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2014 CODING UPDATE
January 2014
Special Ediiton
Latest Medicare News for J11 Part B
What’s Inside...
Annual HCPCS/CPT Coding Update ..................................................................................1
2014 HCPCS Update: Effective January 1, 2014 ................................................................2
2014 HCPCS Modifier Addition ..........................................................................................3
2014 HCPCS, CDT, CPT Code Additions ..................................................................... 4-19
2014 HCPCS, CDT, CPT Code Changes ..................................................................... 20-33
2014 HCPCS, CDT, CPT Code Deletes ...................................................................... 34-39
Bilateral Modifiers: Use of CPT Modifier 50 & HCPCS Modifiers RT & LT............. 40-41
Bilateral Indicator 3 Procedures: Coding Instructions................................................. 42-43
2014 Endoscopy CPT Codes & Families..................................................................... 44-46
Technical & Professional Modifiers: HCPCS Modifier TC & CPT Modifier 26 ........ 47-65
Services Not Reimbursed by Medicare Part B ..................................................................66
Bundled Codes: Status B Indicator ...................................................................................66
Invalid Codes for Medicare: Status Indicator I............................................................ 67-73
Bundled/Excluded Codes: Status P Indicator ...................................................................74
Non-covered Services: Status N Indicator .................................................................. 75-78
Services Same Day/Provider: Status T Indicator ...............................................................79
Annual HCPCS/
CPT Coding
Update
Effective January 1, 2014,
providers must use the
HCPCS/CPT codes that are
valid at the time the service
is rendered. If claims are
submitted with discontinued
codes, they will be rejected.
To ensure prompt and timely
payment of claims, use the
new HCPCS/CPT codes for
2014 beginning with services
rendered on or after January
1, 2014. Each year thereafter, be sure to adopt the new
codes.
palmettogba.com/part b
The J11 Part B Medicare Advisory contains coverage, billing and other information for Jurisdiction 11 Part B. This
information is not intended to constitute legal advice. It is our ofϐicial notice to those we serve concerning their
responsibilities and obligations as mandated by Medicare regulations and guidelines. This information is readily
available at no cost on the Palmetto GBA website. It is the responsibility of each facility to obtain this information
and to follow the guidelines. The J11 Part B Medicare Advisory includes information provided by the Centers for
Medicare & Medicaid Services (CMS) and is current at the time of publication. The information is subject to change
at any time. This bulletin should be shared with all health care practitioners and managerial members of the
provider staff. Bulletins are available at no-cost from our website at http://www.PalmettoGBA.com/Medicare.
CPT only copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the
American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules,
relative value units, conversion factors and/or related components are not assigned by the AMA, and are not part
of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine
or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code
on Dental Procedures and Nomenclature is published in Current Dental Terminology (CDT), Copyright © 2012
American Dental Association (ADA). All rights reserved.
CMS no longer allows a
90-day grace period for
discontinued codes. This
also applies to any mid-year
HCPCS/CPT deletions.
2014 HCPCS Update: Effective January 1, 2014
Recently, Medicare Administrative Contractors (MAC) received the year 2014 additions, changes and
deletions to the Centers for Medicare & Medicaid Services (CMS) Common Procedure Coding System
(HCPCS). The HCPCS codes are effective for dates of service on or after January 1, 2014.
HCPCS is a collection of codes and descriptors that represent procedure, supplies, products and services
which may be provided to Medicare beneficiaries and individuals enrolled in private health insurance programs. HCPCS also contains modifiers, which are two-position codes and descriptors used to indicate that
a service or procedure has been altered by some specific circumstance, but not changed in its definition or
code. The codes and modifiers are divided into three levels:
LEVEL I – Codes and descriptors copyrighted by the American Medical Association’s Current Procedure
Terminology (CPT), Standard Edition. These are five-position numeric codes ranging from CPT codes 00000
to 99999, primarily representing physician services. Level I modifiers are two-position numeric codes.
LEVEL II – Five-position alphanumeric codes, ranging from HCPCS codes A0000 to V9999, representing primarily items and nonphysician services that are not represented in the Level I category. These codes
and descriptors, with the exception of the D series, are approved and maintained by the Alphanumeric
Editorial Panel (consisting of CMS, the Health Insurance Association of America, and the Blue Cross and
Blue Shield Association) and are listed in the HCPCS Level II code book. The D series includes codes
copyrighted by the American Dental Association’s Current Dental Terminology, Second Edition (CDT-2).
Level II modifiers are two-position alphanumeric codes.
LEVEL III – Codes and descriptors developed by Medicare MACs for use at the local level. These are
five-position alphanumeric codes in the W, X, Y or Z series (ranging from HCPCS codes W0000 to Z9999)
representing physician and nonphysician services that are not represented in the Level I or Level II codes.
Level III modifiers are two-position alphanumeric codes in the W, X, Y or Z series.
The year 2014 additions, changes and deletions for the HCPCS codes are listed on the following pages.
Please use this information to supplement your current materials. Note that the codes listed as changes previously may have had different descriptions of service. It is important that the most current HCPCS codes
are submitted on all claims, so please be sure to use the year 2014 versions of the respective code books.
Special Instructions
• The additions and deletions for the 2014 HCPCS Update are effective by date of service instead of
implementation date.
• The procedure codes listed as additions are valid for services performed on or after January 1, 2014. If
these procedure codes are used for dates of service prior to January 1, 2014, the services will be rejected.
• The procedure codes listed as deletions are valid for dates of service up to and including December
31, 2013.
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
2
01/14
2014 HCPCS Modifier Addition HCPCS
Modifier
Description
PM
Post mortem
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
3
01/14
2014 HCPCS, CDT, CPT Code Additions
HCPCS
Code
Description
A4555
Electrode/transducer for use with electrical stimulation device used for cancer treatment,
replacement only
A7047
Oral interface used with respiratory suction pump, each
A9520
Technetium tc-99m, tilmanocept, diagnostic, up to 0.5 millicuries
A9575
Injection, gadoterate meglumine, 0.1 ml
A9599
Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (pet)
imaging, per study dose
C1841
Retinal prosthesis, includes all internal and external components
C5271
Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to
100 sq cm; first 25 sq cm or less wound surface area
C5272
Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up
to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in
addition to code for primary procedure)
C5273
Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area
greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of
infants and children
C5274
Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area
greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part
thereof, or each additional 1% of body area of infants and children, or part thereof (list
separately in addition to code for primary procedure)
C5275
Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25
sq cm or less wound surface area
C5276
Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each
additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for
primary procedure)
C5277
Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to
100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
C5278
Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to
100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional
1% of body area of infants and children, or part thereof (list separately in addition to code for
primary procedure)
C9132
Prothrombin complex concentrate (human), kcentra, per i.u. of factor ix activity
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
4
01/14
HCPCS
Code
Description
C9133
Factor ix (antihemophilic factor, recombinant), rixibus, per i.u.
C9441
Injection, ferric carboxymaltose, 1 mg
C9497
Loxapine, inhalation powder, 10 mg
C9735
Anoscopy; with directed submucosal injection(s), any substance
C9737
Laparoscopy, surgical, esophageal sphincter augmentation with device (e.g., magnetic band)
E0766
Electrical stimulation device used for cancer treatment, includes all accessories, any type
E1352
Oxygen accessory, flow regulator capable of positive inspiratory pressure
G0461
Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex
antibody stain
G0462
Immunohistochemistry or immunocytochemistry, per specimen; each additional single or
multiplex antibody stain (list separately in addition to code for primary procedure)
G0463
Hospital outpatient clinic visit for assessment and management of a patient
G9187
Bundled payments for care improvement initiative home visit for patient assessment performed
by a qualified health care professional for individuals not considered homebound including, but
not limited to, assessment of safety, falls, clinical status, fluid status, medication reconciliation/
management, patient compliance with orders/plan of care, performance of activities of daily
living, appropriateness of care setting; (for use only in the Medicare-approved bundled
payments for care improvement initiative); may not be billed for a 30-day period covered by a
transitional care management code
G9188
Beta-blocker therapy not prescribed, reason not given
G9189
Beta-blocker therapy prescribed or currently being taken
G9190
Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., allergy,
intolerance, other medical reasons)
G9191
Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient
declined, other patient reasons)
G9192
Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other reasons
attributable to the health care system)
G9193
Clinician documented that patient with a diagnosis of major depression was not an eligible
candidate for antidepressant medication treatment or patient did not have a diagnosis of major
depression
G9194
Patient with a diagnosis of major depression documented as being treated with antidepressant
medication during the entire 180 day (6 month) continuation treatment phase
G9195
Patient with a diagnosis of major depression not documented as being treated with
antidepressant medication during the entire 180 day (6 months) continuation treatment phase
G9196
Documentation of medical reason(s) for not ordering first or second generation cephalosporin
for antimicrobial prophylaxis
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
5
01/14
HCPCS
Code
Description
G9197
Documentation of order for first or second generation cephalosporin for antimicrobial
prophylaxis
G9198
Order for first or second generation cephalosporin for antimicrobial prophylaxis was not
documented, reason not given
G9199
Venous thromboembolism (VTE) prophylaxis not administered the day of or the day after
hospital admission for documented reasons (e.g., patient is ambulatory, patient expired during
inpatient stay, patient already on warfarin or another anticoagulant, other medical reason(s) or
eg, patient left against medical advice, other patient reason(s))
G9200
Venous thromboembolism (VTE) prophylaxis was not administered the day of or the day after
hospital admission, reason not given
G9201
Venous thromboembolism (VTE) prophylaxis administered the day of or the day after hospital
admission
G9202
Patients with a positive hepatitis c antibody test
G9203
Rna testing for hepatitis c documented as performed within 12 months prior to initiation of
antiviral treatment for hepatitis c
G9204
Rna testing for hepatitis c was not documented as performed within 12 months prior to initiation
of antiviral treatment for hepatitis c, reason not given
G9205
Patient starting antiviral treatment for hepatitis c during the measurement period
G9206
Patient starting antiviral treatment for hepatitis c during the measurement period
G9207
Hepatitis c genotype testing documented as performed within 12 months prior to initiation of
antiviral treatment for hepatitis c
G9208
Hepatitis c genotype testing was not documented as performed within 12 months prior to
initiation of antiviral treatment for hepatitis c, reason not given
G9209
Hepatitis c quantitative RNA testing documented as performed between 4-12 weeks after the
initiation of antiviral treatment
G9210
Hepatitis c quantitative RNA testing not performed between 4-12 weeks after the initiation of
antiviral treatment for reasons documented by clinician (e.g., patients whose treatment was
discontinued during the testing period prior to testing, other medical reasons, patient declined,
other patient reasons)
G9211
Hepatitis c quantitative RNA testing was not documented as performed between 4-12 weeks
after the initiation of antiviral treatment, reason not given
G9212
Dsm-ivtm criteria for major depressive disorder documented at the initial evaluation
G9213
Dsm-iv-tr criteria for major depressive disorder not documented at the initial evaluation, reason
not otherwise specified
G9214
Cd4+ cell count or cd4+ cell percentage results documented
G9215
Cd4+ cell count or percentage not documented as performed, reason not given
G9216
Pcp prophylaxis was not prescribed at time of diagnosis of hiv, reason not given
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
6
01/14
HCPCS
Code
Description
G9217
Pcp prophylaxis was not prescribed within 3 months of low cd4+ cell count below 200 cells/
mm3, reason not given
G9218
Pcp prophylaxis was not prescribed within 3 months of flow cd4+ cell count below 500 cells/
mm3 or a cd4 percentage below 15%, reason not given
G9219
Pneumocystis jiroveci pneumonia prophylaxis not prescribed within 3 months of low cd4+ cell
count below 200 cells/mm3 for medical reason (i.e., patient’s cd4+ cell count above threshold
within 3 months after cd4+ cell count below threshold, indicating that the patient’s cd4+ levels
are within an acceptable range and the patient does not require pcp prophylaxis)
G9220
Pneumocystis jiroveci pneumonia prophylaxis not prescribed within 3 months of low cd4+ cell
count below 500 cells/mm3 or a cd4 percentage below 15% for medical reason (i.e., patient’s
cd4+ cell count above threshold within 3 months after cd4+ cell count below threshold,
indicating that the patient’s cd4+ levels are within an acceptable range and the patient does not
require pcp prophylaxis)
G9221
Pneumocystis jiroveci pneumonia prophlaxis prescribed
G9222
Pneumocystis jiroveci pneumonia prophylaxis prescribed within 3 months of low cd4+ cell
count below 200 cells/mm3
G9223
Pneumocystis jiroveci pneumonia prophylaxis prescribed within 3 months of low cd4+ cell
count below 500 cells/mm3 or a cd4 percentage below 15%
G9224
Documentation of medical reason for not performing foot exam (e.g., patient with bilateral foot/
leg amputation)
G9225
Foot exam was not performed, reason not given
G9226
Foot examination performed (includes examination through visual inspection, sensory exam
with monofilament, and pulse exam - report when all of the 3 components are completed)
G9227
Functional outcome assessment documented, care plan not documented, documentation the
patient is not eligible for a care plan
G9228
Chlamydia, gonorrhea and syphilis screening results documented (report when results are
present for all of the 3 screenings)
G9229
Chlamydia, gonorrhea, and syphilis not screened, due to documented reason (patient refusal is
the only allowed exclusion)
G9230
Chlamydia, gonorrhea, and syphilis not screened, reason not given
G9231
Documentation of end stage renal disease (esrd), dialysis, renal transplant or pregnancy
G9232
Clinician treating major depressive disorder did not communicate to clinician treating comorbid
condition for specified patient reason
G9233
All quality actions for the applicable measures in the total knee replacement measures group
have been performed for this patient
G9234
I intend to report the total knee replacement measures group
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
7
01/14
HCPCS
Code
Description
G9235
All quality actions for the applicable measures in the general surgery measures group have been
performed for this patient
G9236
All quality actions for the applicable measures in the optimizing patient exposure to ionizing
radiation measures group have been performed for this patient
G9237
I intend to report the general surgery measures group
G9238
I intend to report the optimizing patient exposure to ionizing radiation measures group
G9239
Documentation of reasons for patient initiating maintenance hemodialysis with a catheter as the
mode of vascular access (e.g., patient has a maturing avf/avg, time-limited trial of hemodialysis,
patients undergoing palliative dialysis, other medical reasons, patient declined avf/avg, other
patient reasons, patient followed by reporting nephrologist for fewer than 90 days, other system
reasons)
G9240
Patient whose mode of vascular access is a catheter at the time maintenance hemodialysis is
initiated
G9241
Patient whose mode of vascular access is not a catheter at the time maintenance hemodialysis is
initiated
G9242
Documentation of viral load equal to or greater than 200 copies/ml
G9243
Documentation of viral load less than 200 copies/ml
G9244
Antiretroviral therapy not prescribed
G9245
Antiretroviral therapy prescribed
G9246
Patient did not have at least one medical visit in each 6 month period of the 24 month
measurement period, with a minimum of 60 days between medical visits
G9247
Patient had at least one medical visit in each 6 month period of the 24 month measurement
period, with a minimum of 60 days between medical visits
G9248
Patient did not have a medical visit in the last 6 months
G9249
Patient had a medical visit in the last 6 months
G9250
Documentation of patient pain brought to a comfortable level within 48 hours from initial
assessment
G9251
Documentation of patient with pain not brought to a comfortable level within 48 hours from
initial assessment
G9252
Adenoma(s) or other neoplasm detected during screening colonoscopy
G9253
Adenoma(s) or other neoplasm not detected during screening colonoscopy
G9254
Documentation of patient discharged to home later than post-operative day 2 following CAS
G9255
Documentation of patient discharged to home no later than post operative day 2 following CAS
G9256
Documentation of patient death following CAS
G9257
Documentation of patient stroke following CAS
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
8
01/14
HCPCS
Code
Description
G9258
Documentation of patient stroke following CEA
G9259
Documentation of patient survival and absence of stroke following CAS
G9260
Documentation of patient death following CEA
G9261
Documentation of patient survival and absence of stroke following CEA
G9262
Documentation of patient death in the hospital following endovascular AAA repair
G9263
Documentation of patient survival in the hospital following endovascular AAA repair
G9264
Documentation of patient receiving maintenance hemodialysis for greater than or equal to 90
days with a catheter for documented reasons (e.g., patient is undergoing palliative dialysis with
a catheter, patient approved by a qualified transplant program and scheduled to receive a living
donor kidney transplant, other medical reasons, patient declined avf/avg, other patient reasons)
G9265
Patient receiving maintenance hemodialysis for greater than or equal to 90 days with a catheter
as the mode of vascular access
G9266
Patient receiving maintenance hemodialysis for greater than or equal to 90 days without a
catheter as the mode of vascular access
G9267
Documentation of patient with one or more complications or mortality within 30 days
G9268
Documentation of patient with one or more complications within 90 days
G9269
Documentation of patient without one or more complications and without mortality within 30
days
G9270
Documentation of patient without one or more complications within 90 days
G9271
LDL value < 100
G9272
LDL value >= 100
G9273
Blood pressure has a systolic value of < 140 and a diastolic value of < 90
G9274
Blood pressure has a systolic value of =140 and a diastolic value of = 90 or systolic value < 140
and diastolic value = 90 or systolic value = 140 and diastolic value < 90
G9275
Documentation that patient is a current non-tobacco user
G9276
Documentation that patient is a current tobacco user
G9277
Documentation that the patient is on daily aspirin or has documentation of a valid
contraindication to aspirin automatic contraindications include anti-coagulant use, allergy,
and history of gastrointestinal bleed; additionally, any reason documented by the physician
as a reason for not taking daily aspirin is acceptable (examples include non-steroidal antiinflammatory agents, risk for drug interaction, or uncontrolled hypertension defined as > 180
systolic or > 110 diastolic)
G9278
Documentation that the patient is not on daily aspirin regimen
G9279
Pneumococcal screening performed and documentation of vaccination received prior to
discharge
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
9
01/14
HCPCS
Code
Description
G9280
Pneumococcal vaccination not administered prior to discharge, reason not specified
G9281
Screening performed and documentation that vaccination not indicated/patient refusal
G9282
Documentation of medical reason(s) for not reporting the histological type or nsclc-nos
classification with an explanation (e.g., biopsy taken for other purposes in a patient with a
history of non-small cell lung cancer or other documented medical reasons)
G9283
Non small cell lung cancer biopsy and cytology specimen report documents classification into
specific histologic type or classified as nsclc-nos with an explanation
G9284
Non small cell lung cancer biopsy and cytology specimen report does not document
classification into specific histologic type or classified as nsclc-nos with an explanation
G9285
Specimen site other than anatomic location of lung or is not classified as non small cell lung
cancer
G9286
Documentation of antibiotic regimen prescribed within 7 days of diagnosis or within 10 days
after onset of symptoms
G9287
No antibiotic regimen prescribed within 7 days of diagnosis or within 10 days after onset of
symptoms
G9288
Documentation of medical reason(s) for not reporting the histological type or nsclc-nos
classification with an explanation (e.g., a solitary fibrous tumor in a person with a history of
