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www.ibx.com March 2007 Get Your News on the Internet or NaviNetSM Based on feedback from providers, as of April 1, 2007, all of our publications will be available only on www.ibx.com/providers/ communications, and NaviNetSM. Our publications, Partners in Health Update, Clinical Update, and Coding Guidelines and Policy Update (CGPU) will no longer be mailed to provider offices. This decision was made based on feedback from providers on ways we can reduce the amount of information we send to your office. If you do not have access to the Internet or NaviNetSM, you may call the Provider Supply Line for hard copies of our publications. You will receive a postcard each month when a new issue of Partners In Health Update is available. Please e-mail us with your questions or comments on how we can improve our communication efforts at provider_communications@ibx. com. Working Together For Quality Health Care INSIDE THIS ISSUE NPI ANNOUNCEMENTS • Get it, Share it, Use it Now with IBC • IBC National Provider Identifier (NPI) Dual Use Claims Submission BILLING • Paper Referrals Will No Longer be Accepted After April 1, 2007 • Home Infusion Therapy Precertification Changes PHARMACY • Select Drug Program® Formulary Update • Prescription Drug Updates POLICY • Revisions to the Nerve Conduction Studies and Needle Electromyelograms Policies • 2006 Coding Guidelines and Policy Update (CGPU) Compendium Enclosed PREVENTIVE HEALTH • Encourage Members to Receive Colorectal Cancer Screening • In-home Physician Visiting Program • Supporting Our Members, Your Patients: ConnectionsSM Health Management Programs For articles specific to your area of interest, look for the appropriate icon: Provider Facility Ancillary Additional copies of Partners In Health Update can be printed by going to our website www.ibx.com/providers/communications. Get it, Share it, Use it Now with IBC Get It. Get it NOW from the National Plan and Provider Enumeration System (NPPES). • Get your NPI(s): a unique 10-digit identification number. We recommend you enumerate with your current Corporate ID configuration. • Get it now. Do not wait until the May 23, 2007 compliance date. How to Obtain an NPI The National Plan and Provider Enumeration System (NPPES) is currently accepting applications for NPIs. Providers who have not yet obtained an NPI may apply for it in one of the following ways: Electronic • Get it faster on the Web at https://nppes.cms.hhs.gov. Share It. Share it NOW with IBC, your colleagues, and your billing services. Failure to share your NPI with IBC could result in a disruption in cash flow. • Share your NPI with us before you file your next claim. • Share it with your colleagues who rely on your NPI to submit their claims. • Share it with your billing service, vendor, or clearinghouse. Use It. Use it NOW to identify yourself. • Use it now along with your existing 10-digit legacy provider identifiers on your electronic and paper claims (if you have reported your NPI(s) to IBC). • Use it now to facilitate accurate and streamlined processing of claims. • Use it to be HIPAA-compliant by May 23, 2007. Complete the web-based application online at https://nppes.cms.hhs.gov. It takes approximately 20 minutes to complete and is the most time-efficient method of obtaining an NPI. Paper Providers may wish to obtain a copy of the paper NPI Application/Update Form (CMS-10114) and mail the completed, signed application to the NPI Enumerator. The form will be available only upon request through the NPI Enumerator. Providers who wish to obtain a copy of this form must contact the NPI Enumerator in any of the following ways: Phone: (800) 465-3203 or TTY (800) 692-2326 E-mail: [email protected] Mail: NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059 All the information you need is available at www.ibx.com/providers/npi Failure to prepare could result in a disruption in cash flow. Will you be ready to use your NPI? Time is running out. 2 March 2007 www.ibx.com NPI ANNOUN C E M E N T S IBC National Provider Identifier (NPI) Dual Use Claims Submission IBC NPI Dual Use Claims Submission is one of many preparatory measures that we will implement prior to the NPI compliance date in order to ensure the smoothest transition possible. We are asking all providers who have obtained their NPI(s) and reported them to us to submit all electronic and paper claims with NPIs and 10-digit legacy provider identifiers (identifiers you are currently required to use to identify yourself as an IBC participating health care provider), until otherwise notified. You must also report your Taxonomy codes on all electronic and paper claims. Taxonomy codes identify your specialty or (specialties). Please note that we will not use NPIs to process your claims at this time. We will continue to process claims using your 10-digit legacy identifiers. In addition, we will not include NPIs on SORs or any other outgoing transactions at this time. IBC NPI Dual Use Claims Submission will not complicate, delay, or halt your claims processing. NPI Dual Use Claims Submission Instructions You can find detailed IBC NPI Dual Use Claims Submission instructions in the following locations: • 837P and 837I Companion Guides. The 837P Companion Guide and 837I Companion Guide provide instructions for submitting dual use claims for electronic claims submissions. The companion guides are available online at www.ibx.com/providers/self_service_tools/edi/forms. html. • Current and Revised CMS 1500 Claim Forms and Instructions. This reference tool was published as an enclosure with the October 2006 edition of Partners in Health Update. It provides instructions for submitting dual use www.ibx.com claims for paper submissions. This reference tool is also available at www.ibx.com/providers/npi/ forms.html. Questions Regarding NPI Dual Use Claims Submission Please contact your Network Coordinator with any questions regarding IBC NPI Dual Use Claims Submission. If you have not yet obtained your NPI(s) and reported them to us, please see How to Obtain an NPI, or visit www.ibx.com/providers/npi. You may also visit the following websites for additional information: IBC Provider NPI website www.ibx.com/providers/npi Contains NPI background, FAQs, Submission Instructions, web links, and other information. CMS Main NPI website www.cms.hhs.gov/NationalProvIdentStand Contains NPI Final Rule, FAQs, Fact Sheets, Tip Sheets, NPI Viewlet, Medicare MedLearn Articles, Enumeration Statistics. NPI Enumerator website https://nppes.cms.hhs.gov/NPPES/Welcome.do Main site to enter an NPI application. WEDI NPI White Papers www.wedi.org/snip/ Industry NPI papers, including “NPI Impact on Providers,” “NPI Dual Use Strategy,” “NPI and Subparts,” etc. WEDI NPI Outreach Initiative www.wedi.org/npioi/index.shtml NPI Resource Center with information resources, Industry readiness assessment survey, etc. March 2007 3 BILLIN G Paper Referrals Will No Longer Be Accepted After April 1, 2007 An Important Message for PCPs and Specialists Effective April 1, 2007, we will no longer accept paper referrals with HMO/POS claims for payment. All paper referrals submitted on or after April 1st will be returned to the issuing provider. For PCPs, all referrals should be submitted through NaviNetSM or our Interactive Voice Response (IVR) system. For Specialists, NaviNet or the IVR should be checked to ensure a referral was received for a member before services are rendered. Specialists should no longer accept paper referrals. A fax of an electronically submitted referral may be obtained by the Specialist office via our IVR. This change will help reduce errors by allowing specialists to verify, through NaviNet or the IVR, that a referral is on file in the system and has been submitted correctly, before the provider sees the member. Electronic submission will also help ensure the accuracy and timeliness of claim payments by allowing the specialist to confirm that the group provider number on the referral matches the group provider number on the claim. To get connected to the NaviNet Portal, please call the eBusiness Provider Hotline at (215) 640-7410, or complete our Online Inquiry Form at www.ibx. com/providers/navinet. To submit or inquire on an electronic referral through the IVR, please call (866) 681-7370. For instructions on using the IVR, refer to the October 2006 issue of Partners in Health Update. If you have additional questions, please contact your Network Coordinator. Home Infusion Therapy Precertification Changes Effective April 1, 2007, Care Management Coordination (CMC) will no longer accept faxes as a method to request precertification for home infusion therapy. All requests for infusion therapy dated April 1, 2007 and later must be submitted 4 March 2007 through NaviNetSM or by calling the Health Resource Center at (215) 241-2100, prompt 2, subprompt 4, or (800) 227-3116, prompt 2, subprompt 4, (out-of-area). To request NaviNetSM access, please call (215) 640-7410. www.ibx.com P H ARMACY Select Drug Program® Formulary Updates The Select Drug Program Formulary is a list of FDA-approved medications that were chosen for their effectiveness and value. The list changes periodically as the FutureScripts™ Pharmacy and Therapeutics Committee reviews the formulary to ensure its continued effectiveness. Generic Additions These generic drugs recently became available in the marketplace. When these generic drugs became available, we began covering them at the appropriate generic formulary copayment: Generic Drug Brand Drug buproprion XL 300mg Wellbutrin XL® clarithromycin SR 24 hr hydrocodone tannate/ chlor-tan Formulary Chapter Biaxin® XL HyTanTM ondansetron HCL Zofran® oxandrolone 3. Pain, Nervous System, & Psych 1. Antibiotics & Other Drugs Used for Infections 13. Allergy, Cough, & Cold, Lung Meds 8. Stomach, Ulcer, & Bowel Meds Effective Date December 25, 2006 December 11, 2006 January 15, 2007 January 16, 2007 Anavar 7. Diabetes, Thyroid, Steroids, & Other Miscellaneous Hormones January 8, 2007 oxybutynin chloride Ditropan XL® 14. Urinary and Prostate Meds January 22, 2007 paroxetine HCL susp Paxil® susp phenylephrine HCL/ COD/prometh sodium sulfacetamide lotion Phenergan® VC w/codeine 3. Pain, Nervous System, & Psych 13. Allergy, Cough & Cold, Lung Meds Klaron® 5. Skin Medications ® December 7, 2006 December 18, 2006 November 17, 2006 Brand Addition This brand drug is covered at the appropriate brand formulary copayment: Effective January 1, 2007 Brand Drug Formulary Chapter Prezista™ 1. Antibiotics & Other Drugs Used For Infection Once a brand drug becomes available in the marketplace, and is approved by the FutureScripts Pharmacy and Therapeutics Committee as a formulary drug, it will be added to the formulary and available at the brand formulary copayment. continued on page 6 www.ibx.com March 2007 5 PHARM AC Y Select Drug Program® Formulary Updates (continued) Brand Deletions These brand drugs will be covered at the appropriate Non-Formulary copayment: Effective April 1, 2007 Brand Drug Generic Drug Alesse® lutera, lessina Biaxin XL® clarithromycin SR 24 hr Cyclessa® velivet, cecia Demulen® zovia, kelnor Ditropan XL® oxybutynin chloride Lo/Ovral® low-ogestrel, cryselle Loestrin® microgestin, junel Loestrin® Fe microgestin Fe, junel Fe Micrette® kariva Modicon® necon, nortrel Nordette® levora, portia Nor-QD® camilla, nora-be, errin, jolivette Ortho-Cept® solia, apri, reclipsen Ortho-Cyclen® sprintec, mononessa, previfem Ortho Micronor® camilla, nora-be, errin, jolivette Ortho-Novum® necon, nortrel Ortho Tri-Cyclen® tri-sprintec, trinessa, tri-previfem Paxil® susp paroxetine HCL susp Tri-Norinyl® leena, aranelle Triphasil® trivora, enpresse Wellbutrin XL® buproprion XL 300mg The generic drugs for all of the above brand drugs are on our formulary and available at the generic formulary copayment. 6 March 2007 www.ibx.com P H ARMACY Select Drug Program® Formulary Updates (continued) Brand Drug Generic Drug Formulary Therapeutic Alternatives (available at the formulary copayment) Ortho Tri-Cyclen Lo® Not Available tri-sprintec, trinessa, tri-previfem Rhinocort Aqua® Not Available Nasonex®, Nasocort® AQ, fluticasone Yasmin® Not Available junel, levora, microgestin, portia There is no generic equivalent available for the above brand drugs; however, there are formulary generic and brand therapeutic alternative drugs. These therapeutic alternative drugs are available at the appropriate formulary copayment. www.ibx.com March 2007 7 PHARM AC Y Prescription Drug Updates For members enrolled in an IBC prescription drug program, there will be additional drugs that will require prior authorization, quantity limits or age edits. The purpose of these edits is to make certain that these drugs are being used appropriately and to guard against drug overuse. Drugs Requiring Prior Authorization The prior authorization requirements for the following non-formulary drugs were effective at the time the drugs became available. Brand Drug Generic Drug Effective Date Invega™ Not Available January 5, 2007 Oracea™ Not Available June 10, 2006 The following non-formulary drugs have been added to the list of drugs requiring Prior Authorization for new prescriptions. Members taking these drugs immediately prior to the effective date are not impacted. Brand Drug Generic Drug Effective Date BiDil® Not Available April 1, 2007 Noxafil® Not Available April 1, 2007 Zelapar® Not Available April 1, 2007 Drug with Quantity Limit A quantity limit for the following drug was effective at the time the drug became available in the marketplace: Brand Drug Generic Drug Quantity Limit Effective Date Kadian® 80mg Not Available 60 capsules per 30 days October 1, 2006 Drug with Age Edit An age edit for the following drug was effective at the time the drug became available in the marketplace: Brand Drug Generic Drug Edit Effective Date ZianaTM Gel Not Available Prior Authorization required for members aged 36 and older December 4, 2006 8 March 2007 www.ibx.com POLICY Revisions to the Nerve Conduction Studies and Needle Electromyelograms Policies We have revised the policies on Nerve Conduction Studies (NCS), Policy #07.03.18a, and Needle Electromyelograms (EMGs), Policy #07.03.09b. Our medical policy states that the performing provider should be a physician who has had special training in the diagnosis and treatment of neurological and neuromuscular diseases and in the application of particular neurophysiologic techniques for the study of these disorders. Therefore, only physicians who are properly trained in performing these tests should perform NCS and needle EMGs. Effective for dates of service rendered on or after April 1, 2007, we will cover and consider for reimbursement those NCSs and EMGs included in the above noted policies when performed by physicians in the specialties of Neurology and Physical Medicine & Rehabilitation when the medical necessity criteria outlined in the specific medical policy have been met. This change does not affect services rendered prior to April 1, 2007. Additionally, this change does not affect needle EMG of the anal and urethral sphincter (CPT® code 51785*) that is discussed in policy number 07.03.21a: Electromyelograms of the Anal and Urethral Sphincter. *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. 2006 Coding Guidelines and Policy Update (CGPU) Compendium Enclosed Enclosed is the annual 2006 Coding Guidelines and Policy Update (CGPU) Compendium. The Compendium includes policy summaries published in the past four issues of the quarterly CGPU along with other information that can simplify information retrieval and claims submission processes. www.ibx.com The Compendium also includes previously published articles on the class action settlement, modifier updates, and changes in policy criteria, and a section detailing new, revised, and deleted Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS), and ICD-9 CM codes. March 2007 9 PREVEN T I V E H E A LT H Encourage Members to Receive Colorectal Cancer Screening IBC and the American Cancer Society urge you to encourage your patients to be screened for colorectal cancer. Please know that your personal recommendation has a tremendous influence on a patient’s decision to seek recommended preventive health screenings. You can obtain educational patient materials for your office in English and in Spanish by calling the American Cancer Society directly at (800) ACS-2345 or by visiting their website at www.cancer.org. Adherence to the colorectal cancer screening guidelines may lead to improved patient outcomes. Individual clinical decisions should be tailored to specific patient medical and psychosocial needs. Although this information is adapted from national sources, information in this area might evolve rapidly and lead to changes in recommendations. As changes occur, please update your practice accordingly. Note: This is not a statement of benefits. Benefits may vary based on state requirements, product line (HMO, PPO, etc.), and/or employer group. HMO and PPO member coverage may be verified through Provider Services. In-home Physician Visiting Program IBC has contracted with a professional provider group, Care Level Management (CLM), to provide physician services in the home to complement the care plans as designed by primary care physicians (PCPs). Based on specific criteria, CLM physicians will work with selected Keystone 65 members who suffer from multiple chronic illnesses and have experienced multiple emergency room visits and acute care admissions during the last year. CLM is a nationally recognized group currently working in several states with the Medicare population. CLM physicians will complement and support the current PCP provider network, while visiting the member in the home and providing 24-hour access to a physician who can provide in-home care anytime, day or night as needed. This level of patient-centric, physician-directed care has 10 March 2007 been designed to improve the quality of care and optimum health status for the most chronically ill, frail patients. By optimizing care in the home, the goal of this pilot program is to reduce unnecessary hospitalizations and emergency room visits, thereby improving health status of the member and avoiding unnecessary costs to the member and the health care system. The PCP will be intimately involved in care planning decisions suggested by the CLM physician after an urgent contact with the member. Capitation payments to the PCP will remain unchanged during this pilot. Please call us at (215) 241-2846, with any questions regarding potential enrollees or on-going care as co-managed with CLM physicians. www.ibx.com P R E V E N T I V E HEALTH Supporting Our Members, Your Patients: ConnectionsSM Health Management Programs ConnectionsSM Health Management Program Diseases: • Asthma • CHF • CAD • COPD • Diabetes To refer a patient for Health Coaching for these five chronic diseases or for general health support, or to obtain additional information for your office, call the Connections Health Management Program Provider Support Line at (866) 866-4694. ConnectionsSM Kidney Program Disease: • End-Stage Renal Disease To refer a patient or obtain additional information, call the Connections Kidney Program at (866) 303-4CKP. ConnectionsSM AccordantCareTM Program Diseases: • Seizure Disorders • Rheumatoid Arthritis • Multiple Sclerosis • Crohn’s Disease • Parkinson’s Disease • Systemic Lupus Erythematosus (SLE) • Myasthenia Gravis • Sickle Cell Disease • Cystic Fibrosis • Hemophilia • Scleroderma • Polymyositis • Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) • Amyotrophic Lateral Sclerosis (ALS) • Dermatomyositis • Gaucher Disease To refer a patient or obtain additional information, call the Connections AccordantCareTM Program at (866) 398-8761. www.ibx.com March 2007 11 I M P O RTA N T R E SOURCES View our online provider directories at www.ibx.com Partners in Health monthly Update is a publication of the Provider Communications department for the exchange of information and ideas among the IBC Provider community. Suggestions are welcome. CONTACT INFORMATION: Caroline Crispino Managing Editor Charleen Baselice Production Coordinator Provider Communications Independence Blue Cross 1901 Market Street 35th Floor Philadelphia, PA 19103 [email protected] Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield—independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield words and symbols, and BlueExchange are registered trademarks of the Blue Cross and Blue Shield Association, and association of independent Blue Cross and Blue Shield Plans. This is not a statement of benefits. Benefits may vary based on state requirements, product line (HMO, PPO, Indemnity, etc.), and/or employer groups. Providers should call Provider Services, listed at right, for the member’s applicable benefit information. Members should be instructed to call the number on the back of their identification card. Not all benefit plans use Magellan Behavioral Health, Inc. to administer behavioral health benefits. Please check the back of the member’s ID card for the telephone number to contact for behavioral health services, if applicable. The third-party Web sites mentioned in this publication are maintained by organizations over which IBC exercises no control, and accordingly, IBC disclaims any responsibility for the content, the accuracy of the information, and/or quality of products or services provided by or advertised in these third-party sites. URLs presented for informational purposes only. Certain services/treatments referred to in third-party sites may not be covered by all benefit plans. Members should refer to their benefit contract for complete details of the terms, limitations, and exclusions of their coverage. CPT® (Current Procedural Terminology) 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. Investors in NaviMedix®, Inc. include an affiliate of IBC, which has a minority ownership interest in NaviMedix®, Inc. CARE MANAGEMENT AND COORDINATION Case Management Baby BluePrints® CONNECTIONSSM HEALTH MANAGEMENT PROGRAMS Connections Health Management Program Provider Support Line (215) 567-3570 (800) 313-8628* (215) 241-2198 (800) 598-BABY [2229]* (866) 866-4694 ConnectionsSM Kidney Program (866) 303-4CKP [4257] ConnectionsSM AccordantCareTM Program (866) 398-8761 CORPORATE AND FINANCIAL INVESTIGATIONS DEPARTMENT Anti-Fraud and Corporate Compliance Hotline (866) 282-2707 www.ibx.com/anti-fraud CREDENTIALING VIOLATION HOTLINE (215) 988-6534 www.ibx.com/credentials eBUSINESS Help Desk (215) 241-2305 eBusiness Provider Hotline HEALTH RESOURCE CENTER Healthy LifestylesSM Precertification PHARMACY SERVICES Prescription Drug Authorization Toll Free Fax (215) 640-7410 (215) 241-3367 (800) 275-2583* (215) 241-2100 (800) 227-3116* (888) 678-7012 (888) 671-5285 Direct Ship Injectable (267) 402-1711 (888) 678-7012 Fax (215) 761-9165 Blood Glucose Meter Hotline (888) 494-8213 (option 2) PROVIDER ELECTRONIC DATA INTERCHANGE SERVICES WEB PAGE www.ibx.com/edi PROVIDER INFORMATION and TOOLS WEB PAGE www.ibx.com/providers PROVIDER SERVICES (Policies/Procedures/Claims) HMO (215) 567-3590 (800) 227-3119* PPO PROVIDER SUPPLY LINE (215) 567-3694 (800) 332-2566* (800) 858-4728 * Outside 215 area code Visit our website at www.ibx.com/providers/communications 03/07 ALL R TRADES IED PRINTING UNION LABEL COUNCIL SCRANTON 13 The 2006 CGPU Compendium mailed as an enclosure with this edition of Partners in Health Update. The Compendium has been added to this PDF for your convenience. 2006 Coding Guidelines and Policy Update Compendium www.ibx.com ® GR APHI C C O M M U N I C AT I O UNION INT NS LABEL E R N AT O IO NAL UNI N 526-M 2006 Coding Guidelines And Policy Update COMPENDIUM www.ibx.com Important Note: The medical policies referenced in this document apply to all HMO, POS, and PPO products of Independence Blue Cross (“IBC”), including its affiliates, as well as to traditional indemnity products to the extent the applicable covered services are underwritten by IBC or its affiliates. Please note that some of IBC’s traditional indemnity products are jointly underwritten by Highmark Blue Shield and therefore Highmark’s medical policy may apply. You may refer to the member’s ID card for the entity that is responsible for underwriting the product. This document was developed to assist IBC 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..........................................3 About the Coding Guidelines and Policy Update Compendium.............................3 What are the Primary Reasons that IBC Develops Claim Payment and Medical Policies?................................................3 Class Action Settlement Update...........35 Enhancements to Claim Payment Policy, Processing and Payment Disclosure, and an Appeals Process for Class Action Settlement Providers............................................36 Physician Volunteers Needed to Assist in Developing Medical Policies...........3 Assistant Surgery Modifiers 80, 81, 82.................................................36 Medical Policies Covered: According to Certain Criteria.....................................5 Medical Code Updates.........................39 Medical Policies Not Covered: Considered Experimental/Investigational.................21 Claim Payment Policies........................27 Co-Surgery Modifier 62....................37 CPT® Codes.....................................40 ICD-9 CM Codes.............................90 HCPCS Codes..................................62 2006 Articles........................................31 ICD-9 CM Diagnosis Codes Change for Routine Gynecological Exams................................................32 Billing for Neonatal Hearing Screening Should be Directed to Facility...........................................32 Anesthesia Claims Update.................32 Gardasil® Approved by the FDA......32 Clarifications to the Intensity Modulated Radiation Therapy Policy.................................................33 View Full Policies Online Full descriptions of these policies are available online: www.ibx.com/medpolicy. The Blue Cross and Blue Shield words and symbols are registered marks of the Blue Cross and Blue Shield Association. Independence Blue Cross offers products directly, through its subsidiaries Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield—independent licensees of the Blue Cross and Blue Shield Association. INTRODUCTION About the Coding Guidelines and Policy Update (CGPU) Compendium Over the past year, Independence Blue Cross (IBC) has published four Coding Guidelines and Policy Update (CGPU) newsletters. Some of the primary reasons that IBC develops claim payment and medical policy are to: This 2006 Coding Guidelines and Policy Update Compendium is a collection of relevant policy summaries that have been published in 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 CGPU; however, these updated policies will appear in future issues of CGPU. We encourage you to visit www.ibx.com/providers for expanded, up-to-date versions of each policy. •Comply with legislation (e.g., federal, state, and local legislative mandates). 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. •Ensure a relevant and timely scheduled review of existing policies. This Compendium contains information that you can immediately adopt within your practice to simplify your information retrieval and claims submission processes. *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. Visit www.ibx.com/medpolicy to get the most current, in-depth and up-to-date information on policies affecting health care in your region. Review and accept the terms & conditions, and you can quickly and easily search all active policies. Bookmark this site and check back regularly for the latest information and updates. The 2006 CGPU Compendium can be found at www.ibx.com/providers/communications. You can also check the website to find specific billing codes, in-depth descriptions of services, or other policy-related data. www.ibx.com/providers/communications 43034txt.indd 3 What Are the Primary Reasons That IBC Develops Claim Payment and Medical Policies? •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. • Provide claims submission policies and procedures. Physician Volunteers Needed to Assist in Developing Medical Policies IBC 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 IBC 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 a 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, IBC is seeking physician consultants in the following specialties: • • • • • • • • • Neurosurgery Orthopedics Urology Vascular Surgery Physical Medicine and Rehabilitation Rheumatology Cardiology Gastroenterology Pain Medicine 2/19/07 1:44:19 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium 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 adhere to our confidentiality statement. • Maintain a high ethical standard, evidenced by the absence of any IBC investigation into personal or group claims practices. • Complete and sign a Conflict of Interest Statement and Confidentiality Agreement prior to becoming a member of the advisory panel. 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. Senior Medical Director Claim Payment Policy Department Independence Blue Cross 1901 Market Street Philadelphia, PA 19103-1480 View Full Policies Online Full descriptions of these policies are available online at: www.ibx.com/medpolicy. View full policies online at www.ibx.com/medpolicy 43034txt.indd 4 2006 CGPU Compendium 2/19/07 1:44:19 PM Medical Policies Covered: according to certain criteria www.ibx.com Table of Contents Ambulatory Blood Pressure Monitoring (ABPM) (07.02.09)........................................................ 6 Blepharoplasty with or without a Brow Lift/Repair of Blepharoptosis (11.05.02c)......................................... 6 Bone Growth Stimulators (05.00.09c)........................... 7 High-Frequency Chest Wall Oscillation Devices (05.00.14c)..................................................................... 9 Home Phototherapy for Neonatal Jaundice (07.06.02) ...................................................................... 9 Hospital Beds and Accessories (05.00.56a) ................ 10 Islet Cell Transplantation (11.04.01) .......................... 12 Maze Procedure (11.02.20a) ....................................... 12 Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD) (07.03.03b)................................................... 13 Negative Pressure Wound Therapy (NPWT) Pump (05.00.38a) ....................................................... 13 Outpatient Speech Therapy (10.06.01a) . .................. 15 Reduction Mammaplasty (11.08.02c).......................... 