life, and functional
ability.
1. The technology must have final approval from the appropriate
government regulatory bodies.
• This criterion applies to drugs, biological products,
devices, and diagnostics.
2. The scientific evidence must permit conclusions concerning
the effect of the technology on health outcomes.
• The evidence should consist of well-designed and
well-conducted investigations published in peerreviewed journals. The quality of the body of studies
and the consistency of the results are considered in
evaluating the evidence. Studies are primarily judged
on their statistical power, overall design, and presence
or absence of significant flaws or bias.
• The evidence should demonstrate that the technology
could measure or alter the physiological changes
related to a disease, injury, illness, or condition.
In addition, there should be evidence that such
measurements or alteration affects health outcomes.
• Opinions and evaluations by national medical
associations, consensus panels, or other technology
evaluation bodies are evaluated according to the
scientific quality of the supporting evidence and
rationale. Expert opinion from an individual or
a panel of individuals based on limited study or
empirical evidence is generally inadequate as a sole
source of evidence to permit conclusions regarding
efficacy.
3. The technology must improve the net health outcome.
• The technology’s beneficial effects on health
outcomes should outweigh any harmful effects on
health outcomes.
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4. The technology must be as beneficial as any established
alternatives.
• The technology should improve the net health
outcome as much as, or more than, established
alternatives. Comparison studies with existing
technologies are the most reliable form of evidence.
5. The improvement must be attainable outside the investigative
settings.
• The technology should be available to our members
outside of a trial or research setting.
Covered Benefit vs. Medical Necessity:
What’s the Difference?
Almost all practicing physicians, at some point in their career,
will encounter a response from a Plan Medical Director stating
that a proposed treatment or plan of care is considered not a
covered benefit or not medically necessary.
What’s the difference between these two terms? Is this
difference important to you and your patients? If you disagree
with the Plan’s decision, what should you know before initiating
an appeal?
Recognizing the difference between a covered benefit and a
medically necessary denial of coverage will increase understanding
and promote more productive discussions between Medical
Directors and participating physicians.
What is a Covered Benefit?
A covered benefit is any medical treatment, service, or plan
of care that is specifically defined as eligible for coverage in a
member’s benefit contract. Benefits may be subject to member
cost sharing, visit or day limitations and exclusions.
Benefits may not be the same for each patient. The most
important thing to remember about benefits is that they are
defined in the member’s benefit contract and are the services
that were purchased by the member or, on behalf of the member,
by an employer group. Plan Medical Directors do not have the
option of extending or offering coverage for benefits that are not
part of the member’s individual or group benefit contract.
How is Medical Necessity Determined?
Once it has been determined by the Plan that a proposed
treatment or service is an eligible covered benefit, our Care
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Management and Coordination Department may review a case
for Medical Necessity. In accordance with the Medical Necessity
definition in the member Benefit Materials and Provider
contract.
Is the proposed treatment . . .
• Consistent with Plan policies, coverage requirements, and
utilization guidelines?
• Necessary in order to diagnose and/or treat a member’s
illness or injury?
• Provided in accordance with accepted standards of
medical practice?
• Essential to improve, and as beneficial as any
established alternatives?
• As cost effective as any established alternatives?
• Not solely for the member’s convenience, or the convenience
of the member’s family or health care provider?
Our managed care products provide a comprehensive and broad
range of benefits for members, but sometimes there are no
benefits for certain medically necessary services. For example, the
over-the-counter (OTC) drug calcium carbonate is medically
necessary to treat osteoporosis; however, it is not covered
because OTC drugs are specifically excluded from group benefit
contracts.
We welcome and encourage open discussion between
participating physicians and Medical Directors and between
treating physicians and members. Please remember, however,
that while Medical Directors are always willing and able to consider
additional information in making determinations of medical
necessity, they are unable to extend or provide coverage for services
that are not covered under the member’s benefit contract.
View Full Policies Online
Full descriptions of these policies are available online at:
www.amerihealth.com.
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Physician Volunteers Needed to Assist
in Developing Medical Policies
AmeriHealth is currently recruiting physicians to join our
Policy Committee Advisory Panel. This panel is responsible for
evaluating the scientific evidence and local standards of care
addressed in our medical policies.
Medical policies are research-based documents that allow
AmeriHealth to evaluate the medical necessity of services,
devices, biologics, and procedures for its members. In addition,
medical policies provide guidelines for obtaining benefits and
reimbursement in accordance with the member’s plan. As a
volunteer consultant on the Policy Committee Advisory Panel,
you will evaluate proposed medical policies based on your area(s)
of expertise. As such, your contributions will significantly impact
the care of patients in your region.
At this time, AmeriHealth is seeking physician consultants in
the following specialties:
• Neurosurgery.
• Orthopedics.
• Urology.
• Vascular Surgery.
• Physical Medicine and Rehabilitation.
To qualify as a member of the Policy Committee Advisory
Panel, you must:
• Maintain board certification for each specialty or subspecialty
for which you wish to consult.
• Maintain an active clinical practice in each specialty or
subspecialty for which you wish to consult.
• Understand and agree to abide by our conflict of interest
statement (available upon request prior to participation, and
reviewed and reaffirmed annually upon becoming a member of
the Committee).
• Understand and agree to adhere to our confidentiality
statement.
• Maintain a high ethical standard, evidenced by the absence of
any AmeriHealth investigation into personal or group claims
practices.
If you meet the above criteria and have an interest in sharing
your expertise as a member of the Policy Committee Advisory
Panel, please submit your curriculum vitae to:
Gerald W. Peden, M.D., M.A.
Medical Director, Claim Payment Policy Department
AmeriHealth
1901 Market Street
Philadelphia, PA 19103-1480
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2005 Compendium
MEDICAL POLICIES
COVERED: ACCORDING TO CERTAIN CRITERIA
www.amerihealth.com
TABLE OF CONTENTS
Cardiac Resynchronization Using Implantable
Biventricular Pacemakers for the Treatment of Heart
Failure (11.02.14a) ................................................................. 6
Cervical Traction for In-home Use (05.00.61)....................... 6
Chemical Peels (11.08.08c) .................................................... 7
Circumcision (11.11.05b) ....................................................... 7
Collagen Crosslinks (06.02.16a) ............................................ 7
Computerized Dynamic Posturography (CDP)
(07.03.11b) ............................................................................. 8
Continuous Passive Motion Devices in the
Home Setting (05.00.08b) ..................................................... 8
Otoplasty (11.01.01c) ........................................................... 14
Percutaneous Balloon Valvuloplasty (11.02.03b) .................. 14
Procedures for the Treatment of Gastroesophageal Reflux
Disease (GERD) in Adults (11.03.11a) ............................... 14
Radiofrequency Ablation of Liver Tumors (11.03.09b) ....... 15
Radiofrequency Lesioning of the Spinal Nerves for
Chronic Pain (11.15.09) ....................................................... 15
Reduction Mammoplasty (11.08.02b) ................................. 16
Refractive Keratoplasty (11.05.01a) ..................................... 16
Repair of a Laceration at a Site Previously Pierced for
Cosmetic Reasons (11.08.07c) ............................................. 16
Continuous Subcutaneous Glucose Monitoring
(05.00.24b) ............................................................................. 9
Rhytidectomy and Rhytidoplasty (11.08.13c) ...................... 17
Cornea Transplant (11.05.03b) ............................................ 10
Screening, Diagnostic, and Digital Mammography
(09.00.15a) ........................................................................... 17
Cryoablation of Renal Tumors (11.17.05a) .......................... 10
Cryosurgical Ablation of Hepatic Tumors (11.03.10b) ........ 10
Dermabrasion (11.08.09b) ................................................... 10
Electronic Speech Aids (05.00.23a) ..................................... 11
Extracorporeal Shock Wave Lithotripsy for
Gallstones (11.03.13a).......................................................... 11
Gemtuzumab Ozogamicin (Mylotarg®) (08.00.35a) ........... 11
Human Immunodeficiency Virus (HIV) Genotyping and
Phenotyping (06.02.09a) ...................................................... 12
Speech and Non-Speech Generating Devices (05.00.32) .... 18
Surgical Treatment of Strabismus (11.05.07a) ..................... 19
Total Parenteral Nutrition (TPN)/Intradialytic Parenteral
Nutrition (IDPN) (08.00.17a) ............................................. 19
Trastuzumab (Herceptin) (08.00.33b).................................. 20
Uterine Artery Embolization for the Treatment of
Fibroids (11.06.04a) ............................................................. 20
Zoledronic Acid (Zometa®) (08.00.44a) .............................. 21
Knee Braces (05.00.47) ........................................................ 12
Lipectomy or Liposuction (11.08.03b) ................................ 13
Meniscal Allograft Transplantation (11.14.03b) .................. 13
Osteochondral Autograft Transplantation Procedure
(11.14.09a) ........................................................................... 13
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Cardiac Resynchronization Using
Implantable Biventricular Pacemakers
for the Treatment of Heart Failure
(11.02.14a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Cardiac resynchronization uses biventricular pacing to
coordinate the contraction of the ventricles in order to improve
blood circulation in the individual. A biventricular pacing system
uses conventional pacing technology with a third electrode in
order to sense and pace the left ventricle. The pacing device
can simultaneously stimulate both ventricles in synchrony with
atrial activity. The synchronous contraction of both ventricles
promotes adequate filling of the left ventricle with less backflow
to the left atrium, resulting in more oxygenated blood being
pumped to the body. Clinical studies have shown a sustained
improvement of symptoms and exercise tolerance in individuals
using the device.
Implantable biventricular pacemakers used to treat congestive
heart failure (CHF) and/or heart failure as a primary or
secondary diagnosis are medically necessary for individuals who
meet all of the following criteria:
• Diagnosis of moderate-to-severe heart failure (New York
Heart Association [NYHA] Class III or IV).
• Restrictive cardiomyopathy or treatment-resistant hypertension.
For insertion of a cardiac resynchronization therapy pacemaker,
a primary and secondary code must be reported.
Originally published in Fall 2005 CGPU.
Cervical Traction for In-home Use
(05.00.61)
COVERED: ACCORDING TO CERTAIN CRITERIA
Cervical traction is commonly performed to relieve muscle
spasms in the neck and shoulders, and to relieve the pain of
pinched nerves in the neck. It can be administered by various
techniques ranging from supine mechanical motorized or
pneumatic traction to seated traction, using over-the-door
pulleys with attached weights.
The cervical traction devices described in this policy are
appropriate for use in the home as they do not require
supervision by a trained professional after initial set-up and
instruction. These in-home devices are not to be confused with
traction units, which are designed specifically for facility use and
require attendance by a trained professional.
• QRS duration of greater than or equal to 120 ms.
Cervical traction applied using a mechanical device in the home
setting is medically necessary when both of the following criteria
are met:
• Left ventricular ejection fraction of less than or equal to 35
percent.
• The individual has a musculoskeletal or neurologic impairment
requiring traction equipment.
• Symptomatic despite stable pharmacologic regimen, which
may include any of the following:
• The appropriate use of a home cervical traction device has been
demonstrated to the individual and he/she has tolerated the
selected device.
- Angiotensin-converting enzyme inhibitor.
- Angiotensin receptor blocker.
- Beta blocker.
- Digoxin.
- Diuretic.
Cardiac resynchronization therapy is contraindicated in the
treatment of individuals with any of the following conditions:
• Chronic atrial arrhythmias or ineffective atrial contractions
(unless utilized in conjunction with, or post, atrioventricular
[AV] nodal ablation).
• Unstable angina, myocardial infarction, or coronary artery
revascularization.
Cervical traction applied using a pneumatic device in the home
setting is medically necessary when both of the criteria for the
mechanical device are met and at least one of the following
criteria is met:
• The treating physician orders greater than 20 pounds of
cervical traction.
• The individual has been diagnosed with and treated for
temporomandibular joint (TMJ) dysfunction that may become
worse with mechanical traction.
• The individual has distortion of the lower jaw or neck anatomy
(e.g., radical neck dissection) such that a mechanical cervical
traction device is unable to be utilized.
Originally published in Winter 2005 CGPU.
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2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
Chemical Peels (11.08.08c)
COVERED: ACCORDING TO CERTAIN CRITERIA
• Paraphimosis (the unreplaceable retraction of a narrow foreskin
that causes pain and swelling of the glans).
A chemical peel is the application of caustic material to the skin
in order to smooth defects. Under most circumstances, chemical
peels are a cosmetic service and a benefit contract exclusion.
• Recurrent balanitis and posthitis (inflammation of the
prepuce).
Dermal/epidermal chemical peels are considered cosmetic for
the treatment of:
• Excessive prepuce redundancy.
• End-stage acne scarring.
• Tears in the frenulum (a small sheet of skin underneath the
glans that joins the glans to the foreskin).
• Wrinkles.
• Photo-aged skin.
Dermal/epidermal chemical peels are medically necessary for the
treatment of:
• Active acne when a trial treatment with oral and/or topical
agents has failed as an acne therapy.
• Actinic keratoses.
• Preputial neoplasms.
Treatment of complications such as, but not limited to, postcircumcision adhesions and repair of incomplete circumcision
are medically necessary.
Circumcision performed in the home setting is considered not
medically necessary, regardless of the provider.
Routine neonatal circumcision may be a contract exclusion.
Individual benefits must be verified.
Originally published in Winter 2005 CGPU.
• Other premalignant skin lesions.
All requests for chemical peels require review by the Company’s
Cosmetic Review Team and must include color photographs
and a letter of medical necessity.
Chemical peels not meeting the medical necessity criteria are
considered cosmetic and, therefore, a benefit contract exclusion.
Originally published in Winter 2005 CGPU.
Circumcision (11.11.05b)
COVERED: ACCORDING TO CERTAIN CRITERIA
Circumcision is a surgical procedure in which the prepuce of the
foreskin (the skin that covers the top of the penis) is removed.
When a benefit, routine neonatal circumcision is eligible for
reimbursement consideration when performed by a professional
medical provider in the following settings:
• Initial newborn hospitalization.
• Birthing center where delivery occurred.
Collagen Crosslinks (06.02.16a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Collagen crosslinks are parts of the bone matrix where bone
mineral is deposited. They are biochemical markers that, when
excreted, provide a quantitative measurement of bone resorption.
With respect to quantifying bone resorption, collagen crosslinks
can provide adjunct diagnostic information with bone mass
measurements.
Collagen crosslinks testing is medically necessary when an
individual has a documented diagnosis identified in the policy
and when it is used to:
• Identify individuals with elevated bone resorption whose
response to osteoporosis treatment is being monitored.
• Predict response (as assessed by bone mass measurements)
to US Food and Drug Administration (FDA)-approved
antiresorptive therapy in postmenopausal women.
In addition to neonatal circumcision, circumcision is considered
medically necessary for any of the following conditions:
• Assess response to treatment of individuals with osteoporosis,
Paget’s disease of the bone, or risk for osteoporosis when
treatment may include FDA-approved antiresorptive agents,
antiestrogens, or selective estrogen receptor modulators
(SERMs).
• Phimosis (a tightness of the prepuce that prevents its retraction
over the glans).
For all diagnoses not included in this policy, collagen crosslinks
testing is considered not medically necessary.
• Office setting.
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Tests that are performed for screening purposes in the absence
of signs, symptoms, complaints, or personal history of disease or
injury are considered not medically necessary.
Originally published in Winter 2005 CGPU.
Computerized Dynamic Posturography
(CDP) (07.03.11b)
COVERED: ACCORDING TO CERTAIN CRITERIA
Computerized dynamic posturography (CDP) is a test of
postural stability that evaluates how effectively vestibular system
information is processed. CDP can be performed as a sensory
organization test or as a movement coordination test for the
evaluation of gait disorders in the elderly. It is used to identify,
characterize, and quantify abnormalities when evaluating
balance by adding additional information about inner ear and
spinal (vestibulospinal) function, stance, and sway. CDP is
useful because it may show a dysfunction of the other receptors
important for balance or identify nonorganic disorders. CDP
does not replace other tests but acts as a supplement.
CDP is medically necessary to evaluate individuals who are
diagnosed with one or more of the following:
• Persistent impairment of postural stability and disequilibrium
after trauma to the head, brain, or inner ear with a negative
neurological workup.
• Disequilibrium when conventional testing has not detected an
abnormality.
• History of one or more falls due to persistent vertigo or
dizziness with disequilibrium and normal cardiac evaluation.
CDP performed for diagnoses other than those listed are
considered experimental/investigational and are, therefore, not
covered.
Originally published in Fall 2005 CGPU.
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Continuous Passive Motion Devices in
the Home Setting (05.00.08b)
COVERED: ACCORDING TO CERTAIN CRITERIA
Continuous passive motion (CPM) devices provide mechanical
passive range of motion (ROM) to joints (e.g., knees, hands)
following surgery to maintain or restore strength, mobility, and
functionality. CPM is designed to aid recovery following surgery
on articular tissues, including cartilage, tendons, and ligaments.
When CPM devices are used following knee surgery (e.g., total
knee arthroplasty [TKA]), the customary length of treatment
following surgery is between one and two weeks.
When CPM devices are used following hand surgery (e.g., flexor
or extensor tenolysis) because pain and/or edema impede active
ROM, the average length of postoperative use is between two
and four weeks.
CPM devices can also be used as second-line adjuncts when
traditional therapeutic maneuvers for the hand fail to achieve
meaningful or expected gains in digital ROM (e.g., status-post
proximal interphalangeal [PIP] or metacarpophalangeal [MCP]
arthroplasties, status-post burns).
There is a paucity of literature to indicate that the use of CPM
devices for any other joint (e.g., ankle, shoulder, jaw, hip, wrist,
elbow) is more advantageous when compared with traditional
methods of physical therapy.
The use of CPM devices may begin in a hospital setting. When
CPM devices are used during admissions otherwise approved
for conditions meeting criteria for inpatient level of care, the
devices are incidental to the inpatient stay. A CPM device may
be used postdischarge if an individual is unable to comply with
a physical therapy program. CPM devices in the home setting
are medically necessary for homebound individuals when applied
within seven days of a surgical procedure and are limited to a
maximum of 28 days (beginning with the date of surgery), when
the following medical necessity criteria are met:
• As a postoperative therapy for any of the following knee
procedures:
- TKA (replacement or revision).
- Anterior cruciate ligament (ACL) repair or
reconstruction.
- Lysis of adhesions for arthrofibrosis.
- Open reduction of comminuted intra-articular
fractures.
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2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
- Manipulation of the knee under anesthesia.
- Synovectomy.
- Articular cartilage grafting.
• As a postoperative therapy for any of the following hand
procedures:
- Dupuytren’s disease with pain and/or edema that
impedes active ROM.
- Joint collateral ligament release to the PIP or MCP
joint.
- Flexor or extensor tenolysis with or without
capsulectomy.
- Dorsal and/or volar injuries (e.g., severe crush
injuries) in which tendinous repairs preclude active
ROM.
• As a second-line adjunct when traditional methods of
therapeutic hand maneuvers fail to achieve meaningful or
expected gains in digital ROM (e.g., failure to progress after
two weeks of intensive supervised hand therapy) for any of the
following conditions OR postoperative procedures:
- Intra-articular fractures status-post open reduction
internal fixation (ORIF).
- High-pressure injection injuries to the hand.
- Status-post burns to the hand.
CPM devices in the home setting are not medically necessary
postoperatively for any other joint procedures (e.g., ankle, jaw,
hip, wrist, elbow, shoulder).
Continuous Subcutaneous Glucose
Monitoring (05.00.24b)
COVERED: ACCORDING TO CERTAIN CRITERIA
Continuous subcutaneous glucose monitoring encompasses the
measuring and recording of glucose levels in interstitial fluid and
produces data that depicts trends in glucose measurements. This
testing uses continuous glucose monitoring systems, including
the Continuous Glucose Monitoring System (CGMS)
(Medtronic MiniMed Inc, Northridge, CA).
Continuous subcutaneous glucose monitoring is medically
necessary for the following:
• Individuals with Type I or Type II diabetes who meet all of
the following criteria:
- Instruction by a health care professional in the
management of diabetes.
- Documented average frequency of glucose selftesting of at least four times per day during the
previous month.
- Program of multiple, daily injections of insulin (at
least two per day) with self-adjustment of insulin
dose based on self-testing results.
- Meets one or more of the following criteria while on
the multiple daily injection regimen:
• Glycated hemoglobin (HbA1c) values less
than four or greater than nine.
• Unexplained large fluctuations in daily
glucose values before meals.
CPM devices are covered by the Company on a rental basis only.
• Unexplained frequent hypoglycemic attacks.
When bilateral procedures are performed, only one CPM device
per rental period is covered.
• Episodes of ketoacidosis or hospitalizations
for out-of-control glucose levels.
Originally published in Spring 2005 CGPU.
• Women with Type I or Type II diabetes who are newly
pregnant or have developed gestational diabetes that requires
insulin therapy.
Continuous subcutaneous glucose monitoring should be
performed for a minimum of 24 hours to show glucose trends
effectively. The recommended monitoring period is 72 hours.
Monitoring for less than 24 hours is considered not medically
necessary. This service should be reported only once per
monitoring period regardless of the number of days involved.
Originally published in Winter 2005 CGPU.
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Cornea Transplant (11.05.03b)
COVERED: ACCORDING TO CERTAIN CRITERIA
Cornea transplantation is intended to improve sight in
individuals with irreversible tissue damage of the cornea. Cornea
transplantation involves implanting cadaveric donor tissue into a
recipient. There are two types of cornea transplants:
• Lamellar keratoplasty involves the removal of a partial
thickness of the cornea and the grafting of a partial-thickness
donor cornea.
• Penetrating keratoplasty is more commonly performed and
involves removing the full thickness of the cornea and the
grafting of a donor cornea.
Cornea transplantation is medically necessary for the treatment
of impaired vision from irreversible tissue damage of the cornea.
Originally published in Fall 2005 CGPU.
Cryoablation of Renal Tumors
(11.17.05a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Cryoablation involves the use of liquid nitrogen or argon probes
to freeze and ablate tumor cells.
Cryoablation of small undefined renal lesions suspected to be
malignant or to have malignant potential is medically necessary,
alone or in combination with other therapies, when one or more
of the following medical necessity criteria are met:
• The individual has one or more peripheral renal lesion(s)
less than 3 cm on a solitary kidney or a poorly functioning
contralateral kidney.
• Synchronous bilateral tumors are present in the kidneys.
• The individual has significant comorbidities and refuses or
cannot tolerate nephrectomy.
Originally published in Winter 2005 CGPU.
C OM PE NDIUM
Cryosurgical Ablation of Hepatic
Tumors (11.03.10b)
COVERED: ACCORDING TO CERTAIN CRITERIA
Cryosurgical ablation of hepatic tumors is a technique that
exposes liver tumor tissue to extreme cold in order to produce
cell injury and tissue destruction. A cryoprobe is guided into
the center of a tumor with the aid of intraoperative ultrasound,
and when the center of the tumor is located, cooled liquid
nitrogen or argon gas is pumped into the probe. The tumor
freezes from the center and expands outward resulting in cellular
crystallization, cell shrinkage, and membrane damage. The
freezing process is continued until the tissue is frozen to 1 cm
beyond the confines of the tumor.
Although the most common treatment for hepatic tumors is
surgical resection, cryosurgical ablation is a viable option for
individuals with liver tumors that are nonresectable. Use of
cryosurgical ablation to treat hepatic tumors makes it possible
to preserve more of the normal liver tissue and to destroy liver
tumors without major surgical resection and significant
blood loss.
A variety of cryosurgery systems, components, and
accessories have received approval by the US Food and Drug
Administration (FDA) for use in cryosurgical ablation of
hepatic tumors.
The codes for cryosurgical ablation may be reported only once
per date of service, regardless of the number of tumors and
the number of cryoprobe passes used to treat each tumor and
achieve the tumor-free margin.
Cryosurgical ablation of hepatic tumors is medically necessary
for the treatment of primary or secondary hepatic tumors for
individuals:
• Whose disease may be deemed nonresectable by location or
number of tumors.
• Who have comorbid disease that makes them poor surgical
candidates.
• Who refuse hepatic resection.
Originally published in Summer 2005 CGPU.
Dermabrasion (11.08.09b)
COVERED: ACCORDING TO CERTAIN CRITERIA
Dermabrasion is a procedure used to treat dermal and epidermal
irregularities (e.g., scars) in which skin, particularly the epidermis
10
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
and superficial dermis, is removed. Medical literature supports
dermabrasion for the revision of scars that have resulted from
trauma and reports consistent functional outcomes.
Under most circumstances, dermabrasion is a cosmetic service
and a benefit contract exclusion.
Dermabrasion is medically necessary when one of the following
criteria is met:
• A scar causes functional impairment severe enough to
interfere with the typical activities of daily living (e.g., eating,
getting in and out of bed, dressing, bathing, walking).
• As part of a global reconstructive treatment plan that follows a
burn, trauma, or surgery. (Reconstructive treatment is defined
as any medical or surgical service designed to restore bodily
function or to correct a deformity that has resulted from
trauma or surgery).
All requests for dermabrasion require review by the Company’s
Cosmetic Review Team and must include color photographs
and a letter of medical necessity.
Dermabrasion not meeting the medical necessity criteria is
considered cosmetic and, therefore, a benefit contract exclusion
that is not covered.
Originally published in Summer 2005 CGPU.
Electronic Speech Aids (05.00.23a)
COVERED: ACCORDING TO CERTAIN CRITERIA
When an individual has had a laryngectomy or the larynx is
nonfunctional, the ability to communicate verbally is lost or
impaired. Electronic speech aids are prosthetic devices that assist
these individuals by producing speech as they mouth words.
Electronic speech aids create a vibrating tone from a batterypowered electronic circuit. Once the tone is introduced into the
mouth, the individual shapes the sound into words.
Electronic speech aids are considered medically necessary when
an individual has had a laryngectomy or has a nonfunctional
larynx.
Replacement batteries that are required for the devices described
above can be purchased over the counter and are a benefit
contract exclusion, as they do not meet the definition of durable
medical equipment. Therefore, these items are not covered and
not eligible for reimbursement consideration.
Extracorporeal Shock Wave Lithotripsy
for Gallstones (11.03.13a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Extracorporeal shock wave lithotripsy (ESWL) for gallstones is
a noninvasive procedure that uses high-volume, high-intensity
shock waves (500-1500 shocks over 30 to 120 minutes) to
disintegrate gallstones. This technology may be used alone or in
conjunction with ursodiol (a naturally occurring biliary acid that
assists to further dissolve the fragmented stones).
ESWL in conjunction with ursodiol is considered medically
necessary for the treatment of gallstones in individuals who are
symptomatic with non-calcified single gallstones measuring 20
mm or less and who:
• Are not considered a candidate for either open or laparoscopic
cholecystectomy due to comorbidities (e.g., portal
hypertension).
Originally published in Fall 2005 CGPU.
Gemtuzumab Ozogamicin (Mylotarg®)
(08.00.35a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Gemtuzumab ozogamicin (Mylotarg®) is an intravenous
chemotherapy agent composed of a recombinant humanized
IgG4 kappa antibody conjugated with a cytotoxic antitumor
antibiotic isolated from fermentation of a bacterium. The
antibody portion of gemtuzumab ozogamicin (Mylotarg®)
binds specifically to the CD33 antigen, a sialic acid-dependent
adhesion protein found on the surface of leukemic myeloblasts
and immature normal cells of myelomonocytic lineage, but not
on normal hematopoietic stem cells.
Gemtuzumab ozogamicin (Mylotarg®) is medically necessary
for the following US Food and Drug Administration (FDA)approved indication: Individuals with CD33-positive acute
myeloid leukemia (AML) in first relapse who are 60 years of
age or over and who are not considered candidates for cytotoxic
chemotherapy (i.e., cardiotoxic effects occurred after receiving
cytarabine [ARA-C]).
All off-label indications for gemtuzumab ozogamicin
(Mylotarg®) are considered experimental/investigational.
Originally published in Summer 2005 CGPU.
Originally published in Fall 2005 CGPU.
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Human Immunodeficiency Virus
(HIV) Genotyping and Phenotyping
(06.02.09a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Human immunodeficiency virus (HIV) genotyping or
phenotyping is medically necessary to identify anti-retroviral
(ARV) drugs that would not be active in the treatment
regimen of individuals whose viral load has not been adequately
suppressed or has risen after initial suppression; it can also
be used to identify drug-resistant viruses in new infections in
treatment-naive individuals.
Combination genotyping and phenotyping is considered
experimental/investigational because the efficacy of this service
cannot be established by review of the available published
literature. Therefore, this service is not covered.
Virtual phenotyping is considered experimental/investigational
because the efficacy of this service cannot be established by
review of the available published literature. Therefore, this
service is not covered.
Originally published in Spring 2005 CGPU.
Knee Braces (05.00.47)
COVERED: ACCORDING TO CERTAIN CRITERIA
Knee braces are categorized according to their intended use:
• Functional braces stabilize the knee for activities of daily living.
• Unloader braces unload some of the weight from the medial
compartment of a painful osteoarthritic knee to reduce pain
and help increase mobility by bracing the knee in the valgus
position.
• Rehabilitation braces moderate joint motion in an injured
knee, and are typically used for up to 12 weeks post-injury or
post-operatively.
C OM PE NDIUM
• A custom-fabricated brace is one that is individually made for
a specific individual. It involves substantial work, including
cutting, bending, molding, and sewing, and it may also involve
the incorporation of some prefabricated components.
• A molded-to-patient-model brace is a particular type of
custom-fabricated orthosis in which an impression of the
specific body part is made, and the impression is then used
to make a positive model of the body part. The brace is then
molded on this model.
Prefabricated functional knee braces are medically necessary
for patients with clinically significant knee instability or with
symptomatic (painful) osteoarthritis of the medial compartment
of the knee that is refractory to medical therapy. A prefabricated
functional knee brace is not medically necessary for the lateral
compartment of the knee. Therefore, this service is not covered.
Custom-fabricated functional knee braces (including moldedto-patient-model braces) are not medically necessary unless the
use of a prefabricated brace is contraindicated by unusual knee
size or deformity. A custom-fabricated functional knee brace is
not medically necessary for the lateral compartment of the knee.
Custom-fabricated unloader knee braces (including moldedto-patient-model unloader braces) are medically necessary for
patients with symptomatic (painful) osteoarthritis of the medial
compartment of the knee that is refractory to medical therapy.
A custom-fabricated unloader brace is not medically necessary
for the lateral compartment of the knee.
Rehabilitation knee braces are medically necessary for patients
with knee injuries when the initial request for the brace is made
within 12 weeks post-injury/surgery.
Knee braces worn solely as prophylactic devices (e.g., when the
wearer is participating in sporting activities) are not medically
necessary. Therefore, these devices are not covered.
Knee braces (of any type) are considered not medically necessary
and, therefore, are not covered for all other conditions.
• Prophylactic braces are used on uninjured knees to prevent
injuries such as medial collateral ligament tears. They can be
either prefabricated or custom-fabricated.
Knee braces are purchased, rather than rented. All fitting
and labor required are included in the reimbursement for the
purchase.
Additionally, knee braces can be classified by type of
manufacturing process:
Originally published in Spring 2005 CGPU.
• A prefabricated brace is one that is manufactured in quantity
without a specific individual in mind. Any brace that does
not meet the definition of a custom-fabricated orthosis is
considered prefabricated.
12
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Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
Lipectomy or Liposuction (11.08.03b)
COVERED: ACCORDING TO CERTAIN CRITERIA
A lipectomy may be performed in order to excise a lipoma (fatty
tumor) or to remove excess fatty tissue in order to reshape the
contours of the face, neck, trunk, and/or extremities. Methods
to remove fatty tissue include surgical excision suction-assisted
lipectomy (SAL). Liposuction is the aspiration of subcutaneous
fat by the use of a suction method and various techniques.
Liposuction aids in sculpting targeted areas of the body into
a slimmer profile and is typically reserved for use in young,
healthy individuals who have localized fat deposits that have
been resistant to diet and/or exercise. Liposuction and lipectomy
are often components of cosmetic surgery; however, there are
clinical circumstances when liposuction and/or lipectomy are
used in conjunction with or as a means of performing certain
surgical procedures.
Under most circumstances, a lipectomy and/or liposuction are
cosmetic services and a benefit contract exclusion. However,
the procedure(s) are medically necessary for the following
indications:
Meniscal Allograft Transplantation
(11.14.03b)
COVERED: ACCORDING TO CERTAIN CRITERIA
The meniscus is a wedge-shaped structure, composed of collagen
bundles, located between the tibia and femur on the medial and
lateral aspects of the knee. Because the meniscus is critical to
preserving articular cartilage and retarding degenerative arthritis,
meniscal transplants have become a treatment option for
selected individuals who have undergone meniscectomy.
Contraindications to the procedure include severe degenerative
changes in the knee joint, uncorrected joint instability,
malalignment, and a history of infection in the joint. Individuals
with total meniscectomies who are asymptomatic are not
candidates for meniscal transplantation.
Meniscal allograft transplantation is medically necessary when
all of the following criteria are met:
• The individual has reached skeletal maturity.
• The individual has a history of total or near total
meniscectomy.
• When provided during the removal of a cutaneous lipoma to
relieve movement restriction and/or to correct a functional
impairment.
• The individual has disabling knee pain and a stable knee joint
(or corrective surgery is planned prior to or in combination
with the transplantation).
• When provided in order to create symmetry in projection,
position, size, and/or shape of either the affected breast
(ipsilateral) or unaffected breast (contralateral) when
an individual is undergoing breast reconstruction after
mastectomy.
• There are minimal to absent degenerative changes in the
affected knee.
• When provided to the surrounding area of the breast as part of
a medically necessary reduction mammoplasty.
Osteochondral Autograft
Transplantation Procedure (11.14.09a)
COVERED: ACCORDING TO CERTAIN CRITERIA
• When provided to the surrounding area of the chest during
surgery to reduce gynecomastia when the medical necessity
criteria listed in that specific medical policy are met.
• When provided as a surgical option for the treatment
of axillary hyperhidrosis when medical management
(e.g., medications [botox, anticholinergics, beta-blockers,
benzodiazepines] and/or topical prescriptions) has failed.
Liposuction performed solely to change the appearance of a
body part without improving the physiologic functioning of
that body part is considered cosmetic and, therefore, a benefit
contract exclusion.
Originally published in Winter 2005 CGPU.
Originally published in Spring 2005 CGPU.
Hyaline cartilage is a flexible, elastic tissue that covers the
articular surface of the knee and allows for smooth articulation
of the joint. Osteochondral autograft transplantation (OAT)
(also known as osteochondral autograft transplant system
[OATS] or autogenous osteochondral mosaicplasty) involves
harvesting osteochondral cylinders that include overlays of
normal articular cartilage from minimal weight-bearing knee
areas and transplanting them into articular sites. Osteochondral
autograft transplantation is a one-stage procedure that can
be either open or arthroscopic depending on the size of the
lesion being treated. Limited donor sites and the potential for
morbidity at the donor site restrict the size of the lesion that can
be treated with these procedures.
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13
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Osteochondral autograft transplantation is medically necessary
when all of the following criteria are met:
• The individual has reached skeletal maturity.
• The individual has a full-thickness unipolar defect 1-3 cm2 on
the femoral condyle or patellar articular surface.
• The individual has a stable and aligned knee without meniscal
deficiency that is surrounded by healthy articular cartilage
capable of supporting the graft.
• The individual has the ability and willingness to comply with
the postoperative rehabilitation protocol.
Osteochondral autograft transplantation is considered not
medically necessary when any one of the following conditions
are present:
C OM PE NDIUM
Percutaneous Balloon Valvuloplasty
(11.02.03b)
COVERED: ACCORDING TO CERTAIN CRITERIA
Percutaneous balloon valvuloplasty is a procedure in which a
catheter with a collapsed balloon at the tip is inserted through
the skin into the femoral artery or vein. The catheter is then
advanced into the heart and into the affected valve. Once the
balloon is positioned in the valve, it goes through a cycle of
inflation-deflation in order to decrease the degree of obstruction
in the valve.
Percutaneous balloon valvuloplasty is medically necessary for the
treatment of:
• Degenerative arthritis.
• Mitral valve stenosis for a select group of individuals who have
severe uncomplicated mitral valve stenosis and in whom the
anatomical features of the valve are favorable.
• Uncorrected malalignment and/or ligament instability of the
knee.
• Aortic valve stenosis in neonates, infants, children, and young
adults.
• Meniscal insufficiency.
• Aortic valve stenosis for patients in cardiogenic shock, for
whom the procedure acts as a bridge to surgery.
• Steroid dependency.
• Any associated pathology and/or other conditions that may
affect graft incorporation.
Originally published in Winter 2005 CGPU.
Otoplasty (11.01.01c)
COVERED: ACCORDING TO CERTAIN CRITERIA
Otoplasty is a surgical procedure that is performed to reshape
the outer portion of the ear (auricle) and correct congenital
deformities or defects resulting from traumatic injury.
Otoplasty is medically necessary when performed for the
following indications:
• Congenital defects (e.g., lop ear, cryptotia, microtia, or
macrotia).
• Defects resulting from traumatic injuries.
Otoplasty performed for any other indication is considered
cosmetic and, therefore, a benefit contract exclusion. All requests
for otoplasty require review by the Company’s Cosmetic Review
Team and must include color photographs and a letter of
medical necessity.
Originally published in Fall 2005 CGPU.
• Pulmonic valve stenosis.
Originally published in Spring 2005 CGPU.
Procedures for the Treatment of
Gastroesophageal Reflux Disease
(GERD) in Adults (11.03.11a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Gastroesophageal reflux disease (GERD) is associated with
chronic symptoms of heartburn and/or regurgitation and
mucosal damage of the esophagus, which are produced by the
abnormal reflux of gastric contents. Treatment of GERD is
aimed at relieving and preventing symptoms and preventing
complications. Treatment is individualized based on symptoms
and severity, and can include lifestyle modification, increasing
gastric pH, increasing esophageal clearance, decreasing gastric
volume, increasing gastric emptying, and increasing the tone of
the lower esophageal sphincter (LES).
If, after a reasonable period of medical management following
current standards of practice (e.g., histamine-receptor blockers,
proton pump inhibitors, and promotility agents), the individual’s
condition has failed medical treatment or the individual has
developed comorbidities, the next approach may be surgical
intervention.
14
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Surgical fundoplication and valvuloplasty of the LES are
medically necessary for individuals with any of the following:
• Whose disease may be deemed unresectable due to the
location or number of tumors.
• Failed medical management of GERD.
• Who have co-morbid disease that makes them poor surgical
candidates.
• Complications of GERD such as Barrett’s esophagus or grade
3 or 4 esophagitis.
• Who refuse hepatic resection.
• Medical complications attributable to a large hiatal hernia,
such as bleeding or dysphagia.
Originally published in Spring 2005 CGPU.
• Extraesophageal symptoms, such as asthma, hoarseness, cough,
chest pain, or aspiration, and documented reflux on 24-hour
intraesophageal pH monitoring.
Radiofrequency Lesioning of the Spinal
Nerves for Chronic Pain (11.15.09)
COVERED: ACCORDING TO CERTAIN CRITERIA
Surgical implantation of an antigastroesophageal reflux device
is medically necessary for individuals with documented severe
or life-threatening GERD whose conditions have been resistant
to medical treatment with histamine-receptor blockers, proton
pump inhibitors, or promotility agents, and who also have any
one of the following:
Radiofrequency (RF) lesioning (neuroablation, neurotomy) is
a technique used in the treatment of chronic pain originating
from the spinal nerves. It is alternately termed RF denervation,
rhizotomy, or rhizolysis. The procedure applies RF current
percutaneously to heat up a small volume of nerve tissue, thereby
destroying the nerve and interrupting pain signals from a
specific site (e.g., nerves serving a zygapophyseal [facet] joint or
a degenerated disc). Destruction of the nerve may be permanent
or lasting only a year or so.
• Esophageal involvement with progressive systemic sclerosis.
• Foreshortening of the esophagus such that insufficient tissue
exists to permit a valve reconstruction.
• High surgical risk for valvuloplasty procedure.
RF lesioning of the spinal nerves is medically necessary when all
of the following conditions exist:
• Failed previous attempts at surgical treatment with
valvuloplasty procedures.
• History of severe neck or back pain.
Transesophageal endoscopic treatment for GERD, including
transesophageal endoscopic gastroplasty, radiofrequency
ablation, endoscopic implantation of polymethylmethacrylate
beads, and injections of ethylene-vinyl-alcohol, is considered
experimental/investigational because the safety and/or efficacy
of these services cannot be established by review of the available
published literature. Therefore, these services are not covered.
Originally published in Summer 2005 CGPU.