non-small cell carcinoma or other documented medical reasons )
G9289
Non small cell lung cancer biopsy and cytology specimen report documents classification into
specific histologic type or classified as nsclc-nos with an explanation
G9290
Non small cell lung cancer biopsy and cytology specimen report does not document
classification into specific histologic type or classified as nsclc-nos with an explanation
G9291
Specimen site other than anatomic location of lung, is not classified as non small cell lung
cancer or classified as nsclc-nos
G9292
Documentation of medical reason(s) for not reporting pt category and a statement on thickness
and ulceration and for pt1, mitotic rate (e.g., negative skin biopsies in a patient with a history of
melanoma or other documented medical reasons)
G9293
Pathology report does not include the pt category and a statement on thickness and ulceration
and for pt1, mitotic rate
G9294
Pathology report includes the pt category and a statement on thickness and ulceration and for
pt1, mitotic rate
G9295
Specimen site other than anatomic cutaneous location
G9296
Patients with documented shared decision-making including discussion of conservative (nonsurgical) therapy prior to the procedure
G9297
Shared decision-making including discussion of conservative (non-surgical) therapy prior to the
procedure not documented, reason not given
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
10
01/14
HCPCS
Code
Description
G9298
Patients who are evaluated for venous thromboembolic and cardiovascular risk factors within
30 days prior to the procedure including history of dvt, pe, mi, arrhythmia and stroke
G9299
Patients who are not evaluated for venous thromboembolic and cardiovascular risk factors
within 30 days prior to the procedure including history of dvt, pe, mi, arrhythmia and stroke,
reason not given
G9300
Documentation of medical reason(s) for not completely infusing the prophylactic antibiotic
prior to the inflation of the proximal tourniquet (e.g., a tourniquet was not used)
G9301
Patients who had the prophylactic antibiotic completely infused prior to the inflation of the
proximal tourniquet
G9302
Prophylactic antibiotic not completely infused prior to the inflation of the proximal tourniquet,
reason not given
G9303
Operative report does not identify the prosthetic implant specifications including the prosthetic
implant manufacturer, the brand name of the prosthetic implant and the size of the prosthetic
implant, reason not given
G9304
Operative report identifies the prosthetic implant specifications including the prosthetic implant
manufacturer, the brand name of the prosthetic implant and the size of the prosthetic implant
G9305
Intervention for presence of leak of endoluminal contents through an anastomosis not required
G9306
Intervention for presence of leak of endoluminal contents through an anastomosis required
G9307
No return to the operating room for a surgical procedure, for any reason, within 30 days of the
principal operative procedure
G9308
Unplanned return to the operating room for a surgical procedure, for any reason, within 30 days
of the principal operative procedure
G9309
No unplanned hospital readmission within 30 days of principal procedure
G9310
Unplanned hospital readmission within 30 days of principal procedure
G9311
No surgical site infection
G9312
Surgical site infection
G9313
Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time
of diagnosis for documented reason (e.g., cystic fibrosis, immotile cilia disorders, ciliary
dyskinesia, immune deficiency, prior history of sinus surgery within the past 12 months,
and anatomic abnormalities, such as deviated nasal septum, resistant organisms, allergy to
medication, recurrent sinusitis, chronic sinusitis, or other reasons)
G9314
Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of
diagnosis, reason not given
G9315
Documentation amoxicillin, with or without clavulanate, prescribed as a first line antibiotic at
the time of diagnosis
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
11
01/14
HCPCS
Code
Description
G9316
Documentation of patient-specific risk assessment with a risk calculator based on multiinstitutional clinical data, the specific risk calculator used, and communication of risk
assessment from risk calculator with the patient or family
G9317
Documentation of patient-specific risk assessment with a risk calculator based on multiinstitutional clinical data, the specific risk calculator used, and communication of risk
assessment from risk calculator with the patient or family not completed
G9318
Imaging study named according to standardized nomenclature
G9319
Imaging study not named according to standardized nomenclature, reason not given
G9320
Documentation of medical reason(s) for not naming CT studies according to a standardized
nomenclature provided (e.g., CT studies performed for radiation treatment planning or imageguided radiation treatment delivery)
G9321
Count of previous CT (any type of ct) and cardiac nuclear medicine (myocardial perfusion)
studies documented in the 12-month period prior to the current study
G9322
Count of previous CT and cardiac nuclear medicine (myocardial perfusion) studies not
documented in the 12-month period prior to the current study, reason not given
G9323
Documentation of medical reason(s) for not counting previous CT and cardiac nuclear medicine
(myocardial perfusion) studies (e.g., CT studies performed for radiation treatment planning or
image-guided radiation treatment delivery)
G9324
All necessary data elements not included, reason not given
G9325
Ct studies not reported to a radiation dose index registry due to medical reasons (e.g., CT
studies performed for radiation treatment planning or image-guided radiation treatment
delivery)
G9326
Ct studies performed not reported to a radiation dose index registry, reason not given
G9327
Ct studies performed reported to a radiation dose index registry with all necessary data elements
G9328
Dicom format image data availability not documented in final report due to medical reasons
(e.g., CT studies performed for radiation treatment planning or image-guided radiation
treatment delivery)
G9329
Dicom format image data available to non-affiliated external entities on a secure, media free,
reciprocally searchable basis with patient authorization for at least a 12-month period after the
study not documented in final report, reason not given
G9340
Final report documented that dicom format image data available to non-affiliated external
entities on a secure, media free, reciprocally searchable basis with patient authorization for at
least a 12-month period after the study
G9341
Search conducted for prior patient CT imaging studies completed at non-affiliated external
entities within the past 12-months and are available through a secure, authorized, media-free,
shared archive prior to an imaging study being performed
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
12
01/14
HCPCS
Code
Description
G9342
Search conducted for prior patient imaging studies completed at non-affiliated external entities
within the past 12-months and are available through a secure, authorized, media-free, shared
archive prior to an imaging study being performed not completed, reason not given
G9343
Search for prior patient completed dicom format images not completed due to medical reasons
(e.g., CT studies performed for radiation treatment planning or image-guided radiation
treatment delivery)
G9344
Search for prior patient completed dicom format images not completed due to system reasons
(i.e., facility does not have archival abilities through a shared archival system)
G9345
Follow-up recommendations according to recommended guidelines for incidentally detected
pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed)
based at a minimum on nodule size and patient risk factors documented
G9346
Follow-up recommendations according to recommended guidelines for incidentally detected
pulmonary nodules not documented due to medical reasons (e.g., patients with known
malignant disease, patients with unexplained fever, CT studied performed for radiation
treatment planning or image-guided radiation treatment delivery)
G9347
Follow-up recommendations according to recommended guidelines for incidentally detected
pulmonary nodules not documented, reason not given
G9348
Ct scan of the paranasal sinuses ordered at the time of diagnosis for documented reasons
(e.g., persons with sinusitis symptoms lasting at least 7 to 10 days, antibiotic resistance,
immunocompromised, recurrent sinusitis, acute frontal sinusitis, acute sphenoid sinusitis,
periorbital cellulitis, or other medical)
G9349
Documentation of a CT scan of the paranasal sinuses ordered at the time of diagnosis or
received within 28 days after date of diagnosis
G9350
Ct scan of the paranasal sinuses not ordered at the time of diagnosis or received within 28 days
after date of diagnosis
G9351
More than one CT scan of the paranasal sinuses ordered or received within 90 days after
diagnosis
G9352
More than one CT scan of the paranasal sinuses ordered or received within 90 days after the
date of diagnosis, reason not given
G9353
More than one CT scan of the paranasal sinuses ordered or received within 90 days after
the date of diagnosis for documented reasons (e.g., patients with complications, second CT
obtained prior to surgery, other medical reasons)
G9354
More than one CT scan of the paranasal sinuses not ordered within 90 days after the date of
diagnosis
G9355
Elective delivery or early induction not performed
G9356
Elective delivery or early induction performed
G9357
Post-partum screenings, evaluations and education performed
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
13
01/14
HCPCS
Code
Description
G9358
Post-partum screenings, evaluations and education not performed
G9359
Documentation of negative or managed positive TB screen with further evidence that TB is not
active
G9360
No documentation of negative or managed positive TB screen
J0151
Injection, adenosine for diagnostic use, 1 mg (not to be used to report any adenosine phosphate
compounds, instead use a9270)
J0401
Injection, aripiprazole, extended release, 1 mg
J0717
Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug administered
under the direct supervision of a physician, not for use when drug is self administered)
J1442
Injection, filgrastim (g-csf), 1 microgram
J1446
Injection, tbo-filgrastim, 5 micrograms
J1556
Injection, immune globulin (bivigam), 500 mg
J1602
Injection, golimumab, 1 mg, for intravenous use
J3060
Injection, taliglucerace alfa, 10 units
J3489
Injection, zoledronic acid, 1 mg
J7301
Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg
J7316
Injection, ocriplasmin, 0.125 mg
J7508
Tacrolimus, extended release, oral, 0.1 mg
J9047
Injection, carfilzomib, 1 mg
J9262
Injection, omacetaxine mepesuccinate, 0.01 mg
J9306
Injection, pertuzumab, 1 mg
J9354
Injection, ado-trastuzumab emtansine, 1 mg
J9371
Injection, vincristine sulfate liposome, 1 mg
J9400
Injection, ziv-aflibercept, 1 mg
K0008
Custom manual wheelchair/base
K0013
Custom motorized/power wheelchair base
K0900
Customized durable medical equipment, other than wheelchair
L0455
TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above t-9
vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to
reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and
closures, prefabricated, off-the-shelf
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
14
01/14
HCPCS
Code
Description
L0457
TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior
apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular
spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to
reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf
L0467
TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps,
closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary
pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf
L0469
TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps,
closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength
provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal
and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks,
prefabricated, off-the-shelf
L0641
Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from l-1 to
below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs,
includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen
design, prefabricated, off-the-shelf
L0642
Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends
from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the
intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous
abdomen design, prefabricated, off-the-shelf
L0643
Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from
sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the
intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps,
pendulous abdomen design, prefabricated, off-the-shelf
L0648
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, closures, may include padding, shoulder straps,
pendulous abdomen design, prefabricated, off-the-shelf
L0649
Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior
extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral
frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes
straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design,
prefabricated, off-the-shelf
L0650
Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/
panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength
provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on
intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous
abdomen design, prefabricated, off-the-shelf
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
15
01/14
HCPCS
Code
Description
L0651
Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from
sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid,
produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is
provided by overlapping rigid material and stabilizing closures, includes straps, closures, may
include soft interface, pendulous abdomen design, prefabricated, off-the-shelf
L1812
Knee orthosis, elastic with joints, prefabricated, off-the-shelf
L1833
Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid
support, prefabricated, off-the shelf
L1848
Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s),
prefabricated, off-the-shelf
L3678
Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps,
prefabricated, off-the-shelf
L3809
Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type
L3916
Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may
include soft interface, straps, prefabricated, off-the-shelf
L3918
Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf
L3924
Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-theshelf
L3930
Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/
springs, may include soft interface material, straps, prefabricated, off-the-shelf
L4361
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface
material, prefabricated, off-the-shelf
L4387
Walking boot, non-pneumatic, with or without joints, with or without interface material,
prefabricated, off-the-shelf
L4397
Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for
positioning, may be used for minimal ambulation, prefabricated, off-the-shelf
L5969
Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s)
L8679
Implantable neurostimulator, pulse generator, any type
Q0161
Chlorpromazine hydrochloride, 5 mg, oral, fda approved prescription anti-emetic, for use as a
complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not
to exceed a 48 hour dosage regimen
Q0507
Miscellaneous supply or accessory for use with an external ventricular assist device
Q0508
Miscellaneous supply or accessory for use with an implanted ventricular assist device
Q0509
Miscellaneous supply or accessory for use with any implanted ventricular assist device for
which payment was not made under Medicare part a
Q2028
Injection, sculptra, 0.5 mg
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
16
01/14
HCPCS
Code
Description
Q2050
Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10mg
Q2052
Services, supplies and accessories used in the home under the Medicare intravenous immune
globulin (ivig) demonstration
Q3027
Injection, interferon beta-1a, 1 mcg for intramuscular use
Q3028
Injection, interferon beta-1a, 1 mcg for subcutaneous use
Q4137
Amnioexcel or biodexcel, per square centimeter
Q4138
Biodfence dryflex, per square centimeter
Q4139
Amniomatrix or biodmatrix, injectable, 1 cc
Q4140
Biodfence, per square centimeter
Q4141
Alloskin ac, per square centimeter
Q4142
Xcm biologic tissue matrix, per square centimeter
Q4143
Repriza, per square centimeter
Q4145
Epifix, injectable, 1 mg
Q4146
Tensix, per square centimeter
Q4147
Architect extracellular matrix, per square centimeter
Q4148
Neox 1k, per square centimeter
Q4149
Excellagen, 0.1 cc
S9960
Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)
S9961
Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)
T4544
Adult sized disposable incontinence product, protective underwear/pull-on, above extra-large,
each
CDT Code
Description
D0393
Treatment simulation using 3d image volume
D0394
Digital subtraction of two or more images or image volumes of the same modality
D0395
Fusion of two or more 3d image volumes of one or more modalities
D0601
Caries risk assessment and documentation, with a finding of low risk
D0602
Caries risk assessment and documentation, with a finding of moderate risk
D0603
Caries risk assessment and documentation, with a finding of high risk
D1999
Unspecified preventive procedure, by report
D2921
Reattachment of tooth fragment, incisal edge or cusp
D2941
Interim therapeutic restoration - primary dentition
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
17
01/14
CDT Code
Description
D2949
Restorative foundation for an indirect restoration
D3355
Pulpal regeneration - initial visit
D3356
Pulpal regeneration - interim medication replacement
D3357
Pulpal regeneration - completion of treatment
D3427
Periradicular surgery without apicoectomy
D3428
Bone graft in conjunction with periradicular surgery - per tooth, single site
D3429
Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the
same surgical site
D3431
Biologic materials to aid in soft and osseous tissue regeneration in conjunction with
periradicular surgery
D3432
Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery
D4921
Gingival irrigation - per quadrant
D5863
Overdenture - complete maxillary
D5864
Overdenture - partial maxillary
D5865
Overdenture - complete mandibular
D5866
Overdenture - partial mandibular
D5994
Peridontal medicament carrier with peripheral seal - laboratory processed
D6011
Second stage implant surgery
D6013
Surgical placement of mini implant
D6052
Semi-precision attachment abutment
D8694
Repair of fixed retainers, includes reattachment
D9985
Sales tax
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
18
01/14
CPT Code
CPT Code
CPT Code
CPT Code
10030
37241
64617
97610
19081
37242
64642
99446
19082
37243
64643
99447
19083
37244
64644
99448
19084
43191
64645
99449
19085
43192
64646
99481
19086
43193
64647
99482
19281
43194
66183
9001F
19282
43195
77293
9002F
19283
43196
80155
9003F
19284
43197
80159
9004F
19285
43198
80169
9005F
19286
43211
80171
9006F
19287
43212
80175
9007F
19288
43213
80177
0329T
23333
43214
80180
0330T
23334
43229
80183
0031T
23335
43233
80199
0332T
33366
43253
80203
0333T
34841
43254
81287
0334T
34842
43266
81504
0335T
34843
43270
81507
0336T
34844
43274
87661
0337T
34845
43275
88343
0338T
34846
43276
90673
0339T
34847
43277
92521
0340T
34848
43278
92522
0341T
37217
49405
92523
0342T
37236
49406
92524
0343T
37237
49407
93582
0344T
37238
53256
93583
0345T
37239
64616
94669
0346T
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
19
01/14
2014 HCPCS, CDT, CPT Code Changes
HCPCS Description
Code
A5081
Stoma plug or seal, any type
A9272
Wound suction, disposable, includes dressing, all accessories and components, any type,
each
C2618
Probe/needle, cryoablation
C9734
Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with
magnetic resonance (mr) guidance
E0601
Continuous positive airway pressure (CPAP) device
E2300
Wheelchair accessory, power seat elevation system, any type
E2301
Wheelchair accessory, power standing system, any type
G0416
Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any
method, 10-20 specimens
G0417
Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any
method, 21-40 specimens
G0418
Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any
method, 41-60 specimens
G0419
Surgical pathology, gross and microscopic examination, for prostate needle biopsy, any
method, >60 specimens
G8126
Patient with a diagnosis of major depression documented as being treated with
antidepressant medication during the entire 84 day (12 week) acute treatment phase
G8127
Patient with a diagnosis of major depression not documented as being treated with
antidepressant medication during the entire 84 day (12 week) acute treatment phase
G8417
BMI is documented above normal parameters and a follow-up plan is documented
G8418
BMI is documented below normal parameters and a follow-up plan is documented
G8419
BMI documented outside normal parameters, no follow-up plan documented, no reason
given
G8420
BMI is documented within normal parameters and no follow-up plan is required
G8421
BMI not documented and no reason is given
G8422
BMI not documented, documentation the patient is not eligible for BMI calculation
G8427
Eligible professional attests to documenting in the medical record they obtained, updated,
or reviewed the patient’s current medications
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
20
01/14
HCPCS Description
Code
G8428
Current list of medications not documented as obtained, updated, or reviewed by the
eligible professional, reason not given
G8430
Eligible professional attests to documenting in the medical record the patient is not eligible
for a current list of medications being obtained, updated, or reviewed by the eligible
professional
G8431
Screening for clinical depression is documented as being positive and a follow-up plan is
documented
G8433
Screening for clinical depression not documented, documentation stating the patient is not
eligible
G8442
Pain assessment not documented as being performed, documentation the patient is not
eligible for a pain assessment using a standardized tool
G8451
Beta-blocker therapy for LVEF < 40% not prescribed for reasons documented by the
clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with
an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient
declined, other patient reasons, or other reasons attributable to the healthcare system)
G8509
Pain assessment documented as positive using a standardized tool, follow-up plan not
documented, reason not given
G8510
Screening for clinical depression is documented as negative, a follow-up plan is not
required
G8511
Screening for clinical depression documented as positive, follow up plan not documented,
reason not given
G8535
Elder maltreatment screen not documented; documentation that patient not eligible for the
elder maltreatment screen
G8539
Functional outcome assessment documented as positive using a standardized tool and a
care plan based on identified deficiencies on the date of functional outcome assessment, is
documented
G8540
Functional outcome assessment not documented as being performed, documentation the
patient is not eligible for a functional outcome assessment using a standardized tool
G8542
Functional outcome assessment using a standardized tool is documented; no functional
