Codes That Do Not Meet Payment Determination Criteria - Table I
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 .
Oncology (high-grade prostate cancer), biochemical assay of four proteins (total PSA, free PSA, intact PSAand human kallikrein 2 [hk2]) plus patient age, digital rectal examination status, and no history of positive prostate biopsy, utilizing plasma, prognostic algorithm reported as a probability score
0011M
Oncology, prostate cancer, mrna expression assay of 12 genes (10 content and 2 housekeeping), rt-pcr test utilizing blood plasma and/or urine, algorithms to predict high-grade prostate cancer risk
0012M
Oncology (urothelial), mrna, gene expression profiling by real-time quantitative pcr of five genes (mdk, hoxa13, cdc2 [cdk1], igfbp5, and xcr2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma
0013M
Oncology (urothelial), mrna, gene expression profiling by real-time quantitative pcr of five genes (mdk, hoxa13, cdc2 [cdk1], igfbp5, and cxcr2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma
0019M
Cardiovascular disease, plasma, analysis of protein biomarkers by aptamer-based microarray and algorithm reported as 4-year likelihood of coronary event in high-risk populations
0351T
Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative
0352T
Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen, interpretation and report, real time or referred
0353T
Optical coherence tomography of breast, surgical cavity; real time intraoperative
0354T
Optical coherence tomography of breast, surgical cavity; interpretation and report, real time intraoperative
0355T
Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report
0356T
Insertion of drug-eluting implant (including puntal dilation and implant removal when performed) into lacrimal canaliculus, each
0358T
Biolectrical impedance analysis whole body composition assessment, supine position, with interpretation and report
0359T
Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and caregiver(s), includes administration of standardization and non-standardization tests, detailed behavioral history, patient observational
0360T
Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient
0361T
Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient
0363T
Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more tec
0509T
Electroretinography (erg) with interpretation and report, pattern (perg)
0512T, 0513T
Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound
0514T
Intraoperative visual axis identification using patient fixation (list separately in addition to code for primary procedure)
0621T
Trabeculostomy ab interno by laser
0622T
Trabeculostomy ab interno by laser; with use of ophthalmic endoscope
0632T
Percutaneous transcatheter ultrasound ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance
0634T
Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s)
0635T
Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s)
0636T
Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s)
0637T
Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s)
0638T
Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s)
0639T
Wireless skin sensor thermal anisotropy measurement(s) and assessment of flow in cerebrospinal fluid shunt, including ultrasound guidance, when performed
0887T
End-tidal control of inhaled anesthetic agents and oxygen to assist anesthesia care delivery (list separately in addition to code for primary procedure)
0867T
Transperineal laser ablation of benign prostatic hyperplasia, including imaging guidance; prostate volume greater or equal to 50 ml
0868T
High-resolution gastric electrophysiology mapping with simultaneous patient- symptom profiling, with interpretation and report
0870T
Implantation 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
0871T
Replacement of a subcutaneous peritoneal ascites pump, including reconnection between pump and indwelling bladder and peritoneal catheters, including initial programming and imaging, when performed
0872T
Replacement 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
0873T
Revision of a subcutaneously implanted peritoneal ascites pump system, any component (ascites pump, associated peritoneal catheter, associated bladder catheter), including imaging and programming, when performed
0874T
Removal of a peritoneal ascites pump system, including implanted peritoneal ascites pump and indwelling bladder and peritoneal catheters
0875T
Programming of subcutaneously implanted peritoneal ascites pump system by physician or other qualified health care professional
0876T
Duplex scan of hemodialysis fistula, computer-aided, limited (volume flow, diameter, and depth, including only body of fistula)
0881T
Cryotherapy 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
0882T
Intraoperative 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)
0883T
Intraoperative 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
0884T
Esophagoscopy, 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
0885T
Colonoscopy, 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
0886T
Sigmoidoscopy, 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
0888T
Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance
0893T
Noninvasive assessment of blood oxygenation, gas exchange efficiency, and cardiorespiratory status, with physician or other qualified health care professional interpretation and report
0894T
Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation of the liver allograft following normothermic perfusion
0895T
Connection 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)
0896T
Connection 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)
0897T
Noninvasive 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
0018U
Oncology (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
0031U
CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism), gene analysis, common variants (ie, *1F, *1K, *6, *7)
0036U
Neurology (prion disease), cerebrospinal fluid, detection of prion protein by quaking- induced conformational conversion, qualitative
0041U
Borrelia burgdorferi, antibody detection of 5 recombinant protein groups, by immunoblot, igm
0045U
Oncology (breast ductal carcinoma in situ), mrna, gene expression profiling by real- time rt-pcr of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence score
0051U
Prescription drug monitoring, evaluation of drugs present by lc-ms/ms, urine, 31 drug panel, reported as quantitative results, detected or not detected, per date of service
0052U
Lipoprotein, blood, high resolution fractionation and quantitation of lipoproteins, including all five major lipoprotein classes and subclasses of hdl, ldl, and vldl by vertical auto profile ultracentrifugation
0054U
Prescription drug monitoring, 14 or more classes of drugs and substances, definitive tandem mass spectrometry with chromatography, capillary blood, quantitative report with therapeutic and toxic ranges, including steady-state range for the prescribed dose when detected, per date of service
0061U
Transcutaneous measurement of five biomarkers (tissue oxygenation [sto2], oxyhemoglobin [cthbo2], deoxyhemoglobin [cthbr], papillary and reticular dermal hemoglobin concentrations [cthb1 and cthb2]), using spatial frequency domain imaging (sfdi) and multi-spectral analysis
0067U
Oncology (breast), immunohistochemistry, protein expression profiling of 4 biomarkers (matrix metalloproteinase-1 [mmp-1], carcinoembryonic antigen-related cell adhesion molecule 6 [ceacam6], hyaluronoglucosaminidase [hyal1], highly expressed in cancer protein [hec1]), formalin-fixed paraffin-embedded precancerous breast tissue, algorithm reported as carcinoma risk score
0068U
Candida species panel (c. Albicans, c. Glabrata, c. Parapsilosis, c. Kruseii, c tropicalis, and c. Auris), amplified probe technique with qualitative report of the presence or absence of each species
0078U
Pain management (opioid-use disorder) genotyping panel, 16 common variants (ie, ABCB1, COMT, DAT1, DBH, DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OPRM1), buccal swab or other germline tissue sample, algorithm reported as positive or negative risk of opioid-use disorder
0087U
Cardiology (heart transplant), mrna gene expression profiling by microarray of 1283 genes, transplant biopsy tissue, allograft rejection and injury algorithm reported as a probability score
0088U
Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probability score for rejection
0090U
Oncology (cutaneous melanoma), mrna gene expression profiling by rt-pcr of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a categorical result (ie, benign, indeterminate, malignant)
0094U
Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis
0097U
Gastrointestinal pathogen, multiplex reverse transcription and multiplex amplified probe technique, multiple types or subtypes, 22 targets (campylobacter [c. Jejuni/c. Coli/c. Upsaliensis], clostridium difficile [c. Difficile] toxin a/b, plesiomonas shigelloides, salmonella, vibrio [v. Parahaemolyticus/v. Vulnificus/v. Cholerae], including specific identification of vibrio cholerae, yersinia enterocolitica, enteroaggregative escherichia coli [eaec], enteropathogenic escherichia coli [epec], enterotoxigenic escherichia coli [etec] lt/st, shiga-like toxin-producing escherichia coli [stec] stx1/stx2 [including specific identification of the e. Coli o157 serogroup within stec], shigella/enteroinvasive escherichia coli [eiec], cryptosporidium, cyclospora cayetanensis, entamoeba histolytica, giardia lamblia [also known as g. Intestinalis and g. Duodenalis], adenovirus f 40/41, astrovirus, norovirus gi/gii, rotavirus a, sapovirus [genogroups i, ii, iv, and v])
0105U
Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (eclia) of tumor necrosis factor receptor 1a, receptor superfamily 2 (tnfr1, tnfr2), and kidney injury molecule-1 (kim-1) combined with longitudinal clinical data, including apol1 genotype if available, and plasma (isolated fresh or frozen), algorithm reported as probability score for rapid kidney function decline (RKFD)
0108U
Gastroenterology (Barrett's esophagus), whole slide–digital imaging, including morphometric analysis, computer-assisted quantitative immunolabeling of 9 protein biomarkers (p16, AMACR, p53, cd68, cox-2, cd45ro, hif1a, her-2, k20) and morphology, formalin-fixed paraffin-embedded tissue, algorithm reported as risk of progression to high-grade dysplasia or cancer
0109U
Infectious disease (aspergillus species), real-time PCR for detection of DNA from 4 species (a. Fumigatus, a. Terreus, a. Niger, and a. Flavus), blood, lavage fluid, or tissue, qualitative reporting of presence or absence of each species
0110U
Prescription drug monitoring, one or more oral oncology drug(s) and substances, definitive tandem mass spectrometry with chromatography, serum or plasma from capillary blood or venous blood, quantitative report with steady-state range for the prescribed drug(s) when detected
0112U
Infectious agent detection and identification, targeted sequence analysis (16s and 18s rRNA genes) with drug-resistance gene
0113U
Oncology (prostate), measurement of pca3 and tmprss2-erg in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score
0114U