Radiofrequency Ablation of Liver
Tumors (11.03.09b)
COVERED: ACCORDING TO CERTAIN CRITERIA
Radiofrequency ablation (RFA) utilizes heat derived from
radiofrequency energy to destroy liver tumors. RFA may be
performed via open surgical, laparoscopic, or percutaneous
approaches.
RFA utilizing heat derived from radiofrequency energy is
medically necessary for the treatment of primary or secondary
hepatic tumors for individuals:
• Documented failure of a six month or longer trial of
conservative treatments such as rest, physical therapy,
and/or medication.
• Other treatable causes of pain (e.g., tumors, infections, spinal
stenosis, herniated discs, psychiatric etiologies) have been
ruled out.
• Preprocedure diagnostic facet joint injection provides at least a
50 percent reduction of pain.
In the majority of individuals, up to two levels per side may be
treated. In certain complex cases, treatment of up to six levels per
side may be necessary. Multiple levels may be treated in a single
treatment session.
Procedures may be repeated once, with a six-month rest period
between treatments. If there is no relief after the second
treatment, further treatments will be considered not medically
necessary and are, therefore, not covered.
Originally published in Spring 2005 CGPU.
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Reduction Mammoplasty (11.08.02b)
COVERED: ACCORDING TO CERTAIN CRITERIA
Refractive Keratoplasty (11.05.01a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Reduction mammoplasty is a surgical procedure that excises
a portion of the breast, including the skin and underlying
glandular tissue. This procedure reduces the size, shape, and
weight of mammary tissue to minimize shoulder, neck, or
back pain or recurrent intertrigo in the mammary folds due to
macromastia (a marked enlargement of one or both breasts).
Refractive keratoplasty is a surgical procedure that reshapes
the cornea of the eye in order to correct vision problems such
as myopia (nearsightedness), hyperopia (farsightedness), and
astigmatism.
Reduction mammoplasty is medically necessary when all of the
following medical necessity criteria are met:
• The individual has macromastia (enlargement of the breasts) or
gigantomastia.
• The individual has clinical symptoms of breast, neck, back, or
shoulder pain, or painful shoulder grooving that are present
for a minimum six-week period and not responding to
conservative measures.
• The individual meets the minimum specimen weight of breast
tissue to be removed based on the individual’s body surface area
(BSA).
When a request is made for reduction mammoplasty,
photographs documenting breast size are required.
The Schnur Sliding Scale Chart is used to determine the
minimum estimated specimen weight (in grams) of breast tissue
that the surgeon will remove from each breast, based on the
individual’s BSA.
The simplified formula for calculation of BSA is:
BSA (in m2) = [height (cm)] 0.718 × [weight (kg)] 0.427 × .007449
Requests for reduction mammoplasty procedures that do not
meet medical necessity criteria are considered cosmetic and,
therefore, are not covered.
Originally published in Summer 2005 CGPU.
Refractive keratoplasty is medically necessary to correct an
astigmatism that resulted from trauma or from previous eye
surgery (e.g., cataract, corneal).
To report the repair of surgically induced astigmatism or
astigmatism that resulted from trauma due to the laser in situ
keratomileusis (LASIK) method, use CPT code 66999 with the
narrative: surgically induced astigmatism or astigmatism resulting
from trauma.
Refractive keratoplasty performed for the correction of refractive
defects (e.g., myopia, hyperopia, and astigmatism) in order to
eliminate or reduce the need for prescription or corrective vision
lenses is a benefit contract exclusion for most of the Company’s
products. However, for some of the Company’s products, these
services are a benefit option; therefore, individual member
benefits must be verified.
Originally published in Winter 2005 CGPU.
Repair of a Laceration at a Site
Previously Pierced for Cosmetic
Reasons (11.08.07c)
COVERED: ACCORDING TO CERTAIN CRITERIA
A laceration is a wound or irregular tear of the flesh. Lacerations
may arise in tissues surrounding a site previously pierced for
cosmetic reasons such as, but not limited to, the ear, earlobe,
nose, eyebrow, navel, tongue, and genitalia due to excessive
weight, tension, or trauma. When a laceration at the site of a
body part previously pierced for cosmetic reasons has not been
treated within seven days of occurrence and subsequent scar
formation has occurred, the repair could constitute a cosmetic
alteration.
Repair of a laceration at a site previously pierced for cosmetic
reasons is medically necessary to prevent complications such as,
but not limited to, infection.
Originally published in Spring 2005 CGPU.
16
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
Rhytidectomy and Rhytidoplasty
(11.08.13c)
COVERED: ACCORDING TO CERTAIN CRITERIA
Screening, Diagnostic, and Digital
Mammography (09.00.15a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Rhytidectomy and rhytidoplasty are procedures by which facial
wrinkles are excised and removed through plastic surgery. Also
known as meloplasty or face lift, these surgical procedures
typically aim to correct or improve the skin laxity, jowling, heavy
nasolabial folds, submental and submandibular fat deposits,
and platysma muscle bands. Treatment of these conditions
is typically cosmetic in nature; however, the literature does
support rhytidectomy and rhytidoplasty procedures when they
accompany microneurovascular surgery for the improvement
of a physiologic function, such as restoring symmetric facial
movement that resulted from facial trauma or facial paralysis.
Screening mammography is an imaging modality with the
capability of screening asymptomatic individuals for breast
cancer.
Under most circumstances, rhytidectomy and rhytidoplasty
procedures are cosmetic services and benefit contract exclusions;
however, these procedures are medically necessary when one of
the following criteria are met:
• Microneurovascular surgery is performed to improve
physiologic function, such as restoring symmetric facial
movement that resulted from trauma (e.g., facial fracture,
iatrogenic disorder).
• Functional impairment is due to a disease state (e.g., facial
paralysis from Bell’s palsy, birth trauma, nerve injury/disorder).
• Reconstruction surgery is performed to correct an accidental
injury, previous surgery, or intervention that resulted in
neurological facial damage.
Rhytidectomy and rhytidoplasty procedures used for conditions
not meeting the medical necessity criteria are considered
cosmetic and, therefore, a benefit contract exclusion.
Diagnostic mammography is a radiologic technique that
includes the use of additional radiographic views and special
images known as cone views. Cone views with magnification
is a technique that makes an area of altered breast tissue easier
to evaluate, and allows for the creation of an individualized
treatment plan.
Digital mammography is a technique that utilizes computer
electronics to produce real-time, digitally enhanced X-ray images
of the entire breast and allows health professionals to focus on
specific areas of the breast using magnification, brightness, and/
or contrast.
Coverage is provided for screening and diagnostic
mammography done by any modality (digital or standard).
Benefits may vary per Company product and individual member
benefits must be verified.
If required by the radiology site, the ordering provider should
provide a prescription for the mammography study.
In products and geographic locations with a capitated outpatient
diagnostic radiology program, the member is not required to
utilize the primary care physician’s capitated radiology site
for mammographies and may utilize any of the Company’s
participating radiology sites.
Originally published in Winter 2005 CGPU.
Originally published in Winter 2005 CGPU.
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Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
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Speech and Non-Speech Generating
Devices (05.00.32)
COVERED: ACCORDING TO CERTAIN CRITERIA
Speech generating devices (SGDs) are defined as augmentative
or alternative communication aids that provide individuals with
severe disabilities the ability to meet their functional speaking
needs. Severe expressive speech disability is defined as the
inability or limited ability to communicate daily wants, needs,
and/or thoughts via the spoken or printed word. This disability
is identified by a speech language pathologist (SLP) during a
formal evaluation.
SGDs are considered medically necessary when all of the
following criteria are met:
• The individual has a permanent and/or progressive condition
(e.g., mental retardation, traumatic brain injury, muscular
dystrophy) that results in a severe expressive speech disability
(inability or limited ability to communicate wants, needs, and/
or thoughts).
• The individual cannot meet his/her speaking needs with
spoken or printed communication.
• The individual has had an evaluation by a speech language
pathologist (SLP) to assess his/her functional abilities to access
the technology necessary to operate a SGD.
• The individual and primary caregiver are willing to learn about
and use the SGD device for daily communication.
• The SGD must be one of the following:
- Digitized speech device with limited fringe
vocabulary.
- Synthesized speech device with extensive fringe
vocabulary when the individual functions at one of
the following levels:
• Executive level functioning (cognitive ability
required for complex goal-directed behavior
[e.g., plan, organize, and strategize]).
• Developing executive level functioning
(executive functioning in limited situations
or with a minimal amount of cueing or
prompting).
C OM PE NDIUM
- Speech generating software program with extensive
fringe vocabulary that enables a laptop computer,
desktop computer, or personal digital assistant (PDA)
to act as an SGD.
• The SGD must be accessed by one of the following methods:
- Direct selection, which requires the individual to
exhibit reliable fine motor control.
- Scanning selection, which requires the individual to
exhibit both:
• Reliable gross motor control.
• Excessive loss of and/or unreliable fine
motor control.
Upgrades to SGDs and/or speech generating software programs
functioning as an SGD are considered medically necessary
when the above criteria are met and medical necessity is clearly
documented in a formal evaluation by the SLP; however,
installation of the software program or technical support is not
reimbursed separately.
Mounting systems are considered medically necessary when
documentation of medical necessity is provided in a formal
evaluation by the SLP.
Accessories for SGDs, including access devices, batteries, battery
chargers, and adapters, are considered medically necessary when
documentation of the medical necessity is provided in a formal
evaluation by the SLP.
Non-speech generating devices do not meet the Company’s
definition of durable medical equipment (DME); therefore,
they are a benefit contract exclusion and are neither covered
nor eligible for reimbursement. Any evaluation or therapeutic
services associated with this type of equipment are a benefit
contract exclusion and are neither covered nor eligible for
reimbursement.
Computers, PDA’s, or other devices that are not defined
as SGDs do not meet the Company’s definition of DME;
therefore, they are a benefit contract exclusion and are neither
covered nor eligible for reimbursement.
Originally published in Winter 2005 CGPU.
18
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
Surgical Treatment of Strabismus
(11.05.07a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Strabismus (heterotropia) refers to a deviation of the eye in
which both eyes are not directed, despite both eyes being
uncovered, so that fusion is not possible. Strabismus may occur
as a primary disorder or as a result of other ocular or systemic
disease. Types of strabismus include esotropia (inward deviation),
exotropia (outward deviation), hypertropia (upward deviation),
and hypotropia (downward deviation).
Surgical correction of strabismus is medically necessary for
visually immature children ages 10 and younger.
Surgical correction of strabismus is medically necessary for
visually mature individuals (over the age of 10) who have vision
in both eyes but are unable to maintain fusion and who exhibit
any of the following:
• Diplopia.
• Abnormal head turn.
• Asthenopia.
• Impairment of peripheral vision due to esotropia.
Surgery that is provided only for ocular alignment without an
expected functional benefit is not medically necessary.
Originally published in Winter 2005 CGPU.
Total Parenteral Nutrition (TPN)/
Intradialytic Parenteral Nutrition (IDPN)
(08.00.17a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Total parenteral nutrition (TPN), also known as parenteral
hyperalimentation, involves the delivery of micronutrients and
macronutrients via infusion to an individual with complex
nutritional needs. TPN consists of the optimal levels of
glucose, amino acids, electrolytes, vitamins, minerals, and
fats; the concentration of each component is calculated for
the individual’s specific metabolic need. Its use is associated
with gastrointestinal (GI) anomalies and impaired intestinal
absorption or motility to bolster and/or maintain nutritional
status of moderately to severely malnourished individuals
with medical or surgical conditions. TPN may be part of the
treatment plan for individuals with severe pathology of the
digestive system that does not allow for the absorption of
sufficient nutrients to maintain weight and strength.
TPN is administered through central intravenous line access or a
peripherally inserted central catheter (PICC). An infusion pump
regulates the flow of the solution on either a continuous (24hour) or intermittent schedule.
Intradialytic parenteral nutrition (IDPN) refers to the delivery
of micronutrients and macronutrients to individuals who have
complex nutritional needs during the time of hemodialysis.
IDPN treats protein calorie malnutrition in an effort to decrease
associated morbidity and mortality.
TPN is medically necessary for individuals with the following
condition:
• A clinical diagnosis of a permanent, severe pathology of the
alimentary (digestive) tract that does not allow absorption
of sufficient nutrients to maintain weight and strength
commensurate with the individual’s general condition, as
described by one of the following:
- Disorder of the small intestine and/or its exocrine
glands, which significantly impairs the absorption of
nutrients.
- Disorder of the stomach and/or intestine, which
impairs the ability of nutrients to be transported
through the GI system.
- Hyperemesis gravidarum.
IDPN is medically necessary for individuals with the following
condition:
• A clinical diagnosis of a permanent, severe pathology of the
alimentary tract that does not allow absorption of sufficient
nutrients to maintain weight and strength commensurate with
the individual’s general condition, and both of the following:
- Infusion is necessary because the individual cannot
maintain a vital stability on oral or enteral feedings.
- Infusion is not used as a supplement to a deficient
diet or deficiencies caused by dialysis.
TPN/IDPN is not medically necessary for individuals in any of
the following scenarios:
• When the intravenous infusion is for weight maintenance only,
and one of the following methods can be used:
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19
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- Modifying the nutrient composition of the enteral
diet (e.g., lactose free, gluten free, low in longchain triglycerides, substitution with medium-chain
triglycerides, provision of protein as peptides or
amino acids, etc.)
When services are billed by nonparticipating providers,
reimbursement is subject to any out-of-network penalties,
coinsurance, deductibles, and pre-authorization requirements.
- Utilizing pharmacologic means to treat the etiology
of the malabsorption (e.g., pancreatic enzymes or
bile salts, broad-spectrum antibiotics for bacterial
overgrowth, prokinetic medication for reduced
motility, etc.)
Trastuzumab (Herceptin) (08.00.33b)
COVERED: ACCORDING TO CERTAIN CRITERIA
• When the GI tract is functioning in the presence of one of the
following medical conditions:
- Swallowing disorders (e.g., dysphagia associated with
cerebral vascular accident [CVA].)
- A temporary defect in gastric emptying (e.g.,
metabolic or electrolyte disorders).
- A psychological disorder impairing food intake (e.g.,
depression).
- A metabolic disorder inducing anorexia (e.g., cancer).
- A physical disorder impairing food intake (e.g., severe
dyspnea).
- Side effect of a medication.
- Renal failure and/or dialysis.
When an infusion therapy service in the home setting is covered,
all services provided in association with the infusion therapy
service (e.g., solutions, additives, equipment and/or supplies,
nursing) are covered and eligible for reimbursement.
When the home infusion therapy service is noncovered, all
services provided in association with the infusion therapy service
(e.g., solutions, equipment and/or supplies, nursing) are neither
covered nor eligible for reimbursement consideration.
Services should be reported using the most comprehensive code.
When services are billed by participating home infusion
providers, TPN/IDPN is paid in accordance with a standard fee
schedule based on the number of liters the individual requires.
The fee includes all required equipment and supplies. Skilled
nursing visits are considered for separate reimbursement. Benefit
limits may apply.
Originally published in Summer 2005 CGPU.
Trastuzumab (Herceptin) is a monoclonal antibody that binds
to HER-2/neu and is used for the treatment of individuals with
metastatic breast cancer whose tumors overexpress the human
epidermal growth factor receptor 2 (HER-2)/neu protein.
Trastuzumab (Herceptin) is medically necessary for the
following US Food and Drug Administration (FDA)-approved
indications:
• For the treatment of individuals with metastatic breast cancer
whose tumors overexpress the HER-2/neu protein and who
have received one or more chemotherapy regimens for their
metastatic disease.
• Trastuzumab (Herceptin) in combination with paclitaxel is
indicated for the treatment of individuals with metastatic breast
cancer whose tumors overexpress HER-2/neu protein and who
have not received chemotherapy for their metastatic disease.
All off-label indications for trastuzumab (Herceptin) are
considered experimental/investigational and, therefore, are not
covered.
Originally published in Summer 2005 CGPU.
Uterine Artery Embolization for the
Treatment of Fibroids (11.06.04a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Uterine fibroids (leiomyomas) are extremely common benign
tumors, which are primarily located within the uterine cavity
(submucosal fibroids) or on the serosal surface of the uterus.
Uterine artery embolization (UAE), also known as transcatheter
uterine fibroid embolization (UFE), is a minimally invasive
uterine-sparing treatment option for individuals with uterine
fibroids.
During UAE, a physician (e.g., interventional radiologist)
selectively devascularizes the uterine fibroid tumor by injecting
20
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
various embolic agents into the vessels that provide the blood
supply to the tumor. The particles flow to the fibroids and wedge
into the vessel. The embolic material blocks blood flow to the
fibroid, causing it to shrink while sparing surrounding uterine
structures. As the uterine fibroid shrinks, the pre-procedure
symptoms are relieved or reduced. In most cases, this procedure
is performed bilaterally and requires overnight hospitalization.
This procedure is not recommended for individuals who desire
pregnancy.
UAE is medically necessary as a treatment option for women
with uterine fibroids who display symptoms including, but not
limited to:
• Menorrhagia (excessive menstrual bleeding) as a direct result
from the fibroid (not resulting from hyperplasia, atypia, or
cancer) that interferes with daily activities or causes anemia.
• Pelvic pain or pressure.
• Lower back pain.
• Urinary symptoms related to compression of the bladder (e.g.,
urinary frequency, urgency).
• Gastrointestinal symptoms related to compression of the bowel
(e.g., constipation, bloating).
• Dyspareunia (painful or difficult sexual relations).
• A fibroid that is abdominally palpable.
Repeat transcatheter embolization of uterine arteries to treat
persistent symptoms of uterine fibroids after an initial UAE
is considered experimental/investigational because the safety
and/or efficacy of this service cannot be established by review of
the available published literature. Therefore, this service is not
covered.
Zoledronic Acid (Zometa®) (08.00.44a)
COVERED: ACCORDING TO CERTAIN CRITERIA
Zoledronic acid (Zometa®) is an intravenous (IV)
bisphosphonate drug used for the treatment of hypercalcemia of
malignancy. The principal pharmacologic action of zoledronic
acid (Zometa®) is inhibition of bone resorption. Zoledronic acid
(Zometa®) inhibits the increased osteoclastic activity and skeletal
calcium release that are induced by the various stimulating
factors released by tumors.
Zoledronic acid (Zometa®) is medically necessary for the
following indications as approved by the US Food and Drug
Administration (FDA):
• Hypercalcemia of malignancy.
• Multiple myeloma.
• Documented bone metastases from solid tumors, in
conjunction with standard antineoplastic therapy.
– When used for bone metastases associated with prostate
cancer, zoledronic acid (Zometa®) should be administered
only following one course of hormonal therapy and evidence
that the disease has progressed.
The only off-label indication for zoledronic acid (Zometa®)
that is considered medically necessary is for individuals with
osteolytic lesions due to metastases.
All other off-label indications for zoledronic acid (Zometa®) are
considered experimental/investigational and, therefore, are not
covered.
Originally published in Summer 2005 CGPU.
Originally published in Fall 2005 CGPU.
www.amerihealth.com
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
21
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C OM PE NDIUM
2005 Compendium
MEDICAL POLICIES
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
www.amerihealth.com
TABLE OF CONTENTS
Adoptive Immunotherapy (06.03.07a) ................................. 24
Noninvasive Glucose Sensors (05.00.28a) ............................ 29
Artificial Intervertebral Disc Insertion (11.14.19) ............... 24
Ovarian and Internal Iliac Vein Embolization as Treatment
for Pelvic Congestion Syndrome (11.06.07) ........................ 29
Breast Ductal Lavage and Breast Duct Endoscopy
(11.08.28) ............................................................................. 24
Partial Left Ventriculectomy (11.02.15a) ............................. 29
Cervicography (06.02.13a) ................................................... 25
Pneumatic Thoracic Lumbosacral Orthoses (05.00.22a) ..... 29
Cold Laser Therapy (07.00.14a) .......................................... 25
Protonics® Device (07.08.02a) ............................................. 30
Diagnostic Headspace Analysis of Volatile Organic
Compounds (06.02.22) ........................................................ 25
Pulsed Magnetic Neuromodulation for Incontinence
(07.12.01a) ........................................................................... 30
Direct Measurement of Intermediate-Density
Lipoproteins (06.02.15a) ...................................................... 26
Speculoscopy (07.10.02a) ..................................................... 30
Fluorescence Endoscopy (11.16.05a) ................................... 26
Therapeutic Use of Transcranial Magnetic Stimulation
(07.03.13a) ........................................................................... 30
Hippotherapy (10.00.01a) .................................................... 26
Topical Oxygenation (07.00.09a) ......................................... 31
In Vitro Chemosensitivity and Chemoresistance
Assays (06.02.14b) ............................................................... 27
Treatment of Autism with Secretin (SecreFlo®)
(08.00.56) ............................................................................. 31
Intestinal Rehabilitation Program (07.05.03a) ..................... 27
Vertebral Axial Decompression Therapy (07.08.01a) .......... 31
Intradiscal Electrothermal Therapy (IDET) (11.14.14a)..... 27
Laetrile and Related Substances (08.00.39a) ....................... 27
Magnetic Resonance Imaging (MRI)-Guided Focused
Ultrasound Ablation of Uterine Leiomyomata (Fibroids)
(11.06.06) ............................................................................. 28
Magnetoencephalography (MEG) with Magnetic Source
Imaging (MSI) (07.03.10a) .................................................. 28
Neurofeedback (07.00.12a) .................................................. 28
Noncontact Normothermic Wound
Therapy (07.07.04a) ............................................................. 28
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Medical Policies:
UPDATE
C OM PE NDIUM
NOT COVERED : CONSIDERED EXPERIMENTAL/INVESTIGATIONAL
Adoptive Immunotherapy (06.03.07a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Adoptive immunotherapy is intended to enhance the capability
of a cancer patient’s own immune system to suppress or
eliminate cancer. In adoptive immunotherapy, lymphocytes are
removed from a patient, treated and reproduced in vitro, then
returned to the same patient. This process is not regulated by the
US Food and Drug Administration (FDA).
Adoptive immunotherapy is considered experimental/
investigational because the safety and/or efficacy of this service
cannot be established by review of the available published
literature. Therefore, this service is not covered.
Originally published in Summer 2005 CGPU.
Artificial Intervertebral Disc Insertion
(11.14.19)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
The use of spinal fusion to treat degenerative disc disease alters
the biomechanics of the back and may cause premature disc
degeneration at adjacent levels. To avoid this problem, a new
technique has been developed in which the diseased spinal disc
is surgically replaced with an artificial intervertebral disc that
consists of two metal endplates and a central free component.
The central component is held in place by the surrounding soft
tissues and moves within the disc space during spinal motion.
The goal of this procedure is to reduce or eliminate back pain
while maintaining spinal curvature, flexibility, and load bearing.
Breast Ductal Lavage and Breast Duct
Endoscopy (11.08.28)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Breast ductal lavage is a minimally invasive procedure in which
samples of breast duct cells are collected in order to determine
if they are normal, atypical, suspicious, or malignant. Breast
ductal lavage has been developed as a means of facilitating cell
collection for cytological analysis for individuals at high risk for
breast cancer. A few devices have been approved by the US Food
and Drug Administration (FDA) for ductal lavage; however,
there is a paucity of literature on the topic. It has not yet been
determined whether breast ductal lavage is as effective as
standard diagnostic procedures in detecting early breast cancer.
Breast duct endoscopy is a method that enables direct visual
examination of the lining of the breast milk ducts to search for
abnormal tissue. Because it is hypothesized that breast cancer
starts in the lining of the milk ducts or lobules, breast duct
endoscopy is used to collect cells from these ducts for evaluation.
Breast ductal lavage is considered experimental/investigational
because the safety and/or efficacy of this service cannot be
established by review of the available published literature.
Breast duct endoscopy is considered experimental/investigational
because the safety and/or efficacy of this service cannot be
established by review of the available published literature.
Therefore, this service is not covered.
Originally published in Winter 2005 CGPU.
Artificial intervertebral disc insertion is considered experimental/
investigational because the safety and/or efficacy of this service
cannot be established by review of the available published
literature. Therefore, this service is not covered.
Originally published in Summer 2005 CGPU.
24
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
Cervicography (06.02.13a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Cold Laser Therapy (07.00.14a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Cervicography is an adjunctive cervical screening procedure.
After the Papanicolaou (Pap) smear is obtained, the cervix is
swabbed with an acetic acid solution, and the outside of the
cervix is photographed with a special macrolens strobe-flash
camera. Cervicography is intended to increase the sensitivity of
the Pap smear in screening for cervical abnormalities; it is also
used as a triage tool to determine which patients need further
evaluation with colposcopy and biopsy.
Cold laser therapy, also referred to as low-energy laser therapy
or low-level laser therapy, refers to the use of polarized red-beam
or near infrared light to provide pain relief for various acute and
chronic conditions.
Cervicography has been the subject of randomized studies to
assess its efficacy as:
• A primary screening technique.
• An adjunct to Pap smear screening.
• A triaging strategy for individuals found to have low-grade
lesions on Pap smear.
According to these studies, cervicography alone has inferior
sensitivity compared with cytology. Cervicography, when used
as an adjunct to the Pap smear, may increase its sensitivity for
detecting cervical abnormalities, but will decrease specificity. This
can potentially result in an increase of referrals for unnecessary
colposcopies.
Cervicography is considered experimental/investigational
because the safety and/or efficacy of this service cannot be
established by review of the available published literature.
Therefore, this service is not covered.
Originally published in Fall 2005 CGPU.
Cold laser therapy is considered experimental/investigational
because the safety and/or efficacy of this service cannot be
established by a review of the available published literature.
Therefore, this service is not covered.
Originally published in Winter 2005 CGPU.
Diagnostic Headspace Analysis of
Volatile Organic Compounds (06.02.22)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Detection of volatile products of bacterial metabolism by
means of chemical sensors has been proposed as a method of
increasing the efficiency of analyzing specimens for infections.
Nonvolatile bacterial compounds can be analyzed after chemical
derivatization; more volatile ones can be analyzed following
extraction by means of an organic compound. The technique
of headspace analysis, a modification of organic extraction,
samples the space above the surface of a specimen and detects
volatile organic compounds (VOCs). Historically, the two main
methods of testing for volatile bacterial compounds have been
gas chromatography (GC) and GC-mass spectrometry (GCMS). However, efforts to achieve practical applications for GC
headspace analysis have not been successful.
Semiquantitative analysis of volatile compounds by headspace
analysis is considered experimental/investigational because
the safety and/or efficacy of this service cannot be established
by review of the available published literature. Therefore, this
service is not covered.
Originally published in Spring 2005 CGPU.
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25
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
C OD I N G
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UPDATE
Direct Measurement of IntermediateDensity Lipoproteins (06.02.15a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Hyperlipidemia, the presence of excess fat, or lipids, in the blood,
is associated with the development of atherosclerosis. It is a
preventable and modifiable risk factor for coronary heart disease
(CHD). Clinical signs of this condition are an increase in the
fasting serum cholesterol level, the fasting serum triglyceride
level, or both. Lipids are transported in plasma as components
of remnant lipoprotein complexes. According to the National
Cholesterol Education Program Adult Treatment Panel III
Report, 2001 (ATP III), “prospective studies relating various
remnant measures to CHD risk are limited, and measurement
with specific assays cannot be recommended for routine
practice.” Further studies are needed to determine its
relative efficacy.
Direct measurement of intermediate-density lipoproteins is a
laboratory procedure and not regulated by the U.S. Food and
Drug Administration (FDA). However, Clinical Laboratory
Improvement Amendments (CLIA) establish quality standards
for all laboratory testing.
Direct measurement of intermediate-density lipoproteins is
considered experimental/investigational because the safety and/
or efficacy of this service cannot be established by review
of the available published literature. Therefore, this service is
not covered.
Originally published in Fall 2005 CGPU.
Fluorescence Endoscopy (11.16.05a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
C OM PE NDIUM
A review of the medical literature reveals that there is inadequate
evidence from which to draw definitive conclusions about the
usefulness of fluorescence endoscopy for identifying and locating
suspicious bronchial tissue for biopsy and histological evaluation.
The use of fluorescence endoscopy for detecting lung cancer is
considered experimental/investigational because the safety and/
or efficacy of this procedure cannot be established by review
of the available published literature. Therefore, this service is
not covered.
Originally published in Fall 2005 CGPU.
Hippotherapy (10.00.01a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Hippotherapy is a treatment modality that uses the movement
of a horse to assist individuals with movement dysfunction.
Individuals with spastic cerebral palsy have exaggerated stretch
reflexes, muscle spasms, and increased deep tendon reflexes that
impair ambulation. The natural swaying motion of the horse
produces a pelvic movement in the rider similar to human
ambulation.
Hippotherapy is a benefit contract exclusion for most
Company products.
When not a specific benefit contract exclusion, hippotherapy is
considered experimental/investigational because the safety and/
or efficacy of this service cannot be established by review
of the available published literature. Therefore, this service is
not covered.
Originally published in Fall 2005 CGPU.
The standard diagnostic tool for detecting lung cancer is white
light bronchoscopy (WLB). However, because pre-invasive
tumors are very small (the median dimension of carcinoma in
situ is only 8 mm in diameter), only 40 percent of pre-invasive
tumors can be found by conventional WLB. A proposed
diagnostic adjunct to WLB is fluorescence endoscopy, a
technology for enhancing the detection of carcinoma in situ or
early-stage cancers in individuals who are at high risk for new
cancer development after successful treatment of early-stage
lung cancer.
26
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
In Vitro Chemosensitivity and
Chemoresistance Assays (06.02.14b)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Intradiscal Electrothermal Therapy
(IDET) (11.14.14a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
An in vitro chemoresponse assay is a laboratory test that
determines the sensitivity or resistance of carcinoma (tumor)
cells to specific chemotherapeutric agents. An in vitro
chemosensitivity assay determines the sensitivity of these
agents or cells. An in vitro chemoresistance assay determines
their resistance. Each test involves the exposure of human
tumor cell colonies to anticancer drugs that are subsequently
observed for signs of cytotoxic effects. The purpose of an in vitro
chemoresponse assay is to screen potential anticancer drugs and
predict the effect of these drugs on the tumor(s).
Intradiscal electrothermal therapy (IDET), also known as
intradiscal electrothermal annuloplasty, is considered to be
a minimally invasive procedure intended to treat chronic
lower back pain. Theoretically, the procedure is designed to
compress collagen fibers without causing excessive damage
and to thermocoagulate nerve tissue. IDET is distinct from
percutaneous laser discectomy in that IDET shrinks collagen,
whereas percutaneous laser discectomy ablates disc material.
In vitro chemosensitivity and chemoresistance assays are
considered experimental/investigational because the efficacy of
these services cannot be established by review of the available
published literature. Therefore, this service is not covered.
Originally published in Winter 2005 CGPU.
Intestinal Rehabilitation Program
(07.05.03a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Intestinal rehabilitation is a comprehensive program of dietary
alterations, glutamine supplementation, medication, growth
hormone injections, education, counseling, and physical therapy.
Specialized in-patient and out-patient programs have been
investigated as an alternative to lifelong total parenteral nutrition
(TPN) for individuals with short bowel syndrome. The efficacy
of a comprehensive treatment program in comparison with
dietary modifications, growth hormone injections, or glutamine
supplementation alone has not been established.
A comprehensive program of intestinal rehabilitation is
considered experimental/investigational because the safety and/
or efficacy of the service cannot be established by review
of the available published literature. Therefore, this service is
not covered.
IDET is considered experimental/investigational because the
safety and/or efficacy of this service cannot be established by
review of the available published literature. Therefore, this
service is not covered.
Originally published in Spring 2005 CGPU.
Laetrile and Related Substances
(08.00.39a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Laetrile, also known as Amygdalin, Sarcarcinase, Vitamin B-17,
and Nitriloside, is a natural substance found in the pits of some
fruits and nuts. Laetrile and related substances have been used
as anticancer treatments in humans worldwide. Although many
anecdotal reports and case reports are available, findings from
only two clinical trials have been published.
Laetrile and related substances are considered experimental/
investigational because the US Food and Drug Administration
(FDA) has not issued its final regulatory approval and labeling
of this product. Therefore, this treatment is not covered. If FDA
approval is granted, further review regarding the safety and
efficacy of this service will be undertaken.
Originally published in Spring 2005 CGPU.
Originally published in Spring 2005 CGPU.
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27
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C OD I N G
G U ID ELINES
A ND
PO L IC Y
UPDATE
Magnetic Resonance Imaging (MRI)Guided Focused Ultrasound Ablation
of Uterine Leiomyomata (Fibroids)
(11.06.06)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Uterine leiomyomata, commonly known as fibroids or myomas,
are the most common uterine neoplasms of the female genital
tract. MRI-guided focused ultrasound ablation for uterine
fibroids has been proposed to provide a minimally invasive
alternative for the treatment of uterine fibroids; it involves
focused ultrasound heating of tissue, monitored by MRI. The
device used for MRI-guided focused ultrasound ablation for
uterine fibroids, the ExAblate 2000 System, received US Food
and Drug Administration (FDA) approval on October 22, 2004.
MRI-guided focused ultrasound ablation for uterine
leiomyomata (fibroids) is considered experimental/investigational
because the safety and/or efficacy of this service cannot be
established by review of the available published literature.
Therefore, this service is not covered.
Originally published in Summer 2005 CGPU.
Magnetoencephalography (MEG)
with Magnetic Source Imaging (MSI)
(07.03.10a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Magnetoencephalography (MEG) is a noninvasive functional
imaging technique that serves as a surgical screening and
planning tool for individuals who are scheduled to undergo
neurosurgery. In MEG, the weak magnetic forces associated
with the electrical activity of the brain are recorded externally on
the scalp. Using mathematical modeling, the recorded data are
then analyzed to provide an estimated location of the electrical
activity. This information can be superimposed on an anatomic
image of the brain, typically obtained via magnetic resonance
imaging (MRI), to produce a functional/anatomic image referred
to as magnetic source imaging (MSI).
C OM PE NDIUM
Neurofeedback (07.00.12a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Neurofeedback training is a process of using neural information
to try to teach individuals with certain central nervous system
(CNS) disorders to make changes in their brain functioning.
The source of the feedback data is the electroencephalogram
(EEG). In theory, it may be possible for individuals to learn to
control their brain functions to help treat certain disorders such
as attention deficit/hyperactivity disorders, seizure disorders,
learning disabilities, panic and anxiety disorders, substance
abuse disorders, menopausal hot flashes, depression, sleep
disorders, and stress. The underlying concept of neurofeedback
is similar to biofeedback, except that the information
transmitted to the individual is in the form of EEG tracings,
not physiologic events.
Neurofeedback is considered experimental/investigational
because the safety and/or efficacy of this service cannot be
established by review of the available published literature.
Therefore, this service is not covered.
Originally published in Fall 2005 CGPU.
Noncontact Normothermic Wound
Therapy (07.07.04a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Noncontact normothermic wound therapy (NNWT) is a
wound care procedure that employs radiant heat to promote
wound healing. The theory is that wounds are hypothermic
relative to normal body temperature and that, by increasing their
temperature to normal, wound healing will be advanced.
NNWT is considered experimental/investigational because
the safety and/or efficacy of this service cannot be established
by review of the available published literature. Therefore, this
service is not covered.
Originally published in Summer 2005 CGPU.
MEG with MSI is considered experimental/investigational
because the safety and/or efficacy of this service cannot be
established by review of the available published literature.
Therefore, this service is not covered.
Originally published in Fall 2005 CGPU.
28
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
Noninvasive Glucose Sensors
(05.00.28a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Noninvasive glucose sensors have been developed to
automatically monitor blood glucose levels throughout the day
in individuals with diabetes. The information obtained from
these devices provides data that shows trends and tracking
patterns in blood glucose measurements. These devices are used
as an adjunctive device to supplement, not replace, information
obtained from standard at-home blood glucose monitoring
devices.
Noninvasive glucose sensors are considered experimental/
investigational because the safety and/or efficacy of these devices
cannot be established by review of the available published
literature. Therefore, these devices are not covered.
Originally published in Fall 2005 CGPU.
Partial Left Ventriculectomy (11.02.15a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Partial left ventriculectomy (PLV) is a surgical procedure that
is performed in order to reduce the size of an enlarged heart
in individuals with end-stage congestive heart failure (CHF).
PLV is also known as ventricular reduction surgery, ventricular
remodeling surgery, heart volume reduction surgery, or the
Batista procedure. This surgical approach to the treatment of
CHF is primarily directed at individuals with an underlying
dilated cardiomyopathy who are awaiting cardiac transplantation.
PLV is being investigated as either a bridge to transplantation or
as an alternative to transplantation.
PVL is considered experimental/investigational because the
safety and/or efficacy of this service cannot be established by
review of the available published literature. Therefore, this
service is not covered.
Originally published in Spring 2005 CGPU.
Ovarian and Internal Iliac Vein
Embolization as Treatment for Pelvic
Congestion Syndrome (11.06.07)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Pelvic congestion syndrome is theorized to be caused by
malfunctioning ovarian veins that allow blood to flow backward,
away from the heart, which then pools and builds pressure. The
stretching and bulging of the veins (known as varices) leads to
pain and other symptoms due to the dilatation and congestion
in the veins. It typically affects women during the reproductive
years and is frequently a diagnosis of exclusion.
Ovarian and internal iliac vein embolization as treatment
for pelvic congestion syndrome is considered experimental/
investigational because the safety and/or efficacy of this service
cannot be established by review of the available published
literature. Therefore, this service is not covered.
Originally published in Winter 2005 CGPU.
Pneumatic Thoracic Lumbosacral
Orthoses (05.00.22a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
A thoracic lumbosacral orthosis (TLSO) is a custom-designed
and/or externally-fitted and applied device that is intended
to provide support and/or to control disorders associated
with neuromuscular and/or musculoskeletal dysfunctions
involving the thoracic and lumbosacral spine. Orthotics with
pneumatic components have recently become commercially
available. One of these devices, the Orthotrac Pneumatic Vest,
has pneumatic lifts that are controlled by the individual and
designed to lift the weight of the body off the lumbar spine
and relieve intervertebral compression. It is designed to be used
intermittently two-to-three times during the day for 20 to 60
minute intervals.
The use of a thoracic lumbosacral orthosis that incorporates
pneumatic inflation is considered experimental/investigational
because the safety and/or efficacy of this device cannot be
established by review of the available published literature.
Therefore, this service is not covered.
Originally published in Winter 2005 CGPU.
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C OD I N G
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PO L IC Y
UPDATE
C OM PE NDIUM
Protonics® Device (07.08.02a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Speculoscopy (07.10.02a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
The Protonics® device is a long leg brace with a hinged knee
that provides variable resistance to flexion. The Protonics®
device uses programmable resistance to activate muscle groups
in the back of the thigh (hamstrings), buttocks, and abdominals
and deactivate other muscles during knee flexion. Theoretically,
the resistance system reduces the forward tilt of the femur,
thus reducing patellofemoral pain (PFP). In addition, the
manufacturer states that the muscles are compelled to relearn
proper movement, which, with repetition, will continue even
when the device is removed.
Speculoscopy (PapSure®, Watson Diagnostics, Inc., Corona,
CA) refers to the endoscopic visual examination of the cervix
using specialized blue-white chemiluminescent light, acetic
acid, and low-power magnification. Speculoscopy is used in
conjunction with the conventional Papanicolaou (Pap) smear.
The Protonics® device is considered experimental/investigational
because the efficacy of this device cannot be established by
review of the available published literature. Therefore, this device
is not covered.
Originally published in Fall 2005 CGPU.
Pulsed Magnetic Neuromodulation for
Incontinence (07.12.01a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Pulsed magnetic neuromodulation is a noninvasive technique
that utilizes extracorporeal magnetic innervation (ExMI™)
technology to deliver nerve impulses to the pelvic floor area
to increase muscular contractions in an attempt to improve
bladder control. The NeoControl® Pelvic Floor Therapy
System employs this technology for the treatment of urinary
incontinence in women. The system consists of a control unit
and treatment chair. Pulsing magnetic fields generated by the
chair’s therapeutic head stimulate the individual’s perineal
tissues, nerves, and muscles, reportedly increasing contractions
and improving circulation.
Pulsed magnetic neuromodulation is considered experimental/
investigational because the safety and/or efficacy of this service
cannot be established by review of the available published
literature. Therefore, this service is not covered.
Speculoscopy with or without direct sampling is considered
experimental/investigational because the safety and/or efficacy
of this service cannot be established by review of the available
published literature. Therefore, this service is not covered.
Originally published in Winter 2005 CGPU.
Therapeutic Use of Transcranial
Magnetic Stimulation (07.03.13a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Transcranial magnetic stimulation (TMS) is a noninvasive
method to stimulate the cortical neurons and thus alter brain
activity. Because TMS can deliver rapid, repetitive stimulation
to the brain, it is now being investigated as an alternative to
electroconvulsive therapy (ECT) in the treatment of depression.