deficiencies identified, care plan not required
G8543
Documentation of a positive functional outcome assessment using a standardized tool; care
plan not documented, reason not given
G8569
Prolonged postoperative intubation (> 24 hrs) required
G8570
Prolonged postoperative intubation (> 24 hrs) not required
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
21
01/14
HCPCS Description
Code
G8682
LVF testing documented as being performed prior to discharge or in the previous 12
months
G8683
LVF testing not performed prior to discharge or in the previous 12 months for a medical or
patient documented reason
G8685
LVF testing not documented as being performed prior to discharge or in the previous 12
months, reason not given
G8709
Patient prescribed or dispensed antibiotic for documented medical reason(s) (e.g. intestinal
infection, pertussis, bacterial infection, lyme disease, otitis media, acute sinusitis, acute
pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/
adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis,
impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease
(syphilis, chlamydia, inflammatory diseases (female reproductive organs)), infections of
the kidney, cystitis or uti, and acne)
G8722
Documentation of medical reason(s) for not including the pt category, the pn category or
the histologic grade in the pathology report (e.g., re-excision without residual tumor; noncarcinomasanal canal)
G8730
Pain assessment documented as positive using a standardized tool and a follow-up plan is
documented
G8731
Pain assessment using a standardized tool is documented as negative, no follow-up plan
required
G8733
Elder maltreatment screen documented as positive and a follow-up plan is documented
G8768
Documentation of medical reason(s) for not performing lipid profile (e.g., patients with
palliative goals or for whom treatment of hypertension with standard treatment goals is not
clinically appropriate)
G8772
Documentation of medical reason(s) for not performing urine protein test (e.g., patients
with palliative goals or for whom treatment of hypertension with standard treatment goals
is not clinically appropriate)
G8775
Documentation of medical reason(s) for not performing serum creatinine test (e.g., patients
with palliative goals or for whom treatment of hypertension with standard treatment goals
is not clinically appropriate)
G8778
Documentation of medical reason(s) for not performing diabetes screening test (e.g.,
patients with a diagnosis of diabetes, or with palliative goals or for whom treatment of
hypertension with standard treatment goals is not clinically appropriate)
G8781
Documentation of medical reason(s) for patient not receiving counseling for diet and
physical activity (e.g., patients with palliative goals or for whom treatment of hypertension
with standard treatment goals is not clinically appropriate)
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
22
01/14
HCPCS Description
Code
G8784
Blood pressure reading not documented, documentation the patient is not eligible
G8808
Performance of trans-abdominal or trans-vaginal ultrasound not ordered, reason not given
(e.g., patient has visited the ed multiple times with no documentation of a trans-abdominal
or trans-vaginal ultrasound within ed or from referring eligible professional)
G8810
Rh-immunoglobulin (rhogam) not ordered for reasons documented by clinician (e.g.,
patient had prior documented receipt of rhogam within 12 weeks, patient refusal)
G8880
Documentation of reason(s) sentinel lymph node biopsy not performed (e.g., reasons could
include but not limited to; non-invasive cancer, incidental discovery of breast cancer on
prophylactic mastectomy, incidental discovery of breast cancer on reduction mammoplasty,
pre-operative biopsy proven lymph node (ln) metastases, inflammatory carcinoma, stage
3 locally advanced cancer, recurrent invasive breast cancer, patient refusal after informed
consent)
G8882
Sentinel lymph node biopsy procedure not performed, reason not given
G8887
Documentation of medical reason(s) for most recent blood pressure not being under control
(e.g., patients with palliative goals or for whom treatment of hypertension with standard
treatment goals is not clinically appropriate)
G8891
Documentation of medical reason(s) for most recent LDL-C not under control (e.g.,
patients with palliative goals for whom treatment of hypertension with standard treatment
goals is not clinically appropriate)
G8892
Documentation of medical reason(s) for not performing LDL-C test (e.g. patients with
palliative goals or for whom treatment of hypertension with standard treatment goals is not
clinically appropriate)
G8928
Adjuvant chemotherapy not prescribed or previously received for documented reasons
(e.g., medical co-morbidities, diagnosis date more than 5 years prior to the current visit
date, patient’s cancer has metastasized, medical contraindication/allergy, poor performance
status, other medical reasons, patient refusal, other patient reasons, patient is currently
enrolled in a clinical trial that precludes prescription of chemotherapy, other system
reasons)
G8929
Adjuvant chemotherapy not prescribed or previously received, reason not specified
G8938
BMI is documented as being outside of normal limits, follow-up plan is not documented,
documentation the patient is not eligible
G8939
Pain assessment documented as positive, follow-up plan not documented, documentation
the patient is not eligible
G8940
Screening for clinical depression documented as positive, a follow-up plan not
documented, documentation stating the patient is not eligible
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
23
01/14
HCPCS Description
Code
G8941
Elder maltreatment screen documented as positive, follow-up plan not documented,
documentation the patient is not eligible
G8942
Functional outcomes assessment using a standardized tool is documented within the
previous 30 days and care plan, based on identified deficiencies on the date of the
functional outcome assessment, is documented
G8946
Minimally invasive biopsy method attempted but not diagnostic of breast cancer (e.g., high
risk lesion of breast such as atypical ductal hyperplasia, lobular neoplasia, atypical lobular
hyperplasia, lobular carcinoma in situ, atypical columnar hyperplasica, flat epithelial
atypia, radial scar, complex sclerosing lesion, papillary lesion, or any lesion with spindle
cells)
G8950
Pre-hypertensive or hypertensive blood pressure reading documented, and the indicated
follow-up is documented
G8951
Pre-hypertensive or hypertensive blood pressure reading documented, indicated follow-up
not documented, documentation the patient is not eligible
G8968
Documentation of medical reason(s) for not prescribing warfarin or another oral
anticoagulant that is FDA approved for the prevention of thromboembolism (e.g. patients
with mitral stenosis or prosthetic heart valves, patients with transient or reversible causes
of AF (e.g., pneumonia or hyperthyroidism), postoperative patients, patients who are
pregnant, allergy, risk of bleeding, other medical reasons)
G8969
Documentation of patient reason(s) for not prescribing warfarin or another oral
anticoagulant that is FDA approved (e.g., economic, social, and/or religious impediments,
noncompliance patient refusal, other patient reasons)
G8985
Carrying, moving and handling objects, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
G8990
Other physical or occupational therapy primary functional limitation, current status, at
therapy episode outset and at reporting intervals
G8991
Other physical or occupational therapy primary functional limitation, projected goal status,
at therapy episode outset, at reporting intervals, and at discharge or to end reporting
G8992
Other physical or occupational therapy primary functional limitation, discharge status, at
discharge from therapy or to end reporting
G8993
Other physical or occupational therapy subsequent functional limitation, current status, at
therapy episode outset and at reporting intervals
G8994
Other physical or occupational therapy subsequent functional limitation, projected goal
status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
24
01/14
HCPCS Description
Code
G8995
Other physical or occupational therapy subsequent functional limitation, discharge status,
at discharge from therapy or to end reporting
G8996
Swallowing functional limitation, current status at therapy episode outset and at reporting
intervals
G8997
Swallowing functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
G8998
Swallowing functional limitation, discharge status, at discharge from therapy or to end
reporting
G8999
Motor speech functional limitation, current status at therapy episode outset and at reporting
intervals
G9158
Motor speech functional limitation, discharge status, at discharge from therapy or to end
reporting
G9159
Spoken language comprehension functional limitation, current status at therapy episode
outset and at reporting intervals
G9160
Spoken language comprehension functional limitation, projected goal status at therapy
episode outset, at reporting intervals, and at discharge from or to end reporting
G9161
Spoken language comprehension functional limitation, discharge status, at discharge from
therapy or to end reporting
G9162
Spoken language expression functional limitation, current status at therapy episode outset
and at reporting intervals
G9163
Spoken language expression functional limitation, projected goal status at therapy episode
outset, at reporting intervals, and at discharge from or to end reporting
G9164
Spoken language expression functional limitation, discharge status at discharge from
therapy or to end reporting
G9165
Attention functional limitation, current status at therapy episode outset and at reporting
intervals
G9166
Attention functional limitation, projected goal status at therapy episode outset, at reporting
intervals, and at discharge from or to end reporting
G9167
Attention functional limitation, discharge status at discharge from therapy or to end
reporting
G9168
Memory functional limitation, current status at therapy episode outset and at reporting
intervals
G9169
Memory functional limitation, projected goal status at therapy episode outset, at reporting
intervals, and at discharge from or to end reporting
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
25
01/14
HCPCS Description
Code
G9170
Memory functional limitation, discharge status at discharge from therapy or to end
reporting
G9171
Voice functional limitation, current status at therapy episode outset and at reporting
intervals
G9172
Voice functional limitation, projected goal status at therapy episode outset, at reporting
intervals, and at discharge from or to end reporting
G9173
Voice functional limitation, discharge status at discharge from therapy or to end reporting
G9174
Other speech language pathology functional limitation, current status at therapy episode
outset and at reporting intervals
G9175
Other speech language pathology functional limitation, projected goal status at therapy
episode outset, at reporting intervals, and at discharge from or to end reporting
G9176
Other speech language pathology functional limitation, discharge status at discharge from
therapy or to end reporting
G9186
Motor speech functional limitation, projected goal status at therapy episode outset, at
reporting intervals, and at discharge from or to end reporting
J7507
Tacrolimus, immediate release, oral, 1 mg
L0120
Cervical, flexible, non-adjustable, prefabricated, off-the-shelf (foam collar)
L0160
Cervical, semi-rigid, wire frame occipital/mandibular support, prefabricated, off-the-shelf
L0172
Cervical, collar, semi-rigid thermoplastic foam, two-piece, prefabricated, off-the-shelf
L0174
Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension,
prefabricated, off-the-shelf
L0450
TLSA, flexible, provides trunk support, upper thoracic region, produces intracavitary
pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes
shoulder straps and closures, prefabricated, off-the-shelf
L0454
TLSA flexible, provides trunk support, extends from sacrococcygeal junction to above t-9
vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure
to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder
straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or
otherwise customized to fit a specific patient by an individual with expertise
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
26
01/14
HCPCS Description
Code
L0456
TLSA, flexible, provides trunk support, thoracic region, rigid posterior panel and soft
anterior apron, extends from the sacrococcygeal junction and terminates just inferior
to the scapular spine, restricts gross trunk motion in the sagittal plane, produces
intracavitary pressure to reduce load on the intervertebral disks, includes straps and
closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
L0460
TLSA, triplanar control, modular segmented spinal system, two rigid plastic shells,
posterior extends from the sacrococcygeal junction and terminates just inferior to the
scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft
liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral
strength is provided by overlapping plastic and stabilizing closures, includes straps and
closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
L0466
TLSA, sagittal control, rigid posterior frame and flexible soft anterior apron with straps,
closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary
pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed,
bent, molded, assembled, or otherwise customized to fit a specific patient by an individual
with expertise
L0468
TLSA, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron
with straps, closures and padding, extends from sacrococcygeal junction over scapulae,
lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk
motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on
intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or
otherwise customized to fit a specific patient by an individual with expertise
L0621
Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the
sacroiliac joint, includes straps, closures, may include pendulous abdomen design,
prefabricated, off-the-shelf
L0623
Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the
sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures,
may include pendulous abdomen design, prefabricated, off-the-shelf
L0625
Lumbar orthosis, flexible, provides lumbar support, posterior extends from l-1 to below
l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs,
includes straps, closures, may include pendulous abdomen design, shoulder straps, stays,
prefabricated, off-the-shelf
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
27
01/14
HCPCS Description
Code
L0626
Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from l-1
to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral
discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous
abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or
otherwise customized to fit a specific patient by an individual with expertise
L0627
Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior
extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on
the intervertebral discs, includes straps, closures, may include padding, shoulder straps,
pendulous abdomen design, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an individual with expertise
L0628
Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from
sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load
on the intervertebral discs, includes straps, closures, may include stays, shoulder straps,
pendulous abdomen design, prefabricated, off-the-shelf
L0630
Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends
from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load
on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder
straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an individual with expertise
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, closures, may include padding,
shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed,
bent, molded, assembled, or otherwise customized to fit a specific patient by an individual
with expertise
L0633
Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s),
posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by
rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral
discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous
abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or
otherwise customized to fit a specific patient by an individual with expertise
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
28
01/14
HCPCS Description
Code
L0637
Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/
panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength
provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load
on intervertebral discs, includes straps, closures, may include padding, shoulder straps,
pendulous abdomen design, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an individual with expertise
L0639
Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends
from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to
xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall
strength is provided by overlapping rigid material and stabilizing closures, includes straps,
closures, may include soft interface, pendulous abdomen design, prefabricated item that
has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific
patient by an individual with expertise
L0980
Peroneal straps, prefabricated, off-the-shelf, pair
L0982
Stocking supporter grips, prefabricated, off-the-shelf, set of four (4)
L0984
Protective body sock, prefabricated, off-the-shelf, each
L1600
Hip orthosis, abduction control of hip joints, flexible, frejka type with cover, prefabricated
item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a
specific patient by an individual with expertise
L1610
Hip orthosis, abduction control of hip joints, flexible, (frejka cover only), prefabricated
item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a
specific patient by an individual with expertise
L1620
Hip orthosis, abduction control of hip joints, flexible, (pavlik harness), prefabricated item
that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific
patient by an individual with expertise
L1810
Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an individual with expertise
L1830
Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf
L1832
Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid
support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
L1836
Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, offthe-shelf
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
29
01/14
HCPCS Description
Code
L1843
Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint
(unicentric or polycentric), medial-lateral and rotation control, with or without varus/
valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or
otherwise customized to fit a specific patient by an individual with expertise
L1845
Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint
(unicentric or polycentric), medial-lateral and rotation control, with or without varus/
valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or
otherwise customized to fit a specific patient by an individual with expertise
L1847
Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s),
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
L1850
Knee orthosis, Swedish type, prefabricated, off-the-shelf
L1902
Ankle foot orthosis, ankle gauntlet, prefabricated, off-the-shelf
L1904
Ankle orthosis, ankle gauntlet, custom-fabricated
L1906
Ankle foot orthosis, multiligamentus ankle support, prefabricated, off-the-shelf
L1907
Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom
fabricated
L3100
Hallus-valgus night dynamic splint, prefabricated, off-the-shelf
L3170
Foot, plastic, silicone or equal, heel stabilizer, prafabricated, off-the-shelf, each
L3650
Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
L3660
Shoulder orthosis, figure of eight design abduction restrainer, canvas and webbing,
prefabricated, off-the-shelf
L3670
Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-theshelf
L3675
Shoulder orthosis, vest type abduction restrainer, canvas webbing type or equal,
prefabricated, off-the-shelf
L3677
Shoulder orthosis, shoulder joint design, without joints, may include soft interface,
straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
L3710
Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf
L3762
Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-theshelf
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
30
01/14
HCPCS Description
Code
L3807
Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent,
molded, assembled, or otherwise customized to fit a specific patient by an individual with
expertise
L3908
Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-theshelf
L3912
Hand finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-theshelf
L3915
Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles,
may include soft interface, straps, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an individual with expertise
L3917
Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent,
molded, assembled, or otherwise customized to fit a specific patient by an individual with
expertise
L3923
Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item
that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific
patient by an individual with expertise
L3925
Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion
joint/spring, extension/flexion, may include soft interface material, prefabricated, off-theshelf
L3927
Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/
spring, extension/flexion (e.g. static or ring type), may include soft interface material,
prefabricated, off-the-shelf
L3929
Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/
springs, may include soft interface material, straps, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an
individual with expertise
L4350
Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic,
gel), prefabricated, off-the-shelf
L4360
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface
material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
L4370
Pneumatic full leg splint, prefabricated, off-the-shelf
L4386
Walking boot, non-pneumatic, with or without joints, with or without interface material,
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
31
01/14
HCPCS Description
Code
L4396
Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit,
for positioning, may be used for minimal ambulation, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an
individual with expertise
L4398
Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf
Q5001
Hospice or home health care provided in patient’s home/residence
Q5002
Hospice or home health care provided in assisted living facility
Q5009
Hospice or home health care provided in place not otherwise specified (NOS)
S3870
Comparative genomic hybridization (CGH) microarray testing for developmental delay,
autism spectrum disorder and/or intellectual disability
T4543
Adult sized disposable incontinence product, protective brief/diaper, above extra large,
each
CDT Code
Description
D0350
Oral/facial photographic images obtained intraorally or extraorally
D2950
Core build-up, including any pins when required
D3351
Apexification/recalcification - initial visit (apical closure/calcific repair of
perforations, root resorption, pulp space disinfection, etc.)
