CMS Manual System · 0575T 2020-01-01 Prgrmg dev eval icds ss ip 05741 00000 Q1 E1 9 0576T 2020-01-01 Interrog dev eval icds ss ip 05741 00000 Q1 E1 9 0577T 2020-01-01 Ephys eval

CMS Manual System Department of Health & Human Services (DHHS)

Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS)

Transmittal 4528 Date: February 13, 2020

Change Request 11564 Transmittal 4483, dated December 20, 2019, is being rescinded and replaced by Transmittal 4528, dated February 13, 2020 to add two new attachments due to legislation. All other information remains the same. This Transmittal is no longer sensitive. This instruction may now be posted to the Internet. SUBJECT: January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0 I. SUMMARY OF CHANGES: This notification provides the Integrated OCE instructions and specifications for the Integrated OCE that will be utilized under the Outpatient Prospective Payment System (OPPS) and non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness. The attached recurring update notification applies to publication 100-04, chapter 4, section 40.1. EFFECTIVE DATE: January 1, 2020 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 6, 2020 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents. II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row.

R/N/D CHAPTER / SECTION / SUBSECTION / TITLE

N/A N/A III. FUNDING: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. IV. ATTACHMENTS: Recurring Update Notification

Attachment - Recurring Update Notification

Pub. 100-04 Transmittal: 4528 Date: February 13, 2020 Change Request: 11564 Transmittal 4483, dated December 20, 2019, is being rescinded and replaced by Transmittal 4528, dated February 13, 2020 to add two new attachments due to legislation. All other information remains the same. This Transmittal is no longer sensitive. This instruction may now be posted to the Internet. SUBJECT: January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0 EFFECTIVE DATE: January 1, 2020 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 6, 2020 I. GENERAL INFORMATION A. Background: This instruction informs the A/B Medicare Administrative Contractors (MACs) Part A, the A/B MACs Part Home Health and Hospice (HHH) and the Fiscal Intermediary Shared System (FISS) that the I/OCE is being updated for January 1, 2020. The I/OCE routes all institutional outpatient claims (which includes non-OPPS hospital claims) through a single integrated OCE. The attached recurring update notification applies to publication 100-04, chapter 4, section 40.1. B. Policy: This notification provides the Integrated OCE instructions and specifications for the Integrated OCE that will be utilized under the OPPS and non-OPPS for hospital outpatient departments, community mental health centers, all non-OPPS providers, and for limited services when provided in a home health agency not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non-terminal illness. The I/OCE specifications will be posted to the CMS Website and can be found at http://www.cms.gov/OutpatientCodeEdit/. II. BUSINESS REQUIREMENTS TABLE "Shall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number Requirement Responsibility A/B

MAC DME

MAC

Shared-System

Maintainers

Other

A B HHH

FISS

MCS

VMS

CWF

11564.1 The Shared System Maintainer shall install the Integrated OCE (I/OCE) into their systems.

X

11564.2 Medicare contractors shall identify the I/OCE specifications on the CMS Website at https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.html

X X X

III. PROVIDER EDUCATION TABLE Number Requirement Responsibility

A/B MAC

DME

MAC

CEDI A B H

HH

11564.3 MLN Article: CMS will make available an MLN Matters provider education article that will be marketed through the MLN Connects weekly newsletter shortly after the CR is released. MACs shall follow IOM Pub. No. 100-09 Chapter 6, Section 50.2.4.1, instructions for distributing MLN Connects information to providers, posting the article or a direct link to the article on your website, and including the article or a direct link to the article in your bulletin or newsletter. You may supplement MLN Matters articles with localized information benefiting your provider community in billing and administering the Medicare program correctly. Subscribe to the “MLN Matters” listserv to get article release notifications, or review them in the MLN Connects weekly newsletter.

X X

IV. SUPPORTING INFORMATION Section A: Recommendations and supporting information associated with listed requirements: N/A "Should" denotes a recommendation. X-Ref Requirement Number

Recommendations or other supporting information:

Section B: All other recommendations and supporting information: N/A V. CONTACTS Pre-Implementation Contact(s): Yvonne Young, [email protected] , Marina Kushnirova, [email protected] , Fred Rooke, [email protected] Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR). VI. FUNDING Section A: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements. ATTACHMENTS: 4

Final

Summary of Data Changes

IOCE V21.0 R1 January 2020

Final Summary of Changes v21.0 R1 Jan 2020

Page 2 of 12

Table of Contents APC Changes ....................................................................................................................................................................................................... 4

Added APCs ..................................................................................................................................................................................................... 4

APC Payment Offsets Modified ....................................................................................................................................................................... 5 HCPCS Procedure Code Changes ........................................................................................................................................................................ 6

Modified HCPCS Code APC/Status Indicators/Edit Assignments .................................................................................................................. 6 Mid Quarter Edits Additions ............................................................................................................................................................................ 7

Deductible Coinsurance Not Applicable Removals ......................................................................................................................................... 8 Comprehensive APC HCPCS Additions .......................................................................................................................................................... 9

CAPC Exclusion Additions ............................................................................................................................................................................ 10 Pass-Through Radiopharm HCPCS Additions ............................................................................................................................................... 11


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CPT codes, descriptions and material only are copyright 2019 American Medical Association. All rights reserved. No fee schedules, basic units, relative values or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for the data contained herein. All rights reserved.


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APC Changes

Added APCs

The following APC(s) were added. Added APCs APC Eff Date Description Status Indicator Payment 09341 2019-10-01 Inj ogivri 10 mg K $90.67 09458 2020-01-01 Florbetaben f18 diagnostic G $2,968.00 09459 2020-01-01 Flutemetamol f18 diagnostic G $3,498.00


Page 5 of 12

APC Payment Offsets Modified

The following APC(s) had a modification to the offset amount for applicable pass-through radiopharmaceuticals, skin substitute products, contrast agents, or stress agents. APC Payment Offsets Modified APC Eff Date Description Current

Amount Previous Amount

05591 2020-01-01 Level 1 Nuclear Medicine and Related Services $50.53 $51.65 05592 2020-01-01 Level 2 Nuclear Medicine and Related Services $92.42 $92.41 05593 2020-01-01 Level 3 Nuclear Medicine and Related Services $331.60 $338.91 05594 2020-01-01 Level 4 Nuclear Medicine and Related Services $264.32 $269.87


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HCPCS Procedure Code Changes

Modified HCPCS Code APC/Status Indicators/Edit Assignments

The following HCPCS code(s) had an APC, Status Indicator, or Edit assignment change. Modified HCPCS Code APC/Status Indicators/Edit Assignments HCPCS Eff Date Description APC

Current APC Previous

Status Indicator Current

Status Indicator Previous

Edits Current

Edits Previous

0571T 2020-01-01 Insj/rplcmt icds ss eltrd 05232 00000 J1 E1 9 0572T 2020-01-01 Insertion ss dfb electrode 05222 00000 J1 E1 9 0573T 2020-01-01 Removal ss dfb electrode 05221 00000 Q2 E1 9 0574T 2020-01-01 Repos prev ss impl dfb eltrd 05221 00000 Q2 E1 9 0575T 2020-01-01 Prgrmg dev eval icds ss ip 05741 00000 Q1 E1 9 0576T 2020-01-01 Interrog dev eval icds ss ip 05741 00000 Q1 E1 9 0577T 2020-01-01 Ephys eval icds ss 05211 00000 J1 E1 9 0578T 2020-01-01 Rem interrog dev icds phys M E1 72 9 0579T 2020-01-01 Rem interrog dev icds tech 05741 00000 Q1 E1 9 0580T 2020-01-01 Rmvl ss impl dfb pg only 05221 00000 Q2 E1 9 Q5114 2019-10-01 Inj ogivri 10 mg 09341 00000 K E2 13 Q9982 2020-01-01 Flutemetamol f18 diagnostic 09459 00000 G N Q9983 2020-01-01 Florbetaben f18 diagnostic 09458 00000 G N


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Mid Quarter Edits Additions

The following HCPCS code(s) were added to Mid-Quarter edit 67, 68, 69, 83, or 110. Mid Quarter Edits Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description Approval Date Edit R* Q5114 2019-10-01 Inj ogivri 10 mg 2019-11-29 110 A


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Deductible Coinsurance Not Applicable Removals

The following HCPCS were removed from the Deductible Coinsurance Not Applicable list. Deductible Coinsurance Not Applicable Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* G0404 2020-01-01 Ekg tracing for initial prev R


Page 9 of 12

Comprehensive APC HCPCS Additions

The following HCPCS were assigned an SI = J1 Comprehensive APC, Comprehensive APC HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0571T 2020-01-01 Insj/rplcmt icds ss eltrd A 0572T 2020-01-01 Insertion ss dfb electrode A 0577T 2020-01-01 Ephys eval icds ss A


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CAPC Exclusion Additions

The following HCPCS were added to the CAPC Exclusion list. CAPC Exclusion Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 76706 2017-01-01 Us abdl aorta screen aaa A


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Pass-Through Radiopharm HCPCS Additions

The following HCPCS were added to the Pass-Through Radiopharm HCPCS list. Pass-Through Radiopharm HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* Q9982 2020-01-01 Flutemetamol f18 diagnostic A Q9983 2020-01-01 Florbetaben f18 diagnostic A


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This Page Is Intentionally Left Blank.

2 Summary of Quarterly Release Modifications The modifications of the IOCE for the January 2020, v21.0.R1 release is summarized in the table below. Readers should also read through the entire document and note the highlighted sections, which also indicate changes from the prior release of the software. Some IOCE modifications in the update may be retroactively added to prior releases. If so, the retroactive date appears in the 'Effective Date' column.

Item # Type Effective Date Edits Affected Modification 1 Logic 01/01/2020 24 Modify the software to maintain 28 prior quarters (7 years) of programs in each

release. Remove older versions with each release. The earliest date included for this release is 04/01/2013.

2 Logic 11/29/2019 110 Apply mid-quarter edit 110 (Service provided prior to initial marketing date) to HCPCS Q5114, if reported before 11/29/2019

3 Documentation 01/01/2020 Effective with v21.0 of the IOCE, the quarterly data files are updated with a new structure, file-naming convention, and new tables. The file layout document should be used to aid users in identifying the new tables, layout, file-naming conventions, descriptions, and all applicable values where necessary. Please Note: The quarterly data files used to just contain the content applicable for the quarter being updated. Effective v21.0, the data files represent all the data changes contained in the 28 quarters of programs maintained in the current version of the IOCE. Users should refer to the version range table if not familiar with the lo version and hi version values supplied in the data files.