In addition, TMS is being investigated in the treatment of
epilepsy, Alzheimer’s disease, and other neurological disorders.
The US Food and Drug Administration (FDA) has not
evaluated the use of this procedure for these particular
indications and, therefore, has not issued its final regulatory
approval and labeling for these indications. Published literature
does not support the use of this procedure for off-label use.
However, if FDA approval is granted, further review regarding
the safety and efficacy of this procedure will be undertaken.
Therapeutic use of TMS is considered experimental/
investigational because the safety and/or efficacy of this service
cannot be established by review of the available published
literature. Therefore, this service is not covered.
Originally published in Summer 2005 CGPU.
Originally published in Summer 2005 CGPU.
30
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
Topical Oxygenation (07.00.09a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Topical oxygenation, also referred to as topical hyperbaric
oxygenation, is a technique that delivers 100 percent oxygen
directly to an open, moist wound at a pressure slightly higher
than atmospheric pressure. The theory driving this therapy
is that the high concentrations of oxygen diffuse directly
into the wound to increase the local cellular oxygen tension,
which in turn promotes wound healing. Topical oxygenation is
delivered via a device that surrounds the wound area (usually
an extremity), and oxygen is delivered under pressure from a
source such as a conventional oxygen tank. Topical oxygenation
has been promoted as a treatment for diabetic, arterial, and
venous stasis ulcers, pressure ulcers, burns, amputations, infected
wounds, frostbite, gangrenous lesions, and skin graft sites.
Topical oxygenation is considered experimental/investigational
because the safety and/or efficacy of this service cannot be
established by review of the available published literature.
Therefore, this service is not covered.
Vertebral Axial Decompression Therapy
(07.08.01a)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Vertebral axial decompression is a type of lumbar traction that
was designed to reduce intradiscal pressure and relieve lower
back pain associated with herniated lumbar discs or degenerative
lumbar disc disease. There are various devices approved by the
US Food and Drug Administration (FDA) to deliver this type
of therapy; the designs of these devices differ in the method in
which the individual is secured to the treatment surface and the
position in which the individual is placed.
The use of vertebral axial decompression devices for vertebral
axide decompression therapy is considered experimental/
investigational because the safety and/or efficacy of this service
cannot be established by review of the available published
literature. Therefore, this service is not covered.
Originally published in Fall 2005 CGPU.
Originally published in Summer 2005 CGPU.
Treatment of Autism with Secretin
(SecreFlo®) (08.00.56)
NOT COVERED: CONSIDERED EXPERIMENTAL/
INVESTIGATIONAL
Secretin (SecreFlo™) is a pure hormone that has an amino acid
sequence identical to that of the naturally occurring porcine
secretin. The primary action of this pure peptide drug product
is to increase the volume and bicarbonate content of secreted
pancreatic juices.
The FDA has not issued its final regulatory approval and
labeling for the use of secretin (SecreFlo™) for the treatment of
autism. It is currently being studied in Stage III clinical trials for
the treatment of symptoms of autism, including gastrointestinal
disorders, socialization problems, and sleep disorders.
The use of secretin (SecreFlo™) in the treatment of autism is
considered experimental/investigational because the safety and
efficacy of this treatment has not been established. Therefore,
this service is not covered.
Originally published in Winter 2005 CGPU.
www.amerihealth.com
31
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
C OD I N G
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A ND
PO L IC Y
UPDATE
C OM PE NDIUM
32
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
MEDICAL POLICIES
NOT COVERED: CONSIDERED NOT MEDICALLY
NECESSARY
www.amerihealth.com
TABLE OF CONTENTS
Sensory Stimulation for Coma Patients (07.00.11a) ............ 34
www.amerihealth.com
33
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
C OD I N G
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PO L IC Y
Medical Policies:
UPDATE
C OM PE NDIUM
NOT COVERED : CONSIDERED NOT MEDICALLY NECESSARY
Sensory Stimulation for Coma Patients
(07.00.11a)
NOT COVERED: CONSIDERED NOT MEDICALLY
NECESSARY
Sensory stimulation is aimed at arousing a comatose
individual by utilizing the senses of vision, hearing, smell,
taste, touch, and bodily movements in response to various
stimuli. The goal of sensory stimulation is to heighten
rehabilitative potential.
Sensory stimulation is considered not medically necessary
because the available published literature does not support
the efficacy of this therapy as a useful aid in the treatment
of individuals who are in comas. Therefore, this service is
not covered.
Originally published in Fall 2005 CGPU.
34
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
CLAIM
PAYMENT POLICIES
www.amerihealth.com
TABLE OF CONTENTS
Autologous Blood Services (Collection, Storage, Transfusion,
and Perioperative Salvage) are Considered Eligible for
Reimbursement When the Scheduled Surgical Procedure is
Covered (06.03.05c) ............................................................. 36
Computer-Aided Detection (CAD) System for
Mammography is Considered Eligible for
Reimbursement (09.00.16a) ................................................. 36
Insertion or Application of Urinary Catheters and the
Associated Supplies Provided in the Office Setting are
Considered Eligible for Reimbursement When Certain
Criteria are Met (03.12.04) .................................................. 36
Ostomy Supplies are Considered Eligible for
Reimbursement (05.00.50) ................................................... 37
Photography Used for Documentation/Record-Keeping
Purposes is not Considered a Distinct and Separate Service
from an Evaluation and Management (E&M) Service or
Procedure (00.10.24a) .......................................................... 38
Revision of a Previous Cosmetic Procedure is Not
Considered Eligible for Reimbursement (11.00.01c) ........... 38
Treatment of Medical and Surgical Complications is
Considered Eligible for Reimbursement Consideration
for Acute Conditions (11.00.02c) ........................................ 38
Online Evaluation and Management Service is Not
Considered Eligible for Reimbursement (00.10.35) ............ 37
www.amerihealth.com
35
C OD I N G
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PO L IC Y
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C OM PE NDIUM
Claim Payment Policies
Autologous Blood Services (Collection,
Storage, Transfusion, and Perioperative
Salvage) are Considered Eligible for
Reimbursement When the Scheduled
Surgical Procedure is Covered
(06.03.05c)
Autologous blood collection and storage occurs when an
individual has his/her own blood drawn and stored for personal
use, such as self-donation in advance of a planned surgical
procedure (preoperative).
Autologous blood transfusion is the collection and subsequent
infusion of an individual’s own blood.
Perioperative blood salvage is the collection and reinfusion of
autologous blood lost during (intraoperative) and immediately
after (postoperative) a surgical procedure.
Autologous blood services, including collection, storage,
transfusion, and perioperative salvage, are covered and eligible
for reimbursement consideration by most Company products
and groups when the scheduled surgical procedure is covered.
Individual benefits must be verified, as some group contracts
exclude coverage for these services.
When the transfusion occurs in a participating facility setting,
the associated charges for the transfusion are included in the
facility reimbursement. Autologous blood collection, storage, and
transfusion are not considered routine preadmission
testing services.
Originally published in Summer 2005 CGPU.
Computer-Aided Detection (CAD) System
for Mammography is Considered
Eligible for Reimbursement (09.00.16a)
The use of a computer-aided detection (CAD) system as
a screening and/or diagnostic adjunctive tool for assessing
mammography is covered and eligible for separate
reimbursement when performed in conjunction with a covered
mammography and when the specific CAD system has
been approved by the US Food and Drug Administration
(FDA) for such use. Benefits may vary per Company product,
and individual member benefits must be verified for all
mammography services.
There are specific procedure codes to report the use of a CAD
system with diagnostic and screening mammography. Both the
code for CAD and the appropriate mammography code should
be reported on the same claim.
In geographic areas with a capitated radiology program, this
service is not included in the Capitated Outpatient Diagnostic
Radiology Program and is, therefore, eligible for fee-for-service
reimbursement consideration.
Originally published in Fall 2005 CGPU.
Insertion or Application of Urinary
Catheters and the Associated Supplies
Provided in the Office Setting are
Considered Eligible for Reimbursement
When Certain Criteria are Met
(03.12.04)
Urinary catheters are tube systems that are inserted into the
body to drain and collect urine from the bladder.
Supplies associated with urinary catheters are those that may
be used to assist with the insertion or application of a urinary
catheter. Associated supplies can include things such as an
insertion tray with drainage bags and urinary leg bags.
The Company covers and considers for reimbursement the
professional component of the insertion or application of a
urinary catheter and the specific evaluation and management
(E&M) appropriate to the level of service when provided in an
office setting as follows:
• For physicians contracted on a fee-for-service basis, the
appropriate modifier must be appended to the E&M for
separate reimbursement consideration. These physicians are
eligible for separate reimbursement consideration for the
following services, whether provided alone or in conjunction
with each other:
- The urinary catheter and its associated supplies that
are listed in this policy.
- The specific E&M appropriate to the level of service
code.
- The professional component for the insertion or
application of the catheter.
36
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
• Physicians contracted on a pre-paid (i.e., capitated) basis are
eligible for reimbursement consideration above the monthly
capitation allowance for the insertion or application of the
urinary catheters and the provision of associated supplies above
the monthly capitation allowance. However, reimbursement
for the E&M associated with the service is included in the
monthly capitation and, therefore, is not eligible for separate
reimbursement consideration.
Ostomy Supplies are Considered
Eligible for Reimbursement (05.00.50)
Urinary catheters and the associated supplies may be covered
under the Company’s durable medical equipment (DME) or
prosthetic benefit. The DME and prosthetic benefit vary by
product and/or group contract. Therefore, individual member
benefits must be verified.
The Company covers and considers for reimbursement ostomy
supplies as needed by the member when all of the following
criteria are met:
Originally published in Winter 2005 CGPU.
Online Evaluation and Management
Service is Not Considered Eligible for
Reimbursement (00.10.35)
An online medical evaluation is a type of evaluation and
management (E&M) service provided by a physician or
qualified health care professional to a member using only
Internet resources in response to a member’s online inquiry.
Ostomy supplies are categorized as prosthetic devices and are
used by individuals with a surgically created opening (stoma)
to divert urine, feces, or ileal contents outside of the body. They
can also be used for drainage of an abnormal opening or from a
malfunctioning organ (e.g., fistula).
• The member has the benefit for prosthetics.
• The ostomy supplies are supplied to replace all or part of an
absent body organ or the function of a permanently inoperative
or malfunctioning organ.
• The supplies are prescribed by an eligible health care provider.
• The supplies are supplied by an eligible ancillary provider.
The coverage and reimbursement for ostomy supplies vary by
product and/or group. Individual benefits must be verified.
Originally published in Summer 2005 CGPU.
The reportable services involve the physician’s timely response
to the individual’s inquiry and must involve permanent
storage (electronic or hard copy) of the encounter. The service
encompasses the sum of communication (e.g., related telephone
calls, prescription provision, laboratory orders) pertaining to the
online individual’s encounter or problem.
Physicians may incorporate secure web-based messaging services
or they may utilize vendors to facilitate online communication
with members.
The Company does not cover online E&M services. Since there
is no face-to-face (which implies in person) communication
between the physician and the individual, this service is not
eligible for reimbursement.
The appropriate code should be used for reporting this service.
It is inappropriate to use the unlisted E&M code or any other
E&M code to report this service. This service should not be
reported for member contact (e.g., related telephone calls)
considered to be pre-service or post-service work for other
E&M or non-E&M services.
Originally published in Summer 2005 CGPU.
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Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
37
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Photography Used for Documentation/
Record-Keeping Purposes is not
Considered a Distinct and Separate
Service from an Evaluation and
Management (E&M) Service or
Procedure (00.10.24a)
Clinical photographs (35-mm images, Polaroids, digital images,
and video recordings) used for documentation/record-keeping
purposes may be taken during a medical visit or procedure,
and stored in an individual’s medical record; however, the
photographs do not serve a specific medical diagnostic testing/
diagnostic decision-making purpose.
The Company does not consider taking photographs for
documentation/record-keeping purposes (including those
requested by the Company for medical necessity review) to
be a distinct and separate service from an evaluation and
management (E&M) service or procedure. The Company
considers photography to be an integral part of the E&M
service or procedure. Therefore, reimbursement for this service is
included in the E&M service or procedure.
Originally published in Fall 2005 CGPU.
Revision of a Previous Cosmetic
Procedure is Not Considered Eligible for
Reimbursement (11.00.01c)
A cosmetic procedure changes the appearance of a body part
without improving the physiological functioning of that body
part. Performing an additional procedure to improve, correct, or
further alter the appearance without improving the physiological
function is considered a revision of a cosmetic procedure.
C OM PE NDIUM
Treatment of Medical and Surgical
Complications is Considered Eligible for
Reimbursement Consideration for Acute
Conditions (11.00.02c)
A complication is an untoward event that occurs in the course of
another condition or during its treatment. Complications may be
of either medical or surgical origin, may modify the course of the
original condition, and may require revisions to the treatment
plan.
Treatment of medical and surgical complications including,
but not limited to, complications resulting from cosmetic
or other noncovered procedures, is covered and eligible for
reimbursement consideration by the Company for acute
conditions such as, but not limited to:
• Deep vein thrombosis (DVT).
• Hemorrhage.
• Infection.
• Myocardial infarction (MI).
• Wound dehiscence.
Following the onset of the complication, medical and/or surgical
treatment related to the complication is covered and eligible for
reimbursement consideration by the Company.
Outcomes following cosmetic procedures that have
unsatisfactory cosmetic results are not considered medical or
surgical complications and are not covered.
Originally published in Fall 2005 CGPU.
A procedure performed to revise the outcome of a previous
cosmetic procedure is considered cosmetic and, therefore, a
benefit contract exclusion. Therefore, this service is not covered.
Originally published in Summer 2005 CGPU.
38
2005 Compendium
Full versions of all policies, including all applicable codes, are available online at www.amerihealth.com/providers
2005 ARTICLES
www.amerihealth.com
TABLE OF CONTENTS
Extracorporeal Shock Wave Therapy (ESWT) for
Musculoskeletal Conditions and Plantar Fasciitis ................ 40
Claims with More Than One Unit of Time for
Speech-Pathology Codes Will Reject .................................. 40
Policy and Recommendations for the Use of Menactra®..... 40
Policy Update for DecavacTM .............................................. 41
ICD-9-CM Diagnosis Codes Change for Routine
Gynecological Exams ........................................................... 41
Policy Updates: Modifiers -26 and -TC ............................... 42
Class Action Settlement Update .......................................... 44
www.amerihealth.com
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2005 Articles
Extracorporeal Shock Wave Therapy
(ESWT) for Musculoskeletal Conditions
and Plantar Fasciitis
Effective March 1, 2005, Extracorporeal Shock Wave Therapy
(ESWT) for musculoskeletal conditions and plantar fasciitis will
no longer be a covered service for members of AmeriHealth.
This change is the result of AmeriHealth’s periodic review of
medical policy. As part of this periodic review, the Medical
Policy Department researches available clinical and scientific
information regarding services. As a result of this review process,
the medical policy addressing ESWT for musculoskeletal
conditions and plantar fasciitis has been updated to state that
this service is considered not medically necessary as of March 1,
2005, because the available, published literature does not support
the efficacy of this procedure as a useful aid in the treatment
of these conditions. AmeriHealth will not provide payment or
reimbursement on any claims for services performed for these
conditions on or after March 1, 2005.
Please note: For AmeriHealth 65® members, local Medicare
policy may allow coverage of this service for certain conditions
(New Jersey only).
This article originally appeared in the February 2005 Partners
in Health Update.
Claims With More Than One Unit of Time
for Speech-Pathology Codes Will Reject
Unless otherwise specified in the Current Procedural
Terminology (CPT)* descriptor, common speech-language
pathology codes represent a single evaluation or treatment
session. Therefore, it is inappropriate to report more than one
unit of time for any of the speech therapy codes, including
speech-pathology evaluation (92506), treatment session (92507),
or group treatment session (92508).
All claims submitted incorrectly with greater than one unit of
time for these codes and services will be subject to denial and/or
adjustment with recoupment of overpaid claims.
This article originally appeared in the April 2005 Partners in
Health Update.
Policy and Recommendations for the
Use of Menactra®
Menactra® (Menactra® Meningococcal [Groups A, C, Y, and
W-135] Polysaccharide Diphtheria Toxoid Conjugate Vaccine)
is covered for the prevention and control of meningococcal
disease in the following populations according to the
recommendations of the Advisory Committee on Immunization
Practices (ACIP) to the Centers for Disease Control and
Prevention (CDC):
• Children 11-12 years of age.
• Teens entering high school.
• College freshmen living in dormitories.
Background
On January 14, 2005, the US Food and Drug Administration
(FDA) approved a new meningococcal vaccine that may protect
adolescents and adults 11 to 55 years old against meningococcal
disease. Marketed as Menactra® Meningococcal (Groups A, C,
Y, and W-135) Polysaccharide Diphtheria Toxoid Conjugate
Vaccine, it is indicated for active immunization against the A, C,
Y, and W-135 serogroups of the bacteria Neisseria meningitides
that cause meningococcal disease. The safety and efficacy of
Menactra® have not been established in children younger than
11 years of age or in adults older than 55 years of age.
The vaccine is contraindicated in persons with known
hypersensitivity to any component of the vaccine or to latex,
which is used in the vial stopper. Because of the risk of
hemorrhage, Menactra® should not be given to persons with any
bleeding disorder or to persons on anticoagulant therapy unless
the potential benefit clearly outweighs the risk of administration.
Coding
The applicable Current Procedural Terminology (CPT)* code
for the new Menactra® vaccine is:
90734: Meningococcal conjugate vaccine, serogroups A, C, Y,
and W-135 (tetravalent), for intramuscular use.
This article originally appeared in the Summer 2005 Clinical
Update.
* Current Procedural Terminology (CPT®) is a copyright of the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related
listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark
of the American Medical Association.
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Policy Update for DecavacTM
On March 24, 2004, the U.S. Food and Drug Administration
(FDA) licensed Tetanus and Diphtheria Toxoids Adsorbed,
for adult use (Td vaccine).The vaccine, marketed under the
brand name Decavac™, is the first preservative-free tetanus and
diphtheria vaccine. Manufactured by Aventis Pasteur, Decavac™
has been available as of January 1, 2005, and is indicated for
active immunization of persons seven years of age and older for
the prevention of tetanus and diphtheria.
The Advisory Committee on Immunization Practices (ACIP)
recommends the use of Decavac™ for:
• Persons seven years of age and older who have not been
immunized previously against tetanus and diphtheria as a
primary immunization series of three 0.5 mL doses.
• Use as a routine booster every ten years throughout life for
persons seven years of age and older who have received a
primary series of tetanus and diphtheria-containing vaccines.
• Wound care in persons who have not received a tetanus
toxoid-containing preparation within the preceding five years.
Decavac™ is covered according to these ACIP
recommendations for the prevention and control of tetanus
and diphtheria when any of the above-listed criteria are
met. Decavac™ should not be used as a routine pediatric
immunization for children under seven years of age.
To report Decavac™ for dates of service prior to July 1, 2005,
the following Current Procedural Terminology (CPT) code
should be used:
90749: Unlisted vaccine/toxoid.
When using this code, submit the appropriate NDC number,
49281-291-10, on the claim form.
To report Decavac™ for dates of service on or after July 1,
2005, the following CPT code should be used:
90714: Tetanus and Diphtheria Toxoids Adsorbed, for adult use
(Td), preservative-free, for use in individuals seven years or older,
for intramuscular use.
www.amerihealth.com
To report the standard Td vaccine containing preservatives,
the following CPT* code should continue to be used:
90718: Tetanus and diphtheria toxoids (Td) adsorbed, for use in
individuals seven years or older, for intramuscular use.
This article originally appeared in the Summer 2005 Clinical
Update.
ICD-9-CM Diagnosis Codes Change for
Routine Gynecological Exams
Effective January 1, 2006, capitated PCPs billing for routine
gynecological exams should report diagnosis code V72.31 with
the applicable preventive evaluation and management Current
Procedural Terminology (CPT)* codes 99384-99387 and
99394-99397 or the Healthcare Common Procedure Coding
System (HCPCS) codes S0610 and S0612 for reimbursement
consideration.
Routine gynecological exams reported with ICD-9-CM code
V72.32 for the CPT codes 99384-99387 and 99394-99397 are
no longer eligible for additional payment outside the standard
capitation amount. HCPCS codes S0610 and S0612 may still be
reported with ICD-9-CM code V72.32 when appropriate.
For reference, the diagnosis code narratives are as follows:
• V72.31: Routine gynecological examination.
• V72.32: Encounter for Papanicolaou cervical smear to confirm
findings of a recent normal smear following initial abnormal
smear.
Important reminder: As previously communicated, effective
October 1, 2004, we require all practitioners to report diagnosis
codes to the highest degree of specificity, according to the
ICD-9-CM Coding Manual. If you have questions, please call
Provider Services or your Network Coordinator.
This article originally appeared in the December 2005 Partners
in Health Update.
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Policy Updates: Modifiers -26 and -TC
As part of AmeriHealth’s continued effort to assist providers in
the proper billing of procedures, reduction of billing errors, and
alignment of claims processing policies with national standards,
AmeriHealth is applying the Medicare Physician Fee Schedule
Database Professional Component/Technical Component
(PC/TC) Payment Indicators methodology. The Medicare
payment methodology defines the appropriate and inappropriate
reporting of Modifiers -26 and -TC and will apply to all
professional claims for all AmeriHealth products for CMS 1500
and electronic physician provider claims only.
Claims submitted using Modifier -26 and -TC with procedure
codes, other than those defined by Medicare, will result in
rejection of services. For more information, please visit the
Medicare web site: www.cms.gov.*
Although Medicare does not recognize the “S” HCPCS
procedure codes, AmeriHealth will continue to accept these
procedure codes for claims processing. However, the Modifiers
-26 and -TC will not be accepted for the “S” HCPCS
procedure codes.
Modifier -26 (Professional Component) is used to denote
the portion of the procedure or service performed by a physician,
which includes the interpretation, analysis, and a detailed, signed
and written report of the procedure or service results. Certain
procedures are a combination of a physician component and a
technical component. For procedures with both a technical and
professional component, Modifier -26 is used to indicate that
the professional component of the procedure is being reported
separately. Modifier -26 is required for a facility setting.
C OM PE NDIUM
Modifier -TC (Technical Component) is used to denote the
portion of the procedure or service performed by a technician
or other non-physician personnel and the equipment used
for the procedure or service. This service does not involve any
direct physician care. The technical component includes the
equipment, supplies, technical personnel, and cost attendant to
performing the procedure other than those associated with the
physician component.
Modifier -TC is used to indicate the technical component.
Technical component services should not be reported by
physicians in a hospital/facility setting. Inappropriate submission
will result in the rejection of services. The rejection of services
message will read: “Procedure code cannot be reported in this
place of service.”
It is not appropriate to report Modifiers -26 or -TC in
circumstances when a more appropriate modifier exists to report
the service, or use of Modifier -26 and -TC will result in a
rejection of services. Please refer to the following grid for more
specific information. The rejection of services message will read:
“Invalid procedure code/modifier combination.”
*These websites are maintained by organizations over which AmeriHealth exercises no
control. Accordingly, AmeriHealth expressly disclaims any responsibility for the content,
the accuracy of the information, and/or quality of the products or services provided by
or advertised in these third-party sites. Certain services/treatments referred to in other
sites may not be covered under specific benefit plans. Please refer to benefit contracts for
complete details of the terms, limitations, and exclusions of coverage.
Modifier -26 is a reporting requirement for professional services
rendered in a hospital/facility setting with the applicable
indicators as identified in the following grid. The absence of
Modifier -26 will result in a rejection of services. The rejection
of services message will read: “Modifier -26 required in this
place of service.”
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Use Modifier
-26
Use Modifier
-TC
(0) Physician Codes: Indicator identifies codes that describe physician services. Examples
include visits, consultations, and surgical procedures.
Note: The concept of PC/TC does not apply since physician services cannot be split into
professional and technical components.
No
No
(1) Diagnostic Test for Radiology Services: Indicator identifies codes that describe diagnostic
tests or therapeutic radiology procedures. These codes generally have both a professional
and technical component.
Note:
• Modifier -26 must be reported for physician services rendered in a facility/hospital setting.
• Technical component services should not be reported by physicians in a hospital/facility setting.
• Modifier -TC can be reported in non-facility/hospital setting as appropriate.**
Yes
No**
(2) Professional Component-Only Codes: Indicator identifies stand-alone codes that describe
the physician work portion of selected diagnostic tests for which there is an associated
code that describes the technical component of the diagnostic test only and another
associated code that describes the global test.
No
No
(3) Technical Component-Only Codes: Indicator identifies stand-alone codes that describe the
technical component of selected diagnostic tests for which there is an associated code that
describes the professional component of the diagnostic tests only.
Note: Technical Component-Only Codes should not be reported by physicians in a facility/
hospital setting.
No
No
(4) Global Test-Only Codes: Indicator identifies stand-alone codes for which there are
associated codes that describe: a) the professional component of the test only and b) the
technical component of the test only.
No
No
(5) Incident-To Codes: Indicator identifies codes that describe services incident to a physician’s
services.
No
No
(6) Laboratory Physician Interpretation: Indicator identifies clinical laboratory codes for which
separate payment for interpretations by laboratory physicians may be made.
Note: Modifier 26 must be reported for physician services rendered in a facility/
hospital setting.
Yes
No
(7) Physical Therapy Codes
No
No
(8) Physician Interpretation Codes: Indicator identifies the professional component of clinical
laboratory codes for which separate payment may be made only if the physician
interprets an abnormal smear for hospital inpatient.
No
No
(9) Concept of a professional/technical component does not apply
No
No
Medicare PC/TC Payment Indicator and Definition
This article originally appeared in the July 2005 Partners in Health Update.
www.amerihealth.com
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Class Action Settlement Update
Enhancements to Policy, Payment,
Disclosure and Appeals Process for
Class-Action Settlement Providers
The court-approved class action settlement between
AmeriHealth and providers, who agreed to the terms of the
class-action settlement (Settlement Providers), includes the
following enhancements:
• Improving disclosure to Settlement Providers, including
standard fee schedules, changes to schedules, and medical and
payment policies that may affect payment/reimbursement of
services which will be made available online via NaviNetSM,
our secure provider portal.
• Changing claims processing for Settlement Providers on the
following: selected modifiers (-RT, -LT, -25, -50, -51, -59,
-62, -66, -80, -81, -82); multiple surgical procedures; radiologic
guidance during a procedure; and certain CPT code-level
designations (Modifier -51 exempt, Separate Procedure, and
Add-on codes).
• Introducing a new, two-level, formal claims appeal process for
Settlement Providers.
• Certain of these enhancements are currently available. Others
will be available during the course of this year and will be
announced as they become available.
Claim Payment Policy Note
These policies, in whole or in part, are part of the class-action
settlement with providers. Please note that providers that
opted out of the class action settlement may not be entitled to
certain claim payment policy changes. Therefore, any payments
made pursuant to such policy changes to providers who opted
out of the class-action settlement are subject to retroactive
adjustments. The inclusion of a code/modifier in this policy
does not imply reimbursement. Eligibility, benefits, limitations,
exclusions, precertification/referral requirements, provider
contracts, and policy still apply.
Modifier -25 [Significant Separately
Identifiable Evaluation and Management
(E&M) by the Same Physician on the
Same Day of the Procedure or
Other Service]
Modifier -25 (as defined by the American Medical Association
[AMA]; Current Procedural Terminology [CPT]) is used to
denote a significant, separately identifiable Evaluation and
Management (E&M) service by the same physician on the
same day of the procedure or other service. On the day of a
minor surgical procedure (zero- or 10-day global period) the
physician may need to indicate that the patient’s condition
required a significant, separately identifiable E&M service
above and beyond the other service provided or beyond the
usual preoperative and postoperative care associated with the
procedure that was performed. The E&M procedure may be
prompted by the symptom or condition for which the procedure
and/or service was provided. As such, different diagnoses are not
required for reporting the E&M services on the same date.
The physician should maintain supportive documentation in the
patient’s medical records indicating that a separate and distinct
medical condition was treated on the same day that a procedure
was performed. This distinction may be reported by adding
Modifier -25 to the appropriate level of E&M service.
It is not appropriate to report Modifier -25 in the following
circumstances because either a more appropriate modifier exists
to report the service or use of Modifier -25 as described above is
not applicable to the reported service:
• Appended to an E&M service that resulted in the decision to
perform major surgery (90-day global period).
• When a physician performs ventilation management in
addition to an E&M service.
• When an E&M service is performed on a different day than
the procedure.
• Appended to a surgical procedure code since this modifier is
used to explain the special circumstance of providing the E&M
service on the same day as a procedure.
• When the patient’s trip to the office was strictly for the minor
procedure since reimbursement for the procedure includes the
related pre-service work.
This article originally appeared in the April 2005 Partners in
Health Update.
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Modifiers -RT [Right Side] and -LT
[Left Side]
Modifiers -RT and -LT (as defined by the Centers for Medicare
and Medicaid Services [CMS] Healthcare Common Procedure
Coding System [HCPCS]) are used to denote the side of the
body (right or left) where a service is performed when that
service has the potential to be performed on one or both sides.
The Modifiers -RT and -LT are appropriately appended to
Current Procedural Terminology (CPT) or HCPCS codes that
identify procedures that can be performed on paired organs, e.g.,
arms, ears, eyes, nostrils, kidneys, lungs, and ovaries.
• When two or more physicians each perform distinctly
different, unrelated procedures on the same patient on the
same day.
This article originally appeared in the April 2005 Partners in
Health Update.
Clear Claim Connection™
This article originally appeared in the April 2005 Partners in
Health Update.
In an effort to facilitate increased provider access to payment
rules, AmeriHealth expanded its procedure code inquiry and
disclosure capabilities by offering McKesson’s Clear Claim
Connection™. AmeriHealth currently uses McKesson’s
ClaimCheck® product for clinical relationship logic. Clinical
relationship logic identifies procedure codes that are clinically
inappropriate to be submitted together. Designed to clarify
the claims adjudication outcomes specific to procedure code
relationship logic, Clear Claim Connection™ will supplement
the ClaimCheck® system and aid practices by:
Modifier -51 [Multiple Procedures]
• Decreasing your practice’s time spent researching claims
denials due to inappropriate procedure code combinations.
It is not appropriate to append Modifiers -RT and -LT to
a procedure that is identified in its narrative description as a
bilateral service.
Modifier -51 (as defined by the American Medical Association
[AMA] Current Procedural Terminology [CPT]) is used to
denote when multiple procedures—other than evaluation and
management services—are performed at the same session by the
same provider for the same patient. The primary procedure or
service may be reported as listed and the additional procedure(s)
or service(s) may be identified by appending Modifier -51.
It is appropriate to report Modifier -51 to identify the secondary
procedure or when multiple procedures are performed during
a single operative session regardless of whether the procedures
were through the same incision or performed at a different
anatomical site.
It is not appropriate to report Modifier -51 in the following
circumstances:
• When a procedure code is designated by CPT as an “add-on”
code. Add-on codes are always performed in addition to the
primary procedure and cannot be performed alone.
• When a procedure code is designated by CPT as Modifier -51
exempt.
• When a procedure is considered a component or incidental to
a primary procedure. Any intra-operative services, incidental
surgeries, or components of major surgeries are not separately
billable.
www.amerihealth.com
• Providing easy access to rationales for procedure codes that are
clinically inappropriate to be submitted together.
• Assisting providers in reporting appropriate procedure code
combinations.
This tool is available to Settlement Providers.
This article originally appeared in the October 2005 Partners
in Health Update.
Modifier -50 [Bilateral Procedure]
Modifier -50 is used to denote bilateral procedures, that is
procedures performed on identical sites, aspects, or organs
on both sides of the body during the same operative session
or on the same day. The Centers for Medicare & Medicaid
Services (CMS) has defined codes that are subject to the
bilateral payment rule, i.e., reimbursement at 150 percent of
the fee schedule allowance, which accounts for multiple surgery
adjustments when bilateral surgical procedures are performed.
However, please note that bilateral surgical procedures
performed in conjunction with other surgical procedures may
still be subject to multiple surgery reduction guidelines.
Certain other procedures are not subject to the 150 percent
bilateral payment rule but may still be performed bilaterally.
Payment for these procedures is based on 100 percent of the
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fee schedule allowance for each side, as these are typically
non surgical in nature and would, therefore, not be subject
to multiple surgery adjustment when performed bilaterally.
Reimbursement consideration for services reported with
Modifier -50 is contingent upon eligibility, benefits, exclusions,
precertification/referral requirements, provider contracts and
applicable policies. Since a code appended with Modifier -50
already describes a bilateral service, it is not appropriate to report
multiple units in the units field on the claim. Claims reporting
services with Modifier -50 and more than one (1) unit will be
denied by the Company stating “Multiple units not appropriate
with Modifier -50.”
CMS utilizes a payment methodology by applying bilateral
payment indicators to procedure codes that, when submitted in
combination with Modifier -50, will allow or restrict payment
consideration. The table below identifies and describes each
indicator:
C OM PE NDIUM
It is inappropriate to report codes containing the term
“unilateral” with Modifier -50 if a similar code identified as
“bilateral” already exists. Claims billed for such procedures with
Modifier -50 are subject to rejection of services stating “Invalid
procedure/modifier code combination.”
It is inappropriate to report codes containing the terms
“bilateral” or “unilateral or bilateral” with Modifier -50 because
the narrative already identifies the service as being bilateral
and payment has been pre-calculated to account for additional
services performed. Claims billed for such procedures with
Modifier -50 are subject to rejection of services stating “Invalid
procedure/modifier code combination.”
The following is a link to the Medicare website: www.cms.gov. These sites are
maintained by organizations over which AmeriHealth exercises no control. Accordingly,
AmeriHealth expressly disclaims any responsibility for the content, the accuracy of the
information, and/or quality of the products or services provided by or advertised in
these third-party sites. Certain services/treatments referred to in other sites may not be
covered under specific benefit plans. Please refer to benefit contracts for complete details
of the terms, limitations, and exclusions of coverage.
This article originally appeared in the October 2005 Partners
in Health Update.
CMS Indicator & Description
(0) Bilateral payment is inappropriate because of:
(a) physiology or anatomy or (b) the code descriptor
indicates unilateral and another code for bilateral already
exists; 150-percent payment adjustment does not apply.
(1) Bilateral payment is appropriate. If the code is billed with
the bilateral Modifier -50, payment will be based on 150
percent of the fee schedule amount for a single procedure
as defined by the CMS bilateral payment rule.
(2) Bilateral payment is inappropriate because:
(a) the code descriptor specifically states bilateral; (b) the
code descriptor states procedure may be performed either
unilaterally or bilaterally; or (c) the procedure is usually
performed as a bilateral procedure; 150 percent payment
adjustment does not apply.
Outcome for code/Modifier -50 combination
Invalid procedure code/modifier combination.
Eligible for 150-percent reimbursement consideration.
Eligibility, benefits, exclusions, precertification/referral
requirements, provider contracts, and applicable policies still
apply.
Invalid procedure code/modifier combination.
(3) Bilateral payment is appropriate. If the code is billed with
the bilateral Modifier -50, payment will be based on 100
percent of the fee schedule for each procedure performed
as these are not subject to the bilateral payment rule but
may be performed bilaterally.
Eligible for 200 percent reimbursement consideration.
Eligibility, benefits, exclusions, precertification/referral
requirements, provider contracts, and applicable policies still
apply.
(9) Concept does not apply.
Invalid procedure/modifier code combination.
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Radiologic Guidance of a Procedure
Modifier -51 Exempt
AmeriHealth revised the reimbursement methodologies applied
to claims processing of radiologic guidance and/or supervision
and interpretation of a procedure. Radiologic guidance and/or
supervision and interpretation is performed by either the same
professional provider who performs the surgical procedure or a
different professional provider.
Recently, AmeriHealth revised the reimbursement
methodologies regarding procedure codes that are exempt
from being reported with Modifier -51 (multiple procedures).
Modifier -51 is used when multiple procedures other than
evaluation and management (E&M) services are performed at
the same session by the same provider. Surgical services reported
with modifier -51 are subject to multiple surgical reduction
guidelines.
Radiologic guidance and/or supervision and interpretation of
a procedure that is performed in conjunction with a covered
procedure is eligible for separate reimbursement consideration
by AmeriHealth.
When the same provider performs and reports both the
radiologic and the diagnostic or therapeutic procedures, both
procedures are eligible for reimbursement consideration to the
provider. However, all of the following requirements must be
met:
• Both the radiologic guidance and/or supervision and
interpretation service and the procedure for which it is
performed must be covered for the radiologic guidance and/
or supervision and interpretation to be eligible for separate
reimbursement consideration.
•Documentation in the medical record must reflect the
radiologic guidance and/or supervision and interpretation
procedure(s) performed by the physician. The medical record
must be available to AmeriHealth upon request.
Providers should not submit medical records to AmeriHealth
unless otherwise requested.
This information supersedes the information in the policy
addressing Interventional Radiology.
This article appeared in the December 2005 Partners in Health
Update.
As defined by the American Medical Association (AMA),
Current Procedural Terminology (CPT), Modifier -51 exempt
codes are procedure codes that are exempt or free from being
reported with Modifier -51 because reduction of the work
values has already been accommodated and reflected in the
reimbursement. Multiple surgery reduction logic is not applied
to Modifier -51 exempt procedure codes.
Modifier -51 Exempt codes:
• Should not be reported with Modifier -51 and
• Should not have multiple surgery reduction logic applied when
the Modifier -51 exempt procedure codes are eligible and
reported with other surgical services.
This article appeared in the December 2005 Partners in Health
Update.
Surgical Team Modifier -66
Beginning in January 2006, AmeriHealth will enhance its
processing system to apply the Centers for Medicare &
Medicaid Services (CMS) payment methodology for Surgical
Team Modifier -66 as outlined in its Medicare Physician Fee
Schedule Database found on the CMS website.**
Surgical team Modifier -66 is used to denote a procedure that
requires a team of surgeons (more than two surgeons of different
specialties) to perform various portions of a complicated surgical
procedure. Each surgeon participating in the team surgery is
a member of the surgical team. Participation in team surgery
by a surgeon performing a surgical procedure is indicated by
appending Modifier -66 to the procedure code for that service.
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Prior to adjudication, reimbursement consideration for services
reported with Modifier -66 will be reviewed for medical
necessity and documentation completion. All team surgery
claims require the submission of a completed surgical team
documentation form. When the required documentation is
unavailable or incomplete, claims will be denied.
C OM PE NDIUM
contingent upon eligibility, benefits, exclusions, precertification/
referral requirements, provider contracts, and applicable policies.
CMS utilizes a payment methodology for these types of services
by applying team surgery indicators to procedure codes that,
when submitted in combination with Modifier -66, will allow or
restrict payment consideration:
The table below identifies and describes the processing outcome
associated with each indicator. However, reimbursement is also
CMS Indicator & Description
Outcome for code/modifier -66 combination
(0) Team surgery payment is inappropriate.
Ineligible for team surgery reimbursement consideration.
(1) Team surgery payment is inappropriate unless supporting
documentation establishes medical necessity.
Reimbursement consideration determined upon
receipt and review of medical necessity and supporting
documentation.
(2) Team surgery payment is appropriate.
(9) Concept does not apply.
When determined as eligible by AmeriHealth for surgical team
services, multiple surgical procedures reported by each surgeon
are subject to multiple surgery reduction guidelines.
Medical records, operative reports, the surgical team
documentation form and/or other supporting documentation
should be submitted at the time of claim submission to the
mailing address shown on the surgical team documentation
form.
48
Reimbursement consideration determined upon
receipt and review of medical necessity and supporting
documentation.
Invalid procedure/modifier code combination.
** The following is a link to the Medicare website: www.cms.gov. These sites are
maintained by organizations over which AmeriHealth exercises no control, and
accordingly, AmeriHealth expressly disclaims any responsibility for the content, the
accuracy of the information, and/or quality of the products or services provided by or
advertised in these third-party sites. Certain services/treatments referred to in other
sites may not be covered under specific benefit plans. Please refer to benefit contracts
for complete details of the terms, limitations, and exclusions of coverage.
This article appeared in the December 2005 Partners in Health
Update.
2005 Compendium
MEDICAL CODE UPDATES
www.amerihealth.com
TABLE OF CONTENTS
CPT Codes .......................................................................... 50
HCPCS Codes..................................................................... 77
ICD-9 Codes ..................................................................... 120
As part of the medical/claim payment policy process, the AmeriHealth Procedure Code Review Unit supports medical code
activities. It establishes and maintains the development and documentation of coverage positions for ICD-9, CPT*, and HCPCS
medical codes across all lines of business and all processing systems.