Gastroenterology (Barrett's esophagus), vim and ccna1 methylation analysis, esophageal cells, algorithm reported as likelihood for Barrett's esophagus
0116U
Prescription drug monitoring, enzyme immunoassay of 35 or more drugs confirmed with lc-ms/ms, oral fluid, algorithm results reported as a patient-compliance measurement with risk of drug to drug interactions for prescribed medications
0117U
Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-hpma), quinolinic acid, kynurenic acid), lc-ms/ms, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain
0119U
Cardiology, ceramides by liquid chromatography–tandem mass spectrometry, plasma, quantitative report with risk score for major cardiovascular events
0120U
Oncology (b-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin-fixed paraffin-embedded tissue, algorithm reported as likelihood for primary mediastinal b-cell lymphoma (PMBCL) and diffuse large b-cell lymphoma (DLBCL) with cell of origin subtyping in the latter
0123U
Mechanical fragility, RBC, shear stress and spectral analysis profiling
0130U
Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and, TP53) (List separately in addition to code for primary procedure)
0136U
ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately in addition to code for primary procedure)
0138U
BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) mRNA sequence analysis (List separately in, addition to code for primary procedure)
0143U
Drug assay, definitive, 120 or more drugs or metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring (MRM), with drug or metabolite description, comments including sample validation, per date of service
0144U
Drug assay, definitive, 160 or more drugs or metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring (MRM), with drug or metabolite description, comments including sample validation, per date of service
0145U
Drug assay, definitive, 65 or more drugs or metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring (MRM), with drug or metabolite description, comments including sample validation, per date of service
0146U
Drug assay, definitive, 80 or more drugs or metabolites, urine, by quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring (MRM), with drug or metabolite description, comments including sample validation, per date of service
0147U
Drug assay, definitive, 85 or more drugs or metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring (MRM), with drug or metabolite description, comments including sample validation, per date of service
0148U
Drug assay, definitive, 100 or more drugs or metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring (MRM), with drug or metabolite description, comments including sample validation, per date of service
0149U
Drug assay, definitive, 60 or more drugs or metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring (MRM), with drug or metabolite description, comments including sample validation, per date of service
0150U
Drug assay, definitive, 120 or more drugs or metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (LC-MS/MS) using multiple reaction monitoring (MRM), with drug or metabolite description, comments including sample validation, per date of service
0163U
ONCOLOGY (COLORECTAL) SCREENING, BIOCHEMICAL ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA) OF 3 PLASMA OR SERUM PROTEINS (TERATOCARCINOMA DERIVED GROWTH FACTOR-1 [TDGF-1, CRIPTO- 1], CARCINOEMBRYONIC ANTIGEN [CEA], EXTRACELLULAR MATRIX PROTEIN [ECM]), WITH DEMOGRAPHIC DATA (AGE, GENDER, CRC- SCREENING COMPLIANCE) USING A PROPRIETARY ALGORITHM AND REPORTED AS LIKELIHOOD OF CRC OR ADVANCED ADENOMAS
0164U
GASTROENTEROLOGY (IRRITABLE BOWEL SYNDROME [IBS]), IMMUNOASSAY FOR ANTI- CDTB AND ANTI-VINCULIN ANTIBODIES, UTILIZING PLASMA, ALGORITHM FOR ELEVATED OR NOT ELEVATED QUALITATIVE RESULTS
0166U
LIVER DISEASE, 10 BIOCHEMICAL ASSAYS (A2- MACROGLOBULIN, HAPTOGLOBIN, APOLIPOPROTEIN A1, BILIRUBIN, GGT, ALT, AST, TRIGLYCERIDES, CHOLESTEROL, FASTING GLUCOSE) AND BIOMETRIC AND DEMOGRAPHIC DATA, UTILIZING SERUM, ALGORITHM REPORTED AS SCORES FOR FIBROSIS, NECROINFLAMMATORY ACTIVITY, AND STEATOSIS WITH A SUMMARY INTERPRETATION
0167U
GONADOTROPIN, CHORIONIC (HCG), IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION, BLOOD
0170U
NEUROLOGY (AUTISM SPECTRUM DISORDER [ASD]), RNA, NEXT-GENERATION SEQUENCING, SALIVA, ALGORITHMIC ANALYSIS, AND RESULTS REPORTED AS PREDICTIVE PROBABILITY OF ASD DIAGNOSIS
0202U
Infectious 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
0223U
INFECTIOUS 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 DETECTED OR NOT DETECTED
0224U
Antibody, severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) (Coronavirus disease [COVID-19]), includes titer(s), when performed (Do not report 0224U in conjunction with 86769)
At this time deny, unclear if quantitative IgG medically useful at this time
0225U
Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNA and RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), amplified probe technique, including multiplex reverse transcription for RNA targets, each analyte reported as detected or not detected
0226U
SURROGATE VIRAL NEUTRALIZATION TEST (SVNT), SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ELISA, PLASMA, SERUM
0248U
Oncology (brain), spheroid cell culture in a 3d microenvironment, 12 drug panel, tumor-response prediction for each drug 0249U Oncology (breast), semiquantitative analysis of 32 phosphoproteins and protein analytes, includes laser capture microdissection, with algorithmic analysis and interpretative report
0251U
Hepcidin-25, enzyme-linked immunosorbent assay (elisa), serum or plasma
0253U
Reproductive medicine (endometrial receptivity analysis), rna gene expression profile, 238 genes by next-generation sequencing, endometrial tissue, predictive algorithm reported as endometrial window of implantation (eg, pre-receptive, receptive, post-receptive)
0254U
Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic dna genomic sequence analysis for aneuploidy, and a mitochondrial dna score in euploid embryos, results reported as normal (euploidy),monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy, per embryo tested
0255U
Andrology (infertility), sperm-capacitation assessment of ganglioside gm1 distribution patterns, fluorescence microscopy, fresh or frozen specimen, reported as percentage of capacitated sperm and probability of generating a pregnancy score
0257U
Very long chain acyl-coenzyme a (coa) dehydrogenase (vlcad), leukocyte enzyme activity, whole blood
0258U
Autoimmune (psoriasis), mrna, next- generation sequencing, gene expression profiling of 50-100 genes, skin-surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics
0259U
Nephrology (chronic kidney disease), nuclear magnetic resonance spectroscopy measurement of myo-inositol, valine, and creatinine, algorithmically combined with cystatin c (by immunoassay) and demographic data to determine estimated glomerular filtration rate (gfr), serum, quantitative
0260U
Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping
0261U
Oncology (colorectal cancer), image analysis with artificial intelligence assessment of 4 histologic and immunohistochemical features (cd3 and cd8 within tumor-stroma border and tumor core), tissue, reported as immune response and recurrence-risk score
Neurology (autism spectrum disorder [asd]), quantitative measurements of 16 central carbon metabolites (ie, a- ketoglutarate, alanine, lactate, phenylalanine, pyruvate, succinate, carnitine, citrate, fumarate, hypoxanthine, inosine, malate, s-sulfocysteine, taurine, urate, and xanthine), liquid chromatography tandem mass spectrometry (lc-ms/ms), plasma, algorithmic analysis with result reported as negative or positive (with metabolic subtypes of asd)
0264U
Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping
0265U
Rare constitutional and other heritable disorders, whole genome and mitochondrial dna sequence analysis, blood, frozen and formalin-fixed paraffin- embedded (ffpe) tissue, saliva, buccal swabs or cell lines, identification of single nucleotide and copy number variants
0267U
Rare constitutional and other heritable disorders, identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping and whole genome sequencing
0275U
Hematology (heparin-induced thrombocytopenia), platelet antibody reactivity by flow cytometry, serum
0278U
Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid
0285U
Oncology, response to radiation, cell-free dna, quantitative branched chain dna amplification, plasma, reported as a radiation toxicity score
0286U
Cep72 (centrosomal protein, 72-kda), nudt15 (nudix hydrolase 15) and tpmt (thiopurine s-methyltransferase) (eg, drug metabolism) gene analysis, common variants
0288U
Oncology (lung), mrna, quantitative pcr analysis of 11 genes (bag1, brca1, cdc6, cdk2ap1, erbb3, fut3, il11, lck, rnd3, sh3bgr, wnt3a) and 3 reference genes (esd, tbp, yap1), formalin-fixed paraffin-embedded (ffpe) tumor tissue, algorithmic interpretation reported as a recurrence risk score
0289U
Neurology (alzheimer disease), mrna, gene expression profiling by rna sequencing of 24 genes, whole blood, algorithm reported as predictive risk score
0290U
Pain management, mrna, gene expression profiling by rna sequencing of 36 genes, whole blood, algorithm reported as predictive risk score
0291U
Psychiatry (mood disorders), mrna, gene expression profiling by rna sequencing of 144 genes, whole blood, algorithm reported as predictive risk score
0292U
Psychiatry (stress disorders), mrna, gene expression profiling by rna sequencing of 72 genes, whole blood, algorithm reported as predictive risk score
0293U
Psychiatry (suicidal ideation), mrna, gene expression profiling by rna sequencing of 54 genes, whole blood, algorithm reported as predictive risk score
0294U
Longevity and mortality risk, mrna, gene expression profiling by rna sequencing of 18 genes, whole blood, algorithm reported as predictive risk score
0295U
Oncology (breast ductal carcinoma in situ), protein expression profiling by immunohistochemistry of 7 proteins (cox2, foxa1, her2, ki-67, p16, pr, siah2), with 4 clinicopathologic factors (size, age, margin status, palpability), utilizing formalin-fixed paraffin-embedded (ffpe) tissue, algorithm reported as a recurrence risk score
0296U
Oncology (oral and/or oropharyngeal cancer), gene expression profiling by rna sequencing at least 20 molecular features (eg, human and/or microbial mrna), saliva, algorithm reported as positive or negative for signature associated with malignancy
0297U
Oncology (pan tumor), whole genome sequencing of paired malignant and normal dna specimens, fresh or formalin-fixed paraffin-embedded (ffpe) tissue, blood or bone marrow, comparative sequence analyses and variant identification
0298U
Oncology (pan tumor), whole transcriptome sequencing of paired malignant and normal rna specimens, fresh or formalin-fixed paraffin-embedded (ffpe) tissue, blood or bone marrow, comparative sequence analyses and expression level and chimeric transcript identification
0299U
Oncology (pan tumor), whole genome optical genome mapping of paired malignant and normal DNA specimens, fresh frozen tissue, blood, or bone marrow, comparative structural variant identification
0300U