D3352
Apexification/recalcification - interim medication replacement (apical closure/
calcific repair of perforations, root resorption, pulp space disinfection, etc.)
D3410
Apicoectomy - anterior
D3421
Apicoectomy - bicuspid (first root)
D3425
Apicoectomy - molar (first root)
D3426
Apicoectomy (each additional root)
D4920
Unscheduled dressing change (by someone other than treating dentist or their staff)
D5991
Vesiculobullous disease medicament carrier
D6080
Implant maintenance procedures when prostheses are removed and reinserted,
including cleansing of prostheses and abutments
D8693
Rebonding or recementing of fixed retainers
D9210
Local anesthesia not in conjunction with operative or surgical procedures
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
32
01/14
CPT Code
CPT Code
CPT Code
CPT Code
21015
43205
43263
93654
21016
43206
43264
93656
21557
43215
43265
99170
21558
43216
43273
1040F
21935
43217
47552
3016F
21936
43220
65778
22904
43226
65779
22905
43227
69210
23077
43231
72040
23078
43232
77295
24077
43235
81371
24079
43236
81376
24160
43237
81382
24164
43238
81400
25077
43239
81401
25078
43240
81402
26117
43241
81403
26118
43242
81404
27049
43243
81405
27059
43244
81406
27329
43245
81407
27364
43246
81408
27615
43247
84112
27616
43248
87498
28046
43249
87521
28047
43250
87522
33222
43251
87535
33223
43252
87536
43200
43255
87538
43201
43257
87539
43202
43259
91065
43204
43260
93653
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
33
01/14
2014 HCPCS, CDT, CPT Code Deletes
HCPCS Code
Description
C1204
Technetium tc 99m tilmanocept, diagnostic, up to 0.5 millicuries
C1879
Tissue marker (implantable)
C9130
Injection, immune globulin (bivigam), 500 mg
C9131
Injection, ado-trastuzumab emtansine, 1 mg
C9292
Injection, pertuzumab, 10 mg
C9294
Injection, taliglucerase alfa, 10 units
C9295
Injection, carfilzomib, 1 mg
C9296
Injection, ziv-aflibercept, 1 mg
C9297
Injection, omacetaxine mepesuccinate, 0.01 mg
C9298
Injection, ocriplasmin, 0.125 mg
C9736
Laparoscopy, surgical, radiofrequency ablations of uterine fibroid(s), including intraoperative
guidance and monitoring, when performed
G0275
Renal angiography, non-selective, one or both kidneys, performed at the same time as cardiac
catheterization and/or coronary angiography, includes positioning or placement of any
catheter in the abdominal aorta at or near the origins (ostia) of the renal arteries, injection
of dye, flush aortogram, production of permanent images, and radiologic supervision and
interpretation (list separately in addition to primary procedure)
G8459
Clinician documented that patient is receiving antiviral treatment for hepatitis c
G8462
Clinician documented that patient is not an eligible candidate for counseling regarding
contraception prior to antiviral treatment; patient not receiving antiviral treatment for
hepatitis c
G8463
Patient receiving antiviral treatment for hepatitis c documented
G8553
Prescription(s) generated and transmitted via a qualified erx system
G8556
Referred to a physician (preferably a physician with training in disorders of the ear) for an
otologic evaluation
G8557
Patient is not eligible for the referral for otologic evaluation measure
G8558
Not referred to a physician (preferably a physician with training in disorders of the ear) for an
otologic evaluation, reason not given
G8588
Most recent systolic blood pressure < 140 mmhg
G8589
Most recent systolic blood pressure >= 140 mmhg
G8590
Most recent diastolic blood pressure < 90 mmhg
G8591
Most recent diastolic blood pressure >= 90 mmhg
G8592
No documentation of blood pressure measurement, reason not given
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
34
01/14
HCPCS Code
Description
G8596
Ldl-c was not performed
G8603
Score on the spoken language comprehension functional communication measure at
discharge was higher than at admission
G8604
Score on the spoken language comprehension functional communication measure at
discharge was not higher than at admission, reason not given
G8605
Patient treated for spoken language comprehension but not scored on the spoken language
comprehension functional communication measure either at admission or at discharge
G8606
Score on the attention functional communication measure at discharge was higher than at
admission
G8607
Score on the attention functional communication measure at discharge was not higher than at
admission, reason not given
G8608
Patient treated for attention but not scored on the attention functional communication
measure either at admission or at discharge
G8609
Score on the memory functional communication measure at discharge was higher than at
admission
G8610
Score on the memory functional communication measure at discharge was not higher than at
admission, reason not given
G8611
Patient treated for memory but not scored on the memory functional communication measure
either at admission or at discharge
G8612
Score on the motor speech functional communication measure at discharge was higher than
at admission
G8613
Score on the motor speech functional communication measure at discharge was not higher
than at admission, reason not given
G8614
Patient treated for motor speech but not scored on the motor speech comprehension
functional communication measure either at admission or at discharge
G8615
Score on the reading functional communication measure at discharge was higher than at
admission
G8616
Score on the reading functional communication measure at discharge was not higher than at
admission, reason not given
G8617
Patient treated for reading but not scored on the reading functional communication measure
either at admission or at discharge
G8618
Score on the spoken language expression functional communication measure at discharge
was higher than at admission
G8619
Score on the spoken language expression functional communication measure at discharge
was not higher than at admission, reason not given
G8620
Patient treated for spoken language expression but not scored on the spoken language
expression functional communication measure either at admission or at discharge
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
35
01/14
HCPCS Code
Description
G8621
Score on the writing functional communication measure at discharge was higher than at
admission
G8622
Score on the writing functional communication measure at discharge was not higher than at
admission, reason not given
G8623
Patient treated for writing but not scored on the writing functional communication measure
either at admission or at discharge
G8624
Score on the swallowing functional communication measure at discharge was higher than at
admission
G8625
Score on the swallowing functional communication measure at discharge was not higher than
at admission, reason not given
G8626
Patient treated for swallowing but not scored on the swallowing functional communication
measure at admission or at discharge
G8642
The eligible professional practices in a rural area without sufficient high speed internet access
and requests a hardship exemption from the application of the payment adjustment under
section 1848(a)(5)(a) of the social security act
G8643
The eligible professional practices in an area without sufficient available pharmacies for
electronic prescribing and requests a hardship exemption for the application of the payment
adjustment under section 1848(a)(5)(a) of the social security act
G8644
Eligible professional does not have prescribing privileges
G8741
Patient not treated for spoken language comprehension disorder
G8742
Patient not treated for attention disorder
G8743
Patient not treated for memory disorder
G8744
Patient not treated for motor speech disorder
G8745
Patient not treated for reading disorder
G8746
Patient not treated for spoken language expression disorder
G8747
Patient not treated for writing disorder
G8748
Patient not treated for swallowing disorder
G8790
Most recent office visit systolic blood pressure <130 mm hg
G8791
Most recent office visit systolic blood pressure, 130 to 139 mm hg
G8792
Most recent office visit systolic blood pressure >=140 mm hg
G8793
Most recent office visit diastolic blood pressure, <80 mm hg
G8794
Most recent office visit diastolic blood pressure, 80 - 89 mm hg
G8795
Most recent office visit diastolic blood pressure >=90 mm hg
G8796
Blood pressure measurement not documented, reason not given
G8799
Anticoagulation ordered
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
36
01/14
HCPCS Code
Description
G8800
Anticoagulation not ordered for reasons documented by clinician
G8801
Anticoagulation was not ordered, reason not given
G8812
Patient is not eligible for follow-up cta, duplex, or mra (e.g., patient death, failure to return
for scheduled follow-up exam, planned follow-up study which will meet numerator criteria
has not yet occurred at the time of reporting)
G8813
Follow-up cta, duplex, or mra of the abdomen and pelvis performed
G8814
Follow-up cta, duplex, or mra of the abdomen and pelvis not performed
G8827
Aneurysm minor diameter <= 5.5 cm for women
G8835
Asymptomatic patient with no history of any transient ischemic attack or stroke in any
carotid or vertebrobasilar territory
G8919
Most recent systolic blood pressure < 140 mmhg
G8920
Most recent systolic blood pressure >= 140 mmhg
G8921
Most recent diastolic blood pressure < 90 mmhg
G8922
Most recent diastolic blood pressure >= 90 mmhg
G8945
Aneurysm minor diameter <= 6 cm for men
G8954
Complete and appropriate patient data were reported to a qualified clinical database registry
J0152
Injection, adenosine for diagnostic use, 30 mg (not to be used to report any adenosine
phosphate compounds; instead use a9270)
J0718
Injection, certolizumab pegol, 1 mg
J1440
Injection, filgrastim (g-csf), 300 mcg
J1441
Injection, filgrastim (g-csf), 480 mcg
J3487
Injection, zoledronic acid (zometa), 1 mg
J3488
Injection, zoledronic acid (reclast), 1 mg
J9002
Injection, doxorubicin hydrochloride, liposomal, doxil, 10 mg
L0430
Spinal orthosis, anterior-posterior-lateral control, with interface material, custom fitted
(dewall posture protector only)
Q0090
Levonorgestrel-releasing intrauterine contraceptive system, (skyla), 13.5 mg
Q0165
Prochlorperazine maleate, 10 mg, oral, fda approved prescription anti-emetic, for use as a
complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment,
not to exceed a 48 hour dosage regimen
Q0168
Dronabinol, 5 mg, oral, fda approved prescription anti-emetic, for use as a complete
therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to
exceed a 48 hour dosage regimen
Q0170
Promethazine hydrochloride, 25 mg, oral, fda approved prescription anti-emetic, for use as a
complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment,
not to exceed a 48 hour dosage regimen
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
37
01/14
HCPCS Code
Description
Q0171
Chlorpromazine hydrochloride, 10 mg, oral, fda approved prescription anti-emetic, for use as
a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment,
not to exceed a 48 hour dosage regimen
Q0172
Chlorpromazine hydrochloride, 25 mg, oral, fda approved prescription anti-emetic, for use as
a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment,
not to exceed a 48 hour dosage regimen
Q0176
Perphenazine, 8mg, oral, fda approved prescription anti-emetic, for use as a complete
therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to
exceed a 48 hour dosage regimen
Q0178
Hydroxyzine pamoate, 50 mg, oral, fda approved prescription anti-emetic, for use as a
complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment,
not to exceed a 48 hour dosage regimen
Q0505
Miscellaneous supply or accessory for use with ventricular assist device
Q2027
Injection, sculptra, 0.1 ml
Q2051
Injection, zoledronic acid, not otherwise specified, 1mg
Q3025
Injection, interferon beta-1a, 11 mcg for intramuscular use
Q3026
Injection, interferon beta-1a, 11 mcg for subcutaneous use
S3625
Maternal serum triple marker screen including alpha-fetoprotein (afp), estriol, and human
chorionic gonadotropin (hcg)
S3626
Maternal serum quadruple marker screen including alpha-fetoprotein (afp), estriol, human
chorionic gonadotropin (hcg) and inhibin a
S3833
Complete apc gene sequence analysis for susceptibility to familial adenomatous polyposis
(fap) and attenuated fap
S3834
Single-mutation analysis (in individual with a known apc mutation in the family) for
susceptibility to familial adenomatous polyposis (fap) and attenuated fap
CDT Code
Description
D0363
Cone beam - three-dimensional image reconstruction using existing data, includes multiple
images
D3354
Pulpal regeneration (completion of regenerative treatment in an immature permanent tooth
with a necrotic pulp); does not include final restoration
D5860
Overdenture-complete, by report
D5861
Overdenture-partial, by report
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
38
01/14
CPT Code
CPT Code
13150
49021
19102
49041
19103
49061
19290
50021
19291
58823
19295
64613
23331
64614
23332
75960
32201
77031
37204
77032
37205
92506
37206
0078T
37207
0079T
37208
0080T
37210
0081T
42802
0124T
43219
0183T
43228
0185T
43256
0186T
43258
0192T
43267
0260T
43268
0261T
43269
0318T
43271
43272
43456
43458
44901
47011
48511
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
39
01/14
Bilateral Modifiers: Use of CPT Modifier 50 & HCPCS Modifiers RT & LT
Effective for claims processed on or after January 1, 2014, the codes listed in this article cannot be submitted with CPT modifier 50 (Bilateral Procedure) or HCPCS modifiers RT (Right Side) or LT (Left
Side), or the services will be rejected. These codes are considered bilateral and /or the code descriptions
include possible multiple services.