The following pages detail the new/revised ICD-9, CPT, and HCPCS code updates effective as follows,
unless otherwise specified:
ICD-9: Additions and Revisions have an effective date of 10/1/2005. Deletions have a delete date of 10/1/2005.
CPT: Additions and Revisions have an effective date of 1/1/2006. Deletions have a delete date of 1/1/2006.
HCPCS: Additions and Revisions have an effective date of 1/1/2006. Deletions have a delete date of 1/1/2006.
Please note that the listing of a code in this Compendium does not necessarily indicate that it is a covered procedure.
Current Procedural Terminology (CPT®) is a copyright of the American Medical Association (AMA). All Rights Reserved. No fee
schedules, basic units, relative values, or related listings are included in the CPT. The AMA assumes no liability for the data contained
herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the AMA.
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
01965
Anesthesia for incomplete or missed abortion
procedures
1/1/2006
A
01966
Anesthesia for induced abortion procedures
1/1/2006
A
15040
Harvest of skin for tissue cultured skin autograft, 100sq cm
or less
1/1/2006
A
15110
Epidermal autograft, trunk, arms, legs; first 100 sq cm or
less, or one percent of body area of infants and children
1/1/2006
A
15111
Epidermal autograft, trunk, arms, legs; each additional
100 sq cm, or each additional one percent of body area
of infants and children, or part thereof (List separately in
addition to code for primary procedure)
1/1/2006
A
15115
Epidermal autograft, face, scalp, eyelids, mouth, neck, ears,
orbits, genitalia, hands, feet, and/or multiple digits; first 100
sq cm or less, or one percent of body area of infants and
children
1/1/2006
A
15116
Epidermal autograft, face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits;
each additional 100 sq cm, or each additional one percent
of body area of infants and children, or part thereof (List
separately in addition to code for primary procedure)
1/1/2006
A
15130
Dermal autograft, trunk, arms, legs: first 100 sq cm or less,
or one percent of body area of infants and children
1/1/2006
A
15131
Dermal autograft, trunk, arms, legs; each additional 100 sq
cm, or each additional one percent of body area of infants
and children, or part thereof (List separately in addition to
code for primary procedure)
1/1/2006
A
15135
Dermal autograft, face, scalp, eyelids, mouth, neck, ears,
orbits, genitalia, hands, feet, and/or multiple digits; first 100
sq cm or less, or one percent of body area of infants and
children
1/1/2006
A
15136
Dermal autograft, face, scalp, eyelids, mouth, neck, ears,
orbits, genitalia, hands, feet, and/or multiple digits; each
additional 100 sq cm, or each additional one percent
of body area of infants and children, or part thereof (List
separately in addition to code for primary procedure)
1/1/2006
A
15150
Tissue cultured epidermal autograft, trunk, arms, legs; first 25
sq cm or less
1/1/2006
A
15151
Tissue cultured epidermal autograft, trunk, arms, legs;
additional 1 sq cm to 75 sq cm (List separately in addition to
code for primary procedure)
1/1/2006
A
15152
Tissue cultured epidermal autograft, trunk, arms, legs; each
additional 100 sq cm, or each additional one percent
of body area of infants and children, or part thereof (List
separately in addition to code for primary procedure)
1/1/2006
A
15155
Tissue cultured epidermal autograft, face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or
multiple digits; first 25 sq cm or less
1/1/2006
A
15156
Tissue cultured epidermal autograft, face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or
multiple digits; additional 1 sq cm, to 75 sq cm (List
separately in addition to code for primary procedure)
1/1/2006
Delete Date
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
15157
Tissue cultured epidermal autograft, face, scalp, eyelids,
mouth, neck, ears, orbits, genitalia, hands, feet, and/or
multiple digits; each additional 100 sq cm, or each
additional one percent of body area of infants and children,
or part thereof (List separately in addition to code for
primary procedure)
1/1/2006
A
15170
Acellular dermal replacement, trunk, arms, legs; first 100
sq cm or less, or one percent of body area of infants and
children
1/1/2006
A
15171
Acellular dermal replacement, trunk, arms, legs; each
additional 100 sq cm, or each additional one percent
of body area of infants and children, or part thereof (List
separately in addition to code for primary procedure)
1/1/2006
A
15175
Acellular dermal replacement, face, scalp, eyelids, mouth,
neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits; first 100 sq cm or less, or one percent of body area of
infants and children
1/1/2006
A
15176
Acellular dermal replacement, face, scalp, eyelids, mouth,
neck, ears, orbits, genitalia, hands, feet, and/or multiple
digits; each additional 100 sq cm, or each additional one
percent of body area of infants and children, or part thereof
(List separately in addition to code for primary procedure)
1/1/2006
A
15300
Allograft skin for temporary wound closure, trunk, arms,
legs; first 100 sq cm or less, or one percent of body area of
infants and children
1/1/2006
A
15301
Allograft skin for temporary wound closure, trunk, arms, legs;
each additional 100 sq cm, or each additional one percent
of body area of infants and children, or part thereof (List
separately in addition to code for primary procedure)
1/1/2006
A
15320
Allograft skin for temporary wound closure, face, scalp,
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet,
and/or multiple digits; first 100 sq cm or less, or one percent
of body area of infants and children
1/1/2006
A
15321
Allograft skin for temporary wound closure, face, scalp,
eyelids, mouth, neck, ears, orbits, genitalia, hands, feet,
and/or multiple digits; each additional 100 sq cm, or each
additional one percent of body area of infants and children,
or part thereof (List separately in addition to code for
primary procedure)
1/1/2006
A
15330
Acellular dermal allograft, trunk, arms, legs; first 100 sq cm
or less, or one percent of body area of infants and children
1/1/2006
A
15331
Acellular dermal allograft, trunk, arms, legs; each additional
100 sq cm, or each additional one percent of body area
of infants and children, or part thereof (List separately in
addition to code for primary procedure)
1/1/2006
A
15335
Acellular dermal allograft, face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits;
first 100 sq cm or less, or one percent of body are of infants
and children
1/1/2006
A
15336
Acellular dermal allograft, face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits;
each additional 100sq cm, or each additional one percent
of body area of infants and children, or part thereof, (List
separately in addition to code for primary procedure)
1/1/2006
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Action
A=Addition
D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
15340
Tissue cultured allogenic skin substitute; first 25 sq cm or less
1/1/2006
A
15341
Tissue cultured allogenic skin substitute; each additional 25
sq cm
1/1/2006
A
15360
Tissue cultured allogeneic dermal substitute; trunk, arms,
legs; first 100 sq cm or less, or one percent of body area of
infants and children
1/1/2006
A
15361
Tissue cultured allogeneic dermal substitute; each additional
100 sq cm, or each additional one percent of body area
of infants and children, or part thereof (List separately in
addition to code for primary procedure)
1/1/2006
A
15365
Tissue cultured allogeneic dermal substitute, face, scalp,
eyelids, mouth, neck, ears, orbits, genitalia, hands feet,
and/or multiple digits; first 100 sq cm or less, or one percent
of body area of infants and children
1/1/2006
A
15366
Tissue cultured allogeneic dermal substitute, face, scalp,
eyelids, mouth, neck, ears, orbits, genitalia, hands feet,
and/or multiple digits; each additional 100 sq cm, or each
additional one percent of body area of infants and children,
or part thereof (List separately in addition to code for
primary procedure)
1/1/2006
A
15420
Xenograft skin (dermal), for temporary wound closure, face,
scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands,
feet, and/or multiple digits; first 100 sq cm or less or one
percent of body area of infants and children
1/1/2006
A
15421
Xenograft skin (dermal), for temporary wound closure, face,
scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands,
feet, and/or multiple digits; each additional 100 sq cm, or
each additional one percent of body area of infants and
children, or part thereof (List separately in addition to code
for primary procedure)
1/1/2006
A
15430
Acellular xenograft implant; first 100 sq cm or less, or one
percent of body area of infants and children
1/1/2006
A
15431
Acellular xenograft implant; each additional 100 sq cm, or
each additional one percent of body area of infants and
children, or part thereof (List separately in addition to code
for primary procedure)
1/1/2006
A
22010
Incision and drainage, open, of deep abscess (subfascial),
posterior spine; cervical, thoracic, or cerviocothoracic
1/1/2006
A
22015
Incision and drainage, open, of deep abscess (subfascial),
posterior spine; lumbar, sacral, or lumbosacral
1/1/2006
A
22523
Percutaneous vertebral augmentation, including cavity
creation (fracture reduction and bone biopsy include when
performed) using mechanical device, one vertebral body,
unilateral or bilateral cannulation
(e.g., kyphoplasty); thoracic
1/1/2006
A
22524
Percutaneous vertebral augmentation, including cavity
creation (fracture reduction and bone biopsy include when
performed) using mechanical device, one
vertebral body, unilateral or bilateral cannulation
(e.g., kyphoplasty); lumbar
1/1/2006
Delete Date
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
22525
Percutaneous vertebral augmentation, including cavity
creation (fracture reduction and bone biopsy include when
performed) using mechanical device, one vertebral body,
unilateral or bilateral cannulation (e.g., kyphoplasty); each
additional thoracic or lumbar vertebral body (List separately
in addition to code for primary procedure)
1/1/2006
A
28890
Extracorporeal shock wave, high energy, performed by a
physician, requiring anesthesia other than local, including
ultrasound guidance, involving the plantar fascia
1/1/2006
A
32503
Resection of apical lung tumor (Pancoast tumor), including
chest wall resection, rib(s) resection(s), neurovascular
dissection, when performed; without chest wall
reconstruction(s)
1/1/2006
A
32504
Resection of apical lung tumor (Pancoast tumor), including
chest wall resection, rib(s) resection(s), neurovascular
dissection, when performed; with chest wall reconstruction
1/1/2006
A
33507
Repair of anomalous (e.g., intramural) aortic origin of
coronary artery by unroofing or translocation
1/1/2006
A
33548
Surgical ventricular restoration procedure, includes prosthetic
patch, when performed (e.g., ventricular remodeling, SVR,
SAVER, DOR procedures)
1/1/2006
A
33768
Anastomosis, cavopulmonary, second superior vena cava
(List separately in addition to primary procedure)
1/1/2006
A
33880
Endovascular repair of descending thoracic aorta (e.g.,
aneurysm, pseudoaneurysm, dissection, penetrating
ulcer, intramural hematoma, or traumatic disruption);
involving coverage of left subclavian artery origin, initial
endoprosthesis plus descending thoracic aortic extension(s),
if required, to level of celiac artery origin
1/1/2006
A
33881
Endovascular repair of descending thoracic aorta (e.g.,
aneurysm, pseudoaneurysm, dissection, penetrating
ulcer, intramural hematoma, or traumatic disruption); not
involving coverage of left subclavian artery origin, initial
endoprosthesis plus descending thoracic aortic extension(s),
if required, to level of celiac artery origin
1/1/2006
A
33883
Placement of proximal extension prosthesis for endovascular
repair of descending thoracic aorta (e.g., aneurysm,
pseudoaneurysm, dissection, penetrating ulcer, intramural
hematoma, or traumatic disruption); initial extension
1/1/2006
A
33884
Placement of proximal extension prosthesis for endovascular
repair of descending thoracic aorta (e.g., aneurysm,
pseudoaneurysm, dissection, penetrating ulcer, intramural
hematoma, or traumatic disruption); each additional
proximal extension (List separately in addition to code for
primary procedure)
1/1/2006
A
33886
Placement of distal extension prosthesis(s) delayed after
endovascular repair of descending thoracic aorta
1/1/2006
A
33889
Open subclavian to carotid artery transposition performed in
conjunction with endovascular repair of descending thoracic
aorta, by neck incision, unilateral
1/1/2006
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
33891
Bypass graft, with other than vein, transcervical
retropharyngeal carotid-carotid, performed in conjunction
with endovascular repair of descending thoracic aorta, by
neck incision
1/1/2006
A
33925
Repair of pulmonary artery arborization anomalies by
unifocalization; without cardiopulmonary bypass
1/1/2006
A
33926
Repair of pulmonary artery arborization anomalies by
unifocalization; with cardiopulmonary bypass
1/1/2006
A
36598
Contrast injection(s) for radiologic evaluation of existing
central venous access device, including fluoroscopy, image
documentation and report
1/1/2006
A
37184
Primary percutaneous transluminal mechanical
thrombectomy, noncoronary, arterial or arterial bypass
graft, including fluoroscopic guidance and intraprocedural
pharmacological thrombolytic injection(s); initial vessel
1/1/2006
A
37185
Primary percutaneous transluminal mechanical
thrombectomy, noncoronary, arterial or arterial bypass
graft, including fluoroscopic guidance and intraprocedural
pharmacological thrombolytic injection(s); second and all
subsequent vessel(s) within the same vascular family (List
separately in addition to code for primary mechanical
thrombectomy procedure)
1/1/2006
A
37186
Secondary percutaneous transluminal thrombectomy (e.g.,
nonprimary mechanical, snare basket, suction technique),
noncoronary, arterial or arterial bypass graft, including
fluoroscopic guidance and intraprocedural pharmacological
thrombolytic injections, provided in conjunction with another
percutaneous intervention other than primary mechanical
thrombectomy (List separately in addition to code for primary
procedure)
1/1/2006
A
37187
Percutaneous transluminal mechanical thrombectomy, vein(s),
including intraprocedural pharmacological thrombolytic
injections and fluoroscopic guidance
1/1/2006
A
37188
Percutaneous transluminal mechanical thrombectomy, vein(s),
including intraprocedural pharmacological thrombolytic
injections and fluoroscopic guidance, repeat treatment on
subsequent day during course of thrombolytic therapy
1/1/2006
A
37718
Ligation, division, and stripping, short saphenous vein
1/1/2006
A
37722
Ligation, division and stripping, long (greater) saphenous
veins from saphenofemoral junction to knee or below
1/1/2006
A
43770
Laparoscopy, surgical, gastric restrictive procedure;
placement of adjustable gastric band (gastric band
and subcutaneous port components)
1/1/2006
A
43771
Laparoscopy, surgical, gastric restrictive procedure; revision
of adjustable gastric band component only
1/1/2006
A
43772
Laparoscopy, surgical, gastric restrictive procedure; removal
of adjustable gastric band component only
1/1/2006
A
43773
Laparoscopy, surgical, gastric restrictive procedure; removal
and replacement of adjustable gastric band component only
1/1/2006
A
43774
Laparoscopy, surgical, gastric restrictive procedure;
removal of adjustable gastric band and subcutaneous port
components
1/1/2006
Delete Date
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
43886
Gastric restrictive procedure, open; revision of subcutaneous
port component only
1/1/2006
A
43887
Gastric restrictive procedure, open; removal of subcutaneous
port component only
1/1/2006
A
43888
Gastric restrictive procedure, open; removal and
replacement of subcutaneous port component only
1/1/2006
A
44180
Laparoscopy, surgical, enterolysis (freeing of intestinal
adhesion) (separate procedure)
1/1/2006
A
44186
Laparoscopy, surgical; jejunostomy
(e.g., for decompression or feeding)
1/1/2006
A
44187
Laparoscopy, surgical; ileostomy or jejunostomy,
non-tube
1/1/2006
A
44188
Laparoscopy, surgical; colostomy or skin level cecostomy
1/1/2006
A
44213
Laparoscopy, surgical, mobilization (take-down) of splenic
flexure performed in conjunction with partial colectomy (List
separately in addition to code for primary procedure)
1/1/2006
A
44227
Laparoscopy, surgical, closure of enterostomy, large or small
intestine, with resection and anastomosis
1/1/2006
A
45395
Laparoscopy, surgical; proctectomy, complete, combined
abdominoperineal, with colostomy
1/1/2006
A
45397
Laparoscopy, surgical; proctectomy, combined
abdominoperineal pull-through procedure (e.g., colo-anal
anastomosis), with creation of colonic reservoir (e.g., Jpouch), with diverting enterostomy, when performed
1/1/2006
A
45400
Laparoscopy, surgical; proctopexy (for prolapse)
1/1/2006
A
45402
Laparoscopy, surgical; proctopexy (for prolapse), with
sigmoid resection
1/1/2006
A
45499
Unlisted laparoscopy procedure, rectum
1/1/2006
A
45990
Anorectal exam, surgical, requiring anesthesia (general,
spinal or epidural), diagnostic
1/1/2006
A
46505
Chemodenervation of internal anal sphincter
1/1/2006
A
46710
Repair of ilieoanal pouch fistula/sinus (e.g., perineal or
vaginal), pouch advancement; transperineal approach
1/1/2006
A
46712
Repair of ilieoanal pouch fistula/sinus (e.g., perineal or
vaginal), pouch advancement; combined transperineal and
transabdominal approach
1/1/2006
A
50250
Ablation, open, one or more renal mass lesion(s),
cryosurgical, including intraoperative ultrasound, if
performed
1/1/2006
A
50382
Removal (via snare/capture) and replacement of internally
dwelling ureteral stent via percutaneous approach, including
radiological supervision and interpretation
1/1/2006
A
50384
Removal (via snare/capture) of internally dwelling ureteral
stent via percutaneous approach, including radiological
supervision and interpretation
1/1/2006
A
50387
Removal and replacement of externally accessible
transnephric ureteral stent (e.g., external/internal stent)
requiring fluoroscopic guidance, including radiological
supervision and interpretation
1/1/2006
A
50389
Removal of nephrostomy tube, requiring fluoroscopic
guidance (e.g., with concurrent indwelling ureteral stent)
1/1/2006
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
50592
Ablation, one or more renal tumor(s), percutaneous,
unilateral, radiofrequency
1/1/2006
A
51999
Unlisted laparoscopy procedure, bladder
1/1/2006
A
57295
Revision (including removal) of prosthetic vaginal graft,
vaginal approach
1/1/2006
A
58110
Endometrial sampling (biopsy) performed in conjunction with
colposcopy (List separately in addition to code for primary
procedure)
1/1/2006
A
75956
Endovascular repair of descending thoracic aorta (e.g.,
aneurysm, pseudoaneurysm, dissection, penetrating
ulcer, intramural hematoma, or traumatic disruption);
involving coverage of left subclavian artery origin, initial
endoprosthesis plus descending thoracic aortic extension(s),
if required, to level of celiac artery origin, radiological
supervision and interpretation
1/1/2006
A
75957
Endovascular repair of descending thoracic aorta (e.g.,
aneurysm, pseudoaneurysm, dissection, penetrating
ulcer, intramural hematoma, or traumatic disruption); not
involving coverage of left subclavian artery origin, initial
endoprosthesis plus descending thoracic aortic extension(s),
if required, to level of celiac artery origin, radiological
supervision and interpretation
1/1/2006
A
75958
Placement of proximal extension prosthesis for endovascular
repair of descending thoracic aorta (e.g., aneurysm,
pseudoaneurysm, dissection, penetrating ulcer, intramural
hematoma, or traumatic disruption), radiological supervision
and interpretation
1/1/2006
A
75959
Placement of distal extension prosthesis(s) (delayed) after
endovascular repair of descending thoracic aorta, as
needed, to level of celiac origin, radiological supervision
and interpretation
1/1/2006
A
76376
3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound,
or other tomographic modality; not requiring image
postprocessing on an independent workstation
1/1/2006
A
76377
3D rendering with interpretation and reporting of computed
tomography, magnetic resonance imaging, ultrasound, or
other tomographic modality; requiring image postprocessing
on an independent workstation
1/1/2006
A
77421
Stereoscopic X-ray guidance for localization of target volume
for the delivery of radiation therapy
1/1/2006
A
77422
High energy neutron radiation treatment delivery; single
treatment area using a single port or parallel-opposed ports
with no blocks or simple blocking
1/1/2006
A
77423
High energy neutron radiation treatment delivery;
1 or more isocenter(s) with coplanar or non-coplanar
geometry with blocking and/or wedge, and/or
compensator(s)
1/1/2006
A
82272
Blood, occult, by peroxidase activity (e.g., guaiac),
qualitative, feces, single specimen (eg, from digital
rectal exam)
1/1/2006
A
83037
Hemoglobin; glycosylated (A1C) by device cleared bg FDA
for home use
1/1/2006
Delete Date
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
83631
Lactoferrin, fecal; quantitative
1/1/2006
A
83695
Lipoprotein (a)
1/1/2006
A
83700
Lipoprotein, blood; electrophoretic separation and
quantitation
1/1/2006
A
83701
Lipoprotein, blood; high resolution fractionation and
quantitation of lipoproteins including lipoprotein subclasses
when performed (e.g., electrophoresis ultracentifugation)
1/1/2006
A
83704
Lipoprotein, blood; quantitation of lipoprotein particle
numbers and lipoprotein particle subclasses (e.g., by nuclear
magnetic resonance spectroscopy)
1/1/2006
A
83900
Molecular diagnostics; amplification of patient nucleic acid,
muliplex, first two nucleic acid sequences
1/1/2006
A
83907
Molecular diagnostics; lysis of cells prior to nucleic acid
extraction (e.g., stool specimens, paraffin embedded tissue)
1/1/2006
A
83908
Molecular diagnostics; signal amplification of patient nucleic
acid, each nucleic acid sequence
1/1/2006
A
83909
Molecular diagnostics; separation and identification by high
resolution technique (e.g., capillary electrophoresis)
1/1/2006
A
83914
Mutation identification by enzymatic ligation or
primer extension, single segment, each segment (e.g.,
oligonucleotide ligation assay (OLA), single base chain
extension (SBCE), or allele- specific primer extension (ASPE)
1/1/2006
A
86200
Cyclic citrullinated peptide (CCP), antibody
1/1/2006
A
86355
B cells, total count
1/1/2006
A
86357
Natural killer (NK) cells, total count
1/1/2006
A
86367
Stem cells (i.e., CD34), total count
1/1/2006
86480
Tuberculosis test, cell mediated immunity measurement of
gamma interferon antigen response
1/1/2006
A
86923
Compatibility test each unit; electronic
1/1/2006
A
86960
Volume reduction for blood or blood product (e.g., red blood
cells or platelets), each unit
1/1/2006
A
87209
Smear, primary source with interpretation; complex special
stain (e.g., trichrome, iron hematoxylin) for ova and
parasites
1/1/2006
A
87900
Infectious agent drug susceptibility phenotpye prediction
using regular updated genotypic bioinformatics
1/1/2006
A
88333
Pathology consultation during surgery; cytologic examination
(e.g., touch prep, squash prep), initial site
1/1/2006
A
88334
Pathology consultation diring surgery; cytologic examination
(e.g., touch prep, squash prep) each additional site
1/1/2006
A
88384
Array-based evaluation of multiple molecular probes;
11 through 50 probes
1/1/2006
A
88385
Array-based evaluation of multiple molecular probes;
51 through 250 probes
1/1/2006
A
88386
Array-based evaluation of multiple molecular probes; 251
through 500 probes
1/1/2006
A
89049
Caffeine halothane contracture test (CHCT) for malignant
hyperthermia susceptibility, including interpretation and
report
1/1/2006
A
90649
Human papilloma virus, (HPV) vaccine, types 6, 11, 16, 18
(quadrivalent), 3 dose, for intramuscular use
1/1/2006
A
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
90736
Zoster (shingles) vaccine, live, for subcutaneous injection
1/1/2006
A
90760
Intravenous infusion, hydration; initial, up to 1 hour
1/1/2006
A
90761
Intravenous infusion, hydration; each additional hour, up
to 8 hours (List separately in addition to code for primary
procedure)
1/1/2006
A
90765
Intravenous infusion, for therapy, prophylaxis, or diagnosis
(specify substance or drug); initial, up to 1 hour
1/1/2006
A
90766
Intravenous infusion, for therapy, prophylaxis, or diagnosis
(specify substance or drug); each additional hour, up to
8 hours, (List separately in addition to code for primary
procedure)
1/1/2006
A
90767
Intravenous infusion, for therapy, prophylaxis, or diagnosis
(specify substance or drug); additional sequential infusion,
up to 1 hour (List separately in addition to code for primary
procedure)
1/1/2006
A
90768
Intravenous infusion, for therapy, prophylaxis, or diagnosis
(specify substance or drug); concurrent infusion (List
separately in addition to code for primary procedure)
1/1/2006
A
90772
Therapeutic, prophylactic or diagnostic injection (specify
substance or drug); subcutaneous or intramuscular
1/1/2006
A
90773
Therapeutic, prophylactic or diagnostic injection (specify
substance or drug); intra-arterial
1/1/2006
A
90774
Therapeutic, prophylactic or diagnostic injection (specify
substance or drug); intravenous push, single or initial
substance/drug
1/1/2006
A
90775
Therapeutic, prophylactic or diagnostic injection (specify
substance or drug); each additional sequential intravenous
push of a new substance/drug (List separately in addition to
code for primary procedure)
1/1/2006
A
90779
Unlisted therapeutic, prophylactic or diagnostic intravenous
or intra-arterial injection or infusion
1/1/2006
A
91022
Duodenal Motility (manometric) study
1/1/2006
A
92626
Evaluation of auditory rehabilitation status; first hour
1/1/2006
A
92627
Evaluation of auditory rehabilitation status, each additional
15 minutes (List separately in addition to code for primary
procedure)
1/1/2006
A
92630
Auditory rehabilitation; pre lingual hearing loss
1/1/2006
A
92633
Auditory rehabilitation; post-lingual hearing loss
1/1/2006
A
95251
Ambulatory continuous glucose monitoring of interstitial
tissue fluid via a subcutaneous sensor for up to 72 hours;
physician interpretation and report
1/1/2006
A
95865
Needle electromyography, larynx
1/1/2006
A
95866
Needle electromyography; hemidiaphragm
1/1/2006
A
95873
Electrical stimulation for guidance in conjunction with
chemodenervation (List separately in addition to code for
primary procedure)
1/1/2006
A
95874
Needle electromyography for guidance in conjunction with
chemodenervation (List separately in addition to code for
primary procedure)
1/1/2006
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
96101
Psychological testing (includes psychodiagnostic assessment
of emotionality, intellectual abilities, personality and
psychopathology, e.g., MMPI, Rorschach, WAIS), per hour
of the psychologist’s or physician’s time, both face-to-face
time with the patient and time interpreting test results and
preparing the report
1/1/2006
A
96102
Psychological testing (includes psychodiagnostic assessment
of emotionality, intellectual abilities, personality and
psychopathology, e.g., MMPI and WAIS), with qualified
health care professional interpretation and report,
administered by technician time, face-to-face
1/1/2006
A
96103
Psychological testing (includes psychodiagnostic assessment
of emotionality, intellectual abilities, personality and
psychopathology, e.g., MMPI), administered by computer,
with qualified health care professional interpretation and
report
1/1/2006
A
96116
Neurobehavioral status exam (clinical assessment of thinking,
reasoning and judgment, e.g., acquired knowledge,
attention, language, memory, planning and problem solving,
and visual spatial abilities), per hour psychologist’s or
physician’s time, both face-to-face time with the patient and
time interpreting test results and preparing the report
1/1/2006
A
96118
Neuropsychological testing (e.g., Halstead-Reitan,
Neuropsychological Battery, Wechsler memory scales and
Wisconsin card sorting test), per hour of the psychologists or
physician’s time, both face-to-face time and interpreting test
results and preparing report
1/1/2006
A
96119
Neuropsychological testing (e.g., Halstead-Reitan,
Neuropsychological Battery, Wechsler memory scales and
Wisconsin card sorting test), with qualified health care
professional interpretation and report, administered by
technician, per hour of the technician time, face-to-face
1/1/2006
A
96120
Neuropsychological testing (e.g., Wisconsin card sorting
test), administered by computer, with qualified health care
professional interpertation and report
1/1/2006
A
96401
Chemotherapy administration, subcutaneous or
intramuscular; non-hormonal anti-neoplastic
1/1/2006
A
96402
Chemotherapy administration, subcutaneous or
intramuscular; hormonal anti-neoplastic
1/1/2006
A
96409
Chemotherapy administration, intravenous; push technique,
single or initial substance/drug
1/1/2006
A
96411
Chemotherapy administration, intravenous, push technique,
each additional substance/drug (List separately in addition
to code for primary procedure)
1/1/2006
A
96413
Chemotherapy administration, intravenous infusion
technique; up to 1 hour, single or initial substance/drug
1/1/2006
A
96415
Chemotherapy administration, intravenous infusion
technique; each additional hour, 1 to 8 hours (List separately
in addition to code for primary procedure)
1/1/2006
A
96416
Chemotherapy administration, intravenous infusion
technique; initiation of prolonged chemotherapy infusion
(more than 8 hours), requiring use of a portable or
implantable pump
1/1/2006
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Action
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D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
96417
Chemotherapy administration, intravenous infusion
technique; each additional sequential infusion (different
substance/drug), up to 1 hour (List separately in addition to
code for primary procedure)
1/1/2006
A
96521
Refilling and maintenance of portable pump
1/1/2006
A
96522
Refilling and maintenance of implantable pump or reservoir
for drug delivery, systemic (e.g., intravenous, intra-arterial)
1/1/2006
A
96523
Irrigation of implanted venous access device for drug
delivery systems
1/1/2006
A
97760
Orthotic(s) management and training (including assessment
and fitting when not otherwise reported) upper extremity(s),
lower extremity(s), and/or trunk, each 15 minutes
1/1/2006
A
97761
Prosthetic training, upper and/or lower extremity(s), each 15
minutes
1/1/2006
A
97762
Checkout for orthotic/prosthetic use, established patient,
each 15 minutes
1/1/2006
A
98960
Education and training for patient self-management by a
qualified, nonphysician health care profesional using a
standarized curriculum, face to face with patient (could
include caregiver/family) each 30 minutes; individual patient
1/1/2006
A
98961
Education and Training for patient self-management by a
qualified, nonphysician health care profesional using a
standarized curriculum, face to face with patient (could
include caregiver/family) each 30 minutes; 2-4 patients
1/1/2006
A
98962
Education and Training for patient self-management by a
qualified, nonphysician health care profesional using a
standarized curriculum, face to face with patient (could
include caregiver/family) each 30 minutes; 5-8 patients
1/1/2006
A
99051
Service(s) provided in the office during regularly scheduled
evening, weekend, or holiday office hours, in addition to the
basic service
1/1/2006
A
99053
Service(s) provided between 10:00PM and 8:00 AM
at 24-hour facility, in addition to basic service
1/1/2006
A
99060
Service(s) proviced on an emergency basis, out of the office,
which distupts other scheduled office services,
in addition to basic service
1/1/2006
A
99143
Moderate sedation services (other than those services
described by codes 00100-01999) provided by the same
physician performing the diagnostic or therapeutic service
that the sedation supports, requiring the presence of an
independent trained observer to assist in the monitoring of
the patient’s level of consciousness and physiological status;
under 5 years of age, first 30 minutes of intra-service time
1/1/2006
A
99144
Moderate sedation services (other than those services
described by codes 00100-01999) provided by the same
physician performing the diagnostic or therapeutic service
that the sedation supports, requiring the presence of an
independent trained observer to assist in the monitoring of
the patient’s level of consciousness and physiological status;
age 5 years or older, first 30 minutes intra-service time
1/1/2006
Delete Date
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
99145
Moderate sedation services (other than those services
described by codes 00100-01999) provided by the same
physician performing the diagnostic or therapeutic service
that the sedation supports, requiring the presence of an
independent trained observer to assist in the monitoring of
the patient’s level of consciousness and physiological status;
each additional 15 minutes intra-service time (List separately
in addition to code for primary service)
1/1/2006
A
99148
Moderate sedation services (other than those services
described by codes 00100-01999) provided by a physician
other than the health care professional performing the
diagnostic or therapeutic service that the sedation supports;
under 5 years of age, first 30 minutes intra-service time
1/1/2006
A
99149
Moderate sedation services (other than those services
described by codes 00100-01999) provided by a physician
other than the health care professional performing the
diagnostic or therapeutic service that the sedation supports;
age 5 years or older, first 30 minutes intra-service time
1/1/2006
A
99150
Moderate sedation services (other than those services
described by codes 00100-01999) provided by a physician
other than the health care professional performing the
diagnostic or therapeutic service that the sedation supports;
each additional 15 minutes intra-service time (List separately
in addition to code for primary service)
1/1/2006
A
99300
Subsequent intensive care, per day, for the evaluation and
1/1/2006
management of the recovering infant (present body weight of
2501-5000 grams)
A
99304
Initial nursing facility care, per day, for the evaluation
and management of a patient which requires these three
key components: a detailed or comprehensive history; a
detailed or comprehensive examination; and a medical
decision making that is straightforward or of low complexity.
Counseling and/or coordination of care with other providers
or agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs. Usually,
the problem(s) requiring admission are of low severity.
1/1/2006
A
99305
Initial nursing facility care, per day, for the evaluation and
management of a patient which requires these three key
components: a comprehensive history; a comprehensive
examination; and a medical decision making of moderate
complexity. Counseling and/or coordination of care with
other providers or agencies are provided consistent with the
nature of the problem(s) and the patient’s and/or family’s
needs. Usually, the problem(s) requiring admission are of
moderate severity.
1/1/2006
A
99306
Initial nursing facility care, per day, for the evaluation and
management of a patient which requires these three key
components: a comprehensive history; a comprehensive
examination; and a medical decision making of high
complexity. Counseling and/or coordination of care with
other providers or agencies are provided consistent with the
nature of the problem(s) and the patient’s and/or family’s
needs. Usually, the problem(s) requiring admission are of
high severity.
1/1/2006
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R=Revision
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CPT Code
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Effective Date
of Revision/
Addition
A
99307
Subsequent nursing facility care, per day, for the evaluation
and management of a patient, which requires at least two
of these three key components: a problem focused interval
history; a problem focused examination; straightforward
medical decision making. Counseling and/or coordination
of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient’s
and/or family’s needs. Usually, the patient is stable,
recovering, or improving
1/1/2006
A
99308
Subsequent nursing facility care, per day, for the evaluation
and management of a patient, which requires at least two
of these three key components: an expanded problem
focused interval history; an expanded problem focused
examination; medical decision making of low complexity.
Counseling and/or coordination of care with other providers
or agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs. Usually,
the patient is responding inadequately to therapy or has
developed a minor complication
1/1/2006
A
99309
Subsequent nursing facility care, per day, for the evaluation
and management of a patient, which requires at least two
of these three key components: a detailed interval history; a
detailed examination; medical decision making of moderate
complexity. Counseling and/or coordination of care with
other providers or agencies are provided consistent with the
nature of the problem(s) and the patient’s and/or family’s
needs. Usually, the patient has developed a significant
complication or a significant new problem
1/1/2006
A
99310
Subsequent nursing facility care, per day, for the evaluation
and management of a patient, which requires at least two
of these three key components: a comprehensive interval
history; a comprehensive examination; medical decision
making of high complexity. Counseling and/or coordination
of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient’s
and/or family’s needs. The patient may be unstable or
may have developed a significant new problem requiring
immediate physician attention
1/1/2006
A
99318
Evaluation and management of a patient involving an annual 1/1/2006
nursing facility assessment, which requires these three key
components: a detailed interval history; a comprehensive
examination; and medical decision making that is of low
to moderate complexity. Counseling and/or coordination
of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient’s
and/or family’s needs. Usually, the patient is stable,
recovering, or improving
Delete Date
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
99324
Domiciliary or rest home visit for the evaluation and
management of a new patient, which requires these three
key components: a problem focused history; a problem
focused examination; and straightforward medical decision
making. Counseling and/or coordination of care with other
providers or agencies are provided consistent with the
nature of the problem(s) and the patient’s and/or family’s
needs. Usually, the presenting problem(s) are of low severity.
Physicians typically spend 20 minutes with the patient and/
or family or caregiver
A
99325
Domiciliary or rest home visit for the evaluation and
1/1/2006
management of a new patient, which requires these three
key components: an expanded problem focused history;
an expanded problem focused examination; and medical
decision making of low complexity. Counseling and/or
coordination of care with other providers or agencies are
provided consistent with the nature of the problem(s) and
the patient’s and/or family’s needs. Usually, the presenting
problem(s) are of moderate severity. Physicians typically
spend 30 minutes with the patient and/or family or caregiver
A
99326
Domiciliary or rest home visit for the evaluation and
management of a new patient, which requires these three
key components: a detailed history; a detailed examination;
and medical decision making of moderate complexity.
Counseling and/or coordination of care with other providers
or agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs. Usually,
the presenting problem(s) are of moderate to high severity.
Physicians typically spend 45 minutes with the patient and/
or family or caregiver
1/1/2006
A
99327
Domiciliary or rest home visit for the evaluation and
management of a new patient, which requires these three
key components: a comprehensive history; a comprehensive
examination; and a medical decision making of moderate
complexity. Counseling and/or coordination of care with
other providers or agencies are provided consistent with
the nature of the problem(s) and the patient’s and/or
family’s needs. Usually, the presenting problem(s) are of
high severity. Physicians typically spend 60 minutes with the
patient and/or family or caregiver
1/1/2006
A
99328
Domiciliary or rest home visit for the evaluation and
management of a new patient, which requires these three
key components: a comprehensive history; a comprehensive
examination; and a medical decision making of high
complexity. Counseling and/or coordination of care with
other providers or agencies are provided consistent with the
nature of the problem(s) and the patient’s and/or family’s
needs. Usually, the patient is unstable or has developed
a significant new problem requiring immediate physician
attention. Physicians typically spend 75 minutes with the
patient and/or family or caregiver
1/1/2006
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D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
99334
Domiciliary or rest home visit for the evaluation and
1/1/2006
management of an established patient, which requires
at least two of these three key components: a problem
focused interval history; a problem focused examination;
straightforward medical decision making. Counseling and/
or coordination of care with other providers or agencies are
provided consistent with the nature of the problem(s) and
the patient’s and/or family’s needs. Usually, the presenting
problem(s) are self-limited or minor. Physicians typically
spend 15 minutes with the patient and/or family or caregiver
A
99335
Domiciliary or rest home visit for the evaluation and
management of an established patient, which requires at
least two of these three key components: an expanded
problem focused interval history; an expanded problem
focused examination; medical decision making of low
complexity. Counseling and/or coordination of care with
other providers or agencies are provided consistent with the
nature of the problem(s) and the patient’s and/or family’s
needs. Usually, the presenting problem(s) are of low to
moderate severity. Physicians typically spend 25 minutes
with the patient and/or family or caregiver
1/1/2006
A
99336
Domiciliary or rest home visit for the evaluation and
management of an established patient, which requires at
least two of these three key components: a detailed interval
history; a detailed examination; medical decision making
of moderate complexity. Counseling and/or coordination
of care with other providers or agencies are provided
consistent with the nature of the problem(s) and the patient’s
and/or family’s needs. Usually, the presenting problem(s) are
of moderate to high severity. Physicians typically spend 40
minutes with the patient and/or family or caregiver
1/1/2006
A
99337
Domiciliary or rest home visit for the evaluation and
management of an established patient, which requires at
least two of these three key components: a comprehensive
interval history; a comprehensive examination; medical
decision making of moderate to high complexity. Counseling
and/or coordination of care with other providers or
agencies are provided consistent with the nature of the
problem(s) and the patient’s and/or family’s needs. Usually,
the presenting problem(s) are of moderate to high severity.