Oncology (pan tumor), whole genome sequencing and optical genome mapping of paired malignant and normal DNA specimens, fresh tissue, blood, or bone marrow, comparative sequence analyses and variant identification
0303U
Hematology, red blood cell (rbc) adhesion to endothelial/subendothelial adhesion molecules, functional assessment, whole blood, with algorithmic analysis and result reported as an rbc adhesion index; hypoxic
0304U
Hematology, red blood cell (rbc) adhesion to endothelial/subendothelial adhesion molecules, functional assessment, whole blood, with algorithmic analysis and result reported as an rbc adhesion index; normoxic
0305U
Hematology, red blood cell (rbc) functionality and deformity as a function of shear stress, whole blood, reported as a maximum elongation index
0310U
Pediatrics (vasculitis, kawasaki disease [kd]), analysis of 3 biomarkers (nt- probnp, c-reactive protein, and t-uptake), plasma, algorithm reported as a risk score for kd
0312U
Autoimmune diseases (eg, systemic lupus erythematosus [sle]), analysis of 8 igg autoantibodies and 2 cell-bound complement activation products using enzyme-linked immunosorbent immunoassay (elisa), flow cytometry and indirect immunofluorescence, serum, or plasma and whole blood, individual components reported along with an algorithmic sle-likelihood assessment
0313U
Oncology (pancreas), dna and mrna next-generation sequencing analysis of 74 genes and analysis of cea (ceacam5) gene expression, pancreatic cyst fluid, algorithm reported as a categorical result (ie, negative, low probability of neoplasia or positive, high probability of neoplasia)
0314U
Oncology (cutaneous melanoma), mrna gene expression profiling by rt-pcr of 35 genes (32 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded (ffpe) tissue, algorithm reported as a categorical result (ie, benign, intermediate, malignant)
0315U
Oncology (cutaneous squamous cell carcinoma), mrna gene expression profiling by rt-pcr of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin-embedded (ffpe) tissue, algorithm reported as a categorical risk result (ie, class 1, class 2a, class 2b)
0316U
Borrelia burgdorferi (lyme disease), ospa protein evaluation, urine
0317U
Oncology (lung cancer), four-probe fish (3q29, 3p22.1, 10q22.3, 10cen) assay, whole blood, predictive algorithm- generated evaluation reported as decreased or increased risk for lung cancer
0319U
Nephrology (renal transplant), rna expression by select transcriptome sequencing, using pretransplant peripheral blood, algorithm reported as a risk score for early acute rejection
0320U
Nephrology (renal transplant), rna expression by select transcriptome sequencing, using posttransplant peripheral blood, algorithm reported as a risk score for acute cellular rejection
0322U
Neurology (autism spectrum disorder [asd]), quantitative measurements of 14 acyl carnitines and microbiome-derived metabolites, liquid chromatography with tandem mass spectrometry (lc-ms/ms), plasma, results reported as negative or positive for risk of metabolic subtypes associated with asd
0323U
Infectious agent detection by nucleic acid (dna and rna), central nervous system pathogen, metagenomic next-generation sequencing, cerebrospinal fluid (csf), identification of pathogenic bacteria, viruses, parasites, or fungi
0324U
Oncology (ovarian), spheroid cell culture, 4-drug panel (carboplatin, doxorubicin, gemcitabine, paclitaxel), tumor chemotherapy response prediction for each drug
0325U
Oncology (ovarian), spheroid cell culture, poly (adp-ribose) polymerase (parp) inhibitors (niraparib, olaparib, rucaparib, velparib), tumor response prediction for each drug
0327U
Fetal aneuploidy (trisomy 13, 18, and 21), DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy, includes sex reporting, if performed
0328U
Drug assay, definitive, 120 or more drugs and metabolites, urine, quantitative liquid chromatography with tandem mass spectrometry (lc-ms/ms), includes specimen validity and algorithmic analysis describing drug or metabolite and presence or absence of risks for a significant patient-adverse event, per date of service
0329U
Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite instability and tumor mutational burden utilizing dna and rna from tumor with dna from normal blood or saliva for subtraction, report of clinically significant mutation(s) with therapy associations
0331U
Oncology (hematolymphoid neoplasia), optical genome mapping for copy number alterations and gene rearrangements utilizing dna from blood or bone marrow, report of clinically significant alternations
0333U
Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high- risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement of serum of afp/afp-l3 and oncoprotein des-gamma-carboxy-prothrombin (DCP), algorithm reported as normal or abnormal result
0337U
Oncology (plasma cell disorders and myeloma), circulating plasma cell immunologic selection, identification, morphological characterization, and enumeration of plasma cells based on differential cd138, cd38, cd19, and cd45 protein biomarker expression, peripheral blood
0338U
Oncology (solid tumor), circulating tumor cell selection, identification, morphological characterization, detection and enumeration based on differential epcam, cytokeratins 8, 18, and 19, and cd45 protein biomarkers, and quantification of her2 protein biomarker-expressing cells, peripheral blood
0339U
Oncology (prostate), mRNA expression profiling of hoxc6 and dlx1, reverse transcription polymerase chain reaction (rt-PCR), first-void urine following digital rectal examination, algorithm reported as probability of high-grade cancer
0342U
Oncology (pancreatic cancer), multiplex immunoassay of c5, c4, cystatin c, factor b, osteoprotegerin (OPG), gelsolin, igfbp3, ca125 and multiplex electrochemiluminescent immunoassay (ECLIA) for ca19-9, serum, diagnostic algorithm reported qualitatively as positive, negative, or borderline
0343U
Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (rt-qPCR), urine, reported as molecular evidence of no-, low-, intermediate- or high-risk of prostate cancer
0345U
Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of cyp2d6
0346U
Beta amyloid, ab40 and ab42 by liquid chromatography with tandem mass spectrometry (lc-ms/ms), ratio, plasma
0347U
Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes
0348U
Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes
0349U
Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis, including reported phenotypes and impacted gene-drug interactions
0350U
Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes
0351U
Infectious disease (bacterial or viral), biochemical assays, tumor necrosis factor- related apoptosis-inducing ligand (trail), interferon gamma-induced protein-10 (ip- 10), and c-reactive protein, serum, algorithm reported as likelihood of bacterial infection
0352U
Infectious disease (bacterial vaginosis and vaginitis), multiplex amplified probe technique, for detection of bacterial vaginosis-associated bacteria (bvab-2, atopobium vaginae, and megasphera type 1), algorithm reported as detected or not detected and separate detection of candida species (c. albicans, c. tropicalis, c. parapsilosis, c. dubliniensis), candida glabrata/candida krusei, and trichomonas vaginalis, vaginal-fluid specimen, each result reported as detected or not detected
0353U
Infectious agent detection by nucleic acid (DNA), chlamydia trachomatis and neisseria gonorrhoeae, multiplex amplified probe technique, urine, vaginal, pharyngeal, or rectal, each pathogen reported as detected or not detected
0354U
Human papilloma virus (HPV), high-risk types (ie, 16, 18, 31, 33, 45, 52 and 58) qualitative mRNA expression of e6/e7 by quantitative polymerase chain reaction (qPCR)
0365U
Oncology (bladder), analysis of 10 protein biomarkers (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1 and VEGFA) by immunoassays, urine, algorithm reported, as a probability of bladder cancer
0366U
Oncology (bladder), analysis of 10 protein biomarkers (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1 and VEGFA) by immunoassays, urine, algorithm reported, as a probability of recurrent bladder cancer
0367U
Oncology (bladder), analysis of 10 protein biomarkers (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1 and VEGFA) by immunoassays, urine, diagnostic algorithm reported as a risk score for probability of rapid recurrence of recurrent or persistent cancer following transurethral resection
0368U
Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4, ZNF132 and TWIST1), multiplex quantitative polymerase chain reaction (qPCR), circulating cell-free DNA (cfDNA), plasma, report of risk score for, advanced adenoma or colorectal cancer
0369U
Infectious agent detection by nucleic acid (DNA and RNA), gastrointestinal pathogens, 31 bacterial, viral, and parasitic organisms and identification of 21 associated antibiotic-resistance genes, multiplex amplified probe technique
0370U
Infectious agent detection by nucleic acid (DNA and RNA), surgical wound pathogens, 34 microorganisms and identification of 21 associated antibiotic-resistance genes,, multiplex amplified probe technique, wound swab
0371U
Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogen, semiquantitative identification, DNA from 16 bacterial organisms and 1 fungal organism, multiplex amplified probe technique via quantitative polymerase chain reaction (qPCR), urine
0372U
Infectious disease (genitourinary pathogens), antibiotic-resistance gene detection, multiplex amplified probe technique, urine, reported as an antimicrobial stewardship, risk score
0373U
Infectious agent detection by nucleic acid (DNA and RNA), respiratory tract infection, 17 bacteria, 8 fungus, 13 virus, and 16 antibiotic-resistance genes, multiplex amplified probe technique, upper or lower respiratory specimen
0374U
Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 21 bacterial and fungal organisms and identification of 21 associated, antibiotic-resistance genes, multiplex amplified probe technique, urine
0375U
Oncology (ovarian), biochemical assays of 7 proteins (follicle stimulating hormone, human epididymis protein 4, apolipoprotein A-1, transferrin, beta-2 macroglobulin, prealbumin [ie, transthyretin], and cancer antigen 125), algorithm reported as ovarian, cancer risk score
0376U
Oncology (prostate cancer), image analysis of at least 128 histologic features and clinical factors, prognostic algorithm determining the risk of distant metastases, and prostate cancer-specific mortality, includes predictive algorithm to androgen, deprivation-therapy response, if appropriate
0377U
Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a, lipoprotein profile (including 23 variables)
0378U
RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab
0380U
Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported, genotype and phenotype
0381U
Maple syrup urine disease monitoring by patient-collected blood card sample, quantitative measurement of allo-isoleucine, leucine, isoleucine, and valine, liquid chromatography with tandem mass spectrometry (LC-MS/MS)
0382U
Hyperphenylalaninemia monitoring by patient-collected blood card sample, quantitative measurement of phenylalanine and tyrosine, liquid chromatography with, tandem mass spectrometry (LC-MS/MS)
0383U
