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Codes That Do Not Meet Payment Determination Criteria - Tables II and III

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Codes That Do Not Meet Payment Determination Criteria - Tables II and III

The following table lists the codes for services that do not meet payment determination criteria. If criteria for the use of modifier code GA are met, GA should be appended when billing for the services listed. See Modifier Code GA .

 

Table I (CPT Codes)   Table III (CPT Category III Codes 
 

Table II. HCPCS Codes

HCPCS Codes

Description

A2001Hcpcs: innovamatrix ac, per square centimeter (effective 1/1/2022);  irf pps: miscellaneous with motor >49.15.,without comorbidities
A2002Hcpcs: mirragen advanced wound matrix, per square centimeter (effective 1/1/2022); irf pps: miscellaneous with motor >38.75 & motor <49.15.,without comorbidities
A2004Hcpcs: xcellistem, per square centimeter (effective 1/1/2022); irf pps: miscellaneous with motor <27.85, without comorbidities
A2005Hcpcs: microlyte matrix, per square centimeter (effective 1/1/2022); irf pps: miscellaneous m <46.50 and a <77.50.,without comorbidities
A2006Novosorb synpath dermal matrix, per square centimeter
A2007Restrata, per square centimeter
A2008Theragenesis, per sq cm
A2009Symphony, per sq cm
A2010Apis, per square centimeter
A2011Supra sdrm, per square centimeter
A2012Suprathel, per square centimeter
A2013Innovamatrix fs, per square centimeter
A2019Kerecis omega3 marigen shield, per square centimeter
A2020Ac5 advanced wound system (ac5)
A2021Neomatrix, per square centimeter
A2026Restrata minimatrix, 5 mg
A2027Matriderm, per square centimeter
A2028Micromatrix flex, per mg
A2029Mirotract wound matrix sheet, per cubic centimeter
A2030Miro3d fibers, per milligram
A2031Mirodry wound matrix, per square centimeter
A2032Myriad matrix, per square centimeter
A2033Myriad morcells, 4 milligrams
A2034Foundation drs solo, per square centimeter
A2035Corplex p or Theracor p or Allacor p, per milligram
A2040Microlyte painguard, per square centimeter
A2041Foundation drs+ duo, per square centimeter
A2042Foundation drs+ solo, per square centimeter
A4543Supplies for transcutaneous electrical nerve stimulator, for nerves in the auricular region, per month
A7021Supplies and accessories for lung expansion airway clearance, continuous high frequency oscillation, and nebulization device (e.g., handset, nebulizer kit, biofilter)
A4100Skin substitute, fda cleared as a device, not otherwise specified
A4467Belt, strap, sleeve, garment, or covering, any type​
A4540DISTAL TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR, STIMULATES PERIPHERAL NERVES OF THE UPPER ARM
A4541MONTHLY SUPPLIES FOR USE OF DEVICE CODED AT E0733
A4542SUPPLIES AND ACCESSORIES FOR EXTERNAL UPPER LIMB TREMOR STIMULATOR OF THE PERIPHERAL NERVES OF THE WRIST
A2043Biobrane, per square centimeter
A2044Biobrane glove, each
A2045Novashield or novogen wound matrix, per square centimeter
A4318Female external urinary collection cup, with or without ring attachment, per day
A4560Neuromuscular electrical stimulator (nmes), disposable, replacement only
A4555Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only
A4593Neuromodulation stimulator system, adjunct to rehabilitation therapy regime
A4594Neuromodulation stimulator system, adjunct to rehabilitation therapy regime, mouthpiece each
A4670Automatic blood pressure monitor
A6460Synthetic resorbable wound dressing, sterile, pad size 16 sq. In. Or less, without adhesive border, each dressing
A6461Synthetic resorbable wound dressing, sterile, pad size more than 16 sq. In. But less than or equal to 48 sq. In., without adhesive border, each dressing
A6591External urinary catheter; non-disposable, for use with suction pump, per month
A7023MECHANICAL ALLERGEN PARTICLE BARRIER/INHALATION FILTER, CREAM, NASAL, TOPICAL
A7047

Oral interface used with respiratory suction pump, each

For more detailed information, please see associated medical policy Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea

A7049Expiratory positive airway pressure intranasal resistance valve
A9154Artificial saliva, 1 ml
A9284Spirometer, non-electronic, includes all accessories
A9291Prescription digital behavioral therapy, fda cleared, per course of treatment
A9586Florbetapir F18, diagnostic, per study dose, up to 10 millicuries
A9599Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (PET) imaging, per study dose
B4105In-line cartridge containing digestive enzyme(s) for enteral feeding, each
C1602ORTHOPEDIC/DEVICE/DRUG MATRIX/ABSORBABLE BONE VOID FILLER, ANTIMICROBIAL-ELUTING (IMPLANTABLE)
C1604GRAFT, TRANSMURAL TRANSVENOUS ARTERIAL BYPASS (IMPLANTABLE), WITH ALL DELIVERY SYSTEM COMPONENTS
C1605PACEMAKER, LEADLESS, DUAL CHAMBER (RIGHT ATRIAL AND RIGHT VENTRICULAR IMPLANTABLE COMPONENTS), RATE-RESPONSIVE, INCLUDING ALL NECESSARY COMPONENTS FOR IMPLANTATION
C1833Monitor, cardiac, including intracardiac lead and all system components (implantable)
C8000Support device, extravascular, for arteriovenous fistula (implantable)
C9354Acellular pericardial tissue matrix of nonhuman origin (Veritas), per square centimeter
C9356Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per square centimeter
C9358Dermal substitute, native, non-denatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters
C9360Dermal substitute, native, non-denatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters
C9363Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter
C9364Porcine implant, Permacol, per square centimeter
E0152Walker, battery powered, wheeled, folding, adjustable or fixed height
E0201Penile contracture device, manual, greater than 3 lbs traction force
E0231Noncontact wound warming device (temperature control unit, ac adapter and power cord) for use with warming card and wound cover
E0232Warming card for use with the noncontact wound warming device and noncontact wound warming cover
E0446Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories
E0469Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device
E0487Spirometer, electronic, includes all accessories
E0492POWER SOURCE AND CONTROL ELECTRONICS UNIT FOR ORAL DEVICE/APPLIANCE FOR NEUROMUSCULAR ELECTRICAL STIMULATION OF THE TONGUE MUSCLE, CONTROLLED BY PHONE APPLICATION
E0493ORAL DEVICE/APPLIANCE FOR NEUROMUSCULAR ELECTRICAL STIMULATION OF THE TONGUE MUSCLE, USED IN CONJUNCTION WITH THE POWER SOURCE AND CONTROL ELECTRONICS UNIT, CONTROLLED BY PHONE APPLICATION, 90-DAY SUPPLY
E0530ELECTRONIC POSITIONAL OBSTRUCTIVE SLEEP APNEA TREATMENT, WITH SENSOR, INCLUDES ALL COMPONENTS AND ACCESSORIES, ANY TYPE
E0670Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk
E0676Intermittent limb compression device (includes all accessories) not otherwise specified
E0677Non-pneumatic sequential compression garment, trunk
E0711Upper extremity medical tubing/lines enclosure or covering device, restricts elbow range of motion
E0715Intravaginal device intended to strengthen pelvic floor muscles during kegel exercises
E0716Supplies and accessories for intravaginal device intended to strengthen pelvic floor muscles during kegel exercises
E0721Transcutaneous electrical nerve stimulatory, stimulates nerves in the auricular region
E0732CRANIAL ELECTROTHERAPY STIMULATION (CES) SYSTEM, ANY TYPE
E0733TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR FOR ELECTRICAL STIMULATION OF THE TRIGEMINAL NERVE
E0734EXTERNAL UPPER LIMB TREMOR STIMULATOR OF THE PERIPHERAL NERVES OF THE WRIST
E0735NON-INVASIVE VAGUS NERVE STIMULATOR
E0830Ambulatory traction device, all types, each
E1800Dynamic adjustable elbow extension/flexion device, includes soft interface material
E1801Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1802Dynamic adjustable forearm pronation/supination device, includes soft interface material
E1803Dynamic adjustable elbow extension only device, includes soft interface material
E1804Dynamic adjustable elbow flexion only device, includes soft interface material
E1805Dynamic adjustable wrist extension/flexion device, includes soft interface material
E1806Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1807Dynamic adjustable wrist extension only device, includes soft interface material
E1808Dynamic adjustable wrist flexion only device, includes soft interface material
E1810Dynamic adjustable knee extension/flexion device, includes soft interface material
E1811Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1812Dynamic knee extension/flexion device with active resistance control
E1813Dynamic adjustable knee extension only device, includes soft interface material
E1814Dynamic adjustable knee flexion only device, includes soft interface material
E1815Dynamic adjustable ankle extension/flexion device, includes soft interface material
E1816Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories
E1818Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories
E1820Replacement soft interface material, dynamic adjustable extension/flexion device
E1821Replacement soft interface material/cuffs for bi-directional static progressive stretch device
E1822Dynamic adjustable ankle extension only device, includes soft interface material
E1823Dynamic adjustable ankle flexion only device, includes soft interface material
E1825Dynamic adjustable finger extension/flexion device, includes soft interface material
E1826Dynamic adjustable finger extension only device, includes soft interface material
E1827Dynamic adjustable finger flexion only device, includes soft interface material
E1828Dynamic adjustable toe extension only device, includes soft interface material
E1829Dynamic adjustable toe flexion only device, includes soft interface material
E1830Dynamic adjustable toe extension/flexion device, includes soft interface material
E1831Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1832Static progressive stretch finger device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1840Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material
E1841Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories
E1905Virtual reality cognitive behavioral therapy device (cbt), including pre-programmed therapy software
E2001SUCTION PUMP, HOME MODEL, PORTABLE OR STATIONARY, ELECTRIC, ANY TYPE, FOR USE WITH EXTERNAL URINE MANAGEMENT SYSTEM
E2358Power wheelchair accessory, group 34 nonsealed lead acid battery, each
E2360Power wheelchair accessory, 22 NF nonsealed lead acid battery, each
E2362Power wheelchair accessory, group 24 nonsealed lead acid battery, each
E2364Power wheelchair accessory, U-1 nonsealed lead acid battery, each
E2372Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only
E2513Accessory for speech generating device, electromyographic sensor
E3000SPEECH VOLUME MODULATION SYSTEM, ANY TYPE, INCLUDING ALL COMPONENTS AND ACCESSORIES
E3200Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only
G0183Quantitative software measurements of cardiac volume, cardiac chambers volumes and left ventricular wall mass derived from CT scan(s) data of the chest/heart (with or without contrast) 
G0250Physician review, interpretation and patient management of home INR testing
G0259Injection procedure for sacroiliac joint; arthrography
G0276Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression (pild) or placebo-control, performed in an approved coverage with evidence development (ced) clinical trial
G0281Electrical stimulation, (unattended), to one or more areas, for chronic stage III & stage IV pressure ulcers, arterial ulcers, diabetic ulcers, & venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care
G0282Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281
G0295Electromagnetic therapy, to one or more areas, for wound care other than described in G0329, or for other uses
G0327Colorectal cancer screening; blood-based biomarker.
G0329Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days on conventional care as part of a therapy plan of care
G0409Social work and psychological services, directly relating to and/or furthering the patient's rehabilitation goals, each 15 minutes, face-to-face; individual (services provided by a CORF qualified social worker or psychologist in a CORF)
G0428Collagen Meniscus Implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex)
G0465Autologous platelet rich plasma (prp) for diabetic chronic wounds/ulcers, using an fda-cleared device (includes administration, dressings, phlebotomy, centrifugation, and all other preparatory procedures, per treatment)
G0537Administration of a standardized, evidence-based atherosclerotic cardiovascular disease (ASCVD) risk assessment, 5-15 minutes, not more often than every 12 months
G0538Atherosclerotic cardiovascular disease (ASCVD) risk management services; clinical staff time; per calendar month
G0552Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan
G0553First 20 minutes of monthly treatment management services directly related to the patient's therapeutic use of the digital mental health treatment (dmht) device that augments a behavioral therapy plan, physician/other qualified health care professional ti
G0554Each additional 20 minutes of monthly treatment management services directly related to the patient's therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional
G0555Provision of replacement patient electronics system (e.g., system pillow, handheld reader) for home pulmonary artery pressure monitoring
G05663D radiodensity-value bone imaging, algorithm derived, from previous magnetic resonance examination of the same anatomy
G0680Detection and quantification of coronary artery calcium and/or aortic valve calcification from algorithmic analysis of computed tomography of the chest with report
G2000Blinded administration of convulsive therapy procedure, either electroconvulsive therapy (ect, current covered gold standard) or magnetic seizure therapy (mst, non-covered experimental therapy), performed in an approved ide-based clinical trial, per treatment session
G2214Initial or subsequent psychiatric collaborative care management, first 30 minutes in a month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional
G2250Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment
G9147Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or, urine urea nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration
H2038Skills training and development, per diem
J0591Injection, deoxycholic acid, 1 mg
J0691Injection, lefamulin, 1 mg
J1072Injection, testosterone cypionate (Azmiro), 1 mg
J1938Injection, furosemide, 1 mg
J3304Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg
J3530Nasal vaccine inhalation
J3570Laetrile, amygdalin, vitamin B-17
K1002Cranial electrotherapy stimulation (CES) system with supplies access
K1004Low frequency ultrasonic diathermy treatment device for home use
K1005 Disposable collection and storage bag for breast milk, any size, any type
K1023Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm
K1026Mechanical allergen particle barrier/inhalation filter, cream, nasal, topical
K1028Power source and control electronics unit for oral device/appliance for neuromuscular electrical stimulation of the tongue muscle for the reduction of snoring and obstructive sleep apnea, controlled by phone application
K1029Oral device/appliance for neuromuscular electrical stimulation of the tongue muscle, used in conjunction with the power source and control electronics unit, controlled by phone application, 90-day supply
K1030External recharging system for battery (internal) for use with implanted cardiac contractility modulation generator, replacement only
K1037Docking station for use with oral device/appliance used to reduce upper airway collapsibility
J1072Injection, testosterone cypionate (Azmiro), 1 mg
J1938Injection, furosemide, 1 mg
L0720Cervical-thoracic-lumbar-sacral-orthoses (CTLSO), anterior-posterior-lateral control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L2221Addition to lower extremity orthosis, ankle system, microprocessor-controlled feature plantarflexion and/or dorsiflexion, includes power source
L3161FOOT, ADDUCTUS POSITIONING DEVICE, ADJUSTABLE
L5827Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping
L5969Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s)
L5973Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source
L6700Upper extremity addition, external powered feature, myoelectronic control module, additional EMG inputs, pattern-recognition decoding intent movement
L8608Miscellaneous external component, supply or accessory for use with the argus ii retinal prosthesis system
L8678Electrical stimulator supplies (external) for use with implantable neurostimulator, per month
L8701Powered upper extremity range of motion assist device, elbow, wrist, hand with single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
L8702Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated
M0075Cellular therapy
M0076Prolotherapy
M0100Intragastric hypothermia using gastric freezing
P9027Red blood cells, leukocytes reduced, oxygen/ carbon dioxide reduced, each unit