The patient may be unstable or may have developed a
significant new problem requiring immediate physician
attention. Physicians typically spend 60 minutes with the
patient and/or family or caregiver
1/1/2006
A
99339
Individual physician supervision of a patient (patient not
1/1/2006
present) in home, domiciliary or rest home (eg, assisted
living facility) requiring complex and multidisciplinary care
modalities involving regular physician development and/or
revision of care plans, review of subsequent reports of
patient status, review of related laboratory and other studies,
communication (including telephone calls) for purposes of
assessment or care decisions with health care professional(s),
family member(s), surrogate decision maker(s) (e.g., legal
guardian), and/or key caregiver(s) involved in patient’s care,
integration of new information into the medical treatment
plan and/or adjustment of medical therapy, within a
calendar month; 15-29 minutes
Delete Date
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
A
99340
Individual physician supervision of a patient (patient not
present) in home, domiciliary or rest home (e.g., assisted
living facility) requiring complex and multidisciplinary care
modalities involving regular physician development and/or
revision of care plans, review of subsequent reports of
patient status, review of related laboratory and other studies,
communication (including telephone calls) for purposes of
assessment or care decisions with health care professional(s),
family member(s), surrogate decision maker(s) (e.g., legal
guardian), and/or key caregiver(s) involved in patient’s
care, integration of new information into the medical
treatment plan and/or adjustment of medical therapy, within
a calendar month;
30 minutes or more
1/1/2006
A
0115T
Medication therapy management service(s) provided by a
pharmacist, individual, face-to-face with patient, initial 15
minutes, with assessment, and intervention if provided; initial
encounter
1/1/2006
A
0116T
Medication therapy management service(s) provided by
a pharmacist, individual, face-to-face with patient, initial
15 minutes, with assessment, and intervention if provided;
subsequent encounter
1/1/2006
A
0117T
Medication therapy management service(s) provided by a
pharmacist, individual, face-to-face with patient, initial 15
minutes, with assessment, and intervention if provided; each
additional 15 minutes (List separately in addition to code for
the primary service)
1/1/2006
A
0120T
Ablation, cryosurgical, of fibroadenoma, including
ultrasound guidance, each fibroadenoma
1/1/2006
A
0123T
Fistulization of sclera for glaucoma, through ciliary body
1/1/2006
A
0124T
Conjunctival incision with posterior juxtascleral placement
of pharmacological agent (does not include supply of
medication)
1/1/2006
A
0126T
Common carotid intima-media thickness (IMT) study for
evaluation of atherosclerotic burden or coronary heart
disease risk factor assessment
1/1/2006
A
0130T
Validated, statistically reliable, randomized, controlled,
single-patient clinical investigation of FDA approved chronic
care drugs, provided by a pharmacist, interpretation and
report to the prescribing health care professional
1/1/2006
A
0133T
Upper gastrointestinal endoscopy, including esophagus,
stomach, and either the duodenum and/or jejunum as
appropriate, with injection of implant material into and
along the muscle of the lower esophageal sphincter (e.g., for
treatment of gastroesophageal reflux disease)
1/1/2006
A
0135T
Ablation, renal tumor(s), unilateral, percutaneous,
cryotherapy
1/1/2006
A
0137T
Biopsy, prostate, needle, saturation sampling for prostate
mapping
1/1/2006
A
0140T
Exhaled breath condensate pH
1/1/2006
A
0141T
Pancreatic islet cell transplantation through portal vein,
percutaneous
1/1/2006
A
0142T
Pancreatic islet cell transplantation through portal vein, open
1/1/2006
A
0143T
Laparoscopy, surgical, pancreatic islet cell transplantation
through portal vein
1/1/2006
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CPT Code
Narrative
Effective Date
of Revision/
Addition
A
0144T
Computed tomography, heart, without contrast material,
including image post processing and quantitative evaluation
of coronary calcium
1/1/2006
A
0145T
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image post processing;
cardiac structure and morphology
1/1/2006
A
0146T
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image post processing;
computed tomographic angiography of coronary arteries
(including native and anomalous coronary arteries, coronary
bypass grafts), without quantitative evaluation of coronary
calcium
1/1/2006
A
0147T
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image post processing;
computed tomographic angiography of coronary arteries
(including native and anomalous coronary arteries, coronary
bypass grafts), with quantitative evaluation of coronary
calcium
1/1/2006
A
0148T
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image post processing;
cardiac structure and morphology and computed
tomographic angiography of coronary arteries (including
native and anomalous coronary arteries, coronary bypass
grafts), without quantitative evaluation of coronary calcium
1/1/2006
A
0149T
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image post processing;
cardiac structure and morphology and computed
tomographic angiography of coronary arteries (including
native and anomalous coronary arteries, coronary bypass
grafts), with quantitative evaluation of coronary calcium
1/1/2006
A
0150T
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image post processing;
cardiac structure and morphology in congenital heart
disease
1/1/2006
A
0151T
Computed tomography, heart, without contrast material
followed by contrast material(s) and further sections,
including cardiac gating and 3D image post processing;
function evaluation (left and right ventricular function,
ejection fraction and segmental wall motion)
1/1/2006
A
0152T
Computer aided detection (computer algorithm analysis of
digital image data for lesion detection) with further physician
review for interpretation, with or without digitization of film
radiographic images; chest radiograph(s) (List separately in
addition to code for primary procedure)
1/1/2006
A
0153T
Transcatheter placement of wireless physiologic sensor
in aneurysmal sac during endovascular repair, including
radiological supervision and interpretation and instrument
calibration
1/1/2006
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
A
0154T
Non-invasive physiologic study of implanted wireless
pressure sensor in aneurysmal sac following endovascular
repair, complete study including recording, analysis of
pressure and waveform tracings, interpretation and report
1/1/2006
A
61630
Ballon angioplasty, intracranial (eg, atherosclerotic stenosis),
percutaneous
1/1/2006
A
61635
Transcatheter placement of intravascular stent(s), intracranial
(e.g., atherosclerotic stenosis), including balloon angioplasty,
if performed
1/1/2006
A
61640
Balloon dilatation of intracranial vasospasm, percutaneous;
initial vessel
1/1/2006
A
61641
Balloon dilatation of intracranial vasospasm, percutaneous;
each additional vessel in same vascular family (List
separately in addition to code for primary procedure)
1/1/2006
A
61642
Balloon dilatation of intracranial vasospasm, percutaneous;
each additional vessel in different vascular family (List
separately in addition to code for primary procedure)
1/1/2006
A
64650
Chemodenervation of eccrine glands; both axillae
1/1/2006
A
64653
Chemodenervation of eccrine glands; other area(s)
(e.g., scalp, face, neck), per day
1/1/2006
A
80195
Sirolimus
1/1/2006
A
82271
Blood, occult, by peroxidase activity (e.g., guaiac),
qualitative; other sources
1/1/2006
D
01964
Anesthesia for abortion procedures
1/1/2006
D
15342
Application of bilaminate skin substitute/ neodermis;
25 sq cm
1/1/2006
D
15343
Application of bilaminate skin substitute/ neodermis; each
additional 25 sq cm (List separately in addition to code for
primary procedure)
1/1/2006
D
15350
Application of allograft, skin; 100 cm or less
1/1/2006
D
15351
Application of allograft, skin; each additional 100 sq cm
(List separately in addition to primary procedure)
1/1/2006
D
15810
Salabrasion; 20 sq cm or less
1/1/2006
D
15811
Salabrasion; over 20 sq cm
1/1/2006
D
16010
Dressings and/or debridement, initial or subsequent; under
anesthesia, small
1/1/2006
D
16015
Dressings and/or debridement, initial or subsequent; under
anesthesia, medium or large, or with major debridement
1/1/2006
D
21493
Closed treatment of hyoid fracture; without manipulation
1/1/2006
D
21494
Closed treatment of hyoid fracture; with manipulation
1/1/2006
D
31585
Treatment of closed laryngeal fracture; without manipulation
1/1/2006
D
31586
Treatment of closed laryngeal fracture; with closed
manipulative reduction
1/1/2006
D
32520
Resection of lung; with resection of chest wall
1/1/2006
D
32522
Resection of lung; with reconstruction of chest wall, without
prosthesis
1/1/2006
D
32525
Resection of lung; with major reconstruction of chest wall,
with prosthesis
1/1/2006
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Action
A=Addition
D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
33918
Repair of pulmonary atresia with ventricular septal
defect, by unifocalization of pulmonary arteries; without
cardiopulmonary bypass
1/1/2006
D
33919
Repair of pulmonary atresia with ventricular septal defect, by
unifocalization of pulmonary arteries; with cardiopulmonary
bypass
1/1/2006
D
37720
Ligation and division and complete stripping of long or short
saphenous veins
1/1/2006
D
37730
Ligation and division and complete stripping of long and
short saphenous veins
1/1/2006
D
42325
Fistulization of sublingual salivary cyst (ranula);
1/1/2006
D
42326
Fistulization of sublingual salivary cyst (ranula); with
prosthesis
1/1/2006
D
43638
Gastrectomy, partial, proximal, thoracic or abdominal
approach including esophagogastrostomy, with vagotomy
1/1/2006
D
43639
Gastrectomy, partial, proximal, thoracic or abdominal
approach including esophagogastrostomy, with vagotomy;
with pyloroplasty or pyloromyotomy
1/1/2006
D
44200
Laparoscopy, surgical; enterolysis (freeing of intestinal
adhesion) (separate procedure)
1/1/2006
D
44201
Laparoscopy, surgical; jejunostomy (e.g., for decompression
or feeding)
1/1/2006
D
44239
Unlisted laparoscopy procedure, rectum
1/1/2006
D
69410
Focal application of phase control substance,
middle ear (baffle technique)
1/1/2006
D
76375
Coronal, sagittal, multiplanar, oblique, 3-dimensional
and/or holographic reconstruction of computed tomography,
magnetic resonance imaging, or other tomographic modality
1/1/2006
D
78160
Plasma radioiron disappearance (turnover) rate
1/1/2006
D
78162
Radioiron oral absorption
1/1/2006
D
78170
Radioiron red cell utilization
1/1/2006
D
78172
Chelatable iron for estimation of total body iron
1/1/2006
D
78455
Venous thrombosis study (e.g., radioactive fibrinogen)
1/1/2006
D
82273
Blood, occult, by peroxidase activity (e.g., guaiac),
qualitative; other sources
1/1/2006
D
83715
Lipoprotein, blood; electrophoretic separation and
quantitation
1/1/2006
D
83716
Lipoprotein, blood; high resolution fractionation and
quantitation of lipoproteins inclduing lipoprotein subclasses
when performed (e.g., electrophoresis,
nuclear magnetic resonance, ultracentrifugation)
1/1/2006
D
86064
B cells, total count
1/1/2006
D
86379
Natural killer (NK) cells, total count
1/1/2006
D
86585
Skin test; tuberculosis, tine test
1/1/2006
D
86587
Stem cells (ie, CD34), total count
1/1/2006
D
90780
Intravenous infusion for therapy/diagnosis, administered by
physician or under direct supervision of physician; up to one
hour
1/1/2006
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
90781
Intravenous infusion for therapy/diagnosis, administered
by physician or under direct supervision of physician; each
additional hour, up to eight (8) hours (List separately in
addition to code for primary procedure)
1/1/2006
D
90782
Therapeutic, prophylactic or diagnostic injection (specify
material injected); subcutaneous or intramuscular
1/1/2006
D
90783
Therapeutic, prophylactic or diagnostic injection (specify
material injected); intra arterial
1/1/2006
D
90784
Therapeutic, prophylactic or diagnostic injection (specify
material injected); intravenous
1/1/2006
D
90788
Intramuscular injection of antibiotic (specify)
1/1/2006
D
90799
Unlisted therapeutic, prophylactic or diagnostic injection
1/1/2006
D
90871
Electroconvulsive therapy (includes necessary monitoring);
multiple (ECT) seizures, per day
1/1/2006
D
90939
Hemodialysis access flow study to determine blood flow
in grafts and arteriovenous fistulae by an indicator dilution
method, hook-up; transcutaneous measurement and
disconnection
1/1/2006
D
92330
Prescription, fitting, and supply of ocular prosthesis (artificial
eye), with medical supervision of adaptation
1/1/2006
D
92335
Prescription of ocular prosthesis (artificial eye) and direction
of fitting and supply by independent technician, with medical
supervision of adaptation
1/1/2006
D
92390
Supply of spectacles, except prosthesis for aphakia and low
vision aids
1/1/2006
D
92391
Supply of contact lenses, except prosthesis for aphakia
1/1/2006
D
92392
Supply of low vision aids (A low vision aid is any lens or
device used to aid or improve visual function in a person
whose vision cannot be normalized by conventional
spectacle correction includes reading additions
up to 4D.)
1/1/2006
D
92393
Supply of ocular prosthesis (artificial eye)
1/1/2006
D
92395
Supply of permanent prosthesis for aphakia; spectacles
1/1/2006
D
92396
Supply of permanent prosthesisfor aphakia; contact lenses
1/1/2006
D
92510
Aural rehabilitation following cochlear implant (includes
evaluation of aural rehabilitation status and hearing,
therapeutic services) with or without speech processor
programming
1/1/2006
D
95858
Tensilon test for myasthenia gravis; with electromyographic
recording
1/1/2006
D
96100
Psychological testing (includes psycho-diagnostic assessment
of personality, psychopathology, emotionality, intellectual
abilities, e.g., Wais-r, Rorschach, MMPI) with interpretation
and report, per hour (Minnesota Multiphasic Personality
Inventory, psychometric projective test)
1/1/2006
D
96115
Neurobehavorial status exam (clinical assessment of thinking,
reasoning and judgment, e.g., acquired knowledge,
attention, memory, visual spatial abilities, language
functions, planning) with interpretation and report, per hour
1/1/2006
D
96117
Neuropsychological testing battery (e.g., Halstead-Reitan,
Luria, Wais-R) with interpretation and report, per hour
1/1/2006
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
96400
Chemotherapy administration, subcutaneous or
intramuscular, with or without local anesthesia
1/1/2006
D
96408
Chemotherapy administration, intravenous; push technique
1/1/2006
D
96410
Chemotherapy administration, intravenous; infusion
technique, up to one hour
1/1/2006
D
96412
Chemotherapy administration, infusion technique, one to 8
hours, each additional hour (List separately in addition to
code for primary procedure)
1/1/2006
D
96414
Chemotherapy administration, infusion technique; initiation
of prolonged infusion (more than 8 hours), requiring the use
of a portable or implantable pump
1/1/2006
D
96520
Refilling and maintenance of portable pump
1/1/2006
D
96530
Refilling and maintenance of implantable pump or reservoir
for drug delivery, systemic (e.g., intravenous, intra-arterial)
1/1/2006
D
96545
Provision of chemotherapy agent
1/1/2006
D
97020
Application of a modality to one or more areas; microwave
1/1/2006
D
97504
Orthotics fitting and training, upper extremity(ies), lower
extremity(ies), and/or trunk, each 15 minutes
1/1/2006
D
97520
Prosthetic training, upper and/or lower extremities, each 15
minutes
1/1/2006
D
97703
Checkout for orthotic/prosthetic use, established patient,
each 15 minutes
1/1/2006
D
99052
Services requested between 10:00 PM and 8:00 AM in
addition to basic service
1/1/2006
D
99054
Services requested on Sundays and holidays in addition to
basic service
1/1/2006
D
99141
Sedation with or without analgesia (conscious sedation);
intravenous, intramuscular or inhalation
1/1/2006
D
99142
Sedation with or without analgesia (conscious sedation);
oral, rectal and/or intranasal
1/1/2006
D
99261
Follow up inpatient consultation for an established
patient which requires at least two of these three key
components: a problem focused interval history; a problem
focused examination; a medical decision making that is
straightforward or of low complexity
1/1/2006
D
99262
Follow up inpatient consultation for an established patient
which requires at least two of these three key components:
an expanded problem focused interval history; an expanded
problem focused examination; a medical decision making of
moderate complexity
1/1/2006
D
99263
Follow up inpatient consultation for an established patient
which requires at least two of these three key components: a
detailed interval history; a detailed examination; a medical
decision making of high complexity
1/1/2006
D
99271
Confirmatory consultation for a new or established patient,
which requires these three key components: a problem
focused history; a problem focused examination; and
straightforward medical decision making
1/1/2006
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
99272
Confirmatory consultation for a new or established patient,
which requires these three key components: an expanded
problem focused history; an expanded problem focused
examination; and straightforward medical decision making
1/1/2006
D
99273
Confirmatory consultation for a new or established patient,
which requires these three key components: a detailed
history; a detailed examination; and medical decision
making of low complexity
1/1/2006
D
99274
Confirmatory consultation for a new or established patient,
which requires these three key components: a comprehensive
history; a comprehensive examination; and medical decision
making of moderate complexity
1/1/20066
D
99275
Confirmatory consultation for a new or established patient,
which requires these three key components: a comprehensive
history; a comprehensive examination; and medical decision
making of high complexity
1/1/2006
D
99301
Evaluation and management of a new or established patient
involving an annual nursing facility assessment which
requires these three key components: a detailed interval
history; a comprehensive examination; and a medical
decision making that is straightforward or of low complexity
1/1/2006
D
99302
Evaluation and management of a new or established patient
involving an annual nursing facility assessment which
requires these three key components: a detailed interval
history; a comprehensive examination; and a medical
decision making of moderate to high complexity
1/1/2006
D
99303
Evaluation and management of a new or established patient
involving an annual nursing facility assessment which
requires these three key components: a comprehensive
history; a comprehensive examination; and a medical
decision making of moderate to high complexity
1/1/2006
D
99311
Subsequent nursing facility care, per day, for the evaluation
and management of a new or established patient, which
requires at least two of these three key components: a
problem focused interval history; a problem focused
examination; medical decision making that is straightforward
or of low complexity
1/1/2006
D
99312
Subsequent nursing facility care, per day, for the evaluation
and management of a new or established patient, which
requires at least two of these three key components: an
expanded problem focused interval history; an expanded
problem focused examination; medical decision making of
moderate complexity
1/1/2006
D
99313
Subsequent nursing facility care, per day, for the evaluation
and management of a new or established patient, which
requires at least two of these three key components: a
detailed interval history; a detailed examination; medical
decision making of moderate to high complexity
1/1/2006
D
99321
Domiciliary or rest home visit for the evaluation and
management of a new patient which requires these three
key components: a problem focused history; a problem
focused examination; and medical decision making that is
straightforward or of low complexity
1/1/2006
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
99322
Domiciliary or rest home visit for the evaluation and
management of a new patient which requires these three
key components: an expanded problem focused history;
an expanded problem focused examination; and medical
decision making of moderate complexity
1/1/2006
D
99323
Domiciliary or rest home visit for the evaluation and
management of a new patient which requires these three key
components: a detailed history; a detailed examination; and
medical decision making of high complexity
1/1/2006
D
99331
Domiciliary or rest home visit for the evaluation and
management of an established patient, which requires at
least two of these three key components: a problem focused
interval history; a problem focused examination; medical
decision making that is straightforward or of low complexity
1/1/2006
D
99332
Domiciliary or rest home visit for the evaluation and
management of an established patient, which requires at
least two of these three key components: an expanded
problem focused interval history; an expanded problem
focused examination; medical decision of moderate
complexity
1/1/2006
D
99333
Domiciliary or rest home visit for the evaluation and
management of an established patient, which requires at
least two of these three key components: a detailed interval
history; a detailed examination; medical decision of high
complexity
1/1/2006
D
0010T
Tuberculosis test, cell mediated immunity measurement of
gamma interferon antigen response
1/1/2006
D
0020T
Extracorporeal shock wave therapy; involving plantar fascia
1/1/2006
D
0023T
Infectious agent drug susceptibility phenotype prediction
using genotypic comparison to know genotypic/phenotypic
database, HIV 1
1/1/2006
D
0033T
Endovascular repair of descending thoracic aortic aneurysm,
pseudoaneurysm or dissection; involving coverage of left
subclavian artery origin, initial endoprosthesis
1/1/2006
D
0034T
Endovascular repair of descending thoracic aortic aneurysm,
pseudoaneurysm or dissection; not involving coverage of left
subclavian artery origin, initial endoprosthesis
1/1/2006
D
0035T
Placement of proximal or distal extension prosthesis for
endovascular repair of descending thoracic aortic aneurysm,
pseudoaneurysm or dissection; initial extension
1/1/2006
D
0036T
Placement of proximal or distal extension prosthesis for
endovascular repair of descending thoracic aortic aneurysm,
pseudoaneurysm or dissection; each additional extension
(List separately in addition to code for primary procedure)
1/1/2006
D
0037T
Open subclavian to carotid artery transposition performed in
conjunction with endovascular thoracic aneurysm repair, by
neck incision, unilateral
1/1/2006
D
0038T
Endovascular repair of descending thoracic aortic aneurysm,
pseudoaneurysm or dissection involving coverage of left
subclavian artery origin, initial endoprosthesis, radiological
supervision and interpretation
1/1/2006
D
0039T
Endovascular repair of descending thoracic aortic aneurysm,
pseudoaneurysm or dissection not involving coverage of left
subclavian artery origin, initial endoprosthesis, radiological
supervision and interpretation
1/1/2006
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
D
0040T
Placement of proximal or distal extension prosthesis for
endovascular repair of descending thoracic aortic aneurysm,
pseudoaneurysm of dissection, each extension, radiological
supervision and interpretation
R
15000
Surgical preparation or creation of recipient site by
excision of open wounds, burn eschar, or scar (including
subcutaneous tissues), or incisional release of scar
contracture; first 100 sq cm or one percent of body area of
infants and children
1/1/2006
R
15001
Surgical preparation or creation of recipient site by
excision of open wounds, burn eschar, or scar (including
subcutaneous tissues), or incisional release of scar
contracture; each additional 100 sq cm or each additional
one percent of body area of infants and children (List
separately in addition to code for primary procedure)
1/1/2006
R
15100
Split-thickness autograft, trunk, arms, legs; first 100 sq cm
or less, or one percent of body area of infants and children
(except 15050)
1/1/2006
R
15101
Split-thickness autograft, trunk, arms, legs; each additional
100 sq cm, or each additional one percent of body area
of infants and children, or part thereof (List separately in
addition to code for primary procedure)
1/1/2006
R
15120
Split-thickness autograft, face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits;
first 100 sq cm or less, or one percent of body area of
infants and children (except 15050)
1/1/2006
R
15121
Split-thickness autograft, face, scalp, eyelids, mouth, neck,
ears, orbits, genitalia, hands, feet, and/or multiple digits;
each additional 100 sq cm, or each additional one percent
of body area of infants and children, or apart thereof (List
separately in addition to code for primary procedure)
1/1/2006
R
15400
Xenograft, skin (dermal), for temporary wound closure; trunk,
arms, legs; first 100 sq cm or less, or one percent of body
area of infants and children
1/1/2006
R
15401
Xenograft, skin (dermal), for temporary wound closure; trunk,
arms, legs; each additional 100 sq cm, or each additional
one percent of body area of infants and children, or part
thereof (List separately in addition to code for primary
procedure)
1/1/2006
R
16020
Dressings and/or debridement of partial-thickness burns,
initial or subsequent; small (less than 5% total body surface
area)
1/1/2006
R
16025
Dressings and/or debridement of partial-thickness burns,
initial or subsequent; medium (eg, whole face or whole
extremity, or 5% to 10% total body surface area)
1/1/2006
R
16030
Dressings and/or debridement of partial-thickness burns,
initial or subsequent; large (eg, more than one extremity, or
greater than 10% total body surface area)
1/1/2006
R
30130
Excision inferior turbinate, partial or complete, any method
1/1/2006
R
30140
Submucous resection inferior turbinate, partial or complete,
any method
1/1/2006
R
30801
Cautery and/or ablation, mucosa of inferior turbinates,
unilateral or bilateral, any method; superficial
1/1/2006
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C OM PE NDIUM
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
CPT Code
R
30802
R
R
Narrative
Effective Date
of Revision/
Addition
Cautery and/or ablation, mucosa of inferior turbinates,
unilateral or bilateral, any method; intramural
1/1/2006
30930
Fracture nasal inferior turbinate(s), therapeutic
1/1/2006
31526
Laryngoscopy direct, with or without tracheoscopy;
diagnostic, with operating microscope or telescope
1/1/2006
R
31531
Laryngoscopy, direct, operative with foreign body removal;
with operating microscope or telescope
1/1/2006
R
31536
Laryngoscopy, direct, operative, with biopsy; with operating
microscope or telescope
1/1/2006
R
31541
Laryngoscopy, direct, operative, with excision of tumor
and/or stripping of vocal cords or epiglottis; with operating
microscope or telescope
1/1/2006
R
31561
Laryngoscopy, direct, operative, with arytenoidectomy; with
operating microscope or telescope
1/1/2006
R
31571
Laryngoscopy, direct, with injection into vocal cord(s),
therapeutic; with operating microscope or telescope
1/1/2006
R
33502
Repair of anomalous coronary artery from pulmonary artery
origin; by ligation
1/1/2006
R
33506
Repair of anomalous coronary artery from pulmonary artery
origin; by translocation from pulmonary artery to aorta
1/1/2006
R
34833
Open iliac artery exposure with creation of conduit for
delivery of aortic or iliac endovascular prosthesis, by
abdominal or retroperitoneal incision, unilateral
1/1/2006
R
34834
Open brachial artery exposure to assist in the deployment
of aortic or iliac endovascular prosthesis by arm incision,
unilateral
1/1/2006
R
37209
Exchange of a previously placed intravascular catheter
during thrombolytic therapy
1/1/2006
R
43848
Revision, open, of gastric restrictive procedure for morbid
obesity, other than adjustable gastric band (separate
procedure)
1/1/2006
R
44310
Ileostomy or jejunostomy, non-tube
1/1/2006
R
44320
Colostomy or skin level cecostomy
1/1/2006
R
45119
Proctectomy, combined abdominoperineal pull-through
procedure (e.g., colo-anal anastomosis), with creation of
colonic reservoir (eg, J-pouch), with diverting enterostomy
when performed
1/1/2006
R
45540
Proctopexy (e.g., for prolapse); abdominal approach
1/1/2006
R
45550
Proctopexy (e.g., for prolapse); with sigmoid resection,
abdominal approach
1/1/2006
R
50688
Change of ureterostomy tube or externally accessible ureteral
stent via ileal conduit
1/1/2006
R
52647
Laser coagulation of prostate, including control of
postoperative bleeding, complete (vasectomy, meatotomy,
cystourethroscopy, urethral calibration and/or dilation, and
internal urethrotomy are included if performed)
1/1/2006
R
52648
Laser vaporization of prostate, including control of
postoperative bleeding, complete (vasectomy, meatotomy,
cystourethroscopy, urethral calibration and/or dilation,
internal urethrotomy and transurethral resection of prostate
are included if performed)
1/1/2006
Delete Date
2005 Compendium
CPT CODES
Action
A=Addition
D=Deletion
R=Revision
CPT Code
Narrative
Effective Date
of Revision/
Addition
R
57421
Colposcopy of the entire vagina, with cervix if present;
with biopsy(s) of vagina/cervix
1/1/2006
R
64613
Chemodenervation of muscle(s); neck muscle(s) (e.g., for
spasmodic torticollis, spasmodic dysphonia)
1/1/2006
R
67901
Repair of blepharoptosis; frontalis muscle technique with
suture or other material (e.g., banked fascia)
1/1/2006
R
67902
Repair of blepharoptosis; frontalis muscle technique with
autologous fascial sling (includes obtaining fascia)
1/1/2006
R
75900
Exchange of a previously placed intravascular catheter
during thrombolytic therapy with contrast monitoring,
radiological supervision and interpretation
1/1/2006
R
76012
Radiological supervision and interpretation, percutaneous
vertebroplasty or vertebral augmentation including cavity
creation, per vertebral body; under fluoroscopic guidance
1/1/2006
R
76013
Radiological supervision and interpretation, percutaneous
vertebroplasty or vertebral augmentation including cavity
creation, per vertebral body; under CT guidance
1/1/2006
R
77412
Radiation treatment delivery, three or more separate
treatment areas, custom blocking, tangential ports, wedges,
rotational beam, compensators, electron beam; up to 5 MeV
1/1/2006
R
82270
Blood, occult, by peroxidase activity (e.g., guaiac),
qualitative; feces, consecutive collected specimens with
single determination, for colorectal neoplasm screening (i.e.,
patient was provided three cards or single triple card for
consecutive collection)
1/1/2006
R
83036
Hemoglobin; glycosylated (A1C)
1/1/2006
R
83630
Lactoferrin, fecal; qualitative
1/1/2006
R
83898
Molecular diagnostics; amplification of patient nucleic acid,
each nucleic sequence
1/1/2006
R
83901
Molecular diagnostics; amplification of patient nucleic acid,
multiplex, each additional nucleic acid sequence
(List separately in addition to code for primary procedure)
1/1/2006
R
84238
Receptor assay; non-endocrine (specifiy receptor)
1/1/2006
R
87904
Infectious agent phenotype analysis by nucleic acid (DNA
or RNA) with drug resistance tissue culture analysis, HIV 1;
each additional drug tested (List separately in addition to
code for primary procedure)
1/1/2006
R
88175
Cytopathology, cervical or vaginal (any reporting system),
collected in preservative fluid, automated thin layer
preparation; with screening by automated system and
manual rescreening or review, under physician supervision
1/1/2006
R
90870
Electroconvulsive therapy (includes necessary monitoring)
1/1/2006
R
90940
Hemodialysis access flow study to determine blood flow in
grafts and arteriovenious fistulae by an indicator method
1/1/2006
R
92506
Evaluation of speech, language, voice, communication,
and/or auditory processing
1/1/2006
R
92507
Treatment of speech, language, voice, communication, and/
or auditory processing disorder; individual
1/1/2006
R
92520
Laryngeal function studies (i.e., Aerodynamic testing and
acoustic testing)
1/1/2006
R
92568
Acoustic reflex testing; threshold
1/1/2006
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CPT CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
CPT Code
Narrative
Effective Date
of Revision/
Addition
R
92569
Acoustic reflex testing; decay
1/1/2006
R
95250
Ambulatory continous glucose monitoring of interstitial
tissue fluid via a subcutaneous sensor for up to 72 hours;
calibration of monitor, patient, removal of sensor, and
printout of recording
1/1/2006
R
96405
Chemotherapy administration; intralesional, up to and
including 7 lesions
1/1/2006
R
96406
Chemotherapy administration; intralesional, more than 7
lesions
1/1/2006
R
96423
Chemotherapy administration, intra-arterial; infusion
technique, each additional hour up to 8 hours (List separately
in addition to code for primary procedure)
1/1/2006
R
97024
Application of a modality to one or more areas; diathermy
(e.g., microwave)
1/1/2006
R
97542
Wheelchair management (e.g., assessment, fitting, training),
each 15 minutes
1/1/2006
R
97811
Acupuncture, 1 or more needles, without electrical
stimulation; each additional 15 minutes of personal one-onone contact with the patient, with re-insertion of needle(s) (List
separately in addition to code for primary procedure)
1/1/2006
R
97813
Acupuncture, 1 or more needles; with electrical stimulation,
initial 15 minutes of personal one-on-one contact with the
patient
1/1/2006
R
97814
Acupuncture, one or more needles; with electrical
stimulation, each additional 15 minutes of personal one-onone contact with the patient, with re-insertion of the needle(s)
(List separately in addition to the code for primary procedure
1/1/2006
R
99050
Services provided in the office at times other than regularly
scheduled office hours, or days when the office is normally
closed (e.g., holidays, Saturday or Sunday), in addition to
basic service
1/1/2006
R
99056
Service (s) typically provided in the office, provided
out of the office at the request of the patient, in addition to
basic service
1/1/2006
R
99058
Service (s) provided on an emergency basis in the office,
which disrupts other scheduled office services,
in additoin to basic service
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
A0998
Ambulance response and treatment, no transport
1/1/2006
A
A4218
Sterile saline or water, metered dose dispenser, 10 ml
1/1/2006
A
A4233
Replacement battery, alkaline (other than J cell), for use with
medically necessary home blood glucose monitor, owned by
patient, each
1/1/2006
A
A4234
Replacement battery, alkaline, J cell, for use with
medically necessary home blood glucose monitor owned by
patient, each
1/1/2006
A
A4235
Replacement battery, lithium, for use with medically
necessary home blood glucose monitor owned by patient,
each
1/1/2006
A
A4236
Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each
1/1/2006
A
A4363
Ostomy clamp, any type, replacement only, each
1/1/2006
A
A4411
Ostomy skin barrier, solid 4x4 or equivalent, extended wear, 1/1/2006
with built-in convexity, each
A
A4412
Ostomy pouch, drainable, high output, for use on a barrier
with flange (2-piece system), without filter, each
1/1/2006
A
A4604
Tubing with integrated heating element for use with positive
airway pressure device
1/1/2006
A
A5120
Skin barrier, wipes or swabs, each
1/1/2006
A
A5512
For diabetics only, multiple density insert, direct formed,
molded to foot after external heat source of 230 degrees
Fahrenheit or higher, total contact with patient’s foot,
including arch, base layer minimum of 1/4 inch material of
shore a 35 durometer or 3/16 inch material of shore a 40
durometer (or higher), prefabricated, each
1/1/2006
A
A5513
For diabetics only, multiple density insert, custom molded
from model of patient’s foot, total contact with patient’s foot,
including arch, base layer minimum of 1/4 inch material of
shore a 35 durometer or 3/16 inch material of shore a 40
durometer (or higher), includes arch filler and other shaping
material, custom fabricated, each
1/1/2006
A
A6457
Tubular dressing with or without elastic, any width, per
linear yard
1/1/2006
A
A6513
Compression burn mask, face and/or neck, plastic or equal,
custom fabricated
1/1/2006
A
A6530
Gradient compression stocking, below knee, 18-30 mm Hg,
each
1/1/2006
A
A6531
Gradient compression stocking, below knee, 30-40 mm Hg,
each
1/1/2006
A
A6532
Gradient compression stocking, below knee, 40-50 mm Hg,
each
1/1/2006
A
A6533
Gradient compression stocking, thigh length,
18-30 mm Hg, each
1/1/2006
A
A6534
Gradient compression stocking, thigh length,
30-40 mm Hg, each
1/1/2006
A
A6535
Gradient compression stocking, thigh length,
40-50 mm Hg, each
1/1/2006
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HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
A6536
Gradient compression stocking, full length/chap style,
18-30 mm Hg, each
1/1/2006
A
A6537
Gradient compression stocking, full length/chap style,
30-40 mm Hg, each
1/1/2006
A
A6538
Gradient compression stocking, full length/chap style,
40-50 mm Hg, each
1/1/2006
A
A6539
Gradient compression stocking, waist length,
18-30 mm Hg, each
1/1/2006
A
A6540
Gradient compression stocking, waist length,
30-40 mm Hg, each
1/1/2006
A
A6541
Gradient compression stocking, waist length,
40-50 mm Hg, each
1/1/2006
A
A6542
Gradient compression stocking, custom made
1/1/2006
A
A6543
Gradient compression stocking, lymphedema
1/1/2006
A
A6544
Gradient compression stocking, garter belt
1/1/2006
A
A6549
Gradient compression stocking, not otherwise
specified
1/1/2006
A
A9275
Home glucose disposable monitor, includes test strips
1/1/2006
A
A9281
Reaching/grabbing device, any type, any length, each
1/1/2006
A
A9282
Wig, any type, each
1/1/2006
A
A9535
Injection, methylene blue, 1 mL
1/1/2006
A
A9536
Technetium Tc-99m depreotide, diagnostic, per study dose,
up to 35 millicuries
1/1/2006
A
A9537
Technetium Tc-99m mebrofenin, diagnostic, per study dose,
up to 15 millicuries
1/1/2006
A
A9538
Technetium Tc-99m pyrophosphate, diagnostic, per study
dose, up to 25 millicuries
1/1/2006
A
A9539
Technetium Tc-99m pentetate, diagnostic, per study dose, up
to 25 millicuries
1/1/2006
A
A9540
Technetium Tc-99m macroaggregated albumin, diagnostic,
per study dose, up to 10 millicuries
1/1/2006
A
A9541
Technetium Tc-99m sulfur colloid, diagnostic, per study dose,
up to 20 millicuries
1/1/2006
A
A9542
Indium In-111 ibritumomab tiuxetan, diagnostic, per study
dose, up to 5 millicuries
1/1/2006
A
A9543
Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment
dose, up to 40 millicuries
1/1/2006
A
A9544
Iodine I-131 tositumomab, diagnostic, per study dose
1/1/2006
A
A9545
Iodine I-131 tositumomab, therapeutic, per treatment dose
1/1/2006
A
A9546
Cobalt Co-57/58, cyanocobalamin, diagnostic,
per study dose, up to 1 microcurie
1/1/2006
A
A9547
Indium In-111 oxyquinoline, diagnostic,
per 0.5 millicurie
1/1/2006
A
A9548
Indium In-111 pentetate, diagnostic, per 0.5 millicurie
1/1/2006
A
A9549
Technetium Tc-99m arcitumomab, diagnostic,
per study dose, up to 25 millicuries
1/1/2006
A
A9550
Technetium Tc-99m sodium gluceptate, diagnostic,
per study dose, up to 25 millicuries
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
A9551
Technetium Tc-99m succimer, diagnostic, per study dose, up
to 10 millicuries
1/1/2006
A
A9552
Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose,
up to 45 millicuries
1/1/2006
A
A9553
Chromium Cr-51 sodium chromate, diagnostic,
per study dose, up to 250 microcuries
1/1/2006
A
A9554
Iodine I-125 sodium iothalamate, diagnostic,
per study dose, up to 10 microcuries
1/1/2006
A
A9555
Rubidium Rb-82, diagnostic, per study dose,
up to 60 millicuries
1/1/2006
A
A9556
Gallium Ga-67 citrate, diagnostic, per millicurie
1/1/2006
A
A9557
Technetium Tc-99m bicisate, diagnostic, per study dose, up
to 25 millicuries
1/1/2006
A
A9558
Xenon Xe-133 gas, diagnostic, per 10 millicuries
1/1/2006
A
A9559
Cobalt Co-57 cyanocobalamin, oral, diagnostic,