Tyrosinemia type I monitoring by patient-collected blood card sample, quantitative measurement of tyrosine, phenylalanine, methionine, succinylacetone, nitisinone, liquid chromatography with tandem mass spectrometry (LC-MS/MS)
0384U
Nephrology (chronic kidney disease), carboxymethyllysine, methylglyoxal hydroimidazolone, and carboxyethyl lysine by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and HbA1c and estimated glomerular filtration rate, (GFR), with risk score reported for predictive progression to high-stage kidney disease
0385U
Nephrology (chronic kidney disease), apolipoprotein A4 (ApoA4), CD5 antigen-like (CD5L), and insulin-like growth factor binding protein 3 (IGFBP3) by enzyme-linked immunoassay (ELISA), plasma, algorithm combining results with HDL, estimated glomerular filtration rate (GFR) and clinical data reported as a risk score for developing, diabetic kidney disease
0386U
Gastroenterology (Barrett's esophagus), P16, RUNX3, HPP1, and FBN1 methylation analysis, prognostic and predictive algorithm reported as a risk score for progression to high-grade dysplasia or esophageal cancer
0387U
Oncology (melanoma), autophagy and beclin 1 regulator 1 (AMBRA1) and loricrin (AMLo) by immunohistochemistry, formalin-fixed paraffin-embedded (FFPE) tissue, report for risk of progression
0389U
Pediatric febrile illness (Kawasaki disease [KD]), interferon alpha-inducible protein 27 (IFI27) and mast cell-expressed membrane protein 1 (MCEMP1), RNA, using reverse transcription polymerase chain reaction (RT-qPCR), blood, reported as a risk score for KD
0390U
Obstetrics (preeclampsia), kinase insert domain receptor (KDR), Endoglin (ENG), and retinol-binding protein 4 (RBP4), by immunoassay, serum, algorithm reported as a risk score
0392U
Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication analysis of CYP2D6, reported as impact of gene-drug interaction for each drug
0393U
Neurology (eg, Parkinson disease, dementia with Lewy bodies), cerebrospinal fluid (CSF), detection of misfolded α-synuclein protein by seed amplification assay, qualitative
0394U
Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 16 PFAS compounds by liquid chromatography with tandem mass spectrometry (LC-MS/MS), plasma or serum, quantitative
0395U
Oncology (lung), multi-omics (microbial DNA by shotgun next-generation sequencing and carcinoembryonic antigen and osteopontin by immunoassay), plasma, algorithm reported as malignancy risk for lung nodules in early-stage disease
0398U
Gastroenterology (Barrett esophagus), P16, RUNX3, HPP1, and FBN1 DNA methylation analysis using PCR, formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as risk score for progression to high-grade dysplasia or cancer
0399U
Neurology (cerebral folate deficiency), serum, detection of anti-human folate receptor IgG-binding antibody and blocking autoantibodies by enzyme-linked immunoassay (ELISA), qualitative, and blocking autoantibodies, using a functional blocking assay for IgG or IgM, quantitative, reported as positive or not detected
0401U
Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a coronary event
0402U
Infectious agent (sexually transmitted infection), Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, multiplex amplified probe technique, vaginal, endocervical, or male urine, each pathogen reported as detected or not detected
0403U
Oncology (prostate), mRNA, gene expression profiling of 18 genes, first-catch post-digital rectal examination urine (or processed first-catch urine), algorithm reported as percentage of likelihood of detecting clinically significant prostate cancer
0404U
Oncology (breast), semiquantitative measurement of thymidine kinase activity by immunoassay, serum, results reported as risk of disease progression
0406U
Oncology (lung), flow cytometry, sputum, 5 markers (meso-tetra [4-carboxyphenyl] porphyrin [TCPP], CD206, CD66b, CD3, CD19), algorithm reported as likelihood of lung cancer
0407U
Nephrology (diabetic chronic kidney disease [CKD]), multiplex electrochemiluminescent immunoassay (ECLIA) of soluble tumor necrosis factor receptor 1 (sTNFR1), soluble tumor necrosis receptor 2 (sTNFR2), and kidney injury molecule 1 (KIM-1) combined with clinical data, plasma, algorithm reported as risk for progressive decline in kidney function
0410U
Oncology (pancreatic), DNA, whole genome sequencing with 5-hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected
0411U
Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6
0412U
Beta amyloid, Aβ42/40 ratio, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and qualitative ApoE isoform-specific proteotyping, plasma combined with age, algorithm reported as presence or absence of brain amyloid pathology
0413U
Oncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marrow, report of clinically significant alterations
0415U
Cardiovascular disease (acute coronary syndrome [ACS]), IL-16, FAS, FASLigand, HGF, CTACK, EOTAXIN, and MCP-3 by immunoassay combined with age, sex, family history, and personal history of diabetes, blood, algorithm reported as a 5-year (deleted risk) score for ACS
0416U
Infectious agent detection by nucleic acid (DNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms, including identification of 20 associated antibiotic-resistance genes, if performed, multiplex amplified probe technique, urine
0417U
Rare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes, deletions, insertions, and copy number variants analysis, blood or saliva, identification and categorization of mitochondrial disorder–associated genetic variants
0418U
Oncology (breast), augmentative algorithmic analysis of digitized whole slide imaging of 8 histologic and immunohistochemical features, reported as a recurrence score
0419U
Neuropsychiatry (eg, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype
0420U
ONCOLOGY (UROTHELIAL), MRNA EXPRESSION PROFILING BY REAL-TIME QUANTITATIVE PCR OF MDK, HOXA13, CDC2, IGFBP5, AND CXCR2 IN COMBINATION WITH DROPLET DIGITAL PCR (DDPCR) ANALYSIS OF 6 SINGLE-NUCLEOTIDE POLYMORPHISMS (SNPS) GENES TERT AND FGFR3, URINE, ALGORI
0421U
ONCOLOGY (COLORECTAL) SCREENING, QUANTITATIVE REAL-TIME TARGET AND SIGNAL AMPLIFICATION OF 8 RNA MARKERS (GAPDH, SMAD4, ACY1, AREG, CDH1, KRAS, TNFRSF10B, EGLN2) AND FECAL HEMOGLOBIN, ALGORITHM REPORTED AS A POSITIVE OR NEGATIVE FOR COLORECTAL CANCER RISK
0423U
PSYCHIATRY (EG, DEPRESSION, ANXIETY), GENOMIC ANALYSIS PANEL, INCLUDING VARIANT ANALYSIS OF 26 GENES, BUCCAL SWAB, REPORT INCLUDING METABOLIZER STATUS AND RISK OF DRUG TOXICITY BY CONDITION
0424U
ONCOLOGY (PROSTATE), EXOSOME- BASED ANALYSIS OF 53 SMALL NONCODING RNAS (SNCRNAS) BY QUANTITATIVE REVERSE TRANSCRIPTION POLYMERASE CHAIN REACTION (RT- QPCR), URINE, REPORTED AS NO MOLECULAR EVIDENCE, LOW-, MODERATE- OR ELEVATED-RISK OF PROSTATE CANCER
0425U
GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME), RAPID SEQUENCE ANALYSIS, EACH COMPARATOR GENOME (EG, PARENTS, SIBLINGS)
0426U
GENOME (EG, UNEXPLAINED CONSTITUTIONAL OR HERITABLE DISORDER OR SYNDROME), ULTRA-RAPID SEQUENCE ANALYSIS
0427U
MONOCYTE DISTRIBUTION WIDTH, WHOLE BLOOD (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
GASTROENTEROLOGY, MALABSORPTION EVALUATION OF ALPHA-1-ANTITRYPSIN, CALPROTECTIN, PANCREATIC ELASTASE AND REDUCING SUBSTANCES, FECES, QUANTITATIVE
0431U
GLYCINE RECEPTOR ALPHA1 IGG, SERUM OR CEREBROSPINAL FLUID (CSF), LIVE CELL-BINDING ASSAY (LCBA), QUALITATIVE
0432U
KELCH-LIKE PROTEIN 11 (KLHL11) ANTIBODY, SERUM OR CEREBROSPINAL FLUID (CSF), CELL-BINDING ASSAY, QUALITATIVE
0433U
ONCOLOGY (PROSTATE), 5 DNA REGULATORY MARKERS BY QUANTITATIVE PCR, WHOLE BLOOD, ALGORITHM, INCLUDING PROSTATE-SPECIFIC ANTIGEN, REPORTED AS LIKELIHOOD OF CANCER
0434U
DRUG METABOLISM (ADVERSE DRUG REACTIONS AND DRUG RESPONSE), GENOMIC ANALYSIS PANEL, VARIANT ANALYSIS OF 25 GENES WITH REPORTED PHENOTYPES
0435U
ONCOLOGY, CHEMOTHERAPEUTIC DRUG CYTOTOXICITY ASSAY OF CANCER STEM CELLS (CSCS), FROM CULTURED CSCS AND PRIMARY TUMOR CELLS, CATEGORICAL DRUG RESPONSE REPORTED BASED ON CYTOTOXICITY PERCENTAGE OBSERVED, MINIMUM OF 14 DRUGS OR DRUG COMBINATIONS
0436U
ONCOLOGY (LUNG), PLASMA ANALYSIS OF 388 PROTEINS, USING APTAMER- BASED PROTEOMICS TECHNOLOGY, PREDICTIVE ALGORITHM REPORTED AS CLINICAL BENEFIT FROM IMMUNE CHECKPOINT INHIBITOR THERAPY
0437U
PSYCHIATRY (ANXIETY DISORDERS), MRNA, GENE EXPRESSION PROFILING BY RNA SEQUENCING OF 15 BIOMARKERS, WHOLE BLOOD, ALGORITHM REPORTED AS PREDICTIVE RISK SCORE
0438U
DRUG METABOLISM (ADVERSE DRUG REACTIONS AND DRUG RESPONSE), BUCCAL SPECIMEN, GENE-DRUG INTERACTIONS, VARIANT ANALYSIS OF 33 GENES, INCLUDING DELETION/DUPLICATION ANALYSIS OF CYP2D6, INCLUDING REPORTED PHENOTYPES AND IMPACTED GENE- DRUG INTERACTIONS
0439U
Cardiology (coronary heart disease [CHD]), DNA, analysis of 5 single-nucleotide polymorphisms (SNPs) (rs11716050 [LOC105376934], rs6560711 [WDR37], rs3735222 [SCIN/LOC107986769], rs6820447 [intergenic], and rs9638144 [ESYT2]) and 3 DNA methylation markers (cg00300879 [transcription start site {TSS200} of CNKSR1], cg09552548 [intergenic], and cg14789911 [body of SPATC1L]), qPCR and digital PCR, whole blood, algorithm reported as a 4-tiered risk score for a 3-year risk of symptomatic CHD
0440U
Cardiology (coronary heart disease [CHD]), DNA, analysis of 10 single-nucleotide polymorphisms (SNPs) (rs710987 [LINC010019], rs1333048 [CDKN2B-AS1], rs12129789 [KCND3], rs942317 [KTN1-AS1], rs1441433 [PPP3CA], rs2869675 [PREX1], rs4639796 [ZBTB41], rs4376434 [LINC00972], rs12714414 [TMEM18], and rs7585056 [TMEM18]) and 6 DNA methylation markers (cg03725309 [SARS1], cg12586707 [CXCL1, cg04988978 [MPO], cg17901584 [DHCR24-DT], cg21161138 [AHRR], and cg12655112 [EHD4]), qPCR and digital PCR, whole blood, algorithm reported as detected or not detected for CHD
0441U
Infectious disease (bacterial, fungal, or viral infection), semiquantitative biomechanical assessment (via deformability cytometry), whole blood, with algorithmic analysis and result reported as an index
0442U
Infectious disease (respiratory infection), Myxovirus resistance protein A (MxA) and C-reactive protein (CRP), fingerstick whole blood specimen, each biomarker reported as present or absent
0443U
Neurofilament light chain (NfL), ultra-sensitive immunoassay, serum or cerebrospinal fluid
0444U
Oncology (solid organ neoplasia), targeted genomic sequence analysis panel of 361 genes, interrogation for gene fusions, translocations, or other rearrangements, using DNA from formalin-fixed paraffin-embedded (FFPE) tumor tissue, report of clinically significant variant(s)
0445U
B-amyloid (Abeta42) and phospho tau (181P) (pTau181), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pathology
0446U
Autoimmune diseases (systemic lupus erythematosus [SLE]), analysis of 10 cytokine soluble mediator biomarkers by immunoassay, plasma, individual components reported with an algorithmic risk score for current disease activity
0447U
Autoimmune diseases (systemic lupus erythematosus [SLE]), analysis of 11 cytokine soluble mediator biomarkers by immunoassay, plasma, individual components reported with an algorithmic prognostic risk score for developing a clinical flare
0449U
Carrier screening for severe inherited conditions (eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia), regardless of race or self-identified ancestry, genomic sequence analysis panel, must include analysis of 5 genes (CFTR, SMN1, HBB, HBA1, HBA2)