4 Content 01/01/2020

Make all HCPCS/APC/SI changes as specified by CMS. Updates were made to the following lists (please review the Quarterly Data Table Reports for additional detail). Due to the new table and file structure for Jan 2020, the tables that are updated which reference a list are specified below. DATA_APC

• Added new APCs DATA_CAPC

• Comprehensive APC list (updated list and rank) OFFSET_APC

• Pass-through radiopharmaceutical for offset APC (edit 99) DATA_HCPCS

• C-APC Exclusions list • Non-covered services lists (SI = E1, for edits 9, 28, 50,) • Services not billable to MAC list (SI = M, edit 72) • Separate payment not provided list (SI = E2, edit 13) • Deductible Coinsurance Not Applicable list • Pass-through Radiopharmaceutical

5 Other 01/01/2020

Create 508-compliant versions of the Specifications, Summary of Data Changes and File Layout documents for publication on the CMS web site. Provide MF and PC IOCE software and supporting quarterly data file reports for publication on the CMS web site.

6 Other 01/01/2020

Deliver quarterly software update and all related documentation and files to users via electronic download.

Final


IOCE v21.0 January 2020

Final Summary of Changes v21.0 Jan 2020

Page 2 of 84


Added APCs ..................................................................................................................................................................................................... 5 Deleted APCs ................................................................................................................................................................................................... 6 Modified APC Descriptions ............................................................................................................................................................................. 7 Modified APC Status Indicators ...................................................................................................................................................................... 8 Added Comprehensive APCs ........................................................................................................................................................................... 9 APC Payment Offsets Modified ..................................................................................................................................................................... 10

HCPCS Procedure Code Changes ...................................................................................................................................................................... 11 Added HCPCS Codes .................................................................................................................................................................................... 11 Deleted HCPCS CPT Codes .......................................................................................................................................................................... 17 Modified HCPCS Code Descriptions ............................................................................................................................................................. 20 Modified HCPCS Code APC/Status Indicators/Edit Assignments ................................................................................................................ 23 Mid Quarter Edits Additions .......................................................................................................................................................................... 28 Male Only HCPCS Additions ........................................................................................................................................................................ 29 Female Only HCPCS Additions ..................................................................................................................................................................... 30 Female Only HCPCS Removals .................................................................................................................................................................... 31 Conditional Bilateral Additions ..................................................................................................................................................................... 32 Conditional Bilateral Removals ..................................................................................................................................................................... 33 Independent Bilateral Removals .................................................................................................................................................................... 34 Inherent Bilateral Additions ........................................................................................................................................................................... 35 Deductible Coinsurance Not Applicable Additions ....................................................................................................................................... 36 Deductible Coinsurance Not Applicable Removals ....................................................................................................................................... 37 Non-Standard CT Scan Equipment Procedure Additions .............................................................................................................................. 38 Non-Standard CT Scan Equipment Procedure Removals .............................................................................................................................. 39 Radiology Procedure For Payment Adjustment Additions ............................................................................................................................ 40 Radiology Procedure For Payment Adjustment Removals ............................................................................................................................ 41 Comprehensive APC HCPCS Additions ........................................................................................................................................................ 42 Comprehensive APC HCPCS Removals ....................................................................................................................................................... 43 Complexity Adjusted Code Pair Additions .................................................................................................................................................... 44 Complexity Adjusted Code Pair Removals .................................................................................................................................................... 47 CAPC Exclusion Additions ............................................................................................................................................................................ 50 Device Additions............................................................................................................................................................................................ 52 Device Removals ........................................................................................................................................................................................... 53 Device Procedure Additions .......................................................................................................................................................................... 54 Device Procedure Removals .......................................................................................................................................................................... 55 Device Procedure Edit 92 Bypass Additions ................................................................................................................................................. 56 Daily Mental Health Additions ...................................................................................................................................................................... 57 Daily Mental Health Removals ...................................................................................................................................................................... 58 Mental Health Not Billable Under PHP Edit 80 Additions ............................................................................................................................ 59 Mental Health Not Billable Under PHP Edit 80 Removals ........................................................................................................................... 60 FQHC Non-Covered Additions ...................................................................................................................................................................... 61 FQHC Non-Covered Removals ..................................................................................................................................................................... 62 RHC Modifier HCPCS Conflict Additions .................................................................................................................................................... 63 Pass-Through Device HCPCS Additions ....................................................................................................................................................... 64 Pass-Through Radiopharm HCPCS Additions ............................................................................................................................................... 65


Page 3 of 84

Pass-Through Radiopharm HCPCS Removals .............................................................................................................................................. 66 Skin Substitute High Cost Product Additions ................................................................................................................................................ 67 Skin Substitute Low Cost Product Removals................................................................................................................................................. 68 Pass-Through Device Credit Procedure Additions......................................................................................................................................... 69 Pass-Through Device Credit Procedure Modifications .................................................................................................................................. 70 Terminated Device Procedure Additions ....................................................................................................................................................... 71 Terminated Device Procedure Removals ....................................................................................................................................................... 72 Terminated Device Procedure Modifications ................................................................................................................................................. 73 Drug Administration Addon Procedure Code List Additions ........................................................................................................................ 78 Type One Addon Procedure Code List Additions .......................................................................................................................................... 79 Type One Addon Procedure Code List Removals ......................................................................................................................................... 80

Modifier Changes ............................................................................................................................................................................................... 82 Added Modifiers ............................................................................................................................................................................................ 82 Deleted Modifiers .......................................................................................................................................................................................... 83


Page 4 of 84



Page 5 of 84

APC Changes

Added APCs

The following APC(s) were added. Added APCs APC Eff Date Description Status Indicator Payment 01236 2019-10-01 Inj levoleucovorin nos 0.5mg K $0.58 02024 2020-01-01 Generator, CCM, implant H $0.00 02025 2020-01-01 Cath, pressure,valve-occlu H $0.00 02026 2020-01-01 Orth/devic/drug bn/bn,tis/bn H $0.00 02027 2020-01-01 Probe, robotic, water-jet H $0.00 02028 2020-01-01 Iris prosthesis H $0.00 05495 2020-01-01 Level 5 Intraocular Procedures J1 $20,675.62 09303 2019-10-01 Injection, levoleucovorin G $4.12 09315 2020-01-01 Diphtheria antitoxin K $12.68 09316 2020-01-01 Corticotropin injection K $3,946.50 09317 2020-01-01 Doripenem injection K $0.89 09318 2020-01-01 Inj hydroxyprogst capoat nos K $10.81 09319 2020-01-01 Somatropin injection K $1.67 09320 2020-01-01 Carbidopa levodopa ent 100ml K $219.45 09321 2020-01-01 Fosphenytoin inj pe K $1.73 09331 2020-01-01 Inj, polatuzumab vedotin 1mg G $110.36 09332 2020-01-01 Injection, lefamulin G $0.70 09333 2020-01-01 Inj, brexanolone G $76.74 09334 2020-01-01 Injection, khapzory, 0.5 mg G $2.04 09335 2020-01-01 Oral busulfan K $24.18 09336 2019-10-01 Inj truxima 10 mg K $0.00 09337 2020-01-01 Synojoynt, inj., 1 mg K $6.13 09338 2020-01-01 Inj., triluron, 1 mg K $25.18 09339 2020-01-01 Iodine i-131 iobenguane 1mci G $311.06 09340 2020-01-01 Inj, brolucizumab-dbll, 1 mg K $317.58


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Deleted APCs

The following APC(s) were deleted. Deleted APCs APC Eff Date Description 00873 2020-01-01 Hyalgan supartz visco-3 dose 01253 2020-01-01 Triamcinolone A inj PRS-free 01669 2020-01-01 Erythro lactobionate /500 mg 01743 2020-01-01 Nandrolone decanoate 50 mg 09005 2020-01-01 Reteplase injection 09019 2020-01-01 Caspofungin acetate 09052 2020-01-01 Fluciciovine F-18 09056 2020-01-01 Gallium Ga-68 09075 2020-01-01 Inj, kovaltry, 1 i.u. 09086 2020-01-01 Hepa vacc ped/adol 3 dose 09087 2020-01-01 Inj, clevidipine butyrate 09089 2020-01-01 Oral fludarabine phosphate 09090 2020-01-01 Melphalan oral 2 mg 09091 2020-01-01 Daunorubicin citrate inj 09093 2020-01-01 Plicamycin (mithramycin) inj 09098 2020-01-01 Chorionic gonadotropin/1000u 09130 2020-01-01 Inj, Imm Glob Bivigam, 500mg 09184 2020-01-01 Iodine i-131 iobenguane, dx 09185 2020-01-01 Iodine i-131 iobenguane, tx 09210 2020-01-01 Palonosetron hcl 09293 2020-01-01 Injection, glucarpidase 09323 2019-10-01 Inj., levoleucovorin, 0.5 mg 09497 2020-01-01 Loxapine for inhalation 1 mg


Page 7 of 84

Modified APC Descriptions

The following APC(s) had a description change. Modified APC Descriptions APC Eff Date Description Current Description Previous 01491 2020-01-01 New Technology - Level 1A ($0-$10) New Technology - Level 1A ($0-$10) 01492 2020-01-01 New Technology - Level 1B ($11-$20) New Technology - Level 1B ($11-$20) 01493 2020-01-01 New Technology - Level 1C ($21-$30) New Technology - Level 1C ($21-$30) 01494 2020-01-01 New Technology - Level 1D ($31-$40) New Technology - Level 1D ($31-$40) 01495 2020-01-01 New Technology - Level 1E ($41-$50) New Technology - Level 1E ($41-$50) 01496 2020-01-01 New Technology - Level 1A ($0-$10) New Technology - Level 1A ($0-$10) 01497 2020-01-01 New Technology - Level 1B ($11-$20) New Technology - Level 1B ($11-$20) 01498 2020-01-01 New Technology - Level 1C ($21-$30) New Technology - Level 1C ($21-$30) 01499 2020-01-01 New Technology - Level 1D ($31-$40) New Technology - Level 1D ($31-$40) 01500 2020-01-01 New Technology - Level 1E ($41-$50) New Technology - Level 1E ($41-$50) 01516 2020-01-01 New Technology - Level 16 ($1401 - $1500) New Technology - Level 16 ($1401 - $1500) 09125 2020-01-01 Risperidone, long acting Inj., risperdal consta, 0.5 mg 09179 2020-01-01 Injection, Aristada Initio Inj., aristada initio, 1 mg 09182 2020-01-01 Inj mogamulizumab-kpkc, 1 mg Inj, mogamulizumab-kpkc, 1 mg 09225 2020-01-01 Fluocinolone acetonide implt Inj., retisert, 0.01 mg 09450 2020-01-01 Fluocinol acet intravit imp Inj., iluvien, 0.01 mg