per study dose, up to 1 microcurie
1/1/2006
A
A9560
Technetium Tc-99m labeled red blood cells,
diagnostic, per study dose, up to 30 millicuries
1/1/2006
A
A9561
Technetium Tc-99m oxidronate, diagnostic,
per study dose, up to 30 millicuries
1/1/2006
A
A9562
Technetium Tc-99m mertiatide, diagnostic,
per study dose, up to 15 millicuries
1/1/2006
A
A9563
Sodium phosphate P-32, therapeutic, per millicurie
1/1/2006
A
A9564
Chromic phosphate P-32 suspension, therapeutic,
per millicurie
1/1/2006
A
A9565
Indium In-111 pentetreotide, diagnostic, per millicurie
1/1/2006
A
A9566
Technetium Tc-99m fanolesomab, diagnostic,
per study dose, up to 25 millicuries
1/1/2006
A
A9567
Technetium Tc-99m pentetate, diagnostic, aerosol,
per study dose, up to 75 millicuries
1/1/2006
A
A9698
Non-radioactive contrast imaging material,
not otherwise classified, per study
1/1/2006
A
B4185
Parenteral nutrition solution, per 10 grams lipids
1/1/2006
A
C8950
Intravenous infusion for therapy/diagnosis;
up to one hour
1/1/2006
A
C8951
Intravenous infusion for therapy/diagnosis; each
additional hour (List separately in addition to C8950)
1/1/2006
A
C8952
Therapeutic, prophylactic or diagnostic injection; intravenous
push
1/1/2006
A
C8953
Chemotherapy administration, intravenous;
push technique
1/1/2006
A
C8954
Chemotherapy administration, intravenous; infusion technique, up to one hour
1/1/2006
A
C8955
Chemotherapy administration, intravenous; infusion technique, each hour (List separately in addition to C8954)
1/1/2006
A
C8957
Intravenous infusion for therapy/diagnosis; initiation of
prolonged infusion (more than eight hours),
requiring use of portable or implantable pump
1/1/2006
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C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
E0170
Commode chair with integrated seat lift mechanism, electric,
any type
1/1/2006
A
E0171
Commode chair with integrated seat lift mechanism, nonelectric, any type
1/1/2006
A
E0172
Seat lift mechanism placed over or on top of toilet, any type
1/1/2006
A
E0485
Oral device/appliance used to reduce upper airway
collapsibility, adjustable or non-adjustable, prefabricated,
includes fitting and adjustment
1/1/2006
A
E0486
Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated,
includes fitting and adjustment
1/1/2006
A
E0641
Standing frame system, multi-position (e.g., three-way
stander), any size including pediatric, with or
without wheels
1/1/2006
A
E0642
Standing frame system, mobile (dynamic stander), any size
including pediatric
1/1/2006
A
E0705
Transfer board or device, any type, each
1/1/2006
A
E0762
Transcutaneous electrical joint stimulation device system,
includes all accessories
1/1/2006
A
E0764
Functional neuromuscular stimulator, transcutaneous stimulation of muscles of ambulation with computer control, used for
walking by spinal cord injured, entire system, after completion of training program
1/1/2006
A
E0911
Trapeze bar, heavy duty, for patient weight capacity greater
than 250 pounds, attached to bed, with
grab bar
1/1/2006
A
E0912
Trapeze bar, heavy duty, for patient weight capacity greater
than 250 pounds, free standing, complete with grab bar
1/1/2006
A
E1392
Portable oxygen concentrator, rental
1/1/2006
A
E1812
Dynamic knee, extension/flexion device with active resistance control
1/1/2006
A
E2207
Wheelchair accessory, crutch and cane holder, each
1/1/2006
A
E2208
Wheelchair accessory, cylinder tank carrier, each
1/1/2006
A
E2209
Wheelchair accessory, arm trough, each
1/1/2006
A
E2210
Wheelchair accessory, bearings, any type, replacement
only, each
1/1/2006
A
E2211
Manual wheelchair accessory, pneumatic propulsion tire,
any size, each
1/1/2006
A
E2212
Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each
1/1/2006
A
E2213
Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each
1/1/2006
A
E2214
Manual wheelchair accessory, pneumatic caster tire, any
size, each
1/1/2006
A
E2215
Manual wheelchair accessory, tube for pneumatic caster tire,
any size, each
1/1/2006
A
E2216
Manual wheelchair accessory, foam filled propulsion tire,
any size, each
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
E2217
Manual wheelchair accessory, foam filled caster tire,
any size, each
1/1/2006
A
E2218
Manual wheelchair accessory, foam propulsion tire,
any size, each
1/1/2006
A
E2219
Manual wheelchair accessory, foam caster tire,
any size, each
1/1/2006
A
E2220
Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each
1/1/2006
A
E2221
Manual wheelchair accessory, solid (rubber/plastic) caster
tire (removable), any size, each
1/1/2006
A
E2222
Manual wheelchair accessory, solid (rubber/plastic) caster
tire with integrated wheel, any size, each
1/1/2006
A
E2223
Manual wheelchair accessory, valve, any type, replacement
only, each
1/1/2006
A
E2224
Manual wheelchair accessory, propulsion wheel excludes
tire, any size, each
1/1/2006
A
E2225
Manual wheelchair accessory, caster wheel excludes tire,
any size, replacement only, each
1/1/2006
A
E2226
Manual wheelchair accessory, caster fork, any size, replacement only, each
1/1/2006
A
E2371
Power wheelchair accessory, group 27 sealed lead acid
battery, (e.g., gel cell, absorbed glassmat), each
1/1/2006
A
E2372
Power wheelchair accessory, group 27 non-sealed lead acid
battery, each
1/1/2006
A
G0332
Services for intravenous infusion of immunoglobulin prior to
administration, per infusion encounter (this service is to be
billed in conjunction with administration of immunoglobulin)
1/1/2006
A
G0333
Pharmacy dispensing fee for inhalation drug(s); initial 30day supply as a beneficiary
1/1/2006
A
G0378
Hospital observation service, per hour
1/1/2006
A
G0379
Direct admission of patient for hospital observation care
1/1/2006
A
G8006
Acute myocardial infarction: patient documented to have
received aspirin at arrival
1/1/2006
A
G8007
Acute myocardial infarction: patient not documented to have
received aspirin at arrival
1/1/2006
A
G8008
Clinician documented that acute myocardial infarction
patient was not an eligible candidate to receive aspirin at
arrival measure
1/1/2006
A
G8009
Acute myocardial infarction: patient documented to have
received beta-blocker at arrival
1/1/2006
A
G8010
Acute myocardial infarction: patient not documented to have
received beta-blocker at arrival
1/1/2006
A
G8011
Clinician documented that acute myocardial infarction
patient was not an eligible candidate for beta-blocker at
arrival measure
1/1/2006
A
G8012
Pneumonia: patient documented to have received antibiotic
within four hours of presentation
1/1/2006
A
G8013
Pneumonia: patient not documented to have received antibiotic within four hours of presentation
1/1/2006
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HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G8014
Clinician documented that pneumonia patient was not an
1/1/2006
eligible candidate for antibiotic within four hours of presentation measure
A
G8015
Diabetic patient with most recent hemoglobin A1c level
(within the last six months) documented as greater
than 9%
1/1/2006
A
G8016
Diabetic patient with most recent hemoglobin A1c level
(within the last six months) documented as less than or equal
to 9%
1/1/2006
A
G8017
Clinician documented that diabetic patient was not eligible
candidate for hemoglobin A1c measure
1/1/2006
A
G8018
Clinician has not provided care for the diabetic patient for
the required time for hemoglobin A1c measure
(6 months)
1/1/2006
A
G8019
Diabetic patient with most recent low-density lipoprotein
(within the last 12 months) documented as greater than or
equal to 100 mg/dl
1/1/2006
A
G8020
Diabetic patient with most recent low-density lipoprotein
(within the last 12 months) documented as less than
100 mg/dl
1/1/2006
A
G8021
Clinician documented that diabetic was not an eligible
candidate for low-density lipoprotein measure
1/1/2006
A
G8022
Clinician has not provided care for the diabetic patient for
the required time for low-density lipoprotein measure (12
months)
1/1/2006
A
G8023
Diabetic patient with most recent blood pressure (within the
last six months) documented as equal to or greater than 140
systolic or equal to or greater than 80 diastolic
1/1/2006
A
G8024
Diabetic patient with most recent blood pressure (within the
last six months) documented less than 140 systolic and less
than 80 diastolic
1/1/2006
A
G8025
Clinician documented that the diabetic patient was not an
eligible candidate for blood pressure measure
1/1/2006
A
G8026
Clinician has not provided care for the diabetic patient
for the required time for blood measure (within the last six
months)
1/1/2006
A
G8027
Heart failure patient with left ventricular systolic dysfunction
(LVSD) documented to be on either angiotensin-converting
enzyme inhibitor or angiotensin-receptor blocker therapy
1/1/2006
A
G8028
Heart failure patient with left ventricular systolic dysfunction
(LVSD) not documented to be on either angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker (ACE-1
or ARB) therapy
1/1/2006
A
G8029
Clinician documented that heart failure patient was not an
eligible candidate for either angiotensin-converting enzyme
inhibitor or angiotensin-receptor blocker (ACE-1 or ARB)
therapy measure
1/1/2006
A
G8030
Heart failure patient with left ventricular systolic dysfunction
(LVSD) documented to be on beta-blocker therapy
1/1/2006
A
G8031
Heart failure patient with left ventricular systolic dysfunction
(LVSD) not documented to be on beta-blocker therapy
1/1/2006
A
G8032
Clinician documented that heart failure patient was not an
eligible candidate for beta-blocker therapy measure
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G8033
Prior myocardial infarction – coronary artery disease patient
documented to be on beta-blocker therapy
1/1/2006
A
G8034
Prior myocardial infarction – coronary artery disease patient
not documented to be on beta-blocker therapy
1/1/2006
A
G8035
Clinician documented that prior myocardial infarction
– coronary artery disease patient was not an eligible candidate for beta-blocker therapy measure
1/1/2006
A
G8036
Coronary artery disease patient documented to be on
antiplatelet therapy
1/1/2006
A
G8037
Coronary artery disease patient not documented to be on
antiplatelet therapy
1/1/2006
A
G8038
Clinician documented that coronary artery disease patient
was not an eligible candidate for antiplatelet therapy
measure
1/1/2006
A
G8039
Coronary artery disease – patient with low-density lipoprotein documented to be greater than 100 mg/dL
1/1/2006
A
G8040
Coronary artery disease – patient with low-density lipoprotein documented to be less than or equal to 100 mg/dL
1/1/2006
A
G8041
Clinician documented that coronary artery disease patient
was not an eligible candidate for low-density lipoprotein
measure
1/1/2006
A
G8051
Patient (female) documented to have been assessed for
osteoporosis
1/1/2006
A
G8052
Patient (female) not documented to have been
assessed for osteoporosis
1/1/2006
A
G8053
Clinician documented that (female) patient was not an
eligible candidate for osteoporosis assessment measure
1/1/2006
A
G8054
Patient not documented for the assessment for falls within last
12 months
1/1/2006
A
G8055
Patient documented for the assessment for falls within last 12
months
1/1/2006
A
G8056
Clinician documented that patient was not an eligible
candidate for the falls assessment measure within the last 12
months
1/1/2006
A
G8057
Patient documented to have received hearing
assessment
1/1/2006
A
G8058
Patient not documented to have received hearing
assessment
1/1/2006
A
G8059
Clinician documented that patient was not an eligible candidate for hearing assessment measure
1/1/2006
A
G8060
Patient documented for the assessment of urinary incontinence
1/1/2006
A
G8061
Patient not documented for the assessment of urinary incontinence
1/1/2006
A
G8062
Clinician documented that patient was not an eligible candidate for urinary incontinence assessment measure
1/1/2006
A
G8075
End-stage renal disease patient with documented dialysis
dose of URR greater than or equal to 65%
(or Kt/V greater than or equal to 1.2)
1/1/2006
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C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G8076
End-stage renal disease patient with documented dialysis
dose of URR less than 65% (or Kt/V greater than or equal
to 1.2)
1/1/2006
A
G8077
Clinician documented that end-stage renal disease patient
was not an eligible candidate for URR or Kt/V measure
1/1/2006
A
G8078
End-stage renal disease patient with documented hematocrit
greater than or equal to 33 (or hemoglobin greater than or
equal to 11)
1/1/2006
A
G8079
End-stage renal disease patient with documented hematocrit
less than or equal to 33 (or hemoglobin less than or equal
to 11)
1/1/2006
A
G8080
Clinician documented that end-stage renal disease patient
was not an eligible candidate for hematocrit (hemoglobin)
measure
1/1/2006
A
G8081
End-stage renal disease patient requiring hemodialysis
vascular access documented to have received autogenous
AV fistula
1/1/2006
A
G8082
End-stage renal disease patient requiring hemodialysis
documented to have received vascular access other than
autogenous AV fistula
1/1/2006
A
G8093
Newly diagnosed chronic obstructive pulmonary disease
(COPD) patient documented to have received smoking cessation intervention, within three months of diagnosis
1/1/2006
A
G8094
Newly diagnosed chronic obstructive pulmonary disease
(COPD) patient not documented to have received smoking
cessation intervention, within three months of diagnosis
1/1/2006
A
G8099
Osteoporosis patient documented to have been
prescribed calcium and vitamin D supplements
1/1/2006
A
G8100
Clinician documented that osteoporosis patient was not an
eligible candidate for calcium and vitamin D supplement
measure
1/1/2006
A
G8103
Newly diagnosed osteoporosis patients documented to have
been treated with antiresorptive therapy and/or parathyroid
hormone treatment within three months of diagnosis
1/1/2006
A
G8104
Clinician documented that newly diagnosed osteoporosis pa- 1/1/2006
tient was not an eligible candidate for antiresorptive therapy
and/or parathyroid hormone treatment measure within three
months of diagnosis
A
G8106
Within six months of suffering a nontraumatic fracture,
female patient 65 years of age or older documented to have
undergone bone mineral density testing or to have been
prescribed a drug to treat or prevent osteoporosis
1/1/2006
A
G8107
Clinician documented that female patient 65 years of age
or older who suffered a nontraumatic fracture within the last
6 months was not an eligible candidate for measure to test
bone mineral density or drug to treat or prevent osteoporosis
1/1/2006
A
G8108
Patient documented to have received influenza
vaccination during influenza season
1/1/2006
A
G8109
Patient not documented to have received influenza
vaccination during influenza season
1/1/2006
A
G8110
Clinician documented that patient was not an eligible candidate for influenza vaccination measure
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G8111
Patient (female) documented to have received a mammogram during the measurement year or prior year to the
measurement year
1/1/2006
A
G8112
Patient (female) not documented to have received a mammogram during the measurement year or prior year to the
measurement year
1/1/2006
A
G8113
Clinician documented that female patient was not an eligible
candidate for mammogram measure
1/1/2006
A
G8114
Clinician did not provide care to patient for the
required time of mammography measure
(i.e., measurement year or prior year)
1/1/2006
A
G8115
Patient documented to have received pneumococcal vaccination
1/1/2006
A
G8116
Patient not documented to have received
pneumococcal vaccination
1/1/2006
A
G8117
Clinician documented that patient was not eligible
candidate for pneumococal vaccination measure
1/1/2006
A
G8126
Patient documented as being treated with antidepressant
medication during the entire 12 week acute treatment phase
1/1/2006
A
G8127
Patient not documented as being treated with antidepressant
medication during the entire 12 week acute treatment phase
1/1/2006
A
G8128
Clinician documented that patient was not an eligible
1/1/2006
candidate for antidepressant medication during the entire 12
week acute treatment phase measure
A
G8129
Patient documented as being treated with antidepressant
medication for at least six months continuous treatment
phase
1/1/2006
A
G8130
Patient not documented as being treated with antidepressant
medication during the entire 12 week acute treatment phase
1/1/2006
A
G8131
Clinician documented that patient was not eligible candidate
for antidepressant medication for continuous treatment phase
1/1/2006
A
G8152
Patient documented to have received antibiotic prophylaxis
one hour prior to incision time (two hours for vancomycin)
1/1/2006
A
G8153
Patient not documented to have received antibiotic prophylaxis one hour prior to incision time (two hours for vancomycin)
1/1/2006
A
G8154
Clinician documented that patient was not an eligible candidate for antibiotic prophylaxis one hour prior to
incision time (two hour for vancomycin) measure
1/1/2006
A
G8155
Patient with documented receipt of thromboembolism
prophylaxis
1/1/2006
A
G8156
Patient without documented receipt of thromboembolism
prophylaxis
1/1/2006
A
G8157
Clinician documented that patient was not an eligible candidate for thromboembolism prophylaxis measure
1/1/2006
A
G8158
Patient documented to have coronary artery bypass graft
with use of internal mammary artery
1/1/2006
A
G8159
Patient documented to have coronary artery bypass graft
without use of internal mammary artery
1/1/2006
A
G8160
Clinician documented that patient was not an eligible candidate for coronary artery bypass graft with use of internal
mammary artery measure
1/1/2006
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Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G8161
Patient with isolated coronary artery bypass graft documented to have received pre-operative beta-blockade
1/1/2006
A
G8162
Patient with isolated coronary artery bypass graft
not documented to have received pre-operative
beta-blockade
1/1/2006
A
G8163
Clinician documented that patient with isolated
coronary artery bypass graft was not an eligible
candidate for pre-operative beta-blockade measure
1/1/2006
A
G8164
Patient with isolated coronary artery bypass graft documented to have prolonged intubation
1/1/2006
A
G8165
Patient with isolated coronary artery bypass graft
not documented to have prolonged intubation
1/1/2006
A
G8166
Patient with isolated coronary artery bypass graft
documented to have required surgical re-exploration
1/1/2006
A
G8167
Patient with isolated coronary artery bypass graft
did not require surgical re-exploration
1/1/2006
A
G8170
Patient with isolated coronary artery bypass graft
documented to have been discharged on aspirin or clopidogrel
1/1/2006
A
G8171
Patient with isolated coronary artery bypass graft not documented to have been discharged on aspirin or clopidogrel
1/1/2006
A
G8172
Clinician documented that patient with isolated
coronary artery bypass graft was not an eligible candidate
for antiplatelet therapy at discharge measure
1/1/2006
A
G8182
Clinician has not provided care for the cardiac
patient for the required time for low-density lipoprotein
measure (six months)
1/1/2006
A
G8183
Patient with heart failure and atrial fibrillation documented to
be on Warfarin therapy
1/1/2006
A
G8184
Clinician documented that patient with heart failure and
atrial fibrillation was not an eligible candidate for Warfarin
therapy measure
1/1/2006
A
G8185
Patient diagnosed with symptomatic osteoarthritis with documented annual assessment of function and pain
1/1/2006
A
G8186
Clinician documented that symptomatic osteoarthritis patient
was not an eligible candidate for annual assessment of function and pain measure
1/1/2006
A
G9050
Oncology; primary focus of visit; work-up, evaluation, or
staging at the time of cancer diagnosis or recurrence (For
use in a Medicare-approved demonstration project)
1/1/2006
A
G9051
Oncology; primary focus of visit; treatment decision-making
1/1/2006
after disease is staged or restaged, discussion of treatment
options, supervising/coordinating active cancer directed
therapy or managing consequences of cancer directed therapy (For use in Medicare-approved demonstration project)
A
G9052
Oncology; primary focus of visit; surveillance for disease
recurrence for patient who has completed definitive cancerdirected therapy and currently lacks evidence of recurrent
disease; cancer directed therapy might be considered in
the future (For use in a Medicare-approved demonstration
project)
Delete Date
1/1/2006
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G9053
Oncology; primary focus of visit; expectant management of
1/1/2006
patient with evidence of cancer for whom no cancer directed
therapy is being administered or arranged at present;
cancer directed therapy might be present; cancer directed
therapy might be considered in the future (For use in a Medicare-approved demonstration project)
A
G9054
Oncology; primary focus of visit; supervising, coordinating
1/1/2006
or managing care of patient with terminal cancer or for
whom other medical illness prevents further cancer treatment;
includes symptom management, end-of-life care planning,
management of palliative therapies (For use in a Medicareapproved demonstration project)
A
G9055
Oncology; primary focus of visit; other, unspecified service
not otherwise listed (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9056
Oncology; practice guidelines; management adheres to
guidelines (For use in a Medicare-approved demonstration
project)
1/1/2006
A
G9057
Oncology; practice guidelines; management differs from
guidelines as a result of patient enrollment in an institutional
review board approved clinical trial (For use in a Medicareapproved demonstration project)
1/1/2006
A
G9058
Oncology; practice guidelines; management differs from
guidelines because the treating physician disagrees with
guideline recommendations (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9059
Oncology; practice guidelines; management differs from
guidelines because the patient, after being offered treatment
consistent with guidelines, has opted for alternative treatment
or management, including no treatment (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9060
Oncology; practice guidelines; management differs from
guidelines for reason(s) associated with patient comorbid
illness or performance status not factored into guidelines (For
use in a Medicare-approved demonstration project)
1/1/2006
A
G9061
Oncology; practice guidelines; patient’s condition not addressed by available guidelines (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9062
Oncology; practice guidelines; management differs from
guidelines for other reason(s) not listed (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9063
Oncology; disease status; limited to non-small cell lung
cancer; extent of disease initially established as Stage I
(prior to neo-adjuvant therapy, if any) with no evidence of
disease progression, recurrence, or metastases (For use in a
Medicare-approved demonstration project)
1/1/2006
A
G9064
Oncology; disease status; limited to non-small cell lung
cancer; extent of disease initially established as Stage II
(prior to neo-adjuvant therapy, if any) with no evidence of
disease progression, recurrence, or metastases (For use in a
Medicare-approved demonstration project)
1/1/2006
A
G9065
Oncology; disease status; limited to non-small cell lung
cancer; extent of disease initially established as Stage III a
(prior to neo-adjuvant therapy, if any) with no evidence of
disease progression, recurrence, or metastases (For use in a
Medicare-approved demonstration project)
1/1/2006
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HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G9066
Oncology; disease status; limited to non-small cell lung cancer; stage III B-IV at diagnosis, metastatic, locally recurrent,
or progressive (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9067
Oncology; disease status; limited to non-small cell lung
cancer; extent of disease unknown, under evaluation, not yet
determined, or not listed (For use in a Medicare-approved
demonstration project)
1/1/2006
A
G9068
Oncology; disease status; limited to small cell and combined
small cell/non-small cell; extent of disease initially established as limited with no evidence of disease progression,
recurrence, or metastases (For use in a Medicare-approved
demonstration project)
1/1/2006
A
G9069
Oncology; disease status; small cell lung cancer, limited to
small cell and combined small cell/non-small cell; extensive
stage at diagnosis, metastatic, locally recurrent, or progressive (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9070
Oncology; disease status; small cell lung cancer, limited to
small cell and combined small cell/non-small; extent of disease unknown, under evaluation, pre-surgical, or not listed
(For use in a Medicare-approved demonstration project)
1/1/2006
A
G9071
Oncology; disease status; invasive female breast cancer
(does not include ductal carcinoma in situ); adenocarcinoma
as predominant cell type; Stage I or Stage IIA-IB; or T3,
N1, M0; and ER and/or PR positive; with no evidence of
disease progression, recurrence, or metastases (For use in a
Medicare-approved demonstration project)
1/1/2006
A
G9072
Oncology; disease status; invasive female breast cancer
(does not include ductal carcinoma in situ); adenocarcinoma
as predominant cell type; Stage I, or Stage IIA-IIB; or T3,
N1, M0; and ER and PR negative; with no evidence of
disease progression, recurrence, or metastases (For use in a
Medicare-approved demonstration project)
1/1/2006
A
G9073
Oncology; disease status; invasive female breast cancer
(does not include ductal carcinoma in situ); adenocarcinoma
as predominant cell type; Stage IIIA-IIIB; and not T3, N1,
M0; and ER and/or PR positive; with no evidence of disease
progression, recurrence, or metastases (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9074
Oncology; disease status; invasive female breast cancer
(does not include ductal carcinoma in situ); adenocarcinoma
as predominant cell type; Stage IIIA-IIIB; and not T3, N1,
M0; and ER and PR negative; with no evidence of disease
progression, recurrence, or metastases (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9075
Oncology; disease status; invasive female breast cancer
(does not include ductal carcinoma in situ); adenocarcinoma
as predominant cell type; M1 at diagnosis, metastatic,
locally recurrent, or progressive (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9076
Oncology; disease status; invasive female breast cancer
(does not include ductal carcinoma in situ); adenocarcinoma
as predominant cell type; extent of disease unknown, under
evaluation, pre-surgical or not listed (For use in a Medicareapproved demonstration project)
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G9077
Oncology; disease status; prostate cancer, limited to adenocarcinoma as predominant cell type; T1-T2c and Gleason
2-7 and PSA < or equal to 20 at diagnosis with no evidence
of disease progression, recurrence, or metastases (For use in
a Medicare-approved demonstration project)
1/1/2006
A
G9078
Oncology; disease status; prostate cancer, limited to adenocarcinoma as predominant cell type; T2 or Gleason 8-10 or
PSA > 20 at diagnosis with no evidence of disease progression, recurrence, or metastases (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9079
Oncology; disease status; prostate cancer, limited to adenocarcinoma as predominant cell type; T3b-T4, any N; any T,
N1 at diagnosis with no evidence of disease progression,
recurrence, or metastases (For use in a Medicare-approved
demonstration project)
1/1/2006
A
G9080
Oncology; disease status; prostate cancer, limited to adenocarcinoma; after initial treatment with rising PSA or failure of
PSA decline (For use in a Medicare-approved demonstration
project)
1/1/2006
A
G9081
Oncology; disease status; prostate cancer, limited to adenocarcinoma; non-castrate, incompletely castrate; clinical
metastases or M1 at diagnosis (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9082
Oncology; disease status; prostate cancer, limited to adenocarcinoma; castrate; clinical metastases or M1 at diagnosis
(For use in a Medicare-approved demonstration project)
1/1/2006
A
G9083
Oncology; disease status; prostate cancer, limited to adenocarcinoma; extent of disease unknown, under evaluation or
not listed (For use in a Medicare-approved demonstration
project)
1/1/2006
A
G9084
Oncology; disease status; colon cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; extent
of disease initially established as T1-T3, N0, M0 with no
evidence of disease progression, recurrence, or metastases
(For use in a Medicare-approved demonstration project)
1/1/2006
A
G9085
Oncology; disease status; colon cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; extent of
disease initially established as T4, N0, M0 with no evidence
of disease progression, recurrence, or metastases (For use in
a Medicare-approved demonstration project)
1/1/2006
A
G9086
Oncology; disease status; colon cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; extent of
disease initially established as T1-T4, N1-N2, M0 with no
evidence of disease progression, recurrence, or metastases
(For use in a Medicare-approved demonstration project)
1/1/2006
A
G9087
Oncology; disease status; colon cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; M1 at diagnosis, metastatic, locally recurrent, or progressive with current clinical, radiologic, or biochemical evidence of disease
(For use in a Medicare-approved demonstration project)
1/1/2006
A
G9088
Oncology; disease status; colon cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; M1
at diagnosis, metastatic, locally recurrent, or progressive
without current clinical, radiologic, or biochemical evidence
of disease (For use in a Medicare-approved demonstration
project)
1/1/2006
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Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G9089
Oncology; disease status; colon cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; extent
of disease unknown, not yet determined, under evaluation,
pre-surgical, or not listed (For use in a Medicare-approved
demonstration project)
1/1/2006
A
G9090
Oncology; disease status; rectal cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; extent
of disease initially established as T1-T2, N0, M0 (prior to
neo-adjuvant therapy, if any) with no evidence of disease
progression, recurrence, or metastases (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9091
Oncology; disease status; rectal cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; extent of
disease initially established as T3, N0, M0 (prior to neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or metastases (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9092
Oncology; disease status; rectal cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; extent
of disease initially established as T1-T3, N1-N2, M0 (prior
to neo-adjuvant therapy, if any) with no evidence of disease
progression, recurrence, or metastases (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9093
Oncology; disease status; rectal cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; extent
of disease initially established as T4, any N, M0 (prior to
neo-adjuvant therapy, if any) with no evidence of disease
progression, recurrence, or metastases (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9094
Oncology; disease status; rectal cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; M1 at
diagnosis, metastatic, locally recurrent, or progressive (For
use in a Medicare-approved demonstration project)
1/1/2006
A
G9095
Oncology; disease status; rectal cancer, limited to invasive
cancer, adenocarcinoma as predominant cell type; extent
of disease unknown, not yet determined, under evaluation,
pre-surgical, or not listed (For use in a Medicare-approved
demonstration project)
1/1/2006
A
G9096
Oncology; disease status; esophageal cancer, limited to
adenocarcinoma or squamous cell carcinoma as predominant cell type; extent of disease initially established as T1-T3,
N0-N1 or NX (prior to neo-adjuvant therapy, if any) with no
evidence of disease progression, recurrence, or metastases
(For use in a Medicare-approved demonstration project)
1/1/2006
A
G9097
Oncology; disease status; esophageal cancer,
limited to adenocarcinoma or squamous cell
carcinoma as predominant cell type; extent of disease
initially established as T4, any N, M0 (prior to neo-adjuvant
therapy, if any) with no evidence of disease progression,
recurrence, or metastases (For use in a Medicare-approved
demonstration project)
1/1/2006
A
G9098
Oncology; disease status; esophageal cancer, limited to adenocarcinoma or squamous cell carcinoma as predominant
cell type; M1 at diagnosis, metastatic,
locally recurrent, or progressive (For use in a
Medicare-approved demonstration project)
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G9099
Oncology; disease status; esophageal cancer, limited to adenocarcinoma or squamous cell carcinoma as predominant
cell type; extent of disease unknown, not yet determined,
under evaluation, pre-surgical, or not listed (For use in a
Medicare-approved demonstration project)
1/1/2006
A
G9100
Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell type; post R0 resection
(with or without neo-adjuvant therapy) with no evidence of
disease recurrence, progression, or metastases (For use in a
Medicare-approved demonstration project)
1/1/2006
A
G9101
Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell type; post R1 or R2 resection
(with or without neo-adjuvant therapy) with no evidence of
disease progression, or metastases (For use in a Medicareapproved demonstration project)
1/1/2006
A
G9102
Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell type; clinical or pathologic
M0, unresectable with no evidence of disease progression,
or metastases (For use in a
Medicare-approved demonstration project)
1/1/2006
A
G9103
Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell type; clinical or pathologic
M1 at diagnosis, metastatic, locally recurrent, or progressive
(For use in a Medicare-approved demonstration project)
1/1/2006
A
G9104
Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell type; extent of disease
unknown, under evaluation, not yet determined, pre-surgical,
or not listed (For use in a Medicare-approved demonstration
project)
1/1/2006
A
G9105
Oncology; disease status; pancreatic cancer, limited to
adenocarcinoma as predominant cell type; post R0 resection
without evidence of disease progression, recurrence, or
metastases (For use in a Medicare-approved demonstration
project)
1/1/2006
A
G9106
Oncology; disease status; pancreatic cancer, limited to adenocarcinoma; post R1 or R2 resection with no evidence of
disease progression, or metastases (For use in a Medicareapproved demonstration project)
1/1/2006
A
G9107
Oncology; disease status; pancreatic cancer, limited to adenocarcinoma; unresectable at diagnosis, M1 at diagnosis,
metastatic, locally recurrent, or progressive (For use in a
Medicare-approved demonstration project)
1/1/2006
A
G9108
Oncology; disease status; pancreatic cancer, limited to ad1/1/2006
enocarcinoma; extent of disease unknown, under evaluation,
not yet determined, pre-surgical, or not listed (For use in a
Medicare-approved demonstration project)
A
G9109
Oncology; disease status; head and neck cancer, limited to
cancers of oral cavity, pharynx and larynx with squamous
cell as predominant cell type; extent of disease initially
established as T1-T2 and N0, M0 (prior to neo-adjuvant
therapy, if any) with no evidence of disease progression,
recurrence, or metastases (For use in a Medicare-approved
demonstration project)
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1/1/2006
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Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G9110
Oncology; disease status; head and neck cancer, limited to
1/1/2006
cancers of oral cavity, pharynx and larynx with squamous
cell as predominant cell type; extent of disease initially established as T3-T4 and/or N1-N3, M0 (prior to neo-adjuvant
therapy, if any) with no evidence of disease progression,
recurrence, or metastases (For use in a Medicare-approved
demonstration project)
A
G9111
Oncology; disease status; head and neck cancer, limited to
cancers of oral cavity, pharynx and larynx with squamous
cell as predominant cell type; M1 at diagnosis, metastatic,
locally recurrent, or progressive (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9112
Oncology; disease status; head and neck cancer, limited to
cancers of oral cavity, pharynx and larynx with squamous
cell as predominant cell type; extent of disease unknown,
not yet determined, pre-surgical, or not listed (For use in a
Medicare-approved demonstration project)
1/1/2006
A
G9113
Oncology; disease status; ovarian cancer, limited to epithelial cancer; pathologic Stage IA-IB (grade 1) without evidence
of disease progression, recurrence, or metastases (For use in
a Medicare-approved demonstration project)
1/1/2006
A
G9114
Oncology; disease status; ovarian cancer, limited to epithelial cancer; pathologic Stage IA-IB (grade 2-3); or Stage IC
(all grades); or Stage II; without evidence of disease progression, recurrence, or metastases (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9115
Oncology; disease status; ovarian cancer, limited to
epithelial cancer; pathologic Stage III-IV; without evidence
of progression, recurrence, or metastases (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9116
Oncology; disease status; ovarian cancer, limited to epithelial cancer; evidence of disease progression, or recurrence,
and/or platinum resistance (For use in a Medicare-approved
demonstration project)
1/1/2006
A
G9117
Oncology; disease status; ovarian cancer, limited to epithelial cancer; extent of disease unknown, under evaluation, incomplete surgical staging, pre-surgical staging, or not listed
(For use in a Medicare-approved demonstration project)
1/1/2006
A
G9118
Oncology; disease status; non-Hodgkin’s lymphoma, limited
to follicular lymphoma, mantle cell lymphoma, diffuse large
B-cell lymphoma, peripheral T-cell lymphoma; small lymphocytic lymphoma; Stage I, II at diagnosis, not relapsed, not
refractory (For use in a Medicare-approved demonstration
project)
1/1/2006
A
G9119
Oncology; disease status; non-Hodgkin’s lymphoma, limited 1/1/2006
to follicular lymphoma, mantle cell lymphoma, diffuse large
B-cell lymphoma, peripheral T-cell lymphoma, small lymphocytic lymphoma; Stage III, IV not relapsed, not refractory (For
use in a Medicare-approved demonstration project)
A
G9120
Oncology; disease status; non-Hodgkin’s lymphoma; limited
to follicular lymphoma, diffuse large B-cell lymphoma;
histologically transformed from follicular lymphoma to diffuse
large B-cell lymphoma (For use in a Medicare-approved
demonstration project)
Delete Date
1/1/2006
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
G9121
Oncology; disease status; non-Hodgkin’s lymphoma, limited
to follicular lymphoma, mantle cell lymphoma, diffuse large
B-cell lymphoma, peripheral T-cell lymphoma or small lymphocytic lymphoma; Stage I, II at diagnosis, not relapsed,
not refractory (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9122
Oncology; disease status; non-Hodgkin’s lymphoma, limited
to follicular lymphoma, mantle cell lymphoma, diffuse large
B-cell lymphoma, peripheral T-cell lymphoma or small lymphocytic lymphoma; Stage III, IV at diagnosis, not relapsed,
not refractory (For use in a Medicare-approved demonstration project)
1/1/2006
A
G9123
Oncology; disease status; non-Hodgkin’s lymphoma, limited
to follicular lymphoma, mantle cell lymphoma, diffuse large
B-cell lymphoma, or histologically transformed from follicular
lymphoma to diffuse large B-cell lymphoma; relapsed or
refractory (For use in a Medicare-approved demonstration
project)
1/1/2006
A
G9124
Oncology; disease status; non-Hodgkin’s lymphoma, limited
to follicular lymphoma, mantle cell lymphoma, diffuse
large B-cell lymphoma, peripheral T-cell lymphoma or small
lymphocytic lymphoma; relapsed and refractory (For use in