 

 

Table II. HCPCS Codes (continued)

HCPCS Codes

Description

Q2058Obecabtagene autoleucel, 10 up to 400 million CD19 CAR-positive viable T cells, including leukapheresis and dose preparation procedures, per infusion
Q4103Oasis Burn Matrix, per square centimeter
Q4104Integra Bilayer Matrix Wound Dressing (BMWD), per square centimeter
Q4108Integra Matrix, per square centimeter
Q4110PriMatrix, per square centimeter
Q4111GammaGraft, per square centimeter
Q4112Cymetra, injectable, 1 cc
Q4113Graftjacket Xpress, injectable, 1 cc
Q4115AlloSkin, per square centimeter
Q4117Hyalomatrix, per square centimeter
Q4118Matristem micromatrix, per square centimeter
Q4121Theraskin, per square centimeter
Q4123Alloskin RT, per square centimeter
Q4125Arthroflex, per square centimeter
Q4126Memoderm, Dermaspan, Transgraft or Integuply, per square centimeter
Q4127Talymed, per square centimeter
Q4128Flex HD, Allopatch HD or Matrix HD, per square centimeter [when used for Allopatch HD or Matrix HD]
Q4134hMatrix, per square centimeter
Q4135Mediskin, per square centimeter
Q4136EZ-derm, per square centimeter
Q4137Amnioexcel or BioDExCel, per square centimeter
Q4138Biodfence Dryflex, per square centimeter
Q4139Amniomatrix or BioDMatrix, injectable, 1 cc
Q4140Biodfence, per square centimeter
Q4141Alloskin AC, per square centimeter
Q4142Xcm biologic tissue matrix, per square centimeter
Q4143Repriza, per square centimeter
Q4146TenSIX, per square centimeter
Q4147Architect, Architect PX, or Architect FX, extracellular matrix, per square
Q4148Neox 1k, per square centimeter
Q4149Excellagen, 0.1 cc
Q4150Allowrap DS or dry, per square centimeter
Q4152Dermapure, per square centimeter
Q4153Dermavest and Plurivest, per square centimeter
Q4155Neox Flo or Clarix Flo, 1 mg
Q4156Neox 100, per square centimeter
Q4157Revitalon, per square centimeter
Q4158MariGen, per square centimeter
Q4160NuShield, per square centimeter
Q4161Bio-connekt wound matrix, per square centimeter
Q4162Amniopro flow, bioskin flow, biorenew flow, woundex flow, amniogen-a, amniogen-c, 0.5 cc
Q4163Amniopro, bioskin, biorenew, woundex, amniogen-45, amniogen-200, per square centimeter
Q4164Helicoll, per square centimeter
Q4165Keramatrix, per square centimeter
Q4166Cytal, per square centimeter
Q4167Truskin, per square centimeter
Q4169Artacent wound, per square centimeter
Q4170Cygnus, per square centimeter
Q4171Interfyl, 1 mg
Q4173Palingen or palingen xplus, per square centimeter
Q4174Palingen or promatrx, 0.36 mg per 0.25 cc
Q4175Miroderm, per square centimeter
Q4183Surgigraft, per square centimeter
Q4184Cellesta, per square centimeter
Q4185Cellesta flowable amnion (25 mg per cc); per 0.5 cc
Q4187Epicord, per square centimeter
Q4188Amnioarmor, per square centimeter
Q4189Artacent ac, 1 mg
Q4190Artacent ac, per square centimeter
Q4191Restorigin, per square centimeter
Q4192Restorigin, 1 cc
Q4193Coll-e-derm, per square centimeter
Q4194Novachor, per square centimeter
Q4195Puraply, per square centimeter
Q4196Puraply am, per square centimeter
Q4197Puraply xt, per square centimeter
Q4198Genesis amniotic membrane, per square centimeter
Q4199Cygnus matrix, per square centimeter
Q4200Skin te, per square centimeter
Q4201Matrion, per square centimeter
Q4202Keroxx (2.5g/cc), 1cc
Q4203Derma-gide, per square centimeter
Q4204Xwrap, per square centimeter
Q4205Membrane graft or membrane wrap, per square centimeter
Q4206Fluid flow or fluid gf, 1 cc
Q4208Novafix, per square cenitmeter
Q4209Surgraft, per square centimeter
Q4210Axolotl graft or axolotl dualgraft, per square centimeter
Q4211Amnion bio or axobiomembrane, per square centimeter
Q4212Allogen, per cc
Q4213Ascent, 0.5 mg
Q4214Cellesta cord, per square centimeter
Q4215Axolotl ambient or axolotl cryo, 0.1 mg
Q4216Artacent cord, per square centimeter
Q4217Woundfix, biowound, woundfix plus, biowound plus, woundfix xplus or biowound xplus, per square centimeter
Q4218Surgicord, per square centimeter
Q4219Surgigraft-dual, per square centimeter
Q4220Bellacell hd or surederm, per square centimeter
Q4221Amniowrap2, per square centimeter
Q4222Progenamatrix, per square centimeter
Q4224Human health factor 10 amniotic patch (hhf10-p), per square centimeter
Q4225Amniobind, per square centimeter
Q4226Myown skin, includes harvesting and preparation procedures, per square centimeter
Q4234Xcellerate, per square centimeter
Q4235Amniorepair or altiply, per square centimeter
Q4236Carepatch, per square centimeter
Q4237Cryo-cord, per square centimeter
Q4238Derm-maxx, per square centimeter
Q4239Amnio-maxx or amnio-maxx lite, per square centimeter
Q4240Corecyte, for topical use only, per 0.5 cc
Q4241Polycyte, for topical use only, per 0.5 cc
Q4242Amniocyte plus, per 0.5 cc
Q4244Procenta, per 200 mg
Q4245Amniotext, per cc
Q4246Coretext or protext, per cc
Q4247Amniotext patch, per square centimeter
Q4248Dermacyte amniotic membrane allograft, per square centimeter
Q4251Vim, per square centimeter
Q4252Vendaje, per square centimeter
Q4253Zenith amniotic membrane, per square centimeter
Q4256Mlg-complete, per square centimeter
Q4257Relese, per square centimeter
Q4258Enverse, per square centimeter
Q4259Celera dual layer or celera dual membrane, per square centimeter
Q4260Signature apatch, per square centimeter
Q4262Dual layer impax membrane, per square centimeter
Q4263Surgraft tl, per square centimeter
Q4264Cocoon membrane, per square centimeter
Q4265Neostim tl, per square centimeter
Q4266Neostim membrane, per square centimeter
Q4267Neostim dl, per square centimeter
Q4268Surgraft ft, per square centimeter
Q4269Surgraft xt, per square centimeter
Q4270Complete sl, per square centimeter
Q4271Complete ft, per square centimeter
Q4272Esano a, per square centimeter
Q4273Esano aaa, per square centimeter
Q4274Esano ac, per square centimeter
Q4275Esano aca, per square centimeter
Q4276Orion, per square centimeter
Q4277Woundplus membrane or e-graft, per square centimeter
Q4278Epieffect, per square centimeter
Q4279VENDAJE AC, PER SQUARE CENTIMETER
Q4280Xcell amino matrix, per square centimeter
Q4281Barrera sl or barrera dl, per square centimeter
Q4282Cygnus dual, per square centimeter
Q4283Biovance tri-layer or biovance 3L, per square centimeter
Q4284Dermabind sl, per square centimeter
Q4287DERMABIND DL, PER SQUARE CENTIMETER
Q4288DERMABIND CH, PER SQUARE CENTIMETER
Q4289REVOSHIELD + AMNIOTIC BARRIER, PER SQUARE CENTIMETER
Q4290MEMBRANE WRAP-HYDRO, PER SQUARE CENTIMETER
Q4291LAMELLAS XT, PER SQUARE CENTIMETER
Q4292LAMELLAS, PER SQUARE CENTIMETER
Q4293ACESSO DL, PER SQUARE CENTIMETER
Q4294AMNIO QUAD-CORE, PER SQUARE CENTIMETER
Q4295AMNIO TRI-CORE AMNIOTIC, PER SQUARE CENTIMETER
Q4296REBOUND MATRIX, PER SQUARE CENTIMETER
Q4297EMERGE MATRIX, PER SQUARE CENTIMETER
Q4298AMNICORE PRO, PER SQUARE CENTIMETER
Q4299AMNICORE PRO+, PER SQUARE CENTIMETER
Q4300ACESSO TL, PER SQUARE CENTIMETER
Q4301ACTIVATE MATRIX, PER SQUARE CENTIMETER
Q4302COMPLETE ACA, PER SQUARE CENTIMETER
Q4303COMPLETE AA, PER SQUARE CENTIMETER
Q4304GRAFIX PLUS, PER SQUARE CENTIMETER
Q4305American amnion ac tri-layer, per square centimeter
Q4306American amnion ac, per square centimeter
Q4307American amnion, per square centimeter
Q4308Sanopellis, per square centimeter
Q4309Via matrix, per square centimeter
Q4310Procenta, per 100 mg
Q4311ACESSO, PER SQUARE CENTIMETER
Q4312ACESSO AC, PER SQUARE CENTIMETER
Q4313DERMABIND FM, PER SQUARE CENTIMETER
Q4314REEVA FT, PER SQUARE CENITMETER
Q4315REGENELINK AMNIOTIC MEMBRANE ALLOGRAFT, PER SQUARE CENTIMETER
Q4316AMCHOPLAST, PER SQUARE CENTIMETER
Q4317VITOGRAFT, PER SQUARE CENTIMETER
Q4318E-GRAFT, PER SQUARE CENTIMETER
Q4319SANOGRAFT, PER SQUARE CENTIMETER
Q4320PELLOGRAFT, PER SQUARE CENTIMETER
Q4321RENOGRAFT, PER SQUARE CENTIMETER
Q4322CAREGRAFT, PER SQUARE CENTIMETER
Q4323ALLOPLY, PER SQUARE CENTIMETER