Page 8 of 84

Modified APC Status Indicators

The following APC(s) had status indicator changes. Modified APC Status Indicators APC Eff Date Description Status Indicator Current Status Indicator Previous 01861 2020-01-01 Inj., bendeka 1 mg K G 05182 2020-01-01 Level 2 Vascular Procedures J1 T 05461 2020-01-01 Level 1 Neurostimulator and Related Procedures J1 T 09043 2020-01-01 Inj, afstyla, 1 i.u. K G 09058 2020-01-01 Buprenorphine implant 74.2mg K G 09059 2020-01-01 Vonvendi inj 1 iu vwf:rco K G 09329 2020-01-01 Inj mvasi 10 mg G K 09330 2020-01-01 Inj., kanjinti, 10 mg G K


Page 9 of 84

Added Comprehensive APCs

The following Comprehensive APC(s) were added. Added Comprehensive APCs APC Eff Date Description Status Indicator 05495 2020-01-01 Level 5 Intraocular Procedures J1


Page 10 of 84




05054 2020-01-01 Level 4 Skin Procedures $759.60 $737.11 05055 2020-01-01 Level 5 Skin Procedures $269.44 $185.54 05571 2020-01-01 Level 1 Imaging with Contrast $40.14 $47.13 05572 2020-01-01 Level 2 Imaging with Contrast $71.94 $67.34 05573 2020-01-01 Level 3 Imaging with Contrast $103.89 $96.84 05591 2020-01-01 Level 1 Nuclear Medicine and Related Services $51.65 $49.81 05592 2020-01-01 Level 2 Nuclear Medicine and Related Services $92.41 $92.85 05593 2020-01-01 Level 3 Nuclear Medicine and Related Services $338.91 $335.42 05594 2020-01-01 Level 4 Nuclear Medicine and Related Services $269.87 $329.24 05722 2020-01-01 Level 2 Diagnostic Tests and Related Services $3.57 $3.59


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Added HCPCS Codes

The following HCPCS code(s) were added. Added HCPCS Codes HCPCS Eff Date Description Status

Indicator APC Edit Appr Date Term Date

0139U 2020-01-01 Neuro austm meas 6 c metablt Q4 00000 0140U 2020-01-01 Nfct ds fungi dna 15 trgt A 00000 0141U 2020-01-01 Nfct ds bact&fng gram pos A 00000 0142U 2020-01-01 Nfct ds bact&fng gram neg A 00000 0143U 2020-01-01 Drug assay 120+ rx/metablt Q4 00000 0144U 2020-01-01 Drug assay 160+ rx/metablt Q4 00000 0145U 2020-01-01 Drug assay 65+ rx/metablt Q4 00000 0146U 2020-01-01 Drug assay 80+ rx/metablt Q4 00000 0147U 2020-01-01 Drug assay 85+ rx/metablt Q4 00000 0148U 2020-01-01 Drug assay 100+ rx/metablt Q4 00000 0149U 2020-01-01 Drug assay 60+ rx/metablt Q4 00000 0150U 2020-01-01 Drug assay 120+ rx/metablt Q4 00000 0151U 2020-01-01 Nfct bct/vir resp nfctj 33 A 00000 0152U 2020-01-01 Nfct bct fng prst dna >1000 A 00000 0153U 2020-01-01 Onc breast mrna 101 genes A 00000 0154U 2020-01-01 Fgfr3 gene analysis A 00000 0155U 2020-01-01 Pik3ca gene analysis A 00000 0156U 2020-01-01 Copy number sequence alys A 00000 0157U 2020-01-01 Apc mrna seq alys A 00000 0158U 2020-01-01 Mlh1 mrna seq alys A 00000 0159U 2020-01-01 Msh2 mrna seq alys A 00000 0160U 2020-01-01 Msh6 mrna seq alys A 00000 0161U 2020-01-01 Pms2 mrna seq alys A 00000 0162U 2020-01-01 Hered colon ca trgt mrna pnl A 00000 0563T 2020-01-01 Evac meibomian glnd heat bi Q1 05733 0564T 2020-01-01 Onc chemo rx cytotox csc 14 Q1 05671 0565T 2020-01-01 Autol cell implt adps hrvg Q1 05733 0566T 2020-01-01 Autol cell implt adps njx T 05441 0567T 2020-01-01 Perm flp tube occls w/implt E1 00000 9 0568T 2020-01-01 Intro mix saline&air f/ssg E1 00000 9 0569T 2020-01-01 Ttvr perq appr 1st prosth C 00000 0570T 2020-01-01 Ttvr perq ea addl prosth C 00000 0571T 2020-01-01 Insj/rplcmt icds ss eltrd E1 00000 9 0572T 2020-01-01 Insertion ss dfb electrode E1 00000 9 0573T 2020-01-01 Removal ss dfb electrode E1 00000 9 0574T 2020-01-01 Repos prev ss impl dfb eltrd E1 00000 9 0575T 2020-01-01 Prgrmg dev eval icds ss ip E1 00000 9 0576T 2020-01-01 Interrog dev eval icds ss ip E1 00000 9 0577T 2020-01-01 Ephys eval icds ss E1 00000 9 0578T 2020-01-01 Rem interrog dev icds phys E1 00000 9 0579T 2020-01-01 Rem interrog dev icds tech E1 00000 9 0580T 2020-01-01 Rmvl ss impl dfb pg only E1 00000 9 0581T 2020-01-01 Abltj mal brst tum perq crtx E1 00000 9 0582T 2020-01-01 Trurl abltj mal prst8 tiss E1 00000 9 0583T 2020-01-01 Tmpst auto tube dlvr sys E1 00000 9 0584T 2020-01-01 Perq islet cell transplant C 00000 0585T 2020-01-01 Laps islet cell transplant C 00000 0586T 2020-01-01 Open islet cell transplant C 00000 0587T 2020-01-01 Perq impltj/rplcmt isdns ptn T 05442 0588T 2020-01-01 Revision/removal isdns ptn T 05441 0589T 2020-01-01 Elec alys smpl prgrmg iins S 05742 0590T 2020-01-01 Elec alys cplx prgrmg iins S 05742 0591T 2020-01-01 Hlth&wb coaching indiv 1st E1 00000 9 0592T 2020-01-01 Hlth&wb coaching indiv f-up E1 00000 9 0593T 2020-01-01 Hlth&wb coaching group E1 00000 9 15769 2020-01-01 Grfg autol soft tiss dir exc T 05055 15771 2020-01-01 Grfg autol fat lipo 50 cc/< T 05055 15772 2020-01-01 Grfg autol fat lipo ea addl N 00000 15773 2020-01-01 Grfg autol fat lipo 25 cc/< T 05054 15774 2020-01-01 Gfrg autol fat lipo ea addl N 00000 20560 2020-01-01 Ndl insj w/o njx 1 or 2 musc E1 00000 9 20561 2020-01-01 Ndl insj w/o njx 3+ musc E1 00000 9 20700 2020-01-01 Mnl prep&insj dp rx dlvr dev N 00000 20701 2020-01-01 Rmvl deep rx delivery device N 00000 20702 2020-01-01 Mnl prep&insj imed rx dev N 00000 20703 2020-01-01 Rmvl imed rx delivery device N 00000 20704 2020-01-01 Mnl prep&insj i-artic rx dev N 00000 20705 2020-01-01 Rmvl i-artic rx delivery dev N 00000 21601 2020-01-01 Exc chest wall tumor w/ribs J1 05073


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Added HCPCS Codes HCPCS Eff Date Description Status


21602 2020-01-01 Exc ch wal tum w/o lymphadec C 00000 21603 2020-01-01 Exc ch wal tum w/lymphadec C 00000 3045F 2019-10-01 Hg a1c level 7.0-9.0% M 00000 72 3051F 2020-01-01 Hg a1c>equal 7.0%<8.0% E1 00000 28 3052F 2020-01-01 Hg a1c>equal 8.0%<equal 9.0% E1 00000 28 33016 2020-01-01 Pericardiocentesis w/imaging J1 05182 33017 2020-01-01 Prcrd drg 6yr+ w/o cgen car C 00000 33018 2020-01-01 Prcrd drg 0-5yr or w/anomly C 00000 33019 2020-01-01 Perq prcrd drg insj cath ct C 00000 33858 2020-01-01 As-aort grf f/aortic dsj C 00000 33859 2020-01-01 As-aort grf f/ds oth/thn dsj C 00000 33871 2020-01-01 Transvrs a-arch grf hypthrm C 00000 34717 2020-01-01 Evasc rpr a-iliac ndgft C 00000 34718 2020-01-01 Evasc rpr n/a a-iliac ndgft C 00000 35702 2020-01-01 Expl n/flwd surg uxtr art C 00000 35703 2020-01-01 Expl n/flwd surg lxtr art C 00000 46948 2020-01-01 Int hrhc tranal dartlzj 2+ J1 05313 49013 2020-01-01 Prpertl pel pack hemrrg trma C 00000 49014 2020-01-01 Reexploration pelvic wound C 00000 62328 2020-01-01 Dx lmbr spi pnxr w/fluor/ct T 05442 62329 2020-01-01 Ther spi pnxr csf fluor/ct T 05442 64451 2020-01-01 Njx aa&/strd nrv nrvtg si jt T 05442 64454 2020-01-01 Njx aa&/strd gnclr nrv brnch T 05442 64624 2020-01-01 Dstrj nulyt agt gnclr nrv J1 05431 64625 2020-01-01 Rf abltj nrv nrvtg si jt J1 05431 66987 2020-01-01 Xcapsl ctrc rmvl cplx w/ecp J1 05492 66988 2020-01-01 Xcapsl ctrc rmvl w/ecp J1 05492 74221 2020-01-01 X-ray xm esophagus 2cntrst Q1 05571 74248 2020-01-01 X-ray sm int f-thru std N 00000 78429 2020-01-01 Myocrd img pet 1 std w/ct S 05594 78430 2020-01-01 Myocrd img pet rst/strs w/ct S 05594 78431 2020-01-01 Myocrd img pet rst&strs ct S 01522 78432 2020-01-01 Myocrd img pet 2rtracer S 01523 78433 2020-01-01 Myocrd img pet 2rtracer ct S 01523 78434 2020-01-01 Aqmbf pet rest & rx stress N 00000 78830 2020-01-01 Rp loclzj tum spect w/ct 1 S 05593 78831 2020-01-01 Rp loclzj tum spect 2 areas S 05593 78832 2020-01-01 Rp loclzj tum spect w/ct 2 S 05594 78835 2020-01-01 Rp quan meas single area N 00000 80145 2020-01-01 Drug assay adalimumab Q4 00000 80187 2020-01-01 Drug assay posaconazole Q4 00000 80230 2020-01-01 Drug assay infliximab Q4 00000 80235 2020-01-01 Drug assay lacosamide Q4 00000 80280 2020-01-01 Drug assay vedolizumab Q4 00000 80285 2020-01-01 Drug assay voriconazole Q4 00000 81277 2020-01-01 Cytogenomic neo microra alys A 00000 81307 2020-01-01 Palb2 gene full gene seq A 00000 81308 2020-01-01 Palb2 gene known famil vrnt A 00000 81309 2020-01-01 Pik3ca gene trgt seq alys A 00000 81522 2020-01-01 Onc breast mrna 12 genes A 00000 81542 2020-01-01 Onc prostate mrna 22 cnt gen A 00000 81552 2020-01-01 Onc uveal mlnma mrna 15 gene A 00000 87563 2020-01-01 M. genitalium amp probe Q4 00000 90694 2020-01-01 Vacc aiiv4 no prsrv 0.5ml im E1 00000 9 90912 2020-01-01 Bfb training 1st 15 min A 00000 90913 2020-01-01 Bfb training ea addl 15 min A 00000 92201 2020-01-01 Opscpy extnd rta draw uni/bi Q1 05733 92202 2020-01-01 Opscpy extnd on/mac draw Q1 05733 92549 2020-01-01 Cdp-sot 6 cond w/i&r mct&adt Q1 05734 93356 2020-01-01 Myocrd strain img spckl trck N 00000 93985 2020-01-01 Dup-scan hemo compl bi std S 05523 93986 2020-01-01 Dup-scan hemo compl uni std S 05522 95700 2020-01-01 Eeg cont rec w/vid eeg tech S 05722 95705 2020-01-01 Eeg w/o vid 2-12 hr unmntr S 05722 95706 2020-01-01 Eeg wo vid 2-12hr intmt mntr S 05722 95707 2020-01-01 Eeg w/o vid 2-12hr cont mntr S 05722 95708 2020-01-01 Eeg wo vid ea 12-26hr unmntr S 05723 95709 2020-01-01 Eeg w/o vid ea 12-26hr intmt S 05723 95710 2020-01-01 Eeg w/o vid ea 12-26hr cont S 05723 95711 2020-01-01 Veeg 2-12 hr unmonitored S 05722 95712 2020-01-01 Veeg 2-12 hr intmt mntr S 05722 95713 2020-01-01 Veeg 2-12 hr cont mntr S 05723 95714 2020-01-01 Veeg ea 12-26 hr unmntr S 05723 95715 2020-01-01 Veeg ea 12-26hr intmt mntr S 05723 95716 2020-01-01 Veeg ea 12-26hr cont mntr S 05724 95717 2020-01-01 Eeg phys/qhp 2-12 hr w/o vid M 00000 72 95718 2020-01-01 Eeg phys/qhp 2-12 hr w/veeg M 00000 72