0531U
Infectious disease (acid-fast bacteria and invasive fungi), DNA (673 organisms), nextgeneration sequencing, plasma
0532U
Rare diseases (constitutional disease/hereditary disorders), rapid whole genome and mitochondrial DNA sequencing for single nucleotide variants, insertions/deletions, copy number variations, peripheral blood, buffy coat, saliva, buccal or tissue sample, r
0533U
Drug metabolism (adverse drug reactions and drug response), genotyping of 16 genes (i.e., ABCG2, CYP2B6, CYP2C9, CYP2C19, CYP2C, CYP2D6, CYP3A5, CYP4F2, DPYD, G6PD, GGCX, NUDT15, SLCO1B1, TPMT, UGT1A1, VKORC1), reported as metabolizer status and transporter
0534U
Oncology (prostate), microRNA, single-nucleotide polymorphisms (SNPs) analysis by rt-PCR of 32 variants, using buccal swab, algorithm reported as a risk score
0535U
Perfluoroalkyl substances (pfas) (e.g., perfluorooctanoic acid, perfluorooctane sulfonic acid), by liquid chromatography with tandem mass spectrometry (LCMS/MS), plasma or serum, quantitative
0537U
Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, next generation sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm reported as positive or negative
0541U
Cardiovascular disease (HDL reverse cholesterol transport), cholesterol efflux capacity, LC-MS/MS, quantitative measurement of 5 distinct HDL-bound apolipoproteins (apolipoproteins A1, C1, C2, C3, AND C4), serum, algorithm reported as prediction of corona
0542U
Nephrology (renal transplant), urine, nuclear magnetic resonance (NMR) spectroscopy measurement of 84 urinary metabolites, combined with patient data, quantification of bk virus (human polyomavirus 1) using real-time PCR and serum creatinine, algorithm r
0545U
Acetylcholine receptor (ACHR), antibody identification by immunofluorescence, using live cells, reported as positive or negative
0546U
Low-density lipoprotein receptor-related protein 4 (LRP4), antibody identification by immunofluorescence, using live cells, reported as positive or negative
Glial fibrillary acidic protein (GFAP), chemiluminescent enzyme immunoassay, using plasma
0549U
Oncology (urothelial), DNA, quantitative methylated real time PCR of TRNA-Cys, SIM2, and NKX1-1, using urine, diagnostic algorithm reported as a probability index for bladder cancer and/or upper tract urothelial carcinoma (UTUC)
0550U
Oncology (prostate), enzyme linked immunosorbent assays (ELISA) for total prostate specific antigen (PSA) and free PSA, serum, combined with age, previous negative prostate biopsy status, digital rectal examination findings, prostate volume, and image and
0551U
Tau, phosphorylated, ptau217, by single-molecule array (ultrasensitive digital protein detection), using plasma
0553U
Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and a mitochondrial DNA score, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, or mosaic, per embryo tested
0554U
Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal (euploidy), monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested
0555U
Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and a mitochondrial DNA score, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, or mosaic, per embryo tested
0556U
Infectious Disease (Bacterial Or Viral Respiratory Tract Infection), Pathogen-Specific DNA And RNA By Real-Time PCR, 12 Targets, Nasopharyngeal Or Oropharyngeal Swab, Including Multiplex Reverse Transcription For RNA Targets, Each Analyte Reported As Detected
0558U
Oncology (Colorectal), Quantitative Enzyme-Linked Immunosorbent Assay (Elisa) For Secreted Colorectal Cancer Protein Marker (Bf7 Antigen), Using Serum, Result Reported As Indicative Of Response/No Response To Therapy Or Disease Progression/Regression
0559U
Oncology (Breast), Quantitative Enzyme-Linked Immunosorbent Assay (Elisa) For Secreted Breast Cancer Protein Marker (Bf9 Antigen), Serum, Result Reported As Indicative Of Response/No Response To Therapy Or Disease Progression/Regression
0560U
Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood and tumor tissue, baseline assessment for design and construction of a personalized variant panel to evaluate current MRD and for comparison to subsequent MRD assessments
0561U
Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood, subsequent assessment with comparison to initial assessment to evaluate for MRD
0562U
Oncology (solid tumor), targeted genomic sequence analysis, 33 genes, detection of single-nucleotide variants (SNVs), insertions and deletions, copy-number amplifications, and translocations in human genomic circulating cell-free DNA, plasma, reported as presence of actionable variants
0563U
Infectious Disease (Bacterial And/Or Viral Respiratory Tract Infection), Pathogen-Specific Nucleic Acid (DNA Or RNA), 11 Viral Targets And 4 Bacterial Targets, Qualitative RT-PCR, Upper Respiratory Specimen, Each Pathogen Reported As Positive Or Negative
0564U
Infectious Disease (Bacterial And/Or Viral Respiratory Tract Infection), Pathogen-Specific Nucleic Acid (DNA Or RNA), 10 Viral Targets And 4 Bacterial Targets, Qualitative RT-PCR, Upper Respiratory Specimen, Each Pathogen Reported As Positive Or Negative
0565U
Oncology (hepatocellular carcinoma), next-generation sequencing methylation pattern assay to detect 6626 epigenetic alterations, cell free DNA, plasma, algorithm reported as cancer signal detected or not detected
0566U
Oncology (lung), qPCR based analysis of 13 differentially methylated regions (CCDC181, HOXA7, LRRC8A, MARCHF11, MIR129-2, NCOR2, PANTR1, PRKCB, SLC9A3, TBR1_2, TRAP1, VWC2, ZNF781), pleural fluid, algorithm reported as a qualitative result
0567U
Rare diseases (constitutional/heritable disorders), whole-genome sequence analysis combination of short and long reads, for single-nucleotide variants, insertions/deletions and characterized intronic variants, copy-number variants, duplications/deletions, mobile element insertions, runs of homozygosity, aneuploidy, and inversions, mitochondrial DNA sequence and deletions, short tandem repeat genes, methylation status of selected regions, blood, saliva, amniocentesis, chorionic villus sample or tissue, identification and categorization of genetic variants
0569U
Oncology (solid tumor), next generation sequencing analysis of tumor methylation markers (>20000 differentially methylated regions) present in cell-free circulating tumor DNA (ctDNA), whole blood, algorithm reported as presence or absence of ctDNA with tumor fraction, if appropriate
0572U
Oncology (Prostate), High-Throughput Telomere Length Quantification By Fish, Whole Blood, Diagnostic Algorithm Reported As Risk Of Prostate Cancer
0573U
Oncology (Pancreas), 3 Biomarkers (Glucose, Carcinoembryonic Antigen, And Gastricsin), Pancreatic Cyst Lesion Fluid, Algorithm Reported As Categorical Mucinous Or Non-Mucinous
0574U
Mycobacterium Tuberculosis, Culture Filtrate Protein–10-KDA (CFP-10), Serum Or Plasma, Liquid Chromatography Mass Spectrometry (LC-MS)
0614U
Inborn error of metabolism (primary mitochondrial disease), mitochondrial analysis of 4 enzyme complexes by stained blue native polyacrylamide gel electrophoresis (page), frozen tissue (muscle, liver, heart, cultured skin fibroblasts), diagnostic qualitative result
0615U
Borrelia burgdorferi (lyme disease), antibody detection of 26 recombinant protein groups, by immunoassay, igm
0629U
Infectious disease (tuberculosis), dna, analysis of 1 target by pcr with clustered regularly interspaced short palindromic repeat (crispr)-based probe detection, plasma or serum, qualitative report as detected or not detected
CPT Codes
Description
15775
Punch graft for hair transplant; 1 to 15 punch grafts
15776
more than 15 punch grafts
15879
Suction assisted lipectomy; lower extremity
17360
Chemical exfoliation for acne (eg, acne paste, acid)
19105
Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma
20932
Allograft, includes templating, cutting, placement and internal fixation, when performed; osteoarticular, including articular surface and contiguous bone (list separately in addition to code for primary procedure)
20933
Allograft, includes templating, cutting, placement and internal fixation, when performed; hemicortical intercalary, partial (ie, hemicylindrical) (list separately in addition to code for primary procedure)
20939
Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (list separately in addition to code for primary procedure)
20983
Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation
22505
Manipulation of spine requiring anesthesia, any region, effective 5/1/11
22586
Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, l5-s1 interspace
Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar
Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (list separately in addition to code for primary procedure)
22862
Revision including replacement of total disc arthroplasty (artificial disc) anterior approach, lumbar, single interspace
Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level
22868
Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure)
22869
Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level
22870
Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure)
24370
Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component
24371
Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component
27278
Arthrodesis, sacroiliac joint, percutaneous or minimally invasive, with image guidance, includes obtaining bone graft when performed, unilateral; placement of intra-articular device(s), without cortical piercing
28890
Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia
33265
Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without cardiopulmonary bypass
33266
Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary bypass
33276
INSERTION OF PHRENIC NERVE STIMULATOR SYSTEM (PULSE GENERATOR AND STIMULATING LEAD[S]), INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND PULSE GENERATOR INITIAL ANALYSIS WITH DIAGNOSTIC MODE ACTIVATION, WHEN PERFORMED
33277
INSERTION OF PHRENIC NERVE STIMULATOR TRANSVENOUS SENSING LEAD (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
33278
REMOVAL OF PHRENIC NERVE STIMULATOR, INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND INTERROGATION AND PROGRAMMING, WHEN PERFORMED; SYSTEM, INCLUDING PULSE GENERATOR AND LEAD(S)
33279
REMOVAL OF PHRENIC NERVE STIMULATOR, INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND INTERROGATION AND PROGRAMMING, WHEN PERFORMED; TRANSVENOUS STIMULATION OR SENSING LEAD(S) ONLY
33280
REMOVAL OF PHRENIC NERVE STIMULATOR, INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND INTERROGATION AND PROGRAMMING, WHEN PERFORMED; PULSE GENERATOR ONLY
33281
REPOSITIONING OF PHRENIC NERVE STIMULATOR TRANSVENOUS LEAD(S)
33287
REMOVAL AND REPLACEMENT OF PHRENIC NERVE STIMULATOR, INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND INTERROGATION AND PROGRAMMING, WHEN PERFORMED; PULSE GENERATOR
33288
REMOVAL AND REPLACEMENT OF PHRENIC NERVE STIMULATOR, INCLUDING VESSEL CATHETERIZATION, ALL IMAGING GUIDANCE, AND INTERROGATION AND PROGRAMMING, WHEN PERFORMED; TRANSVENOUS STIMULATION OR SENSING LEAD(S)
33289
Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring.