a Medicare-approved demonstration project)
1/1/2006
A
G9125
Oncology; disease status; non-Hodgkin’s lymphoma, limited
to follicular lymphoma, mantle cell lymphoma, diffuse
large B-cell lymphoma, peripheral T-cell lymphoma or small
lymphocytic lymphoma; diagnostic evaluation, stage not
determined, evaluation of possible relapse or non-response
to therapy, or not listed (For use in a Medicare-approved
demonstration project)
1/1/2006
A
G9126
Oncology; disease status; ovarian cancer, limited to pathologically stage patients with epithelial cancer; Stage IA/IB
(For use in a Medicare-approved demonstration project)
1/1/2006
A
G9127
Oncology; disease status; limited to multiple myeloma, systemic disease; smoldering, Stage I (For use in a Medicareapproved demonstration project)
1/1/2006
A
G9128
Oncology; disease status; limited to multiple myeloma,
systemic disease; Stage II or higher (For use in a Medicareapproved demonstration project)
1/1/2006
A
G9129
Oncology; disease status; chronic myelogenous leukemia,
limited to Philadelphia chromosome positive and/or Bcr-Abl
positive; extent of disease unknown, under evaluation, not
listed, or treatment options being considered (For use in a
Medicare-approved demonstration project)
1/1/2006
A
G9130
Oncology; disease status; limited to multiple myeloma, systemic disease; extent of disease unknown, under evaluation,
or not listed (For use in a Medicare-approved demonstration
project)
1/1/2006
A
J0132
Injection, acetylcysteine, 100 mg
1/1/2006
A
J0133
Injection, acyclovir, 5 mg
1/1/2006
A
J0278
Injection, amikacin sulfate, 100 mg
1/1/2006
A
J0365
Injection, aprotonin, 10,000 kiu
1/1/2006
A
J0480
Injection, basiliximab, 20 mg
1/1/2006
A
J0795
Injection, corticorelin ovine triflutate, 1 microgram
1/1/2006
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C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
J0881
Injection, darbepoetin alfa, 1 microgram (non-ESRD use)
1/1/2006
A
J0882
Injection, darbepoetin alfa, 1 microgram (for ESRD on
dialysis)
1/1/2006
A
J0885
Injection, epoetin alfa, (for non-ESRD use), 1000 units
1/1/2006
A
J0886
Injection, epoetin alfa, 1000 units (for ESRD on dialysis)
1/1/2006
A
J1162
Injection, digoxin immune fab (ovine), per vial
1/1/2006
A
J1265
Injection, dopamine HCl, 40 mg
1/1/2006
A
J1430
Injection, ethanolamine oleate, 100 mg
1/1/2006
A
J1451
Injection, fomepizole, 15 mg
1/1/2006
A
J1566
Injection, immune globulin, intravenous, lyophilized (e.g.,
powder), 500 mg
1/1/2006
A
J1567
Injection, immune globulin, intravenous, non-lyophilized
(e.g., liquid), 500 mg
1/1/2006
A
J1640
Injection, hemin, 1 mg
1/1/2006
A
J1675
Injection, histrelin acetate, 10 micrograms
1/1/2006
A
J1751
Injection, iron dextran 165, 50 mg
1/1/2006
A
J1752
Injection, iron dextran 267, 50 mg
1/1/2006
A
J1945
Injection, lepirudin, 50 mg
1/1/2006
A
J2278
Injection, ziconotide, 1 microgram
1/1/2006
A
J2325
Injection, nesiritide, 0.1 mg
1/1/2006
A
J2425
Injection, palifermin, 50 micrograms
1/1/2006
A
J2503
Injection, pegaptanib sodium, 0.3 mg
1/1/2006
A
J2504
Injection, pegademase bovine, 25 IU
1/1/2006
A
J2513
Injection, pentastarch, 10% solution, 100 mL
1/1/2006
A
J2805
Injection, sincalide, 5 micrograms
1/1/2006
A
J2850
Injection, secretin, synthetic, human, 1 microgram
1/1/2006
A
J3285
Injection, treprostinil, 1 mg
1/1/2006
A
J3355
Injection, urofollitropin, 75 IU
1/1/2006
A
J3471
Injection, hyaluronidase, ovine, preservative free, per 1 USP
unit (up to 999 USP units)
1/1/2006
A
J3472
Injection, hyaluronidase, ovine, preservative free, per 1000
USP units
1/1/2006
A
J7188
Injection, von Willebrand factor complex, human, IU
1/1/2006
A
J7189
Factor VIIA (antihemophilic factor, recombinant), per 1
microgram
1/1/2006
A
J7306
Levonorgestrel (contraceptive) implant system, including
implants and supplies
1/1/2006
A
J7341
Dermal (substitute) tissue of non-human origin, with or
without other bioengineered or processed elements, with
metabolically active elements, per square centimeter
1/1/2006
A
J7620
Albuterol, up to 2.5 mg and ipratropium bromide, up to
0.5 mg, non-compounded inhalation solution, administered
through DME
1/1/2006
A
J7627
Budesonide, powder, compounded for inhalation solution,
administered through DME, unit dose form, up to 0.5 mg
1/1/2006
A
J7640
Formoterol, inhalation solution administered through DME,
unit dose form, 12 micrograms
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
J8498
Antiemetic drug, rectal/suppository, not otherwise
specified
A
J8515
Cabergoline, oral, 0.25 mg
1/1/2006
A
J8540
Dexamethasone, oral, 0.25 mg
1/1/2006
A
J8597
Antiemetic drug, oral, not otherwise specified
1/1/2006
A
J9025
Injection, azacitidine, 1 mg
1/1/2006
A
J9027
Injection, clofarabine, 1 mg
1/1/2006
A
J9175
Injection, Elliotts B solution, 1 mL
1/1/2006
A
J9225
Histrelin implant, 50 mg
1/1/2006
A
J9264
Injection, paclitaxel protein-bound particles, 1 mg
1/1/2006
A
L0491
TLSO, sagittal-coronal control, modular segmented spinal
system, two rigid plastic shells, posterior extends from the
sacrococcygeal junction and terminates just inferior to the
scapular spine, anterior extends from the symphysis pubis
to the xiphoid, soft liner, restricts gross trunk motion in the
sagittal and coronal planes, lateral strength is provided by
overlapping plastic and stabilizing closures, includes straps
and closures, prefabricated, includes fitting and adjustment
1/1/2006
A
L0492
TLSO, sagittal-coronal control, modular segmented spinal
system, three rigid plastic shells, posterior extends from the
sacrococcygeal junction and terminates just inferior to the
scapular spine, anterior extends from the symphysis pubis
to the xiphoid, soft liner, restricts gross trunk motion in the
sagittal and coronal planes, lateral strength is provided by
overlapping plastic and stabilizing closures, includes straps
and closures, prefabricated, includes fitting and adjustment
1/1/2006
A
L0621
Sacroiliac orthosis, flexible, provides pelvic-sacral support,
reduces motion about the sacroiliac joint, includes straps,
closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment
1/1/2006
A
L0622
Sacroiliac orthosis, flexible, provides pelvic-sacral support,
reduces motion about the sacroiliac joint, includes straps,
closures, may include pendulous abdomen design, custom
fabricated
1/1/2006
A
L0623
Sacroiliac orthosis, provides pelvic-sacral support, with rigid
or semi-rigid panels over the sacrum and abdomen, reduces
motion about the sacroiliac joint, includes straps, closures,
may include pendulous abdomen design, prefabricated,
includes fitting and adjustment
1/1/2006
A
L0624
Sacroiliac orthosis, provides pelvic-sacral support, with rigid
or semi-rigid panels placed over the sacrum and abdomen,
reduces motion about the sacroiliac joint, includes straps,
closures, may include pendulous abdomen design, custom
fabricated
1/1/2006
A
L0625
Lumbar orthosis, flexible, provides lumbar support, posterior
extends from L1 to below L5 vertebra, produces intracavitary
pressure to reduce load on the intervertebral discs, includes
straps, closures, may include pendulous abdomen design,
shoulder straps, stays, prefabricated, includes fitting and
adjustment
1/1/2006
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Delete Date
1/1/2006
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C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
L0626
Lumbar orthosis, sagittal control, with rigid posterior
panel(s), posterior extends from L1 to below L5 vertebra,
produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design,
prefabricated, includes fitting and adjustment
A
L0627
Lumbar orthosis, sagittal control, with rigid anterior and
1/1/2006
posterior panels, posterior extends from L1 to below L5 vertebra, produces intracavitary pressure to reduce load on the
intervertebral discs, includes straps, closures, may include
padding, shoulder straps, pendulous abdomen design,
prefabricated, includes fitting and adjustment
A
L0628
Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T9
vertebra, produces intracavitary pressure to reduce load
on the intervertebral discs, includes straps, closures, may
include stays, shoulder straps, pendulous abdomen design,
prefabricated, includes fitting and adjustment
1/1/2006
A
L0629
Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T9
vertebra, produces intracavitary pressure to reduce load
on the intervertebral discs, includes straps, closures, may
include stays, shoulder straps, pendulous abdomen design,
custom fabricated
1/1/2006
A
L0630
Lumbar-sacral orthosis, sagittal control, with rigid posterior
panel(s), posterior extends from sacrococcygeal junction to
T9 vertebra, produces intracavitary pressure to reduce load
on the intervertebral discs, includes straps, closures, may
include padding, stays, shoulder straps, pendulous abdomen
design, prefabricated, includes fitting and adjustment
1/1/2006
A
L0631
Lumbar-sacral orthosis, sagittal control, with rigid anterior
and posterior panels, posterior extends from sacrococcygeal
junction to T9 vertebra, produces intracavitary pressure
to reduce load on the intervertebral discs, includes straps,
pendulous abdomen design, prefabricated, includes fitting
and adjustment
1/1/2006
A
L0632
Lumbar-sacral orthosis, sagittal control, with rigid anterior
and posterior panels, posterior extends from sacrococcygeal
junction to T9 vertebra, produces intracavitary pressure
to reduce load on the intervertebral discs, includes straps,
closures, may include padding, shoulder straps, pendulous
abdomen design, custom fabricated
1/1/2006
A
L0633
Lumbar-sacral orthosis, sagittal-coronal control, with rigid
posterior frame/panel(s), posterior extends from sacrococcygeal junction to T9 vertebra, lateral strength provided by
rigid lateral frame/panels, produces intracavitary pressure
to reduce load on intervertebral discs, includes straps,
closures, may include padding, stays, shoulder straps,
pendulous abdomen design, prefabricated, includes fitting
and adjustment
1/1/2006
Delete Date
1/1/2006
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
L0634
Lumbar-sacral orthosis, sagittal-coronal control, with rigid
posterior frame/panel(s), posterior extends from sacrococcygeal junction to T9 vertebra, lateral strength provided by
rigid lateral frame/panel(s), produces intracavitary pressure
to reduce load on intervertebral discs, includes straps,
closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated
A
L0635
Lumbar-sacral orthosis, sagittal-coronal control, lumbar flex1/1/2006
ion, rigid posterior frame/panel(s), lateral articulating design
to flex the lumbar spine, posterior extends from sacrococcygeal junction to T9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to
reduce load on intervertebral discs, includes straps, closures,
may include padding, anterior panel, pendulous abdomen
design, prefabricated, includes fitting and adjustment
A
L0636
Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design
to flex the lumbar spine, posterior extends from sacrococcygeal junction to T9 vertebra, lateral strength provided by
rigid lateral frame/panels, produces intracavitary pressure
to reduce load on intervertebral discs, includes straps,
closures, may include padding, anterior panel, pendulous
abdomen design, custom fabricated
1/1/2006
A
L0637
Lumbar-sacral orthosis, sagittal-coronal control, with rigid
anterior and posterior frame/panels, posterior extends from
sacrococcygeal junction to T9 vertebra, lateral strength
provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes
straps, closures, may include padding, shoulder straps,
pendulous abdomen design, prefabricated, includes fitting
and adjustment
1/1/2006
A
L0638
Lumbar-sacral orthosis, sagittal-coronal control, with rigid
anterior and posterior frame/panels, posterior extends from
sacrococcygeal junction to T9 vertebra, lateral strength
provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes
straps, closures, may include padding, shoulder straps,
pendulous abdomen design, custom fabricated
1/1/2006
A
L0639
Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/
panel(s), posterior extends from sacrococcygeal junction
to T9 vertebra, anterior extends from symphysis pubis to
xyphoid, produces intracavitary pressure to reduce load
on the intervertebral discs, overall strength is provided by
overlapping rigid material and stabilizing closures, includes
straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment
1/1/2006
A
L0640
Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/
panel(s), posterior extends from sacrococcygeal junction
to T9 vertebra, anterior extends from symphysis pubis to
xyphoid, produces intracavitary pressure to reduce load
on the intervertebral discs, overall strength is provided by
overlapping rigid material and stabilizing closures, includes
straps, closures, may include soft interface, pendulous abdomen design, custom fabricated
1/1/2006
A
L0859
Addition to halo procedure, magnetic resonance image compatible systems, rings and pins, any material
1/1/2006
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1/1/2006
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C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
L2034
Knee ankle foot orthosis, full plastic, single upright, with or
without free motion knee, medial lateral
rotation control, with or without free motion ankle, custom
fabricated
1/1/2006
A
L2387
Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint
1/1/2006
A
L3671
Shoulder orthosis, shoulder cap design, without joints, may
include soft interface, straps, custom fabricated, includes
fitting and adjustment
1/1/2006
A
L3672
Shoulder orthosis, abduction positioning (airplane
design), thoracic component and support bar, without
joints, may include soft interface, straps, custom fabricated,
includes fitting and adjustment
1/1/2006
A
L3673
Shoulder orthosis, abduction positioning (airplane
design), thoracic component and support bar, includes nontorsion joint/turnbuckle, may include soft interface, straps,
custom fabricated, includes fitting and adjustment
1/1/2006
A
L3702
Elbow orthosis, without joints, may include soft
interface, straps, custom fabricated, includes fitting and
adjustment
1/1/2006
A
L3763
Elbow wrist hand orthosis, rigid, without joints, may include
soft interface, straps, custom fabricated, includes fitting and
adjustment
1/1/2006
A
L3764
Elbow wrist hand orthosis, includes one or more nontorsion
joints, elastic bands, turnbuckles, may include soft interface,
straps, custom fabricated, includes fitting and adjustment
1/1/2006
A
L3765
Elbow wrist hand finger orthosis, rigid, without joints, may
include soft interface, straps, custom fabricated, includes
fitting and adjustment
1/1/2006
A
L3766
Elbow wrist hand finger orthosis, includes one or more
nontorsion joints, elastic bands, turnbuckles, may include
soft interface, straps, custom fabricated, includes fitting and
adjustment
1/1/2006
A
L3905
Wrist hand orthosis, includes one or more nontorsion joints,
elastic bands, turnbuckles, may include soft interface, straps,
custom fabricated, includes fitting and adjustment
1/1/2006
A
L3913
Hand finger orthosis, without joints, may include soft
interface, straps, custom fabricated, includes fitting and
adjustment
1/1/2006
A
L3919
Hand orthosis, without joints, may include soft interface,
straps, custom fabricated, includes fitting and adjustment
1/1/2006
A
L3921
Hand finger orthosis, includes one or more nontorsion joints,
elastic bands, turnbuckles, may include soft interface, straps,
custom fabricated, includes fitting and adjustment
1/1/2006
A
L3933
Finger orthosis, without joints, may include soft interface,
custom fabricated, includes fitting and adjustment
1/1/2006
A
L3935
Finger orthosis, nontorsion joint, may include soft interface,
custom fabricated, includes fitting and adjustment
1/1/2006
A
L3961
Shoulder elbow wrist hand orthosis, shoulder cap design,
without joints, may include soft interface, straps, custom
fabricated, includes fitting and adjustment
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
L3967
Shoulder elbow wrist hand orthosis, abduction positioning
(airplane design), thoracic component and support bar,
without joints, may include soft interface, straps, custom
fabricated, includes fitting and adjustment
1/1/2006
A
L3971
Shoulder elbow wrist hand orthosis, shoulder cap design,
includes one or more nontorsion joints, elastic bands,
turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
1/1/2006
A
L3973
Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support
bar, includes one or more nontorsion joints, elastic bands,
turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
1/1/2006
A
L3975
Shoulder elbow wrist hand finger orthosis, shoulder cap
design, without joints, may include soft interface, straps,
custom fabricated, includes fitting and adjustment
1/1/2006
A
L3976
Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support
bar, without joints, may include soft interface, straps, custom
fabricated, includes fitting and adjustment
1/1/2006
A
L3977
Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands,
turnbuckles, may include soft interface, straps, custom
fabricated, includes fitting and adjustment
1/1/2006
A
L3978
Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support
bar, includes one or more nontorsion joints, elastic bands,
turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
1/1/2006
A
L5703
Ankle, symes, molded to patient model, socket without solid
ankle cushion heel
1/1/2006
A
L5858
Addition to lower extremity prosthesis, endoskeletal knee
shin system, microprocessor control feature, stance phase
only, includes electronic sensor(s), any type
1/1/2006
A
L5971
All lower extremity prosthesis, solid ankle cushion heel
(SACH) foot, replacement only
1/1/2006
A
L6621
Upper extremity prosthesis addition, flexion/extension
wrist with or without friction, for use with external powered
terminal device
1/1/2006
A
L6677
Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow
1/1/2006
A
L6883
Replacement socket, below elbow/wrist disarticulation,
molded to patient model, for use with or without external
power
1/1/2006
A
L6884
Replacement socket, above elbow disarticulation, molded to
patient model, for use with or without external power
1/1/2006
A
L6885
Replacement socket, shoulder disarticulation/interscapular
thoracic, molded to patient model, for use with or without
external power
1/1/2006
A
L7400
Addition to upper extremity prosthesis, below elbow/wrist
disarticulation, ultralight material (titanium, carbon fiber or
equal)
1/1/2006
A
L7401
Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal)
1/1/2006
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Delete Date
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C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
A
L7402
Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium,
carbon fiber or equal)
1/1/2006
A
L7403
Addition to upper extremity prosthesis, below elbow/wrist
disarticulation, acrylic material
1/1/2006
A
L7404
Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material
1/1/2006
A
L7405
Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material
1/1/2006
A
L7600
Prosthetic donning sleeve, any material, each
1/1/2006
A
L8609
Artificial cornea
1/1/2006
A
L8623
Lithium ion battery for use with cochlear implant device
speech processor, other than ear level,
replacement, each
1/1/2006
A
L8624
Lithium ion battery for use with cochlear implant device
speech processor, ear level, replacement, each
1/1/2006
A
L8680
Implantable neurostimulator electrode, each
1/1/2006
A
L8681
Patient programmer (external) for use with implantable
programmable neurostimulator pulse generator
1/1/2006
A
L8682
Implantable neurostimulator radiofrequency receiver
1/1/2006
A
L8683
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
1/1/2006
A
L8684
Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and
bladder management, replacement
1/1/2006
A
L8685
Implantable neurostimulator pulse generator, single array,
rechargeable, includes extension
1/1/2006
A
L8686
Implantable neurostimulator pulse generator, single array,
non-rechargeable, includes extension
1/1/2006
A
L8687
Implantable neurostimulator pulse generator, dual
array, rechargeable, includes extension
1/1/2006
A
L8688
Implantable neurostimulator pulse generator, dual
array, non-rechargeable, includes extension
1/1/2006
A
L8689
External recharging system for implanted
neurostimulator, replacement only
1/1/2006
A
Q0510
Pharmacy supply fee for initial immunosuppressive drug(s),
first month following transplant
1/1/2006
A
Q0511
Pharmacy supply fee for oral anti-cancer, oral
anti-emetic or immunosuppressive drug(s); for the first prescription in a 30-day period
1/1/2006
A
Q0512
Pharmacy supply fee for oral anti-cancer, oral
anti-emetic or immunosuppressive drug(s); for a
subsequent prescription in a 30-day period
1/1/2006
A
Q0513
Pharmacy dispensing fee for inhalation drug(s);
per 30 days
1/1/2006
A
Q0514
Pharmacy dispensing fee for inhalation drug(s);
per 90 days
1/1/2006
A
Q0515
Injection, sermorelin acetate, 1 microgram
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
A
S2068
Breast reconstruction with deep inferior epigastric
perforator (deep) flap, including microvascular
anastomosis and closure of donor site, unilateral
1/1/2006
A
S2078
Laparoscopic supracervical hysterectomy (subtotal
hysterectomy), with or without removal of tube(s),
with or without removal of ovary(s)
1/1/2006
A
S2079
Laparoscopic esophagomyotomy (Heller type)
1/1/2006
A
S3854
Gene expression profiling panel for use in the
management of breast cancer treatment
1/1/2006
A
V2788
Presbyopia correcting function of intraocular lens
1/1/2006
D
A4254
Replacement battery, any type, for use with medically necessary home blood glucose monitor owned by patient, each
1/1/2006
D
A4260
Levonorgestrel (contraceptive) implants system,
including implants and supplies
1/1/2006
D
A4643
Supply of additional high dose contrast material(s) during
magnetic resonance imaging, (e.g., gadoteridol injection)
1/1/2006
D
A4644
Supply of low osmolar contrast material (100-199 mgs of
iodine)
1/1/2006
D
A4645
Supply of low osmolar contrast material (200-299 mgs of
iodine)
1/1/2006
D
A4646
Supply of low osmolar contrast material (300-399 mgs of
iodine)
1/1/2006
D
A4647
Supply of paramagnetic contrast material,
(e.g., gadolinium)
1/1/2006
D
A4656
Needle, any size, each
1/1/2006
D
A5119
Skin barrier, wipes or swabs, per box 50
1/1/2006
D
A5509
For diabetics only, direct formed, molded to foot with external heat source (i.e. heat gun) multiple density insert
1/1/2006
D
A5511
For diabetics only, custom-molded from model of patient’s
foot, multiple density insert(s), custom-fabricated, per shoe
1/1/2006
D
A6551
Canister set for negative pressure wound therapy electrical
pump, stationary or portable, each
1/1/2006
D
A9511
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc 99m, depreotide, per millicurie
1/1/2006
D
A9513
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m mebrofenin, per millicurie
1/1/2006
D
A9514
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m pyrophosphate, per millicurie
1/1/2006
D
A9515
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m pentetate, per millicurie
1/1/2006
D
A9519
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m macroaggregated albumin, per mCi
1/1/2006
D
A9520
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m sulfur colloid, per millicurie
1/1/2006
D
A9522
Supply of radiopharmaceutical diagnostic imaging agent,
indium-111 ibritumomab tiuxetan, per millicurie
1/1/2006
D
A9523
Supply of radiopharmaceutical therapeutic imaging agent,
yttrium-90 ibritumomab tiuxetan, per millicurie
1/1/2006
D
A9525
Supply of low or iso-osmolar contrast material, 10 mg of
iodine
1/1/2006
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HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
A9533
Supply of radiopharmaceutical diagnostic imaging agent,
I-131 tositumomab, per millicurie
1/1/2006
D
A9534
Supply of radiopharmaceutical therapeutic imaging agent,
I-131 tositumomab, per millicurie
1/1/2006
D
B4184
Parenteral nutrition solution; lipids, 10% with
administration set (500 mL = 1 unit)
1/1/2006
D
B4186
Parenteral nutrition solution, lipids, 20% with
administration set (500 mL = 1 unit)
1/1/2006
D
C1079
Supply of radiopharmaceutical diagnostic imaging agent,
cyanocobalamin Co 57/58, per 0.5
microcurie
1/1/2006
D
C1080
Supply of radiopharmaceutical diagnostic imaging agent,
I-131 tositumomab, per dose
1/1/2006
D
C1081
Supply of radiopharmaceutical therapeutic imaging agent,
I-131 tositumomab, per dose
1/1/2006
D
C1082
Supply of radiopharmaceutical diagnostic imaging agent,
indium-111 ibritumomab tiuxetan, per dose
1/1/2006
D
C1083
Supply of radiopharmaceutical therapeutic imaging agent,
yttrium-90 ibritumomab tiuxetan, per dose
1/1/2006
D
C1091
Supply of radiopharmaceutical diagnostic imaging agent,
indium-111 oxyquinoline, per 0.5 millicurie
1/1/2006
D
C1092
Supply of radiopharmaceutical diagnostic imaging agent,
indium-111 pentetate, per 0.5 millicurie
1/1/2006
D
C1093
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m fanolesomab, per dose
(10 - 20 millicuries)
1/1/2006
D
C1122
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m arcitumomab, per vial
1/1/2006
D
C1200
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m sodium glucoheptonate,
per vial
1/1/2006
D
C1201
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m succimer, per vial
1/1/2006
D
C1305
Graftskin, per 44 square centimeters
1/1/2006
D
C1775
Supply of radiopharmaceutical diagnostic imaging agent,
fluorodeoxyglucose F18 (2-deoxy-2-[18f]
fluoro-d-glucose), per dose (4-40 mci/mL)
1/1/2006
D
C9000
Injection, sodium chromate Cr-51, per 0.25 millicurie
1/1/2006
D
C9007
Baclofen intrathecal screening kit (1 amp)
1/1/2006
D
C9008
Baclofen intrathecal refill kit, per 500 mcg
1/1/2006
D
C9009
Baclofen intrathecal refill kit, per 2000 mcg
1/1/2006
D
C9013
Supply of Co-57 cobaltous chloride, radiopharmaceutical
diagnostic imaging agent
1/1/2006
D
C9102
Supply of radiopharmaceutical diagnostic imaging agent,
51 sodium chromate, per 50 mCi
1/1/2006
D
C9103
Supply of radiopharmaceutical diagnostic imaging agent,
sodium iothalamate I-125 injection, per 10 uCi
1/1/2006
D
C9105
Injection, hepatitis B immune globulin, per 1 mL
1/1/2006
D
C9112
Injection, perflutren lipid microsphere, per 2 mL vial
1/1/2006
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
C9123
Human fibroblast derived temporary skin substitute, per 247
square centimeters
D
C9127
Injection, paclitaxel protein-bound particles, per 1 mg
1/1/2006
D
C9128
Injection, pegaptanib sodium, per 0.3 mg
1/1/2006
D
C9129
Injection, clofarabine, per 1 mg
1/1/2006
D
C9200
Bilayered cellular matrix, per 36 square centimeters
1/1/2006
D
C9201
Dermagraft, per 37.5 sq. cm.
1/1/2006
D
C9202
Injection, suspension of microspheres of human serum albumin with octafluoropropane, per 3 mL
1/1/2006
D
C9203
Injection, perflexane lipid microspheres, per 10 mL vial
1/1/2006
D
C9205
Injection, oxaliplatin, per 5 mg
1/1/2006
D
C9206
Collagen-glycosaminoglycan bilayer matrix, per cm2
1/1/2006
D
C9211
Injection, alefacept, for intravenous use, per 7.5 mg
1/1/2006
D
C9212
Injection, alefacept, for intramuscular use, per 7.5 mg
1/1/2006
D
C9218
Injection, azacitidine, per 1 mg
1/1/2006
D
C9223
Injection, adenosine for therapeutic or diagnostic use, 6
mg (not to be used to report any adenosine phosphate
compounds, instead use A9270)
1/1/2006
D
C9226
Injection, ziconotide for intrathecal infusion, per 5 mcg
1/1/2006
D
C9400
Supply of radiopharmaceutical diagnostic imaging agent,
thallous chloride Tl-201, brand name, per mCi,
brand name
1/1/2006
D
C9401
Supply of therapeutic radiopharmaceutical, strontium-89
chloride, brand name, per mCi
1/1/2006
D
C9402
Supply of radiopharmaceutical therapeutic imaging agent,
I-131 sodium iodide capsule, per mCi, brand name
1/1/2006
D
C9403
Supply of radiopharmaceutical diagnostic agent, I-131
sodium iodide capsule, per mCi
1/1/2006
D
C9404
Supply of radiopharmaceutical diagnostic agent, I-131
sodium iodide solution, per mCi, brand name
1/1/2006
D
C9405
Supply of radiopharmaceutical therapeutic agent, I-131
sodium iodide solution, per mCi, brand name
1/1/2006
D
C9410
Injection, dexrazoxane HCl, per 250 mg, brand name
1/1/2006
D
C9411
Injection, pamidronate disodium, per 30 mg,
brand name
1/1/2006
D
C9413
Sodium hyaluronate, per 20 to 25 mg dose for
intra-articular injection, brand name
1/1/2006
D
C9414
Etoposide, oral, 50 mg, brand name
1/1/2006
D
C9415
Doxorubicin HCl, 10 mg, brand name
1/1/2006
D
C9417
Bleomycin sulfate, 15 units, brand name
1/1/2006
D
C9418
Cisplatin, powder or solution, per 10 mg, brand name
1/1/2006
D
C9419
Injection, cladribine, per 1 mg, brand name
1/1/2006
D
C9420
Cyclophosphamide, 100 mg, brand name
1/1/2006
D
C9421
Cyclophosphamide, lyophilized, 100 mg, brand name
1/1/2006
D
C9422
Cytarabine, 100 mg, brand name
1/1/2006
D
C9423
Dacarbazine, 100 mg, brand name
1/1/2006
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HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
C9424
Daunorubicin, 10 mg
1/1/2006
D
C9425
Etoposide, 10 mg, brand name
1/1/2006
D
C9426
Floxuridine, 500 mg, brand name
1/1/2006
D
C9427
Ifosfamide, 1 gm, brand name
1/1/2006
D
C9428
Mesna, 200 mg, brand name
1/1/2006
D
C9429
Idarubicin hydrochloride, 5 mg, brand name
1/1/2006
D
C9430
Leuprolide acetate, per 1 mg, brand name
1/1/2006
D
C9431
Paclitaxel, 30 mg, brand name
1/1/2006
D
C9432
Mitomycin, 5 mg, brand name
1/1/2006
D
C9433
Thiotepa, 15 mg, brand name
1/1/2006
D
C9435
Injection, gonadorelin HCl, brand name, per 100 mcg
1/1/2006
D
C9436
Azathioprine, parenteral, brand name, per 100 mg
1/1/2006
D
C9437
Carmustine, brand name, 100 mg
1/1/2006
D
C9438
Cyclosporine, oral, 100 mg, brand name
1/1/2006
D
C9439
Diethylstilbestrol diphosphate, brand name, 250 mg
1/1/2006
D
C9440
Vinorelbine tartrate, brand name, per 10 mg
1/1/2006
D
C9704
Injection or insertion of inert substance for submucosal/intramuscular injection(s) into the upper gastrointestinal tract,
under fluoroscopic guidance
1/1/2006
D
C9713
Non-contact laser vaporization of prostate, including coagulation control of intraoperative and post-operative bleeding
1/1/2006
D
C9718
Kyphoplasty, one vertebral body, unilateral or bilateral
injection
1/1/2006
D
C9719
Kyphoplasty, one vertebral body, unilateral or bilateral
injection; each additional vertebral body (List separately in
addition to code for primary procedure)
1/1/2006
D
C9720
High-energy (greater than 0.22mj/mm2) extracorporeal
shock wave (ESW) treatment for chronic lateral epicondylitis
(tennis elbow)
1/1/2006
D
C9721
High-energy (greater than 0.22mj/mm2) extracorporeal
shock wave (ESW) treatment for chronic plantar fasciitis
1/1/2006
D
C9722
Stereoscopic kV X-ray imaging with infrared tracking for
localization of target volume (do not report C9722 in conjunction with G0173, G0243, G0251, G0339 or G0340)
1/1/2006
D
E0169
Commode chair with seat lift mechanism
1/1/2006
D
E0590
Dispensing fee covered drug administered through DME
nebulizer suction pump, home model, portable
12/31/2006
D
E0752
Implantable neurostimulator electrode, each
1/1/2006
D
E0754
Patient programmer (external) for use with implantable
programmable neurostimulator pulse generator
1/1/2006
D
E0756
Implantable neurostimulator pulse generator
1/1/2006
D
E0757
Implantable neurostimulator radiofrequency receiver
1/1/2006
D
E0758
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
1/1/2006
D
E0759
Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and
bladder management, replacement
1/1/2006
D
E0953
Pneumatic tire, each
1/1/2006
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
E0954
Semi-pneumatic caster, each
1/1/2006
D
E0972
Wheelchair accessory, transfer board or device, each
1/1/2006
D
E0996
Tire, solid, each
1/1/2006
D
E1000
Tire, pneumatic caster
1/1/2006
D
E1001
Wheel, single
1/1/2006
D
E1025
Lateral thoracic support, non-contoured, for pediatric wheelchair, each (includes hardware)
1/1/2006
D
E1026
Lateral thoracic support, contoured, for pediatric wheelchair,
each (includes hardware)
1/1/2006
D
E1027
Lateral/anterior support, for pediatric wheelchair, each
(includes hardware)
1/1/2006
D
E1210
Motorized wheelchair, fixed full length arms, swing away
detachable elevating leg rest
1/1/2006
D
E1211
Motorized wheelchair, detachable arms desk or full length
swing away, detachable elevating leg rest
1/1/2006
D
E1212
Motorized wheelchair, fixed full length arms, swing away
detachable foot rests
1/1/2006
D
E1213
Motorized wheelchair, detachable arms desk or full length,
swing away detachable foot rests
1/1/2006
D
G0030
PET myocardial perfusion imaging, (following previous PET,
G0030-G0047); single study, rest or stress (exercise and/or
pharmacologic)
1/1/2006
D
G0031
PET myocardial perfusion imaging, (following previous PET,
G0030-G0047); multiple studies, rest or stress (exercise
and/or pharmacologic)
1/1/2006
D
G0032
PET myocardial perfusion imaging, (following rest SPECT,
78464); single study, rest or stress (exercise and/or pharmacologic)
1/1/2006
D
G0033
PET myocardial perfusion imaging, (following rest SPECT,
78464); multiple studies, rest or stress (exercise and/or
pharmacologic)
1/1/2006
D
G0034
PET myocardial perfusion imaging, (following stress SPECT,
78465); single study, rest or stress (exercise and/or pharmacologic)
1/1/2006
D
G0035
PET myocardial perfusion imaging, (following stress SPECT,
78465); multiple studies, rest or stress (exercise and/or
pharmacologic)
1/1/2006
D
G0036
PET myocardial perfusion imaging, (following coronary
angiography, 93510-93529); single study, rest or stress
(exercise and/or pharmacologic)
1/1/2006
D
G0037
PET myocardial perfusion imaging, (following coronary
angiography, 93510-93529); multiple studies, rest or stress
(exercise and/or pharmacologic)
1/1/2006
D
G0038
PET myocardial perfusion imaging, (following stress planar
myocardial perfusion, 78460); single study, rest or stress
(exercise and/or pharmacologic)
1/1/2006
D
G0039
PET myocardial perfusion imaging, (following stress planar
myocardial perfusion, 78460); multiple studies, rest or stress
(exercise and/or pharmacologic)
1/1/2006
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UPDATE
C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
G0040
PET myocardial perfusion imaging, (following stress echocardiogram, 93350); single study, rest or stress (exercise
and/or pharmacologic)
1/1/2006
D
G0041
PET myocardial perfusion imaging, (following stress echocardiogram, 93350); multiple studies, rest or stress (exercise
and/or pharmacologic)
1/1/2006
D
G0042
PET myocardial perfusion imaging, (following stress nuclear
ventriculogram, 78481 or 78483); single study, rest or
stress (exercise and/or pharmacologic)
1/1/2006
D
G0043
PET myocardial perfusion imaging, (following stress nuclear
ventriculogram, 78481 or 78483); multiple studies, rest or
stress (exercise and/or pharmacologic)
1/1/2006
D
G0044
PET myocardial perfusion imaging, (following rest ECG,
93000); single study, rest or stress (exercise and/or pharmacologic)
1/1/2006
D
G0045
PET myocardial perfusion imaging, (following rest ECG,
93000); multiple studies, rest or stress (exercise and/or
pharmacologic)
1/1/2006
D
G0046
PET myocardial perfusion imaging, (following stress ECG,
93015); single study, rest or stress (exercise and/or pharmacologic)
1/1/2006
D
G0047
PET myocardial perfusion imaging, (following stress ECG,
93015); multiple studies, rest or stress (exercise and/or
pharmacologic)
1/1/2006
D
G0110
NETT pulm-rehab; education/skills training, individual
1/1/2006
D
G0111
NETT pulm-rehab; education/skills training, group
1/1/2006
D
G0112
NETT pulm-rehab; nutritional guidance, initial
1/1/2006
D
G0113
NETT pulm-rehab; nutritional guidance, subsequent
1/1/2006
D
G0114
NETT pulm-rehab; psychosocial consultation
1/1/2006
D
G0115
NETT pulm-rehab; psychological testing
1/1/2006
D
G0116
NETT pulm-rehab; psychosocial counseling
1/1/2006
D
G0125
PET imaging regional or whole body; single pulmonary
nodule
1/1/2006
D
G0210
PET imaging whole body; diagnosis; lung cancer, non-small
cell
1/1/2006
D
G0211
PET imaging whole body; initial staging; lung cancer; nonsmall cell (replaces studies, rest or stress (exercise and/or
pharmacologic)
1/1/2006
D
G0212
PET imaging whole body; restaging; lung cancer; nonsmall
1/1/2006
D
G0213
PET imaging whole body; diagnosis; colorectal
1/1/2006
D
G0214
PET imaging whole body; initial staging; colorectal
1/1/2006
D
G0215
PET imaging whole body; restaging; colorectal cancer
1/1/2006
D
G0216
PET imaging whole body; diagnosis; melanoma
1/1/2006
D
G0217
PET imaging whole body; initial staging; melanoma
1/1/2006
D
G0218
PET imaging whole body; restaging; melanoma
1/1/2006
D
G0220
PET imaging whole body; diagnosis; lymphoma
1/1/2006
D
G0221
PET imaging whole body; initial staging; lymphoma
1/1/2006
D
G0222
PET imaging whole body; restaging; lymphoma
1/1/2006
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
G0223
PET imaging whole body or regional; diagnosis; head and
neck cancer; excluding thyroid and CNS cancers
1/1/2006
D
G0224
PET imaging whole body or regional; initial staging; head
and neck cancer; excluding thyroid and CNS cancers
1/1/2006
D
G0225
PET imaging whole body or regional; restaging; head and
neck cancer, excluding thyroid and CNS cancers
1/1/2006
D
G0226
PET imaging whole body; diagnosis; esophageal cancer
1/1/2006
D
G0227
PET imaging whole body; initial staging; esophageal cancer
1/1/2006
D
G0228
PET imaging whole body; restaging; esophageal cancer
1/1/2006
D
G0229
PET imaging; metabolic brain imaging for pre-surgical evaluation of refractory seizures
1/1/2006
D
G0230
PET imaging; metabolic assessment for myocardial
viability following inconclusive SPECT study
1/1/2006
D
G0231
PET, whole body, for recurrence of colorectal or colorectal
metastatic cancer; gamma cameras only
1/1/2006
D
G0232
PET, whole body, for staging and characterization of lymphoma; gamma cameras only
1/1/2006
D
G0233
PET, whole body, for recurrence of melanoma or
melanoma metastatic cancer; gamma cameras only
1/1/2006
D
G0234
PET, regional or whole body, for solitary pulmonary nodule
following CT or for initial staging of pathologically diagnosed non-small cell lung cancer; gamma
cameras only
1/1/2006
D
G0235
PET imaging, any site, not otherwise specified
1/1/2006
D
G0242
Multi-source photon stereotactic radiosurgery (cobalt 60
multi-source converging beams) plan, including dose volume
histograms for target and critical structure tolerances, plan
optimization performed for highly conformal distributions,
plan positional accuracy and dose verification, all lesions
treated, per course of treatment
1/1/2006
D
G0244
Observation care provided by a facility to a patient with
CHF, chest pain, or asthma, minimum eight hours
1/1/2006
D
G0253
PET imaging for breast cancer, full and partial-ring
PET scanners only, staging/restaging of local regional recurrence or distant metastases (i.e., staging/restaging after or
prior to course of treatment)
1/1/2006
D
G0254
PET imaging for breast cancer, full and partial- ring
PET scanners only, evaluation of response to treatment,
performed during course of treatment
1/1/2006
D
G0258
Intravenous infusion during separately payable
observation stay, per observation stay (must be reported
with G0244)
1/1/2006
D
G0263
Direct admission of patient with diagnosis of congestive
heart failure, chest pain or asthma for observation services
that meet all criteria for G0244
1/1/2006
D
G0264
Initial nursing assessment of patient directly admitted to
observation with diagnosis other than CHF, chest pain or
asthma or patient directly admitted to observation with diagnosis of CHF, chest pain or asthma when the observation
stay does not qualify for G0244
1/1/2006
D
G0279
Extracorporeal shock wave therapy; involving elbow epicondylitis
1/1/2006
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UPDATE
C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
G0280
Extracorporeal shock wave therapy; involving other than
elbow epicondylitis or plantar fasciitis
1/1/2006
D
G0296
PET imaging, full and partial ring PET scanner only, for restaging of previously treated thyroid cancer of follicular cell
origin following negative I-131 whole body scan
1/1/2006
D
G0336
PET imaging, brain imaging for the differential diagnosis of
Alzheimer’s disease with aberrant features vs.