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95719 2020-01-01 Eeg phys/qhp ea incr w/o vid M 00000 72 95720 2020-01-01 Eeg phy/qhp ea incr w/veeg M 00000 72 95721 2020-01-01 Eeg phy/qhp>36<60 hr w/o vid M 00000 72 95722 2020-01-01 Eeg phy/qhp>36<60 hr w/veeg M 00000 72 95723 2020-01-01 Eeg phy/qhp>60<84 hr w/o vid M 00000 72 95724 2020-01-01 Eeg phy/qhp>60<84 hr w/veeg M 00000 72 95725 2020-01-01 Eeg phy/qhp>84 hr w/o vid M 00000 72 95726 2020-01-01 Eeg phy/qhp>84 hr w/veeg M 00000 72 96156 2020-01-01 Hlth bhv assmt/reassessment Q3 05822 96158 2020-01-01 Hlth bhv ivntj indiv 1st 30 Q3 05822 96159 2020-01-01 Hlth bhv ivntj indiv ea addl N 00000 96164 2020-01-01 Hlth bhv ivntj grp 1st 30 Q3 05821 96165 2020-01-01 Hlth bhv ivntj grp ea addl N 00000 96167 2020-01-01 Hlth bhv ivntj fam 1st 30 Q3 05821 96168 2020-01-01 Hlth bhv ivntj fam ea addl N 00000 96170 2020-01-01 Hlth bhv ivntj fam wo pt 1st E1 00000 9 96171 2020-01-01 Hlth bhv ivntj fam w/o pt ea E1 00000 9 97129 2020-01-01 Ther ivntj 1st 15 min A 00000 97130 2020-01-01 Ther ivntj ea addl 15 min A 00000 98970 2020-01-01 Qnhp ol dig e/m svc 5-10min B 00000 62 98971 2020-01-01 Qnhp ol dig em svc 11-20min B 00000 62 98972 2020-01-01 Qnhp ol dig e/m svc 21+ min B 00000 62 99421 2020-01-01 Ol dig e/m svc 5-10 min M 00000 72 99422 2020-01-01 Ol dig e/m svc 11-20 min M 00000 72 99423 2020-01-01 Ol dig e/m svc 21+ min M 00000 72 99458 2020-01-01 Rem physiol mntr ea addl 20 N 00000 99473 2020-01-01 Self-meas bp pt educaj/train Q1 05731 99474 2020-01-01 Self-meas bp 2 readg bid 30d M 00000 72 A4226 2020-01-01 Weekly supply maint cgs pump N 00000 A9590 2020-01-01 Iodine i-131 iobenguane 1mci G 09339 B4187 2020-01-01 Omegaven, 10 grams lipids B 00000 62 C1734 2020-01-01 Orth/devic/drug bn/bn,tis/bn H 02026 55 C1824 2020-01-01 Generator, ccm, implant H 02024 55 C1839 2020-01-01 Iris prosthesis H 02028 55 C1982 2020-01-01 Cath, pressure,valve-occlu H 02025 55 C2596 2020-01-01 Probe, robotic, water-jet H 02027 55 C9043 2019-10-01 Injection, levoleucovorin G 09303 55 C9054 2020-01-01 Injection, lefamulin G 09332 55 C9055 2020-01-01 Inj, brexanolone G 09333 55 C9757 2020-01-01 Spine/lumbar disk surgery J1 05115 55 C9758 2020-01-01 Interatrial shunt ide T 01589 55 D0419 2020-01-01 Assess of salivary flow E1 00000 9 D1551 2020-01-01 Recement space maint - max S 05871 D1552 2020-01-01 Recement space maint - man S 05871 D1553 2020-01-01 Recement unilat space maint S 05871 D1556 2020-01-01 Rem fixed unilat space maint E1 00000 50 D1557 2020-01-01 Remove fixed bilat maint max E1 00000 50 D1558 2020-01-01 Remove fixed bilat man E1 00000 50 D2753 2020-01-01 Crown porc fused to titanium E1 00000 50 D5284 2020-01-01 Rem unilat dent flex base E1 00000 50 D5286 2020-01-01 Rem unilat dent 1 pc resin E1 00000 50 D6082 2020-01-01 Imp crown porc to base alloy E1 00000 28 D6083 2020-01-01 Imp crown porc to noble allo E1 00000 28 D6084 2020-01-01 Imp crown porc to titanium E1 00000 28 D6086 2020-01-01 Imp crown base alloys E1 00000 28 D6087 2020-01-01 Implant crown noble alloys E1 00000 28 D6088 2020-01-01 Imp crown titanium alloys E1 00000 28 D6097 2020-01-01 Abut crown porc to titanium E1 00000 28 D6098 2020-01-01 Imp retain porc to base allo E1 00000 9 D6099 2020-01-01 Imp retainer for fpd E1 00000 9 D6120 2020-01-01 Imp retain porc to titanium E1 00000 9 D6121 2020-01-01 Retain metal fpd base alloys E1 00000 9 D6122 2020-01-01 Retain metal fpd noble alloy E1 00000 9 D6123 2020-01-01 Retain metal fpd titanium E1 00000 9 D6195 2020-01-01 Abut retain porc to titanium E1 00000 9 D6243 2020-01-01 Pontic porcelain to titanium E1 00000 50 D6753 2020-01-01 Retain crown porc to titaniu E1 00000 50 D6784 2020-01-01 Retainer crown 3/4 titanium E1 00000 9 D7922 2020-01-01 Place intra-socket bio dress E1 00000 28 D8696 2020-01-01 Rep of ortho appliance max E1 00000 50 D8697 2020-01-01 Rep of ortho appliance man E1 00000 50 D8698 2020-01-01 Recement fixed retainer max E1 00000 50 D8699 2020-01-01 Recement fixed retainer man E1 00000 50 D8701 2020-01-01 Repair fixed retainer max E1 00000 50 D8702 2020-01-01 Repair of fixed retainer man E1 00000 50 D8703 2020-01-01 Replace broken retainer max E1 00000 50 D8704 2020-01-01 Replace broken retainer man E1 00000 50


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D9997 2020-01-01 Dent case mgmt special needs E1 00000 28 E0787 2020-01-01 Cgs dose adj insulin inf pmp Y 00000 61 E2398 2020-01-01 Wc dynamic pos back hardware Y 00000 61 G1000 2020-01-01 Cdsm applied pathways E1 00000 112 G1001 2020-01-01 Cdsm evicore E1 00000 112 G1002 2020-01-01 Cdsm medcurrent E1 00000 112 G1003 2020-01-01 Cdsm medicalis E1 00000 112 G1004 2020-01-01 Cdsm ndsc E1 00000 112 G1005 2020-01-01 Cdsm nia E1 00000 112 G1006 2020-01-01 Cdsm test approp E1 00000 112 G1007 2020-01-01 Cdsm aim E1 00000 112 G1008 2020-01-01 Cdsm cranberry pk E1 00000 112 G1009 2020-01-01 Cdsm sage health E1 00000 112 G1010 2020-01-01 Cdsm stanson E1 00000 112 G1011 2020-01-01 Cdsm qualified nos E1 00000 112 G2021 2020-01-01 Hea care pract tx in place E1 00000 112 G2022 2020-01-01 Benef refuses service, mod E1 00000 112 G2058 2020-01-01 Ccm add 20min N 00000 G2061 2020-01-01 Qual nonmd est pt 5-10m M 00000 72 G2062 2020-01-01 Qual nonmd est pt 11-20m M 00000 72 G2063 2020-01-01 Qual nonmd est pt 21>min M 00000 72 G2064 2020-01-01 Md mang high risk dx 30 M 00000 72 G2065 2020-01-01 Clin mang h risk dx 30 S 05822 G2066 2020-01-01 Inter devc remote 30d Q1 05741 G2067 2020-01-01 Med assist tx meth wk E1 00000 112 G2068 2020-01-01 Med assist tx bupre oral E1 00000 112 G2069 2020-01-01 Med assist tx inject E1 00000 112 G2070 2020-01-01 Med assist tx implant E1 00000 112 G2071 2020-01-01 Med tx remove implant E1 00000 112 G2072 2020-01-01 Med tx insert/remove imp E1 00000 112 G2073 2020-01-01 Med tx naltrexone E1 00000 112 G2074 2020-01-01 Med assist tx no drug E1 00000 112 G2075 2020-01-01 Med tx meds nos E1 00000 112 G2076 2020-01-01 Intake act w/med exam E1 00000 112 G2077 2020-01-01 Periodic assessment E1 00000 112 G2078 2020-01-01 Take-home meth E1 00000 112 G2079 2020-01-01 Take-hom buprenorphine E1 00000 112 G2080 2020-01-01 Add 30 mins counsel E1 00000 112 G2081 2020-01-01 Pt 66+ snp or ltc pos > 90d M 00000 72 G2082 2020-01-01 Visit esketamine 56m or less S 01508 G2083 2020-01-01 Visit esketamine, > 56m S 01511 G2086 2020-01-01 Off base opioid tx 70min S 05823 G2087 2020-01-01 Off base opioid tx, 60 m S 05823 G2088 2020-01-01 Off base opioid tx, add30 N 00000 G2089 2020-01-01 A1c level 7 to 9% M 00000 72 G2090 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2091 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2092 2020-01-01 Ace arb arni M 00000 72 G2093 2020-01-01 Med doc rsn no ace arn arni M 00000 72 G2094 2020-01-01 Pt rsn no ace arn arni M 00000 72 G2095 2020-01-01 Sys rsn no ace arn arni M 00000 72 G2096 2020-01-01 No rsn ace arb arni M 00000 72 G2097 2020-01-01 Child dx uri 3d of other dx M 00000 72 G2098 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2099 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2100 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2101 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2102 2020-01-01 Dil retinal eye exam M 00000 72 G2103 2020-01-01 7 stereo photos interpret M 00000 72 G2104 2020-01-01 Eye img valid w/7 stereo M 00000 72 G2105 2020-01-01 Pt 66+ lt ints > 90 M 00000 72 G2106 2020-01-01 Pt 66+ lt ints > 90 M 00000 72 G2107 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2108 2020-01-01 Pt 66+ lt ints > 90 M 00000 72 G2109 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2110 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2112 2020-01-01 Pred<=5 mg ra glu <6m M 00000 72 G2113 2020-01-01 Pred>5 mg >6m, no chg da M 00000 72 G2114 2020-01-01 Pt 66-80 frailty and med dem M 00000 72 G2115 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2116 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2117 2020-01-01 Pt 66-80 frailty and adv ill M 00000 72 G2118 2020-01-01 Pt 81+ frailty M 00000 72 G2119 2020-01-01 Calc vitd opt M 00000 72 G2120 2020-01-01 No calc vitd opt M 00000 72 G2121 2020-01-01 Psy dep anx ap and icd asse M 00000 72 G2122 2020-01-01 Psy/dep/anx/apandicd noasse M 00000 72