17 The Boston® Scleral Lens (07.13.11) ................... 18 Trigger Point Injections (11.14.02c) ........................... 19 www.ibx.com/providers/communications 43034txt.indd 5 2/19/07 1:44:19 PM C o ding G uid e l in e s and P o l ic y U pdat e Medical Policies Covered: Ambulatory Blood Pressure Monitoring (ABPM) (07.02.09) Covered: According to Certain Criteria Ambulatory blood pressure monitoring (ABPM) involves the use of a noninvasive device that measures blood pressure in 24-hour cycles. The device consists of a portable sphygmomanometer attached to a recording device. The information it provides can help a physician determine whether an individual is truly hypertensive or is exhibiting white coat hypertension (WCH). The ABPM device is fitted to and removed from the individual by a trained technician. The sphygmomanometer inflates at predetermined times, generally every 30 minutes, and the blood pressure recorded at each inflation is stored. The individual performs normal activities while wearing the monitor. Automated ABPM is considered more accurate than individual self-monitoring. Therefore, it is generally thought that readings obtained at frequent intervals throughout the day and night would help the physician better manage the individual’s care. These stored 24-hour measurements are later interpreted at the physician’s office. A clinician is required to interpret the collected data by uploading it onto a computer where device-specific programs are used to categorize and analyze the measurements. ABPM is considered medically necessary for individuals who meet the definition criteria of WCH and have no evidence of end-organ damage. ABPM is covered for individuals requiring 24-hour monitoring of their blood pressure to confirm the diagnosis. Physician interpretation is medically necessary and required for reimbursement. Therefore, ABPM utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer, with recording only or scanning analysis with report only (no mention of physician interpretation), is not eligible for separate reimbursement when billed alone or in conjunction with another service. When a primary care physician (PCP) is contracted to provide medically necessary and preventive care services on a monthly capitation basis, this service is included in the monthly capitation payment. Originally published in Winter 2006 CGPU. C o mp e ndium According to Certain Criteria Blepharoplasty with or without a Brow Lift/Repair of Blepharoptosis (11.05.02c) Covered: According to Certain Criteria Blepharoptosis is the condition of droopiness of the upper eyelid due to underlying eye muscle dysfunction (e.g., levator muscle or Muller’s muscle). Surgical repair of this condition, including repair of the eye muscle, is performed in conjunction with the blepharoplasty procedure. A blepharoplasty procedure includes the removal of redundant skin of the upper and/or lower eyelids and the removal of protruding periorbital fat. This procedure can be performed for either cosmetic or reconstructive purposes. When performed for cosmetic reasons, the surgery reshapes eye-related structures in order to improve appearance and self-esteem; when provided as part of a reconstructive procedure, the surgery reshapes eye-related structures in order to improve functional ability. Blepharoplasty can be performed alone or in conjunction with other procedures such as a brow lift. Under most circumstances, a blepharoplasty with or without a brow lift and/or repair of blepharoptosis is a cosmetic service and a benefit contract exclusion. However, each of these procedures is medically necessary when performed as functional or reconstructive surgeries in certain clinical situations. Blepharoplasty Blepharoplasty is medically necessary when performed to correct: •Prosthetic difficulties in an anophthalmic (without an eye) socket. •Disorders of visual impairment caused by redundant skin of the eyelid or eyebrow that include, but are not limited to: -V isual impairment due to dermatochalasis, blepharochalasis, or ptosis of the eyelid. -Symptomatic, redundant skin that is resting on the upper lashes. -Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper eyelid skin. Lower eyelid blepharoplasty is generally not medically indicated to treat conditions that cause visual field View full policies online at www.ibx.com/medpolicy 43034txt.indd 6 2006 CGPU Compendium 2/19/07 1:44:20 PM obstruction because the lower eyelids are not usually associated with visual impairment. In the absence of visual impairment, lower eyelid blepharoplasty is considered a cosmetic service and, therefore, not covered. -The upper eyelid indicates the presence of dermatitis. Requests for lower eyelid blepharoplasty are considered on an individual basis when documentation (including the individual’s chief complaint and preoperative photographs) demonstrates that the procedure is medically necessary for reconstructive reasons. - The brow position is below the superior orbital rim. Blepharoptosis Repair Blepharoptosis repair is medically necessary when performed as functional/reconstructive surgery to correct a visual impairment due to drooping or displacement of the upper eyelid. Brow Ptosis Repair Brow ptosis repair is medically necessary when performed as functional/reconstructive surgery to correct either of the following: • Visual impairment due to droop or displacement of the brow. • Brow malposition that would prevent adequate correction of dermatochalasis, blepharochalasis, or blepharoptosis. Documentation Requirements All requests for any of the procedures listed above require a letter of medical necessity that describes the individual’s chief complaints and that justifies the need for surgery to correct the functional impairment. Additionally, when blepharoplasty is to be performed as a functional/reconstructive surgery to correct visual impairment, the following additional documentation is required: • Preoperative color photographs that include a view of the individual: in forward gaze, looking up, and looking down, and that demonstrate one or more of the following: -The upper eyelid margin is within 2.5 mm (onefourth of the diameter of the visible iris) of the corneal light reflex (margin-to-reflex distance [MRD] less than 2.5 mm) with the individual in primary gaze. - The upper eyelid skin rests on the eyelashes. www.ibx.com/providers/communications 43034txt.indd 7 -The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmic socket. •A written interpretation of the results of both the taped and untaped automated visual field studies must be submitted and must demonstrate one of the following: -The upper visual field has improved by at least eight degrees or 20 percent with the eyelid taped as compared with the visual field obtained without taping (two sets of visual fields are required). -V isual field obstruction by the eyelid limits the upper visual field to within 30 degrees of fixation. If both a blepharoplasty and a brow ptosis repair are planned, the need for both must be documented. This requires photographs showing the affect of the drooping, redundant skin; the skin resting on the upper eyelid; the presence of dermatitis; or the actual presence of blepharoptosis. Originally published in Fall 2006 CGPU. Bone Growth Stimulators (05.00.09c) Covered: According to Certain Criteria Noninvasive bone growth stimulators consist of an external power supply and externally applied coils or a transducer that generate a weak electrical current through the site where bone growth is desired. Noninvasive devices use pulsed electromagnetic fields (PEMFs), capacitative coupling, or combined magnetic fields technology to generate the current. Ultrasonic bone growth stimulators are noninvasive devices that accelerate fracture healing by emitting low-intensity, pulsed ultrasound signals on the skin surface over the fracture site. Ultrasonic bone growth stimulators are used in conjunction with cast immobilization. Electrical bone growth stimulators are used for nonunion fracture(s) of long bone, which is defined by Medicare to include the following: the clavicle, humerus, radius, ulna, metacarpal, femur, tibia, fibula, malleolus, and metatarsal. Studies of bone growth stimulators in the treatment of fresh fractures (less than seven days) and in delayed union and nonunion fractures of both long and short bone indicate that insufficient scientific evidence exists to demonstrate the effectiveness of electrical bone growth stimulators in fresh and delayed union fractures. In addition, the safety 2/19/07 1:44:20 PM C o ding G uid e l in e s and P o l ic y U pdat e and effectiveness of electrical bone growth stimulators in individuals under the age of 17 has not been established in clinical trials. Electrical bone growth stimulators (noninvasive/invasive) are considered medically necessary and, therefore, covered for individuals 17 years of age or older when one of the following conditions is present: • A fracture secondary to congenital pseudarthrosis (755.8). • A nonunion fracture (733.82) of a long bone (includes the following: the clavicle, humerus, radius, ulna, metacarpal, femur, tibia, fibula, malleolus, metatarsal). -Nonunion fracture is defined as the point at which healing has stopped (three months or greater from the initial fracture) and further healing (as evidenced by serial radiographic documentation) has ceased. • A failed joint fusion. -Post-surgical joint fusion failure is defined as radiologic documentation of nonunion nine months or more after surgical fixation of the fracture. Electrical bone growth stimulators (noninvasive/invasive) are considered medically necessary and, therefore, covered following spinal surgery (V45.4) when one of the following criteria is met: •A failed spinal fusion when the surgery was performed a minimum of nine months from the last surgery. •A multilevel spinal fusion surgery (e.g., L3-L5, L4-S1, etc.). •Revisional spinal fusion surgery due to a previously failed spinal fusion at the same level. Unless any exclusion criteria exists, low-intensity ultrasonic bone growth stimulators (noninvasive) are considered medically necessary and, therefore, covered for any of the following: • Fresh (less than seven days), closed or Grade l open, tibial diaphysis fracture (823.20, 823.30) when used as an adjunct to closed reduction and cast immobilization. C o mp e ndium • Nonunion fractures (733.82) of the clavicle, scapula, humerus, radius, ulna, carpal, metacarpal, phalanges (fingers or toes), femur, patella, tibia, fibula, malleolus, talus, calcaneus, cuboid, navicular, cuneiform, tarsal, metatarsal, rib(s), sternum, and pelvis. - Nonunion fracture is defined as the point at which healing has stopped (three months or greater from the initial fracture) and further healing (as evidenced by serial radiographic documentation) has ceased. If one or more of the following exclusion criteria exist, lowintensity ultrasonic bone growth stimulators are considered experimental/investigational and, therefore, not covered because the safety and/or efficacy of this device for these conditions cannot be established by review of the available published literature: • For a fracture of the skull or vertebrae. • For a fracture that is tumor-related. • For concurrent use with any other noninvasive osteogenic stimulator. • In individuals under the age of 17. • For a fresh fracture other than one of the tibial diaphysis or distal radius. • For a delayed union fracture (a recent fracture [three months or less from the initial fracture], where healing has not advanced at the “average” rate for the location and type of fracture). For all other indications, electrical bone growth stimulators and low-intensity ultrasonic bone growth stimulators are considered experimental/investigational and, therefore, not covered because the safety and/or efficacy of these devices cannot be established by review of the available published literature. Examples of other indications include, but are not limited to: individuals under the age of 17, fresh fractures (except ultrasonic stimulator use for fractures of the tibial diaphysis or distal radius), and delayed union fractures. Originally published in Fall 2006 CGPU. • Fresh, closed fracture of the distal radius (Colles fracture [813.41, 813.42]) when used as an adjunct to closed reduction and cast immobilization. View full policies online at www.ibx.com/medpolicy 43034txt.indd 8 2006 CGPU Compendium 2/19/07 1:44:20 PM High-Frequency Chest Wall Oscillation Devices (05.00.14c) Covered: According to Certain Criteria A high-frequency chest wall oscillation device is designed to enhance the mobilization of bronchial secretions. The device is an inflatable vest that is connected by two tubes to a small air-pulse generator. Oscillating positive air pressure causes the vest to inflate and deflate up to 25 times a minute, creating a vibratory motion that aids in the mobilization of secretions. The action of the device creates mini-coughs that dislodge mucus from the bronchial walls, thus increasing mobilization of the mucus toward the central airways. The oscillating action also thins the secretions and makes them easier to remove by coughing or suctioning. High-frequency chest wall oscillation devices can be used for individuals who have cystic fibrosis or bronchiectasis and require chest physiotherapy, manual chest percussion, postural drainage, and device-assisted coughing to help them clear their lungs. A four- to six-week trial of a high-frequency chest wall oscillation device is considered medically necessary and, therefore, covered for the treatment of individuals with a documented history that confirms a failure of standard treatments (e.g., manual chest percussion, postural drainage) to adequately mobilize retained bronchial secretions and one of the following diagnoses: • Cystic fibrosis. •Bronchiectasis, confirmed by computed tomography (CT) scan, and documentation of one of the following: -Daily productive cough for at least six continuous months. -Frequent (i.e., more than two per year) exacerbations of respiratory infection requiring antibiotic therapy. Continued coverage of the device after the trial is considered medically necessary and, therefore, covered when the effectiveness of the device has been demonstrated by: •Documentation that the device has been used daily or as prescribed. • Documentation of increased expectoration of mucus. If the trial of the device is successful and the individual wishes to continue using the device, continued authorization for the device must be obtained. The ordering physician must provide a letter of medical necessity to the Company stating compliance with the above requirements. www.ibx.com/providers/communications 43034txt.indd 9 High-frequency chest wall oscillation devices for any diagnosis other than cystic fibrosis or bronchiectasis are considered not medically necessary and, therefore, not covered because the available published literature does not support the use of this device for the treatment of any other diagnosis. Originally published in Fall 2006 CGPU. Home Phototherapy for Neonatal Jaundice (07.06.02) Covered: According to Certain Criteria Phototherapy is often used to treat neonatal jaundice and involves the continuous application of ultraviolet light via a lamp or a fiberoptic system to a newborn for a prescribed period of time. The fiberoptic system consists of a pad of woven fibers that transport light from a light source to the baby. This covered fiberoptic pad is placed directly against the baby to bathe the skin in light. Phototherapy uses blue wavelengths of light to convert the bilirubin to less toxic water-soluble photoisomers, which are then excreted in bile and urine. Phototherapy can be administered in a hospital or home setting (home phototherapy). It is important to note that the use of phototherapy in the home setting is contraindicated in the presence of risk factors. Home phototherapy devices do not consistently provide the same degree of irradiance as those available in the hospital. Due to the questionable efficiency of home phototherapy for neonatal jaundice, the American Academy of Pediatrics states that home phototherapy is considered inappropriate for infants with higher bilirubin concentrations. Home phototherapy is considered medically necessary for full-term newborns who are diagnosed with neonatal jaundice and have none of the risk factors, major or minor, that have been identified by the American Academy of Pediatrics.* The following are major risk factors that have been identified by the American Academy of Pediatrics for the development of severe hyperbilirubinemia in infants of 35 weeks or more gestation: •Predischarge total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) level in the high-risk zone. • Jaundice observed within the first 24 hours. 2/19/07 1:44:20 PM C o ding G uid e l in e s and P o l ic y U pdat e •Blood group incompatibility with positive direct antiglobulin test, other known hemolytic disease (e.g., glucose-6-phosphate-dehydrogenase [G6PD] deficiency), elevated end tidal carbon monoxide (ETCOc). • Gestational age 35-36 weeks. • Previous sibling received phototherapy. • Cephalohematoma or significant bruising. •Exclusive breastfeeding, particularly if nursing is not going well and weight loss is excessive. • East Asian race. The following are minor risk factors identified by the American Academy of Pediatrics for the development of severe hyperbilirubinemia in infants of 35 weeks or more gestation: •Predischarge TSB or TcB level in the high intermediaterisk zone • Gestational age 37-38 weeks • Jaundice observed before discharge • Previous sibling with jaundice • Macrosomic infant of a diabetic mother • Maternal age of 25 years or more • Male gender *Reproduced with permission from Pediatrics, Vol. 114, Pages 297-316, Copyright © 2004 by the American Academy of Pediatrics (AAP). Originally published in Winter 2006 CGPU. Hospital Beds and Accessories (05.00.56a) Covered: According to Certain Criteria A hospital bed is a bed with head and leg elevation and height adjustment features that are used to assist individuals who require adjustment or repositioning to alleviate pain, prevent contractures, prevent respiratory infections, and to allow individuals to transfer to and from bed with increased independence. Hospital bed accessories are additions to a bed that are not provided as part of the original bed. Accessories that may be needed for the essential functioning of the hospital bed in 10 View full policies online at www.ibx.com/medpolicy 43034txt.indd 10 C o mp e ndium relation to the individual’s condition include trapeze bars, bed cradles, or side rails. Medically Necessary Fixed-height Hospital Beds A fixed-height hospital bed (E0250, E0251, E0290, E0291) is medically necessary when the individual meets one or more of the following medical necessity criteria: •The individual has a medical condition that requires positioning of the body in ways that are not feasible in an ordinary bed. The elevation of the head/upper body of less than 30 degrees does not usually require the use of a hospital bed. •The individual requires head elevation of more than 30 degrees most of the time due to congestive heart failure (CHF), problems with aspiration, or chronic pulmonary disease. Pillows or wedges must have been considered and ruled out. •The individual requires positioning of the body in ways that are not feasible in an ordinary bed to alleviate pain. •The individual requires traction equipment, which can only be attached to a hospital bed. Variable-height Hospital Beds A variable-height hospital bed (E0255, E0256, E0292, E0293) is medically necessary for individuals with severely debilitating diseases and conditions (including, but not limited to severe cardiac conditions, spinal cord injuries, amyotrophic lateral sclerosis [ALS], and multiple sclerosis) when all of the following apply: •The individual meets one or more of the medical necessity criteria for a fixed-height hospital bed. •The individual requires a bed height that cannot be attained with a fixed hospital bed and that allows them to be transferred to a chair, wheelchair, or standing position. Semi-Electric Hospital Beds A semi-electric hospital bed (E0260, E0261, E0294, E0295) is medically necessary when the individual meets one or more of the medical necessity criteria for a fixed-height hospital bed and both of the following criteria: • The individual’s condition requires that their body position be changed frequently and/or that their body 2006 CGPU Compendium 2/19/07 1:44:20 PM position may be changed immediately when necessary (i.e., no delay can be tolerated). • The individual is able to operate the controls and cause the adjustments. Exceptions to this requirement can be made in cases of spinal cord injury (SCI) and brain injury. Heavy-duty Hospital Beds A heavy-duty hospital bed (E0301, E0303) is medically necessary when the individual meets one or more of the medical necessity criteria for a fixed-height hospital bed and when the individual’s weight exceeds 350 pounds but is less than 600 pounds. Extra-heavy-duty Hospital Beds An extra-heavy-duty hospital bed (E0302, E0304) is medically necessary when the individual meets one or more of the medical necessity criteria for a fixed-height hospital bed and when the individual’s weight exceeds 600 pounds. Pediatric Hospital Beds • Bed cradle (E0280): When the individual has a medical condition that requires the prevention of contact with bed coverings (i.e., burns, diabetic ulcers, gout). • Trapeze equipment (E0910, E0940): When the individual requires this device to do any one of the following: - Sit up because of a respiratory condition. - Change body position for other medical reasons. - Get in or out of bed. • Heavy-duty trapeze equipment (E0911, E0912): When the individual meets both of the following criteria: -The individual meets the criteria for regular trapeze equipment. - The individual weighs more than 250 pounds. • Side rails (E0305, E0310): When the individual’s condition requires that they have bed side rails and the rails are a part of or an accessory to the hospital bed. A pediatric hospital bed is medically necessary when the individual meets all of the medical necessity criteria for one of the hospital beds specified above. Not Medically Necessary Not Medically Necessary The following hospital bed accessory is considered not medically necessary: Total Electric Hospital Beds A total electric hospital bed (E0265, E0266, E0296, E0297) is considered not medically necessary and, therefore, not covered because the electric height adjustment feature does not aid in the treatment of the individual’s condition. Institutional Hospital Beds An institutional hospital bed (E0270) is considered not medically necessary and, therefore, not covered because it is deemed inappropriate for home use. These beds include oscillating beds, circulating beds, and Stryker frame beds. Hospital Bed Accessories Medically Necessary The following hospital bed accessories are considered medically necessary when the individual meets the medical www.ibx.com/providers/communications 43034txt.indd 11 necessity requirement for the specified bed and meets the additional criteria as indicated below: • Trapeze bars (E0910, E0911) will be considered not medically necessary and, therefore, not covered when they are used on an ordinary bed. Not Primarily Medical In Nature (Benefit Exclusion) • Safety enclosures (E0316) (nylon netting that encloses the top and sides of a hospital bed) are considered benefit exclusions and, therefore, not covered as these devices are not primarily medical in nature. Additionally, these devices have safety concerns associated with them. For Medicare members, safety enclosures are considered not medically necessary, and, therefore, not covered; these devices have safety concerns associated with them. • A bed board (E0273, E0315) (a device placed under a mattress to make the mattress firmer) is considered a benefit exclusion and, therefore, not covered because its use is not primarily medical in nature. • An over bed table (E0274, E0315) is considered a benefit exclusion and, therefore, not covered because its use is not primarily medical in nature. Originally published in Fall 2006 CGPU. 11 2/19/07 1:44:20 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium Islet Cell Transplantation (11.04.01) Covered: According to Certain Criteria Maze Procedure (11.02.20a) Covered: According to Certain Criteria Islet cell transplant tissue comes from either the patient (autologous transplant) or from a cadaveric donor (allogeneic transplant). Islet cell transplantation may benefit an individual who does not have a functioning pancreas. Currently only individuals with either chronic pancreatitis or type 1 diabetes mellitus have been the subject of clinical investigations. The Maze procedure is a surgical procedure intended to restore normal heart rhythm in individuals afflicted with atrial fibrillation or atrial flutter that does not respond to medical therapy. It can be performed alone or in conjunction with other cardiac surgeries for restoring the normal electrical impulses of the heart. The procedure is done under general anesthesia while the individual is on cardiopulmonary bypass (a machine that performs the functions of the heart and lungs during the surgery). Access to the heart is obtained through a sternal incision. The cardiothoracic surgeon then makes several incisions in the right and left atria of the heart to create a pathway (maze) for the electrical impulses to flow, thus restoring the normal rhythm of the heart. These incisions create a direction for the impulse to flow from the sinoatrial (SA) node to the atrioventricular (AV) node and block the re-entry of impulses that result in atrial fibrillation or atrial flutter. Autologous islet transplantation is a technique to prevent the serious morbidity of surgical induced diabetes due to the removal of the individual’s pancreas. Although the pancreatectomy and transplant can be performed on two different days, the transplant is generally performed during the pancreatectomy procedure. During the pancreatectomy, a suspension is created by mixing plasma and the isolated islet cells collected from the individual’s own resected pancreatic specimen. This suspension is then injected into the portal vein of the liver, where the cells function as a free graft. There is no risk of rejection because, unlike allogeneic organ/tissue transplants, the individual’s own islet cells are used in the procedure. Autologous islet cell transplantation is considered medically necessary and, therefore, covered as an adjunct to a total or near-total pancreatectomy in individuals with chronic pancreatitis. Autologous islet cell transplantation is considered experimental/investigational for all other indications 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. Allogeneic islet cell transplantation is considered experimental/investigational for all indications because the safety and/or efficacy of this service can not be established by review of the available published literature. Therefore, this service is not covered. Originally published in Winter 2006 CGPU. 12 View full policies online at www.ibx.com/medpolicy 43034txt.indd 12 Results may not be evident immediately due to cardiac swelling, and some individuals may experience temporary fibrillation up to three months following the procedure. The fibrillation normally stops after the heart has had time to heal completely. The Maze procedure is considered medically necessary and, therefore, covered for the treatment of atrial fibrillation or atrial flutter in individuals with any of the following clinical indications: • Resistance to drug therapy. • Intolerance of drug therapy. • Atrial fibrillation or atrial flutter for more than six months with an enlarged left atrium. • High risk for thromboembolism (i.e., previous thromboembolism or long-standing atrial fibrillation with mitral valve disease). Originally published in Spring 2006 CGPU. 2006 CGPU Compendium 2/19/07 1:44:21 PM Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD) (07.03.03b) Covered: According to Certain Criteria Evaluation All of the following are considered medically necessary and, therefore, covered for the medical evaluation of attentiondeficit hyperactivity disorder (ADHD): • A complete physical examination within the last 12 months (including blood tests such as lead levels and quantitative plasma amino acid assays to detect phenylketonuria). • A comprehensive medical history. • Interviews with the parents and child to establish problem pattern of behavior and parent-child and childpeer conflicts. Neuropsychological testing for the evaluation of a previously diagnosed ADHD is considered not medically necessary and, therefore, not covered. It should only be performed if there is a suspicion of a neurological deficit that requires additional evaluation. Management Pharmacological therapy in the management of ADHD may be covered under the prescription plan when the member has a pharmacy benefit. Not Medically Necessary Nontraditional treatments for ADHD such as, but not limited to, the following, have not shown positive health outcomes and are, therefore, considered not medically necessary and are not covered: • Elimination diets (e.g., Feingold diet). • Nutritional supplements (e.g., megadoses of vitamins). Experimental/Investigational Nontraditional treatments for ADHD lack validation and scientific support and are, therefore, considered experimental/investigational and are not covered. Examples of nontraditional treatments for ADHD include: • Sensory integration therapy. • Optometric vision training (orthoptic/pleoptic). • Interactive metronome training (a computerized version of keeping the beat, which provides auditory feedback). • Chiropractic therapy. Originally published in Summer 2006 CGPU. Negative Pressure Wound Therapy (NPWT) Pump (05.00.38a) Covered: According to Certain Criteria Negative pressure wound therapy (NPWT), also known as vacuum-assisted closure, is the application of controlled negative pressure (vacuum pressure) to a wound using an electrical pump. The NPWT vacuum pressure pump is used to apply from 25 mm to greater than 200 mm Hg of pressure to a wound, either continuously or intermittently. Medical Necessity A NPWT pump and the supplies necessary for its use are considered medically necessary and, therefore, covered for chronic nonhealing wounds (of at least 30 days duration) as specified below when all of the following applicable conditions are met: • For chronic nonhealing ulcers or wounds, all of the following program measures should apply or be considered and ruled out by an eligible health care professional prior to the application of a NPWT pump: • Antifungal therapy. - Any wound-specific therapeutic measures. • Electroencephalogram (EEG) biofeedback. -Documentation in the individual’s medical record of the evaluation, wound measurements (length, depth, and width), and general care performed and documented by a health care professional. • Antimotion sickness medication. • Spinal manipulation. Physical, occupational, and/or speech therapy is considered not medically necessary and, therefore, not covered in the www.ibx.com/providers/communications 43034txt.indd 13 treatment of ADHD, unless the individual has a neurological or physical deficit that requires such therapy. -Wound assessments are performed and documented at least weekly (e.g., size [length, depth, and width], 13 2/19/07 1:44:21 PM C o ding G uid e l in e s and P o l ic y U pdat e color, exudate type and amount, odor, evidence of healing, sinus tracking or tunneling, pain, type of dressing used). -Application of dressings to maintain a moist wound environment. -Debridement of necrotic tissue (if present) by a health care professional. -Evaluation of and provision for adequate nutritional status. • The following wound-specific therapeutic measures (if applicable) must be applied or considered and ruled out by an eligible health care professional prior to the application of a NPWT pump for the following specific types of ulcers and wounds: - For Stage III or IV pressure ulcers: ºThe individual has been appropriately turned and positioned. ºThe individual has used a group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis. (A group 2 or 3 support surface is not required if the ulcer is not on the trunk or pelvis. For more information on support surfaces, refer to the policy addressing this topic.) ºThe individual’s moisture and incontinence have been appropriately managed. - For neuropathic (e.g., diabetic) ulcers: ºThe individual has been on a comprehensive diabetic management program. ºThe individual has experienced reduced pressure on a foot ulcer as a result of using the appropriate modalities (such as, but not limited to, the following: total contact casts; removable cast walkers; half shoes; saline wetto-dry dressings; debridement of all necrotic, callus, and fibrous tissue; crutches). - For venous insufficiency ulcers: ºThe individual has had compression bandages and/or garments consistently applied. º The individual has applied leg elevation. º The individual has applied ambulation. 