Q4324AMNIOTX, PER SQUARE CENTIMETER
Q4325ACAPATCH, PER SQUARE CENTIMETER
Q4327DUOAMNION, PER SQUARE CENTIMETER
Q4328MOST, PER SQUARE CENTIMETER
Q4329SINGLAY, PER SQUARE CENTIMETER
Q4330TOTAL, PER SQUARE CENTIMETER
Q4331AXOLOTL GRAFT, PER SQUARE CENTIMETER
Q4332AXOLOTL DUALGRAFT, PER SQUARE CENTIMETER
Q4333ARDEOGRAFT, PER SQUARE CENTIMETER
Q4334Amnioplast 1, per square centimeter
Q4335Amnioplast 2, per square centimeter
Q4336Artacent c, per square centimeter
Q4337Artacent trident, per square centimeter
Q4338Artacent velos, per square centimeter
Q4339Artacent vericlen, per square centimeter
Q4340Simpligraft, per square centimeter
Q4341Simplimax, per square centimeter
Q4342Theramend, per square centimeter
Q4343Dermacyte ac matrix amniotic membrane allograft, per square centimeter
Q4344Tri-membrane wrap, per square centimeter
Q4345Matrix hd allograft dermis, per square centimeter
Q4346Shelter dm matrix, per square centimeter
Q4347Rampart dl matrix, per square centimeter
Q4348Sentry sl matrix, per square centimeter
Q4349Mantle dl matrix, per square centimeter
Q4350Palisade dm matrix, per square centimeter
Q4351Enclose tl matrix, per square centimeter
Q4352Overlay sl matrix, per square centimeter
Q4353Xceed tl matrix, per square centimeter
Q4354Palingen dual-layer membrane, per square centimeter
Q4355Abiomend Xplus membrane and Abiomend Xplus hydromembrane, per square centimeter
Q4356Abiomend membrane and Abiomend hydromembrane, per square centimeter
Q4357Xwrap plus, per square centimeter
Q4358Xwrap dual, per square centimeter
Q4359Choriply, per square centimeter
Q4360Amchoplast fd, per square centimeter
Q4361Epixpress, per square centimeter
Q4362Cygnus disk, per square centimeter
Q4363Amnio burgeon membrane and hydromembrane, per square centimeter
Q4364Amnio burgeon Xplus membrane and xplus hydromembrane, per square centimeter
Q4365Amnio burgeon dual-layer membrane, per square centimeter
Q4366Dual layer amnio burgeon x-membrane, per square centimeter
Q4367Amniocore sl, per square centimeter
Q4368Amchothick, per square centimeter
Q4369Amnioplast 3, per square centimeter
Q4370Aeroguard, per square centimeter
Q4371Neoguard, per square centimeter
Q4372Amchoplast excel, per square centimeter
Q4373Membrane wrap lite, per square centimeter
Q4375Duograft ac, per square centimeter
Q4376Duograft aa, per square centimeter
Q4377Trigraft ft, per square centimeter
Q4378Renew ft matrix, per square centimeter
Q4379Amniodefend ft matrix, per square centimeter
Q4380Advograft one, per square centimeter
Q4382Advograft dual, per square centimeter
Q4418Biolab membrane wrap flow, per square centimeter (add-on, list separately in addition to primary procedure)
Q4419Biolab membrane wrap lite flow, per square centimeter (add-on, list separately in addition to primary procedure)
Q4421Biolab membrane wrap solo, per square centimeter (add-on, list separately in addition to primary procedure)
Q4422A/c wrap, per square centimeter (add-on, list separately in addition to primary procedure)
Q4423Biolab tri-membrane wrap flow, per square centimeter (add-on, list separately in addition to primary procedure)
Q4424Revive ft, per square centimeter (add-on, list separately in addition to primary procedure)
Q4425Revive tl, per square centimeter (add-on, list separately in addition to primary procedure)
Q4426Dermabind tl + or dermabind tl x,  per square centimeter (add-on, list separately in addition to primary procedure)
Q4427Dermabind dl n or dermabind dl + or dermabind dl x, per square centimeter (add-on, list separately in addition to primary procedure)
Q4428Dermabind sl n or dermabind sl + or dermabind sl x, per square centimeter (add-on, list separately in addition to primary procedure)
Q4429Dermabind ch n or dermabind ch x, per square centimeter (add-on, list separately in addition to primary procedure)
Q4435Renati membrane, per square centimeter (add-on, list separately in addition to primary procedure)
Q4436Renati ac membrane, per square centimeter (add-on, list separately in addition to primary procedure)
Q4437Revival ac, per square centimeter (add-on, list separately in addition to primary procedure)
Q4438Pretect, per square centimeter (add-on, list separately in addition to primary procedure)
Q4439Instagraft, per square centimeter (add-on, list separately in addition to primary procedure)
Q4440Curamatrix, per square centimeter (add-on, list separately in addition to primary procedure)
Q9982Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries
Q9983Florbetaben F18, diagnostic, per study dose, up to 8.1 millicuries
S1091Stent, noncoronary, temporary, with delivery system (Propel)
S2080Laser-assisted uvuolopalatoplasty (LAUP)
S2103Adrenal tissue transplant to brain (effective 09/01/2014)
S2205Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, under direct vision; using arterial graft(s), 2 coronary arterial grafts
S2206Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using arterial grafts
S2207Minimally invasive direct coronary artery bypass surgery involving mini-toracotomy or mini-sternotomy surgery, performed under direct vision; using venous graft only, single coronary venous graft
S2208Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using single arterial and venous graft(s), single venous graft
S2209Minimally invasive direct coronary artery bypass surgery involving mini-thoracotomy or mini-sternotomy surgery, performed under direct vision; using 2 arterial grafts and single venous graft
S3650Saliva test, hormone level; during menopause
S3652to assess preterm labor risk
S3852DNA analysis for APOE epsilon 4 allele for susceptibility to Alzheimer's disease
S3902Ballistocardiogram
S3904Masters two step
S4988Penile contracture device, manual, greater than 3 lbs traction force
S8080Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical
S9002Intra-vaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device
S9025Omnicardiogram/cardiointegram
S9432Medical foods for non-inborn errors of metabolism
T1505Electronic medication compliance management device, includes all components and accessories, not otherwise classified
T2050Financial management, self-directed, waiver; per diem
T2051Supports brokerage, self-directed, waiver; per diem
T4545Incontinence product, disposable, penile wrap, each
V2525Contact lens, hydrophilic, dual focus, per lens
0202Unfectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
0017MOncology (diffuse large b-cell lymphoma [dlbcl]), mrna, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin-embedded tissue, algorithm reported as cell of origin

 

View Table I (CPT Codes)  Table II (HCPCS Codes)

Table III. CPT Category III Codes

CPT Procedure Codes

Description

0202Unfectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected.
0017MOncology (diffuse large b-cell lymphoma [dlbcl]), mrna, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin-embedded tissue, algorithm reported as cell of origin
0085TBreath test for heart transplant rejection
0095T

Removal of total disc arthroplasty (artificial disc), interior approach, each additional interspace, cervical

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0098T

Revision, including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0100TPlacement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy
0101TExtracorporeal shock wave involving musculoskeletal system, not otherwise specified; high energy
0102TExtracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle
0111TLong-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes
0126TCommon carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor assessment
0159TComputer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis with further physician review for interpretation, breast MRI
0163T