HCPCS
Codes
CPT Code
CPT Code
CPT Code
CPT Code
CPT Code
33881
52300
58720
69210
92004
G0202
33976
52301
58800
70330
92012
G0204
33978
54130
58805
71110
92014
G0268
34803
54135
58900
71111
92020
36221
54430
58920
73050
92025
36252
54901
58925
73520
92060
36254
55041
58940
73565
92065
37185
55200
58950
75716
92072
37186
55250
58951
75733
92081
38562
55300
58952
75743
92082
38571
55450
58953
75803
92083
38572
55815
58954
75807
92100
40701
55845
58956
75822
92132
40702
55865
58957
75833
92133
40843
56632
58958
75842
92134
42507
57109
61000
76102
92136*
42508
57111
61001
76514
92140
42509
57112
61253
76516
92227
42510
57531
63045
76519*
92228
50540
58210
63046
76645
92250
51575
58548
63047
77057
92260
51585
58565
63295
77059
92265
51595
58600
64600
77071
92270
51820
58605
64611
78458
92275
52290
58700
64615
92002
92283
CPT Code
0201T
11010
11011
11012
21193
21194
21195
21196
27158
27392
27395
30801
30802
30905
30906
31231
32853
32854
33880
*= Indicates Global & Technical Component (TC) Only
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
40
01/14
CPT Code
CPT Code
92284
92587
92285
92588
92286
92596
92287
92620
92312
92625
92316
92626
92550
92640
92552
93880
95553
93922
92555
93923
92556
93924
92557
93925
92561
93930
92562
93965
92563
93970
92564
95865
92565
95868
92567
95925
92568
95926
92570
95928
92571
95929
92572
95930
92575
95938
92576
95939
92577
96000
92579
96001
92582
96002
92583
96003
92584
96004
92585
92586
*= Indicates Global & Technical Component (TC) Only
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
41
01/14
Bilateral Indicator 3 Procedures
Coding Instructions
The following procedure codes have a Bilateral Indicator “3” on the Medicare Physician Fee Schedule
Database (MPFSDB). This means, when performed bilaterally, the full fee schedule amount is payable for
“each” side. The 50% reduction that occurs with Bilateral Indicator “1” procedure codes is not applicable
to Bilateral Indicator “3” procedure codes.
In order to receive the full fee schedule amount for Bilateral Indicator “3” procedure codes performed
bilaterally, the days/units (quantity billed) field must reflect “2” even when submitting CPT Modifier 50
or when submitting HCPCS Modifiers RT and LT on the same detail line.
Example 1:
CPT Code
CPT Modifier
Days/Units
92235
50
“2”
CPT Code
HCPCS Modifier
Days/Units
92235
RTLT
“2”
Example 2:
The global, technical, and professional components of the following procedure codes currently have a Bilateral 3 indicator: (Also, applicable when submitted with CPT modifier 26 or HCPCS modifier TC)
CPT Code
70030
70120
70130
70190
70332
70554
70555
73000
73010
73020
73030
73040
73060
73070
73080
73085
73090
73092
73100
73110
73115
73120
73130
73140
73200
73201
73202
73218
73219
73220
73221
73222
73223
73701
73702
73706
73718
73719
73720
73721
73722
73723
73725
76510
76511
76512
76513
76529
92235
92240
73525
73530
73550
73560
73562
73564
73580
73590
73592
73600
73610
73615
73620
73630
73650
73660
73700
95885
95886
95887
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
42
01/14
The listed components of the following procedure codes currently have a Bilateral 3 indicator:
CPT Code
70336-26
76519-26
92070
92136-26
92225
92226
92230
Important: These instructions apply only to Bilateral Indicator “3” procedure codes. When billing Bilateral
Indicator “1” services with CPT Modifier 50, the days/units must be submitted as “1.”
The MPFSDB indicators for procedure codes can be viewed by accessing the following website:
http://www.cms.hhs.gov/PFSlookup/ (then select the Physician Fee Schedule Search link).
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
43
01/14
2014 Endoscopy CPT Codes & Families
Overview: Special rules for multiple endoscopic procedures apply if the procedure is billed with another
endoscopy in the same family (i.e., another endoscopy that has the same base procedure). These codes are
Status A.
Endoscopic Base
CPT Code
CPT Code
29806
29805
29807
29805
29819
29805
29820
29805
29821
29805
29822
29805
29823
29805
29824
29805
29825
29805
29827
29805
29828
29805
29834
29830
29835
29830
29836
29830
29837
29830
29838
29830
29843
29840
29844
29840
29845
29840
29846
29840
29847
29840
29861
29860
29862
29860
29863
29860
29871
29870
29873
29870
29874
29870
29875
29870
29876
29870
29877
29870
29879
29870
29880
29870
Endoscopic Base
CPT Code
CPT Code
29881
29870
29882
29870
29883
29870
29884
29870
29885
29870
29886
29870
29887
29870
29914
29860
29915
29860
29916
29860
31510
31505
31511
31505
31512
31505
31513
31505
31527
31525
31528
31525
31529
31525
31530
31525
31531
31526
31535
31525
31536
31526
31540
31525
31541
31526
31545
31526
31546
31526
31560
31525
31561
31526
31570
31525
31571
31526
31576
31575
31577
31575
31578
31575
Endoscopic Base
CPT Code
CPT Code
31579
31575
31623
31622
31624
31622
31625
31622
31628
31622
31629
31622
31630
31622
31631
31622
31634
31622
31635
31622
31636
31622
31638
31622
31640
31622
31641
31622
31645
31622
31647
31622
31648
31622
31660
31622
31661
31622
38570
49320
43192
43191
43193
43191
43194
43191
43195
43191
43196
43191
43198
43197
43201
43200
43202
43200
43204
43200
43205
43200
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
44
01/14
Endoscopic Base
CPT Code
CPT Code
43206
43200
43211
43200
43212
43200
43213
43200
43214
43200
43215
43200
43216
43200
43217
43200
43220
43200
43226
43200
43227
43200
43229
43200
43231
43200
43232
43200
43233
43235
43236
43235
43237
43235
43238
43235
43239
43235
43240
43235
43241
43235
43242
43235
43243
43235
43244
43235
43245
43235
43246
43235
43247
43235
43248
43235
43249
43235
43250
43235
43251
43235
43252
43235
43253
43235
43254
43235
43255
43235
43257
43235
43259
43235
Endoscopic Base
CPT Code
CPT Code
43261
43260
43262
43260
43263
43260
43264
43260
43265
43260
43266
43235
43270
43235
43274
43260
43275
43260
43276
43260
43277
43260
43278
43260
44361
44360
44363
44360
44364
44360
44365
44360
44366
44360
44369
44360
44370
44360
44372
44360
44373
44360
44377
44376
44378
44376
44379
44376
44389
44388
44390
44388
44391
44388
44392
44388
44393
44388
44394
44388
44397
44388
45303
45300
45305
45300
45307
45300
45308
45300
45309
45300
45315
45300
Endoscopic Base
CPT Code
CPT Code
45317
45300
45320
45300
45321
45300
45327
45300
45331
45330
45332
45330
45333
45330
45334
45330
45335
45330
45337
45330
45338
45330
45339
45330
45340
45330
45345
45330
45379
45378
45380
45378
45381
45378
45382
45378
45383
45378
45384
45378
45385
45378
45386
45378
45387
45378
45391
45378
45392
45378
46604
46600
46606
46600
46608
46600
46610
46600
46611
46600
46612
46600
46614
46600
46615
46600
47553
47552
47554
47552
47555
47552
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
45
01/14
Endoscopic Base
CPT Code
CPT Code
47556
47552
49321
49320
49322
49320
49323
49320
49324
49320
49325
49320
50555
50551
50557
50551
50561
50551
50572
50570
50574
50570
50575
50570
50576
50570
50580
50570
50953
50951
50955
50951
50957
50951
50961
50951
50974
50970
50976
50970
52001
52000
52005
52000
52007
52000
52010
52000
52204
52000
52214
52000
52224
52000
52234
52000
52235
52000
52240
52000
52250
52000
52260
52000
52265
52000
52270
52000
52275
52000
52276
52000
52277
52000
Endoscopic Base
CPT Code
CPT Code
52281
52000
52282
52000
52283
52000
52285
52000
52287
52000
52290
52000
52300
52000
52301
52000
52305
52000
52310
52000
52315
52000
52317
52000
52318
52000
52320
52000
52325
52000
52327
52000
52330
52000
52332
52000
52334
52000
52341
52000
52342
52000
52343
52000
52344
52000
52345
52351
52346
52351
52352
52351
52353
52351
52354
52351
52355
52351
52356
52351
52400
52000
52402
52000
57454
57452
57455
57452
57456
57452
57460
57452
57461
57452
Endoscopic Base
CPT Code
CPT Code
58541
49320
58550
49320
58558
58555
58559
58555
58560
58555
58561
58555
58562
58555
58563
58555
58565
58555
58660
49320
58661
49320
58662
49320
58670
49320
58671
49320
58672
49320
58673
49320
66711
66710
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
46
01/14
Technical & Professional Modifiers: HCPCS Modifier TC & CPT Modifier 26
The following codes listed in this article may be submitted with CPT modifier 26 or HCPCS modifier
TC for services rendered in 2014 Claims submitted with an invalid combination of CPT/HCPCS codes
and/or CPT modifier 26 or HCPCS modifier TC will be rejected. These services must be resubmitted as
new claims with the correct code/modifier combinations. (HCPCS codes and modifiers begin with an alpha
character. CPT codes and modifiers begin with a numeric character.)
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
G0106
TC
G0389
26
0076T
26
51736
TC
G0106
26
G0398
TC
0159T
TC
51736
26
G0120
TC
G0398
26
0159T
26
51741
TC
G0120
26
G0399
TC
0182T
TC
51741
26
G0122
TC
G0399
26
0182T
26
51784
TC
G0122
26
G0400
TC
0240T
TC
51784
26
G0130
TC
G0400
26
0240T
26
51785
TC
G0130
26
G0416
TC
0241T
TC
51785
26
G0202
TC
G0416
26
0241T
26
51792
TC
G0202
26
G0417
TC
0243T
TC
51792
26
G0204
TC
G0417
26
0243T
26
51797
TC
G0204
26
G0418
TC
0244T
TC
51797
26
G0206
TC
G0418
26
0244T
26
54240
TC
G0206
26
G0419
TC
0255T
TC
54240
26
G0219
TC
G0419
26
0255T
26
54250
TC
G0219
26
G0452
26
51725
TC
54250
26
G0235
TC
G0461
TC
51725
26
59020
TC
G0235
26
G0461
26
51726
TC
59020
26
G0252
TC
G0462
TC
51726
26
59025
TC
G0252
26
G0462
26
51727
TC
59025
26
G0255
TC
Q0035
TC
51727
26
62252
TC
G0255
26
Q0035
26
51728
TC
62252
26
G0365
TC
0075T
TC
51728
26
70015
TC
G0365
26
0075T
26
51729
TC
70015
26
G0389
TC
0076T
TC
51729
26
70030
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
47
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
70030
26
70260
26
70450
26
70542
26
70100
TC
70300
TC
70460
TC
70543
TC
70100
26
70300
26
70460
26
70543
26
70110
TC
70310
TC
70470
TC
70544
TC
70110
26
70310
26
70470
26
70544
26
70120
TC
70320
TC
70480
TC
70545
TC
70120
26
70320
26
70480
26
70545
26
70130
TC
70328
TC
70481
TC
70546
TC
70130
26
70328
26
70481
26
70546
26
70134
TC
70330
TC
70482
TC
70547
TC
70134
26
70330
26
70482
26
70547
26
70140
TC
70332
TC
70486
TC
70548
TC
70140
26
70332
26
70486
26
70548
26
70150
TC
70336
TC
70487
TC
70549
TC
70150
26
70336
26
70487
26
70549
26
70160
TC
70350
TC
70488
TC
70551
TC
70160
26
70350
26
70488
26
70551
26
70170
TC
70355
TC
70490
TC
70552
TC
70170
26
70355
26
70490
26
70552
26
70190
TC
70360
TC
70491
TC
70553
TC
70190
26
70360
26
70491
26
70553
26
70200
TC
70370
TC
70492
TC
70554
TC
70200
26
70370
26
70492
26
70554
26
70210
TC
70371
TC
70496
TC
70555
TC
70210
26
70371
26
70496
26
70555
26
70220
TC
70373
TC
70498
TC
70557
TC
70220
26
70373
26
70498
26
70557
26
70240
TC
70380
TC
70540
TC
70558
TC
70240
26
70380
26
70540
26
70558
26
70250
TC
70390
TC
70542
TC
70559
TC
70250
26
70390
26
70260
TC
70450
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
48
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
70559
26
71250
26
72074
26
72141
TC
71010
TC
71260
TC
72080
TC
72141
26
71010
26
71260
26
72080
26
72142
TC
71015
TC
71270
TC
72090
TC
72142
26
71015
26
71270
26
72090
26
72146
TC
71020
TC
71275
TC
72100
TC
72146
26
71020
26
71275
26
72100
26
72147
TC
71021
TC
71550
TC
72110
TC
72147
26
71021
26
71550
26
72110
26
72148
TC
71022
TC
71551
TC
72114
TC
72148
26
71022
26
71551
26
72114
26
72149
TC
71023
TC
71552
TC
72120
TC
72149
26
71023
26
71552
26
72120
26
72156
TC
71030
TC
71555
TC
72125
TC
72156
26
71030
26
71555
26
72125
26
72157
TC
71034
TC
72010
TC
72126
TC
72157
26
71034
26
72010
26
72126
26
72158
TC
71035
TC
72020
TC
72127
TC
72158
26
71035
26
72020
26
72127
26
72159
TC
71100
TC
72040
TC
72128
TC
72159
26
71100
26
72040
26
72128
26
72170
TC
71101
TC
72050
TC
72129
TC
72170
26
71101
26
72050
26
72129
26
72190
TC
71110
TC
72052
TC
72130
TC
72190
26
71110
26
72052
26
72130
26
72191
TC
71111
TC
72069
TC
72131
TC
72191
26
71111
26
72069
26
72131
26
72192
TC
71120
TC
72070
TC
72132
TC
72192
26
71120
26
72070
26
72132
26
72193
TC
71130
TC
72072
TC
72133
TC
72193
26
71130
26
72072
26
72133
26
72194
TC
71250
TC
72074
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
49
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
72194
26
72295
26
73120
26
73520
TC
72195
TC
73000
TC
73130
TC
73520
26
72195
26
73000
26
73130
26
73525
TC
72196
TC
73010
TC
73140
TC
73525
26
72196
26
73010
26
73140
26
73530
TC
72197
TC
73020
TC
73200
TC
73530
26
72197
26
73020
26
73200
26
73540
TC
72198
TC
73030
TC
73201
TC
73540
26
72198
26
73030
26
73201
26
73550
TC
72200
TC
73040
TC
73202
TC
73550
26
72200
26
73040
26
73202
26
73560
TC
72202
TC
73050
TC
73206
TC
73560
26
72202
26
73050
26
73206
26
73562
TC
72220
TC
73060
TC
73218
TC
73562
26
72220
26
73060
26
73218
26
73564
TC
72240
TC
73070
TC
73219
TC
73564
26
72240
26
73070
26
73219
26
73565
TC
72255
TC
73080
TC
73220
TC
73565
26
72255
26
73080
26
73220
26
73580
TC
72265
TC
73085
TC
73221
TC
73580
26
72265
26
73085
26
73221
26
73590
TC
72270
TC
73090
TC
73222
TC
73590
26
72270
26
73090
26
73222
26
73592
TC
72275
TC
73092
TC
73223
TC
73592
26
72275
26
73092
26
73223
26
73600
TC
72285
TC
73100
TC
73225
TC
73600
26
72285
26
73100
26
73225
26
73610
TC
72291
TC
73110
TC
73500
TC
73610
26
72291
26
73110
26
73500
26
73615
TC
72292
TC
73115
TC
73510
TC
73615
26
72292
26
73115
26
73510
26
73620
TC
72295
TC
73120
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
50
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
73620
26
74010
26
74210
26
74270
TC
73630
TC
74020
TC
74220
TC
74270
26
73630
26
74020
26
74220
26
74280
TC
73650
TC
74022
TC
74230
TC
74280
26
73650
26
74022
26
74230
26
74283
TC
73660
TC
74150
TC
74235
TC
74283
26
73660
26
74150
26
74235
26
74290
TC
73700
TC
74160
TC
74240
TC
74290
26
73700
26
74160
26
74240
26
74291
TC
73701
TC
74170
TC
74241
TC
74291
26
73701
26
74170
26
74241
26
74300
TC
73702
TC
74174
TC
74245
TC
74300
26
73702
26
74174
26
74245
26
74301
TC
73706
TC
74175
TC
74246
TC
74301
26
73706
26
74175
26
74246
26
74305
TC
73718
TC
74176
TC
74247
TC
74305
26
73718
26
74176
26
74247
26
74320
TC
73719
TC
74177
TC
74249
TC
74320
26
73719
26
74177
26
74249
26
74327
TC
73720
TC
74178
TC
74250
TC
74327
26
73720
26
74178
26
74250
26
74328
TC
73721
TC
74181
TC
74251
TC
74328
26
73721
26
74181
26
74251
26
74329
TC
73722
TC
74182
TC
74260
TC
74329
26
73722
26
74182
26
74260
26
74330
TC
73723
TC
74183
TC
74261
TC
74330
26
73723
26
74183
26
74261
26
74340
TC
73725
TC
74185
TC
74262
TC
74340
26
73725
26
74185
26
74262
26
74355
TC
74000
TC
74190
TC
74263
TC
74355
26
74000
26
74190
26
74263
26