14 View full policies online at www.ibx.com/medpolicy 43034txt.indd 14 C o mp e ndium • For complications of surgical, subacute, or traumatic wounds (e.g., postoperative flap, dehiscence, skin graft failure, traumatic amputation, gunshot wounds, or burns) when accelerated granulation tissue formation cannot be achieved by topical wound treatments and is a medical necessity as demonstrated by documentation of conditions such as, but not limited to, any of the following: - The presence of excessive wound drainage. - Large wounds not amenable to primary closure. - Conditions that slow healing times (e.g., diabetes). - Infection. -The wound is a chronic and nonhealing wound of at least 30 days duration. Initial NPWT pump treatments may begin during an inpatient stay for wounds encountered in the inpatient setting. Treatment with the NPWT pump beyond the inpatient stay may continue (upon discharge) in the home setting, subject to meeting the above medical necessity criteria. Continued Coverage For continuing coverage of up to four months, an eligible health care professional must: • Directly assess the wound(s) being treated with the NPWT pump device and document findings. • Supervise or directly perform the NPWT pump dressing changes and document findings. • Document changes in the ulcer’s dimensions and characteristics (e.g., size [length, depth, and width], color, exudate type and amount, odor, and evidence of healing) at least weekly. For continued coverage beyond four months, continued documentation demonstrating wound healing is required and will be evaluated by a Company medical director. Not Medically Necessary Treatment with an NPWT pump and supplies is considered not medically necessary and, therefore, not covered when: • Adequate wound healing has occurred. • Any measurable degree of wound healing has failed to occur over the prior month. 2006 CGPU Compendium 2/19/07 1:44:21 PM • Cancer is present in the wound. • The equipment or supplies are no longer being used for the individual, regardless of whether it is a result of the health care professional’s orders. • The eligible health care professional fails to perform and document the following on a weekly basis: -Direct assessment of the wound(s) being treated with the NPWT pump. -Supervision or directly performing the ulcer/wound dressing changes. -Changes in the ulcer’s dimensions (length, depth, and width) at least weekly. • Necrotic tissue with eschar is present if debridement has not been attempted. • There is a fistula to an organ or body cavity within the vicinity of the wound. • Untreated osteomyelitis exists within the vicinity of the wound. Supplies for NPWT An individual is eligible for a maximum of 15 wound care sets (A6550) per wound per month, unless there is documentation that the wound size requires more than one wound care set for each dressing change. An individual is eligible for a maximum of 10 canisters (A7000) per month, unless there is documentation evidencing a large volume of drainage (90 ml of exudate/day). An NPWT pump (E2402) must be capable of accommodating more than one wound dressing set for multiple wounds on an individual. Therefore, more than one E2402 billed per individual for the same time period will be denied as not medically necessary. Originally published in Fall 2006 CGPU. Outpatient Speech Therapy (10.06.01a) Covered: According to Certain Criteria Speech pathology services are services that are deemed necessary for the diagnosis of speech and language disorders. Speech therapy is the medically prescribed treatment of speech and language disorders due to disease, surgery, www.ibx.com/providers/communications 43034txt.indd 15 injury, congenital anomalies, speech language delay, or previous therapeutic processes that result in communication disabilities and/or swallowing disorders. Medical Necessity Criteria Speech pathology evaluation and services related to the speech therapy process that are within the scope of the member’s benefit contract are considered medically necessary and, therefore, are covered when all of the following criteria are met: • The evaluation is prescribed by a physician and performed by a speech/language pathologist who is licensed in the state where the services are being performed and who is certified by the American Speech-Language-Hearing Association (ASHA). • The services must be of such a complex nature that they can only be performed by a speech/language pathologist. • The medical condition must be such that there is a reasonable expectation that the services will bring about a significant improvement within a reasonable time frame, regardless of whether the individual has a coexisting disorder. • The services are provided in accordance with an ongoing plan of care specific to the diagnosis. -The plan of care should be updated at least weekly, or more frequently as the treatment progresses, and as goals change or are met. Upon request, documentation must be available that shows measurable progress toward meeting the short- and long-term goals outlined in the plan of care. • The therapy is performed for a communication disorder that is a result of at least one of the following: -Disease (e.g., Parkinson’s disease that results in increased difficulty in swallowing and speaking). -Surgery (e.g., surgical removal of a malignant growth on the head or neck). -Injury (e.g., automobile accident that results in a subdural hematoma influencing the speech center and causing neurogenic stuttering or aphasia following a cerebrovascular accident [CVA]). -Congenital anomalies (e.g., inborn defect of the skull, cleft lip, or cleft palate). 15 2/19/07 1:44:21 PM C o ding G uid e l in e s and P o l ic y U pdat e -Speech-language delay that is developmental in nature. or • The therapy is performed for a swallowing disorder (dysphagia) that results from a condition such as, but not limited to, a CVA regardless of whether a communication disorder also exists. Speech therapy performed for reasons other than those listed above is considered not medically necessary and, therefore not covered except as required by law. Conditions that do not Meet Medical Necessity Criteria Conditions or situations that do not meet medical necessity criteria for speech pathology evaluation and services related to the speech therapy process include, but are not limited to: • Psychological speech delay. • Behavior problems (e.g., impulsive behavior). • Except as required by law, mental retardation, autism, attention disorders, or pervasive developmental disorders (PDDs) in the absence of a documented communication co-morbidity that is amenable to speech therapy with a reasonable expectation of achieving sustainable, measurable improvement in a reasonable time frame. -Social communication disorder is not considered a medically necessary co-morbidity. • Stammering and stuttering with the following exception: -Speech therapy is considered medically necessary and, therefore, covered for neurogenic stuttering caused by acquired brain damage. • Programs that are primarily educational in nature or that support an academic program. • Speech therapy for the maintenance of a chronic condition when the therapeutic goals of a treatment plan have been achieved, no additional functional improvement is apparent or expected to occur, and the provision of services for a condition ceases to be of therapeutic value. -Maintenance therapy is defined as a continuation of care and management of the individual when the therapeutic goals of a treatment plan have been 16 View full policies online at www.ibx.com/medpolicy 43034txt.indd 16 C o mp e ndium achieved, no additional functional improvement is apparent or expected to occur, and the provision of services for a condition ceases to be of therapeutic value. This includes maintenance services that seek to prevent disease, promote health, and prolong and enhance the quality of life. • Services that otherwise would not require the skills of a qualified speech/language pathologist, such as treatments that maintain function by using routines and repetitions. -Examples of these services include, but are not limited to, word drills for developmental articulation errors, computer-based programs (e.g., Fast Forward), and procedures that may be performed by the individual, family, and/or caregivers. Duplicate Therapy When individuals are receiving both occupational and speech therapy, the therapies must provide different treatments with separate treatment plans and goals in order for each to be covered and be separately reimbursed. Otherwise, the therapy is considered duplicate therapy and coverage and reimbursement is only available for one therapy. Benefit Limitations Limitations, frequency, and annual maximums may be applied and vary by product or by group. Individual member benefits must be verified, as speech therapy benefits vary by product and group. Speech Therapy Services Provided in Conjunction with Speech Generating Devices, Electronic Speech Aids, and Computer-Based Programs Speech generating devices including computer-based programs: Speech therapy provided in association with a speech generating device, including a computer-based program, is considered medically necessary and, therefore, covered when the device is considered medically necessary consistent with the applicable medical policy. Electronic speech aids and other electronic devices for speech: Electronic speech aids/devices are considered medically necessary and, therefore, covered only when an individual has 2006 CGPU Compendium 2/19/07 1:44:22 PM had a laryngectomy or has a nonfunctional larynx consistent with the applicable medical policy. There are several electronic speech aids/devices approved by the U.S. Food and Drug Administration (FDA) for use with speech therapy. Speech therapy provided in association with an approved electronic speech aid/device is considered medically necessary and, therefore, covered in accordance with the terms defined in the applicable medical policy. Electronic speech devices that are designed to improve fluency problems (such as stuttering) rather than aid in communication disabilities are considered experimental/ investigational because the efficacy of these devices cannot be established by review of the available published literature. Therefore, these devices are not covered. Examples of these types of electronic devices include, but are not limited to: • SpeechEasy ( Janus Development Group, Inc., Greenville, N.C.). • F luencyMaster (National Medical Equipment, Inc., New Hyde Park, N.Y.). Originally published in Summer 2006 CGPU. Reduction Mammaplasty (11.08.02c) Covered: According to Certain Criteria Reduction mammaplasty is a surgical procedure that excises a portion of the breast, including the skin and underlying glandular tissue to reduce the size, shape, and weight of mammary tissue. In some selected cases (e.g., when the breasts are not too large and the skin has good elasticity), liposuction can be utilized. However, in most cases, only fat, not glandular breast tissue, can be successfully removed by liposuction. For all products except Medicare Advantage, the following criteria are applicable: Reduction mammaplasty is considered medically necessary and, therefore, covered when all of the following medical necessity criteria are met: • A n individual has macromastia (enlargement of the breasts) or gigantomastia. • Clinical symptoms of breast, neck, back, or shoulder pain, or painful shoulder grooving are present for a minimum six-week period and have not responded to conservative measures (e.g., support bra, exercises, heat/ cold treatment, non-steroidal anti-inflammatory drugs (NSAIDs)/muscle relaxants). www.ibx.com/providers/communications 43034txt.indd 17 • The individual meets the minimum specimen weight of breast tissue to be removed based on the individual’s body surface area (BSA). - Simplified formula for calculation of body surface area: BSA (in m2) = [height (cm)] 0.718 X [weight (kg)] 0.427 X 0.007449 • Any individual 40 years of age or older is required to have a mammogram which is negative for cancer within the year prior to the planned surgery. When a request is made for reduction mammaplasty, photographs documenting breast size are required. For Medicare Advantage Members only, the following criteria are applicable: Reduction mammaplasty is considered reconstructive surgery and medically necessary for symptomatic individuals with macromastia when all of the following criteria are met: • The individual has significant symptoms that interfere with normal daily activities, including at least one of the following: -Symptomatic neck, back, or shoulder pain not related to other causes (e.g., poor posture, acute strains, poor lifting techniques). - Significant breast pain. - Brachial plexus irritation. - Clinical, nonseasonal submammary intertrigo. ºMedicare requires that hypertrophy of breast (611.1) be reported as the primary diagnosis, with one of the following clinical conditions reported as a secondary diagnosis: □Other specified erythematous condition (695.89). □ Pain in joint, shoulder region (719.41). □ Cervicalgia (723.1). □Unspecified musculoskeletal disorders and symptoms referable to neck (723.9). □ Pain in thoracic spine (724.1). □ Unspecified backache (724.5). □ Unspecified osteoporosis (733.00). □ Senile osteoporosis (733.01). 17 2/19/07 1:44:22 PM C o ding G uid e l in e s and P o l ic y U pdat e □ Kyphosis (acquired) (postural) (737.10). • The amount of breast tissue anticipated to be removed is at least 350 grams per breast. • Conservative treatment has failed. Examples of conservative treatment include, but are not limited to: - Appropriate support bra. - Conservative analgesia (NSAIDs). -In individuals where obesity is a documented risk factor, a legitimate, medically-based attempt to reduce and maintain weight (e.g., diet, exercise). - Appropriate medical management of intertrigo. Requests for reduction mammaplasty that do not meet medical necessity criteria are considered cosmetic, and therefore are not covered. Originally published in Fall 2006 CGPU. The Boston® Scleral Lens (07.13.11) Covered: According to Certain Criteria A contact lens that covers the cornea and the adjacent portion of the white of the eye (sclera) is called a scleral contact lens and is sometimes referred to as a corneal liquid bandage. The BOSTON® Scleral Lens (BSL), which is more specifically termed the BOSTON® Equalens II, is the only rigid gas-permeable scleral contact lens that is commercially available in the U.S. and that can be post-fabricated for the treatment of persistent corneal epithelial defects (PED). Currently, it is only post-fabricated and distributed by the Boston Foundation for Sight in Needham, Mass. The BSL, unlike a traditional rigid gas-permeable contact lens, is a specially designed, fluid-ventilated, gas-permeable scleral contact lens. It is designed to maintain a bubblefree reservoir of oxygenated aqueous fluid over the corneal surface at a neutral hydrostatic pressure. Due to the fact that air bubbles are avoided, the fluid reservoir functions as a liquid corneal bandage that offers unique therapeutic benefits for the management of severe ocular surface disease, in addition to its traditional role of masking irregular corneal astigmatism. C o mp e ndium was Stevens-Johnson syndrome. The BSL has also been shown to be effective in preventing the recurrence of PED in anesthetic corneas. The BSL is considered medically necessary and, therefore, covered to alleviate pain and photophobia for PED that have been documented as disabling and that have symptoms that are not significantly relieved with medical treatment. The BSL is also considered medically necessary and, therefore, covered to improve visual acuity in individuals for whom surgery is either undesirable and/or contraindicated due to any of the following conditions: •Stevens-Johnson disease (a syndrome of systemic, as well as more severe, mucocutaneous lesions that results in corneal opacities, perforations, and/or blindness). •Conditions that result from a chemical and/or traumatic injury. • Postradiotherapy complications. • Recurrent corneal erosion. • Congenital and/or postsurgical lid defect(s). • Ocular cicatricial pemphigoid. • Exposure keratitis. • Toxic epidermal necrolysis. •Lacrimal and/or meibomian gland obliteration or deficiency. • Superior limbal keratoconjunctivitis. • Sjögren syndrome. • Inflammatory corneal degeneration. •Neurotrophic corneal disease (e.g., corneal denervation that is related to acoustic neuroma surgery, trigeminal ganglion obliteration, diabetes mellitus, herpetic syndrome, congenital dysautonomia [Reily-Day syndrome]). • Corneal edema. Originally published in Winter 2006 CGPU. Although limited, compelling evidence exists that shows that the BSL is effective in alleviating pain and photophobia and improves the vision of patients with PED. In the majority of studies, the most frequent specific indication for the BSL 18 View full policies online at www.ibx.com/medpolicy 43034txt.indd 18 2006 CGPU Compendium 2/19/07 1:44:22 PM Trigger Point Injections (11.14.02c) Covered: According to Certain Criteria Trigger point injection is one of many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. Trigger point injections are considered medically necessary and, therefore, covered when performed for myofascial pain syndrome (MPS) when at least one of the following situations is present: meet the medical necessity criteria listed in this policy. • Additional reimbursement will not be made for the injection of water, saline, or local anesthetics. Dry needling of trigger points is considered medically necessary and, therefore, covered. The medical necessity criteria for dry needling of trigger points are the same as those for trigger point injections. Originally published in Fall 2006 CGPU. •Noninvasive medical management (e.g., analgesics, passive physical therapy, ultrasound therapy, range-ofmotion, and/or active exercises) is unsuccessful. •Joint movement is mechanically blocked, as when the coccygeus muscle is involved. Trigger point injections are appropriate when administered to any of the following body regions: • Head. • Cervical spine. • Left upper extremities, including shoulder. • Right upper extremities, including shoulder. • Left lower extremities, including hip. • Right lower extremities, including hip. • Thoracic spine (including the trapezius and scapular areas). • Lumbosacral spine. When a given region is injected, it is considered one injection service, regardless of the number of injections administered within that region. • It is expected that this procedure would not be performed on more than three body regions on a given date of service. • Trigger point injections for a specific body region should not be performed more frequently than once a month. -Requests for more frequent injections require additional documentation of medical necessity. Medications listed in the coding table are eligible for separate reimbursement when used for trigger point injections that www.ibx.com/providers/communications 43034txt.indd 19 19 2/19/07 1:44:22 PM C o ding G uid e l in e s and P o l ic y 20 View full policies online at www.ibx.com/medpolicy 43034txt.indd 20 U pdat e C o mp e ndium 2006 CGPU Compendium 2/19/07 1:44:22 PM Medical Policies NOT Covered: CONSIDERED EXPERIMENTAL/ INVESTIGATIONAL www.ibx.com Table of Contents Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure (11.14.17)........... 22 Cryoablation of Neuromas (11.15.21) ........................ 22 Dual-Energy X-ray Absorptiometry (DEXA) Body Composition Study (09.00.20a).......................... 22 Infrared Heating Pad Systems (07.00.18a).................. 22 Intraperitoneal Hyperthermic Chemotherapy (IPHC) (11.00.13) ...................................................... 23 Ocular Photoscreening (07.13.12)............................... 23 Prolotherapy (11.14.15b).............................................. 24 Scintimammography (09.00.39)................................... 24 Subfascial Endoscopic Perforator Surgery (SEPS) (11.02.23) ....................................................... 24 Surgical Ventricular Restoration (SVR) (11.02.24) .... 24 Thermography (07.02.13a) ......................................... 25 www.ibx.com/providers/communications 43034txt.indd 21 21 2/19/07 1:44:22 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium Medical Policies Not Covered: Considered Experimental/Investigational Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure (11.14.17) Not Covered: Considered Experimental/ Investigational Dual-Energy X-ray Absorptiometry (DEXA) Body Composition Study (09.00.20a) Not Covered: Considered Experimental/ Investigational Computer-assisted navigational orthopedic procedures use navigational systems during musculoskeletal surgery to provide additional information and to further integrate preoperative planning with how the surgery is being performed. Navigational systems are typically used to improve the placement and positioning of a prosthetic and/or surgical instrument during the procedure. Computer-assisted navigational orthopedic procedures can also be used as an adjunct to fixation of pelvic, acetabular, or femoral fractures and as an adjunct to hip or knee arthroplasty procedures. A full-body DEXA is a noninvasive method for assessing body fat and composition. It can also be combined with an additional measurement of total body water and contribute to a body composition assessment that is based on a fourcompartment mode: bone, fat, dry fat-free soft tissue, and water. A computer-assisted musculoskeletal surgical navigational orthopedic procedure 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 2006 CGPU. Cryoablation of Neuromas (11.15.21) Not Covered: Considered Experimental/ Investigational Cryoanalgesia, also known as cryosurgery, cryolysis, cryoneurolysis, and cryoablation, uses extremely low temperatures to produce a reversible nerve block similar to that delivered by local anesthesia. No randomized or controlled studies have tested cryoanalgesia specifically for pain control of neuromas. Cryoablation of neuromas 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 2006 CGPU. DEXA body composition study 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 2006 CGPU. Infrared Heating Pad Systems (07.00.18a) Not Covered: Considered Experimental/ Investigational Monochromatic infrared energy (MIRE), applied via an infrared heating pad system, has been used to treat various conditions related to circulation and pain. An infrared heating pad system consists of a pad or pads containing mechanisms that generate infrared, or near-infrared, light (e.g., luminous gallium aluminum arsenide diodes) and a power source. The pads are placed on the skin for 30 to 45 minutes, three times weekly, as a treatment program for diabetic neuropathy, ischemic ulcers, and/or musculoskeletal conditions such as back, foot, or myofascial pain. No randomized, controlled studies have been conducted to assess the efficacy of the technique or its long-term effects. Treatment of wounds, diabetic neuropathy, and/or musculoskeletal conditions with infrared heating pad systems 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. Originally published in Spring 2006 CGPU. 22 View full policies online at www.ibx.com/medpolicy 43034txt.indd 22 2006 CGPU Compendium 2/19/07 1:44:23 PM Intraperitoneal Hyperthermic Chemotherapy (IPHC) (11.00.13) Not Covered: Considered Experimental/ Investigational Intraperitoneal hyperthermic chemotherapy (IPHC) is a procedure that includes a combination of cytoreductive surgery (debulking or macroscopically removing all visible tumors) with heated chemotherapy delivered intraperitoneally immediately following the surgery. The extent of this surgery plays a significant role in treatment because of the limited 1-3 mm penetration of cytostatic drugs into the peritoneal tissue. The goal of IPHC is to eliminate microscopic metastases that are too small to be identified and removed during cytoreductive surgery. It is theorized that heated chemotherapy increases cytotoxicity and will enhance penetration of chemotherapy into the tumor. In addition, hyperthermia itself has a cytotoxic effect on tumor tissue. IPHC has been explored in a number of studies over the past 20 years. The majority of research evidence includes phase II trials and case series. There are few phase III trials. Also, the populations studied included only a small number of individuals with various locations of primary cancer, different stages of peritoneal carcinomatosis, and varying degrees of success with cytoreductive surgery. Additional research is needed to further define the criteria used to select which individuals should receive hyperthermia, and to identify the most effective drug combination for peritoneal administration. In addition, some of the technical aspects of the procedure such as the optimal temperature of the chemotherapeutic agents, the length of time for the IPHC perfusion, and the efficacy and safety of open and closed chemoperfusion need to be determined and standardized. IPHC in conjunction with cytoreductive surgery 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. Ocular Photoscreening (07.13.12) Not Covered: Considered Experimental/ Investigational Ocular photoscreening has been investigated as an alternative screening method to detect the risk factors for amblyopia, which include strabismus (a misalignment of the eyes in any direction), media opacities (e.g., cataracts) and refractive errors (e.g., myopia, hyperopia, astigmatism, presbyopia). It is based on the principle of photorefraction, in which the refractive state of the eye is assessed via the pattern of light that is reflected through the pupil. Ocular photoscreening involves the use of a camera or video system that is equipped for photoscreening. By using this equipment, images of the pupillary reflexes (autonomic reflex constrictions caused by light) and red reflex (a circular red light reflected from the retina of the eye) are obtained. The images can then be analyzed based on the position of the corneal light reflex, as well as the overall reflection of light from the fundus, which provides information on the child’s fixation pattern and the presence or absence of strabismus. Ocular photoscreening is performed in a darkened room and requires little cooperation from the child, other than fixating on a target for the duration of the photoscreening process. The photographs can then be analyzed by the evaluator or sent to a central laboratory for analysis by an ophthalmologist or specially-trained personnel. Test results are typically graded as pass, fail, or repeat photoscreening. Ocular photoscreening is considered experimental/ investigational because the safety and/or efficacy of this service cannot be established by review of the current available published literature. Therefore, this service is not covered. Originally published in Winter 2006 CGPU. Originally published in Winter 2006 CGPU. www.ibx.com/providers/communications 43034txt.indd 23 23 2/19/07 1:44:23 PM C o ding G uid e l in e s and P o l ic y U pdat e Prolotherapy (11.14.15b) Not Covered: Considered Experimental/ Investigational Prolotherapy consists of a series of intraligamentous and intratendinous injections of sclerosing agents that alleviate chronic pain by inducing the proliferation of new cells. There are three classes of proliferant solutions used in prolotherapy: chemical irritants (e.g., phenol), osmotic shock agents (e.g., hypertonic dextrose and glycerin), and chemotactic agents (e.g., morrhuate sodium, a fatty acid derivative of cod liver oil). Prolotherapy should not be confused with trigger point injections, which relieve pain by infusing anesthetics and/or anti-inflammatory agents into affected areas. Prolotherapy 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. Reporting prolotherapy using the trigger point injection CPT® procedure code or any other code is a misrepresentation of the actual service rendered. These services are subject to post-payment review and audit procedures. Originally published in Fall 2006 CGPU. Scintimammography (09.00.39) Not Covered: Considered Experimental/ Investigational Scintimammography, also known as mammoscintigraphy, has been proposed primarily as an adjunct to standard film mammography using radiopharmaceutical agents (radioactive tracer [e.g., technetium-99m sestamibi]) to provide tumorspecific imaging of the breast. Scintimammography has also been proposed for the detection of axillary lymph node metastases in individuals with breast carcinoma; however, it has not been fully investigated for this purpose. There is insufficient data comparing the use of scintimammography for decision-making regarding nodal dissection versus standard nodal dissection. Although scintimammography is currently being performed, the published medical literature does not support its efficacy in differentiating malignancies when compared with using surgical biopsy. Scintimammography is considered experimental/ investigational because the safety and/or efficacy of this service cannot be established by review of the available 24 View full policies online at www.ibx.com/medpolicy 43034txt.indd 24 C o mp e ndium published literature. Therefore, this service is not covered. Originally published in Summer 2006 CGPU. Subfascial Endoscopic Perforator Surgery (SEPS) (11.02.23) Not Covered: Considered Experimental/ Investigational Subfascial endoscopic perforator surgery (SEPS) is performed as a minimally invasive way to treat individuals with chronic venous insufficiency of the lower extremities. Guided by ultrasound scanning, small incisions are made into the skin that is unaffected by severe chronic venous insufficiency. Using endoscopic techniques, the perforating veins are clipped or divided by endoscopic scissors. SEPS is considered experimental/investigational because the efficacy of this procedure cannot be established by review of the available published literature. Therefore, this service is not covered. Originally published in Summer 2006 CGPU. Surgical Ventricular Restoration (SVR) (11.02.24) Not Covered: Considered Experimental/ Investigational Surgical ventricular restoration (SVR) is a procedure that is designed to restore or remodel the left ventricle to its normal spherical shape and size in individuals who have akinetic (non-moving) segments of the heart. This condition may be secondary to either dilated cardiomyopathy or postinfarction left ventricular aneurysm. The SVR procedure is most commonly performed after coronary artery bypass grafting (CABG) and may also proceed or be followed by procedures such as mitral valve repair or replacement, endocardectomy, and cryoablation for the treatment of ventricular tachycardia. The SVR procedure may also be referred to as ventricular remodeling or surgical anterior ventricular endocardial restoration (SAVER). SVR 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 2006 CGPU. 2006 CGPU Compendium 2/19/07 1:44:23 PM Thermography (07.02.13a) Not Covered: Considered Experimental/ Investigational Thermography is the measurement of self-emanating infrared radiation that reveals temperature variations at the surface of the body. The thermographic device senses body temperature and demonstrates areas of differing heat emission by producing brightly colored patterns on a liquid crystal display. Each color represents a specific temperature level. Interpretation of these color patterns according to designated anatomic distribution is thought to aid in diagnosing a vast array of disease, such as, but not limited to, breast cancer, Raynaud’s phenomenon, headache, and reflex sympathetic dystrophy. The American College of Radiology, the American Medical Association, and the American Academy of Neurology have all issued documents that do not recommend or endorse thermography as a diagnostic technology. Thermography 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. Originally published in Spring 2006 CGPU. www.ibx.com/providers/communications 43034txt.indd 25 25 2/19/07 1:44:23 PM C o ding G uid e l in e s and P o l ic y 26 View full policies online at www.ibx.com/medpolicy 43034txt.indd 26 U pdat e C o mp e ndium 2006 CGPU Compendium 2/19/07 1:44:23 PM Claim payment Policies www.ibx.com Table of Contents Associated Services Performed in Conjunction with Dental Services Considered Eligible for Reimbursement When Certain Criteria are Met (00.01.18a)............................................................ 