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G2123 2020-01-01 Pt 66-80 frailty med dem M 00000 72 G2124 2020-01-01 Pt 66-80 frailty adv ill M 00000 72 G2125 2020-01-01 Pt 81+ frailty M 00000 72 G2126 2020-01-01 Pt 66+ frailty adv ill M 00000 72 G2127 2020-01-01 Pt 66+ frailty med dem M 00000 72 G2128 2020-01-01 No aspirin med rsn M 00000 72 G2129 2020-01-01 No bp outpt M 00000 72 G2130 2020-01-01 Pt 66+ lt inst > 90 M 00000 72 G2131 2020-01-01 Pt 81+ frailty M 00000 72 G2132 2020-01-01 Pt 66-80 frailty and med dem M 00000 72 G2133 2020-01-01 Pt 66-80 frailty and adv ill M 00000 72 G2134 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2135 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2136 2020-01-01 Bk pain vas 6-20wk = 3 M 00000 72 G2137 2020-01-01 Bk pain vas 6-20wk > 3 M 00000 72 G2138 2020-01-01 Bk pain vas 9-15mo = 3 M 00000 72 G2139 2020-01-01 Bk pain vas 9-20mo > 3 M 00000 72 G2140 2020-01-01 Leg pain vas 6-20wk = 3 M 00000 72 G2141 2020-01-01 Leg pain vas 6-20wk > 3 M 00000 72 G2142 2020-01-01 Fs odi 9-15mo postop<= 22 M 00000 72 G2143 2020-01-01 Fs odi 9-15mo > 22 M 00000 72 G2144 2020-01-01 Fs odi 6-20wk postop > 22 M 00000 72 G2145 2020-01-01 Fsodi 6-20wk >22 or chg 30pt M 00000 72 G2146 2020-01-01 Leg pain vas 9-15mo <= 3 M 00000 72 G2147 2020-01-01 Leg pain vas 9-15mo > 3 M 00000 72 G2148 2020-01-01 Mpm used M 00000 72 G2149 2020-01-01 No mpm med rsn M 00000 72 G2150 2020-01-01 No mpm M 00000 72 G2151 2020-01-01 Dx degen neuro M 00000 72 G2152 2020-01-01 Res change sc =0 M 00000 72 G2153 2020-01-01 Hosp dur meas pd M 00000 72 G2154 2020-01-01 Td 9 yrs start end meas M 00000 72 G2155 2020-01-01 Hist contraindications M 00000 72 G2156 2020-01-01 No prior td or hx contra M 00000 72 G2157 2020-01-01 Pneum vacc 12 mo 60+ M 00000 72 G2158 2020-01-01 Pneum vacc adv rx M 00000 72 G2159 2020-01-01 No pneum vacc 12 mo 60+ M 00000 72 G2160 2020-01-01 Herpzos 50+ M 00000 72 G2161 2020-01-01 Adv rx zos M 00000 72 G2162 2020-01-01 No herpzos 50+ M 00000 72 G2163 2020-01-01 Infl vacc 07/01 to 06/30 M 00000 72 G2164 2020-01-01 Adv rx infl vacc M 00000 72 G2165 2020-01-01 No infl vacc 07/01 to 06/30 M 00000 72 G2166 2020-01-01 No pt adm dx no neck fs prom M 00000 72 G2167 2020-01-01 Res change sc < 0 M 00000 72 J0179 2020-01-01 Inj, brolucizumab-dbll, 1 mg K 09340 J0642 2019-10-01 Injection, khapzory, 0.5 mg B 00000 62 J0642 2020-01-01 Injection, khapzory, 0.5 mg G 09334 J9199 2020-01-01 Injection, infugem, 200 mg N 00000 J9309 2020-01-01 Inj, polatuzumab vedotin 1mg G 09331 K1001 2020-01-01 Electronic posa treatment Y 00000 61 K1002 2020-01-01 Ces system w/supplies access E1 00000 9 K1003 2020-01-01 Whirlpool tub walkin portabl Y 00000 61 K1004 2020-01-01 Lo freq us diathermy device Y 00000 61 K1005 2020-01-01 Disp col sto bag breast milk Y 00000 61 L2006 2020-01-01 Kaf sng/dbl swg/stn mcpr cus A 00000 L8033 2020-01-01 Nipple prosthesis custom, ea A 00000 M1106 2020-01-01 Start eoc doc med rec M 00000 72 M1107 2020-01-01 Docu dx degen neuro M 00000 72 M1108 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1109 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1110 2020-01-01 Oc ni pt selfdc 1-2 vis M 00000 72 M1111 2020-01-01 Start eoc doc med rec M 00000 72 M1112 2020-01-01 Docu dx degen neuro M 00000 72 M1113 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1114 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1115 2020-01-01 Oc ni pt selfdc 1-2 vis M 00000 72 M1116 2020-01-01 Start eoc doc med rec M 00000 72 M1117 2020-01-01 Docu dx degen neuro M 00000 72 M1118 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1119 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1120 2020-01-01 Oc ni pt selfdc 1-2 vis M 00000 72 M1121 2020-01-01 Start eoc doc med rec M 00000 72 M1122 2020-01-01 Docu dx degen neuro M 00000 72 M1123 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1124 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1125 2020-01-01 Oc ni pt selfdc 1-2 vis M 00000 72


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M1126 2020-01-01 Start eoc doc med rec M 00000 72 M1127 2020-01-01 Docu dx degen neuro M 00000 72 M1128 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1129 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1130 2020-01-01 Oc ni pt self dc 1-2 vis M 00000 72 M1131 2020-01-01 Docu dx degen neuro M 00000 72 M1132 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1133 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1134 2020-01-01 Oc ni pt self dc 1-2 vis M 00000 72 M1135 2020-01-01 Start eoc doc med rec M 00000 72 M1136 2020-01-01 Start eoc doc med rec M 00000 72 M1137 2020-01-01 Docu dx degen neuro M 00000 72 M1138 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1139 2020-01-01 Oc ni pt self dc 1-2 vis M 00000 72 M1140 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1141 2020-01-01 Fs no oks M 00000 72 M1142 2020-01-01 Emerge cases M 00000 72 M1143 2020-01-01 Ni rehab med chiro M 00000 72 M1144 2020-01-01 Oc no ind pt 1-2 vis M 00000 72 P9099 2020-01-01 Blood component/product noc E2 00000 13