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0164TRemoval of total disc arthroplasty (artificial disc), anterior approach, lumbar, each additional interspace
0165T

Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, lumbar, each additional interspace

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0190TPlacement of intraocular radiation source applicator
0195T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0196T

Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L4-L5 interspace (List separately in addition to code for primary procedure)

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0198TMeasurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report
0200TPercutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, one or more needles
0201TPercutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, two or more needles
0202TPosterior vertebral joint(s) arthroplasty (e.g., facet joint(s) replacement) including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine
0206TAlgorithmic analysis, remote, of electrocardiographic-derived data with computer probability assessment, including report
0207TEvacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral
0219TPlacement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical (Do not report 0219T-0221T with any radiological service)
0220T

thoracic (Do not report 0219T-0221T with any radiological service)

0221T

lumbar (Do not report 0219T-0221T with any radiological service)

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0222T

each additional vertebral segment (List separately in addition to code for primary procedure) (Use 0222T in conjunction with 0219T-0221T)

For more detailed information, please see associated medical policy Spinal Interventional Pain Management and Spine Surgery

0232TInjection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed
0263TIntramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest (effective 7/1/11)
0264T

complete procedure excluding bone marrow harvest

0265T

unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy

0266TImplantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)
0267T

lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)

0268T

pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)

0269TRevision or removal of carotid sinus baroflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)
0270T

lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)

0271T

pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) (effective 7/1/11)

0272TInterrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (eg, battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day) (effective 7/1/11)
0273T

with programming (effective 7/1/11)

0274TPercutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic (effective 7/1/11)
0275T

lumbar

0278TTranscutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes)
0312TVagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming
0313TVagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator
0314TVagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator
0315TVagus nerve blocking therapy (morbid obesity); removal of pulse generator
0316TVagus nerve blocking therapy (morbid obesity); replacement of pulse generator
0317TVagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when performed
0330TTear film imaging, unilateral or bilateral, with interpretation and report
0333TVisual evoked potential, screening of visual acuity, automated
0335TExtra-osseous subtalar joint implant for talotarsal stabilization
0337TEndothelial function assessment, using peripheral vascular response to reactive hyperemia, non-invasive (eg, brachial artery ultrasound, peripheral artery tonometry), unilateral or bilateral
0338TTranscatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral
0339TTranscatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral
0340TAblation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance
0341TQuantitative pupillometry with interpretation and report, unilateral or bilateral
0342TTherapeutic apheresis with selective hdl delipidation and plasma reinfusion
0346TUltrasound, elastography (list separately in addition to code for primary procedure) (except when billed for hepatitis C)
0356TInsertion of drug-eluting implant (including punctual dilation and implant removal when performed) into lacrimal canaliculus, each
0358TBioelectrical impedance analysis whole body composition assessment, supine position, with interpretation and report
0378TVisual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional
0379TTechnical support and patient instructions, surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional
0380TComputer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report
0381TExternal heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional
0382TExternal heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only
0383TExternal heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional
0384TExternal heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only
0385TExternal heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional
0386TExternal heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only
0387TTranscatheter insertion or replacement of permanent leadless pacemaker, ventricular
0388TTranscatheter removal of permanent leadless pacemaker, ventricular
0389TProgramming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system
0390TPeri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system
0391TInterrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system
0397TEndoscopic retrograde cholangiopancreatography (ercp), with optical endomicroscopy (list separately in addition to code for primary procedure)
0398TMagnetic resonance image guided high intensity focused ultrasound (mrgfus), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed
0404TTranscervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency
0408TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes
0409TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only
0410TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only
0411TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only
0412TRemoval of permanent cardiac contractility modulation system; pulse generator only
0413TRemoval of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular)
0414TRemoval and replacement of permanent cardiac contractility modulation system pulse generator only
0415TRepositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead)
0416TRelocation of skin pocket for implanted cardiac contractility modulation pulse generator
0417TProgramming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility m
0418TInterrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiac contractility modulation system
0421TTransurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)
0423TSecretory type ii phospholipase a2 (spla2-iia)
0424TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator)
0425TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; sensing lead only
0426TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; stimulation lead only
0427TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; pulse generator only
0428TRemoval of neurostimulator system for treatment of central sleep apnea; pulse generator only
0429TRemoval of neurostimulator system for treatment of central sleep apnea; sensing lead only
0430TRemoval of neurostimulator system for treatment of central sleep apnea; stimulation lead only
0431TRemoval and replacement of neurostimulator system for treatment of central sleep apnea, pulse generator only
0432TRepositioning of neurostimulator system for treatment of central sleep apnea; stimulation lead only
0433TRepositioning of neurostimulator system for treatment of central sleep apnea; sensing lead only
0434TInterrogation device evaluation implanted neurostimulator pulse generator system for central sleep apnea
0435TProgramming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; single session
0436TProgramming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; during sleep study
0437TImplantation of non-biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall (list separately in addition to primary procedure)
0439TMyocardial contrast perfusion echocardiography; at rest or with stress, for assessment of myocardial ischemia or viability (list separately in addition to primary procedure)
0440TAblation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve
0441TAblation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve; lower extremity distal/peripheral nerve
0442TAblation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve)
0443TReal time spectral analysis of prostate tissue by fluorescence spectroscopy
0444TInitial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral
0445TSubsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral
0450TInsertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device; each additional device (list separately in addition to code for primary procedure)
0451TInsertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes)
0452TInsertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes); aortic counterpulsation device and vascular hemostatic seal
0453TInsertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes); mechano-electrical skin interface
0454TInsertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes); subcutaneous electrode
0455TRemoval of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes)
0456TRemoval of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes); aortic counterpulsation device and vascular
0457TRemoval of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes); mechano-electrical skin interface
0458TRemoval of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes); subcutaneous electrode
0459TRelocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device,mechano- electrical skin interface and electrodes
0460TRepositioning of previously implanted aortic counterpulsation ventricular assist device, subcutaneous electrode
0461TRepositioning of previously implanted aortic counterpulsation ventricular assist device, subcutaneous electrode; aortic counterpulsation device
0462TProgramming device evaluation (in person) with iterative adjustment of the implantable mechano-electrical skin interface and/or external driver to test the function of the device and select optimal permanent programmed values with analysis, including review
0463TInterrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day
0464TVisual evoked potential, testing for glaucoma, with interpretation and report
0465TSuprachoroidal injection of a pharmacologic agent (does not include supply of medication)
0466TInsertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (list separately in addition to code for primary procedure)
0467TRevision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator
0468TRemoval of chest wall respiratory sensor electrode or electrode array
0470TOptical coherence tomography (oct) for microstructural and morphological imaging of skin, image acquisition, interpretation, and report; first lesion
0474TInsertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space​
0471TOptical coherence tomography (oct) for microstructural and morphological imaging of skin, image acquisition, interpretation, and report; each additional lesion (list separately in additional to code for primary procedure)
0472TDevice evaluation, interrogation, and initial programming of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, with iterative adjustment of the implantable device to test functionality, select optimal permanent programmed values with analysis, including visual training, with review and report by a qualified health care professional
0473TDevice evaluation and interrogation of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, including reprogramming and visual training, when performed, with review and report by a qualified health care professional
0497TExternal patient-activated, physician- or other qualified health care professional-prescribed, electrocardiographic rhythm derived event recorder without 24 hour attended monitoring; in-office connection
For more detailed information, please see associated medical policy Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry.
0498TExternal patient-activated, physician- or other qualified health care professional-prescribed, electrocardiographic rhythm derived event recorder without 24 hour attended monitoring; review and interpretation by a physician or other qualified health care professional per 30 days with at least one patient-generated triggered event
For more detailed information, please see associated medical policy Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry.
0541TMyocardial imaging by magnetocardiography (mcg) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning- derived clinical scoring, and automated report generation, single study
0542TMyocardial imaging by magnetocardiography (mcg) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images, quantitative analysis of magnetic dipoles, machine learning- derived clinical scoring, and automated report generation, single study; interpretation and report
0525TInsertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; complete system (electrode and implantable monitor)
0526TInsertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; electrode only
0527TInsertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable monitor only
0528TProgramming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report
0529TInterrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report
0530TRemoval of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor)
0531TRemoval of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only
0532TRemoval of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only
0533TContinuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes set-up, patient training, configuration of monitor, data upload, analysis and initial report configuration, download review, interpretation and report
0534TContinuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; set-up, patient training, configuration of monitor
0535TContinuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
0536TContinuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
0546T Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
0547T Bone-material quality testing by microindentation(s) of the tibia(s), with results reported as a score
0548T Transperineal periurethral balloon continence device; bilateral placement, including cystoscopy and fluoroscopy
0549T Transperineal periurethral balloon continence device; unilateral placement, including cystoscopy and fluoroscopy
0550T Transperineal periurethral balloon continence device; removal, each balloon
0551T Transperineal periurethral balloon continence device; adjustment of balloon(s) fluid volume
0552T Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional
0553T Percutaneous transcatheter placement of iliac arteriovenous anastomosis implant, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention
0554T Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data, assessment of bone strength and fracture risk and bone mineral density, interpretation and report
0555T Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; retrieval and transmission of the scan data
0556T Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; assessment of bone strength and fracture risk and bone mineral density
0557T Bone strength and fracture risk using finite element analysis of functional data, and bone-mineral density, utilizing data from a computed tomography scan; interpretation and report
0558T Computed tomography scan taken for the purpose of biomechanical computed tomography analysis
0559T Anatomic model 3d-printed from image data set(s); first individually prepared and processed component of an anatomic structure
0560T Anatomic model 3d-printed from image data set(s); each additional individually prepared and processed component of an anatomic structure (list separately in addition to code for primary procedure)
0561T Anatomic guide 3d-printed and designed from image data set(s); first anatomic guide
0562T Anatomic guide 3d-printed and designed from image data set(s); each additional anatomic guide (list separately in addition to code for primary procedure)
0565TAutologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation
0566TAutologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral
0567TPermanent fallopian tube occlusion with degradable biopolymer implant, transcervical approach, including transvaginal ultrasound
0568TIntroduction of mixture of saline and air for sonosalpingography to confirm occlusion of fallopian tubes, transcervical approach, including transvaginal ultrasound and pelvic ultrasound
0571TInsertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed 
0572TInsertion of substernal implantable defibrillator electrode
0573TRemoval of substernal implantable defibrillator electrode
0574TRepositioning of previously implanted substernal implantable defibrillator-pacing electrode
0575T Programming device evaluation (in person) of implantable cardioverter-defibrillator system with substernal electrode, with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional 
0576TInterrogation device evaluation (in person) of implantable cardioverter-defibrillator system with substernal electrode, with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter
0577TElectrophysiological evaluation of implantable cardioverter- defibrillator system with substernal electrode (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)
0578TInterrogation device evaluation(s) (remote), up to 90 days, substernal lead implantable cardioverter-defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional
0579TInterrogation device evaluation(s) (remote), up to 90 days, substernal lead implantable cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results
0580TRemoval of substernal implantable defibrillator pulse generator only
0596TTemporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement
0597TTemporary female intraurethral valve-pump (ie, voiding prosthesis); replacement
0598T Real-time fluorescence wound imaging with clinical darkness, to identify location of bacterial wound pathogens and measure wound size, per session; first anatomic site (e.g., lower extremity, right leg)
0599T Real-time fluorescence wound imaging with clinical darkness, to identify location of bacterial wound pathogens and measure wound size, per session; each additional anatomic site (e.g., upper extremity, left leg) (list separately in addition to code for primary procedure)