28 Modifiers LT/RT: Left Side/Right Side Procedures (03.00.10)................................................... 28 Work Hardening and Work Conditioning is Not Covered Under Most of the Company’s Products (10.05.02)...................................................... 29 www.ibx.com/providers/communications 43034txt.indd 27 27 2/19/07 1:44:23 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium Claim Payment Policies Associated Services Performed in Conjunction with Dental Services Considered Eligible for Reimbursement When Certain Criteria are Met (00.01.18a) Dental services include procedures and/or surgery that relate to the teeth, jaw, and/or mouth (e.g., routine cleanings, fillings). The Company covers and considers for reimbursement charges that are associated with noncovered dental procedures or surgery, including anesthesia, when any of the following conditions are met: •The individual has a comorbid condition that would potentially increase the risk of the procedure being performed. • The individual is severely disabled. • The individual is a child. •The individual’s admission to the Ambulatory Surgery Center (ASC), Short Procedure Unit (SPU), or hospital setting is appropriate/necessary to ensure and safeguard the individual’s health. This policy applies to services that are performed in the following settings: ASC, SPU, hospital outpatient, or inpatient. This policy applies whether or not the dental service is eligible under the medical benefits. For information on dental services that are covered under the medical benefits, refer to the individual and/or group benefit contract. Originally published in Spring 2006 CGPU. Modifiers LT/RT: Left Side/Right Side Procedures (03.00.10) Modifiers LT/RT are used to indicate the side of the body on which a service or procedure is performed. Modifiers LT/RT do not indicate a bilateral service and should not be used to report a service or procedure that is performed bilaterally. Modifier 50 should be used to report bilateral services or procedures. The Company has established the following guidelines for the appropriate reporting of Modifiers LT/RT with the appropriate procedure codes: • Modifiers LT/RT should be used to identify procedures that can be performed on contralateral anatomic sites (e.g., bones, joints), paired organs (e.g., ears, eyes, nasal passages, kidneys, lungs, ovaries), or extremities (e.g., arms, legs). • Modifiers LT/RT should be used to indicate that the procedure is performed on only one side of the body. It is inappropriate to use Modifiers LT/RT to identify bilateral services or procedures because a more appropriate modifier exists. To report a bilateral service or procedure, the appropriate procedure code and/or modifier should be used. Multiple surgery reduction logic will be applied when appropriate. Additional reporting requirements for Modifiers LT/RT: • The medical records must clearly support the appropriate use of Modifiers LT/RT. • Medical records, notes, and/or other documentation should not be attached to the claim unless specifically required and/or requested by the Company. • Claims submitted with Modifiers LT/RT are subject to post-reimbursement clinical review and potential retractions for inappropriate use. Originally published in Spring 2006 CGPU. 28 View full policies online at www.ibx.com/medpolicy 43034txt.indd 28 2006 CGPU Compendium 2/19/07 1:44:23 PM Work Hardening and Work Conditioning is Not Covered Under Most of the Company’s Products (10.05.02) Work hardening services address physical, functional, behavioral and vocational needs of the worker by utilizing real or simulated work activities. Additionally, work hardening includes education (e.g., body mechanics, work pacing, safety and injury prevention). A work hardening program begins at four hours per day and builds to eight hours per day over the course of the program, usually four weeks. Work hardening requires a specific return-to-work goal. Work hardening services relate directly to specific work skills and do not provide any diagnostic or therapeutic rehabilitation benefit for the individual. Work conditioning (including reconditioning) utilizes physical conditioning and functional activities related to work. These services bridge a gap between acute outpatient therapy and a structured work hardening program or return to work. Work conditioning/re-conditioning may or may not include an education component. Work conditioning/ re-conditioning is typically four hours/day or less and there is no specific return to work goal required. Work hardening and work conditioning are benefit contract exclusions for some of the Company’s products. If the group benefit contract does not provide a specific exclusion for work hardening, the service is considered not medically necessary as it is considered vocational in nature and does not provide any diagnostic or therapeutic benefit of a medical nature for the individual. Originally published in Summer 2006 CGPU. www.ibx.com/providers/communications 43034txt.indd 29 29 2/19/07 1:44:24 PM C o ding G uid e l in e s and P o l ic y 30 View full policies online at www.ibx.com/medpolicy 43034txt.indd 30 U pdat e C o mp e ndium 2006 CGPU Compendium 2/19/07 1:44:24 PM 2006 articles www.ibx.com Table of Contents ICD-9 CM Diagnosis Codes Change for Routine Gynecological Exams................................................... 32 Billing for Neonatal Hearing Screening Should be Directed to Facility.................................................. 32 Anesthesia Claims Update........................................... 32 Gardasil® Approved by the FDA................................. 32 Clarifications to the Intensity Modulated Radiation Therapy Policy............................................. 33 www.ibx.com/providers/communications 43034txt.indd 31 31 2/19/07 1:44:24 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium 2006 Articles ICD-9 CM Diagnosis Codes Change for Routine Gynecological Exams Please call Provider Services or your Network Coordinator with any questions. Effective January 1, 2006, capitated PCPs who bill for routine gynecological exams should report diagnosis code V72.31 with the applicable preventive evaluation and management (E&M) Current Procedural Terminology (CPT®) codes 99384-99387 and 99394-99397 or Healthcare Common Procedure Coding System (HCPCS) codes S0610 and S0612 for reimbursement consideration. This article originally appeared in the March 2006 Partners in Health Update. Routine gynecological exams that are reported with ICD-9 CM code V72.32 for CPT codes 99384-99387 and 99394-99397 are no longer eligible for additional payment outside of 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 January 2006 Partners in Health Update. Billing for Neonatal Hearing Screening Should be Directed to Facility Independence Blue Cross (IBC) has recently received inquiries from members who received bills for hearing screenings provided to their newborns before discharge from a facility. Please be advised that newborn hearing screenings are covered services and included within the facility’s payment for the delivery and are not eligible for separate billing to IBC or to the member. In the event that a provider has a contract or arrangement with a facility to provide these screenings, the provider must look to that facility for payment and not to IBC or to our members. 32 View full policies online at www.ibx.com/medpolicy 43034txt.indd 32 Anesthesia Claims Update Effective August 1, 2006, as part of the standard claims adjudication process, ClaimCheck clinical relationship logic will be applied to claims reported with anesthesia services. ClaimCheck is the code relationship editing tool that is integrated into the claims adjudication process for professional claims processing. For information regarding ClaimCheck clinical relationship logic, please refer to the Clear Claim Connection tool which is available through the NaviNetSM Portal. You may also refer to the user guide that was mailed to you in December 2005. The ClaimCheck system applies to professional claims for products processed on the MHS system only. PA Traditional Indemnity and CMM products are not affected. This article originally appeared in the July 2006 Partners in Health Update. Gardasil® Approved by the FDA In June, the U.S. Food and Drug Administration (FDA) approved the biologic license application for Gardasil® (Quadrivalent Human Papillomavirus [Types 6, 11, 16, 18] Recombinant Vaccine). Gardasil® is a new vaccine indicated for females ages 9 to 26 for the prevention of the following conditions caused by HPV types 6, 11, 16, and 18: • Cervical cancer • Genital warts And the following precancerous or dysplastic lesions: • Cervical adenocarcinoma in situ (AIS) • Cervical intraepithelial neoplasia (CIN) grade 1, grade 2, and grade 3 • Vulvar intraepithelial neoplasia (VIN) grade 2 and grade 3 • Vaginal intraepithelial neoplasia (VaIN) grade 2 and grade 3 2006 CGPU Compendium 2/19/07 1:44:24 PM Coverage Statement Coverage Limitations Gardasil® (Quadrivalent Human Papillomavirus [Types 6, 11, 16, 18] Recombinant Vaccine) is considered medically necessary and, therefore, covered as a three-dose regimen for use in females ages 9 to 26 for the prevention of cervical cancer; genital warts; AIS; CIN grade 1, 2, and 3; VIN grade 2 and 3; and VaIN grade 2 and 3 for those members who have an immunization benefit. The following CPT® codes are not to be reported when the services are performed as part of developing an IMRT plan that is reported using CPT code 77301, even if the services are performed on different dates, as reimbursement for the following codes is already included in CPT code 77301. Reimbursement for MRI guidance for placement of radiation therapy fields is already included in CPT code 77301 and should not be separately reported, regardless of the date of service. This article originally appeared in the October 2006 Partners in Health Update. Clarifications to the Intensity Modulated Radiation Therapy Policy To review the full version of this policy, go to www.ibx.com/medpolicy. This article originally appeared in the November 2006 Partners in Health Update. Effective December 6, 2006, we will amend the criteria for medical policy #09.00.17b – Intensity Modulated Radiation Therapy (IMRT). The annual review of this policy led to the addition of the following coverage limitations based on the current literature on this topic. 76370 Computerized axial tomographic guidance for placement of radiation therapy fields 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation 77280 Therapeutic radiology simulation-aided field setting, simple 77285 Therapeutic radiology simulation-aided field setting; intermediate 77290 Therapeutic radiology simulation-aided field setting; complex 77295 Therapeutic radiology simulation-aided field setting; three-dimensional simulation 77305 Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel opposed unmodified ports directed to a single area of interest) 77310 Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more treatment ports directed to a single area of interest) 77315 Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations) 77321 Special teletherapy port plan, particles, hemibody, total body 77331 Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician 77336 Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy 77370 Special medical radiation physics consultation www.ibx.com/providers/communications 33 C o ding G uid e l in e s and P o l ic y 34 View full policies online at www.ibx.com/medpolicy 43034txt.indd 34 U pdat e C o mp e ndium 2006 CGPU Compendium 2/19/07 1:44:24 PM class action settlement update www.ibx.com Table of Contents Enhancements to Claim Payment Policy, Processing and Payment Disclosure, and an Appeals Process for Class Action Settlement Providers......................... 36 Assistant Surgery Modifiers 80, 81, 82........................ 36 Co-Surgery Modifier 62.............................................. 37 www.ibx.com/providers/communications 43034txt.indd 35 35 2/19/07 1:44:24 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium Class Action Settlement Update: Enhancements to Claim Payment Policy, Processing and Payment Disclosure, and an Appeals Process for Class Action Settlement Providers The class action settlements of Gregg, et al. v. Independence Blue Cross, et al. Good v. Independence Blue Cross, et al., and Pennsylvania Orthopaedic Society v. Independence Blue Cross, et al. include the following enhancements for providers who agreed to the settlement: • 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. • C hanging claims processing for Settlement Providers on the following: selected modifiers (25, 50, 51, 59, 62, 66, 80, 81, 82, RT, LT), multiple surgical procedures, radiological guidance during a procedure, and certain Current Procedural Terminology (CPT®) code-level designations (e.g., Modifier 51 Exempt, Separate Procedure, Add-on Codes). • Introducing a two-level formal claims appeal process for Settlement Providers. Certain of these enhancements are currently available. Others will be announced as they become available. This article originally appeared in the January 2006 Partners in Health Update. Assistant Surgery Modifiers 80, 81, 82 IBC has enhanced its processing system to apply the Centers for Medicare & Medicaid Services (CMS) payment methodology for modifiers that represent assistant surgery [Assistant Surgeon 80; Minimum Assistant Surgeon 81; Assistant Surgeon (when qualified resident surgeon not available) 82] as outlined in the Medicare Physician Fee Schedule Database on the CMS website.* Assistant surgery Modifiers 80, 81, and 82 are used to denote surgical procedures that require both a primary and an assistant surgeon because of the complexity and/or time requirement of the surgery. An assistant surgeon is a surgeon who actively assists and supports a primary surgeon during a surgical procedure. Both primary and assistant surgeons should report the same procedure code. The assistant surgeon 36 View full policies online at www.ibx.com/medpolicy 43034txt.indd 36 should append the most appropriate assistant surgery modifier based on the narrative. The table below identifies and describes the intended processing outcome that is associated with each indicator. However, reimbursement consideration for services that are reported with Modifiers 80, 81, and/or 82 are also contingent upon eligibility, benefits, exclusions, precertification/referral requirements, provider contracts, and/or applicable policies. Payment for these procedures is based on 20 percent of the fee schedule allowance for the surgical service. Please note that assistant surgical services that are performed in conjunction with other surgical services may be subject to multiple surgery reduction guidelines. CMS utilizes a payment methodology for these types of services by applying assistant surgery payment indicators to procedure codes that, when submitted in combination with Modifiers 80, 81, and/or 82, will allow or restrict payment consideration: CMS Indicator and Description Outcome for the Code/ Modifier 80, 81, and/or 82 Combination (0) Assistant surgery payment is inappropriate unless documentation supports medical necessity. Ineligible for assistant surgery; additional consideration determined on an appeal basis only. (1) Assistant surgery payment is inappropriate. Ineligible for assistant surgery reimbursement consideration. (2) Assistant surgery payment is appropriate. Eligible for assistant surgery reimbursement consideration. (9) Concept does not apply. Invalid procedure/ modifier code combination. Medical records, operative reports, and/or other supporting documentation should not be appended to the claim or submitted to the Company unless specifically requested by the Company. *The following is a link to the Medicare website: www.cms.gov. These sites are maintained by organizations over which Independence Blue Cross exercises no control and, accordingly, Independence Blue Cross expressly disclaims any responsibility for the content, the accuracy of the information, and/or quality 2006 CGPU Compendium 2/19/07 1:44:25 PM 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 January 2006 Partners in Health Update. Co-Surgery Modifier 62 IBC has enhanced its processing system to apply the Centers for Medicare & Medicaid Services (CMS) payment methodology for Co-surgery Modifier 62 as outlined in the Medicare Physician Fee Schedule Database on the CMS website.* Co-surgery Modifier 62 is used to denote when two surgeons act as primary surgeons during the same operative procedure or session for the same individual because of the complexity of the procedure and/or the patient’s condition. The cosurgeons are typically of different specialties and perform consecutive or overlapping parts of the same procedure or simultaneous procedures during the same session with one of the following exceptions for co-surgeons of the same specialty: • Each surgeon must perform a distinct part of the surgical procedure that requires the distinct skills of each surgeon. • Each surgeon performs the same procedure(s) simultaneously for different regions/organs (e.g., bilateral lung reduction, bilateral knee replacements). In such cases, the operative report must reflect the necessity of two primary surgeons with the same skills. Each of the two surgeons should submit the same procedure code that represents the entire surgical procedure appended with Modifier 62. The table below identifies and describes the final processing outcome that is associated with each indicator; however, reimbursement consideration for services that are reported with Modifier 62 are also 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 co-surgery payment indicators to procedure codes that, when submitted in combination with Modifier 62, will allow or restrict payment consideration: CMS Indicator and Description Outcome for the Code/ Modifier 62 (0) Co-surgery payment is inappropriate. Ineligible for co-surgery reimbursement consideration. (1) Co-surgery payment is inappropriate unless supporting documentation establishes medical necessity. Ineligible for co-surgery; additional consideration determined on an appeal basis only. (2) Co-surgery payment is appropriate. Eligible for co-surgery reimbursement consideration. (9) Concept does not apply. Invalid procedure/modifier code combination. It is inappropriate to report Modifier 62 when one surgeon acts as an assistant to the primary surgeon or when more than two surgeons act as primary surgeons during the same operative session. Medical records, operative reports, and/or other supporting documentation should not be appended to the claim or submitted to the Company unless specifically requested by the Company. *The following is a link to the Medicare website: www.cms.gov. These sites are maintained by organizations over which Independence Blue Cross exercises no control and, accordingly, Independence Blue Cross 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 January 2006 Partners in Health Update. Payment for these procedures is based on 62.5 percent of the fee schedule allowance for the service. Please note that cosurgery services that are performed in conjunction with other co-surgery services are subject to multiple surgery reduction guidelines. www.ibx.com/providers/communications 43034txt.indd 37 37 2/19/07 1:44:25 PM C o ding G uid e l in e s and P o l ic y 38 View full policies online at www.ibx.com/medpolicy 43034txt.indd 38 U pdat e C o mp e ndium 2006 CGPU Compendium 2/19/07 1:44:25 PM Medical code updates www.ibx.com Table of Contents CPT®* Codes............................................................... 40 HCPCS Codes............................................................. 62 ICD-9 CM Codes....................................................... 90 As part of the medical/claim payment policy process, the Independence Blue Cross Procedure Code Review Unit supports medical code activities. It establishes and maintains the development and documentation of coverage positions for ICD-9 CM, CPT, and HCPCS medical codes across all lines of business and all processing systems. The following pages detail the new/revised ICD-9 CM, CPT, and HCPCS code updates effective as follows, unless otherwise specified: ICD-9 CM: Additions and Revisions have an effective date of 10/1/2006. Deletions have a delete date of 10/1/2006. CPT: Additions and Revisions have an effective date of 1/1/2007. Deletions have a delete date of 1/1/2007. HCPCS: Additions and Revisions have an effective date of 10/1/2006 or 1/1/2007. Deletions have a delete date of 1/1/2007. Please note that the listing of a code in this Compendium does not necessarily guarantee coverage or reimbursement for a 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. www.ibx.com/providers/communications 43034txt.indd 39 39 2/19/07 1:44:25 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code Narrative A 00625 Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; not utilizing 1 lung ventilation 1/1/2007 A 00626 Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; utilizing 1 - lung ventilation 1/1/2007 A 15002 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, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children 1/1/2007 A 15003 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, trunk, arms, legs; each additional 100 sq cm or each additional 1% of body area of infants and children (List separately in addition to the code for the primary procedure) 1/1/2007 A 15004 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, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children 1/1/2007 A 15005 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, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm or 1% of body area of infants and children (List separately in addition to code for primary procedure) 1/1/2007 A 15731 Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap) 1/1/2007 A 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy 1/1/2007 A 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) 1/1/2007 A 17311 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage up to 5 tissue blocks 1/1/2007 40 View full policies online at www.ibx.com/medpolicy 43034txt.indd 40 Effective Date of Revision/ Addition Delete Date 2006 CGPU Compendium 2/19/07 1:44:25 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code Narrative A 17312 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) 1/1/2007 A 17313 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks 1/1/2007 A 17314 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) 1/1/2007 A 17315 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure) 1/1/2007 A 19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma 1/1/2007 A 19300 Mastectomy for gynecomastia 1/1/2007 A 19301 Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy); 1/1/2007 A 19302 Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy 1/1/2007 A 19303 Mastectomy, simple, complete 1/1/2007 A 19304 Mastectomy, subcutaneous 1/1/2007 A 19305 Mastectomy, radical, including pectoral muscle, axillary lymph nodes 1/1/2007 A 19306 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) 1/1/2007 A 19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle 1/1/2007 A 22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 41 Effective Date of Revision/ Addition Delete Date 41 2/19/07 1:44:26 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code Narrative A 22527 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; one or more additional levels (List separately in addition to code for primary procedure) 1/1/2007 A 22857 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace 1/1/2007 A 22862 Revision including replacement of total disc arthroplasty (artificial disc) anterior approach, lumbar, single interspace 1/1/2007 A 22865 Removal of total disc arthroplasty (artificial disc), anterior approach, lumbar, single interspace 1/1/2007 A 25109 Excision of tendon, forearm and/or wrist, flexor or extensor, each 1/1/2007 A 25606 Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation 1/1/2007 A 25607 Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation 1/1/2007 A 25608 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments 1/1/2007 A 25609 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments 1/1/2007 A 27325 Neurectomy, hamstring muscle 1/1/2007 A 27326 Neurectomy, popliteal (gastrocnemius) 1/1/2007 A 28055 Neurectomy, intrinsic musculature of feet 1/1/2007 A 32998 Ablation therapy for reduction or eradication of one or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral 1/1/2007 A 33202 Insertion of epicardial electrode(s); open incision (e.g., thoracotomy, median sternotomy, subxiphoid approach) 1/1/2007 A 33203 Insertion of epicardial electrode(s); endoscopic approach (e.g., thoracoscopy, pericardioscopy) 1/1/2007 A 33254 Operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure) 1/1/2007 A 33255 Operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure); without cardiopulmonary bypass 1/1/2007 A 33256 Operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure); with cardiopulmonary bypass 1/1/2007 A 33265 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (e.g., modified maze procedure), without cardiopulmonary bypass 1/1/2007 A 33266 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (e.g., maze procedure), without cardiopulmonary bypass 1/1/2007 A 33675 Closure of multiple ventricular septal defects; 1/1/2007 A 33676 Closure of multiple ventricular septal defects; with pulmonary valvotomy or infundibular resection (acyanotic) 1/1/2007 A 33677 Closure of multiple ventricular septal defects; with removal of pulmonary artery band, with or without gusset 1/1/2007 42 View full policies online at www.ibx.com/medpolicy 43034txt.indd 42 Effective Date of Revision/ Addition Delete Date 2006 CGPU Compendium 2/19/07 1:44:26 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code A 33724 Repair of isolated partial anomalous pulmonary venous return (e.g., Scimitar Syndrome) 1/1/2007 A 33726 Repair of pulmonary venous stenosis 1/1/2007 A 35302 Thromboendarterectomy, including patch graft, if performed; superficial femoral artery 1/1/2007 A 35303 Thromboendarterectomy, including patch graft, if performed; popliteal artery 1/1/2007 A 35304 Thromboendarterectomy, including patch graft, if performed; tibioperoneal trunk artery 1/1/2007 A 35305 Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial vessel 1/1/2007 A 35306 Thromboendarterectomy, including patch graft, if performed; each additional tibial or peroneal artery (List separately in addition to code for primary procedure) 1/1/2007 A 35537 Bypass graft, with vein; aortoiliac 1/1/2007 A 35538 Bypass graft, with vein; aortobi-iliac 1/1/2007 Effective Date of Revision/ Addition A 35539 Bypass graft, with vein; aortofemoral 1/1/2007 A 35540 Bypass graft, with vein; aortobifemoral 1/1/2007 A 35637 Bypass graft, with other than vein; aortoiliac 1/1/2007 A 35638 Bypass graft, with other than vein; aortobi-iliac 1/1/2007 A 35883 Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with nonautogenous patch graft (e.g., Dacron, ePTFE, bovine pericardium) 1/1/2007 A 35884 Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with autogenous vein patch graft 1/1/2007 A 37210 Uterine fibroid embolization (UFE, embolization of the uterine arteries to treat uterine fibroids, leiomyomata), percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging necessary to complete the procedure 1/1/2007 A 43647 Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum 1/1/2007 A 43648 Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum 1/1/2007 A 43881 Implantation or replacement of gastric neurostimulator electrodes, antrum, open 1/1/2007 A 43882 Revision or removal of gastric neurostimulator electrodes, antrum, open 1/1/2007 A 44157 Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed 1/1/2007 A 44158 Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed 1/1/2007 A 47719 Anastomosis, choledochal cyst, without excision 1/1/2007 A 48105 Resection or debridement of pancreas and peripancreatic tissue for acute necrotizing pancreatitis 1/1/2007 A 48548 Pancreaticojejunostomy, side-to-side anastomosis (Puestowtype operation) 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 43 Narrative Delete Date 43 2/19/07 1:44:27 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code A 49324 Laparoscopy, surgical; with insertion of intraperitoneal cannula or catheter, permanent 1/1/2007 A 49325 Laparoscopy, surgical; with revision of previously placed intraperitoneal cannula or catheter, with removal of intraluminal obstructive material if performed 1/1/2007 A 49326 Laparoscopy, surgical; with omentopexy (omental tacking procedure) (List separately in addition to code for primary procedure) 1/1/2007 A 49402 Removal of peritoneal foreign body from peritoneal cavity 1/1/2007 A 49435 Insertion of subcutaneous extension to intraperitoneal cannula or catheter with remote chest exit site (List separately in addition to code for primary procedure) 1/1/2007 A 49436 Delayed creation of exit site from embedded subcutaneous segment of intraperitoneal cannula or catheter 1/1/2007 A 54865 Exploration of epididymis, with or without biopsy 1/1/2007 A 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy 1/1/2007 A 55876 Placement of interstitial device(s) for radiation therapy guidance (e.g., fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple 1/1/2007 A 56442 Hymenotomy, simple incision 1/1/2007 A 57296 Revision (including removal) prosthetic vaginal graft; open abdominal approach 1/1/2007 Narrative A 57558 Dilation and curettage of cervical stump 1/1/2007 A 58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; 1/1/2007 A 58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) 1/1/2007 A 58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; 1/1/2007 A 58544 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) 1/1/2007 A 58548 Laparoscopy surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed 1/1/2007 A 58957 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; 1/1/2007 A 58958 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy 1/1/2007 A 64910 Nerve repair; with synthetic conduit or vein allograft (e.g., nerve tube), each nerve 1/1/2007 A 64911 Nerve repair; with autogenous vein graft (includes harvest of vein graft), each nerve 1/1/2007 A 67346 Biopsy of extraocular muscle 1/1/2007 44 View full policies online at www.ibx.com/medpolicy 43034txt.indd 44 Effective Date of Revision/ Addition Delete Date 2006 CGPU Compendium 2/19/07 1:44:27 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code A 70554 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration 1/1/2007 A 70555 Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing 1/1/2007 A 72291 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance 1/1/2007 A 72292 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance 1/1/2007 A 76776 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation 1/1/2007 A 76813 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation 1/1/2007 A 76814 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure) 1/1/2007 A 76998 Ultrasonic guidance, intraoperative 1/1/2007 A 77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) 1/1/2007 A 77002 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) 1/1/2007 A 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction 1/1/2007 A 77011 Computed tomography guidance for stereotactic localization 1/1/2007 A 77012 Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation 1/1/2007 A 77013 Computed tomography guidance for, and monitoring of, parenchymal tissue ablation 1/1/2007 A 77014 Computed tomography guidance for placement of radiation therapy fields 1/1/2007 A 77021 Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 45 Narrative Effective Date of Revision/ Addition Delete Date 45 2/19/07 1:44:28 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code A 77022 Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation 1/1/2007 A 77031 Stereotactic localization guidance for breast biopsy or needle placement (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation 1/1/2007 A 77032 Mammographic guidance for needle placement, breast (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation 1/1/2007 A 77051 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; diagnostic mammography (List separately in addition to code for primary procedure) 1/1/2007 A 77052 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; screening mammography (List separately in addition to code for primary procedure) 1/1/2007 A 77053 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation 1/1/2007 A 77054 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 1/1/2007 A 77055 Mammography; unilateral 1/1/2007 A 77056 Mammography; bilateral 1/1/2007 A 77057 Screening mammography, bilateral (2-view film study of each breast) 1/1/2007 A 77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral 1/1/2007 A 77059 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral 1/1/2007 A 77071 Manual application of stress performed by physician for joint radiography, including contralateral joint if indicated 1/1/2007 A 77072 Bone age studies 1/1/2007 A 77073 Bone length studies (orthoroentgenogram, scanogram) 1/1/2007 A 77074 Radiologic examination, osseous survey; limited (e.g., for metastases) 1/1/2007 A 77075 Radiologic examination, osseous survey; complete (axial and appendicular skeleton) 1/1/2007 A 77076 Radiologic examination, osseous survey, infant 1/1/2007 A 77077 Joint survey, single view, 2 or more joints (specify) 1/1/2007 A 77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) 1/1/2007 A 77079 Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 1/1/2007 A 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) 1/1/2007 Narrative 46 View full policies online at www.ibx.com/medpolicy 43034txt.indd 46 Effective Date of Revision/ Addition Delete Date 2006 CGPU Compendium 2/19/07 1:44:28 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code A 77081 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 1/1/2007 A 77082 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; vertebral fracture assessment 1/1/2007 A 77083 Radiographic absorptiometry (e.g., photodensitometry, radiogrammetry), 1 or more sites 1/1/2007 A 77084 Magnetic resonance (e.g., proton) imaging, bone marrow blood supply 1/1/2007 A 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cerebral lesion(s) consisting of 1 session; multi-source Cobalt 60 based 1/1/2007 A 77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cerebral lesion(s) consisting of 1 session; linear accelerator based 1/1/2007 A 77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions 1/1/2007 A 77435 Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions 1/1/2007 A 82107 Alfa-fetoprotein (AFP); AFP-L3 fraction isoform and total AFP (including ratio) 1/1/2007 A 83698 Lipoprotein-associated phospholipase A2, (Lp-PLA2) 1/1/2007 A 83913 Molecular diagnostics; RNA stabilization 1/1/2007 A 86788 Antibody; West Nile virus, IgM 1/1/2007 A 86789 Antibody; West Nile virus 1/1/2007 A 87305 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Aspergillus 1/1/2007 A 87498 Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique 1/1/2007 A 87640 Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique 1/1/2007 A 87641 Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique 1/1/2007 A 87653 Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus, group B, amplified probe technique 1/1/2007 A 87808 Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis 1/1/2007 A 91111 Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus with physician interpretation and report 1/1/2007 A 92025 Computerized corneal topography, unilateral or bilateral, with interpretation and report 1/1/2007 A 92640 Diagnostic analysis with programming of auditory brainstem implant, per hour 1/1/2007 A 94002 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 47 Narrative Effective Date of Revision/ Addition Delete Date 47 2/19/07 1:44:29 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code Narrative A 94003 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day 1/1/2007 A 94004 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; nursing facility, per day 1/1/2007 A 94005 Home ventilator management care plan oversight of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living) requiring review of status, review of laboratories and other studies and revision of orders and respiratory care plan (as appropriate), within a calendar month, 30 minutes or more. 1/1/2007 A 94610 Intrapulmonary surfactant administration by a physician through endotracheal tube 1/1/2007 A 94644 Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour 1/1/2007 A 94645 Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition to code for primary procedure) 1/1/2007 A 94774 Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; includes monitor attachment, download of data, physician review, interpretation, and preparation of a report 1/1/2007 A 94775 Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; monitor attachment only (includes hook-up, initiation of recording and disconnection) 1/1/2007 A 94776 Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; monitoring, download of information, receipt of transmission(s) and analyses by computer only 1/1/2007 A 94777 Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; physician review, interpretation and preparation of report only 1/1/2007 A 95012 Nitric oxide expired gas determination 1/1/2007 A 96020 Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or psychologist, with review of test results and reports 1/1/2007 A 96040 Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family 1/1/2007 A 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma 1/1/2007 A 99363 Anticoagulant management for an outpatient taking warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; initial 90 days of therapy (must include a minimum of 8 INR measurements) 1/1/2007 48 View full policies online at www.ibx.com/medpolicy 43034txt.indd 48 Effective Date of Revision/ Addition Delete Date 2006 CGPU Compendium 2/19/07 1:44:29 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code Narrative A 99364 Anticoagulant management for an outpatient taking warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; each subsequent 90 days of therapy (must include a minimum of 8 INR measurements) 1/1/2007 A 0162T Electronic analysis and programming, reprogramming of gastric neurostimulator (i.e., morbid obesity) 1/1/2007 A 0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace 1/1/2007 A 0164T Removal of total disc arthroplasty, anterior approach, lumbar, each additional interspace 1/1/2007 A 0165T Revision of total disc arthroplasty, anterior approach, lumbar, each additional interspace 1/1/2007 A 0166T Transmyocardial transcatheter closure of ventricular septal defect, with implant; without cardiopulmonary bypass 1/1/2007 A 0167T Transmyocardial transcatheter closure of ventricular septal defect, with implant; with cardiopulmonary bypass 1/1/2007 A 0168T Rhinophototherapy, intranasal application of ultraviolet and visible light, bilateral 1/1/2007 A 0169T Stereotactic placement of infusion catheter(s) in the brain for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s) 1/1/2007 A 0170T Repair of anorectal fistula with plug (e.g., porcine small intestine submucosa [SIS]) 1/1/2007 A 0171T Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level 1/1/2007 A 0172T Insertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; each additional level (List separately in addition to code for primary procedure) 1/1/2007 A 0173T Monitoring of intraocular pressure during vitrectomy surgery (List separately in addition to code for primary procedure) 1/1/2007 A 0174T Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure) 1/1/2007 A 0175T Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation 1/1/2007 A 0176T Transluminal dilation of aqueous outflow canal; without retention of device or stent 1/1/2007 A 0177T Transluminal dilation of aqueous outflow canal; with retention of device or stent 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 49 Effective Date of Revision/ Addition Delete Date 49 2/19/07 1:44:30 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code D 01995 Regional intravenous administration of local anesthetic agent or other medication (upper or lower extremity) 1/1/2007 D 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 1/1/2007 D 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) 1/1/2007 D 15831 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, (e.g., abdominoplasty) 1/1/2007 D 17304 Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation including the first routine stain (e.g., hematoxylin and eosin, toluidine blue); first stage, fresh tissue technique, up to 5 specimens 1/1/2007 D 17305 Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation including the first routine stain (e.g., hematoxylin and eosin, toluidine blue); second stage, fixed or fresh tissue, up to 5 specimens 1/1/2007 D 17306 Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation including the first routine stain (e.g., hematoxylin and eosin, toluidine blue); third stage, fixed or fresh tissue, up to 5 specimens 1/1/2007 D 17307 Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation including the first routine stain (e.g., hematoxylin and eosin, toluidine blue); additional stage(s), up to 5 specimens, each stage 1/1/2007 D 17310 Chemosurgery (Mohs micrographic technique), including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation including the first routine stain (e.g., hematoxylin and eosin, toluidine blue); each additional specimen, after the first 5 specimens; fixed or fresh tissue, any stage (List separately in addition to code for primary procedure) 1/1/2007 D 19140 Mastectomy for gynecomastia 1/1/2007 D 19160 Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy); 1/1/2007 Narrative 50 View full policies online at www.ibx.com/medpolicy 43034txt.indd 50 Effective Date of Revision/ Addition Delete Date 2006 CGPU Compendium 2/19/07 1:44:30 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code D 19162 Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy 1/1/2007 D 19180 Mastectomy, simple, complete 1/1/2007 D 19182 Mastectomy, subcutaneous 1/1/2007 D 19200 Mastectomy, radical, including pectoral muscle, axillary lymph nodes 1/1/2007 D 19220 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) 1/1/2007 D 19240 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle 1/1/2007 D 21300 Closed treatment of skull fracture without operation 1/1/2007 D 25611 Percutaneous skeletal fixation of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, with or without fracture of ulnar styloid, requiring manipulation, with or without external fixation 1/1/2007 D 25620 Open treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, with or without fracture of ulnar styloid, with or without internal or external fixation 1/1/2007 D 26504 Reconstruction of tendon pulley, each tendon; with tendon prosthesis (separate procedure) 1/1/2007 D 27315 Neurectomy, hamstring muscle 1/1/2007 D 27320 Neurectomy, popliteal (gastrocnemius) 1/1/2007 D 28030 Neurectomy, intrinsic musculature of feet 1/1/2007 D 31700 Catheterization, transglottic (separate procedure) 1/1/2007 D 31708 Instillation of contrast material for laryngography or bronchography, without catheterization 1/1/2007 D 31710 Catheterization for bronchography, with or without instillation of contrast material 1/1/2007 D 33200 Insertion of permanent pacemaker with epicardial electrode(s); by thoracotomy 1/1/2007 D 33201 Insertion of permanent pacemaker with epicardial electrode(s); by xiphoid approach 1/1/2007 D 33245 Insertion of epicardial single or dual chamber pacing cardioverter defibrillator electrodes by thoracotomy; 1/1/2007 D 33246 Insertion of epicardial single or dual chamber pacing cardioverter defibrillator electrodes by thoracotomy; with insertion of pulse generator 1/1/2007 D 33253 Operative incisions and reconstruction of atria for treatment of atrial fibrillation or atrial flutter (e.g., maze procedure) 1/1/2007 D 35381 Thromboendarterectomy, with or without patch graft; femoral and/or popliteal, and/or tibioperoneal 1/1/2007 D 35507 Bypass graft, with vein; subclavian-carotid 1/1/2007 D 35541 Bypass graft, with vein; aortoiliac or bi iliac 1/1/2007 D 35546 Bypass graft, with vein; aortofemoral or bifemoral 1/1/2007 D 35641 Bypass graft, with other than vein; aortoiliac or bi iliac 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 51 Narrative Effective Date of Revision/ Addition Delete Date 51 2/19/07 1:44:30 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code D 44152 Colectomy, total, abdominal, without proctectomy; with rectal mucosectomy, ileonal anastomosis, with or without loop ileostomy 1/1/2007 D 44153 Colectomy, total, abdominal, without proctectomy; with rectal mucosectomy, ileonal anastomosis, creation of ileal reservoir (S or J), with or without loop ileostomy 1/1/2007 D 47716 Anastomosis, choledochal cyst, without excision 1/1/2007 D 48005 Resection or debridement of pancreas and peripancreatic tissue for acute necrotizing pancreatitis 1/1/2007 D 48180 Pancreaticojejunostomy, side-to-side anastomosis (Puestowtype operation) 1/1/2007 D 49085 Removal of peritoneal foreign body from peritoneal cavity 1/1/2007 D 54152 Circumcision, using clamp or other device; except newborns 1/1/2007 D 54820 Exploration of epididymis, with or without biopsy 1/1/2007 D 55859 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy 1/1/2007 D 56720 Hymenotomy, simple incision 1/1/2007 D 57820 Dilation and curettage of cervical stump 1/1/2007 Narrative Delete Date D 67350 Biopsy of extraocular muscle 1/1/2007 D 75998 Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) 1/1/2007 D 76003 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) 1/1/2007 D 76005 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction 1/1/2007 D 76006 Manual application of stress performed by physician for joint radiography, including contralateral joint if indicated 1/1/2007 D 76012 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance 1/1/2007 D 76013 Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance 1/1/2007 D 76020 Bone age studies 1/1/2007 D 76040 Bone length studies (orthoroentgenogram, scanogram) 1/1/2007 D 76061 Radiologic examination, osseous survey; limited (e.g., for metastases) 1/1/2007 D 76062 Radiologic examination, osseous survey; complete (axial and appendicular skeleton) 1/1/2007 52 View full policies online at www.ibx.com/medpolicy 43034txt.indd 52 Effective Date of Revision/ Addition 2006 CGPU Compendium 2/19/07 1:44:31 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code D 76065 Radiologic examination, osseous survey; infant 1/1/2007 D 76066 Joint survey, single view, two or more joints (specify) 1/1/2007 D 76070 Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine) 1/1/2007 D 76071 Computed tomography, bone mineral density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 1/1/2007 D 76075 Dual energy x-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine) 1/1/2007 D 76076 Dual energy x-ray absorptiometry (DXA), bone density study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 1/1/2007 D 76077 Dual energy x-ray absorptiometry (DXA), bone density study, one or more sites; vertebral fracture assessment 1/1/2007 D 76078 Radiographic absorptiometry (e.g., photodensitometry, radiogrammetry), one or more sites 1/1/2007 D 76082 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; diagnostic mammography (List separately in addition to code for primary procedure) 1/1/2007 D 76083 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; screening mammography (List separately in addition to code for primary procedure) 1/1/2007 D 76086 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation 1/1/2007 D 76088 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 1/1/2007 D 76090 Mammography, unilateral 1/1/2007 D 76091 Mammography, bilateral 1/1/2007 D 76092 Screening mammography, bilateral (two view film study of each breast) 1/1/2007 D 76093 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral 1/1/2007 D 76094 Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral 1/1/2007 D 76095 Stereotactic localization guidance for breast biopsy or needle placement (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation 1/1/2007 D 76096 Mammographic guidance for needle placement, breast (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation 1/1/2007 D 76355 Computed tomography guidance for stereotactic localization 1/1/2007 D 76360 Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 53 Narrative Effective Date of Revision/ Addition Delete Date 53 2/19/07 1:44:31 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code D 76362 Computed tomography guidance for, and monitoring of, visceral tissue ablation 1/1/2007 D 76370 Computed tomography guidance for placement of radiation therapy fields 1/1/2007 D 76393 Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation 1/1/2007 D 76394 Magnetic resonance guidance for, and monitoring of, visceral tissue ablation 1/1/2007 D 76400 Magnetic resonance (e.g., proton) imaging, bone marrow blood supply 1/1/2007 D 76778 Ultrasound, transplanted kidney, B-scan and/or real time with image documentation, with or without duplex Doppler study 1/1/2007 D 76986 Ultrasonic guidance, intraoperative 1/1/2007 D 78704 Kidney imaging; with function study (i.e., imaging renogram) 1/1/2007 D 78715 Kidney vascular flow only 1/1/2007 D 78760 Testicular imaging; 1/1/2007 D 91060 Gastric saline load test 1/1/2007 D 92573 Lombard test 1/1/2007 D 94656 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; first day 1/1/2007 D 94657 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; subsequent days 1/1/2007 D 95078 Provocative testing (e.g., Rankle test) 1/1/2007 D 0044T Whole body integumentary photography, at request of a physician, for monitoring of high risk patients; with dysplastic nevus syndrome or familial melanoma 1/1/2007 D 0045T Whole body integumentary photography, at request of a physician, for monitoring of high risk patients; with history of dysplastic nevi or personal history of melanoma 1/1/2007 D 0082T Stereotactic body radiation therapy, treatment delivery, one or more treatment areas, per day 1/1/2007 D 0083T Stereotactic body radiation therapy, treatment management, per day 1/1/2007 D 0091T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); single interspace, lumbar 1/1/2007 D 0094T Removal of total disc arthroplasty, anterior approach; single interspace, lumbar 1/1/2007 D 0097T Revision of total disc arthroplasty, anterior approach; single interspace, lumbar 1/1/2007 D 0120T Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma 1/1/2007 Narrative 54 View full policies online at www.ibx.com/medpolicy 43034txt.indd 54 Effective Date of Revision/ Addition Delete Date 2006 CGPU Compendium 2/19/07 1:44:32 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code D 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) R 15100 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) 1/1/2007 R 15101 Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 1/1/2007 R 15110 Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 1/1/2007 R 15111 Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 1/1/2007 R 15115 Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 1/1/2007 R 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 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 1/1/2007 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 1% of body area of infants and children (except 15050) 1/1/2007 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 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 1/1/2007 R 15130 Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 1/1/2007 R 15131 Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 1/1/2007 R 15135 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 1/1/2007 R 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 1% of body area of infants or children or part thereof (List separately in addition to code for primary procedure) 1/1/2007 R 15152 Tissue cultured epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 55 Narrative Effective Date of Revision/ Addition Delete Date 1/1/2007 55 2/19/07 1:44:32 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code Narrative R 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 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 1/1/2007 R 15170 Acellular dermal replacement, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 1/1/2007 R 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 1% of body area of infants and children 1/1/2007 R 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 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 1/1/2007 R 15336 Acellular dermal allograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 1/1/2007 R 15360 Tissue cultured allogeneic dermal substitute; trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 1/1/2007 R 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 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 1/1/2007 R 15400 Xenograft, skin (dermal), for temporary wound closure; trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 1/1/2007 R 15401 Xenograft, skin (dermal), for temporary wound closure; trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children or part thereof (List separately in addition to code for primary procedure) 1/1/2007 R 17000 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion 1/1/2007 R 17003 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) 1/1/2007 R 17004 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions 1/1/2007 R 17110 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions 1/1/2007 56 View full policies online at www.ibx.com/medpolicy 43034txt.indd 56 Effective Date of Revision/ Addition Delete Date 2006 CGPU Compendium 2/19/07 1:44:33 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code Narrative R 17111 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; 15 or more lesions 1/1/2007 R 19361 Breast reconstruction with latissimus dorsi flap without prosthetic implant 1/1/2007 R 25600 Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation 1/1/2007 R 25605 Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation 1/1/2007 R 26170 Excision of tendon, palm, flexor or extensor, single, each tendon 1/1/2007 R 26180 Excision of tendon, finger, flexor or extensor, each tendon 1/1/2007 R 33681 Closure of single ventricular septal defect, with or without patch; 1/1/2007 R 33684 Closure of single ventricular septal defect, with or without patch; with pulmonary valvotomy or infundibular resection (acyanotic) 1/1/2007 R 33688 Closure of single ventricular septal defect, with or without patch; with removal of pulmonary artery band, with or without gusset 1/1/2007 R 35301 Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incision 1/1/2007 R 35311 Thromboendarterectomy, including patch graft, if performed; subclavian, innominate, by thoracic incision 1/1/2007 R 35321 Thromboendarterectomy, including patch graft, if performed; axillary-brachial 1/1/2007 R 35331 Thromboendarterectomy, including patch graft, if performed; abdominal aorta 1/1/2007 R 35341 Thromboendarterectomy, including patch graft, if performed; mesenteric, celiac, or renal 1/1/2007 R 35351 Thromboendarterectomy, including patch graft, if performed; iliac 1/1/2007 R 35355 Thromboendarterectomy, including patch graft, if performed; iliofemoral 1/1/2007 R 35361 Thromboendarterectomy, including patch graft, if performed; combined aortoiliac 1/1/2007 R 35363 Thromboendarterectomy, including patch graft, if performed; combined aortoiliofemoral 1/1/2007 R 35371 Thromboendarterectomy, including patch graft, if performed; common femoral 1/1/2007 R 35372 Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral 1/1/2007 R 35501 Bypass graft, with vein; common carotid-ipsilateral internal carotid 1/1/2007 R 35506 Bypass graft, with vein; carotid-subclavian or subclaviancarotid 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 57 Effective Date of Revision/ Addition Delete Date 57 2/19/07 1:44:33 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code R 35509 Bypass graft, with vein; carotid-contralateral carotid 1/1/2007 R 35601 Bypass graft, with other than vein; common carotidipsilateral internal carotid 1/1/2007 R 44211 Laparoscopy, surgical; colectomy, total abdominal, with proctectomy, with ileoanal anastomosis, creation of ileal reservoir (S or J), with look ileostomy, includes rectal mucosectomy, when performed 1/1/2007 R 51720 Bladder instillation of anticarcinogenic agent (including retention time) 1/1/2007 R 52204 Cystourethroscopy, with biopsy(s) 1/1/2007 R 54150 Circumcision, using clamp or other device with regional dorsal penile or ring block; neonate (28 days of age or less) 1/1/2007 R 54160 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less) 1/1/2007 R 54161 Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age 