37788
Penile revascularization, artery, with or without vein graft
For more detailed information, please see associated medical policy Erectile Dysfunction
37790
Penile venous occlusive procedure
For more detailed information, please see associated medical policy Erectile Dysfunction
43197
Flexible transnasal esophagoscopy
43198
Flexible transnasal esophagoscopy
43210
Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed
43257
Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease
43284
Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie. Magnetic band), including curoplasty when performed
43285
Removal of esophageal sphincter augmentation device
43290
Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon
43291
Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s)
Repair of anorectal fistula with plug (e.g., porcine small intestine submucosa (SIS). Note: this code replaces 0170T
47383
Ablation, 1 or more liver tumor(s), percutaneous, cryoablation
52284
CYSTOURETHROSCOPY, WITH MECHANICAL URETHRAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY BY DRUG-COATED BALLOON CATHETER FOR URETHRAL STRICTURE OR STENOSIS, MALE, INCLUDING FLUOROSCOPY, WHEN PERFORMED
53451
Periurethral transperineal adjustable balloon continence device; bilateral insertion, including cystourethroscopy and imaging guidance
53452
Periurethral transperineal adjustable balloon continence device; unilateral insertion, including cystourethroscopy and imaging guidance
53453
Periurethral transperineal adjustable balloon continence device; removal, each balloon
Insertion of a temporary prostatic urethral stent, including urethral measurement Note: this code replaces 0084T
53860
Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
57465
Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect (List separately in addition to code for primary procedure)
58580
TRANSCERVICAL ABLATION OF UTERINE FIBROID(S), INCLUDING INTRAOPERATIVE ULTRASOUND GUIDANCE AND MONITORING, RADIOFREQUENCY
60660
Ablation of 1 or more thyroid nodule(s), one lobe or the isthmus, percutaneous, including imaging guidance, radiofrequency
60661
Ablation of 1 or more thyroid nodule(s), additional lobe, percutaneous, including imaging guidance, radiofrequency (list separately in addition to code for primary procedure)
61736
Laser interstitial thermal therapy (litt) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; single trajectory for 1 simple lesion
61737
Laser interstitial thermal therapy (litt) of lesion, intracranial, including burr hole(s), with magnetic resonance imaging guidance, when performed; multiple trajectories for multiple or complex lesion(s)
61870
Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical
62287
Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar
64580
Incision for implantation of neurostimulator electrodes; neuromuscular
64555
Percutaneous implantation of neurostimulator electrodes; peripheral nerve [excludes sacral nerve]
67516
SUPRACHOROIDAL SPACE INJECTION OF PHARMACOLOGIC AGENT (SEPARATE PROCEDURE)
68841
Insertion of drug-eluting implant, including punctal dilation when performed, into lacrimal canaliculus, each
76014
MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (e.g., surgical reports, imaging reports, medical device databases, device vendors, review of prior imaging), analyzing current MR conditional status of individual components and systems, and consulting published professional guidance with written report; initial 15 minutes
76015
MR safety implant and/or foreign body assessment by trained clinical staff, including identification and verification of implant components from appropriate sources (e.g., surgical reports, imaging reports, medical device databases, device vendors, review of prior imaging), analyzing current MR conditional status of individual components and systems, and consulting published professional guidance with written report; each additional 30 minutes (list separately in addition to code for primary procedure)
76016
MR safety determination by a physician or other qualified health care professional responsible for the safety of the MR procedure, including review of implant MR conditions for indicated MR examination, analysis of risk vs clinical benefit of performing MR examination, and determination of MR equipment, accessory equipment, and expertise required to perform examination, with written report
76017
MR safety medical physics examination customization, planning and performance monitoring by medical physicist or MR safety expert, with review and analysis by physician or other qualified health care professional to prioritize and select views and imaging sequences, to tailor MR acquisition specific to restrictive requirements or artifacts associated with MR conditional implants or to mitigate risk of non-conditional implants or foreign bodies, with written report
76018
MR safety implant electronics preparation under supervision of physician or other qualified health care professional, including MR -specific programming of pulse generator and/or transmitter to verify device integrity, protection of device internal circuitry from MR electromagnetic fields, and protection of patient from risks of unintended stimulation or heating while in the MR room, with written report
76019
MR safety implant positioning and/or immobilization under supervision of physician or other qualified health care professional, including application of physical protections to secure implanted medical device from MR-induced translational or vibrational forces, magnetically induced functional changes, and/or prevention of radiofrequency burns from inadvertent tissue contact while in the MR room, with written report
77089
Trabecular bone score (tbs), structural condition of the bone microarchitecture; using dual x-ray absorptiometry (dxa) or other imaging data on gray-scale variogram, calculation, with interpretation and report on fracture-risk
77090
Trabecular bone score (tbs), structural condition of the bone microarchitecture; technical preparation and transmission of data for analysis to be performed elsewhere
77091
Trabecular bone score (tbs), structural condition of the bone microarchitecture; technical calculation only
77092
Trabecular bone score (tbs), structural condition of the bone microarchitecture; interpretation and report on fracture-risk only by other qualified health care professional
80145
Adalimumab
80235
LACOSAMIDE
80280
VEDOLIZUMAB
81230
CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22)
SLCO1B1 (Solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (EG, *5)
81346
TYMS (Thymidylate Synthetase) (eg, 5-Fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant)
81410
Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2,, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK
81411
Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1
81418
Drug metabolism (eg, pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including cyp2c19, cyp2d6, and cyp2d6 duplication/deletion analysis
81422
Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood
81425
Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence, analysis
81426
Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to code for primary procedure)
81427
Genome (eg, unexplained constitutional or heritable disorder or syndrome); re- evaluation of previously obtained genome sequence (eg, updated knowledge or, unrelated condition/syndrome)
81440
Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP
81449
Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes (eg, alk, braf, cdkn2a, egfr, erbb2, kit, kras, met, nras, pdgfra, pdgfrb, pgr, pik3ca, pten, ret), interrogation for sequence variants and copy number variants or rearrangements, if performed; rna analysis
81451
Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, 5-50 genes (eg, braf, cebpa, dnmt3a, ezh2, flt3, idh1, idh2, jak2, kit, kras, mll, notch1, npm1, nras), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mrna expression levels, if performed; rna analysis
81456
Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes (eg, alk, braf, cdkn2a, cebpa, dnmt3a, egfr, erbb2, ezh2, flt3, idh1, idh2, jak2, kit, kras, met, mll, notch1, npm1, nras, pdgfra, pdgfrb, pgr, pik3ca, pten, ret), interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mrna expression levels, if performed; rna analysis
81470
X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1,, OCRL, RPS6KA3, and SLC16A2
81471
X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2
81490
Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score
81493
Coronary artery disease, mrna, gene expression profiling by real-time rt-pcr of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score
81500
Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4), utilizing serum, with menopausal status, algorithm reported as a risk score
81503
Oncology (ovarian), biochemical assays of five proteins (CA-125, apolipoprotein A1, beta-2 microglobulin, transferrin, and pre-albumin), utilizing serum, algorithm reported as a risk score
81504
Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores
81506
Endocrinology (type 2 diabetes), biochemical assays of seven analytes (glucose, hba1c, insulin, hs-crp, adoponectin, ferritin, interleukin 2-receptor alpha), utilizing serum or plasma, algorithm reporting a risk score
81514
Infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, Bacterial Vaginosis Associated Bacteria-2 (BVAB-2), and Lactobacillus species (L. crispatus and L. jensenii), utilizing vaginal-fluid specimens, algorithm reported as a positive or negative for high likelihood of bacterial vaginosis, includes separate detection of Trichomonas vaginalis and/or Candida species (C. albicans, C. tropicalis, C. parapsilosis, C. dubliniensis), Candida glabrata, Candida krusei, when reported
81525
Oncology (colon), mrna, gene expression profiling by real-time rt-pcr of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score
81529
Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis
81535
Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by dapi stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination
81536
Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by dapi stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination; each additional single drug or drug combination (list separately in addition to code for primary procedure)
81538
Oncology (lung), mass spectrometric 8-protein signature, including amyloid a, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival
81539
Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score
81540
Oncology (tumor of unknown origin), mrna, gene expression profiling by real-time rt-pcr of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype
81551
Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm, reported as a likelihood of prostate cancer detection on repeat biopsy
81554
Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP])
81558
Transplantation medicine (allograft rejection, kidney), MRNA, gene expression profiling by quantitative polymerase chain reaction (QPCR) of 139 genes, utilizing whole blood, algorithm reported as a binary categorization as transplant excellence, which indicates immune quiescence, or not transplant excellence, indicating subclinical rejection
81560
Transplantation Medicine (Allograft Rejection, Pediatric Liver And Small Bowel), Measurement Of Donor And Third-Party-Induced Cd154+T-Cytotoxic Memory Cells, Utilizing Whole Peripheral Blood, Algorithm Reported As A Rejection Risk Score
82172
Apolipoprotein, each (except when billed for hepatitis C)
Lipoprotein, blood; electrophoretic separation and quantitation
83701
high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (e.g., electrophoresis, ultracentrifugation)
83704
quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (e.g., nuclear magnetic resonance spectroscopy)
83722
Lipoprotein, direct measurement; small dense ldl cholesterol
83876
Meyloperoxidase (MPO)
83884
Assay neurofilament light chain (NFL)
83951
Des-Gamma-Carboxy-Prothrombin (DCP)
83987
PH; exhaled breath condensate
84431
Thromboxane metabolite(s), including thromboxane if performed, urine
84393
Tau, phosphorylated (e.g., pTau 181, pTau 217), each
84394
Tau, total (tTau)
86141
C-reactive protein; high sensitivity (HSCRP)
86152
Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood);
Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required
Infectious agent detection by nucleic acid (DNA or RNA); central nervous system pathogen (eg, Neisseria meningitidis, Streptococcus pneumoniae, Listeria, Haemophilus influenzae, E. coli, Streptococcus agalactiae, enterovirus, human parechovirus, herpes simplex virus type 1 and 2, human herpesvirus 6, cytomegalovirus, varicella zoster virus, Cryptococcus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets
87513
Infectious agent detection by nucleic acid (DNA or RNA); Helicobacter Pylori (H. pylori), clarithromycin resistance, amplified probe technique
87505
Infectious agent detection by nucleic acid (dna or rna); gastrointestinal pathogen (eg, clostridium difficile, e. Coli, salmonella, shigella, norovirus, giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets
87506
Infectious agent detection by nucleic acid (dna or rna); gastrointestinal pathogen (eg, clostridium difficile, e. Coli, salmonella, shigella, norovirus, giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets
87507
Infectious agent detection by nucleic acid (dna or rna); gastrointestinal pathogen (eg, clostridium difficile, e. Coli, salmonella, shigella, norovirus, giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets
87623
Infectious agent detection by nucleic acid (dna or rna); human papillomavirus (hpv), low-risk types (eg, 6, 11, 42, 43, 44)
87900
Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics
88104
Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with, interpretation
89290
Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-, implantation genetic diagnosis); less than or equal to 5 embryos
89291
Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-, implantation genetic diagnosis); greater than 5 embryos
89329
Sperm evaluation; hamster penetration test
91111
Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus with physician interpretation and report (effective 9/1/11)
91112
Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report
91113
Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report
92066
Orthoptic training; under supervision of a physician or other qualified health care professional
92132
Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral
92145
Corneal hysteresis determination, by air impulse stimulation, unilateral or bilateral, with interpretation and report
92512
Nasal function studies (e.g., rhinomanometry)
92517
Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP)
92518
Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; ocular (oVEMP)
92519
Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) and ocular (oVEMP)
92548
Computerized dynamic posturography
92634
Hearing aid fitting services, unilateral or bilateral, including device analysis, programming, verification, counseling, orientation, and training, and, when performed, hearing assistive device, supplemental technology fitting services; first 60 minutes
This code Does Not Meet Payment Determination Criteria for Commercial but will pay for QUEST
92635
Hearing aid fitting services, unilateral or bilateral, including device analysis, programming, verification, counseling, orientation, and training, and, when performed, hearing assistive device, supplemental technology fitting services; each additional 15 minutes (list separately in addition to code for primary procedure)
This code Does Not Meet Payment Determination Criteria for Commercial but will pay for QUEST
92636
Hearing aid post-fitting follow-up services, unilateral or bilateral, including confirmation of physical fit, validation of patient benefit and performance, sound quality of device, adjustment(s) (eg, verification, programming adjustment[s], device connection[s], and device training), as indicated, and, when performed, hearing assistive device, supplemental technology fitting services; first 30 minutes
This code Does Not Meet Payment Determination Criteria for Commercial but will pay for QUEST
92637
Hearing aid post-fitting follow-up services, unilateral or bilateral, including confirmation of physical fit, validation of patient benefit and performance, sound quality of device, adjustment(s) (eg, verification, programming adjustment[s], device connection[s], and device training), as indicated, and, when performed, hearing assistive device, supplemental technology fitting services; each additional 15 minutes (list separately in addition to code for primary procedure)
This code Does Not Meet Payment Determination Criteria for Commercial but will pay for QUEST
92638
Behavioral verification of amplification including aided thresholds, functional gain, speech-in-noise, when performed (list separately in addition to code for primary procedure)
This code Does Not Meet Payment Determination Criteria for Commercial but will pay for QUEST
92642
Hearing assistive device, supplemental technology fitting services (eg, personal frequency modulation [fm]/digital modulation [dm] system, remote microphone, alerting devices)
This code Does Not Meet Payment Determination Criteria for Commercial but will pay for QUEST
92971
Cardioassist-method of circulatory assist
92972
PERCUTANEOUS TRANSLUMINAL CORONARY LITHOTRIPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
93025
Microvolt T-wave alternans for assessment of ventricular arrhythmias
93050
Arterial pressure waveform analysis for assessment of central arterial pressures, includes obtaining waveform(s), digitization and application of nonlinear mathematical transformations to determine central arterial pressures and augmentation index, with interpretation and report, upper extremity artery, non-invasive
93150
THERAPY ACTIVATION OF IMPLANTED PHRENIC NERVE STIMULATOR SYSTEM, INCLUDING ALL INTERROGATION AND PROGRAMMING
93151
INTERROGATION AND PROGRAMMING (MINIMUM ONE PARAMETER) OF IMPLANTED PHRENIC NERVE STIMULATOR SYSTEM
93152
INTERROGATION AND PROGRAMMING OF IMPLANTED PHRENIC NERVE STIMULATOR SYSTEM DURING POLYSOMNOGRAPHY
93153
INTERROGATION WITHOUT PROGRAMMING OF IMPLANTED PHRENIC NERVE STIMULATOR SYSTEM
93228
External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional
93229
External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional
93264
Remote monitoring of a wireless pulmonary artery pressure sensor.
93278
Signal-averaged electrocardiography (SAECG), with or without ECG
93702
Bioimpedance spectroscopy (BIS), extracellular fluid analysis for lymphedema assessment(s)
93895
Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral
94400
Breathing response to CO2 (CO2 response curve)
95012
Nitric oxide expired gas determination
95803
Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording)
95919
Quantitative pupillometry with physician or other qualified health care professional interpretation and report, unilateral or bilateral
95924
Testing of an autonomic nervous system function; combined parasympathetic and sympathetic adrenergic function testing with at least 5 minutes of passive tilt.
95905
Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed with interpretation and report
95961
Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of physician attendance
95962
each additional hour of physician attendance
95980
Electronic analysis of implanted neurostimulator pulse generator system (e.g., rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; intraoperative, with programming
95981
subsequent, without programming
95982
subsequent, with reprogramming
96000
Comprehensive computer-based motion analysis by video-taping and 3D kinematics
96001
with dynamic plantar pressure measurements during walking
96002
Dynamic surface electromyography, during walking or other functional activities, 1 to 12 muscles
96003
Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle
96004
Physician review & interpretation of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report
96156
Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)
96158
Health behavior intervention, individual, face-to-face; initial 30 minutes
96159
Health behavior intervention, individual, face-to-face; each additional 15 minutes (list separately in addition to code for primary service)
96164
Health behavior intervention, group (2 or more patients), face-to-face; initial 30 minutes
96165
Health behavior intervention, group (2 or more patients), face-to-face; each additional 15 minutes (list separately in addition to code for primary service)
96167
Health behavior intervention, family (with the patient present), face-to-face; initial 30 minutes
96168
Health behavior intervention, family (with the patient present), face-to-face; each additional 15 minutes (list separately in addition to code for primary service)
96170
Health behavior intervention, family (without the patient present), face-to-face; initial 30 minutes
96171
Health behavior intervention, family (without the patient present), face-to-face; each additional 15 minutes (list separately in addition to code for primary service)
96202
Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); initial 60 minutes
96203
Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); each additional 15 minutes (list separately in addition to code for primary service)
96931
Reflectance confocal microscopy (rcm) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion
96932
Reflectance confocal microscopy (rcm) for cellular and sub-cellular imaging of skin; image acquisition only, first lesion
96934
Reflectance confocal microscopy (rcm) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (list separately in addition to code for primary procedure)
96935
Reflectance confocal microscopy (rcm) for cellular and sub-cellular imaging of skin; image acquisition only, each additional lesion (list separately in addition to code for primary procedure)
96936
Reflectance confocal microscopy (rcm) for cellular and sub-cellular imaging of skin; interpretation and report only, each additional lesion (list separately in addition to code for primary procedure)
97037
APPLICATION OF A MODALITY TO 1 OR MORE AREAS; LOW-LEVEL LASER THERAPY (IE, NONTHERMAL AND NON-ABLATIVE) FOR POST-OPERATIVE PAIN REDUCTION
97610
Topical wound treatment with low frequency, non-contact, non-thermal ultrasound with wound assessment and instructions
Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with on-site analysis
G2168
SERVICES PERFORMED BY A PHYSICAL THERAPIST ASSISTANT IN THE HOME HEALTH SETTING IN THE DELIVIERY OF A SAFE AND EFFECTIVE PHYSICAL THERAPY MAINTENANCE PROGRAM, EACH 15 MINUTES
G2169
SERVICES PERFORMED BY A OCCUPATIONAL THERAPIST ASSISTANT IN THE HOME HEALTH SETTING IN THE DELIVIERY OF A SAFE AND EFFECTIVE OCCUPATIONAL THERAPY MAINTENANCE PROGRAM, EACH 15 MINUTES
As a result of a revisions made to the Hematopoietic Stem Cell Transplantation for Epithelial Ovarian Cancer policy (effective 4/22/16), the following code does not meet payment determination criteria: 38204.
4.23
05/03/2016
Added code 93895: Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral.
4.24
05/03/2016
Deleted code: 61630 Balloon angioplasty, intracranial (e.g., atherosclerotic stenosis), percutaneous ] from Table I. CPT Codes.
4.25
08/31/2016
Added codes: C9349 Puraply, and Puraply Antimicrobial, any type, per square centimeter C9354 Acellular pericardial tissue matrix of nonhuman origin (Veritas), per square centimeter C9356 Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per square centimeter C9358 Dermal substitute, native, non-denatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters C9360 Dermal substitute, native, non-denatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters C9363 Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter C9364 Porcine implant, Permacol, per square centimeter Q4103 Oasis Burn Matrix, per square centimeter Q4104 Integra Bilayer Matrix Wound Dressing (BMWD), per square centimeter Q4108 Integra Matrix, per square centimeter Q4110 PriMatrix, per square centimeter Q4111 GammaGraft, per square centimeter Q4112 Cymetra, injectable, 1 cc Q4113 Graftjacket Xpress, injectable, 1 cc Q4114 Integra Flowable Wound Matrix, injectable, 1 cc Q4115 AlloSkin, per square centimeter Q4116 AlloDerm, per square centimeter Q4118 (correct to read: Matristem micromatrix, per square centimeter) Q4123 Alloskin RT, per square centimeter Q4125 Arthroflex, per square centimeter Q4126 Memoderm, Dermaspan, Transgraft or Integuply, per square centimeter Q4127 Talymed, per square centimeter Q4128 Flex HD, Allopatch HD or Matrix HD, per square centimeter [when used for Allopatch HD or Matrix HD] Q4129 Unite Biomatrix, per square centimeter Q4134 hMatrix, per square centimeter Q4135 Mediskin, per square centimeter Q4136 EZ-derm, per square centimeter Q4137 Amnioexcel or BioDExCel, per square centimeter Q4138 Biodfence Dryflex, per square centimeter Q4139 Amniomatrix or BioDMatrix, injectable, 1 cc Q4140 Biodfence, per square centimeter Q4141 Alloskin AC, per square centimeter Q4142 Xcm biologic tissue matrix, per square centimeter Q4143 Repriza, per square centimeter Q4146 TenSIX, per square centimeter Q4147 Architect, Architect PX, or Architect FX, extracellular matrix, per square Q4148 Neox 1k, per square centimeter Q4149 Excellagen, 0.1 cc Q4150 Allowrap DS or dry, per square centimeter Q4151 Amnioband or Guardian, per square centimeter Q4152 Dermapure, per square centimeter Q4153 Dermavest and Plurivest, per square centimeter Q4155 Neox Flo or Clarix Flo, 1 mg Q4156 Neox 100, per square centimeter Q4157 Revitalon, per square centimeter Q4158 MariGen, per square centimeter Q4159 Affinity, per square centimeter Q4160 NuShield, per square centimeter Q4161 Bio-connekt wound matrix, per square centimeter Q4162 Amniopro flow, bioskin flow, biorenew flow, woundex flow, amniogen-a, amniogen-c, 0.5 cc Q4163 Amniopro, bioskin, biorenew, woundex, amniogen-45, amniogen-200, per square centimeter Q4164 Helicoll, per square centimeter Q4165 Keramatrix, per square centimeter Removed codes: Q4117 (note about policy; leave the code in the list) Q4118 (note about policy; leave the code in the list) Q4119 (note about policy; leave the code in the list) Q4121 (note about policy; leave the code in the list)
4.26
09/20/2016
Revised the description for the 0346T in Table III to read as follows: Ultrasound, elastography (list separately in addition to code for primary procedure) (except when billed for hepatitis B or C).