 

Table III. CPT Category III Codes (continued)

CPT Procedure Codes

Description

0600T Ablation, irreversible electroporation; 1 or more tumors per organ, other than liver or prostate, including imaging guidance, when performed, percutaneous
0601TAblation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance, when performed, open
0602TGlomerular filtration rate (GFR) measurement(s), transdermal
0603TGlomerular filtration rate (GFR) monitoring, transdermal, including sensor placement and administration of more than one dose of fluorescent pyrazine agent, each 24 hours
0607TRemote monitoring of an external continuous pulmonary fluid monitoring system
0608TRemote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency- derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm
0609TMagnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); acquisition of single voxel data, per disc, on biomarkers
0610TMagnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); transmission of biomarker data for software analysis
0611TMagnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); 
0612TMagnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); interpretation and report
0615TEye-movement analysis without spatial calibration, with interpretation and report
0616TInsertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens
0617TInsertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with removal of crystalline lens and insertion of intraocular lens
0618TInsertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with secondary intraocular lens placement or intraocular lens exchange
0619TCystourethroscopy with transurethral anterior prostate commissurotomy and drug delivery, including transrectal ultrasound and fluoroscopy, when performed
0640TNoncontact near-infrared spectroscopy studies of flap or wound (eg, for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [sto2]); image acquisition, interpretation and report, each flap or wound
0641TNoncontact near-infrared spectroscopy studies of flap or wound (eg, for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [sto2]); image acquisition only, each flap or wound
0642TNoncontact near-infrared spectroscopy studies of flap or wound (eg, for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [sto2]); interpretation and report only, each flap or wound
0662TScalp cooling, mechanical; initial measurement and calibration of cap
0663TScalp cooling, mechanical; placement of device, monitoring, and removal of device (list separately in addition to code for primary procedure)
0672TEndovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence
0674TLaparoscopic insertion of new or replacement of permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including an implantable pulse generator and diaphragmatic lead(s)
0675TLaparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; first lead
0676TLaparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; each additional lead (list separately in addition to code for primary procedure)
0677TLaparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; first repositioned lead
0678TLaparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; each additional repositioned lead (list separately in addition to code for primary procedure) repositioned lead
0679TLaparoscopic removal of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function
0680TInsertion or replacement of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, with connection to existing lead(s)
0681TRelocation of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, with connection to existing dual leads
0682TRemoval of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function
0683TProgramming device evaluation (in-person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function
0684TPeri-procedural device evaluation (in-person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review, and report by a physician or other qualified health care professional, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function
0685TInterrogation device evaluation (in-person) with analysis, review and report by a physician or other qualified health care professional, including connection, recording and disconnection per patient encounter, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function
0691TAutomated analysis of an existing computed tomography study for vertebral fracture(s), including assessment of bone density when performed, data preparation, interpretation, and report
0692TTherapeutic ultrafiltration
0693TComprehensive full body computer-based markerless 3d kinematic and kinetic motion analysis and report
0695TBody surface–activation mapping of pacemaker or pacing cardioverter-defibrillator lead(s) to optimize electrical synchrony, cardiac resynchronization therapy device, including connection, recording, disconnection, review, and report; at time of implant or replacement
0696TBody surface–activation mapping of pacemaker or pacing cardioverter-defibrillator lead(s) to optimize electrical synchrony, cardiac resynchronization therapy device, including connection, recording, disconnection, review, and report; at time of follow-up interrogation or programming device evaluation
0700TMolecular fluorescent imaging of suspicious nevus; first lesion
0701TMolecular fluorescent imaging of suspicious nevus; each additional lesion (list separately in addition to code for primary procedure)
0704TRemote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment
0705TRemote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days
0706TRemote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month
0707TInjection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), including imaging guidance and arthroscopic assistance for joint visualization
0708TIntradermal cancer immunotherapy; preparation and initial injection
0709TIntradermal cancer immunotherapy; each additional injection (list separately in addition to code for primary procedure)
0710TNoninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; including data preparation and transmission, quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability, data review, interpretation and report
0711TNoninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data preparation and transmission
0712TNoninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability
0713TNoninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data review, interpretation and report
0714TTransperineal laser ablation of benign prostatic hyperplasia, including imaging guidance
0715TPercutaneous transluminal coronary lithotripsy (list separately in addition to code for primary procedure)
0716TCardiac acoustic waveform recording with automated analysis and generation of coronary artery disease risk score
0717TAutologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCS
0718TAutologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral
0719TPosterior vertebral joint replacement, including bilateral facetectomy, laminectomy, and radical discectomy, including imaging guidance, lumbar spine, single segment
0720TPercutaneous electrical nerve field stimulation, cranial nerves, without implantation
0725TVestibular device implantation, unilateral
0726TRemoval of implanted vestibular device, unilateral
0727TRemoval and replacement of implanted vestibular device, unilateral
0728TDiagnostic analysis of vestibular implant, unilateral; with initial programming
0729TDiagnostic analysis of vestibular implant, unilateral; with subsequent programming
0730TTrabeculotomy by laser, including optical coherence tomography (OCT) guidance
0731TAugmentative AI-based facial phenotype analysis with report
0732TImmunotherapy administration with electroporation, intramuscular
0733TRemote body and limb kinematic measurement-based therapy ordered by a physician or other qualified health care professional; supply and technical support, per 30 days
0734TRemote body and limb kinematic measurement-based therapy ordered by a physician or other qualified health care professional; treatment management services by a physician or other qualified health care professional, per calendar month
0737TXenograft implantation into the articular surface
0779TGastrointestinal myoelectrical activity study, stomach through colon, with interpretation and report
0792TApplication of silver diamine fluoride 38%, by a physician or other qualified health care professional
0793TPercutaneous transcatheter thermal ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance
0794TPatient-specific, assistive, rules-based algorithm for ranking pharmaco-oncologic treatment options based on the patient's tumor-specific cancer marker information obtained from prior molecular pathology, immunohistochemical, or other pathology results which have been previously interpreted and reported separately
0805TTranscatheter superior and inferior vena cava prosthetic valve implantation (ie, caval valve implantation [cavi]); percutaneous femoral vein approach
0806TTranscatheter superior and inferior vena cava prosthetic valve implantation (ie, caval valve implantation [cavi]); open femoral vein approach
0807TPulmonary tissue ventilation analysis using software-based processing of data from separately captured cinefluorograph images; in combination with previously acquired computed tomography (ct) images, including data preparation and transmission, quantification of pulmonary tissue ventilation, data review, interpretation and report
0808TPulmonary tissue ventilation analysis using software-based processing of data from separately captured cinefluorograph images;in combination with computed tomography (ct) images taken for the purpose of pulmonary tissue ventilation analysis, including data preparation and transmission, quantification of pulmonary tissue ventilation, data review, interpretation and report
0810TSubretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies
0813TESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL, WITH VOLUME ADJUSTMENT OF INTRAGASTRIC BARIATRIC BALLOON
0814TPERCUTANEOUS INJECTION OF CALCIUM-BASED BIODEGRADABLE OSTEOCONDUCTIVE MATERIAL, PROXIMAL FEMUR, INCLUDING IMAGING GUIDANCE, UNILATERAL
0816TOPEN INSERTION OR REPLACEMENT OF INTEGRATED NEUROSTIMULATION SYSTEM FOR BLADDER DYSFUNCTION INCLUDING ELECTRODE(S) (EG, ARRAY OR LEADLESS), AND PULSE GENERATOR OR RECEIVER, INCLUDING ANALYSIS, PROGRAMMING, AND IMAGING GUIDANCE, WHEN PERFORMED, POSTERIOR TIBIAL NERVE; SUBCUTANEOUS
0817TOPEN INSERTION OR REPLACEMENT OF INTEGRATED NEUROSTIMULATION SYSTEM FOR BLADDER DYSFUNCTION INCLUDING ELECTRODE(S) (EG, ARRAY OR LEADLESS), AND PULSE GENERATOR OR RECEIVER, INCLUDING ANALYSIS, PROGRAMMING, AND IMAGING GUIDANCE, WHEN PERFORMED, POSTERIOR TIBIAL NERVE; SUBFASCIAL
0818TREVISION OR REMOVAL OF INTEGRATED NEUROSTIMULATION SYSTEM FOR BLADDER DYSFUNCTION, INCLUDING ANALYSIS, PROGRAMMING, AND IMAGING, WHEN PERFORMED, POSTERIOR TIBIAL NERVE; SUBCUTANEOUS
0819TREVISION OR REMOVAL OF INTEGRATED NEUROSTIMULATION SYSTEM FOR BLADDER DYSFUNCTION, INCLUDING ANALYSIS, PROGRAMMING, AND IMAGING, WHEN PERFORMED, POSTERIOR TIBIAL NERVE; SUBFASCIAL
0823TTRANSCATHETER INSERTION OF PERMANENT SINGLE-CHAMBER LEADLESS PACEMAKER, RIGHT ATRIAL, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY AND/OR RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY, CAVOGRAPHY) AND DEVICE EVALUATION (EG INTERROGATION OR PRORAMMING), WHEN PERFORMED
0824TTRANSCATHETER REMOVAL OF PERMANENT SINGLE-CHAMBER LEADLESS PACEMAKER, RIGHT ATRIAL, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY AND/OR RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY, CAVOGRAPHY), WHEN PERFORMED
0825TTRANSCATHETER REMOVAL AND REPLACEMENT OF PERMANENT SINGLE-CHAMBER LEADLESS PACEMAKER, RIGHT ATRIAL, INCLUDING IMAGING GUIDANCE (EG, FLUOROSCOPY, VENOUS ULTRASOUND, RIGHT ATRIAL ANGIOGRAPHY AND/OR RIGHT VENTRICULOGRAPHY, FEMORAL VENOGRAPHY, CAVOGRAPHY) AND DEVICE EVALUATION (EG, INTERROGATION OR PROGRAMMING), WHEN PERFORMED
0826TROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, LEADLESS PACEMAKER SYSTEM IN SINGLE-CARDIAC CHAMBER