1/1/2007 R 58950 Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; 1/1/2007 R 58951 Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy 1/1/2007 R 58952 Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors) 1/1/2007 R 61107 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device 1/1/2007 R 61210 Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure) 1/1/2007 R 64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 1/1/2007 R 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver 1/1/2007 R 70540 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s) 1/1/2007 R 70542 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; with contrast material(s) 1/1/2007 R 70543 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences 1/1/2007 R 71275 Computed tomographic angiography, chest (noncoronary) without contrast material(s), followed by contrast material(s) and further sections, including image postprocessing 1/1/2007 R 76536 Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation 1/1/2007 Narrative 58 View full policies online at www.ibx.com/medpolicy 43034txt.indd 58 Effective Date of Revision/ Addition Delete Date 2006 CGPU Compendium 2/19/07 1:44:34 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code R 76604 Ultrasound, chest, (includes mediastinum) real time with image documentation 1/1/2007 R 76645 Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation 1/1/2007 R 76700 Ultrasound, abdominal, real time with image documentation; complete 1/1/2007 R 76705 Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up) 1/1/2007 R 76770 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete 1/1/2007 R 76775 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; limited 1/1/2007 R 76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete 1/1/2007 R 76857 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (e.g., for follicles) 1/1/2007 R 76880 Ultrasound, extremity, nonvascular, real time with image documentation 1/1/2007 R 76940 Ultrasound guidance for, and monitoring of, parenchymal tissue ablation 1/1/2007 R 78700 Kidney imaging morphology; 1/1/2007 R 78707 Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention 1/1/2007 R 78708 Kidney imaging morphology; with vascular flow and function, single study, with pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic) 1/1/2007 R 78709 Kidney imaging morphology; with vascular flow and function, multiple studies, with and without pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic) 1/1/2007 R 78710 Kidney imaging morphology; tomographic (SPECT) 1/1/2007 R 78730 Urinary bladder residual study (List separately in addition to code for primary procedure) 1/1/2007 R 78761 Testicular imaging; with vascular flow 1/1/2007 R 87088 Culture, bacterial; with isolation and presumptive identification of each isolate, urine 1/1/2007 R 88106 Cytopathology, fluids, washings or brushings, except cervical or vaginal; simple filter method with interpretation 1/1/2007 R 88107 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears and simple filter preparation with interpretation 1/1/2007 R 89060 Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) 1/1/2007 R 90655 Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 59 Narrative Effective Date of Revision/ Addition Delete Date 59 2/19/07 1:44:34 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code R 90656 Influenza virus vaccine, split virus, preservative free, when administered to children 3 years and older for intramuscular use 1/1/2007 R 90657 Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use 1/1/2007 R 90658 Influenza virus vaccine, split virus, when administered to children 3 years of age and older, for intramuscular use 1/1/2007 R 90669 Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use 1/1/2007 R 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP) when administered to children younger than 7 years, for intramuscular use 1/1/2007 R 90702 Diphtheria, and tetanus toxoids (DT) adsorbed, preservative free, when administered to children younger than 7 years, for intramuscular use 1/1/2007 R 90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservative free when administered to children 7 years or older, for intramuscular use 1/1/2007 R 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to children 7 years or older, for intramuscular use 1/1/2007 R 90718 Tetanus and diphtheria toxoids (Td) adsorbed when administered to children 7 years or older, for intramuscular use 1/1/2007 R 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to children 2 years or older, for subcutaneous or intramuscular use 1/1/2007 R 94620 Pulmonary stress testing; simple (e.g., 6 minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry) 1/1/2007 R 99251 Inpatient 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 1/1/2007 R 99252 Inpatient consultation for a new or established patient which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and a straightforward medical decision making 1/1/2007 R 99253 Inpatient consultation for a new or established patient which requires these three key components: a detailed history; a detailed examination; and medical decision of low complexity 1/1/2007 R 99254 Inpatient 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 1/1/2007 R 99255 Inpatient 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 1/1/2007 Narrative 60 View full policies online at www.ibx.com/medpolicy 43034txt.indd 60 Effective Date of Revision/ Addition Delete Date 2006 CGPU Compendium 2/19/07 1:44:35 PM CPT CODES Action A=Addition D=Deletion R=Revision CPT ®* Code Narrative R 0062T Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; single level 1/1/2007 R 0063T Percutaneous intradiscal annuloplasty, any method except electrothermal, unilateral or bilateral including fluoroscopic guidance; one or more additional levels (List separately in addition to 0062T for primary procedure) 1/1/2007 R 0068T Acoustic heart sound recording and computer analysis; with interpretation and report 1/1/2007 R 0069T Acoustic heart sound recording and computer analysis; only 1/1/2007 R 0070T Acoustic heart sound recording and computer analysis; interpretation and report only 1/1/2007 R 0087T Sperm evaluation, Hyaluronan sperm binding test 1/1/2007 R 0090T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression) cervical; single interspace 1/1/2007 R 0092T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression) cervical; each additional interspace (List separately in addition to the code for primary procedure) 1/1/2007 R 0093T Removal of total disc arthroplasty, anterior approach cervical; single interspace 1/1/2007 R 0095T Removal of total disc arthroplasty, anterior approach cervical; each additional innerspace (List separately in addition to code for primary procedure) 1/1/2007 R 0096T Revision of total disc arthroplasty, anterior approach cervical; single interspace 1/1/2007 R 0098T Revision of total disc arthroplasty, anterior approach cervical; each additional interspace 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 61 Effective Date of Revision/ Addition Delete Date 61 2/19/07 1:44:35 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition A C9231 Injection, decitabine, per 1 mg 10/1/2006 A C9727 Insertion of implants into the soft palate; minimum of three implants 10/1/2006 A K0738 Portable gaseous oxygen system, rental: home compressor used to fill portable oxygen cylinders, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing 10/1/2006 A K0800 Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds 10/1/2006 A K0801 Power operated vehicle, group 1 heavy duty, patient weight capacity, 301 to 450 lbs 10/1/2006 A K0802 Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds 10/1/2006 A K0806 Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds 10/1/2006 A K0807 Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 pounds 10/1/2006 A K0808 Power operated vehicle, group 2 very heavy duty, patient weight capacity 451 to 600 pounds 10/1/2006 A K0812 Power operated vehicle, not otherwise classified 10/1/2006 A K0813 Power wheelchair, group 1 standard, portable, sling/ solid seat and back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0814 Power wheelchair, group 1 standard, portable, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0815 Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0816 Power wheelchair, group 1 standard, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0821 Power wheelchair, group 2 standard, portable, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0822 Power wheelchair, group 2 standard, sling/solid seat/ back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0823 Power wheelchair, group 2 standard, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/ back, patient weight capacity 301 to 450 pounds 10/1/2006 A K0825 Power wheelchair, group 2 heavy duty, captain’s chair, patient weight capacity 301 to 450 pounds 10/1/2006 A K0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds 10/1/2006 A K0827 Power wheelchair, group 2 very heavy duty, captain’s chair, patient weight capacity 451 to 600 pounds 10/1/2006 62 View full policies online at www.ibx.com/medpolicy 43034txt.indd 62 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:35 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition A K0828 Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more 10/1/2006 A K0829 Power wheelchair, group 2 extra heavy duty, captain’s chair, patient weight capacity 601 pounds or more 10/1/2006 A K0830 Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0831 Power wheelchair, group 2 standard, seat elevator, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0835 Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0836 Power wheelchair, group 2 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0837 Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds 10/1/2006 A K0838 Power wheelchair, group 2 heavy duty, single power option, captain’s chair, patient weight capacity 301 to 450 pounds 10/1/2006 A K0839 Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds 10/1/2006 A K0840 Power wheelchair, group 2 extra heavy duty, single power option sling/solid seat/back, patient weight capacity 601 pounds or more 10/1/2006 A K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0842 Power wheelchair, group 2 standard, multiple power option, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0843 Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds 10/1/2006 A K0848 Power wheelchair, group 3 standard, sling/solid seat/ back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0849 Power wheelchair, group 3 standard, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/ back, patient weight capacity 301 to 450 pounds 10/1/2006 A K0851 Power wheelchair, group 3 heavy duty, captain’s chair, patient weight capacity 301 to 450 pounds 10/1/2006 A K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds 10/1/2006 A K0853 Power wheelchair, group 3 very heavy duty, captain’s chair, patient weight capacity, 451 to 600 pounds 10/1/2006 A K0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more 10/1/2006 www.ibx.com/providers/communications 43034txt.indd 63 Narrative Delete Date 63 2/19/07 1:44:36 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition A K0855 Power wheelchair, group 3 extra heavy duty, captain’s chair, patient weight capacity 601 pounds or more 10/1/2006 A K0856 Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0857 Power wheelchair, group 3 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0858 Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds 10/1/2006 A K0859 Power wheelchair, group 3 heavy duty, single power option, captain’s chair, patient weight capacity 301 to 450 pounds 10/1/2006 A K0860 Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds 10/1/2006 A K0861 Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0862 Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds 10/1/2006 A K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds 10/1/2006 A K0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more 10/1/2006 A K0868 Power wheelchair, group 4 standard, sling/solid seat/ back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0869 Power wheelchair, group 4 standard, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/ back, patient weight capacity 301 to 450 pounds 10/1/2006 A K0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds 10/1/2006 A K0877 Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds 10/1/2006 A K0878 Power wheelchair, group 4 standard, single power option, captain’s chair, patient weight capacity up to and including 300 pounds 10/1/2006 A K0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds 10/1/2006 A K0880 Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds 10/1/2006 A K0884 Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds 10/1/2006 64 View full policies online at www.ibx.com/medpolicy 43034txt.indd 64 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:36 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition A K0885 Power wheelchair, group 4 standard, multiple power option, captain’s chair, weight capacity up to and including 300 pounds 10/1/2006 A K0886 Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds 10/1/2006 A K0890 Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds 10/1/2006 A K0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds 10/1/2006 A K0898 Power wheelchair, not otherwise classified 10/1/2006 A K0899 Power mobility devise, not coded by SADMERC or does not meet criteria 10/1/2006 A S0147 Injection, alglucosidase ALFA, 20 mg 10/1/2006 A S2325 Hip core decompression 10/1/2006 A A4461 Surgical dressing holder, non-reusable, each 1/1/2007 A A4463 Surgical dressing holder, reusable, each 1/1/2007 A A4559 Coupling gel or paste, for use with ultrasound device, per oz 1/1/2007 A A4600 Sleeve for intermittent limb compression device, replacement only, each 1/1/2007 A A4601 Lithium ion battery for non-prosthetic use, replacement 1/1/2007 A A8000 Helmet, protective, soft, prefabricated, includes all components and accessories 1/1/2007 A A8001 Helmet, protective, hard, prefabricated, includes all components and accessories 1/1/2007 A A8002 Helmet, protective, soft, custom fabricated, includes all components and accessories 1/1/2007 A A8003 Helmet, protective, hard, custom fabricated, includes all components and accessories 1/1/2007 A A8004 Hoft interface for helmet, replacement only 1/1/2007 A A9279 Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified 1/1/2007 A A9527 Iodine I-125, sodium iodide solution, therapeutic, per millicurie 1/1/2007 A A9568 Technetium Tc-99m arcitumomab, diagnostic, per study dose, up to 45 millicuries 1/1/2007 A C1821 Interspinous process distraction device (implantable) 1/1/2007 A C9232 Injection, idursulfase, 1 mg 1/1/2007 A C9233 Injection, ranibizumab, 0.5 mg 1/1/2007 A C9234 Injection, alglucosidase alfa, 10 mg 1/1/2007 A C9235 Injection, panitumumab, 10 mg 1/1/2007 A C9350 Microporous collagen tube of non-human origin, per centimeter length 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 65 Narrative Delete Date 65 2/19/07 1:44:37 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition A C9351 Acellular dermal tissue matrix of non-human origin, per square centimeter (do not report C9351 in conjunction with J7345) 1/1/2007 A D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver 1/1/2007 A D0273 Bitewings - three films 1/1/2007 A D0360 Cone beam CT - craniofacial data capture 1/1/2007 A D0362 Cone beam - two-dimensional image reconstruction using existing data, includes multiple images 1/1/2007 A D0363 Cone beam - three-dimensional image reconstruction using existing data, includes multiple images 1/1/2007 A D0486 Accession of brush biopsy sample, microscopic examination, preparation and transmission of written report 1/1/2007 A D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients 1/1/2007 A D1555 Removal of fixed space maintainer 1/1/2007 A D4230 Anatomical crown exposure - four or more contiguous teeth per quadrant 1/1/2007 A D4231 Anatomical crown exposure - one to three teeth per quadrant 1/1/2007 A D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant 1/1/2007 A D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment 1/1/2007 A D6092 Recement implant/abutment supported crown 1/1/2007 A D6093 Recement implant/abutment supported fixed partial denture 1/1/2007 A D7292 Surgical placement: temporary anchorage device [screw retained plate] requiring surgical flap 1/1/2007 A D7293 Surgical placement: temporary anchorage device requiring surgical flap 1/1/2007 A D7294 Surgical placement: temporary anchorage device without surgical flap 1/1/2007 A D7951 Sinus augmentation with bone or bone substitutes 1/1/2007 A D7998 Intraoral placement of a fixation device not in conjunction with a fracture 1/1/2007 A D8693 Rebonding or recementing; and/or repair, as required, of fixed retainers 1/1/2007 A D9120 Fixed partial denture sectioning 1/1/2007 A D9612 Therapeutic parenteral drugs, two or more administrations, different medications 1/1/2007 A E0676 Intermittent limb compression device (includes all accessories), not otherwise specified 1/1/2007 A E0936 Continuous passive motion exercise device for use other than knee 1/1/2007 66 View full policies online at www.ibx.com/medpolicy 43034txt.indd 66 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:37 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition A E2373 Power wheelchair accessory, hand or chin control interface, mini-proportional, compact, or short throw remote joystick or touchpad, proportional, including all related electronics and fixed mounting hardware 1/1/2007 A E2374 Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only 1/1/2007 A E2375 Power wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only 1/1/2007 A E2376 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only 1/1/2007 A E2377 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue 1/1/2007 A E2381 Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each 1/1/2007 A E2382 Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each 1/1/2007 A E2383 Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each 1/1/2007 A E2384 Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each 1/1/2007 A E2385 Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each 1/1/2007 A E2386 Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each 1/1/2007 A E2387 Power wheelchair accessory, foam filled caster tire, any size, replacement only, each 1/1/2007 A E2388 Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each 1/1/2007 A E2389 Power wheelchair accessory, foam caster tire, any size, replacement only, each 1/1/2007 A E2390 Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each 1/1/2007 A E2391 Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each 1/1/2007 A E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each 1/1/2007 A E2393 Power wheelchair accessory, valve for pneumatic tire tube, any type, replacement only, each 1/1/2007 A E2394 Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each 1/1/2007 A E2395 Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each 1/1/2007 A E2396 Power wheelchair accessory, caster fork, any size, replacement only, each 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 67 Narrative Delete Date 67 2/19/07 1:44:38 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition A G0377 Administration of vaccine for Part D Drug 1/1/2007 A G0380 Level 1 hospital emergency visit provided in a type B department or facility of the hospital: (the department or facility must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) 1/1/2007 A G0381 Level 2 hospital emergency visit provided in a type B department or facility of the hospital: (the department or facility must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) 1/1/2007 A G0382 Level 3 hospital emergency visit provided in a type B department or facility of the hospital: (the department or facility must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) 1/1/2007 68 View full policies online at www.ibx.com/medpolicy 43034txt.indd 68 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:38 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition A G0383 Level 4 hospital emergency visit provided in a type B department or facility of the hospital: (the department or facility must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) 1/1/2007 A G0384 Level 5 hospital emergency visit provided in a type B department or facility of the hospital: (the department or facility must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) 1/1/2007 A G0389 Ultrasound b-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening 1/1/2007 A G0390 Trauma response team associated with hospital critical care service 1/1/2007 A G0392 Transluminal balloon angioplasty, percutaneous; for maintenance of hemodialysis access, arteriovenous fistula or graft; arterial 1/1/2007 A G0393 Transluminal balloon angioplasty, percutaneous; for maintenance of hemodialysis access, arteriovenous fistula or graft; venous 1/1/2007 A G0394 Blood occult test (e.g., guaiac), feces, for single determination for colorectal neoplasm (i.e., patient was provided three cards or single triple card for consecutive collection) 1/1/2007 A G8191 Clinician documented to have given order for prophylactic antibiotic to be given within one hour (if Vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required) 1/1/2007 A G8192 Clinician documented to have given the prophylactic antibiotic within one hour (if Vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 69 Narrative Delete Date 69 2/19/07 1:44:38 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition A G8193 Clinician did not document that an order for prophylactic antibiotic to be given within one hour (if Vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required) was given 1/1/2007 A G8194 Clinician documented that patient was not an eligible candidate for prophylactic antibiotic 1/1/2007 A G8195 Clinician documented to have given the prophylactic antibiotic within one hour (if Vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) 1/1/2007 A G8196 Clinician did not document a prophylactic antibiotic was administered within one hour (if Vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required) 1/1/2007 A G8197 Patient documented to have order for prophylactic antibiotic to be given within one hour (if Vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required) 1/1/2007 A G8198 Patient documented to have order for Cefazolin or Cefuroxime for antimicrobial prophylaxis 1/1/2007 A G8199 Clinician documented to have given Cefazolin or Cefuroxime for antimicrobial prophylaxis 1/1/2007 A G8200 Order for Cefazolin or Cefuroxime for antimicrobial prophylaxis not documented 1/1/2007 A G8201 Patient was not an eligible candidate for Cefazolin or Cefuroxime for antimicrobial prophylaxis 1/1/2007 A G8202 Clinician documented an order was given to discontinue prophylactic antibiotics within 24 hours of surgical end time 1/1/2007 A G8203 Clinician documented that prophylactic antibiotics were discontinued within 24 hours of surgical end time 1/1/2007 A G8204 Clinician did not document an order was given to discontinue prophylactic antibiotics within 24 hours of surgical end time 1/1/2007 A G8205 Clinician documented that patient was not an eligible candidate for prophylactic antibiotic discontinuation within 24 hours of surgical end time 1/1/2007 A G8206 Clinician documented that prophylactic antibiotic was given 1/1/2007 A G8207 Clinician documented an order was given to discontinue prophylactic antibiotics within 48 hours of surgical end time 1/1/2007 A G8208 Clinician documented that prophylactic antibiotics were discontinued within 48 hours of surgical end time 1/1/2007 A G8209 Clinician did not document an order was given to discontinue prophylactic antibiotics within 48 hours of surgical end time 1/1/2007 A G8210 Clinician documented patient was not an eligible candidate for discontinuation of prophylactic antibiotic discontinuation within 48 hours of surgical end time 1/1/2007 A G8211 Clinician documented that prophylactic antibiotic was given 1/1/2007 70 View full policies online at www.ibx.com/medpolicy 43034txt.indd 70 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:39 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition A G8212 Clinician documented an order was given for appropriate venous thromboembolism (VTE) prophylaxis to be given within 24 hrs prior to incision time or 24 hours after surgery end time 1/1/2007 A G8213 Clinician documented to have given VTE prophylaxis within 24 hrs prior to incision time or 24 hours after surgery end time 1/1/2007 A G8214 Clinician did not document an order was given for appropriate venous thromboembolism (VTE) prophylaxis to be given within 24 hrs prior to incision time or 24 hours after surgery end time 1/1/2007 A G8215 Clinician documented that patient was not an eligible candidate for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time 1/1/2007 A G8216 Patient documented to have received DVT prophylaxis by end of hospital day two 1/1/2007 A G8217 Patient not documented to have received DVT prophylaxis by end of hospital day 2 1/1/2007 A G8218 Patient was not an eligible candidate for DVT prophylaxis by end of hospital day 2, including physician documentation that patient is ambulatory 1/1/2007 A G8219 Patient documented to have received DVT prophylaxis by end of hospital day 2 1/1/2007 A G8220 Patient not documented to have received DVT prophylaxis by end of hospital day 2 1/1/2007 A G8221 Clinician documented that patient was not an eligible candidate for DVT prophylaxis by the end of hospital day 2, including physician documentation that patient is ambulatory 1/1/2007 A G8222 Patient documented to have been prescribed antiplatelet therapy at discharge 1/1/2007 A G8223 Patient not documented to have received prescription for antiplatelet therapy at discharge 1/1/2007 A G8224 Clinician documented that patient was not an eligible candidate for antiplatelet therapy at discharge, including identification from medical record that patient is on anticoagulation therapy 1/1/2007 A G8225 Patient documented to have been prescribed an anticoagulant at discharge 1/1/2007 A G8226 Patient not documented to have received prescription for anticoagulant therapy at discharge 1/1/2007 A G8227 Patient not documented to have permanent, persistent, or paroxysmal atrial fibrillation 1/1/2007 A G8228 Clinician documented that patient was not an eligible candidate for anticoagulant therapy at discharge 1/1/2007 A G8229 Patient documented to have been administered or considered for T-PA 1/1/2007 A G8230 Patient not eligible for T-PA administration, ischemic stroke symptom onset of more than 3 hours 1/1/2007 A G8231 Patient not documented to have received T-PA or not documented to have been considered a candidate for T-PA administration 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 71 Narrative Delete Date 71 2/19/07 1:44:39 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition A G8232 Patient documented to have received dysphagia screening prior to taking any foods, fluids or medication by mouth 1/1/2007 A G8234 Patient not documented to have received dysphagia screening 1/1/2007 A G8235 Patient not receiving or ineligible to receive food, fluids or medication by mouth, or documentation of NPO (nothing by mouth) order 1/1/2007 A G8236 Clinician documented that patient was not an eligible candidate for dysphagia screening prior to taking any foods, fluids or medication by mouth 1/1/2007 A G8237 Patient documented to have received order for rehabilitation services or documentation of consideration for rehabilitation services 1/1/2007 A G8238 Patient not documented to have received order for or consideration for rehabilitation services 1/1/2007 A G8239 Internal carotid stenosis patient below 30%, reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement not necessary 1/1/2007 A G8240 Internal carotid stenosis patient in the 30-99% range, and no documentation of reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement 1/1/2007 A G8241 Clinician documented that patient whose final report of the carotid imaging study performed (neck MRA, neck CTA, neck duplex ultrasound, carotid angiogram), with characterization of an internal carotid stenosis in the 3099% range, was not an eligible candidate for reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement 1/1/2007 A G8242 Patient documented to have received CT or MRI with presence or absence of hemorrhage, mass lesion and acute infarction documented in the final report 1/1/2007 A G8243 Patient not documented to have received CT or MRI and the presence or absence of hemorrhage, mass lesion and acute infarction not documented in the final report 1/1/2007 A G8245 Clinician documented presence or absence alarm symptoms 1/1/2007 A G8246 Patient was not an eligible candidate for medical history review with assessment of new or changing moles 1/1/2007 A G8247 Patient with alarm symptom(s) documented to have had upper endoscopy performed or referral for upper endoscopy 1/1/2007 A G8248 Patient with at least one alarm symptom not documented to have had upper endoscopy or referral for upper endoscopy 1/1/2007 A G8249 Clinician documented that patient was not an eligible candidate for upper endoscopy 1/1/2007 A G8250 Patient with suspicion of Barrett’s esophagus in endoscopy report and documented to have received an esophageal biopsy 1/1/2007 A G8251 Patient not documented to have received an esophageal biopsy when suspicion of Barrett’s esophagus is indicated in the endoscopy report 1/1/2007 72 View full policies online at www.ibx.com/medpolicy 43034txt.indd 72 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:40 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition A G8252 Clinician documented that patient was not an eligible candidate for esophageal biopsy 1/1/2007 A G8253 Patient documented to have received an order for a barium swallow test 1/1/2007 A G8254 Patient with no documentation order for barium swallow test 1/1/2007 A G8255 Clinician documentation that patient was an eligible candidate for barium swallow test 1/1/2007 A G8256 Clinician documented reconciliation of discharge medications with current medication list in medical record 1/1/2007 A G8257 Clinician has not documented reconciliation of discharge medications with current medication list in medical record 1/1/2007 A G8258 Patient was not an eligible candidate for discharge medications review 1/1/2007 A G8259 Patient documented to have surrogate decision maker or advance care plan in medical record 1/1/2007 A G8260 Patient