4.27
10/19/2016
Added code 91200 - Liver elastography, mechanically induced shear wave (eg, vibration), without imaging, with interpretation and report – (EXCEPT WHEN BILLED WITH HEPATITIS C)
4.28
02/09/2017
Code 0375T was removed from the list as it is now covered and criteria exists within the policy.
4.30
05/11/2017
Code 81528 was removed from the list as it is now considered medically necessary and resides in the CRC-Screening policy.
Updated link name from Artificial Disc Replacement, Cervical To Artificial Intervertebral Disc: Cervical Spine.
4.31
05/26/2017
The request to add the following codes were completed. The earlier request was found to have truncated descriptions. 0446T, 0447T, 0448T, 0449T, 0450T, 0451T, 0452T, 0453T, 0454T, 0455T, 0456T, 0457T, 0458T, 0459T, 0460T, 0461T, 0462T, 0463T, 0464T, 0465T, 0466T, 0467T, 0468T, 22853, 22854, 22859, 22867, 22868, 22869, 22870, A4467, 0437T, 0439T, 0440T, 0445T, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4172, Q4173, Q4174, Q4175, 0441T, 0442T, 0443T, 0444T, Q9982, Q9983, 43284, 43285, 58674, 62380, 81327, 81539
4.31
05/26/2017
The following codes were removed from the table: 22853, 22854, 22859.
4.32
10/17/2017
Removed obsolete CPT codes.
4.33
10/24/2017
Added code: 0474T Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space.
4.33
10/24/2017
Added code A4467: Belt, strap, sleeve, garment, or covering, any type
Corneal Collagen Cross-Linking is now considered medically necessary. Removed CPT code 0402T from the DNMPDC. 0402T - Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed)
4.36
11/22/2017
Removed the following codes: 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa (Note: this code denies for patients older than 18 years of age) 31296 Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (eg, balloon dilation) (Note: this code denies for patients older than 18 years of age) 31297 Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (eg, balloon dilation) (Note: this code denies for patients older than 18 years of age) 31660 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe For more detailed information, please see associated medical policy Bronchial Thermoplasty 31661 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes For more detailed information, please see associated medical policy Bronchial Thermoplasty
4.37
11/28/2017
Removed the following codes: 27415 Osteochondral allograft, knee, open 27416 Osteochondral autograft(s), knee, open (e.g., mosaicplasty) (includes harvesting of autograft(s)) 28446 Open osteochondral autograft, talus (includes obtaining graft(s)) 29867 Arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty)
4.38
03/13/2018
Added A4648 (Tissue marker, implantable, any type, each) to page, under Table II. HCPCS Codes.
Removed codes 81283, 81328, 81334, 81335, 81346, and 81448.
4.42
04/30/2018
Added codes 81283, 81328, 81334, 81335, 81346, and 81448. Previously removed in error.
4.43
05/18/2018
Removed code 38204 from Codes That Do Not Meet Payment Determination Criteria page because precert is required for HCT policies. This code should not deny.
4.44
06/04/2018
Removed code A4648.
4.45
07/19/2018
Added codes 0497T and 0498T.
4.46
07/25/2018
Added codes 81521 and 81541.
4.47
08/02/2018
Added codes 81227, 81291, 81355, and S3852 to the list. Removed cpt code 84145 (Procalcitonin (PCT) Note: code replaces 0194T) from list.
4.48
09/18/2018
Changed "Genetic Testing - Oncology" to match new title of target page: Genetic Testing of Inherited Cancer Predisposition.
4.49
09/27/2018
Removed code Q4151 Amnioband or Guardian, per square centimeter.
Updated the following links: Policy title change from "Spinal Interventional Pain Management and Lumbar Spine Surgery" to "Spinal Interventional Pain Management and Spine Surgery". Policy title change from "Artificial Intervertebral Disc: Cervical Spine" to "Artificial Intervertebral Disc Replacement - Cervical".
4.52
10/22/2018
Added 0375T- Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels
4.53
10/25/2018
Added: 0078U Pain management (opioid-use disorder) genotyping panel, 16 common variants (ie, ABCB1, COMT, DAT1, DBH, DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OPRM1), buccal swab or other germline tissue sample, algorithm reported as positive or negative risk of opioid-use disorder. 0514T Intraoperative visual axis identification using patient fixation (list separately in addition to code for primary procedure). 0509T Electroretinography (erg) with interpretation and report, pattern (perg).
4.54
10/29/2018
Added: 0062U Autoimmune (systemic lupus erythematosus), igg and igm analysis of 80 biomarkers, utilizing serum, algorithm reported with a risk score; 0063U Neurology (autism), 32 amines by lc-ms/ms, using plasma, algorithm reported as metabolic signature associated with autism spectrum disorder.
4.55
11/02/2018
Added: 0067U Oncology (breast), immunohistochemistry, protein expression profiling of 4 biomarkers (matrix metalloproteinase-1 [mmp-1], carcinoembryonic antigen-related cell adhesion molecule 6 [ceacam6], hyaluronoglucosaminidase [hyal1], highly expressed in cancer protein [hec1]), formalin-fixed paraffin-embedded precancerous breast tissue, algorithm reported as carcinoma risk score; 0068U Candida species panel (c. Albicans, c. Glabrata, c. Parapsilosis, c. Kruseii, c tropicalis, and c. Auris), amplified probe technique with qualitative report of the presence or absence of each species; 0085T Breath test for heart transplant rejection
4.56
11/05/2018
Added the following into Table III: 0070U CYP2D6 (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) 0071U CYP2D6 (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) 0072U CYP2D6 (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) 0073U CYP2D6 (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) 0074U CYP2D6 (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) 0075U CYP2D6 (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) 0076U CYP2D6 (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)
4.57
11/05/2018
Added codes to Table I: 0512T, 0513T, 0045U, 0047U, 0048U, 0051U, 0052U, 0054U, 0057U. Added code to Table II: Q9993.
The following codes were removed from the tables: S8049- terminated 04/01/2012; 0193T- terminated 01/01/2011; 0276T- terminated 01/01/2013; 0277T- terminated 01/01/2013.
4.60
11/29/2018
The following codes were added to table I: 77046, 77047, 77048, 77049.
Removed code 90625 - Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use - not fda approved.
4.69
03/20/2019
Removed code 74623: Computed tomographic colonography screening, including image postprocessing. Code added Colorectal Cancer Screening policy as a covered test effective 5/1/2017, removed from Does not meet list in accordance with policy.
4.70
04/11/2019
Updated the link to Artificial Intervertebral Disc Replacement - Cervical archived policy.
4.71
04/18/2019
Removed code Q4116.
4.72
06/03/2019
Removed code 0399T.
4.73
06/24/2019
Removed code 83993.
4.74
07/09/2019
Added codes 0546T-0562T to Table III.
4.75
08/20/2019
Removed CPT code 91200.
4.76
09/30/2019
Removed CPT code S8092.
4.77
10/04/2019
Added the CPT codes to the table - 0105U, 0108U, 0109U, 0110U, 0112U, 0113U, 0114U, 0116U, 0117U, 0118U, 0119U, 0120U, 0123U, 0125U, 0126U, 0127U, 0128U. The following HCPCS codes have been added to the table - Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226.
4.78
10/07/2019
Removed the following CPT Procedure codes from the table: 0446T, 0447T, 0448T.
4.79
10/07/2019
Removed the following CPT codes from the table: 33990, 33991, 33992, 33993.
4.80
11/14/2019
Added the following CPT code to Table II: A9587 - Gallium Ga-68, Dotatate, Diagnostic, 0.1 Millicurie – FOR PROSTATE CANCER.
4.81
11/15/2019
Removed CPT code: 75571 - Cardiac computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium Note: this code replaces 0144T.
4.82
11/18/2019
Added the following CPT codes to the table: 0143U, 0144U, 0145U, 0146U, 0147U, 0148U, 0149U, 0150U
4.83
11/22/2019
Added the following CPT codes to Table III: 0565T, 0566T, 0567T, 0568T, 0571T, 0572T, 0573T, 0574T, 0575T, 0576T, 0577T, 0578T, 0579T, 0580T
4.84
12/04/2019
Added the following CPT code: 58674 - Laparoscopy, surgical, ablation of uterine fibroids(s) including intraoperative ultrasound guidance and monitoring, radiofrequency
4.85
12/26/2019
Added the following CPT codes to Table I: 80280, 80235, 96156, 96158, 96159, 96164, 96165, 96167, 96168, 96170, 96171.
4.86
02/05/2020
Remove CPT code 62380.
4.87
05/06/2020
Added the following codes to Table I: 81542, 0010M, 0011M, 0012M, 0013M, 0037U, 0041U, 0087U, 0088U, 0089U, 0090U, 0094U, 0101U, 0102U, 0103U, 0104U
The following codes were added to the table: 0216U, 0217U, 0228U, 0229U, 0621T, 0622T , 0632T , 0634T, 0635T, 0636T, 0637T, 0638T, 0639T, 55880, 57465, 81419, 81513, 81514, 81529, 81554, 92517, 92518, 92519
4.99
02/25/2021
Removed codes 0102U and 0103U from the DNMPDC table. Both codes have been added to the Genetic Testing for BRCA1 or BRCA2 for Hereditary Breast/ Ovarian Cancer Syndrome and Other High-Risk Cancers policy effective July 1, 2020. These codes now require precertification.