0827TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, FLUIDS, WASHINGS, OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SMEARS WITH INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0828TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, FLUIDS, WASHINGS, OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SIMPLE FILTER METHOD WITH INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0829TIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS, AND INTERPRETATION (EG, SACCOMANNO TECHNIQUE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0830TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, SELECTIVE-CELLULAR ENHANCEMENT TECHNIQUE WITH INTERPRETATION (EG, LIQUID-BASED SLIDE PREPARATION METHOD), EXCEPT CERVICAL OR VAGINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0831TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), REQUIRING INTERPRETATION BY PHYSICIAN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0832TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; SCREENING AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0833TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; PREPARATION, SCREENING AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0834TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; EXTENDED STUDY INVOLVING OVER 5 SLIDES AND/OR MULTIPLE STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0835TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE CYTOHISTOLOGIC STUDY TO DETERMINE ADEQUACY FOR DIAGNOSIS, FIRST EVALUATION EPISODE, EACH SITE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDU
0836TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE CYTOHISTOLOGIC STUDY TO DETERMINE ADEQUACY FOR DIAGNOSIS, EACH SEPARATE ADDITIONAL EVALUATION EPISODE, SAME SITE (LIST SEPARATELY IN ADDITION TO CODE 
0837TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; INTERPRETATION AND REPORT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0838TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CONSULTATION AND REPORT ON REFERRED SLIDES PREPARED ELSEWHERE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0839TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING PREPARATION OF SLIDES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0840TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR CONSULTATION, COMPREHENSIVE, WITH REVIEW OF RECORDS AND SPECIMENS, WITH REPORT ON REFERRED MATERIAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0841TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR PATHOLOGY CONSULTATION DURING SURGERY; FIRST TISSUE BLOCK, WITH FROZEN SECTION(S), SINGLE SPECIMEN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0842TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR PATHOLOGY CONSULTATION DURING SURGERY; EACH ADDITIONAL TISSUE BLOCK WITH FROZEN SECTION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0843TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR PATHOLOGY CONSULTATION DURING SURGERY; CYTOLOGIC EXAMINATION (EG, TOUCH PREPARATION, SQUASH PREPARATION), INITIAL SITE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0844TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR PATHOLOGY CONSULTATION DURING SURGERY; CYTOLOGIC EXAMINATION (EG, TOUCH PREPARATION, SQUASH PREPARATION), EACH ADDITIONAL SITE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0845TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR IMMUNOFLUORESCENCE, PER SPECIMEN; INITIAL SINGLE ANTIBODY STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0846TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR IMMUNOFLUORESCENCE, PER SPECIMEN; EACH ADDITIONAL SINGLE ANTIBODY STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0847TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR EXAMINATION AND SELECTION OF RETRIEVED ARCHIVAL (IE, PREVIOUSLY DIAGNOSED) TISSUE(S) FOR MOLECULAR ANALYSIS (EG, KRAS MUTATIONAL ANALYSIS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0848TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR IN SITU HYBRIDIZATION (EG, FISH), PER SPECIMEN; INITIAL SINGLE PROBE STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0849TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR IN SITU HYBRIDIZATION (EG, FISH), PER SPECIMEN; EACH ADDITIONAL SINGLE PROBE STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0850TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR IN SITU HYBRIDIZATION (EG, FISH), PER SPECIMEN; EACH MULTIPLEX PROBE STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0851TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR SEMIQUANTITATIVE), MANUAL, PER SPECIMEN; INITIAL SINGLE PROBE STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0852TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR SEMIQUANTITATIVE), MANUAL, PER SPECIMEN; EACH ADDITIONAL SINGLE PROBE STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0853TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR SEMIQUANTITATIVE), MANUAL, PER SPECIMEN; EACH MULTIPLEX PROBE STAIN PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0854TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH WRITTEN REPORT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0855TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR BONE MARROW, SMEAR INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0856TDIGITIZATION OF GLASS MICROSCOPE SLIDES FOR ELECTRON MICROSCOPY, DIAGNOSTIC (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0857TOPTO-ACOUSTIC IMAGING, BREAST, UNILATERAL, INCLUDING AXILLA WHEN PERFORMED, REAL-TIME WITH IMAGE DOCUMENTATION, AUGMENTATIVE ANALYSIS AND REPORT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
0858TEXTERNALLY APPLIED TRANSCRANIAL MAGNETIC STIMULATION WITH CONCOMITANT MEASUREMENT OF EVOKED CORTICAL POTENTIALS WITH AUTOMATED REPORT
0859TNONCONTACT NEAR-INFRARED SPECTROSCOPY (EG, FOR MEASUREMENT OF DEOXYHEMOGLOBIN, OXYHEMOGLOBIN, AND RATIO OF TISSUE OXYGENATION), OTHER THAN FOR SCREENING FOR PERIPHERAL ARTERIAL DISEASE, IMAGE ACQUISITION, INTERPRETATION, AND REPORT; EACH ADDITIONAL ANATOMIC SITE
0860TNONCONTACT NEAR-INFRARED SPECTROSCOPY (EG, FOR MEASUREMENT OF DEOXYHEMOGLOBIN, OXYHEMOGLOBIN, AND RATIO OF TISSUE OXYGENATION), FOR SCREENING FOR PERIPHERAL ARTERIAL DISEASE, INCLUDING PROVOCATIVE MANEUVERS, IMAGE ACQUISITION, INTERPRETATION, AND REPORT, ONE OR BOTH LOWER EXTREMITIES
0861TREMOVAL OF PULSE GENERATOR FOR WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING; BOTH COMPONENTS (BATTERY AND TRANSMITTER)
0862TRELOCATION OF PULSE GENERATOR FOR WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING, INCLUDING DEVICE INTERROGATION AND PROGRAMMING; BATTERY COMPONENT ONLY
0863TRELOCATION OF PULSE GENERATOR FOR WIRELESS CARDIAC STIMULATOR FOR LEFT VENTRICULAR PACING, INCLUDING DEVICE INTERROGATION AND PROGRAMMING; TRANSMITTER COMPONENT ONLY
0864TLOW-INTENSITY EXTRACORPOREAL SHOCK WAVE THERAPY INVOLVING CORPUS CAVERNOSUM, LOW ENERGY
0867TTransperineal laser ablation of benign prostatic hyperplasia, including imaging guidance; prostate volume greater or equal to 50 ml
0868THigh-resolution gastric electrophysiology mapping with simultaneous patient- symptom profiling, with interpretation and report
0870TImplantation of subcutaneous peritoneal ascites pump system, percutaneous, including pump-pocket creation, insertion of tunneled indwelling bladder and peritoneal catheters with pump connections, including all imaging and initial programming, when performed
0871TReplacement of a subcutaneous peritoneal ascites pump, including reconnection between pump and indwelling bladder and peritoneal catheters, including initial programming and imaging, when performed
0872TReplacement of indwelling bladder and peritoneal catheters, including tunneling of catheter(s) and connection with previously implanted peritoneal ascites pump, including imaging and programming, when performed
0873TRevision of a subcutaneously implanted peritoneal ascites pump system, any component (ascites pump, associated peritoneal catheter, associated bladder catheter), including imaging and programming, when performed
0874TRemoval of a peritoneal ascites pump system, including implanted peritoneal ascites pump and indwelling bladder and peritoneal catheters
0875TProgramming of subcutaneously implanted peritoneal ascites pump system by physician or other qualified health care professional
0876TDuplex scan of hemodialysis fistula, computer-aided, limited (volume flow, diameter, and depth, including only body of fistula)
0881TCryotherapy of the oral cavity using temperature regulated fluid cooling system, including placement of an oral device, monitoring of patient tolerance to treatment, and removal of the oral device
0882TIntraoperative therapeutic electrical stimulation of peripheral nerve to promote nerve regeneration, including lead placement and removal, upper extremity, minimum of 10 minutes; initial nerve (list separately in addition to code for primary procedure)
0883TIntraoperative therapeutic electrical stimulation of peripheral nerve to promote nerve regeneration, including lead placement and removal, upper extremity, minimum of 10 minutes; each additional nerve (list separately in addition to code for primary procedure
0884TEsophagoscopy, flexible, transoral, with initial transendoscopic mechanical dilation (eg, nondrug-coated balloon) followed by therapeutic drug delivery by drug-coated balloon catheter for esophageal stricture, including fluoroscopic guidance, when performed
0885TColonoscopy, flexible, with initial transendoscopic mechanical dilation (eg, nondrug-coated balloon) followed by therapeutic drug delivery by drug-coated balloon catheter for colonic stricture, including fluoroscopic guidance, when performed
0886TSigmoidoscopy, flexible, with initial transendoscopic mechanical dilation (eg, nondrug-coated balloon) followed by therapeutic drug delivery by drug-coated balloon catheter for colonic stricture, including fluoroscopic guidance, when performed
0887TEnd-tidal control of inhaled anesthetic agents and oxygen to assist anesthesia care delivery (list separately in addition to code for primary procedure)
0888THistotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance
0893TNoninvasive assessment of blood oxygenation, gas exchange efficiency, and cardiorespiratory status, with physician or other qualified health care professional interpretation and report
0894TCannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation of the liver allograft following normothermic perfusion
0895TConnection of liver allograft to normothermic machine perfusion device, hemostasis control; initial 4 hours of monitoring time, including hourly physiological and laboratory assessments (eg, perfusate temperature, perfusate ph, hemodynamic parameters, bile production, bile ph, bile glucose, biliary bicarbonate, lactate levels, macroscopic assessment)
0896TConnection of liver allograft to normothermic machine perfusion device, hemostasis control; each additional hour, including physiological and laboratory assessments (eg, perfusate temperature, perfusate ph, hemodynamic parameters, bile production, bile ph, bile glucose, biliary bicarbonate, lactate levels, macroscopic assessment) (list separately in addition to code for primary procedure)
0897TNoninvasive augmentative arrhythmia analysis derived from quantitative computational cardiac arrhythmia simulations, based on selected intervals of interest from 12-lead electrocardiogram and uploaded clinical parameters, including uploading clinical parameters with interpretation and report
0901TPlacement of bone marrow sampling port, including imaging guidance when performed
0902TQTC interval derived by augmentative algorithmic analysis of input from an external, patient-activated mobile ECG device
0915TInsertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator and dual transvenous electrodes/leads
0916TInsertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; pulse generator only
0917TInsertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; single transvenous lead (pacing or defibrillation) only
0918TInsertion of permanent cardiac contractility modulation-defibrillation system component(s), including fluoroscopic guidance, and evaluation and programming of sensing and therapeutic parameters; dual transvenous leads (pacing and defibrillation) only
0919TRemoval of a permanent cardiac contractility modulation-defibrillation system component(s); pulse generator only
0920TRemoval of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous pacing lead only
0921TRemoval of a permanent cardiac contractility modulation-defibrillation system component(s); single transvenous defibrillation lead only 
0922TRemoval of a permanent cardiac contractility modulation-defibrillation system component(s); dual (pacing and defibrillation) transvenous leads only 
0923TRemoval and replacement of permanent cardiac contractility modulation-defibrillation pulse generator only 
0924TRepositioning of previously implanted cardiac contractility modulation-defibrillation transvenous electrode(s)/lead(s), including fluoroscopic guidance and programming of sensing and therapeutic parameters 
0925TRelocation of skin pocket for implanted cardiac contractility modulation-defibrillation pulse generator 
0926TProgramming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation-defibrillation system 
0927TInterrogation device evaluation (in person) with analysis, review, and report, including connection, recording, and disconnection, per patient encounter, implantable cardiac contractility modulation-defibrillation system 