74360
TC
74010
TC
74210
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
51
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
74360
26
74710
26
75630
26
75801
TC
74363
TC
74740
TC
75635
TC
75801
26
74363
26
74740
26
75635
26
75803
TC
74400
TC
74742
TC
75658
TC
75803
26
74400
26
74742
26
75658
26
75805
TC
74410
TC
74775
TC
75705
TC
75805
26
74410
26
74775
26
75705
26
75807
TC
74415
TC
75557
TC
75710
TC
75807
26
74415
26
75557
26
75710
26
75809
TC
74420
TC
75559
TC
75716
TC
75809
26
74420
26
75559
26
75716
26
75810
TC
74425
TC
75561
TC
75726
TC
75810
26
74425
26
75561
26
75726
26
75820
TC
74430
TC
75563
TC
75731
TC
75820
26
74430
26
75563
26
75731
26
75822
TC
74440
TC
75565
TC
75733
TC
75822
26
74440
26
75565
26
75733
26
75825
TC
74445
TC
75571
TC
75736
TC
75825
26
74445
26
75571
26
75736
26
75827
TC
74450
TC
75572
TC
75741
TC
75827
26
74450
26
75572
26
75741
26
75831
TC
74455
TC
75573
TC
75743
TC
75831
26
74455
26
75573
26
75743
26
75833
TC
74470
TC
75574
TC
75746
TC
75833
26
74470
26
75574
26
75746
26
75840
TC
74475
TC
75600
TC
75756
TC
75840
26
74475
26
75600
26
75756
26
75842
TC
74480
TC
75605
TC
75774
TC
75842
26
74480
26
75605
26
75774
26
75860
TC
74485
TC
75625
TC
75791
TC
75860
26
74485
26
75625
26
75791
26
75870
TC
74710
TC
75630
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
52
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
75870
26
75953
26
76000
26
76498
TC
75872
TC
75954
TC
76001
TC
76498
26
75872
26
75954
26
76001
26
76499
TC
75880
TC
75956
TC
76010
TC
76499
26
75880
26
75956
26
76010
26
76506
TC
75885
TC
75957
TC
76080
TC
76506
26
75885
26
75957
26
76080
26
76510
TC
75887
TC
75958
TC
76098
TC
76510
26
75887
26
75958
26
76098
26
76511
TC
75889
TC
75959
TC
76100
TC
76511
26
75889
26
75959
26
76100
26
76512
TC
75891
TC
75962
TC
76101
TC
76512
26
75891
26
75962
26
76101
26
76513
TC
75893
TC
75964
TC
76102
TC
76513
26
75893
26
75964
26
76102
26
76514
TC
75894
TC
75966
TC
76120
TC
76514
26
75894
26
75966
26
76120
26
76516
TC
75896
TC
75968
TC
76125
TC
76516
26
75896
26
75968
26
76125
26
76519
TC
75898
TC
75970
TC
76376
TC
76519
26
75898
26
75970
26
76376
26
76529
TC
75901
TC
75978
TC
76377
TC
76529
26
75901
26
75978
26
76377
26
76536
TC
75902
TC
75980
TC
76380
TC
76536
26
75902
26
75980
26
76380
26
76604
TC
75945
TC
75982
TC
76390
TC
76604
26
75945
26
75982
26
76390
26
76645
TC
75946
TC
75984
TC
76496
TC
76645
26
75946
26
75984
26
76496
26
76700
TC
75952
TC
75989
TC
76497
TC
76700
26
75952
26
75989
26
76497
26
76705
TC
75953
TC
76000
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
53
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
76705
26
76818
26
76882
26
76975
TC
76770
TC
76819
TC
76885
TC
76975
26
76770
26
76819
26
76885
26
76977
TC
76775
TC
76820
TC
76886
TC
76977
26
76775
26
76820
26
76886
26
76998
TC
76776
TC
76821
TC
76930
TC
76998
26
76776
26
76821
26
76930
26
76999
TC
76800
TC
76825
TC
76932
TC
76999
26
76800
26
76825
26
76932
26
77001
TC
76801
TC
76826
TC
76936
TC
77001
26
76801
26
76826
26
76936
26
77002
TC
76802
TC
76827
TC
76937
TC
77002
26
76802
26
76827
26
76937
26
77003
TC
76805
TC
76828
TC
76940
TC
77003
26
76805
26
76828
26
76940
26
77011
TC
76810
TC
76830
TC
76941
TC
77011
26
76810
26
76830
26
76941
26
77012
TC
76811
TC
76831
TC
76942
TC
77012
26
76811
26
76831
26
76942
26
77013
TC
76812
TC
76856
TC
76945
TC
77013
26
76812
26
76856
26
76945
26
77014
TC
76813
TC
76857
TC
76946
TC
77014
26
76813
26
76857
26
76946
26
77021
TC
76814
TC
76870
TC
76948
TC
77021
26
76814
26
76870
26
76948
26
77022
TC
76815
TC
76872
TC
76950
TC
77022
26
76815
26
76872
26
76950
26
77051
TC
76816
TC
76873
TC
76965
TC
77051
26
76816
26
76873
26
76965
26
77052
TC
76817
TC
76881
TC
76970
TC
77052
26
76817
26
76881
26
76970
26
77053
TC
76818
TC
76882
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
54
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
77053
26
77082
26
77328
26
77761
TC
77054
TC
77084
TC
77331
TC
77761
26
77054
26
77084
26
77331
26
77762
TC
77055
TC
77280
TC
77332
TC
77762
26
77055
26
77280
26
77332
26
77763
TC
77056
TC
77285
TC
77333
TC
77763
26
77056
26
77285
26
77333
26
77776
TC
77057
TC
77290
TC
77334
TC
77776
26
77057
26
77290
26
77334
26
77777
TC
77058
TC
77293
TC
77338
TC
77777
26
77058
26
77293
26
77338
26
77778
TC
77059
TC
77295
TC
77399
TC
77778
26
77059
26
77295
26
77399
26
77785
TC
77072
TC
77299
TC
77421
TC
77785
26
77072
26
77299
26
77421
26
77786
TC
77073
TC
77300
TC
77470
TC
77786
26
77073
26
77300
26
77470
26
77787
TC
77074
TC
77301
TC
77499
TC
77787
26
77074
26
77301
26
77499
26
77789
TC
77075
TC
77305
TC
77600
TC
77789
26
77075
26
77305
26
77600
26
77790
TC
77076
TC
77310
TC
77605
TC
77790
26
77076
26
77310
26
77605
26
77799
TC
77077
TC
77315
TC
77610
TC
77799
26
77077
26
77315
26
77610
26
78012
TC
77078
TC
77321
TC
77615
TC
78012
26
77078
26
77321
26
77615
26
78013
TC
77080
TC
77326
TC
77620
TC
78013
26
77080
26
77326
26
77620
26
78014
TC
77081
TC
77327
TC
77750
TC
78014
26
77081
26
77327
26
77750
26
78015
TC
77082
TC
77328
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
55
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
78015
26
78122
26
78227
26
78300
TC
78016
TC
78130
TC
78230
TC
78300
26
78016
26
78130
26
78230
26
78305
TC
78018
TC
78135
TC
78231
TC
78305
26
78018
26
78135
26
78231
26
78306
TC
78020
TC
78140
TC
78232
TC
78306
26
78020
26
78140
26
78232
26
78315
TC
78070
TC
78185
TC
78258
TC
78315
26
78070
26
78185
26
78258
26
78320
TC
78071
TC
78190
TC
78261
TC
78320
26
78071
26
78190
26
78261
26
78350
TC
78072
TC
78191
TC
78262
TC
78350
26
78072
26
78191
26
78262
26
78399
TC
78075
TC
78195
TC
78264
TC
78399
26
78075
26
78195
26
78264
26
78414
TC
78099
TC
78199
TC
78270
TC
78414
26
78099
26
78199
26
78270
26
78428
TC
78102
TC
78201
TC
78271
TC
78428
26
78102
26
78201
26
78271
26
78445
TC
78103
TC
78202
TC
78272
TC
78445
26
78103
26
78202
26
78272
26
78451
TC
78104
TC
78205
TC
78278
TC
78451
26
78104
26
78205
26
78278
26
78452
TC
78110
TC
78206
TC
78282
TC
78452
26
78110
26
78206
26
78282
26
78453
TC
78111
TC
78215
TC
78290
TC
78453
26
78111
26
78215
26
78290
26
78454
TC
78120
TC
78216
TC
78291
TC
78454
26
78120
26
78216
26
78291
26
78456
TC
78121
TC
78226
TC
78299
TC
78456
26
78121
26
78226
26
78299
26
78457
TC
78122
TC
78227
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
56
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
78457
26
78580
26
78647
26
78801
TC
78458
TC
78582
TC
78650
TC
78801
26
78458
26
78582
26
78650
26
78802
TC
78459
TC
78597
TC
78660
TC
78802
26
78459
26
78597
26
78660
26
78803
TC
78466
TC
78598
TC
78699
TC
78803
26
78466
26
78598
26
78699
26
78804
TC
78468
TC
78599
TC
78700
TC
78804
26
78468
26
78599
26
78700
26
78805
TC
78469
TC
78600
TC
78701
TC
78805
26
78469
26
78600
26
78701
26
78806
TC
78472
TC
78601
TC
78707
TC
78806
26
78472
26
78601
26
78707
26
78807
TC
78473
TC
78605
TC
78708
TC
78807
26
78473
26
78605
26
78708
26
78811
TC
78481
TC
78606
TC
78709
TC
78811
26
78481
26
78606
26
78709
26
78812
TC
78483
TC
78607
TC
78710
TC
78812
26
78483
26
78607
26
78710
26
78813
TC
78491
TC
78608
TC
78725
TC
78813
26
78491
26
78608
26
78725
26
78814
TC
78492
TC
78609
TC
78730
TC
78814
26
78492
26
78609
26
78730
26
78815
TC
78494
TC
78610
TC
78740
TC
78815
26
78494
26
78610
26
78740
26
78816
TC
78496
TC
78630
TC
78761
TC
78816
26
78496
26
78630
26
78761
26
78999
TC
78499
TC
78635
TC
78799
TC
78999
26
78499
26
78635
26
78799
26
79005
TC
78579
TC
78645
TC
78800
TC
79005
26
78579
26
78645
26
78800
26
79101
TC
78580
TC
78647
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
57
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
79101
26
88106
TC
88304
TC
88343
26
79200
TC
88106
26
88304
26
88346
TC
79200
26
88108
TC
88305
TC
88346
26
79300
TC
88108
26
88305
26
88347
TC
79300
26
88112
TC
88307
TC
88347
26
79403
TC
88112
26
88307
26
88348
TC
79403
26
88120
TC
88309
TC
88348
26
79440
TC
88120
26
88309
26
88349
TC
79440
26
88121
TC
88311
TC
88349
26
79445
TC
88121
26
88311
26
88355
TC
79445
26
88125
TC
88312
TC
88355
26
79999
TC
88125
26
88312
26
88356
TC
79999
26
88160
TC
88313
TC
88356
26
83020
26
88160
26
88313
26
88358
TC
84165
26
88161
TC
88314
TC
88358
26
84166
26
88161
26
88314
26
88360
TC
84181
26
88162
TC
88319
TC
88360
26
84182
26
88162
26
88319
26
88361
TC
85390
26
88172
TC
88323
TC
88361
26
85576
26
88172
26
88323
26
88362
TC
86153
26
88173
TC
88331
TC
88362
26
86255
26
88173
26
88331
26
88365
TC
86256
26
88177
TC
88332
TC
88365
26
86320
26
88177
26
88332
26
88367
TC
86325
26
88182
TC
88333
TC
88367
26
86327
26
88182
26
88333
26
88368
TC
86334
26
88199
TC
88334
TC
88368
26
86335
26
88199
26
88334
26
88371
26
87164
26
88300
TC
88342
TC
88372
26
87207
26
88300
26
88342
26
88380
TC
88104
TC
88302
TC
88343
TC
88380
26
88104
26
88302
26
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
58
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
88381
TC
91110
26
92134
26
92541
TC
88381
26
91111
TC
92136
TC
92541
26
88387
TC
91111
26
92136
26
92542
TC
88387
26
91112
TC
92228
TC
92542
26
88388
TC
91112
26
92228
26
92543
TC
88388
26
91120
TC
92235
TC
92543
26
88399
TC
91120
26
92235
26
92544
TC
88399
26
91122
TC
92240
TC
92544
26
89060
26
91122
26
92240
26
92545
TC
91010
TC
91132
TC
92250
TC
92545
26
91010
26
91132
26
92250
26
92546
TC
91013
TC
91133
TC
92265
TC
92546
26
91013
26
91133
26
92265
26
92548
TC
91020
TC
91299
TC
92270
TC
92548
26
91020
26
91299
26
92270
26
92585
TC
91022
TC
92025
TC
92275
TC
92585
26
91022
26
92025
26
92275
26
92587
TC
91030
TC
92060
TC
92283
TC
92587
26
91030
26
92060
26
92283
26
92588
TC
91034
TC
92065
TC
92284
TC
92588
26
91034
26
92065
26
92284
26
92978
TC
91035
TC
92081
TC
92285
TC
92978
26
91035
26
92081
26
92285
26
92979
TC
91037
TC
92082
TC
92286
TC
92979
26
91037
26
92082
26
92286
26
93024
TC
91038
TC
92083
TC
92287
TC
93024
26
91038
26
92083
26
92287
26
93025
TC
91040
TC
92132
TC
92499
TC
93025
26
91040
26
92132
26
92499
26
93278
TC
91065
TC
92133
TC
92540
TC
93278
26
91065
26
92133
26
92540
26
93279
TC
91110
TC
92134
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
59
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
93279
26
93304
26
93453
26
93562
TC
93280
TC
93306
TC
93454
TC
93562
26
93280
26
93306
26
93454
26
93571
TC
93281
TC
93307
TC
93455
TC
93571
26
93281
26
93307
26
93455
26
93572
TC
93282
TC
93308
TC
93456
TC
93572
26
93282
26
93308
26
93456
26
93600
TC
93283
TC
93312
TC
93457
TC
93600
26
93283
26
93312
26
93457
26
93602
TC
93284
TC
93314
TC
93458
TC
93602
26
93284
26
93314
26
93458
26
93603
TC
93285
TC
93315
TC
93459
TC
93603
26
93285
26
93315
26
93459
26
93609
TC
93286
TC
93317
TC
93460
TC
93609
26
93286
26
93317
26
93460
26
93610
TC
93287
TC
93318
TC
93461
TC
93610
26
93287
26
93318
26
93461
26
93612
TC
93288
TC
93320
TC
93464
TC
93612
26
93288
26
93320
26
93464
26
93615
TC
93289
TC
93321
TC
93505
TC
93615
26
93289
26
93321
26
93505
26
93616
TC
93290
TC
93325
TC
93530
TC
93616
26
93290
26
93325
26
93530
26
93618
TC
93291
TC
93350
TC
93531
TC
93618
26
93291
26
93350
26
93531
26
93619
TC
93292
TC
93351
TC
93532
TC
93619
26
93292
26
93351
26
93532
26
93620
TC
93293
TC
93451
TC
93533
TC
93620
26
93293
26
93451
26
93533
26
93621
TC
93303
TC
93452
TC
93561
TC
93621
26
93303
26
93452
26
93561
26
93304
TC
93453
TC
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
60
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
93622
TC
93890
TC
93979
TC
94620
26
93622
26
93890
26
93979
26
94621
TC
93623
TC
93892
TC
93980
TC
94621
26
93623
26
93892
26
93980
26
94680
TC
93624
TC
93893
TC
93981
TC
94680
26
93624
26
93893
26
93981
26
94681
TC
93631
TC
93922
TC
93990
TC
94681
26
93631
26
93922
26
93990
26
94690
TC
93640
TC
93923
TC
94010
TC
94690
26
93640
26
93923
26
94010
26
94726
TC
93641
TC
93924
TC
94060
TC
94726
26
93641
26
93924
26
94060
26
94727
TC
93642
TC
93925
TC
94070
TC
94727
26
93642
26
93925
26
94070
26
94728
TC
93660
TC
93926
TC
94150
TC
94728
26
93660
26
93926
26
94150
26
94729
TC
93662
TC
93930
TC
94200
TC
94729
26
93662
26
93930
26
94200
26
94750
TC
93724
TC
93931
TC
94250
TC
94750
26
93724
26
93931
26
94250
26
94772
TC
93745
TC
93965
TC
94375
TC
94772
26
93745
26
93965
26
94375
26
94799
TC
93799
TC
93970
TC
94400
TC
94799
26
93799
26
93970
26
94400
26
95782
TC
93880
TC
93971
TC
94450
TC
95782
26
93880
26
93971
26
94450
26
95783
TC
93882
TC
93975
TC
94452
TC
95783
26
93882
26
93975
26
94452
26
95800
TC
93886
TC
93976
TC
94453
TC
95800
26
93886
26
93976
26
94453
26
95801
TC
93888
TC
93978
TC
94620
TC
95801
26
93888
26
93978
26
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
61
01/14
Code
Modifier
Code
Modifier
Code
Modifier
Code
Modifier
95803
TC
95861
TC
95905
TC
95928
26
95803
26
95861
26
95905
26
95929
TC
95805
TC
95863
TC
95907
TC
95929
26
95805
26
95863
26
95907
26
95930
TC
95806
TC
95864
TC
95908
TC
95930
26
95806
26
95864
26
95908
26
95933
TC
95807
TC
95865
TC
95909
TC
95933
26
95807
26
95865
26
95909
26
95937
TC
95808
TC
95866
TC
95910
TC
95937
26
95808
26
95866
26
95910
26
95938
TC
95810
TC
95867
TC
95911
TC
95938
26
95810
26
95867
26
95911
26
95939
TC
95811
TC
95868
TC
95912
TC
95939
26
95811
26
95868
26
95912
26
95943
TC
95812
TC
95869
TC
95913
TC
95943
26
95812
26
95869
26
95913
26
95950
TC
95813
TC
95870
TC
95921
TC
95950
26
95813
26
95870
26
95921
26
95951
TC
95816
TC
95872
TC
95922
TC
95951
26
95816
26
95872
26
95922
26
95953
TC
95819
TC
95873
TC
95923
TC
95953
26
95819
26
95873
26
95923
26
95954
TC
95822
TC
95874
TC
95924
TC
95954
26
95822
26
95874
26
95924
26
95955
TC
95824
TC
95875
TC
95925
TC
95955
26
95824
26
95875
26
95925
26
95956
TC
95827
TC
95885
TC
95926
TC
95956
26
95827
26
95885
26
95926
26
95957
TC
95829
TC
95886
TC
95927
TC
95957
26
95829
26
95886
26
95927
26
95958
TC
95860
TC
95887
TC
95928
TC
95958
26
95860
26
95887
26
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
62
01/14
Code
Modifier
95961
TC
95961
26
95962
TC
95962
26
95965
TC
95965
26
95966
TC
95966
26
95967
TC
95967
26
96020
TC
96020
26
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
63
01/14
MPFSDB Indicator Chart
A
Active code. These codes are separately paid under the physician fee schedule if covered. There
will be RVUs and payment amounts for codes with this status. The presence of an “A” indicator
does not mean that Medicare has made a national coverage determination regarding the service;
carriers remain responsible for coverage decisions in the absence of a national Medicare policy.