Page 17 of 84

Deleted HCPCS CPT Codes

The following HCPCS code(s) were deleted. Deleted HCPCS CPT Codes HCPCS Eff Date Description 0009M 2020-01-01 Fetal aneuploidy trisom risk 0081U 2020-01-01 Onc uveal mlnma mrna 15 gene 0085U 2020-01-01 Cdtb&vinculin igg antb ia 0205T 2020-01-01 Inirs each vessel add-on 0206T 2020-01-01 Cptr dbs alys car elec dta 0249T 2020-01-01 Ligation hemorrhoid w/us 0254T 2020-01-01 Evasc rpr iliac art bifur 0341T 2020-01-01 Quant pupillometry w/ rprt 0357T 2020-01-01 Cryopreservation oocyte(s) 0375T 2020-01-01 Total disc arthrp ant appr 0377T 2020-01-01 Anoscpy inj agent for incont 0380T 2020-01-01 Comp animat ret imag series 0399T 2020-01-01 Myocardial strain imaging 0482T 2020-01-01 Absl quan myocrd bld flo pet 19260 2020-01-01 Removal of chest wall lesion 19271 2020-01-01 Revision of chest wall 19272 2020-01-01 Extensive chest wall surgery 19304 2020-01-01 Mast subq 20926 2020-01-01 Removal of tissue for graft 3051F 2019-10-01 Hg a1c>equal 7.0%<8.0% 3052F 2019-10-01 Hg a1c>equal 8.0%<equal 9.0% 33010 2020-01-01 Drainage of heart sac 33011 2020-01-01 Repeat drainage of heart sac 33015 2020-01-01 Incision of heart sac 33860 2020-01-01 Ascending aortic graft 33870 2020-01-01 Transverse aortic arch graft 35721 2020-01-01 Exploration femoral artery 35741 2020-01-01 Exploration popliteal artery 35761 2020-01-01 Exploration of artery/vein 43401 2020-01-01 Esophagus surgery for veins 64402 2020-01-01 N block inj facial 64410 2020-01-01 N block inj phrenic 64413 2020-01-01 N block inj cervical plexus 74241 2020-01-01 X-ray upper gi delay w/kub 74245 2020-01-01 X-ray upper gi&small intest 74247 2020-01-01 Contrst x-ray uppr gi tract 74249 2020-01-01 Contrst x-ray uppr gi tract 74260 2020-01-01 X-ray exam of small bowel 76930 2020-01-01 Echo guide cardiocentesis 78205 2020-01-01 Liver imaging (3d) 78206 2020-01-01 Liver image (3d) with flow 78320 2020-01-01 Bone imaging (3d) 78607 2020-01-01 Brain imaging (3d) 78647 2020-01-01 Cerebrospinal fluid scan 78710 2020-01-01 Kidney imaging (3d) 78805 2020-01-01 Abscess imaging ltd area 78806 2020-01-01 Abscess imaging whole body 78807 2020-01-01 Nuclear localization/abscess 90911 2020-01-01 Biofeedback peri/uro/rectal 92225 2020-01-01 Special eye exam initial 92226 2020-01-01 Special eye exam subsequent 93299 2020-01-01 Interrog eval icpms/scrms 95827 2020-01-01 Eeg all night recording 95831 2020-01-01 Limb muscle testing manual 95832 2020-01-01 Hand muscle testing manual 95833 2020-01-01 Body muscle testing manual 95834 2020-01-01 Body muscle testing manual 95950 2020-01-01 Ambulatory eeg monitoring 95951 2020-01-01 Eeg monitoring/videorecord 95953 2020-01-01 Eeg monitoring/computer 95956 2020-01-01 Eeg monitor technol attended 96150 2020-01-01 Assess hlth/behave init 96151 2020-01-01 Assess hlth/behave subseq 96152 2020-01-01 Intervene hlth/behave indiv 96153 2020-01-01 Intervene hlth/behave group 96154 2020-01-01 Interv hlth/behav fam w/pt 96155 2020-01-01 Interv hlth/behav fam no pt 97127 2020-01-01 Ther ivntj w/focus cog funcj 98969 2020-01-01 Online service by hc pro 99444 2020-01-01 Online e/m by phys/qhp C9407 2020-01-01 Iodine i-131 iobenguane, dx C9408 2020-01-01 Iodine i-131 iobenguane, tx D1550 2020-01-01 Recement space maintainer


Page 18 of 84

Deleted HCPCS CPT Codes HCPCS Eff Date Description D1555 2020-01-01 Remove fix space maintainer D8691 2020-01-01 Repair ortho appliance D8692 2020-01-01 Replacement retainer D8693 2020-01-01 Rebond/recement retainers D8694 2020-01-01 Repair fixed retainers G0365 2020-01-01 Vessel mapping hemo access G0515 2020-01-01 Cognitive skills development G8649 2020-01-01 Rafscrs ki no scor G8653 2020-01-01 Rafscrs hi no scor G8657 2020-01-01 Rafscrs llfai no scor G8665 2020-01-01 Rafscrs si no scor G8669 2020-01-01 Rafscrs G8673 2020-01-01 Rafscrs goi no scor G8861 2020-01-01 Dxa ordered for osteo G8978 2020-01-01 Mobility current status G8979 2020-01-01 Mobility goal status G8980 2020-01-01 Mobility d/c status G8981 2020-01-01 Body pos current status G8982 2020-01-01 Body pos goal status G8983 2020-01-01 Body pos d/c status G8984 2020-01-01 Carry current status G8985 2020-01-01 Carry goal status G8986 2020-01-01 Carry d/c status G8987 2020-01-01 Self care current status G8988 2020-01-01 Self care goal status G8989 2020-01-01 Self care d/c status G8990 2020-01-01 Other pt/ot current status G8991 2020-01-01 Other pt/ot goal status G8992 2020-01-01 Other pt/ot d/c status G8993 2020-01-01 Sub pt/ot current status G8994 2020-01-01 Sub pt/ot goal status G8995 2020-01-01 Sub pt/ot d/c status G8996 2020-01-01 Swallow current status G8997 2020-01-01 Swallow goal status G8998 2020-01-01 Swallow d/c status G8999 2020-01-01 Motor speech current status G9017 2020-01-01 Amantadine hcl 100mg oral G9018 2020-01-01 Zanamivir,inhalation pwd 10m G9019 2020-01-01 Oseltamivir phosphate 75mg G9020 2020-01-01 Rimantadine hcl 100mg oral G9033 2020-01-01 Amantadine hcl oral brand G9034 2020-01-01 Zanamivir, inh pwdr, brand G9035 2020-01-01 Oseltamivir phosp, brand G9036 2020-01-01 Rimantadine hcl, brand G9158 2020-01-01 Motor speech d/c status G9159 2020-01-01 Lang comp current status G9160 2020-01-01 Lang comp goal status G9161 2020-01-01 Lang comp d/c status G9162 2020-01-01 Lang express current status G9163 2020-01-01 Lang express goal status G9164 2020-01-01 Lang express d/c status G9165 2020-01-01 Atten current status G9166 2020-01-01 Atten goal status G9167 2020-01-01 Atten d/c status G9168 2020-01-01 Memory current status G9169 2020-01-01 Memory goal status G9170 2020-01-01 Memory d/c status G9171 2020-01-01 Voice current status G9172 2020-01-01 Voice goal status G9173 2020-01-01 Voice d/c status G9174 2020-01-01 Speech lang current status G9175 2020-01-01 Speech lang goal status G9176 2020-01-01 Speech lang d/c status G9186 2020-01-01 Motor speech goal status G9472 2020-01-01 No dxa no med hx no rv sx G9742 2020-01-01 Psych sympt assessed G9743 2020-01-01 Psych symp not assessed, rns G9941 2020-01-01 Pre and post vas wthn 3 mos G9944 2020-01-01 Vas 3 mon pre and 1 yr post G9947 2020-01-01 Pre and post vas wthn 3 mos M1000 2020-01-01 Pain scr as mod to sevr M1001 2020-01-01 Pln to adrs pain doc M1002 2020-01-01 Pln to adrs pain not doc M1030 2020-01-01 Pt clin ind img hd M1042 2020-01-01 Ftl st mea sco ot odi 3 mo M1044 2020-01-01 Ftl st mea odi 3 mo M1047 2020-01-01 Fs msrd oks pre and post M1048 2020-01-01 Fsm wth scr odi pre and post


Page 19 of 84

Deleted HCPCS CPT Codes HCPCS Eff Date Description M1050 2020-01-01 Fs msrd odi pre and post M1053 2020-01-01 Pre and post vas wthn 3 mos 3045F 2020-01-01 Hg a1c level 7.0-9.0%


Page 20 of 84

Modified HCPCS Code Descriptions

The following HCPCS code(s) had a description change. Modified HCPCS Code Descriptions HCPCS Eff Date Description Current Description Previous 0124U 2020-01-01 Ftl cgen abnor 3 analytes Ftl cgen abnor 3 analtyes 0402T 2019-01-01 Colgn cross-link crn med sep Collagen crosslinking cornea 0409T 2016-01-01 Insj/rplc car modulj pls gn Insj/rplc cardiac modulj pls gn 0423T 2016-01-01 Assay secretory type ii pla2 Assay secretory type ii pla2` 0434T 2016-01-01 Interro eval npgs apnea Interro eval npgs sleep apnea 11921 2015-01-01 Correct skn color 6.1-20.0cm Correct skn color 6.1-20.0cm 2022F 2020-01-01 Dilat rta xm evc rtnopthy Dil retina exam interp rev 2024F 2020-01-01 7 fld rta photo evc rtnopthy 7 field photo interp doc rev 3084F 2020-01-01 Kt/v >= 1.7 Kt/v >/= 1.7 31233 2020-01-01 Nsl/sins ndsc dx max sinusc Nasal/sinus endoscopy dx 31235 2020-01-01 Nsl/sins ndsc dx sphn sinusc Nasal/sinus endoscopy dx 31292 2020-01-01 Nsl/sins ndsc med/inf dcmprn Nasal/sinus endoscopy surg 31293 2020-01-01 Nsl/sins ndsc med&inf dcmprn Nasal/sinus endoscopy surg 31294 2020-01-01 Nsl/sins ndsc surg on dcmprn Nasal/sinus endoscopy surg 31295 2020-01-01 Nsl/sins ndsc surg max sins Sinus endo w/balloon dil 31296 2020-01-01 Nsl/sins ndsc surg frnt sins Sinus endo w/balloon dil 31297 2020-01-01 Nsl/sins ndsc surg sphn sins Sinus endo w/balloon dil 31298 2020-01-01 Nsl/sins ndsc surg frnt&sphn Nsl/sins ndsc w/sins dilat 33275 2020-01-01 Tcat rmvl perm ldls pm w/img Tcat rmvl perm ldls pm 35701 2020-01-01 Expl n/flwd surg neck art Exploration carotid artery 43763 2019-01-01 Rplc gtube revj gstrst trc Rplc gtube revj gstrst trc 46945 2020-01-01 Int hrhc lig 1 hroid w/o img Remove by ligat int hem grp 46946 2020-01-01 Int hrhc lig 2+hroid w/o img Remove by ligat int hem grps 54640 2020-01-01 Orchiopexy ingun/scrot appr Suspension of testis 62270 2020-01-01 Dx lmbr spi pnxr Spinal fluid tap diagnostic 62272 2020-01-01 Ther spi pnxr drg csf Drain cerebro spinal fluid 64400 2020-01-01 Njx aa&/strd trigeminal nrv N block inj trigeminal 64405 2020-01-01 Njx aa&/strd gr ocpl nrv N block inj occipital 64408 2020-01-01 Njx aa&/strd vagus nrv N block inj vagus 64415 2020-01-01 Njx aa&/strd brach plexus N block inj brachial plexus 64416 2020-01-01 Njx aa&/strd brach plex nfs N block cont infuse b plex 64417 2020-01-01 Njx aa&/strd axillary nrv N block inj axillary 64418 2020-01-01 Njx aa&/strd sprscap nrv N block inj suprascapular 64420 2020-01-01 Njx aa&/strd ntrcost nrv 1 N block inj intercost sng 64421 2020-01-01 Njx aa&/strd ntrcost nrv ea N block inj intercost mlt 64425 2020-01-01 Njx aa&/strd ii ih nerves N block inj ilio-ing/hypogi 64430 2020-01-01 Njx aa&/strd pudendal nerve N block inj pudendal 64435 2020-01-01 Njx aa&/strd paracrv nrv N block inj paracervical 64445 2020-01-01 Njx aa&/strd sciatic nerve N block inj sciatic sng 64446 2020-01-01 Njx aa&/strd sciatic nrv nfs N blk inj sciatic cont inf 64447 2020-01-01 Njx aa&/strd femoral nerve N block inj fem single 64448 2020-01-01 Njx aa&/strd fem nerve nfs N block inj fem cont inf 64449 2020-01-01 Njx aa&/strd lmbr plex nfs N block inj lumbar plexus 64450 2020-01-01 Njx aa&/strd other pn/branch N block other peripheral 66711 2020-01-01 Ecp ciliary body destruction Ciliary endoscopic ablation 66982 2020-01-01 Xcapsl ctrc rmvl cplx wo ecp Cataract surgery complex 66984 2020-01-01 Xcapsl ctrc rmvl w/o ecp Cataract surg w/iol 1 stage 74022 2020-01-01 X-ray exam complete abdomen X-ray exam series abdomen 74210 2020-01-01 X-ray xm phrnx&/crv esoph c+ Contrst x-ray exam of throat 74220 2020-01-01 X-ray xm esophagus 1cntrst Contrast x-ray esophagus 74230 2020-01-01 X-ray xm swlng funcj c+ Cine/vid x-ray throat/esoph 74240 2020-01-01 X-ray xm upr gi trc 1cntrst X-ray upper gi delay w/o kub 74246 2020-01-01 X-ray xm upr gi trc 2cntrst Contrst x-ray uppr gi tract 74250 2020-01-01 X-ray xm sm int 1cntrst std X-ray exam of small bowel 74251 2020-01-01 X-ray xm sm int 2cntrst std X-ray exam of small bowel 74270 2020-01-01 X-ray xm colon 1cntrst std Contrast x-ray exam of colon 74280 2020-01-01 X-ray xm colon 2cntrst std Contrast x-ray exam of colon 76805 2020-01-01 Ob us >= 14 wks sngl fetus Ob us >/= 14 wks sngl fetus 76810 2020-01-01 Ob us >= 14 wks addl fetus Ob us >/= 14 wks addl fetus 78459 2020-01-01 Myocrd img pet single study Heart muscle imaging (pet) 78491 2020-01-01 Myocrd img pet 1std rst/strs Heart image (pet) single 78492 2020-01-01 Myocrd img pet mlt rst&strs Heart image (pet) multiple 78800 2020-01-01 Rp loclzj tum 1 area 1 d img Tumor imaging limited area 78801 2020-01-01 Rp loclzj tum 2+area 1+d img Tumor imaging mult areas 78802 2020-01-01 Rp loclzj tum whbdy 1 d img Tumor imaging whole body 78803 2020-01-01 Rp loclzj tum spect 1 area Tumor imaging (3d) 78804 2020-01-01 Rp loclzj tum whbdy 2+d img Tumor imaging whole body 81350 2020-01-01 Ugt1a1 gene common variants Ugt1a1 gene 90734 2020-01-01 Menacwyd/menacwycrm vacc im Mcv4 menacwy vaccine im 92548 2020-01-01 Cdp-sot 6 cond w/i&r Posturography 92626 2020-01-01 Eval aud funcj 1st hour Eval aud rehab status 92627 2020-01-01 Eval aud funcj ea addl 15 Eval aud status rehab add-on 93784 2020-01-01 Ambl bp mntr w/software Ambulatory bp monitoring