0928TInterrogation device evaluation (remote), up to 90 days, cardiac contractility modulation-defibrillation system with interim analysis and report(s) by a physician or other qualified health care professional 
0929TInterrogation device evaluation (remote), up to 90 days, cardiac contractility modulation-defibrillation system, remote data acquisition(s), receipt of transmissions, technician review, technical support, and distribution of results 
0930TElectrophysiologic evaluation of cardiac contractility modulation-defibrillator leads, including defibrillation-threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), at time of initial implantation or replacement with testing of cardiac contractility modulation-defibrillator pulse generator 
0931TElectrophysiologic evaluation of cardiac contractility modulation-defibrillator leads, including defibrillation-threshold evaluation (induction of arrhythmia, evaluation of sensing and therapy for arrhythmia termination), separate from initial implantation or replacement with testing of cardiac contractility modulation-defibrillator pulse generator 
0932TNoninvasive detection of heart failure derived from augmentative analysis of an echocardiogram that demonstrated preserved ejection fraction, with interpretation and report by a physician or other qualified health care professional 
0933TTranscatheter implantation of wireless left atrial pressure sensor for long-term left atrial pressure monitoring, including sensor calibration and deployment, right heart catheterization, transseptal puncture, imaging guidance, and radiological supervision and interpretation 
0934TRemote monitoring of a wireless left atrial pressure sensor for up to 30 days, including data from daily uploads of left atrial pressure recordings, interpretation(s) and trend analysis, with adjustments to the diuretics plan, treatment paradigm thresholds, medications or lifestyle modifications, when performed, and report(s) by a physician or other qualified health care professional 
0935TCystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of ureteral sheath(s) and multiple conformable electrodes, contrast injection(s), and fluoroscopy, bilateral 
0936TPhotobiomodulation therapy of retina, single session 
0937TExternal electrocardiographic recording for greater than 15 days up to 30 days by continuous rhythm recording and storage; including recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional 
0938TExternal electrocardiographic recording for greater than 15 days up to 30 days by continuous rhythm recording and storage; recording (including connection and initial recording) 
0939TExternal electrocardiographic recording for greater than 15 days up to 30 days by continuous rhythm recording and storage; scanning analysis with report 
0940TExternal electrocardiographic recording for greater than 15 days up to 30 days by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional 
0941TCystourethroscopy, flexible; with insertion and expansion of prostatic urethral scaffold using integrated cystoscopic visualization 
0942TCystourethroscopy, flexible; with removal and replacement of prostatic urethral scaffold 
0943TCystourethroscopy, flexible; with removal of prostatic urethral scaffold 
0944T3d contour simulation of target liver lesion(s) and margin(s) for image-guided percutaneous microwave ablation 
0945TIntraoperative assessment for abnormal (tumor) tissue, in-vivo, following partial mastectomy (e.g., lumpectomy) using computer-aided fluorescence imaging (list separately in addition to code for primary procedure) 
0946TOrthopedic implant movement analysis using paired computed tomography (CT) examination of the target structure, including data acquisition, data preparation and transmission, interpretation and report (including CT scan of the joint or extremity performed with paired views) 
0947TMagnetic resonance image guided low intensity focused ultrasound (MRGFUS), stereotactic blood-brain barrier disruption using microbubble resonators to increase the concentration of blood-based biomarkers of target, intracranial, including stereotactic nav
0002UOncology (colorectal), quantitative assessment of three urine metabolites (ascorbic acid, succinic acid and carnitine) by liquid chromatography with tandem mass spectrometry (lc-ms/ms) using multiple reaction monitoring acquisition, algorithm reported as likelihood of adenomatous polyps
0003UOncology (ovarian) biochemical assays of five proteins (apolipoprotein a-1, ca 125 ii, follicle stimulating hormone, human epididymis protein 4, transferrin), utilizing serum, algorithm reported as a likelihood score
0007UDrug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including dna authentication in comparison to buccal dna, per date of service
0008UHelicobacter pylori detection and antibiotic resistance, dna, 16s and 23s rrna, gyra, pbp1, rdxa and rpob, next generation sequencing, formalin-fixed paraffin embedded or fresh tissue, predictive, reported as positive or negative for resistance to clarithromycin, fluoroquinolones, metronidazole, amoxicillin, tetracycline and rifabutin
0009UOncology (breast cancer), erbb2 (her2) copy number by fish, tumor cells from formalin fixed paraffin embedded tissue isolated using image-based dielectrophoresis (dep) sorting, reported as erbb2 gene amplified or non-amplified
0010UInfectious disease (bacterial), strain typing by whole genome sequencing, phylogenetic-based report of strain relatedness, per submitted isolate
0011UPrescription drug monitoring, evaluation of drugs present by lc- ms/ms, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug compounds and metabolites
0018UOncology (thyroid), microrna profiling by rt-pcr of 10 microrna sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy
0019UOncology, rna, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents
0021UOncology (prostate), detection of 8 autoantibodies (arf 6, nkx3-1, 5’- utr-bmi1, cep 164, 3’-utr-ropporin, desmocollin, aurkaip- 1, csnk2a2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk score
0022UTargeted genomic sequence analysis panel, non-small cell lung neoplasia, dna and rna analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence/absence of variants and associated therapy(ies) to consider
0024UGlycosylated acute phase proteins (glyca), nuclear magnetic resonance spectroscopy, quantitative
0025UTenofovir, by liquid chromatography with tandem mass spectrometry (lc-ms/ms), urine, quantitative
0029UDrug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, cyp1a2, cyp2c19, cyp2c9, cyp2d6, cyp3a4, cyp3a5, cyp4f2, slco1b1, vkorc1 and rs12777823)
0032UComt (catechol-o-methyltransferase)(drug metabolism) gene analysis, c.472g>a (rs4680) variant
0033UHtr2a (5-hydroxytryptamine receptor 2a), htr2c (5-hydroxytryptamine receptor 2c) (eg, citalopram metabolism) gene analysis, common variants (ie, htr2a rs7997012 [c.614-2211t>c], htr2c rs3813929 [c.- 759c>t] and rs1414334 [c.551-3008c>g])
0039UDeoxyribonucleic acid (dna) antibody, double stranded, high avidity
0050UTargeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements
0053UOncology (prostate cancer), fish analysis of 4 genes (asap1, hdac9, chd1 and pten), needle biopsy specimen, algorithm reported as probability of higher tumor grade
0055UCardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma
0056UHematology (acute myelogenous leukemia), DNA, whole genome next- generation sequencing to detect gene rearrangement(s), blood or bone marrow, report of specific gene rearrangement(s)
0058UOncology (merkel cell carcinoma), detection of antibodies to the merkel cell polyoma virus oncoprotein (small t antigen), serum, quantitative
0059UOncology (merkel cell carcinoma), detection of antibodies to the merkel cell polyoma virus capsid protein (vp1), serum, reported as positive or negative
0060UTWIN ZYGOSITY, GENOMIC TARGETED SEQUENCE ANALYSIS OF CHROMOSOME 2, USING CIRCULATING CELL-FREE FETAL DNA IN MATERNAL BLOOD
0062UAutoimmune (systemic lupus erythematosus), igg and igm analysis of 80 biomarkers, utilizing serum, algorithm reported with a risk score
0063UNeurology (autism), 32 amines by lc-ms/ms, using plasma, algorithm reported as metabolic signature associated with autism spectrum disorder
0070UCYP2D6 (Cytochrome P450, family 2, subfamily D, Polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (IE, *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35, *36, *41, *57, *61, *63, *68, *83, *XN)
0071UCYP2D6 (Cytochrome P450, family 2, subfamily d, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (list separately in addition to code for primary procedure)
0072UCYP2D6 (Cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (list separately in addition to code for primary procedure)
0073UCYP2D6 (Cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (list separately in addition to code for primary procedure)
0074UCYP2D6 (Cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, non-duplicated gene when duplication/multiplication is trans) (list separately in addition to code for primary procedure)
0075UCYP2D6 (Cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 5' gene duplication/multiplication) (list separately in addition to code for primary procedure)
0076UCYP2D6 (Cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 3' gene duplication/ multiplication) (list separately in addition to code for primary procedure)
0153UOncology (breast), MRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s) with information on immune cell involvement
0173UPsychiatry (ie, depression, anxiety), genomic analysis panel, includes variant analysis of 14 genes
0174UOncology (solid tumor), mass spectrometric 30 protein targets, formalin- fixed paraffin-embedded tissue, 
0175UPsychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 15 genes
0355UApol1 (apolipoprotein l1) (eg, chronic kidney disease), risk variants (g1, g2)
0356UOncology (oropharyngeal), evaluation of 17 dna biomarkers using droplet digital pcr (ddpcr), cell-free dna, algorithm reported as a prognostic risk score for cancer recurrence
0357UOncology (melanoma), artificial intelligence (ai)-enabled quantitative mass spectrometry analysis of 142 unique pairs of glycopeptide and product fragments, plasma, prognostic, and predictive algorithm reported as likely, unlikely, or uncertain benefit from immunotherapy agents
0358UNeurology (mild cognitive impairment), analysis of ?-amyloid 1-42 and 1-40, chemiluminescence enzyme immunoassay, cerebral spinal fluid, reported as positive, likely positive, or negative
0359UOncology (prostate cancer), analysis of all prostate-specific antigen (psa) structural isoforms by phase separation and immunoassay, plasma, algorithm reports risk of cancer
0360UOncology (lung), enzyme-linked immunosorbent assay (elisa) of 7 autoantibodies (p53, ny-eso-1, cage, gbu4-5, sox2, mage a4, and hud), plasma, algorithm reported as a categorical result for risk of malignancy
0361UNeurofilament light chain, digital immunoassay, plasma, quantitative
0362UOncology (papillary thyroid cancer), gene-expression profiling via targeted hybrid capture-enrichment rna sequencing of 82 content genes and 10 housekeeping genes, formalin-fixed paraffin embedded (ffpe) tissue, algorithm reported as one of three molecular subtypes
0363UOncology (urothelial), mrna, gene- expression profiling by real-time quantitative pcr of 5 genes (mdk, hoxa13, cdc2 [cdk1], igfbp5, and cxcr2), utilizing urine, algorithm incorporates age, sex, smoking history, and macrohematuria frequency, reported as a risk score for having urothelial carcinoma
0522UCarbonic anhydrase VI, parotid specific/secretory protein and salivary protein 1 (SP1), IgG, IgM, and IgA antibodies, chemiluminescence, semiqualitative, blood 
0524UObstetrics (preeclampsia), sFlt1/PlGF ratio, immunoassay, utilizing serum or plasma, reported as a value 
0525UOncology, spheroid cell culture, 11-drug panel (carboplatin, docetaxel, doxorubicin, etoposide, gemcitabine, niraparib, olaparib, paclitaxel, rucaparib, topotecan, veliparib) ovarian, fallopian, or peritoneal response prediction for each drug 
0526UNephrology (renal transplant), quantification of CXCL10 chemokines, flow cytometry, urine, reported as pg/mL creatinine baseline and monitoring over time 
0527UHerpes simplex virus (HSV) types 1 and 2 and Varicella zoster virus (VZV), amplified probe technique, each pathogen reported as detected or not detected 
0528ULower respiratory tract infectious agent detection, 18 bacteria, 8 viruses, and 7 antimicrobial resistance genes, amplified probe technique, including reverse transcription for RNA targets, each analyte reported as detected or not detected with semiquantitative results for 15 bacteria 
0529UHematology (venous thromboembolism [VTE]), genome-wide single-nucleotide polymorphism variants, including F2 and F5 gene analysis, and Leiden variant, by microarray analysis, saliva, report as risk score for VTE 