not documented to have surrogate decision maker or advance care plan in medical record 1/1/2007 A G8261 Clinician documented that patient was not an eligible candidate for surrogate decision maker or advance care plan 1/1/2007 A G8262 Patient documented to have been assessed for presence or absence of urinary incontinence 1/1/2007 A G8263 Patient not documented to have been assessed for presence or absence of urinary incontinence 1/1/2007 A G8264 Clinician documented that patient was not an eligible candidate for an assessment of the presence or absence of urinary incontinence 1/1/2007 A G8265 Patient documented to have received characterization of urinary incontinence 1/1/2007 A G8266 Patient not documented to have received characterization of urinary incontinence 1/1/2007 A G8267 Patient documented to have received a plan of care for urinary incontinence 1/1/2007 A G8268 Patient not documented to have received plan of care for urinary incontinence 1/1/2007 A G8269 Clinician has not provided care for the patient for the required time to develop plan of care for urinary incontinence 1/1/2007 A G8270 Patient documented to have received screening for fall risk (2 or more falls in the past year or any fall with injury in the past year) 1/1/2007 A G8271 Patient with no documentation of screening for fall risks (2 or more falls in the past year or any fall with injury in the past year) 1/1/2007 A G8272 Clinician documentation that patient was not an eligible candidate for fall risk screening 1/1/2007 A G8273 Clinician has not provided care for the patient for the required time to screen for fall risk 1/1/2007 A G8274 Clinician has not documented presence or absence of alarm symptoms 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 73 Narrative Delete Date 73 2/19/07 1:44:40 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition A G8275 Patient documented to have medical history taken which included assessment of new or changing moles 1/1/2007 A G8276 Patient not documented to have received medical history with assessment of new or changing moles 1/1/2007 A G8277 Patient was not an eligible candidate for medical history review with assessment of new or changing moles 1/1/2007 A G8278 Patient documented to have received complete physical skin exam 1/1/2007 A G8279 Patient not documented to have received a complete physical skin exam 1/1/2007 A G8280 Patient was not an eligible candidate for complete physical skin exam during the reporting year 1/1/2007 A G8281 Patient documented to have received counseling to perform a self-examination 1/1/2007 A G8282 Patient not documented to have received counseling to perform a self-examination 1/1/2007 A G8283 Patient was not an eligible candidate for counseling to perform self-examination 1/1/2007 A G8284 Patient documented to have received a prescription for pharmacologic therapy for osteoporosis 1/1/2007 A G8285 Patient not documented to have received pharmacologic therapy 1/1/2007 A G8286 Clinician documented that patient was not an eligible candidate for pharmacologic therapy 1/1/2007 A G8287 Clinician has not provided care for the patient for the required time for the pharmacologic therapy measure 1/1/2007 A G8288 Patient documented to have received calcium and vitamin D or counseling on both calcium and vitamin D use, and exercise 1/1/2007 A G8289 Patient with no documentation of calcium and vitamin D use or counseling regarding both calcium and vitamin D use, or exercise 1/1/2007 A G8290 Clinician documentation that patient was not an eligible candidate for calcium and vitamin D, and exercise during the reporting year 1/1/2007 A G8291 Clinician has not provided care for the patient for the required time for the calcium, vitamin D, and exercise measure 1/1/2007 A G8292 COPD patient with spirometry results documented 1/1/2007 A G8293 COPD patient without spirometry results documented 1/1/2007 A G8294 COPD patient was not eligible for spirometry results 1/1/2007 A G8295 COPD patient documented to have received inhaled bronchodilator therapy 1/1/2007 A G8296 COPD patient not documented to have inhaled bronchodilator therapy prescribed 1/1/2007 A G8297 COPD patient was not eligible for inhaled bronchodilator therapy 1/1/2007 A G8298 Patient documented to have received optic nerve head evaluation 1/1/2007 74 View full policies online at www.ibx.com/medpolicy 43034txt.indd 74 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:41 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition A G8299 Patient not documented to have received optic nerve head evaluation 1/1/2007 A G8300 Clinician documented that patient was not an eligible candidate for optic nerve head evaluation during the reporting year 1/1/2007 A G8301 Clinician has not provided care for the primary open-angle glaucoma patient for the required time for optic nerve head evaluation measure 1/1/2007 A G8302 Patient documented to have a specific target intraocular pressure range goal 1/1/2007 A G8303 Patient not documented to have a specific target intraocular pressure range goal 1/1/2007 A G8304 Clinician documented that patient was not an eligible candidate for a specific target intraocular pressure range goal 1/1/2007 A G8305 Clinician has not provided care for the primary open-angle glaucoma patient for the required time for treatment range goal documentation measurement 1/1/2007 A G8306 Primary open-angle glaucoma patient with intraocular pressure above the target range goal documented to have received plan of care 1/1/2007 A G8307 Primary open-angle glaucoma patient with intraocular pressure at or below goal, no plan of care necessary 1/1/2007 A G8308 Primary open-angle glaucoma patient with intraocular pressure above the target range goal, and not documented to have received plan of care during the reporting year 1/1/2007 A G8309 Patient documented to have been prescribed/ recommended antioxidant vitamin or mineral supplement 1/1/2007 A G8310 Patient not documented to have been prescribed/ recommended at least one antioxidant vitamin or mineral supplement during the reporting year 1/1/2007 A G8311 Clinician documentation that patient was not an eligible candidate for antioxidant vitamin or mineral supplement during the reporting year 1/1/2007 A G8312 Clinician has not provided care for the age-related macular degeneration patient for the required time for antioxidant supplement prescription/recommended measure 1/1/2007 A G8313 Patient documented to have received macular exam, including documentation of the presence or absence of macular thickening or hemorrhage and the level of macular degeneration severity 1/1/2007 A G8314 Patient not documented to have received macular exam with documentation of presence or absence of macular thickening or hemorrhage and no documentation of level of macular degeneration severity 1/1/2007 A G8315 Clinician documentation that patient was not an eligible candidate for macular examination during the reporting year 1/1/2007 A G8316 Clinician has not provided care for the age-related macular degeneration patient for the required time for macular examination measurement 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 75 Narrative Delete Date 75 2/19/07 1:44:41 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition A G8317 Patient documented to have visual functional status assessed 1/1/2007 A G8318 Patient documented not to have visual functional status assessed 1/1/2007 A G8319 Clinician documented that patient was not an eligible candidate for assessment of visual functional status 1/1/2007 A G8320 Clinician has not provided care for the cataract patient for the required time for assessment of visual functional status measurement 1/1/2007 A G8321 Patient documented to have had pre-surgical axial length, corneal power measurement and method of intraocular lens power calculation 1/1/2007 A G8322 Patient not documented to have had pre-surgical axial length, corneal power measurement and method of intraocular lens power calculation 1/1/2007 A G8323 Clinician documentation that patient was not an eligible candidate for pre-surgical axial length, corneal power measurement and method of intraocular lens power calculation 1/1/2007 A G8324 Clinician has not provided care for the cataract patient for the required time for pre-surgical measurement and intraocular lens power calculation measure 1/1/2007 A G8325 Patient documented to have received fundus evaluation within six months prior to cataract surgery 1/1/2007 A G8326 Patient not documented to have received fundus evaluation within six months prior to cataract surgery 1/1/2007 A G8327 Patient was not an eligible candidate for pre-surgical fundus evaluation 1/1/2007 A G8328 Clinician has not provided care for the cataract patient for the required time for fundus evaluation measurement 1/1/2007 A G8329 Patient documented to have received dilated macular or fundus exam with level of severity of retinopathy and the presence or absence of macular edema documented 1/1/2007 A G8330 Patient not documented to have received dilated macular or fundus exam with level of severity of retinopathy and the presence or absence of macular edema not documented 1/1/2007 A G8331 Clinician documentation that patient was not an eligible candidate for dilated macular or fundus exam during the reporting year 1/1/2007 A G8332 Clinician has not provided care for the diabetic retinopathy patient for the required time for macular edema and retinopathy measurement 1/1/2007 A G8333 Patient documented to have had findings of macular or fundus exam communicated to the physician managing the diabetes care 1/1/2007 A G8334 Documentation of findings of macular or fundus exam not communicated to the physician managing the patient’s ongoing diabetes care 1/1/2007 A G8335 Clinician documentation that patient was not an eligible candidate for the findings of their macular or fundus exam being communicated to the physician managing their diabetes care during the reporting year 1/1/2007 76 View full policies online at www.ibx.com/medpolicy 43034txt.indd 76 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:42 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition A G8336 Clinician has not provided care for the diabetic retinopathy patient for the required time for physician communication measurement 1/1/2007 A G8337 Clinician documented that communication was sent to the physician managing ongoing care of patient that a fracture occurred and that the patient was or should be tested or treated for osteoporosis 1/1/2007 A G8338 Clinician has not documented that communication was sent to the physician managing ongoing care of patient that a fracture occurred and that the patient was or should be tested or treated for osteoporosis 1/1/2007 A G8339 Patient was not an eligible candidate for communication with the physician managing the patient’s ongoing care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis 1/1/2007 A G8340 Patient documented to have had central DEXA performed and results documented or central DEXA ordered or pharmacologic therapy prescribed 1/1/2007 A G8341 Patient not documented to have had central DEXA measurement or pharmacologic therapy 1/1/2007 A G8342 Clinician documented that patient was not an eligible candidate for central DEXA measurement or prescribing pharmacologic 1/1/2007 A G8343 Clinician has not provided care for the patient for the required time for central DEXA measurement or pharmacological therapy measure 1/1/2007 A G8344 Patient documented to have had central DEXA ordered or performed and results documented or pharmacological therapy prescribed 1/1/2007 A G8345 Patient not documented to have had central DEXA measurement ordered or performed or pharmacologic therapy 1/1/2007 A G8346 Clinician documented that patient was not an eligible candidate for central DEXA measurement or pharmacologic therapy 1/1/2007 A G8347 Clinician has not provided care for the patient for the required time for central DEXA measurement or pharmacological therapy measure 1/1/2007 A G9131 Oncology; disease status; invasive female breast cancer (does not include ductal carcinoma in situ); adenocarcinoma as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 A G9132 Oncology; disease status; prostate cancer, limited to adenocarcinoma; hormone-refractory/androgenindependent (e.g., rising PSA on anti-androgen therapy or post-orchiectomy); clinical metastases (for use in a Medicare-approved demonstration project) 1/1/2007 A G9133 Oncology; disease status; prostate cancer, limited to adenocarcinoma; hormone-responsive; clinical metastases or M1 at diagnosis (for use in a Medicare-approved demonstration project) 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 77 Narrative Delete Date 77 2/19/07 1:44:42 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition A G9134 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular classification; stage I, II at diagnosis, not relapsed, not refractory (for use in a Medicare-approved demonstration project) 1/1/2007 A G9135 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular classification; stage III, IV, not relapsed, not refractory (for use in a Medicare-approved demonstration project) 1/1/2007 A G9136 Oncology; disease status; non-Hodgkin’s lymphoma, transformed from original cellular diagnosis to a second cellular classification (for use in a Medicare-approved demonstration project) 1/1/2007 A G9137 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular classification; relapsed/refractory (for use in a Medicare-approved demonstration project) 1/1/2007 A G9138 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular classification; 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) 1/1/2007 A G9139 Oncology; disease status; chronic myelogenous leukemia, limited to Philadelphia chromosome positive and/or BCR-ABL positive; extent of disease unknown, staging in progress, not listed (for use in a Medicare-approved demonstration project) 1/1/2007 A H0049 Alcohol and/or drug screening 1/1/2007 A H0050 Alcohol and/or drug services, brief intervention, per 15 minutes 1/1/2007 A J0129 Injection, abatacept, 10 mg 1/1/2007 A J0348 Injection, anadulafungin, 1 mg 1/1/2007 A J0364 Injection, apomorphine hydrochloride, 1 mg 1/1/2007 A J0594 Injection, busulfan, 1 mg 1/1/2007 A J0894 Injection, decitabine, 1 mg 1/1/2007 A J1324 Injection, enfuvirtide, 1 mg 1/1/2007 A J1458 Injection, galsulfase, 1 mg 1/1/2007 A J1562 Injection, immune globulin, subcutaneous, 100 mg 1/1/2007 A J1740 Injection, ibandronate sodium, 1 mg 1/1/2007 A J2170 Injection, mecasermin, 1 mg 1/1/2007 A J2248 Injection, micafungin sodium, 1 mg 1/1/2007 A J2315 Injection, naltrexone, depot form, 1 mg 1/1/2007 A J3243 Injection, tigecycline, 1 mg 1/1/2007 A J3473 Injection, hyaluronidase, recombinant, 1 usp unit 1/1/2007 A J7187 Injection, Von Willebrand factor complex, human, ristocetin cofactor, per IU 1/1/2007 A J7311 Fluocinolone acetonide, intravitreal implant 1/1/2007 A J7319 Hyaluronan (sodium hyaluronate) or derivative, intraarticular injection, per injection 1/1/2007 78 View full policies online at www.ibx.com/medpolicy 43034txt.indd 78 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:43 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition A J7345 Dermal (substitute) tissue of non-human origin, with or without other bioengineered or processed elements, without metabolically active elements, per square centimeter 1/1/2007 A J7346 Dermal (substitute) tissue of human origin, injectable, with or without other bioengineered or processed elements, but without metabolically active elements, 1 cc 1/1/2007 A J7607 Levalbuterol, inhalation solution, compounded product, administered through DME, concentrated form, 0.5 mg 1/1/2007 A J7609 Albuterol, inhalation solution, compounded product, administered through DME, unit dose, 1 mg concentrated form, 1 mg 1/1/2007 A J7610 Albuterol, inhalation solution, compounded product, administered through DME, unit dose, 1 mg concentrated form, 1 mg 1/1/2007 A J7615 Levalbuterol, inhalation solution, compounded product, administered through DME, unit dose, 0.5 mg 1/1/2007 A J7634 Budesonide, inhalation solution, compounded product, administered through DME, concentrated form, per 0.25 milligram 1/1/2007 A J7645 Ipratropium bromide, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 A J7647 Soetharine HCL, inhalation solution, compounded product, administered through DME, concentrated form, per milligram 1/1/2007 A J7650 Isoetharine HCL, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 A J7657 Isoproterenol HCL, inhalation solution, compounded product, administered through DME, concentrated form, per milligram 1/1/2007 A J7660 Isoproterenol HCL, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 A J7667 Metaproterenol sulfate, inhalation solution, compounded product, concentrated form, per 10 milligrams 1/1/2007 A J7670 Metaproterenol sulfate, inhalation solution, compounded product, administered through DME, unit dose form, per 10 milligrams 1/1/2007 A J7685 Tobramycin, inhalation solution, compounded product, administered through DME, unit dose form, per 300 milligrams 1/1/2007 A J8650 Nabilone, oral, 1 mg 1/1/2007 A J9261 Injection, nelarabine, 50 mg 1/1/2007 A L1001 Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, each 1/1/2007 A L3806 Wrist hand finger orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface material, straps, custom fabricated, includes fitting and adjustment 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 79 Narrative Delete Date 79 2/19/07 1:44:43 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition A L3808 Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment 1/1/2007 A L3915 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment 1/1/2007 A L5993 Addition to lower extremity prosthesis, heavy duty feature, foot only, (for patient weight greater than 300 lbs) 1/1/2007 A L5994 Addition to lower extremity prosthesis, heavy duty feature, knee only, (for patient weight greater than 300 lbs) 1/1/2007 A L6611 Addition to upper extremity prosthesis, external powered, additional switch, any type 1/1/2007 A L6624 Upper extremity addition, flexion/extension and rotation wrist unit 1/1/2007 A L6639 Upper extremity addition, heavy duty feature, any elbow 1/1/2007 A L6703 Terminal device, passive hand/mitt, any material, any size 1/1/2007 A L6704 Terminal device, sport/recreational/work attachment, any material, any size 1/1/2007 A L6706 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined 1/1/2007 A L6707 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined 1/1/2007 A L6708 Terminal device, hand, mechanical, voluntary opening, any material, any size 1/1/2007 A L6709 Terminal device, hand, mechanical, voluntary closing, any material, any size 1/1/2007 A L7007 Electric hand, switch or myoelectric controlled, adult 1/1/2007 A L7008 Electric hand, switch or myoelectric, controlled, pediatric 1/1/2007 A L7009 Electric hook, switch or myoelectric controlled, adult 1/1/2007 A L8690 Auditory osseointegrated device, includes all internal and external components 1/1/2007 A L8691 Auditory osseointegrated device, external sound processor, replacement 1/1/2007 A L8695 External recharging system for battery (external) for use with implantable neurostimulator 1/1/2007 A Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) 1/1/2007 A Q4082 Drug or biological, not otherwise classified, part B drug competitive acquisition program (cap) 1/1/2007 A Q4083 Hyaluronan or derivative, Hyalgan or Supartz, for intraarticular injection, per dose 1/1/2007 A Q4084 Hyaluronan or derivative, Synvisc, for intra-articular injection, per dose 1/1/2007 A Q4085 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose 1/1/2007 A Q4086 Hyaluronan or derivative, Orthovisc, for intra-articular injection per dose 1/1/2007 A Q5001 Hospice care provided in patient’s home/residence 1/1/2007 80 View full policies online at www.ibx.com/medpolicy 43034txt.indd 80 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:43 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition Delete Date A Q5002 Hospice care provided in assisted living facility 1/1/2007 A Q5003 Hospice care provided in nursing long term care facility (LTC) or non-skilled nursing facility (NF) 1/1/2007 A Q5004 Hospice care provided in skilled nursing facility (SNF) 1/1/2007 A Q5005 Hospice care provided in inpatient hospital 1/1/2007 A Q5006 Hospice care provided in inpatient hospice facility 1/1/2007 A Q5007 Hospice care provided in long term care facility 1/1/2007 A Q5008 Hospice care provided in inpatient psychiatric facility 1/1/2007 A Q5009 Hospice care provided in place not otherwise specified (NOS) 1/1/2007 A S0180 Etonogestrel (contraceptive) implant system, including implant and supplies 1/1/2007 A S2344 Nasal/sinus endoscopy, surgical; with enlargement of sinus ostium opening using inflatable device (i.e., balloon sinuplasty) 1/1/2007 A S3855 Genetic testing for detection of mutations in the presenilin, 1 gene 1/1/2007 A T4543 Disposable incontinence product, brief/diaper, bariatric, each 1/1/2007 D A0800 Ambulance transport provided between the hours of 7pm and 7am 1/1/2007 D A4348 Male external catheter with integral collection compartment, extended wear, each (e.g., 2 per month) 1/1/2007 D A4359 Urinary suspensory without leg bag, each 1/1/2007 D A4462 Abdominal dressing holder, each 1/1/2007 D A4632 Replacement battery for external infusion pump, any type, each 1/1/2007 D A9549 Technetium Tc-99m arcitumomab, diagnostic, per study dose, up to 25 millicuries 1/1/2007 D C1178 Injection, busulfan, per 6 mg 1/1/2007 D C2632 Brachytherapy solution, iodine-125, per mci 1/1/2007 D C8950 Intravenous infusion for therapy/diagnosis; up to 1 hour 1/1/2007 D C8951 Intravenous infusion for therapy/diagnosis; each additional hour (list separately in addition to C8950) 1/1/2007 D C8952 Therapeutic, prophylactic or diagnostic injection; intravenous push of each new substance/drug 1/1/2007 D C8953 Chemotherapy administration, intravenous; push technique 1/1/2007 D C8954 Chemotherapy administration, intravenous; infusion technique, up to one hour 1/1/2007 D C8955 Chemotherapy administration, intravenous; infusion technique, each additional hour (list separately in addition to C8954) 1/1/2007 D C9220 Sodium hyaluronate per 30 mg dose, for intra-articular injection 1/1/2007 D C9221 Acellular dermal tissue matrix, per 16 sq. cm. 1/1/2007 D C9222 Decellularized soft tissue scaffold, per 1 cc 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 81 Narrative 81 2/19/07 1:44:44 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition Delete Date D C9224 Injection, galsulfase, per 5 mg 1/1/2007 D C9225 Injection, fluocinolone acetonide intravitreal implant, per 0.59 mg 1/1/2007 D C9227 Injection, micafungin sodium, per 1 mg 1/1/2007 D C9228 Injection, tigecycline, per 1 mg 1/1/2007 D C9229 Injection, ibandronate sodium, per 1 mg 1/1/2007 D C9230 Injection, abatacept, per 10 mg 1/1/2007 D C9231 Injection, decitabine, per 1 mg 1/1/2007 D D1201 Topical application of fluoride (including prophylaxis)-child 1/1/2007 D D1205 Topical application of fluoride (including prophylaxis)-adult 1/1/2007 D D6971 Cast post as part of bridge retainer 1/1/2007 D E0164 Commode chair, mobile, with fixed arms 1/1/2007 D E0166 Commode chair, mobile, with detachable arms 1/1/2007 D E0180 Pressure pad, alternating with pump 1/1/2007 D E0701 Helmet with face guard and soft interface material, prefabricated 1/1/2007 D E0977 Wedge cushion, wheelchair 1/1/2007 D E0997 Caster with a fork 1/1/2007 D E0998 Caster without fork 1/1/2007 D E0999 Pneumatic tire with wheel 1/1/2007 D E2320 Power wheelchair accessory, hand or chin control interface, remote joystick or touchpad, proportional, including all related electronics, and fixed mounting hardware 1/1/2007 D G0107 Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations 1/1/2007 D G0243 Multi-source photon stereotactic radiosurgery, delivery including collimator changes and custom plugging, complete course of treatment, all lesions 1/1/2007 D G9127 Oncology; disease status; limited to multiple myeloma, systemic disease; smoldering, stage I (for use in a Medicare-approved demonstration project) 1/1/2007 D J2912 Injection, sodium chloride, 0.9%, per 2 ml 1/1/2007 D J7188 Injection, Von Willebrand factor complex, human, IU 1/1/2007 D J7317 Sodium hyaluronate, per 20 to 25 mg dose for intraarticular injection 1/1/2007 D J7320 Hylan G-F 20, 16 mg, for intra-articular injection 1/1/2007 D J7350 Dermal (substitute) tissue of human origin, injectable, with or without other bioengineered or processed elements, but without metabolized active elements, per 10 mg 1/1/2007 D K0090 Rear wheel tire for power wheelchair, any size, each 1/1/2007 D K0091 Rear wheel tire tube other than zero pressure for power wheelchair, any size, each 1/1/2007 82 View full policies online at www.ibx.com/medpolicy 43034txt.indd 82 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e 2006 CGPU Compendium 2/19/07 1:44:45 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition Delete Date D K0092 Rear wheel assembly for power wheelchair, complete, each 1/1/2007 D K0093 Rear wheel, zero pressure tire tube (flat free insert) for power wheelchair, any size, each 1/1/2007 D K0094 Wheel tire for power base, any size, each 1/1/2007 D K0095 Wheel tire tube other than zero pressure for each base, any size, each 1/1/2007 D K0096 Wheel assembly for power base, complete, each 1/1/2007 D K0097 Wheel zero pressure tire tube (flat free insert) for power base, any size, each 1/1/2007 D K0099 Front caster for power wheelchair 1/1/2007 D L0100 Cranial orthosis (helmet), with or without soft interface, molded to patient model 1/1/2007 D L0110 Cranial orthosis (helmet), with or without soft-interface, non-molded 1/1/2007 D L3902 Wrist hand finger orthosis, external powered, compressed gas, custom-fabricated 1/1/2007 D L3914 Wrist hand orthosis, wrist extension cock-up, prefabricated, includes fitting/adjustment 1/1/2007 D L6700 Terminal device, hook, Dorrance, or equal, model #3 1/1/2007 D L6705 Terminal device, hook, Dorrance, or equal, model #5 1/1/2007 D L6710 Terminal device, hook, Dorrance, or equal, model #5X 1/1/2007 D L6715 Terminal device, hook, Dorrance, or equal, model #5XA 1/1/2007 D L6720 Terminal device, hook, Dorrance, or equal, model #6 1/1/2007 D L6725 Terminal device, hook, Dorrance, or equal, model #7 1/1/2007 D L6730 Terminal device, hook, Dorrance, or equal, model #7LO 1/1/2007 D L6735 Terminal device, hook, Dorrance, or equal, model #8 1/1/2007 D L6740 Terminal device, hook, Dorrance, or equal, model #8X 1/1/2007 D L6745 Terminal device, hook, Dorrance, or equal, model #88X 1/1/2007 D L6750 Terminal device, hook, Dorrance, or equal, model #10P 1/1/2007 D L6755 Terminal device, hook, Dorrance, or equal, model #10X 1/1/2007 D L6765 Terminal device, hook, Dorrance, or equal, model #12P 1/1/2007 D L6770 Terminal device, hook, Dorrance, or equal, model #99X 1/1/2007 D L6775 Terminal device, hook, Dorrance, or equal, model #555 1/1/2007 D L6780 Terminal device, hook, Dorrance, or equal, model #ss555 1/1/2007 D L6790 Terminal device, hook, Accu hook, or equal 1/1/2007 D L6795 Terminal device, hook, 2 load, or equal 1/1/2007 D L6800 Terminal device, hook, APRL VC, or equal 1/1/2007 D L6806 Terminal device, hook, TRS Grip, Grip III, VC, or equal 1/1/2007 D L6807 Terminal device, hook, Grip I, Grip II, VC, or equal 1/1/2007 D L6808 Terminal device, hook, TRS Adept, infant or child, VC, or equal 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 83 Narrative 83 2/19/07 1:44:45 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition Delete Date D L6809 Terminal device, hook, TRS Super Sport, passive 1/1/2007 D L6825 Terminal device, hand, Dorrance, VO 1/1/2007 D L6830 Terminal device, hand, APRL, VC 1/1/2007 D L6835 Terminal device, hand, Sierra, VO 1/1/2007 D L6840 Terminal device, hand, Becker Imperial 1/1/2007 D L6845 Terminal device, hand, Becker Lock Grip 1/1/2007 D L6850 Terminal device, hand, Becker Plylite 1/1/2007 D L6855 Terminal device, hand, Robin-Aids, VO 1/1/2007 D L6860 Terminal device, hand, Robin-Aids, VO soft 1/1/2007 D L6865 Terminal device, hand, passive hand 1/1/2007 D L6867 Terminal device, hand, Detroit infant hand (mechanical) 1/1/2007 D L6868 Terminal device, hand, passive infant hand, (Steeper, Hosmer or equal) 1/1/2007 D L6870 Terminal device, hand, child mitt 1/1/2007 D L6872 Terminal device, hand, NYU child hand 1/1/2007 D L6873 Terminal device, hand, mechanical infant hand, steeper or equal 1/1/2007 D L6875 Terminal device, hand, Bock, VC 1/1/2007 D L6880 Terminal device, hand, Bock, VO 1/1/2007 D L7010 Electronic hand, Otto Bock, Steeper or equal, switch controlled 1/1/2007 D L7015 Electronic hand, System Teknik, Variety Village or equal, switch controlled 1/1/2007 D L7020 Electronic greifer, Otto Bock or equal, switch controlled 1/1/2007 D L7025 Electronic hand, Otto Bock or equal, myoelectronically controlled 1/1/2007 D L7030 Electronic hand, System Teknik, Variety Village or equal, myoelectronically controlled 1/1/2007 D L7035 Electronic Greifer, Otto Bock or equal, myoelectronically controlled 1/1/2007 D S2262 Abortion for maternal indication, 25 weeks or greater 1/1/2007 D S4036 Intravaginal culture (IVC), case rate 1/1/2007 R S0316 Disease Management Program, follow-up/reassessment R A4216 Sterile water, saline and/or dextrose, diluent/flush, 10 ml 1/1/2007 R A4306 Disposable drug delivery system, flow rate of less than 50 ml per hour 1/1/2007 R A4326 Male external catheter with integral collection chamber, any type, each 1/1/2007 R A4394 Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce 1/1/2007 R A4558 Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz 1/1/2007 R A5105 Urinary suspensory; with or without leg bag, with or without tube, each 1/1/2007 84 View full policies online at www.ibx.com/medpolicy 43034txt.indd 84 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e 10/1/2006 2006 CGPU Compendium 2/19/07 1:44:46 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition R D0120 Periodic oral evaluation - established patient 1/1/2007 R D0480 Accession of exfoliative cytologic smears, microscopic examination, the preparation and transmission of written report 1/1/2007 R D2952 Post and core in addition to crown, indirectly fabricated 1/1/2007 R D2953 Each additional indirectly fabricated post - same tooth 1/1/2007 R D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated 1/1/2007 R D6976 Each additional indirectly fabricated post - same tooth 1/1/2007 R D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant 1/1/2007 R D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant 1/1/2007 R D7944 Osteotomy-segmented or subapical 1/1/2007 R