B
Payment for covered services are always bundled into payment for other services not specified. There will be no RVUs or payment amounts for these codes and no separate payment is
ever made. When these services are covered, payment for them is subsumed by the payment
for the services to which they are incident (an example is a telephone call from a hospital nurse
regarding care of a patient).
C
Carriers price the code. Carriers will establish RVUs and payment amounts for these services,
generally on an individual case basis following review of documentation such as an operative
report.
D
Deleted/discontinued codes.
E
Excluded from physician fee schedule by regulation. These codes are for items and/or services
that CMS chose to exclude from the fee schedule payment by regulation. No RVUs or payment
amounts are shown and no payment may be made under the fee schedule for these codes. Payment for them, when covered, continues under reasonable charge procedures.
F
Deleted/discontinued codes. (Code not subject to a 90 day grace period.) These codes are deleted
effective with the beginning of the year and are never subject to a grace period. This indicator
is no longer effective beginning with the 2005 fee schedule as of January 1, 2005.
G=
Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment
for, these services. (Code subject to a 90 day grace period.) This indicator is no longer effective
beginning with the 2005 fee schedule as of January 1, 2005.
H
Deleted modifier. For 2000 and later years, either the TC or PC component shown for the code
has been deleted and the deleted component is shown in the data base with the H status.
I
Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for,
these services. (Code NOT subject to a 90 day grace period.)
J
Anesthesia services (no relative value units or payment amounts for anesthesia codes on the
database, only used to facilitate the identification of anesthesia services.)
L
Local codes. Carriers will apply this status to all local codes in effect on January 1, 1998 or
subsequently approved by central office for use. Carriers will complete the RVUs and payment
amounts for these codes.
M
Measurement codes, used for reporting purposes only.
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
64
01/14
N
Non-covered service. These codes are carried on the HCPCS tape as noncovered services.
P
Bundled/excluded codes. There are no RVUs and no payment amounts for these services. No
separate payment is made for them under the fee schedule.
If the item or service is covered as incident to a physician service and is provided on the same
day as a physician service, payment for it is bundled into the payment for the physician service
to which it is incident (an example is an elastic bandage furnished by a physician incident to a
physician service).
If the item or service is covered as other than incident to a physician service, it is excluded
from the fee schedule (for example, colostomy supplies) and is paid under the other payment
provision of the Act.
R
Restricted coverage. Special coverage instructions apply.
T
There are RVUs and payment amounts for these services, but they are only paid if there are no
other services payable under the physician fee schedule billed on the same date by the same
provider. If any other services payable under the physician fee schedule are billed on the same
date by the same provider, these services are bundled into the physician services for which
payment is made.
X
Statutory exclusion. These codes represent an item or service that is not in the statutory definition of “physician services” for fee schedule payment purposes. No RVUs or payment amounts
are shown for these codes and no payment may be made under the physician fee schedule.
(Examples are ambulances services and clinical diagnostic laboratory services.)
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
65
01/14
Services Not Reimbursed by Medicare Part B
When the Medicare Physician Fee Schedule Database is updated, the Centers for Medicare & Medicaid
Services (CMS) defines certain services that will not be reimbursed by Medicare Part B. The effective date
for these services is January 1, 2014.
Bundled Codes: Status B Indicator
Payment for covered services is always bundled into payment for other services not specified. When
these services are covered, payment for them is subsumed by the payment for the services to which they
are incident (an example is a telephone call from a hospital nurse regarding care of a patient). You cannot
bill the patient for these services. (The TC modifier is a HCPCS modifier and the 26 modifier is a CPT
modifier.)
HCPCS
Code
A4262
A4263
A4270
A4300
A4550
G0269
Q3031
R0076
CPT Code
15850
20930
20936
22841
36000
36416
38204
90885
90887
90889
92352
92353
92354
92355
92358
CPT Code
92371
92531
92532
92533
92534
92605
92606
92618
92921
92925
92929
92934
92938
92944
93740
93770
94005
94150
94150
94150
96040
96902
97010
97602
98960
CPT Code
98961
98962
99000
99001
99002
99024
99050
99051
99053
99056
99058
99060
99070
99071
99078
99080
99090
99091
99100
99116
99135
99140
99288
99339
99340
CPT Code
99358
99359
99363
99364
99366
99367
99368
99374
99377
99379
99380
99446
99447
99448
99449
99485
99486
99487
99488
99489
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
66
01/14
Invalid Codes for Medicare: Status Indicator I
Codes with a status indicator of “I” are not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment for, these services.
HCPCS
Code
A0021
A0080
A0090
A0100
A0110
A0120
A0130
A0140
A0160
A0170
A0180
A0190
A0200
A0210
A0225
A0380
A0390
A0998
A4232
A4264
A4266
A4267
A4268
A4269
A4466
A4555
A4566
A4570
A4580
A4590
A9152
A9153
HCPCS
Code
A9180
A9272
A9274
A9279
G8559
G8560
G8561
G8562
G8563
G8564
G8565
G8566
G8567
G8568
G9050
G9051
G9052
G9053
G9054
G9055
G9056
G9057
G9058
G9059
G9060
G9061
G9062
H0001
H0002
H0003
H0004
H0005
HCPCS
Code
H0006
H0007
H0008
H0009
H0010
H0011
H0012
H0013
H0014
H0015
H0016
H0017
H0018
H0019
H0020
H0021
H0022
H0023
H0024
H0025
H0026
H0027
H0028
H0029
H0030
H0031
H0032
H0033
H0034
H0035
H0036
H0037
HCPCS
Code
H0038
H0039
H0040
H0041
H0042
H0043
H0044
H0045
H0046
H0047
H0048
H0049
H0050
H1000
H1001
H1002
H1003
H1004
H1005
H1010
H1011
H2000
H2001
H2010
H2011
H2012
H2013
H2014
H2015
H2016
H2017
H2018
HCPCS
Code
H2019
H2020
H2021
H2022
H2023
H2024
H2025
H2026
H2027
H2028
H2029
H2030
H2031
H2032
H2033
H2034
H2035
H2036
H2037
J1826
J7306
J7307
J8565
P7001
Q3028
S0012
S0014
S0017
S0020
S0021
S0023
HCPCS
Code
S0028
S0030
S0032
S0034
S0039
S0040
S0073
S0074
S0077
S0078
S0080
S0081
S0088
S0090
S0091
S0092
S0093
S0104
S0106
S0108
S0109
S0117
S0119
S0122
S0126
S0128
S0132
S0136
S0137
S0138
S0139
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
67
01/14
HCPCS
Code
S0140
S0142
S0145
S0148
S0155
S0156
S0157
S0160
S0164
S0166
S0169
S0170
S0171
S0172
S0174
S0175
S0176
S0177
S0178
S0179
S0182
S0183
S0187
S0189
S0190
S0191
S0194
S0195
S0197
S0199
S0201
S0207
S0208
S0209
S0215
S0220
S0221
HCPCS
Code
S0250
S0255
S0257
S0260
S0265
S0270
S0271
S0272
S0273
S0274
S0280
S0281
S0302
S0310
S0315
S0316
S0317
S0320
S0340
S0341
S0342
S0353
S0354
S0390
S0395
S0400
S0500
S0504
S0506
S0508
S0510
S0512
S0514
S0515
S0516
S0518
S0580
HCPCS
Code
S0581
S0590
S0592
S0595
S0596
S0601
S0610
S0612
S0613
S0618
S0620
S0621
S0622
S0630
S0800
S0810
S0812
S1001
S1002
S1015
S1016
S1030
S1031
S1040
S1090
S2053
S2054
S2055
S2060
S2061
S2065
S2066
S2067
S2068
S2070
S2079
S2080
HCPCS
Code
S2083
S2095
S2102
S2103
S2107
S2112
S2115
S2117
S2118
S2120
S2140
S2142
S2150
S2152
S2202
S2205
S2206
S2207
S2208
S2209
S2225
S2230
S2235
S2260
S2265
S2266
S2267
S2300
S2325
S2340
S2341
S2342
S2348
S2350
S2351
S2360
S2361
HCPCS
Code
S2400
S2401
S2402
S2403
S2404
S2405
S2409
S2411
S2900
S3000
S3005
S3600
S3601
S3620
S3630
S3645
S3650
S3652
S3655
S3708
S3721
S3722
S3800
S3840
S3841
S3842
S3844
S3845
S3846
S3849
S3850
S3852
S3853
S3854
S3855
S3861
HCPCS
Code
S3865
S3866
S3870
S3890
S3900
S3902
S3904
S4005
S4011
S4013
S4014
S4015
S4016
S4017
S4018
S4020
S4021
S4022
S4023
S4025
S4026
S4027
S4028
S4030
S4031
S4035
S4037
S4040
S4042
S4981
S4989
S4990
S4991
S4993
S4995
S5000
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
68
01/14
HCPCS
Code
S5001
S5010
S5011
S5012
S5013
S5014
S5035
S5036
S5100
S5101
S5102
S5105
S5108
S5109
S5110
S5111
S5115
S5116
S5120
S5121
S5125
S5126
S5130
S5131
S5135
S5136
S5140
S5141
S5145
S5146
S5150
S5151
S5160
S5161
S5162
S5165
S5170
HCPCS
Code
S5175
S5180
S5181
S5185
S5190
S5199
S5497
S5498
S5501
S5502
S5517
S5518
S5520
S5521
S5522
S5523
S5550
S5551
S5552
S5553
S5560
S5561
S5565
S5566
S5570
S5571
S8030
S8035
S8037
S8040
S8042
S8055
S8080
S8085
S8092
S8096
S8097
HCPCS
Code
S8100
S8101
S8110
S8120
S8121
S8130
S8131
S8185
S8186
S8189
S8210
S8262
S8265
S8270
S8301
S8415
S8420
S8421
S8422
S8423
S8424
S8425
S8426
S8427
S8428
S8429
S8430
S8431
S8450
S8451
S8452
S8460
S8490
S8930
S8940
S8948
S8950
HCPCS
Code
S8990
S8999
S9001
S9007
S9015
S9024
S9025
S9034
S9055
S9056
S9061
S9083
S9088
S9090
S9097
S9098
S9110
S9117
S9122
S9123
S9124
S9125
S9126
S9127
S9128
S9129
S9131
S9140
S9141
S9145
S9150
S9152
S9208
S9209
S9211
S9212
S9213
HCPCS
Code
S9214
S9325
S9326
S9327
S9328
S9329
S9330
S9331
S9335
S9336
S9338
S9339
S9340
S9341
S9342
S9343
S9345
S9346
S9347
S9348
S9349
S9351
S9353
S9355
S9357
S9359
S9361
S9363
S9364
S9365
S9366
S9367
S9368
S9370
S9372
S9373
HCPCS
Code
S9374
S9375
S9376
S9377
S9379
S9381
S9401
S9430
S9433
S9434
S9435
S9436
S9437
S9438
S9439
S9441
S9442
S9443
S9444
S9445
S9446
S9447
S9449
S9451
S9452
S9453
S9454
S9455
S9460
S9465
S9470
S9472
S9473
S9474
S9475
S9476
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
69
01/14
HCPCS
Code
S9480
S9482
S9484
S9485
S9490
S9494
S9497
S9500
S9501
S9502
S9503
S9504
S9529
S9537
S9538
S9542
S9558
S9559
S9560
S9562
S9590
S9810
S9900
S9960
S9961
S9970
S9975
S9976
S9977
S9981
S9982
S9986
S9988
S9989
S9990
S9991
S9992
HCPCS
Code
S9994
S9996
S9999
T1000
T1001
T1002
T1003
T1004
T1005
T1006
T1007
T1009
T1010
T1012
T1013
T1014
T1015
T1016
T1017
T1018
T1019
T1020
T1021
T1022
T1023
T1024
T1025
T1026
T1027
T1028
T1029
T1030
T1031
T1502
T1503
T1505
T1999
HCPCS
Code
T2001
T2002
T2003
T2004
T2005
T2007
T2010
T2011
T2012
T2013
T2014
T2015
T2016
T2017
T2018
T2019
T2020
T2021
T2022
T2023
T2024
T2025
T2026
T2027
T2028
T2029
T2030
T2031
T2032
T2033
T2034
T2035
T2036
T2037
T2038
T2039
T2040
HCPCS
Code
T2041
T2042
T2043
T2044
T2045
T2046
T2048
T2049
T2101
T4541
T4542
T5001
T5999
CDT Code
D0210
D0220
D0230
D0290
D0310
D0320
D0321
D0322
D0330
D0340
D0350
D1352
D3354
D4210
D4211
D4212
D5913
D5914
D5915
CDT Code
CDT Code
D5916
D6011
D5919
D6040
D5922
D6050
D5923
D6055
D5924
D6080
D5925
D6090
D5926
D6095
D5927
D6100
D5928
D6101
D5929
D6102
D5931
D6103
D5932
D6104
D5933
D6199
D5934
D7251
D5935
D7285
D5936
D7286
D5937
D7287
D5952
D7295
D5953
D7310
D5954
D7320
D5955
D7340
D5958
D7350
D5959
D7410
D5960
D7411
D5982
D7412
D5988
D7413
D5992
D7414
D5993
D7415
D5994
D7440
D5999
D7441
D6010
D7450
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
70
01/14
CDT Code
CDT Code
CDT Code
CDT Code
CPT Code
CPT Code
D7451
D7780
D7948
D9985
1005F
1152F
D7460
D7810
D7949
D9999
1008F
1153F
D7461
D7820
D7950
CPT Code
1015F
1157F
D7465
D7830
D7955
0001F
1018F
1158F
D7471
D7840
D7960
0005F
1019F
1159F
D7472
D7850
D7970
0012F
1022F
1160F
D7473
D7852
D7971
0014F
1026F
1180F
D7485
D7854
D7972
0015F
1030F
1182F
D7490
D7856
D7980
0501F
1034F
1183F
D7510
D7858
D7981
0502F
1035F