View Table I (CPT Codes) 
 
Rev#:Date:Nature of Change:
4.105/29/20261100-1677778-1879102 The following codes have been added: A2043, A2044, A2045, A4318, L2221, Q4418, Q4419, Q4421, Q4422, Q4423, Q4424, Q4425, Q4426, Q4427, Q4428, Q4429, Q4435, Q4436, Q4437, Q4438, Q4439, Q4440, A2040, A2041, A2042, G0680
4.005/07/20261100-1677778-1825750 The following codes have been removed:  0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T
3.411/20/20251100-1205570-1624500 Updated the description for codes 0598T, 0599T, and 0600T.
3.307/01/20251100-1205542-1290100 The following codes have been added to Table II: Q2058, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382, Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375.
3.205/08/20251100-1205528-1334400 Added codes: G0183 and G0566
3.104/29/20251100-1205521-1324401 The following codes have been added to Table II:  A9154, A2030, A2031, A2032, A2033, A2034, A2035, E0201, E1832, J1072, J1938, L0720, L5827, L6700, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367
3.002/20/20251100-1205507-1250755
The following codes have been added to Table II: E1803, E1804, E1807, E1808, E1813, E1814, E1822, E1823, E1826, E1827, E1828, E1829, G0537, G0538, G0552, G0553, G0554, G0555, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353
The following codes have been added to Table III: 0901T, 0902T, 0915T, 0916T, 0917T, 0918T, 0919T, 0920T, 0921T, 0922T, 0923T, 0924T, 0925T, 0926T, 0927T, 0928T, 0929T, 0930T, 0931T, 0932T, 0933T, 0934T, 0935T, 0936T, 0937T, 0938T, 0939T, 0940T, 0941T, 0942T, 0943T, 0944T, 0945T, 0946T, 0947T, 0522U, 0524U, 0525U, 0526U, 0527U, 0528U, 0529U
2.05 (v42)10/22/20241100-956547-1162854
The following codes have been added to Table II: A2027, A2028, A2029, A4543, A7021, C8000, E0469, E0715, E0716, E0721, E2513, E3200, P9027, Q4334, Q4335, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345
The following code has been revised: Q4336
2.04 (v41)10/08/20241100-956547-1154189
Code G0249 has been removed from Table 2
2.03 (v40)07/03/20241100-956532-1081850
Codes added to Table 2
C1605, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4323, Q4324, Q4325, Q4327, Q4328, Q4329, Q4330, Q4333, Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4331, Q4332, Q4326 
Codes added to Table 3
0887T, 0867T, 0868T, 0870T, 0871T, 0872T, 0873T, 0874T, 0875T, 0876T, 0881T, 0882T, 0883T, 0884T, 0885T, 0886T, 0888T, 0893T, 0894T, 0895T, 0896T, 0897T
2.02 (v39)05/01/2024Code added to Table III: 0779T
2.01 (v38)04/29/2024Codes added to Table II: 
A2026, A4593, A4594, E0152, K1037, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, S4988, S9002
2.00 (v37)01/31/2024Codes added to Table II:
A4540, A4541, A4542, A7023, C1602, C1604, E0492, E0493, E0530, E0732, E0733, E0734, E0735, E2001, E3000, L3161, Q4279, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304
Codes added to Table III:
0813T, 0814T, 0816T, 0817T, 0818T, 0819T, 0823T, 0824T, 0825T, 0826T, 0827T, 0828T, 0829T, 0830T, 0831T, 0832T, 0833T, 0834T, 0835T, 0836T, 0837T, 0838T, 0839T, 0840T, 0841T, 0842T, 0843T, 0844T, 0845T, 0846T, 0847T, 0848T, 0849T, 0850T, 0851T, 0852T, 0853T, 0854T, 0855T, 0856T, 0857T, 0858T, 0859T, 0860T, 0861T, 0862T, 0863T, 0864T
1.32 (v36)09/01/2023Removed codes: 0005U, 0030U, 0179
1.31 (v35)07/31/2023Added the following codes to Table II: Q4272, Q4273, Q4274, Q4275, Q4276, Q4277, Q4278, Q4280, Q4281, Q4282, Q4283, Q4284
Added the following codes to Table III: 0792T, 0793T, 0794T, 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T, 0805T, 0806T, 0807T, 0808T, 0810T
1.30 (v34)07/10/2023Removed code: G0166
1.29 (v33)06/16/2023Removed code: Q4159
1.28 (v32)05/30/2022Removed codes: 0012U, 0013U, 0014U
1.27 (v31)05/23/2023Added codes: A2019, A2020, A2021, A4560, A6591, A7049, E0677, E0711, E1905, L8678, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270, Q427
1.26 (v30)04/14/2023Added codes 0662T and 0663T.
1.25 (v29)03/07/2023Added code S1091.
1.24 (v28)03/02/2023Removed code A9272 as it is included in the medical policy.
1.23 (v27)01/31/2023The following codes were added to Table II: Q4262, Q4263, Q4264, Q4236
The following codes were added to Table III: 0355U, 0356U, 0357U, 0358U, 0359U, 0360U, 0361U, 0362U, 0363U
1.22 (v26)01/20/2023Removed codes: Q4114 and Q4168.
1.21 (v25)12/05/2022The following codes were added to Table II: A2001, A2002, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A4100, A9291, C1833, G0465, H2038, K1023, K1026, K1028, K1029, K1030, Q4199, Q4224, Q4225, Q4251, Q4252, Q4253, Q4256, Q4257, Q4258, Q4259, Q4260, S9432, T2050, T2051, V2525
The following codes were added to Table III: 0672T, 0674T, 0675T, 0676T, 0677T, 0678T, 0679T, 0680T, 0681T, 0682T, 0683T, 0684T, 0685T, 0691T, 0692T, 0693T, 0695T, 0696T, 0700T, 0701T, 0704T, 0705T, 0706T, 0707T, 0708T, 0709T, 0710T, 0711T, 0712T, 0713T
1.20 (v24)10/06/2022The following codes were added to Table III: 0716T, 0717T, 0718T, 0719T, 0720T, 0725T, 0726T, 0727T, 0728T, 0729T, 0730T, 0731T, 0732T, 0733T, 0734T, 0737T
0716T, 0717T, 0718T, 0719T, 0720T, 0725T, 0726T, 0727T, 0728T, 0729T, 0730T, 0731T, 0732T, 0733T, 0734T, 0737
1.19 (v23)08/04/2022Added a quick link to Table IV (Audio-Only Interactions), then removed.
1.18 (v22)08/03/2022Removed codes 0613T and 0614T
1.17 (v21)07/05/2022Removed code 0449T 
1.16 (v20)04/07/2022The following codes were removed: Q4172, Q4236, Q9993, 0004U, 0006U, 0015U, 0020U, 0254T, 0375T, 0396T, 0400T, 0401T, 0405T
1.15 (v19)02/25/2022Added CPT code 0153U to Table III.
1.14 (v18)12/01/20210597T Removal of substernal implantable defibrillator pulse generator only - code has been corrected to 0580T.
1.13 (v17)07/02/2021Removed CTP CODES from Table III: 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T. Codes have been removed as they are plan exclusions.
1.12 (v16)07/01/2021Added HCPCS code to Table II: G0327
Added CPT codes to Table III: 0640T, 0641T, 0642T, 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T
Reversed order of Change History entries (most recent at top.)
1.11 (v15)05/12/2021Removed code A9587 from Table II.
1.10 (v14)03/02/2021Added codes 0017M, G2214, G2250 to Table II.
1.9 (v13)02/25/2021Removed code 0026U from Table III.
1.8 (v12)10/01/2020Removed code 0376T from Table III.
1.7 (v11)08/27/2020Added additional information to codes 0497T and 0498T.
1.8 (v10)08/12/2020Added the following codes to Table III: 0050U, 0053U, 0055U, 0056U, 0058U, 0059
1.5  (v9)08/11/2020Added code 0060U to Table III.
1.4 (v8)07/28/2020Added the following codes to Table II: J0591, J0691, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4244, Q4245, Q4246, Q4247, Q4248
Added the following codes to Table III: 0597T, 0596T, 0614T, 0174U, 0179U, 0602T, 0603T, 0607T, 0608T, 0609T, 0610T, 0611T, 0612T, 0613T, 0615T, 0616T, 0617T, 0618T, 0619T, 0173U, 0175U, 0596T , 0597T , 0598T , 0599T , 0600T , 0601T
1.3 (v7)06/23/2020Removed from code Artificial Intervertebral Disc Replacement - Cervical - Archived from 0375T and updated smart link in 0095T/0098T code. 
1.2 (v6)05/27/2020Added code: 0202U
1.1 (v5)05/06/2020Added the following codes to table III: 0551T, 0552T, 0553T, 0554T, 0555T, 0556T, 0557T, 0558T, 0559T
1.002/25/2020Added the following codes to the list: K1002, K1004, K1005
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