Page 21 of 84

Modified HCPCS Code Descriptions HCPCS Eff Date Description Current Description Previous 93786 2020-01-01 Ambl bp mntr w/sw rec only Ambulatory bp recording 93788 2020-01-01 Ambl bp mntr w/sw a/r Ambulatory bp analysis 93790 2020-01-01 Ambl bp mntr w/sw i&r Review/report bp recording 93792 2020-01-01 Pt/caregiver traing home inr Pt/caregiver trainj home inr 94728 2020-01-01 Airwy resist by oscillometry Pulm funct test oscillometry 95813 2020-01-01 Eeg extnd mntr 61-119 min Eeg over 1 hour 95836 2020-01-01 Ecog impltd brn npgt <30 d Ecog impltd brn npgt </30 d 97605 2020-01-01 Neg press wound tx <=50 cm Neg press wound tx </=50 cm 97607 2020-01-01 Neg press wnd tx <=50 sq cm Neg press wnd tx </=50 sq cm 97760 2020-01-01 Orthotic mgmt&traing 1st enc Orthotic mgmt&trainj 1st enc 97761 2020-01-01 Prosthetic traing 1st enc Prosthetic trainj 1st enc 99457 2020-01-01 Rem physiol mntr 1st 20 min Rem physiol mntr 20 min mo A4407 2019-10-01 Ext wear ost skn barr <=4sq" Ext wear ost skn barr <=4sq A4408 2019-10-01 Ext wear ost skn barr >4sq" Ext wear ost skn barr >4sq A4719 2019-10-01 "y set" tubing y set tubing B4185 2020-01-01 Pn soln nos 10 grams lipids Parenteral sol 10 gm lipids C8903 2020-01-01 Mri w/cont, breast, uni Mri w/cont, breast, uni C8906 2020-01-01 Mri w/cont, breast, bi Mri w/cont, breast, bi C8937 2019-01-01 Cad breast mri CAD breast MRI C9041 2019-04-01 Inj, coagulation factor xa Inj, coagulation factor Xa C9756 2019-07-01 Fluorescence lymph map w/icg Fluorescence lymph map w/ICG E2201 2019-10-01 Man w/ch acc seat w>=20"<24" Man w/ch acc seat w>=20"<24 G0108 2020-01-01 Diab manage trn per indiv Diab manage trn per indiv G2000 2018-10-01 Blinded conv. tx mdd clin tr Blinded conv. Tx MDD clin tr G2012 2019-01-01 Brief check in by md/qhp Brief check in by MD/QHP G8650 2020-01-01 Rafs crs ki no scor no surv Rafscrs ki no scor no surv G8654 2020-01-01 Rafs crs hi no scor no surv Rafscrs hi no scor no surv G8662 2020-01-01 Rafs crs lbi no scor no surv Rafscrs lbi no scor no surv G8666 2020-01-01 Rafs crs si no scor no surv Rafscrs si no scor no surv G8670 2020-01-01 Rafs crs ewh no scor no surv Rafscrs ewh no scor no surv G9349 2020-01-01 Ct within 28 days Doc sinus ct 28d G9359 2020-01-01 Neg mgd pos tb notact Doc of neg or man pos tb scn G9405 2020-01-01 Recd f/u w/in 7d dc Recd f/u w/in 7d disch G9469 2020-01-01 Rec cortico>90d or 1rx 900mg Rec cortico>60d or 1rx 600mg G9510 2020-01-01 Remis12m not phq-9 score <5 Remis 12m not phq-9 score <5 G9519 2020-01-01 Final ref +/- 1.0 w/in 90d Final ref +/- 0.5 w/in 90d G9520 2020-01-01 Refract not +/- 1.0 w/in 90d Refract not +/- 0.5 w/in 90d G9547 2020-01-01 Cys ren les or adren Incid finding liver/kid/adre G9548 2020-01-01 No f/u rec image study Abd imag and followup rec G9549 2020-01-01 Doc med rsn for f/u imag Doc med rsn for follow imag G9550 2020-01-01 Imag rec Abd imag and followup no rec G9551 2020-01-01 Imag no les Abd imag no les,kid/livr/adr G9595 2020-01-01 Doc shnt/tum/coag Doc shnt/tum/coag/thrombocyt G9663 2020-01-01 Fast/dir ldl <= 190 mg/dl Fast/dir ldl = 190 mg/dl G9695 2017-01-01 Long act inhal bronchdil pre Long act inhal bronchdil pres G9699 2017-01-01 Long inhal bronchdil no pres Long inhal bronchdil no presc G9785 2020-01-01 Path report sent Pathology report sent G9786 2020-01-01 Path report not sent Pathology report not sent G9798 2020-01-01 D/c ami btw 7/1-6/30 meas pd D/c ami btw 7/1-6/30 mst per G9898 2020-01-01 Pt 66+ snp or ltc pos Snp/lg trm cre pt w/pos cde G9901 2020-01-01 Pt 66+ snp or ltc pos Snp/lg trm cre pt w/pos cde G9910 2020-01-01 Pt 66+ snp or ltc pos Snp/lg trm cre pt w/pos cde G9917 2020-01-01 Adv dem crgvr limited Doc med rsn no funct status G9927 2020-01-01 Doc no warf /fda pt trial Doc no warf /fda pt trial G9938 2020-01-01 Pt 66+ snp or ltc pos Snp/lg trm cre pt w/pos cde G9945 2020-01-01 Pt w/cancer scoliosis Pt w/cancer scoliosis G9946 2020-01-01 Bk pain no vas Bk pn nt msr vas pre-pst 1y G9949 2020-01-01 Leg pain no vas Lg pn nt msr vas scl pre/pst G9984 2020-01-01 Remote e/m est. pt 15mins Remote e/m est. pt 15mins J0641 2019-10-01 Inj levoleucovorin nos 0.5mg Inj., levoleucovorin, 0.5 mg J2794 2019-10-01 Inj risperdal consta, 0.5 mg Inj., risperdal consta, 0.5 mg J9201 2020-01-01 In gemcitabine hcl nos 200mg Gemcitabine hcl injection J9204 2019-10-01 Inj mogamulizumab-kpkc, 1 mg Inj, mogamulizumab-kpkc, 1 mg L8608 2019-01-01 Arg ii ext com/sup/acc misc Arg II ext com/sup/acc misc M1009 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1010 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1011 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1012 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1013 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1014 2020-01-01 Dc epi care doc medrec Pt tx and final eval comp M1015 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1043 2020-01-01 Fs no odi 9-15mo Ftl st mea sco no ot odi M1045 2020-01-01 Fs oks 9-15mo = 37 Fsm wth scr oks pre and post M1046 2020-01-01 Fs oks 9-15mo = 37 Fsm wth scr no oks pre and p M1049 2020-01-01 Fs wth scr no odi pre and p Fsm wth scr no odi pre and p M1052 2020-01-01 Lg pn not meas w/ vas 1yr po Lg pn nt msr vas scl pre/pst Q4220 2019-10-01 Bellacell hd, surederm sq cm Bellacell HD, Surederm sq cm Q5114 2019-07-01 Inj ogivri 10 mg Inj ogivri 10 mg


Page 22 of 84

Modified HCPCS Code Descriptions HCPCS Eff Date Description Current Description Previous Q9985 2017-07-01 Inj hydroxyprogesterone, NOS Inj, hydroxyprogesterone, NOS Q9988 2017-07-01 Platelet pheresis path reduc Platelets pheresis path reduc S0285 2016-07-01 Cnslt before screen colonosc Cnslt before screen colonoscop S1036 2014-07-01 Art pancreas ext transmitter Art pancreas ext transmitter. V5190 2019-01-01 Hearing aid monaural glasses Hearing aid monaural glasses