1450F
D7520
D7860
D7982
0503F
1050F
1451F
D7530
D7865
D7983
0505F
1052F
1500F
D7540
D7870
D7990
0507F
1055F
1501F
D7550
D7872
D7991
0514F
1060F
1502F
D7560
D7873
D7995
0516F
1061F
1503F
D7610
D7874
D7996
0519F
1065F
1504F
D7620
D7875
D7999
0525F
1066F
1505F
D7630
D7876
D9210
0535F
1070F
2001F
D7640
D7877
D9211
0545F
1071F
2002F
D7650
D7880
D9212
0550F
1110F
2004F
D7660
D7899
D9215
0551F
1116F
2014F
D7670
D7910
D9220
0555F
1118F
2018F
D7671
D7911
D9221
0575F
1121F
2020F
D7680
D7912
D9241
0580F
1127F
2028F
D7710
D7920
D9242
0581F
1128F
2029F
D7720
D7921
D9310
0582F
1134F
2030F
D7730
D7941
D9410
0583F
1135F
2031F
D7740
D7943
D9420
0584F
1136F
2035F
D7750
D7944
D9430
1000F
1137F
2044F
D7760
D7945
D9440
1002F
1150F
2050F
D7770
D7946
D9450
1003F
1151F
2060F
D7771
D7947
D9610
1004F
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
71
01/14
CPT Code
CPT Code
CPT Code
CPT Code
CPT Code
CPT Code
27215
3089F
3293F
3552F
4016F
4145F
27216
3090F
3294F
3555F
4017F
4149F
27217
3091F
3317F
3572F
4018F
4150F
27218
3092F
3318F
3573F
4019F
4153F
3006F
3093F
3324F
3650F
4030F
4155F
3008F
3110F
3325F
3751F
4033F
4157F
3011F
3111F
3330F
3752F
4041F
4158F
3015F
3112F
3331F
3753F
4050F
4159F
3018F
3115F
3351F
3754F
4051F
4163F
3019F
3117F
3352F
3755F
4052F
4165F
3020F
3118F
3353F
3756F
4053F
4167F
3025F
3119F
3354F
3757F
4054F
4168F
3027F
3130F
3450F
3758F
4055F
4169F
3028F
3132F
3451F
3759F
4056F
4174F
3035F
3140F
3452F
3760F
4058F
4176F
3037F
3141F
3490F
3761F
4060F
4178F
3040F
3142F
3491F
3762F
4062F
4180F
3042F
3150F
3492F
3763F
4063F
4181F
3055F
3200F
3493F
38207
4064F
4182F
3056F
3216F
3497F
38208
4065F
4185F
3073F
3218F
3498F
38209
4066F
4186F
3074F
3220F
3500F
38210
4067F
4188F
3075F
3230F
3502F
38211
4069F
4189F
3077F
3266F
3503F
38212
4070F
4190F
3078F
3268F
3511F
38213
4073F
4191F
3079F
3278F
3512F
38214
4077F
4200F
3080F
3279F
3513F
38215
4079F
4201F
3082F
3280F
3514F
4003F
4133F
4210F
3083F
3281F
3515F
4011F
4134F
4220F
3084F
3290F
3520F
4012F
4135F
4221F
3085F
3291F
3550F
4014F
4136F
4230F
3088F
3292F
3551F
4015F
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
72
01/14
CPT Code
CPT Code
CPT Code
CPT Code
CPT Code
4240F
4554F
81508
95120
99510
4242F
4555F
81509
95125
99511
4267F
4556F
81510
95130
99512
4268F
4557F
81511
95131
99600
4269F
4558F
81512
95132
99601
4270F
4559F
81599
95133
99602
4271F
4560F
88342
95134
4274F
4561F
88342
95941
4276F
4562F
88342
97005
4279F
4563F
88343
97006
4280F
5005F
88343
97014
4290F
5020F
88343
99241
4293F
5060F
88375
99242
4300F
5062F
9001F
99243
4301F
5100F
9002F
99244
4305F
5200F
9005F
99245
4306F
5250F
90281
99251
4324F
6005F
90283
99252
4326F
6040F
90287
99253
4330F
6070F
90288
99254
4350F
6080F
90291
99255
4450F
6090F
90384
99375
4470F
6100F
90386
99378
44705
7020F
90389
99500
4480F
76140
90399
99501
4481F
80055
90658
99502
4540F
80100
90723
99503
4541F
80101
90738
99504
4550F
80104
90748
99505
4551F
81500
90863
99506
4552F
81503
92630
99507
4553F
81506
92633
99509
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
73
01/14
Bundled/Excluded Codes: Status P Indicator Codes with a status indicator of “P” are bundled/excluded codes. If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it
is bundled into the payment for the physician service to which it is incident (an example is an elastic
bandage furnished by a physician incident to a physician service). If the item or service is covered as other
than incident to a physician service, it is excluded from the fee schedule (for example, colostomy supplies)
and is paid under the other payment provision of the Act. No separate payment will be made for them under
the Medicare Physician Fee Schedule.
HCPCS
Code
HCPCS
Code
HCPCS
Code
HCPCS
Code
HCPCS
Code
HCPCS
Code
A4211
A4335
A4470
A5114
A6217
A6247
A4212
A4338
A4480
A5121
A6218
A6248
A4220
A4340
A4556
A5122
A6219
A6250
A4253
A4344
A4557
A5126
A6220
A6251
A4256
A4346
A4558
A5131
A6221
A6252
A4258
A4351
A4649
A6154
A6222
A6253
A4259
A4352
A5051
A6196
A6223
A6254
A4265
A4354
A5052
A6197
A6224
A6255
A4301
A4355
A5053
A6198
A6228
A6256
A4305
A4356
A5054
A6199
A6229
A6257
A4306
A4357
A5055
A6203
A6230
A6258
A4310
A4358
A5061
A6204
A6234
A6259
A4311
A4361
A5062
A6205
A6235
A6260
A4312
A4362
A5063
A6206
A6236
A6261
A4313
A4364
A5071
A6207
A6237
A6262
A4314
A4367
A5072
A6208
A6238
A6266
A4315
A4397
A5073
A6209
A6239
A6402
A4316
A4398
A5081
A6210
A6240
A6403
A4320
A4399
A5082
A6211
A6241
A6404
A4322
A4400
A5093
A6212
A6242
V2520
A4326
A4402
A5102
A6213
A6243
A4327
A4404
A5105
A6214
A6244
A4328
A4455
A5112
A6215
A6245
A4330
A4465
A5113
A6216
A6246
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
74
01/14
Non-covered Services: Status N Indicator These are non-covered services and will not be paid by Medicare Part B. (The TC modifier is a HCPCS
modifier and the 26 modifier is a CPT modifier.)
HCPCS
Code
HCPCS
Code
HCPCS
Code
HCPCS
Code
HCPCS
Code
HCPCS
Code
A0888
A6549
G0255
T4523
V5014
V5243
A4210
A9270
G0282
T4524
V5020
V5244
A4250
A9273
G0295
T4525
V5030
V5245
A4252
A9275
G0428
T4526
V5040
V5246
A4261
A9276
G9013
T4527
V5050
V5247
A4490
A9277
G9014
T4528
V5060
V5248
A4495
A9278
G9016
T4529
V5070
V5249
A4500
A9280
G9147
T4530
V5080
V5250
A4510
A9281
J3520
T4531
V5090
V5251
A4520
A9282
J3535
T4532
V5095
V5252
A4554
A9283
J3570
T4533
V5100
V5253
A4575
A9300
J7300
T4534
V5110
V5254
A4627
A9586
J7301
T4535
V5120
V5255
A4670
G0122
J7302
T4536
V5130
V5256
A6000
G0122
J7303
T4537
V5140
V5257
A6413
G0122
J7304
T4538
V5150
V5258
A6530
G0219
J8499
T4539
V5160
V5259
A6533
G0219
J8515
T4540
V5170
V5260
A6534
G0219
M0075
T4543
V5180
V5261
A6535
G0235
M0076
T4544
V5190
V5262
A6536
G0235
M0100
V2025
V5200
V5263
A6537
G0235
M0300
V2702
V5210
V5264
A6538
G0252
M0301
V2787
V5220
V5265
A6539
G0252
P2031
V2788
V5230
V5266
A6540
G0252
Q0144
V5008
V5240
V5267
A6541
G0255
T4521
V5010
V5241
V5268
A6544
G0255
T4522
V5011
V5242
V5269
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
75
01/14
HCPCS
Code
CDT Code
CDT Code
CDT Code
CDT Code
CDT Code
D0273
D1320
D2650
D2933
D3330
V5270
D0363
D1330
D2651
D2934
D3331
V5271
D0364
D1351
D2652
D2940
D3332
V5272
D0365
D1555
D2662
D2941
D3333
V5273
D0366
D2140
D2663
D2949
D3346
V5274
D0367
D2150
D2664
D2950
D3347
V5275
D0368
D2160
D2710
D2951
D3348
V5281
D0369
D2161
D2712
D2952
D3351
V5282
D0370
D2330
D2720
D2953
D3352
V5283
D0371
D2331
D2721
D2954
D3353
V5284
D0380
D2332
D2722
D2955
D3355
V5285
D0381
D2335
D2740
D2957
D3356
V5286
D0382
D2390
D2750
D2960
D3357
V5287
D0383
D2391
D2751
D2961
D3410
V5288
D0384
D2392
D2752
D2962
D3421
V5289
D0385
D2393
D2780
D2971
D3425
V5290
D0386
D2394
D2781
D2975
D3426
V5298
D0391
D2410
D2782
D2980
D3427
V5336
D0393
D2420
D2783
D2981
D3428
V5362
D0394
D2430
D2790
D2982
D3429
V5363
D0395
D2510
D2791
D2983
D3430
V5364
D0415
D2520
D2792
D2990
D3431
D0417
D2530
D2794
D3110
D3432
D0418
D2542
D2799
D3120
D3450
D0425
D2543
D2910
D3220
D3470
D0470
D2544
D2915
D3221
D3910
D0486
D2610
D2920
D3222
D3920
D1110
D2620
D2921
D3230
D3950
D1120
D2630
D2929
D3240
D4230
D1206
D2642
D2930
D3310
D4231
D1208
D2643
D2931
D3320
D4240
D1310
D2644
D2932
CDT Code
D0120
D0140
D0145
D0160
D0170
D0180
D0190
D0191
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
76
01/14
CDT Code
CDT Code
CDT Code
CDT Code
CDT Code
CDT Code
D4241
D5422
D5863
D6074
D6605
D6940
D4245
D5510
D5864
D6075
D6606
D6950
D4249
D5520
D5865
D6076
D6607
D6975
D4261
D5610
D5866
D6077
D6608
D6980
D4265
D5620
D5867
D6078
D6609
D6985
D4266
D5630
D5875
D6079
D6610
D6999
D4267
D5640
D5899
D6091
D6611
D7270
D4274
D5650
D5986
D6092
D6612
D7272
D4275
D5660
D5991
D6093
D6613
D7280
D4276
D5670
D6012
D6094
D6614
D7282
D4320
D5671
D6013
D6190
D6615
D7290
D4321
D5710
D6051
D6194
D6624
D7292
D4341
D5711
D6053
D6205
D6634
D7293
D4342
D5720
D6054
D6210
D6710
D7294
D4910
D5721
D6056
D6211
D6720
D7311
D4920
D5730
D6057
D6212
D6721
D7871
D4921
D5731
D6058
D6214
D6722
D7951
D4999
D5740
D6059
D6240
D6740
D7952
D5110
D5741
D6060
D6241
D6750
D7953
D5120
D5750
D6061
D6242
D6751
D7963
D5130
D5751
D6062
D6245
D6752
D7997
D5140
D5760
D6063
D6250
D6780
D7998
D5211
D5761
D6064
D6251
D6781
D8010
D5212
D5810
D6065
D6252
D6782
D8020
D5213
D5811
D6066
D6253
D6783
D8030
D5214
D5820
D6067
D6545
D6790
D8040
D5225
D5821
D6068
D6548
D6791
D8050
D5226
D5850
D6069
D6600
D6792
D8060
D5281
D5851
D6070
D6601
D6793
D8070
D5410
D5860
D6071
D6602
D6794
D8080
D5411
D5861
D6072
D6603
D6930
D8090
D5421
D5862
D6073
D6604
Continued on next page
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
77
01/14
CDT Code
CPT Code
CPT Code
CPT Code
CPT Code
D8210
43842
88007
92595
99397
D8220
48160
88012
93668
99401
D8660
55970
88014
96110
99402
D8670
55980
88016
96155
99403
D8680
58300
88020
97810
99404
D8690
61640
88025
97811
99408
D8691
61641
88027
97813
99409
D8692
61642
88028
97814
99411
D8693
65760
88029
98943
99412
D8694
65765
88036
98966
99420
D8999
65767
88037
98967
99429
D9120
65771
88040
98968
99441
D9612
69090
88045
98969
99442
D9910
69710
88099
99026
99443
D9911
74263
90875
99027
99444
D9920
74263
90876
99075
99450
D9941
74263
90882
99172
D9942
76390
92015
99173
D9970
76390
92310
99174
D9971
76390
92314
99381
D9972
78350
92340
99382
D9973
78350
92341
99383
D9974
78350
92342
99384
D9975
78351
92370
99385
78609
92551
99386
CPT Code
78609
92559
99387
0085T
78609
92560
99391
0188T
80050
92590
99392
0189T
86910
92591
99393
22526
86911
92592
99394
22527
88000
92593
99395
37216
88005
92594
99396
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
78
01/14
Services Same Day/Provider: Status T Indicator
These services are only paid if there are no other services payable under the physician fee schedule
billed on the same date by the same provider if the same provider submits any other services payable
under the physician fee schedule on the same date, these services are bundled into the physician service(s)
for which payment is made.
HCPCS Code
G0117
G0118
CPT Code
36591
36592
36598
94760
94761
96523
CPT codes, descriptors and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Current Dental Terminology, fourth edition (CDT) (including procedure codes, nomenclature, descriptors and
other data contained therein) is copyright by the American Dental Association. ©2002, 2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
79
01/14
CMS Offers FREE Medicare Training for Providers
CMS Web Training
The Centers for Medicare & Medicaid Services (CMS) has launched a series of education and training programs
designed to leverage emerging Internet and satellite technologies to offer just-in-time training to Medicare providers and suppliers throughout the United States. Many of these programs include free, downloadable computer/Web based training courses. These courses are also available on CD-ROM.
http://www.cms.gov/MLNGenInfo
Palmetto GBA Medicare Customer Information and Outreach
Training Available
Important Telephone Numbers
Provider Contact Center
1-866-830-3043 (Toll-Free)
To request a Medicare Education meeting/seminar at no
cost to you, complete and fax the form located on the
http://www.PalmettoGBA.com/J11B/forms.
Electronic Data Interchange (EDI)
Technical Support
(866) 749-4301
http://www.PalmettoGBA.com/Medicare
Important Sources For You
Medicare Beneficiary Call Center
1-800-MEDICARE (1-800-633-4227)
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http://www.cms.gov
http://www.cms.gov/MLNGenInfo
http://www.cms.gov/CMSforms/CMSforms/list.asp
TTY 1-877-486-2048
Attention: Billing Manager
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