D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report 1/1/2007 R D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 1/1/2007 R D9610 Therapeutic parenteral drug, single administration 1/1/2007 R E0163 Commode chair, mobile or stationary, with fixed arms 1/1/2007 R E0165 Commode chair, mobile or stationary, with detachable arms 1/1/2007 R E0167 Pail or pan for use with commode chair, replacement only 1/1/2007 R E0181 Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty 1/1/2007 R E0182 Pump for alternating pressure pad, for replacement only 1/1/2007 R E0190 Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories 1/1/2007 R E0720 Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation 1/1/2007 R E0730 Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation 1/1/2007 R E0967 Manual wheelchair accessory, hand rim with projections, any type, each 1/1/2007 R E2209 Arm trough, with or without hand support, each 1/1/2007 R G0103 Prostate cancer screening; prostate specific antigen test (PSA) 1/1/2007 R G0332 Services for intravenous infusion of immunoglobulin prior to administration (this service is to be billed in conjunction with administration of immunoglobulin) 1/1/2007 R G9067 Oncology; disease status; limited to non-small cell lung cancer; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 85 Narrative Delete Date 85 2/19/07 1:44:46 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition R G9070 Oncology; disease status; small cell lung cancer, limited to small cell and combined small cell/non-small; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 R G9083 Oncology; disease status; prostate cancer, limited to adenocarcinoma; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 R G9089 Oncology; disease status; colon cancer, limited to invasive cancer; adenocarcinoma as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 R G9095 Oncology; disease status; rectal cancer, limited to invasive cancer; adenocarcinoma as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 R G9099 Oncology; disease status; esophageal cancer, limited to adenocarcinoma or squamous cell carcinoma as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 R G9104 Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 R G9108 Oncology; disease status; pancreatic cancer, limited to adenocarcinoma; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 R 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, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 R G9117 Oncology; disease status; ovarian cancer, limited to epithelial cancer; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 R G9130 Oncology; disease status; limited to multiple myeloma, systemic disease; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) 1/1/2007 R J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg 1/1/2007 R J7612 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 0.5 mg 1/1/2007 R J7613 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg 1/1/2007 R J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg 1/1/2007 86 View full policies online at www.ibx.com/medpolicy 43034txt.indd 86 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:46 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition R J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME 1/1/2007 R J7622 Beclomethasone, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 R J7624 Betamethasone, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 R J7626 Budesonide, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, up to 0.5 mg 1/1/2007 R J7627 Budesonide, inhalation solution, compounded product, administered through DME, unit dose form, up to 0.5 mg 1/1/2007 R J7628 Bitolterol mesylate, inhalation solution, compounded product, administered through DME, concentrated form, per milligram 1/1/2007 R J7629 Bitolterol mesylate, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 R J7633 Budesonide, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per 0.25 milligram 1/1/2007 R J7635 Atropine, inhalation solution, compounded product, administered through DME, concentrated form, per milligram 1/1/2007 R J7636 Atropine, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 R J7637 Dexamethasone, inhalation solution, compounded product, administered through DME, concentrated form, per milligram 1/1/2007 R J7638 Dexamethasone, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 R J7640 Formoterol, inhalation solution, compounded product, administered through DME, unit dose form, 12 micrograms 1/1/2007 R J7641 Flunisolide, inhalation solution, compounded product, administered through DME, unit dose, per milligram 1/1/2007 R J7642 Glycopyrrolate, inhalation solution, compounded product, administered through DME, concentrated form, per milligram 1/1/2007 R J7643 Glycopyrrolate, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 R J7644 Ipratropium bromide, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per milligram 1/1/2007 R J7648 Isoetharine HCL, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per milligram 1/1/2007 R J7649 Isoetharine HCL, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per milligram 1/1/2007 R J7658 Isoproterenol HCL, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per milligram 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 87 Narrative Delete Date 87 2/19/07 1:44:47 PM C o ding G uid e l in e s and P o l ic y HCPCS Code Narrative Effective Date of Revision/ Addition R J7659 Isoproterenol HCL, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per milligram 1/1/2007 R J7668 Metaproterenol sulfate, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per 10 milligrams 1/1/2007 R J7669 Metaproterenol sulfate, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per 10 milligrams 1/1/2007 R J7680 Terbutaline sulfate, inhalation solution, compounded product, administered through DME, concentrated form, per milligram 1/1/2007 R J7681 Terbutaline sulfate, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 R J7682 Tobramycin, inhalation solution, FDA-approved final product, non-compounded, unit dose form, administered through DME, per 300 milligrams 1/1/2007 R J7683 Triamcinolone, inhalation solution, compounded product, administered through DME, concentrated form, per milligram 1/1/2007 R J7684 Triamcinolone, inhalation solution, compounded product, administered through DME, unit dose form, per milligram 1/1/2007 R L0631 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, pendulous abdomen design, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment 1/1/2007 R L5848 Addition to endoskeletal knee-shin system, hydraulic fluid stance extension, dampening feature, with or without adjustability 1/1/2007 R L5995 Addition to lower extremity prosthesis, heavy duty feature, other than foot or knee, (for patient weight greater than 300 lbs) 1/1/2007 R L6805 Addition to terminal device, modifier wrist unit 1/1/2007 R L6810 Addition to terminal device, Pincher tool, Otto Bock or equal precision pinch device 1/1/2007 R L6881 Automatic grasp feature, addition to upper limb electric prosthetic terminal device 1/1/2007 R L6884 Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power 1/1/2007 R L7040 Prehensile actuator, Hosmer or equal switch controlled 1/1/2007 R L7045 Electric hook, child, Michigan or equal switch or myoelectric controlled, pediatric 1/1/2007 R L8614 Cochlear device/system, includes all internal and external components 1/1/2007 R L8689 External recharging system for implanted battery (internal) for use with implantable neurostimulator, replacement only 1/1/2007 88 View full policies online at www.ibx.com/medpolicy 43034txt.indd 88 C o mp e ndium HCPCS CODES Action A=Addition D=Deletion R=Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:47 PM Action A=Addition D=Deletion R=Revision HCPCS CODES HCPCS Code Effective Date of Revision/ Addition R P9011 Blood, split unit 1/1/2007 R S1040 Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) 1/1/2007 R S2260 Induced abortion, 17 to 24 weeks, any surgical method 1/1/2007 R S2265 Induced abortion for fetal indication, 25 to 28 weeks 1/1/2007 R S2266 Induced abortion for fetal indication, 29 to 31 weeks 1/1/2007 R S2267 Induced abortion for fetal indication, 32 weeks or greater 1/1/2007 R T5001 Positioning seat for persons with special orthopedic needs, for use in vehicles 1/1/2007 www.ibx.com/providers/communications 43034txt.indd 89 Narrative Delete Date 89 2/19/07 1:44:48 PM C o ding G uid e l in e s and P o l ic y ICD-9 CM Code Narrative 43034txt.indd 90 Effective Date of Revision / Addition A V18.51 Family history, colonic polyps 10/1/2006 A V18.59 Family history, other digestive disorders 10/1/2006 A V26.34 Testing of male for genetic disease carrier status 10/1/2006 A V26.35 Encounter for testing of male partner of habitual aborter 10/1/2006 A V26.39 Other genetic testing of male 10/1/2006 A V45.86 Bariatric surgery status 10/1/2006 A V58.30 Encounter for change or removal of nonsurgical wound dressing 10/1/2006 A V58.31 Encounter for change or removal of surgical wound dressing 10/1/2006 A V58.32 Encounter for removal of sutures 10/1/2006 A V72.11 Encounter for hearing examination following failed hearing screening 10/1/2006 A V72.19 Other examination of ears and hearing 10/1/2006 A V82.71 Screening for genetic disease carrier status 10/1/2006 A V82.79 Other genetic screening 10/1/2006 A V85.51 Body mass index, pediatric, less than 5th percentile for age 10/1/2006 A V85.52 Body mass index, pediatric, 5th percentile to less than 85th percentile for age 10/1/2006 A V85.53 Body mass index, pediatric, 85th percentile to less than 95th percentile for age 10/1/2006 A V85.54 Body mass index, pediatric, greater than or equal to 95th percentile for age 10/1/2006 A V86.0 Estrogen receptor positive status [ER+] 10/1/2006 A V86.1 Estrogen receptor negative status [ER-] 10/1/2006 A 052.2 Postvaricella myelitis 10/1/2006 A 053.14 Herpes zoster myelitis 10/1/2006 A 054.74 Herpes simplex myelitis 10/1/2006 A 238.71 Essential thrombocythemia 10/1/2006 A 238.72 Low grade myelodysplastic syndrome lesions 10/1/2006 A 238.73 High grade myelodysplastic syndrome lesions 10/1/2006 A 238.74 Myelodysplastic syndrome with 5q deletion 10/1/2006 A 238.75 Myelodysplastic syndrome, unspecified 10/1/2006 A 238.76 Myelofibrosis with myeloid metaplasia 10/1/2006 A 238.79 Other lymphatic and hematopoietic tissues 10/1/2006 A 277.30 Amyloidosis, unspecified 10/1/2006 A 277.31 Familial Mediterranean fever 10/1/2006 A 277.39 Other amyloidosis 10/1/2006 A 284.01 Constitutional red blood cell aplasia 10/1/2006 A 284.09 Other constitutional aplastic anemia 10/1/2006 A 284.1 Pancytopenia 10/1/2006 A 284.2 Myelophthisis 10/1/2006 A 288.00 Neutropenia, unspecified 10/1/2006 90 View full policies online at www.ibx.com/medpolicy C o mp e ndium ICD-9 CM CODES Action A=Addition D=Deletion R-Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:48 PM Action A=Addition D=Deletion R-Revision ICD-9 CM CODES ICD-9 CM Code A 288.01 Congenital neutropenia 10/1/2006 A 288.02 Cyclic neutropenia 10/1/2006 A 288.03 Drug induced neutropenia 10/1/2006 A 288.04 Neutropenia due to infection 10/1/2006 A 288.09 Other neutropenia 10/1/2006 A 288.4 Hemophagocytic syndromes 10/1/2006 A 288.50 Leukocytopenia, unspecified 10/1/2006 A 288.51 Lymphocytopenia 10/1/2006 A 288.59 Other decreased white blood cell count 10/1/2006 A 288.60 Leukocytosis, unspecified 10/1/2006 A 288.61 Lymphocytosis (symptomatic) 10/1/2006 A 288.62 Leukemoid reaction 10/1/2006 A 288.63 Monocytosis (symptomatic) 10/1/2006 A 288.64 Plasmacytosis 10/1/2006 A 288.65 Basophilia 10/1/2006 A 288.69 Other elevated white blood cell count 10/1/2006 A 289.53 Neutropenic splenomegaly 10/1/2006 A 289.83 Myelofibrosis 10/1/2006 A 323.01 Encephalitis and encephalomyelitis in viral diseases classified elsewhere 10/1/2006 A 323.02 Myelitis in viral diseases classified elsewhere 10/1/2006 A 323.41 Other encephalitis and encephalomyelitis due to infection classified elsewhere 10/1/2006 A 323.42 Other myelitis due to infection classified elsewhere 10/1/2006 A 323.51 Encephalitis and encephalomyelitis following immunization procedures 10/1/2006 A 323.52 Myelitis following immunization procedures 10/1/2006 A 323.61 Infectious acute disseminated encephalomyelitis (ADEM) 10/1/2006 A 323.62 Other postinfectious encephalitis and encephalomyelitis 10/1/2006 A 323.63 Postinfectious myelitis 10/1/2006 A 323.71 Toxic encephalitis and encephalomyelitis 10/1/2006 A 323.72 Toxic myelitis 10/1/2006 A 323.81 Other causes of encephalitis and encephalomyelitis 10/1/2006 A 323.82 Other causes of myelitis 10/1/2006 A 331.83 Mild cognitive impairment, so stated 10/1/2006 A 333.71 Athetoid cerebral palsy 10/1/2006 A 333.72 Acute dystonia due to drugs 10/1/2006 A 333.79 Other acquired torsion dystonia 10/1/2006 A 333.85 Subacute dyskinesia due to drugs 10/1/2006 A 333.94 Restless legs syndrome (RLS) 10/1/2006 A 338.0 Central pain syndrome 10/1/2006 A 338.11 Acute pain due to trauma 10/1/2006 A 338.12 Acute post-thoracotomy pain 10/1/2006 www.ibx.com/providers/communications 43034txt.indd 91 Narrative Effective Date of Revision / Addition Delete Date 91 2/19/07 1:44:49 PM C o ding G uid e l in e s and P o l ic y ICD-9 CM Code Narrative 43034txt.indd 92 Effective Date of Revision / Addition A 338.18 Other acute postoperative pain 10/1/2006 A 338.19 Other acute pain 10/1/2006 A 338.21 Chronic pain due to trauma 10/1/2006 A 338.22 Chronic post-thoracotomy pain 10/1/2006 A 338.28 Other chronic postoperative pain 10/1/2006 A 338.29 Other chronic pain 10/1/2006 A 338.3 Neoplasm related pain (acute) (chronic) 10/1/2006 A 338.4 Chronic pain syndrome 10/1/2006 A 341.20 Acute (transverse) myelitis nos 10/1/2006 A 341.21 Acute (transverse) myelitis in conditions classified elsewhere 10/1/2006 A 341.22 Idiopathic transverse myelitis 10/1/2006 A 377.43 Optic nerve hypoplasia 10/1/2006 A 379.60 Inflammation (infection) of postprocedural bleb, unspecified 10/1/2006 A 379.61 Inflammation (infection) of postprocedural bleb, stage 1 10/1/2006 A 379.62 Inflammation (infection) of postprocedural bleb, stage 2 10/1/2006 A 379.63 Inflammation (infection) of postprocedural bleb, stage 3 10/1/2006 A 389.15 Sensorineural hearing loss, unilateral 10/1/2006 A 389.16 Sensorineural hearing loss, asymmetrical 10/1/2006 A 429.83 Takotsubo syndrome 10/1/2006 A 478.11 Nasal mucositis (ulcerative) 10/1/2006 A 478.19 Other disease of nasal cavity and sinuses 10/1/2006 A 518.7 Transfusion related acute lung injury (TRALI) 10/1/2006 A 519.11 Acute bronchospasm 10/1/2006 A 519.19 Other diseases of trachea and bronchus 10/1/2006 A 521.81 Cracked tooth 10/1/2006 A 521.89 Other specific diseases of hard tissues of teeth 10/1/2006 A 523.00 Acute gingivitis, plaque induced 10/1/2006 A 523.01 Acute gingivitis, non-plaque induced 10/1/2006 A 523.10 Chronic gingivitis, plaque induced 10/1/2006 A 523.11 Chronic gingivitis, non-plaque induced 10/1/2006 A 523.30 Aggressive periodontitis, unspecified 10/1/2006 A 523.31 Aggressive periodontitis, localized 10/1/2006 A 523.32 Aggressive periodontitis, generalized 10/1/2006 A 523.33 Acute periodontitis 10/1/2006 A 523.40 Chronic periodontitis, unspecified 10/1/2006 A 523.41 Chronic periodontitis, localized 10/1/2006 A 523.42 Chronic periodontitis, generalized 10/1/2006 A 525.60 Unspecified unsatisfactory restoration of tooth 10/1/2006 A 525.61 Open restoration margins 10/1/2006 A 525.62 Unrepairable overhanging of dental restorative materials 10/1/2006 92 View full policies online at www.ibx.com/medpolicy C o mp e ndium ICD-9 CM CODES Action A=Addition D=Deletion R-Revision U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:49 PM Action ICD-9 CM CODES A=Addition D=Deletion R-Revision ICD-9 CM Code A 525.63 A Fractured dental restorative material without loss of material 10/1/2006 525.64 Fractured dental restorative material with loss of material 10/1/2006 A 525.65 Contour of existing restoration of tooth biologically incompatible with oral health 10/1/2006 A 525.66 Allergy to existing dental restorative material 10/1/2006 A 525.67 Poor aesthetics of existing restoration 10/1/2006 A 525.69 Other unsatisfactory restoration of existing tooth 10/1/2006 A 526.61 Perforation of root canal space 10/1/2006 A 526.62 Endodontic overfill 10/1/2006 A 526.63 Endodontic underfill 10/1/2006 A 526.69 Other periradicular pathology associated with previous endodontic treatment 10/1/2006 A 528.00 Stomatitis and mucositis, unspecified 10/1/2006 A 528.01 Mucositis (ulcerative) due to antineoplastic therapy 10/1/2006 A 528.02 Mucositis (ulcerative) due to other drugs 10/1/2006 A 528.09 Other stomatitis and mucositis (ulcerative) 10/1/2006 A 538 Gastrointestinal mucositis (ulcerative) 10/1/2006 A 608.20 Torsion of testis, unspecified 10/1/2006 A 608.21 Extravaginal torsion of spermatic cord 10/1/2006 A 608.22 Intravaginal torsion of spermatic cord 10/1/2006 A 608.23 Torsion of appendix testis 10/1/2006 A 608.24 Torsion of appendix epididymis 10/1/2006 A 616.81 Mucositis (ulcerative) of cervix, vagina, and vulva 10/1/2006 A 616.89 Other inflammatory disease of cervix, vagina and vulva 10/1/2006 A 618.84 Cervical stump prolapse 10/1/2006 A 629.29 Other female genital mutilation status 10/1/2006 A 629.81 Habitual aborter without current pregnancy 10/1/2006 A 629.89 Other specified disorders of female genital organs 10/1/2006 A 649.00 Tobacco use disorder complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable 10/1/2006 A 649.01 Tobacco use disorder complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition 10/1/2006 A 649.02 Tobacco use disorder complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication 10/1/2006 A 649.03 Tobacco use disorder complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication 10/1/2006 A 649.04 Tobacco use disorder complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication 10/1/2006 A 649.10 Obesity complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable 10/1/2006 www.ibx.com/providers/communications 43034txt.indd 93 Narrative Effective Date of Revision / Addition Delete Date 93 2/19/07 1:44:50 PM C o ding G uid e l in e s and P o l ic y U pdat e ICD-9 CM CODES Action Effective Date of Revision / Addition A=Addition D=Deletion R-Revision ICD-9 CM Code A 649.11 Obesity complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition 10/1/2006 A 649.12 Obesity complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication 10/1/2006 A 649.13 Obesity complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication 10/1/2006 A 649.14 Obesity complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication 10/1/2006 A 649.20 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable 10/1/2006 A 649.21 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition 10/1/2006 A 649.22 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication 10/1/2006 A 649.23 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication 10/1/2006 A 649.24 Bariatric surgery status complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication 10/1/2006 A 649.30 Coagulation defects complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable 10/1/2006 A 649.31 Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition 10/1/2006 A 649.32 Coagulation defects complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication 10/1/2006 A 649.33 Coagulation defects complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication 10/1/2006 A 649.34 Coagulation defects complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication 10/1/2006 A 649.40 Epilepsy complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care or not applicable 10/1/2006 A 649.41 Epilepsy complicating pregnancy, childbirth, or the puerperium, delivered, with or without mention of antepartum condition 10/1/2006 A 649.42 Epilepsy complicating pregnancy, childbirth, or the puerperium, delivered, with mention of postpartum complication 10/1/2006 A 649.43 Epilepsy complicating pregnancy, childbirth, or the puerperium, antepartum condition or complication 10/1/2006 A 649.44 Epilepsy complicating pregnancy, childbirth, or the puerperium, postpartum condition or complication 10/1/2006 A 649.50 Spotting complicating pregnancy, unspecified as to episode of care or not applicable 10/1/2006 Narrative 94 View full policies online at www.ibx.com/medpolicy 43034txt.indd 94 C o mp e ndium Delete Date 2006 CGPU Compendium 2/19/07 1:44:50 PM Action ICD-9 CM CODES ICD-9 CM Code A 649.51 Spotting complicating pregnancy, delivered, with or without mention of antepartum condition 10/1/2006 A 649.53 Spotting complicating pregnancy, antepartum condition or complication 10/1/2006 A 649.60 Uterine size date discrepancy, unspecified as to episode of care or not applicable 10/1/2006 A 649.61 Uterine size date discrepancy, delivered, with or without mention of antepartum condition 10/1/2006 A 649.62 Uterine size date discrepancy, delivered, with mention of postpartum complication 10/1/2006 A 649.63 Uterine size date discrepancy, antepartum condition or complication 10/1/2006 A 649.64 Uterine size date discrepancy, postpartum condition or complication 10/1/2006 A 729.71 Nontraumatic compartment syndrome of upper extremity 10/1/2006 A 729.72 Nontraumatic compartment syndrome of lower extremity 10/1/2006 A 729.73 Nontraumatic compartment syndrome of abdomen 10/1/2006 A 729.79 Nontraumatic compartment syndrome of other sites 10/1/2006 A 731.3 Major osseous defects 10/1/2006 A 768.7 Hypoxic-ischemic encephalopathy (HIE) 10/1/2006 A 770.87 Respiratory arrest of newborn 10/1/2006 A 770.88 Hypoxemia of newborn 10/1/2006 A 775.81 Other acidosis of newborn 10/1/2006 A 775.89 Other neonatal endocrine and metabolic disturbances 10/1/2006 A 779.85 Cardiac arrest of newborn 10/1/2006 A 780.32 Complex febrile convulsions 10/1/2006 A 780.96 Generalized pain 10/1/2006 A 780.97 Altered mental status 10/1/2006 A 784.91 Postnasal drip 10/1/2006 A 784.99 Other symptoms involving head and neck 10/1/2006 A 788.64 Urinary hesitancy 10/1/2006 A 788.65 Straining on urination 10/1/2006 A 793.91 Image test inconclusive due to excess body fat 10/1/2006 A 793.99 Other nonspecific abnormal findings on radiological and other examinations of body structure 10/1/2006 A 795.06 Papanicolaou smear of cervix with cytologic evidence of malignancy 10/1/2006 A 795.81 Elevated carcinoembryonic antigen [CEA] 10/1/2006 A 795.82 Elevated cancer antigen 125 [CA 125] 10/1/2006 A 795.89 Other abnormal tumor markers 10/1/2006 A 958.90 Compartment syndrome, unspecified 10/1/2006 A 958.91 Traumatic compartment syndrome of upper extremity 10/1/2006 A 958.92 Traumatic compartment syndrome of lower extremity 10/1/2006 A 958.93 Traumatic compartment syndrome of abdomen 10/1/2006 www.ibx.com/providers/communications 43034txt.indd 95 Effective Date of Revision / Addition A=Addition D=Deletion R-Revision Narrative Delete Date 95 2/19/07 1:44:51 PM C o ding G uid e l in e s and P o l ic y U pdat e ICD-9 CM CODES Action C o mp e ndium Effective Date of Revision / Addition A=Addition D=Deletion R-Revision ICD-9 CM Code A 958.99 Traumatic compartment syndrome of other sites 10/1/2006 A 995.20 Unspecified adverse effect of unspecified drug, medicinal and biological substance 10/1/2006 A 995.21 Arthus phenomenon 10/1/2006 A 995.22 Unspecified adverse effect of anesthesia 10/1/2006 A 995.23 Unspecified adverse effect of insulin 10/1/2006 A 995.27 Other drug allergy 10/1/2006 A 995.29 Unspecified adverse effect of other drug, medicinal and biological substance 10/1/2006 D V18.5 Family history of digestive disorders 10/1/2006 D V58.3 Attention to dressings and sutures 10/1/2006 D V72.1 Examination of ears and hearing 10/1/2006 D 238.7 Neoplasm of uncertain behavior of other lymphatic and hematopoietic tissues 10/1/2006 D 277.3 Amyloidosis 10/1/2006 D 284.0 Constitutional aplastic anemia 10/1/2006 D 288.0 Aplastic anemia and other bone marrow failure syndromes 10/1/2006 D 323.0 Encephalitis, myelitis, and encephalomyelitis in viral diseases classified elsewhere 10/1/2006 D 323.4 Other encephalitis due to infection classified elsewhere 10/1/2006 D 323.5 Encephalitis, myelitis, and encephalomyelitis following immunization procedures 10/1/2006 D 323.6 Postinfectious encephalitis, myelitis, and encephalomyelitis 10/1/2006 D 323.7 Toxic encephalitis, myelitis, and encephalomyelitis 10/1/2006 D 323.8 Other causes of encephalitis, myelitis, and encephalomyelitis 10/1/2006 D 333.7 Acquired torsion dystonia 10/1/2006 D 478.1 Other diseases of nasal cavity and sinuses 10/1/2006 D 519.1 Other diseases of trachea and bronchus, not elsewhere classified 10/1/2006 D 521.8 Other specified diseases of hard tissues of teeth 10/1/2006 D 523.0 Acute gingivitis 10/1/2006 D 523.1 Chronic gingivitis 10/1/2006 D 523.3 Aggressive and acute periodontitis 10/1/2006 D 523.4 Chronic periodontitis 10/1/2006 D 528.0 Stomatitis and mucositis (ulcerative) 10/1/2006 D 608.2 Torsion of testis 10/1/2006 D 616.8 Other specified inflammatory disease of cervix, vagina, and vulva 10/1/2006 D 629.8 Other specified disorder of female genital organs 10/1/2006 D 775.8 Other neonatal endocrine and metabolic disturbances 10/1/2006 D 784.9 Other symptoms involving head and neck 10/1/2006 D 793.9 Nonspecific abnormal findings on radiological and other examination of other site of body 10/1/2006 Narrative 96 View full policies online at www.ibx.com/medpolicy 43034txt.indd 96 Delete Date 2006 CGPU Compendium 2/19/07 1:44:52 PM Action ICD-9 CM CODES ICD-9 CM Code D 995.2 R 255.10 Hyperaldosteronism, unspecified 10/1/2006 R 285.29 Anemia of other chronic disease 10/1/2006 R 323.1 Encephalitis, myelitis, and encephalomyelitis in rickettsial diseases classified elsewhere 10/1/2006 R 323.2 Encephalitis, myelitis, and encephalomyelitis in protozoal diseases classified elsewhere 10/1/2006 R 323.9 Unspecified cause of encephalitis, myelitis, and encephalomyelitis 10/1/2006 R 333.6 Genetic torsion dystonia 10/1/2006 R 345.40 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures without mention of intractable epilepsy 10/1/2006 R 345.41 Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures with intractable epilepsy 10/1/2006 R 345.50 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures without mention of intractable epilepsy 10/1/2006 R 345.51 Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures with intractable epilepsy 10/1/2006 R 345.80 Other forms of epilepsy and recurrent seizures without mention of intractable epilepsy 10/1/2006 R 345.81 Other forms of epilepsy and recurrent seizures, with intractable epilepsy 10/1/2006 R 389.11 Sensory hearing loss, bilateral 10/1/2006 R 389.12 Neural hearing loss, bilateral 10/1/2006 R 389.14 Central hearing loss, bilateral 10/1/2006 R 389.18 Sensorineural hearing loss of combined types, bilateral 10/1/2006 R 403.00 Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified 10/1/2006 R 403.10 Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease 10/1/2006 R 403.90 Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified 10/1/2006 R 403.91 Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease 10/1/2006 R 404.00 Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified 10/1/2006 R 404.01 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified 10/1/2006 R 404.02 Hypertensive heart and chronic kidney disease, malignant, without heart failure and with chronic kidney disease stage V or end stage renal disease 10/1/2006 www.ibx.com/providers/communications 43034txt.indd 97 Effective Date of Revision / Addition A=Addition D=Deletion R-Revision Narrative Other and unspecified adverse effect of drug, medicinal and biological substance Delete Date 10/1/2006 97 2/19/07 1:44:52 PM C o ding G uid e l in e s and P o l ic y C o mp e ndium ICD-9 CM CODES Narrative Effective Date of Revision / Addition 404.03 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage V or end stage renal disease 10/1/2006 R 404.10 Hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified 10/1/2006 R 404.11 Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified 10/1/2006 R 404.12 Hypertensive heart and chronic kidney disease, benign, without heart failure and with chronic kidney disease stage V or end stage renal disease 10/1/2006 R 404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage V or end stage renal disease 10/1/2006 R 404.90 Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage I through stage IV, or unspecified 10/1/2006 R 404.91 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified 10/1/2006 R 404.92 Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage V or end stage renal disease 10/1/2006 R 404.93 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage V or end stage renal disease 10/1/2006 R 524.21 Malocclusion, angle’s class I 10/1/2006 R 524.22 Malocclusion, angle’s class II 10/1/2006 R 524.23 Malocclusion, angle’s class III 10/1/2006 R 524.35 Rotation of tooth/teeth 10/1/2006 R 600.00 Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) 10/1/2006 R 600.01 Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) 10/1/2006 R 600.20 Benign localized hyperplasia of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS) 10/1/2006 R 600.21 Benign localized hyperplasia of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) 10/1/2006 R 600.90 Hyperplasia of prostate, unspecified, without urinary obstruction and other lower urinary symptoms (LUTS) 10/1/2006 R 600.91 Hyperplasia of prostate, unspecified, with urinary obstruction and other lower urinary symptoms (LUTS) 10/1/2006 R 768.3 Fetal distress first noted during labor and delivery, in liveborn infant 10/1/2006 R 780.31 Febrile convulsions (simple), unspecified 10/1/2006 R 780.95 Excessive crying of child, adolescent, or adult 10/1/2006 R 873.63 Tooth (broken) (fractured) (due to trauma), without mention of complication 10/1/2006 R 873.73 Tooth (broken) (fractured) (due to trauma), complicated 10/1/2006 Action A=Addition D=Deletion R-Revision ICD-9 CM Code R 98 View full policies online at www.ibx.com/medpolicy 43034txt.indd 98 U pdat e Delete Date 2006 CGPU Compendium 2/19/07 1:44:53 PM Action ICD-9 CM CODES ICD-9 CM Code R 995.91 Sepsis 10/1/2006 R 995.92 Severe sepsis 10/1/2006 R 995.93 Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction 10/1/2006 R 995.94 Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction 10/1/2006 R V26.31 Testing of female for genetic disease carrier status 10/1/2006 R V26.32 Other genetic testing of female 10/1/2006 www.ibx.com/providers/communications 43034txt.indd 99 Effective Date of Revision / Addition A=Addition D=Deletion R-Revision Narrative Delete Date 99 2/19/07 1:44:53 PM C o ding G uid e l in e s and P o l ic y U pdat e C o mp e ndium NOTES 100 View full policies online at www.ibx.com/medpolicy 43034txt.indd 100 2006 CGPU Compendium 2/19/07 1:44:53 PM