fronto-temporal dimentia
1/1/2006
D
G0338
Linear-accelerator-based stereotactic radiosurgery plan,
including dose volume histograms for target and critical
structure tolerances, plan optimization performed for highly
conformal distributions, plan positional accuracy and dose
verification, all lesions treated, per course of treatment
1/1/2006
D
G0345
Intravenous infusion, hydration; initial, up to one hour
1/1/2006
D
G0346
Each additional hour, up to eight (8) hours (List separately in
addition to code for primary procedure)
1/1/2006
D
G0347
Intravenous infusion, for therapeutic/diagnostic (specify
substance or drug); initial, up to one hour
1/1/2006
D
G0348
Each additional hour, up to eight (8) hours
(List separately in addition to code for primary
procedure and report in conjunction with G0347)
1/1/2006
D
G0349
Additional sequential infusion, up to one hour (List separately
in addition to code for primary procedure)
1/1/2006
D
G0350
Concurrent infusion (List separately in addition to code for
primary procedure) report only once per substance/drug
regardless of duration, report G0350 in conjunction with
G0345
1/1/2006
D
G0351
Therapeutic or diagnostic injection (specify substance or
drug); subcutaneous or intramuscular
1/1/2006
D
G0353
Intravenous push, single or initial substance/drug
1/1/2006
D
G0354
Each additional sequential intravenous push (List separately
in addition to code for primary procedure)
1/1/2006
D
G0355
Chemotherapy administration, subcutaneous or intramuscular non-hormonal
1/1/2006
D
G0356
Hormonal anti-neoplastic
1/1/2006
D
G0357
Intravenous, push technique, single or initial
substance/drug
1/1/2006
D
G0358
Intravenous, push technique, each additional substance/
drug (List separately in addition to code for primary procedure)
1/1/2006
D
G0359
Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug
1/1/2006
D
G0360
Each additional hour, one to eight (8) hours (List separately
in addition to code for primary procedure) use G0360 in
conjunction with G0359
1/1/2006
D
G0361
Initiation of prolonged chemotherapy infusion (more than
eight hours), requiring the use of a portable or implantable
pump
1/1/2006
D
G0362
Each additional sequential infusion (different substance/
drug), up to one hour (use with G0359)
1/1/2006
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
G0363
Irrigation of implanted venous access device for drug delivery systems (do not report G0363 if an injection or infusion
is provided on the same day)
1/1/2006
D
G0369
Pharmacy supply fee for initial immunosuppressive drug(s)
first month following transplant
1/1/2006
D
G0370
Pharmacy supply fee for oral anti-cancer, oral anti-emetic or
immunosuppressive drug(s)
1/1/2006
D
G0371
Pharmacy dispensing fee for inhalation drug(s); per 30 days
1/1/2006
D
G0374
Pharmacy dispensing fee for inhalation drug(s); per 90 days
1/1/2006
D
G9021
Chemotherapy assessment for nausea and/or vomiting,
patient reported, performed at the time of chemotherapy
administration; assessment level one: not at all. (For use in a
Medicare-approved demonstration project)
1/1/2006
D
G9022
Chemotherapy assessment for nausea and/or vomiting,
patient reported, performed at the time of chemotherapy
administration; assessment level two: a little. (For use in a
Medicare-approved demonstration project)
1/1/2006
D
G9023
Chemotherapy assessment for nausea and/or vomiting,
patient reported, performed at the time of chemotherapy
administration; assessment level three: quite a bit. (For use in
a Medicare-approved demonstration project)
1/1/2006
D
G9024
Chemotherapy assessment for nausea and/or vomiting,
patient reported, performed at the time of chemotherapy
administration; assessment level four: very much. (For use in
a Medicare-approved demonstration project)
1/1/2006
D
G9025
Chemotherapy assessment for pain, patient reported, performed at the time of chemotherapy administration; assessment level one: not at all. (For use in a Medicare-approved
demonstration project)
1/1/2006
D
G9026
Chemotherapy assessment for pain, patient reported,
performed at the time of chemotherapy administration; assessment level two: a little. (For use in a Medicare-approved
demonstration project)
1/1/2006
D
G9027
Chemotherapy assessment for pain, patient reported,
performed at the time of chemotherapy administration; assessment level three: quite a bit. (For use in a Medicare-approved demonstration project)
1/1/2006
D
G9028
Chemotherapy assessment for pain, patient reported, performed at the time of chemotherapy administration; assessment level four: very much. (For use in a Medicare-approved
demonstration project)
1/1/2006
D
G9029
Chemotherapy assessment for lack of energy (fatigue),
patient reported, performed at the time of chemotherapy
administration; assessment level one: not at all. (For use in a
Medicare-approved demonstration project)
1/1/2006
D
G9030
Chemotherapy assessment for lack of energy (fatigue),
patient reported, performed at the time of chemotherapy
administration; assessment level two: a little. (For use in a
Medicare-approved demonstration project)
1/1/2006
D
G9031
Chemotherapy assessment for lack of energy (fatigue),
patient reported, performed at the time of chemotherapy
administration; assessment level three: quite a bit. (For use in
a Medicare-approved demonstration project)
1/1/2006
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HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
G9032
Chemotherapy assessment for lack of energy (fatigue),
patient reported, performed at the time of chemotherapy
administration; assessment level four: very much. (For use in
a Medicare-approved demonstration project)
1/1/2006
D
J0880
Injection, darbepoetin alfa, 5 mcg
1/1/2006
D
J1563
Injection, immune globulin, intravenous, 1 g
1/1/2006
D
J1564
Injection, immune globulin, intravenous, 10 mg
1/1/2006
D
J1750
Injection, iron dextran, 50 mg
1/1/2006
D
J2324
Injection, nesiritide, 0.25 mg
1/1/2006
D
J7051
Sterile saline or water, up to 5 cc
1/1/2006
D
J7616
Albuterol, up to 5 mg and ipratropium bromide, up to 1 mg,
compounded inhalation solution, administered through DME
1/1/2006
D
J7617
Levalbuterol, up to 2.5 mg and ipratropium bromide,
up to 1 mg, compounded inhalation solution,
administered through DME
1/1/2006
D
K0064
Zero pressure tube (flat free inserts), any size, each
1/1/2006
D
K0066
Solid tire, any size, each
1/1/2006
D
K0067
Pneumatic tire, any size, each
1/1/2006
D
K0068
Pneumatic tire tube, each
1/1/2006
D
K0074
Pneumatic caster tire, any size, each
1/1/2006
D
K0075
Semi-pneumatic caster tire, any size, each
1/1/2006
D
K0076
Solid caster tire, any size, each
1/1/2006
D
K0078
Pneumatic caster tire tube, each
1/1/2006
D
K0102
Crutch and cane holder, each
1/1/2006
D
K0104
Cylinder tank carrier, each
1/1/2006
D
K0106
Arm trough, each
1/1/2006
D
K0415
Prescription antiemetic drug, oral, per 1 mg, for use in conjunction with oral anti-cancer drug, not otherwise specified
1/1/2006
D
K0416
Prescription antiemetic drug, rectal, per 1 mg, for use in conjunction with oral anti-cancer drug, not otherwise specified
1/1/2006
D
K0452
Wheelchair bearings, any type
1/1/2006
D
K0600
Functional neuromuscular stimulator, transcutaneous stimulation of muscles of ambulation with computer control, used for
walking by spinal cord injured, entire system, after completion of training program
1/1/2006
D
K0618
TLSA, sagittal-coronal control, modular segmented
spinal system, two rigid plastic shells, posterior extends from
the sacrococcygeal junction and terminates just inferior to
the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the
sagittal and coronal planes, lateral strength is provided by
overlapping plastic and stabilizing closures, includes straps
and closures, prefabricated, includes fitting and adjustment
1/1/2006
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
K0619
TLSO, sagittal-coronal control, modular segmented
spinal system, three rigid plastic shells, posterior extends
from the sacrococcygeal junction and terminates just inferior
to the scapular spine, anterior extends from the symphysis
pubis to the xiphoid, soft liner, restricts gross trunk motion in
the sagittal and coronal planes, lateral strength is provided
by overlapping plastic and stabilizing closures, includes
straps and closures, prefabricated, includes fitting and
adjustment
1/1/2006
D
K0620
Tubular elastic dressing, any width, per linear yard
1/1/2006
D
K0628
For diabetics only, multiple density insert, direct formed,
molded to foot after external heat source of 230 degrees
Fahrenheit or higher, total contact with patient’s foot,
including arch, base layer minimum of 1/4 inch material of
shore a 35 durometer or 3/16 inch material of shore a 40
durometer (or higher), prefabricated, each
1/1/2006
D
K0629
For diabetics only, multiple density insert, custom molded
from model of patient’s foot, total contact with patient’s foot,
including arch, base layer minimum of 3/16 inch material
of shore A 35 durometer or higher, includes arch filler and
other shaping material, custom fabricated, each
1/1/2006
D
K0630
Sacroiliac orthosis, flexible, provides pelvic-sacral support,
reduces motion about the sacroiliac joint, includes straps,
closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment
1/1/2006
D
K0631
Sacroiliac orthosis, flexible, provides pelvic-sacral support,
reduces motion about the sacroiliac joint, includes straps,
closures, may include pendulous abdomen design, custom
fabricated
1/1/2006
D
K0632
Sacroiliac orthosis, provides pelvic-sacral support, with rigid
or semi-rigid panels placed over the sacrum and abdomen,
reduces motion about the sacroiliac joint, includes straps,
closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment
1/1/2006
D
K0633
Sacroiliac orthosis, provides pelvic-sacral support, with rigid
or semi-rigid panels placed over the sacrum and abdomen,
reduces motion about the sacroiliac joint, includes straps,
closures, may include pendulous abdomen design, custom
fabricated
1/1/2006
D
K0634
Lumbar orthosis, flexible, provides lumbar support, posterior
extends from L1 to below L5 vertebra, produces intracavitary
pressure to reduce load on the intervertebral discs, includes
straps, closures, may include pendulous abdomen design,
shoulder straps, stays, prefabricated, includes fitting and
adjustment
1/1/2006
D
K0635
Lumbar orthosis, sagittal control, with rigid posterior
panel(s), posterior extends from L1 to below L5 vertebra,
produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design,
prefabricated, includes fitting and adjustment
1/1/2006
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C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
K0636
Lumbar orthosis, sagittal control, with rigid anterior and
posterior panels, posterior extends from L1 to below L5 vertebra, produces intracavitary pressure to reduce load on the
intervertebral discs, includes straps, closures, may include
padding, shoulder straps, pendulous abdomen design,
prefabricated, includes fitting and adjustment
1/1/2006
D
K0637
Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T9
vertebra, produces intracavitary pressure to reduce load
on the intervertebral discs, includes straps, closures, may
include stays, shoulder straps, pendulous abdomen design,
prefabricated, includes fitting and adjustment
1/1/2006
D
K0638
Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T9
vertebra, produces intracavitary pressure to reduce load
on the intervertebral discs, includes straps, closures, may
include stays, shoulder straps, pendulous abdomen design,
custom fabricated
1/1/2006
D
K0639
Lumbar-sacral orthosis, sagittal control, with rigid posterior
panel(s), posterior extends from sacrococcygeal junction to
T9 vertebra, produces intracavitary pressure to reduce load
on the intervertebral discs, includes straps, closures, may
include padding, stays, shoulder straps, pendulous abdomen
design, prefabricated, includes fitting and adjustment
1/1/2006
D
K0640
Lumbar-sacral orthosis, sagittal control, with rigid anterior
and posterior panels, posterior extends from sacrococcygeal
junction to T9 vertebra, produces intracavitary pressure
to reduce load on the intervertebral discs, includes straps,
pendulous abdomen design, prefabricated, includes fitting
and adjustment
1/1/2006
D
K0641
Lumbar-sacral orthosis, sagittal control, with rigid anterior
and posterior panels, posterior extends from sacrococcygeal
junction to T9 vertebra, produces intracavitary pressure
to reduce load on the intervertebral discs, includes straps,
closures, may include padding, shoulder straps, pendulous
abdomen design, custom fabricated
1/1/2006
D
K0642
Lumbar-sacral orthosis, sagittal-coronal control, with rigid
posterior frame/panel(s), posterior extends from sacrococcygeal junction to T9 vertebra, lateral strength provided by
rigid lateral frame/panels, produces intracavitary pressure
to reduce load on intervertebral discs, includes straps,
closures, may include padding, stays, shoulder straps,
pendulous abdomen design, prefabricated, includes fitting
and adjustment
1/1/2006
D
K0643
Lumbar-sacral orthosis, sagittal-coronal control, with rigid
posterior frame/panel(s), posterior extends from sacrococcygeal junction to T9 vertebra, lateral strength provided by
rigid lateral frame/panels, produces intracavitary pressure
to reduce load on intervertebral discs, includes straps,
closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated
1/1/2006
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
K0644
Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design
to flex the lumbar spine, posterior extends from sacrococcygeal junction to T9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to
reduce load on intervertebral discs, includes straps, closures,
may include padding, anterior panel, pendulous abdomen
design, prefabricated, includes fitting and adjustment
1/1/2006
D
K0645
Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design
to flex the lumbar spine, posterior extends from sacrococcygeal junction to T9 vertebra, lateral strength provided by
rigid lateral frame/panels, produces intracavitary pressure
to reduce load on intervertebral discs, includes straps,
closures, may include padding, anterior panel, pendulous
abdomen design, custom fabricated
1/1/2006
D
K0646
Lumbar-sacral orthosis, sagittal-coronal control, with rigid
anterior and posterior frame/panels, posterior extends from
sacrococcygeal junction to T9 vertebra, lateral strength
provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes
straps, closures, may include padding, shoulder straps,
pendulous abdomen design, prefabricated, includes fitting
and adjustment
1/1/2006
D
K0647
Lumbar-sacral orthosis, sagittal-coronal control, with rigid
anterior and posterior frame/panels, posterior extends from
sacrococcygeal junction to T9 vertebra, lateral strength
provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes
straps, closures, may include padding, shoulder straps,
pendulous abdomen design, custom fabricated
1/1/2006
D
K0648
Lumbar-sacral orthosis, sagittal-coronal control,
rigid shell(s)/panel(s) posterior extends from
sacrococcygeal junction to T9 vertebra, anterior extends
from symphysis pubis to xyphoid, produces intracavitary
pressure to reduce load on the intervertebral discs, overall
strength is provided by overlapping rigid material and
stabilizing closures, includes straps, closures, may include
soft interface, pendulous abdomen design, prefabricated,
includes fitting and adjustment
1/1/2006
D
K0649
Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/
panel(s), posterior extends from sacrococcygeal junction
to T9 vertebra, anterior extends from symphysis pubis to
xiphoid, produces intracavitary pressure to reduce load
on the intervertebral discs, overall strength is provided by
overlapping rigid material and stabilizing closures, includes
straps, closures, may include soft interface, pendulous abdomen design, custom fabricated
1/1/2006
D
K0670
Addition to lower extremity prosthesis, endoskeletal knee
shin system, microprocessor control feature, stance phase
only, includes electronic sensor(s), any type
1/1/2006
D
K0671
Portable oxygen concentrator, rental
1/1/2006
D
K0731
Lithium ion battery for use with cochlear implant device
speech processor, other than ear level,
replacement, each
1/1/2006
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C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
K0732
Lithium ion battery for use with cochlear implant device
speech processor, ear level, replacement, each
1/1/2006
D
L0860
Addition to halo procedures, magnetic resonance
image compatible system
1/1/2006
D
L1750
Legg Perthes orthosis, Legg Perthes sling (Sam Brown type),
prefabricated, includes fitting and adjustment
1/1/2006
D
L2039
Knee ankle foot orthosis, full plastic, single upright, polyaxial hinge, medial lateral rotation control, with or without
free motion ankle, custom fabricated
1/1/2006
D
L3963
Shoulder elbow wrist hand orthosis, molded shoulder, arm,
forearm and wrist, with articulating elbow joint, customfabricated
1/1/2006
D
L8100
Gradient compression stocking, below knee,
18-30 mmHg, each
1/1/2006
D
L8110
Gradient compression stocking, below knee,
30-40 mmHg, each
1/1/2006
D
L8120
Gradient compression stocking, below knee,
40-50 mmHg, each
1/1/2006
D
L8130
Gradient compression stocking, thigh length,
18-30 mmHg, each
1/1/2006
D
L8140
Gradient compression stocking, thigh length,
30-40 mmHg, each
1/1/2006
D
L8150
Gradient compression stocking, thigh length,
40-50 mmHg, each
1/1/2006
D
L8160
Gradient compression stocking, full length/chap style,
18-30 mmHg, each
1/1/2006
D
L8170
Gradient compression stocking, full length/chap style,
30-40 mmHg, each
1/1/2006
D
L8180
Gradient compression stocking, full length/chap style,
40-50 mmHg, each
1/1/2006
D
L8190
Gradient compression stocking, waist length,
18-30 mmHg, each
1/1/2006
D
L8195
Gradient compression stocking, waist length,
30-40 mmHg, each
1/1/2006
D
L8200
Gradient compression stocking, waist length,
40-50 mmHg, each
1/1/2006
D
L8210
Gradient compression stocking, custom made
1/1/2006
D
L8220
Gradient compression stocking, lymphedema
1/1/2006
D
L8230
Gradient compression stocking, garter belt
1/1/2006
D
L8239
Gradient compression stocking, not otherwise specified
1/1/2006
D
L8620
Lithium ion battery for use with cochlear implant device,
replacement, each
1/1/2006
D
Q0136
Injection, epoetin alpha, (for non-ESRD use),
per 1000 units
1/1/2006
D
Q0137
Injection, darbepoetin alfa, 1 mcg (non-ESRD use)
1/1/2006
D
Q0187
Factor VIIA (coagulation factor, recombinant)
per 1.2 mg
1/1/2006
D
Q1001
New technology intraocular lens category 1 as
defined in federal register notice, vol 65, dated
May 3, 2000
6/30/2005
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
Q2001
Oral, cabergoline, 0.5 mg
D
Q2002
Injection, Elliotts B solution, per ml
1/1/2006
D
Q2003
Injection, aprotinin, 10,000 kiu
1/1/2006
D
Q2005
Injection, corticorelin ovine triflutate, per dose
1/1/2006
D
Q2006
Injection, digoxin immune fab (ovine), per vial
1/1/2006
D
Q2007
Injection, ethanolamine oleate, 100 mg
1/1/2006
D
Q2008
Injection, fomepizole, 15 mg
1/1/2006
D
Q2011
Injection, hemin, per 1 mg
1/1/2006
D
Q2012
Injection, pegademase bovine, 25 IU
1/1/2006
D
Q2013
Injection, pentastarch, 10% solution, per 100 mL
1/1/2006
D
Q2014
Injection, sermorelin acetate, 0.5 mg
1/1/2006
D
Q2018
Injection, urofollitropin, 75 IU
1/1/2006
D
Q2019
Injection, basiliximab, 20 mg
1/1/2006
D
Q2020
Injection, histrelin acetate, 10 mcg
1/1/2006
D
Q2021
Injection, lepirudin, 50 mg
1/1/2006
D
Q2022
Von Willebrand factor complex, human, per IU
1/1/2006
D
Q3000
Supply of radiopharmaceutical diagnostic imaging agent,
rubidium RB-82, per dose
1/1/2006
D
Q3002
Supply of radiopharmaceutical diagnostic imaging agent,
gallium Ga- 67, per mCi
1/1/2006
D
Q3003
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m bicisate, per unit dose
1/1/2006
D
Q3004
Supply of radiopharmaceutical diagnostic imaging agent,
xenon Xe-133, per 10 mCi
1/1/2006
D
Q3005
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m mertiatide, per mCi
1/1/2006
D
Q3006
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m gluceptate, per 5 mCi
1/1/2006
D
Q3007
Supply of radiopharmaceutical diagnostic imaging agent,
sodium phosphate P-32, per mCi
1/1/2006
D
Q3008
Supply of radiopharmaceutical diagnostic imaging agent,
indium 111 ,Äî in pentetreotide, per 3 mCi
1/1/2006
D
Q3009
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m oxidronate, per mCi
1/1/2006
D
Q3010
Supply of radiopharmaceutical diagnostic imaging agent,
technetium Tc-99m - ,Äî labeled red blood cells, per mCi
1/1/2006
D
Q3011
Supply of radiopharmaceutical diagnostic imaging agent,
chromic phosphate P-32 suspension, per mCi
1/1/2006
D
Q3012
Supply of oral radiopharmaceutical diagnostic imaging
agent, cyanocobalamin cobalt Co-57, per 0.5 mCi
1/1/2006
D
Q4054
Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis)
1/1/2006
D
Q4055
Injection, epoetin alfa, 1000 units (for ESRD on dialysis)
1/1/2006
D
Q4075
Injection, acyclovir, 5 mg
1/1/2006
D
Q4076
Injection, dopamine HCl, 40 mg
1/1/2006
D
Q4077
Injection, treprostinil, 1 mg
1/1/2006
D
Q9941
Injection, immune globulin, intravenous, lyophilized, 1g
1/1/2006
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1/1/2006
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C OM PE NDIUM
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
D
Q9942
Injection, immune globulin, intravenous, lyophilized, 10 mg
1/1/2006
D
Q9943
Injection, immune globulin, intravenous, non-lyophilized, 1g
1/1/2006
D
Q9944
Injection, immune globulin, intravenous, non-lyophilized, 10 mg
1/1/2006
D
S0071
Injection, acyclovir sodium, 50 mg
1/1/2006
D
S0072
Injection, amikacin sulfate, 100 mg
1/1/2006
D
S0114
Injection, treprostinil sodium, 0.5 mg
1/1/2006
D
S0118
Injection, ziconotide, for intrathecal infusion, 1 mcg
1/1/2006
D
S0168
Injection, azacitidine, 100 mg
1/1/2006
D
S0173
Dexamethasone, oral, 4 mg
1/1/2006
D
S2082
Laparoscopy, surgical; gastric restrictive procedure, adjustable gastric band (includes placement of subcutaneous port)
1/1/2006
D
S2090
Ablation, open, one or more renal tumor(s); cryosurgical
1/1/2006
D
S2091
Ablation, percutaneous, one or more renal tumor(s);
cryosurgical
1/1/2006
D
S2215
Upper gastrointestinal endoscopy, including esophagus,
stomach, and either the duodenum and/or jejunum as appropriate; with injection of implant material into and along
the muscle of the lower esophageal sphincter for treatment of
gastroesophageal reflux disease
1/1/2006
D
S8095
Wig (for medically-induced or congenital hair loss)
1/1/2006
D
S8434
Interim post-operative orthotic device for upper
extremity, custom made
1/1/2006
D
T2006
Ambulance response and treatment, no transport
1/1/2006
R
A4215
Needle, sterile, any size, each
1/1/2006
R
A4216
Sterile water, saline and/or dextrose (diluent), 10 mL
1/1/2006
R
A4372
Ostomy skin barrier, solid 4x4 or equivalent,
standard wear, with built-in convexity, each
1/1/2006
R
A4630
Replacement batteries, medically necessary, transcutaneous
electrical stimulator (TENS), owned by patient
1/1/2006
R
A4641
Radiopharmaceutical, diagnostic, not otherwise
classified
1/1/2006
R
A4642
Indium In-111 satumomab pendetide, diagnostic,
per study dose, up to 6 millicuries
1/1/2006
R
A6550
Wound care set, for negative pressure wound therapy
electrical pump, includes all supplies and accessories
1/1/2006
R
A7032
Replacement cushion for use on nasal application device
mask interface, replacement only, each
1/1/2006
R
A7033
Pillow for use on nasal cannula type interface,
replacement only, pair
1/1/2006
R
A9500
Technetium Tc-99m sestamibi, diagnostic,
per study dose, up to 40 millicuries
1/1/2006
R
A9502
Technetium Tc-99m tetrofosmin, diagnostic,
per study dose, up to 40 millicuries
1/1/2006
R
A9503
Technetium Tc-99m medronate, diagnostic,
per study dose, up to 30 millicuries
1/1/2006
R
A9504
Technetium Tc-99m apcitide, diagnostic,
per study dose, up to 20 millicuries
1/1/2006
R
A9505
Thallium Tl-201 thallous chloride, diagnostic, per millicurie
1/1/2006
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
R
A9507
Indium In-111 capromab pendetide, diagnostic,
per study dose, up to 10 millicuries
1/1/2006
R
A9508
Iodine I-131 iobenguane sulfate, diagnostic,
per 0.5 millicurie
1/1/2006
R
A9510
Technetium Tc-99m disofenin, diagnostic,
per study dose, up to 15 millicuries
1/1/2006
R
A9512
Technetium Tc-99m pertechnetate, diagnostic, per millicurie
1/1/2006
R
A9516
Iodine I-123 sodium iodide capsule(s), diagnostic,
per 100 microcuries
1/1/2006
R
A9517
Iodine I-131 sodium iodide capsule(s), therapeutic,
per millicurie
1/1/2006
R
A9521
Technetium Tc-99m exametazime, diagnostic,
per study dose, up to 25 millicuries
1/1/2006
R
A9526
Nitrogen N-13 ammonia, diagnostic, per study dose, up to
40 millicuries
1/1/2006
R
A9528
Iodine I-131 sodium iodide capsule(s), diagnostic,
per millicurie
1/1/2006
R
A9529
Iodine I-131 sodium iodide solution, diagnostic,
per millicurie
1/1/2006
R
A9530
Iodine I-131 sodium iodide solution, therapeutic,
per millicurie
1/1/2006
R
A9531
Iodine I-131 sodium iodide, diagnostic,
per microcurie (up to 100 microcuries)
1/1/2006
R
A9532
Iodine I-125 serum albumin, diagnostic,
per 5 microcuries
1/1/2006
R
A9600
Strontium Sr-89 chloride, therapeutic, per millicurie
1/1/2006
R
A9605
Samarium Sm-153 lexidronam, therapeutic,
per 50 millicuries
1/1/2006
R
A9699
Radiopharmaceutical, therapeutic, not otherwise classified
1/1/2006
R
B4149
Enteral formula, manufactured, blenderized natural foods
with intact nutrients, includes proteins, fats, carbohydrates,
vitamins and minerals, may include fiber, administered
through an enteral feeding tube, 100 calories = 1 unit
1/1/2006
R
C1894
Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser
1/1/2006
R
E0116
Crutch, underarm, other than wood, adjustable or fixed,
each with pad, tip, handgrip, with or without shock absorber, each
1/1/2006
R
E0637
Combination sit to stand system, any size including
pediatric, with seat lift feature, with or without wheels
1/1/2006
R
E0638
Standing frame system, one position (e.g. upright, supine or
prone stander), any size including pediatric, with or without
wheels
1/1/2006
R
E0935
Continuous passive motion exercise device for use on knee only
1/1/2006
R
E0971
Manual wheelchair accessory, anti-tipping device, each
1/1/2006
R
E1038
Transport chair, adult size, patient weight capacity up to and
including 300 pounds
1/1/2006
R
E1039
Transport chair, adult size, heavy duty, patient
weight capacity greater than 300 pounds
1/1/2006
www.amerihealth.com
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HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
HCPCS Code
Narrative
Effective Date
of Revision/
Addition
R
G9041
Services provided by a qualified occupational
therapist in a low vision demonstration project
1/1/2006
R
G9042
Services provided by an orientation & mobility
specialist in a low vision demonstration project
1/1/2006
R
G9043
Services provided by a low vision therapist in a
low vision demonstration project
1/1/2006
R
G9044
Services provided by a certified rehabilitation teacher
in a low vision demonstration project
1/1/2006
R
J7340
Dermal and epidermal, (substitute) tissue of human origin,
with or without bioengineered or processed elements, with
metabolically active elements, per square centimeter
1/1/2006
R
J7342
Dermal (substitute) tissue of human origin, with or without
other bioengineered or processed elements, with metabolically active elements, per square centimeter
1/1/2006
R
J7343
Dermal and epidermal, (substitute) tissue of non-human
origin, with or without other bioengineered or processed
elements, without metabolically active elements, per square
centimeter
1/1/2006
R
J7344
Dermal (substitute) tissue of human origin, with or without
other bioengineered or processed elements, without metabolically active elements, per square centimeter
1/1/2006
R
J7350
Dermal (substitute) tissue of human origin, injectable, with
or without other bioengineered or processed elements, but
without metabolized active elements, per 10 mg
1/1/2006
R
J7626
Budesonide inhalation solution, non-compounded, administered through DME, unit dose form, up to 0.5 mg
1/1/2006
R
K0669
Wheelchair accessory, wheelchair seat or back
cushion, does not meet specific code criteria or no written
coding verification from SADMERC
1/1/2006
R
L1832
Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated,
includes fitting and adjustment
1/1/2006
R
L1843
Knee orthosis, single upright, thigh and calf, with adjustable
flexion and extension joint (unicentric or polycentric), mediallateral and rotation control, with or without varus/valgus
adjustment, prefabricated, includes fitting and adjustment
1/1/2006
R
L1844
Knee orthosis, single upright, thigh and calf, with adjustable
flexion and extension joint (unicentric or polycentric), mediallateral and rotation control, with or without varus/valgus
adjustment, custom fabricated
1/1/2006
R
L1845
Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric),
medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment
1/1/2006
R
L1846
Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric),
medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
1/1/2006
R
L2036
Knee ankle foot orthosis, full plastic, double upright, with or
without free motion knee, with or without free motion ankle,
custom fabricated
1/1/2006
Delete Date
2005 Compendium
HCPCS CODES
Action
A=Addition
D=Deletion
R=Revision
ICD-9 Code
Narrative
Effective Date
of Revision/
Addition
R
L2037
Knee ankle foot orthosis, full plastic, single upright, with or
without free motion knee, with or without free motion ankle,
custom fabricated
1/1/2006
R
L2038
Knee ankle foot orthosis, full plastic, with or without free motion knee joint, multi-axis ankle, custom fabricated
1/1/2006
R
L2405
Addition to knee joint, drop, lock, each
1/1/2006
R
L3170
Foot, plastic, silicone or equal, heel stabilizer, each
1/1/2006
R
L3215
Orthopedic footwear, ladies’ shoe, oxford, each
1/1/2006
R
L3216
Orthopedic footwear, ladies’ shoe, depth inlay, each
1/1/2006
R
L3217
Orthopedic footwear, ladies’ shoe, hightop, depth inlay, each
1/1/2006
R
L3219
Orthopedic footwear, men’s shoe, oxford, each
1/1/2006
R
L3221
Orthopedic footwear, men’s shoe, depth inlay, each
1/1/2006
R
L3222
Orthopedic footwear, men’s shoe, hightop, depth inlay, each
1/1/2006
R
L3230
Orthopedic footwear, custom shoe, depth inlay, each
1/1/2006
R
L3906
Wrist hand orthosis, custom fabricated, includes
fitting and adjustment
1/1/2006
R
L3923
Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, includes fitting and adjustment
1/1/2006
www.amerihealth.com
Delete Date
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C OM PE NDIUM
ICD-9 CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
ICD-9 Code
Narrative
Effective Date
of Revision/
Addition
A
259.5
Androgen insensitivity syndrome
10/1/2005
A
276.50
Volume depletion, unspecified
10/1/2005
A
276.51
Dehydration
10/1/2005
A
276.52
Hypovolemia
10/1/2005
A
278.02
Overweight
10/1/2005
A
287.30
Primary thrombocytopenia, unspecified
10/1/2005
A
287.31
Immune thrombocytopenic purpura
10/1/2005
A
287.32
Evans’ syndrome
10/1/2005
A
287.33
Congenital and hereditary thrombocytopenic purpura
10/1/2005
A
287.39
Other primary thrombocytopenia
10/1/2005
A
291.82
Alcohol induced sleep disorders
10/1/2005
A
292.85
Drug induced sleep disorders
10/1/2005
A
327.00
Organic insomnia, unspecified
10/1/2005
A
327.01
Insomnia due to medical condition classified
elsewhere
10/1/2005
A
327.02
Insomnia due to mental disorder
10/1/2005
A
327.09
Other organic insomnia
10/1/2005
A
327.10
Organic hypersomnia, unspecified
10/1/2005
A
327.11
Idiopathic hypersomnia with long sleep time
10/1/2005
A
327.12
Idiopathic hypersomnia without long sleep time
10/1/2005
A
327.13
Recurrent hypersomnia
10/1/2005
A
327.14
Hypersomnia due to medical condition classified
elsewhere
10/1/2005
A
327.15
Hypersomnia due to mental disorder
10/1/2005
A
327.19
Other organic hypersomnia
10/1/2005
A
327.20
Organic sleep apnea, unspecified
10/1/2005
A
327.21
Primary central sleep apnea
10/1/2005
A
327.22
High altitude periodic breathing
10/1/2005
A
327.23
Obstructive sleep apnea (adult) (pediatric)
10/1/2005
A
327.24
Idiopathic sleep related nonobstructive alveolar
hypoventilation
10/1/2005
A
327.25
Congenital central alveolar hypoventilation syndrome
10/1/2005
A
327.26
Sleep related hypoventilation/hypoxemia in
conditions classifiable elsewhere
10/1/2005
A
327.27
Central sleep apnea in conditions classified elsewhere
10/1/2005
A
327.29
Other organic sleep apnea
10/1/2005
A
327.30
Circadian rhythm sleep disorder, unspecified
10/1/2005
A
327.31
Circadian rhythm sleep disorder, delayed sleep
phase type
10/1/2005
A
327.32
Circadian rhythm sleep disorder, advanced sleep phase type
10/1/2005
A
327.33
Circadian rhythm sleep disorder, irregular sleep-wake type
10/1/2005
A
327.34
Circadian rhythm sleep disorder, free-running type
10/1/2005
A
327.35
Circadian rhythm sleep disorder, jet lag type
10/1/2005
Delete Date
2005 Compendium
ICD-9 CODES
Action
A=Addition
D=Deletion
R=Revision
ICD-9 Code
Narrative
Effective Date
of Revision/
Addition
A
327.36
Circadian rhythm sleep disorder, shift work type
10/1/2005
A
327.37
Circadian rhythm sleep disorder in conditions
classified elsewhere
10/1/2005
A
327.39
Other circadian rhythm sleep disorder
10/1/2005
A
327.40
Organic parasomnia, unspecified
10/1/2005
A
327.41
Confusional arousals
10/1/2005
A
327.42
REM sleep behavior disorder
10/1/2005
A
327.43
Recurrent isolated sleep paralysis
10/1/2005
A
327.44
Parasomnia in conditions classified elsewhere
10/1/2005
A
327.49
Other organic parasomnia
10/1/2005
A
327.51
Periodic limb movement disorder
10/1/2005
A
327.52
Sleep related leg cramps
10/1/2005
A
327.53
Sleep related bruxism
10/1/2005
A
327.59
Other organic sleep related movement disorders
10/1/2005
A
327.8
Other organic sleep disorders
10/1/2005
A
362.03
Nonproliferative diabetic retinopathy NOS
10/1/2005
A
362.04
Mild nonproliferative diabetic retinopathy
10/1/2005
A
362.05
Moderate nonproliferative diabetic retinopathy
10/1/2005
A
362.06
Severe nonproliferative diabetic retinopathy
10/1/2005
A
362.07
Diabetic macular edema
10/1/2005
A
426.82
Long QT syndrome
10/1/2005
A
443.82
Erythromelalgia
10/1/2005
A
525.40
Complete edentulism, unspecified
10/1/2005
A
525.41
Complete edentulism, class I
10/1/2005
A
525.42
Complete edentulism, class II
10/1/2005
A
525.43
Complete edentulism, class III
10/1/2005
A
525.44
Complete edentulism, class IV
10/1/2005
A
525.50
Partial edentulism, unspecified
10/1/2005
A
525.51
Partial edentulism, class I
10/1/2005
A
525.52
Partial edentulism, class II
10/1/2005
A
525.53
Partial edentulism, class III
10/1/2005
A
525.54
Partial edentulism, class IV
10/1/2005
A
567.21
Peritonitis (acute) generalized
10/1/2005
A
567.22
Peritoneal abscess
10/1/2005
A
567.23
Spontaneous bacterial peritonitis
10/1/2005
A
567.29
Other suppurative peritonitis
10/1/2005
A
567.31
Psoas muscle abscess
10/1/2005
A
567.38
Other retroperitoneal abscess
10/1/2005
A
567.39
Other retroperitoneal infections
10/1/2005
A
567.81
Choleperitonitis
10/1/2005
A
567.82
Sclerosing mesenteritis
10/1/2005
A
567.89
Other specified peritonitis
10/1/2005
A
585.1
Chronic kidney disease, stage I
10/1/2005
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Delete Date
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UPDATE
C OM PE NDIUM
ICD-9 CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
ICD-9 Code
Narrative
Effective Date
of Revision/
Addition
A
585.2
Chronic kidney disease, stage II (mild)
10/1/2005
A
585.3
Chronic kidney disease, stage III (moderate)
10/1/2005
A
585.4
Chronic kidney disease, stage IV (severe)
10/1/2005
A
585.5
Chronic kidney disease, stage V
10/1/2005
A
585.6
End stage renal disease
10/1/2005
A
585.9
Chronic kidney disease, unspecified
10/1/2005
A
599.60
Urinary obstruction, unspecified
10/1/2005
A
599.69
Urinary obstruction, not elsewhere classified
10/1/2005
A
651.70
Multiple gestation following (elective) fetal reduction,
unspecified as to episode of care or not applicable
10/1/2005
A
651.71
Multiple gestation following (elective) fetal reduction, delivered, with or without mention of antepartum condition
10/1/2005
A
760.77
Anticonvulsants
10/1/2005
A
760.78
Antimetabolic agents
10/1/2005
A
763.84
Meconium passage during delivery
10/1/2005
A
770.10
Fetal and newborn aspiration, unspecified
10/1/2005
A
770.11
Meconium aspiration without respiratory symptoms
10/1/2005
A
770.12
Meconium aspiration with respiratory symptoms
10/1/2005
A
770.13
Aspiration of clear amniotic fluid without respiratory
symptoms
10/1/2005
A
770.14
Aspiration of clear amniotic fluid with respiratory symptoms
10/1/2005
A
770.15
Aspiration of blood without respiratory symptoms
10/1/2005
A
770.16
Aspiration of blood with respiratory symptoms
10/1/2005
A
770.17
Other fetal and newborn aspiration without
respiratory symptoms
10/1/2005
A
770.18
Other fetal and newborn aspiration with respiratory symptoms
10/1/2005
A
770.85
Aspiration of postnatal stomach contents without
respiratory symptoms
10/1/2005
A
770.86
Aspiration of postnatal stomach contents with
respiratory symptoms
10/1/2005
A
779.84
Meconium staining
10/1/2005
A
780.95
Other excessive crying
10/1/2005
A
799.01
Asphyxia
10/1/2005
A
799.02
Hypoxemia
10/1/2005
A
996.40
Unspecified mechanical complication of internal
orthopedic device, implant, and graft
10/1/2005
A
996.41
Mechanical loosening of prosthetic joint
10/1/2005
A
996.42
Dislocation of prosthetic joint
10/1/2005
A
996.43
Prosthetic joint implant failure
10/1/2005
A
996.44
Peri-prosthetic fracture around prosthetic joint
10/1/2005
A
996.45
Peri-prosthetic osteolysis
10/1/2005
A
996.46
Articular bearing surface wear of prosthetic joint
10/1/2005
A
996.47
Other mechanical complication of prosthetic joint implant
10/1/2005
Delete Date
2005 Compendium
ICD-9 CODES
Action
A=Addition
D=Deletion
R=Revision
ICD-9 Code
Narrative
Effective Date
of Revision/
Addition
A
996.49
Other mechanical complication of other internal
orthopedic device, implant, and graft
A
V12.42
Infections of the central nervous system
10/1/2005
A
V12.60
Unspecified disease of respiratory system
10/1/2005
A
V12.61
Pneumonia (recurrent)
10/1/2005
A
V12.69
Other diseases of respiratory system
10/1/2005
A
V13.02
Urinary (tract) infection
10/1/2005
A
V13.03
Nephrotic syndrome
10/1/2005
A
V15.88
History of fall
10/1/2005
A
V17.81
Osteoporosis
10/1/2005
A
V17.89
Other musculoskeletal diseases
10/1/2005
A
V18.9
Genetic disease carrier
10/1/2005
A
V26.31
Testing for genetic disease carrier status
10/1/2005
A
V26.32
Other genetic testing
10/1/2005
A
V26.33
Genetic counseling
10/1/2005
A
V46.13
Encounter for weaning from respirator [ventilator]
10/1/2005
A
V46.14
Mechanical complication of respirator [ventilator]
10/1/2005
A
V49.84
Bed confinement status
10/1/2005
A
V58.11
Encounter for antineoplastic chemotherapy
10/1/2005
A
V58.12
Encounter for antineoplastic immunotherapy
10/1/2005
A
V59.70
Egg (oocyte) (ovum) donor, unspecified
10/1/2005
A
V59.71
Egg (oocyte) (ovum) donor, under age 35, anonymous
recipient
10/1/2005
A
V59.72
Egg (oocyte) (ovum) donor, under age 35, designated
recipient
10/1/2005
A
V59.73
Egg (oocyte) (ovum) donor, age 35 and over,
anonymous recipient
10/1/2005
A
V59.74
Egg (oocyte) (ovum) donor, age 35 and over,
designated recipient
10/1/2005
A
V62.84
Suicidal ideation
10/1/2005
A
V64.00
Vaccination not carried out, unspecified reason
10/1/2005
A
V64.01
Vaccination not carried out because of acute illness
10/1/2005
A
V64.02
Vaccination not carried out because of chronic
illness or condition
10/1/2005
A
V64.03
Vaccination not carried out because of immune
compromised state
10/1/2005
A
V64.04
Vaccination not carried out because of allergy to
vaccine or component
10/1/2005
A
V64.05
Vaccination not carried out because of caregiver refusal
10/1/2005
A
V64.06
Vaccination not carried out because of patient refusal
10/1/2005
A
V64.07
Vaccination not carried out for religious reasons
10/1/2005
A
V64.08
Vaccination not carried out because patient had
disease being vaccinated against
10/1/2005
A
V64.09
Vaccination not carried out for other reason
10/1/2005
A
V69.5
Behavioral insomnia of childhood
10/1/2005
A
V72.42
Pregnancy examination or test, positive result
10/1/2005
www.amerihealth.com
Delete Date
10/1/2005
123
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UPDATE
C OM PE NDIUM
ICD-9 CODES
Action
A=Addition
D=Deletion
R=Revision
A ND
ICD-9 Code
Narrative
Effective Date
of Revision/
Addition
Delete Date
A
V72.86
Encounter for blood typing
10/1/2005
A
V85.0
Body Mass Index less than 19, adult
10/1/2005
A
V85.1
Body Mass Index between 19-24, adult
10/1/2005
A
V85.21
Body Mass Index 25.0-25.9, adult
10/1/2005
A
V85.22
Body Mass Index 26.0-26.9, adult
10/1/2005
A
V85.23
Body Mass Index 27.0-27.9, adult
10/1/2005
A
V85.24
Body Mass Index 28.0-28.9, adult
10/1/2005
A
V85.25
Body Mass Index 29.0-29.9, adult
10/1/2005
A
V85.30
Body Mass Index 30.0-30.9, adult
10/1/2005
A
V85.31
Body Mass Index 31.0-31.9, adult
10/1/2005
A
V85.32
Body Mass Index 32.0-32.9, adult
10/1/2005
A
V85.33
Body Mass Index 33.0-33.9, adult
10/1/2005
A
V85.34
Body Mass Index 34.0-34.9, adult
10/1/2005
A
V85.35
Body Mass Index 35.0-35.9, adult
10/1/2005
A
V85.36
Body Mass Index 36.0-36.9, adult
10/1/2005
A
V85.37
Body Mass Index 37.0-37.9, adult
10/1/2005
A
V85.38
Body Mass Index 38.0-38.9, adult
10/1/2005
A
V85.39
Body Mass Index 39.0-39.9, adult
10/1/2005
A
V85.4
Body Mass Index 40 and over, adult
10/1/2005
D
276.5
Volume depletion
10/1/2005
D
287.3
Primary thrombocytopenia
10/1/2005
D
567.2
Other suppurative peritonitis
10/1/2005
D
567.8
Other specified peritonitis
10/1/2005
D
996.4
Mechanical complication of internal orthopedic
device, implant, and graft
10/1/2005
D
V12.6
Diseases of respiratory system
10/1/2005
D
V17.8
Other musculoskeletal diseases
10/1/2005
D
V26.3
Genetic counseling and testing
10/1/2005
R
278
Overweight, obesity and other hyperalimentation
10/1/2005
R
278.0
Overweight and obesity
10/1/2005
R
285.21
Anemia in chronic kidney disease
10/1/2005
R
307.45
Circadian rhythm sleep disorder of nonorganic origin
10/1/2005
R
403
Hypertensive kidney disease
10/1/2005
R
403.00
Hypertensive kidney disease, malignant,
without chronic kidney disease
10/1/2005
R
403.01
Hypertensive kidney disease, malignant,
with chronic kidney disease
10/1/2005
R
403.10
Hypertensive kidney disease, benign,
without chronic kidney disease
10/1/2005
R
403.11
Hypertensive kidney disease, benign,
with chronic kidney disease
10/1/2005
R
403.90
Hypertensive kidney disease, unspecified,
without chronic kidney disease
10/1/2005
R
403.91
Hypertensive kidney disease, unspecified,
with chronic kidney disease
10/1/2005
2005 Compendium
ICD-9 CODES
Action
A=Addition
D=Deletion
R=Revision
ICD-9 Code
Narrative
Effective Date
of Revision/
Addition
R
404
Hypertensive heart and kidney disease
10/1/2005
R
404.00
Hypertensive heart and kidney disease, malignant,
without heart failure or chronic kidney disease
10/1/2005
R
404.01
Hypertensive heart and kidney disease, malignant,
with heart failure
10/1/2005
R
404.02
Hypertensive heart and kidney disease, malignant,
with chronic kidney disease
10/1/2005
R
404.03
Hypertensive heart and kidney disease, malignant,
with heart failure and chronic kidney disease
10/1/2005
R
404.10
Hypertensive heart and kidney disease, benign,
without heart failure or chronic kidney disease
10/1/2005
R
404.11
Hypertensive heart and kidney disease, benign,
with heart failure
10/1/2005
R
404.12
Hypertensive heart and kidney disease, benign,
with chronic kidney disease
10/1/2005
R
404.13
Hypertensive heart and kidney disease, benign,
with heart failure and chronic kidney disease
10/1/2005
R
404.90
Hypertensive heart and kidney disease, unspecified,
without heart failure or chronic kidney disease
10/1/2005
R
404.91
Hypertensive heart and kidney disease, unspecified,
with heart failure
10/1/2005
R
404.92
Hypertensive heart and kidney disease, unspecified,
with chronic kidney disease
10/1/2005
R
404.93
Hypertensive heart and kidney disease, unspecified,
with heart failure and chronic kidney disease
10/1/2005
R
567
Peritonitis and retroperitoneal infections
10/1/2005
R
585
Chronic kidney disease (CKD)
10/1/2005
R
599.6
Urinary obstruction
10/1/2005
R
728.87
Muscle weakness (generalized)
10/1/2005
R
770.1
Fetal and newborn aspiration
10/1/2005
R
780.51
Insomnia with sleep apnea, unspecified
10/1/2005
R
780.52
Insomnia, unspecified
10/1/2005
R
780.53
Hypersomnia with sleep apnea, unspecified
10/1/2005
R
780.54
Hypersomnia, unspecified
10/1/2005
R
780.55
Disruptions of 24 hour sleep wake cycle, unspecified
10/1/2005
R
780.57
Unspecified sleep apnea
10/1/2005
R
780.58
Sleep related movement disorder, unspecified
10/1/2005
R
799.0
Asphyxia and hypoxemia
10/1/2005
R
V28.0
Screening for chromosomal anomalies by amniocentesis
10/1/2005
R
V28.1
Screening for raised alpha-fetoprotein levels in
amniotic fluid
10/1/2005
R
V46.1
Respirator [ventilator]
10/1/2005
R
V58.1
Encounter for antineoplastic chemotherapy and
immunotherapy
10/1/2005
R
V64.0
Vaccination not carried out
10/1/2005
www.amerihealth.com
Delete Date
125
C OD I N G
G U ID ELINES
A ND
PO L IC Y
UPDATE
C OM PE NDIUM
NOTES
126
2005 Compendium
ICD-9 CODES
A LL
R
TRADES
IED PRINTING
UNION
LABEL
COUNCIL
SCRANTON
13