Page 23 of 84






Edits Current

Edits Previous

0002M 2020-01-01 Liver dis 10 assays w/ash Q4 E1 9 0003M 2020-01-01 Liver dis 10 assays w/nash Q4 E1 9 0071U 2020-01-01 Cyp2d6 full gene sequence A N 0072U 2020-01-01 Cyp2d6 gen cyp2d6-2d7 hybrid A N 0073U 2020-01-01 Cyp2d6 gen cyp2d7-2d6 hybrid A N 0074U 2020-01-01 Cyp2d6 nonduplicated gene A N 0075U 2020-01-01 Cyp2d6 5' gene dup/mlt A N 0076U 2020-01-01 Cyp2d6 3' gene dup/mlt A N 00802 2020-01-01 Anesth fat layer removal N C 00865 2020-01-01 Anesth removal of prostate N C 00944 2020-01-01 Anesth vaginal hysterectomy N C 01214 2020-01-01 Anesth hip arthroplasty N C 0126T 2020-01-01 Chd risk imt study 05731 05732 0130U 2020-01-01 Hered colon ca do mrna pnl A N 0131U 2020-01-01 Hered brst ca rltd do pnl 13 A N 0132U 2020-01-01 Hered ova ca rltd do pnl 17 A N 0133U 2020-01-01 Hered prst8 ca rltd do 11 A N 0134U 2020-01-01 Hered pan ca mrna pnl 18 gen A N 0135U 2020-01-01 Hered gyn ca mrna pnl 12 gen A N 0136U 2020-01-01 Atm mrna seq alys A N 0137U 2020-01-01 Palb2 mrna seq alys A N 0138U 2020-01-01 Brca1 brca2 mrna seq alys A N 0266T 2020-01-01 Implt/rpl crtd sns dev total 05464 05463 0267T 2020-01-01 Implt/rpl crtd sns dev lead J1 T 0268T 2020-01-01 Implt/rpl crtd sns dev gen 05464 05463 0270T 2020-01-01 Rev/remvl crtd sns dev lead J1 Q2 0271T 2020-01-01 Rev/remvl crtd sns dev gen J1 Q2 0296T 2020-01-01 Ext ecg recording 05733 05734 0308T 2020-01-01 Insj ocular telescope prosth 05495 05494 0313T 2020-01-01 Laps rmvl nstim array vagus J1 T 0314T 2020-01-01 Laps rmvl vgl arry&pls gen J1 Q2 0315T 2020-01-01 Rmvl vagus nerve pls gen J1 Q2 0316T 2020-01-01 Replc vagus nerve pls gen 05464 05463 0356T 2020-01-01 Insrt drug device for iop 05692 05733 0358T 2020-01-01 Bia whole body 05731 05732 0421T 2020-01-01 Waterjet prostate abltj cmpl 05376 05375 0427T 2020-01-01 Insj/rplc nstim apnea pls gn 05464 05463 0428T 2020-01-01 Rmvl nstim apnea pls gen J1 Q2 0429T 2020-01-01 Rmvl nstim apnea sen ld J1 Q2 0430T 2020-01-01 Rmvl nstim apnea stimj ld J1 Q2 0431T 2020-01-01 Rmvl/rplc nstim apnea pls gn 05464 05463 0432T 2020-01-01 Repos nstim apnea stimj ld J1 T 0433T 2020-01-01 Repos nstim apnea sensing ld J1 T 0440T 2020-01-01 Abltj perc uxtr/perph nrv 05431 05432 0441T 2020-01-01 Abltj perc lxtr/perph nrv 05431 05432 0467T 2020-01-01 Revj/rplmnt ch respir eltrd J1 Q2 0468T 2020-01-01 Rmvl ch wal respir eltrd/ra J1 Q2 0499T 2020-01-01 Cysto f/urtl strix/stenosis 05374 05373 0503T 2020-01-01 Cor ffr alys gnrj ffr mdl 01511 01516 0541T 2020-01-01 Myocardial imaging mcg 05723 05722 0548T 2020-01-01 Tprnl balo cntnc dev bi 05376 05377 15782 2020-01-01 Dermabrasion other than face 05073 05072 12 12 15830 2020-01-01 Exc skin abd 12 15847 2020-01-01 Exc skin abd add-on 12 15931 2020-01-01 Remove sacrum pressure sore 05073 05072 2023F 2020-01-01 Dilat rta xm w/o rtnopthy E1 M 9 72 2025F 2020-01-01 7 fld rta photo w/o rtnopthy E1 M 9 72 2033F 2020-01-01 Eye img valid w/o rtnopthy E1 M 9 72 20912 2020-01-01 Remove cartilage for graft 12 21210 2020-01-01 Face bone graft 12 21235 2020-01-01 Ear cartilage graft 12 21700 2020-01-01 Revision of neck muscle 05114 05113 21811 2020-01-01 Optx of rib fx w/fixj scope 05114 05113 21812 2020-01-01 Treatment of rib fracture 05114 05113 22101 2020-01-01 Remove part thorax vertebra 05114 05113 22633 2020-01-01 Lumbar spine fusion combined 05115 00000 J1 C 22634 2020-01-01 Spine fusion extra segment N C 22869 2020-01-01 Insj stablj dev w/o dcmprn 05115 05116 23031 2020-01-01 Drain shoulder bursa 05073 05072 23174 2020-01-01 Remove humerus lesion 05114 05113 23180 2020-01-01 Remove collar bone lesion 05114 05113


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Modified HCPCS Code APC/Status Indicators/Edit Assignments HCPCS Eff Date Description APC




Edits Current

Edits Previous

23182 2020-01-01 Remove shoulder blade lesion 05114 05113 23333 2020-01-01 Remove shoulder fb deep 05073 05072 23406 2020-01-01 Incise tendon(s) & muscle(s) 05114 05113 23440 2020-01-01 Remove/transplant tendon 05114 05113 23930 2020-01-01 Drainage of arm lesion 05073 05072 24330 2020-01-01 Revision of arm muscles 05114 05113 24582 2020-01-01 Treat humerus fracture 05114 05113 25077 2020-01-01 Resect forearm/wrist tum<3cm 05073 05072 25135 2020-01-01 Remove & graft wrist lesion 05114 05113 25263 2020-01-01 Repair forearm tendon/muscle 05114 05113 25392 2020-01-01 Shorten radius & ulna 05114 05113 25393 2020-01-01 Lengthen radius & ulna 05114 05113 25670 2020-01-01 Treat wrist dislocation 05114 05113 25685 2020-01-01 Treat wrist fracture 05114 05113 25909 2020-01-01 Amputation follow-up surgery 05114 05113 26352 2020-01-01 Repair/graft hand tendon 05114 05113 26358 2020-01-01 Repair/graft hand tendon 05114 05113 26518 2020-01-01 Fusion of knuckle joints 05114 05113 26530 2020-01-01 Revise knuckle joint 05114 05113 27033 2020-01-01 Exploration of hip joint 05114 05113 27060 2020-01-01 Removal of ischial bursa 05114 05113 27065 2020-01-01 Remove hip bone les super 05114 05113 27086 2020-01-01 Remove hip foreign body 05073 05072 27130 2020-01-01 Total hip arthroplasty 05115 00000 J1 C 27350 2020-01-01 Removal of kneecap 05114 05113 27393 2020-01-01 Lengthening of thigh tendon 05114 05113 27403 2020-01-01 Repair of knee cartilage 05114 05113 27477 2020-01-01 Surgery to stop leg growth 05114 05113 27485 2020-01-01 Surgery to stop leg growth 05114 05113 27499 2020-01-01 Decompression of thigh/knee 05114 05113 27650 2020-01-01 Repair achilles tendon 05114 05113 28070 2020-01-01 Removal of foot joint lining 05114 05113 28130 2020-01-01 Removal of ankle bone 05114 05113 28299 2020-01-01 Correction hallux valgus 05114 05113 28307 2020-01-01 Incision of metatarsal 05114 05113 28310 2020-01-01 Revision of big toe 05114 05113 28576 2020-01-01 Treat foot dislocation 05114 05113 29861 2020-01-01 Hip arthro w/fb removal 05114 05113 29905 2020-01-01 Subtalar arthro w/exc 05114 05113 30460 2020-01-01 Revision of nose 12 30462 2020-01-01 Revision of nose 12 30465 2020-01-01 Repair nasal stenosis 12 3051F 2020-01-01 Hg a1c>equal 7.0%<8.0% E1 M 28 72 30520 2020-01-01 Repair of nasal septum 12 3052F 2020-01-01 Hg a1c>equal 8.0%<equal 9.0% E1 M 28 72 31201 2020-01-01 Removal of ethmoid sinus 05163 05164 32551 2020-01-01 Insertion of chest tube J1 T 32557 2020-01-01 Insert cath pleura w/ image J1 T 36473 2020-01-01 Endovenous mchnchem 1st vein 12 36474 2020-01-01 Endovenous mchnchem add-on 12 36475 2020-01-01 Endovenous rf 1st vein 12 36476 2020-01-01 Endovenous rf vein add-on 12 36478 2020-01-01 Endovenous laser 1st vein 12 36479 2020-01-01 Endovenous laser vein addon 12 36482 2020-01-01 Endoven ther chem adhes 1st 12 36483 2020-01-01 Endoven ther chem adhes sbsq 12 36555 2020-01-01 Insert non-tunnel cv cath J1 T 36556 2020-01-01 Insert non-tunnel cv cath J1 T 36569 2020-01-01 Insj picc 5 yr+ w/o imaging J1 T 36573 2020-01-01 Insj picc rs&i 5 yr+ J1 T 36576 2020-01-01 Repair tunneled cv cath J1 T 36580 2020-01-01 Replace cvad cath J1 T 36584 2020-01-01 Compl rplcmt picc rs&i J1 T 36596 2020-01-01 Mech remov tunneled cv cath J1 T 36597 2020-01-01 Reposition venous catheter J1 T 36901 2020-01-01 Intro cath dialysis circuit J1 T 37184 2020-01-01 Prim art m-thrmbc 1st vsl 05193 05192 37213 2020-01-01 Thromblytic art/ven therapy J1 T 37214 2020-01-01 Cessj therapy cath removal J1 T 37565 2020-01-01 Ligation of neck vein J1 T 37615 2020-01-01 Ligation of neck artery J1 T 37761 2020-01-01 Ligate leg veins open J1 T 37780 2020-01-01 Revision of leg vein J1 T 38222 2020-01-01 Dx bone marrow bx & aspir 05073 05072 38300 2020-01-01 Drainage lymph node lesion 05073 05072 38305 2020-01-01 Drainage lymph node lesion 05073 05072


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Edits Current

Edits Previous

40812 2020-01-01 Excise/repair mouth lesion 05163 05164 41828 2020-01-01 Excision of gum lesion 05163 05164 12 12 41870 2020-01-01 Gum graft 05163 05164 42405 2020-01-01 Biopsy of salivary gland 05163 05164 42800 2020-01-01 Biopsy of throat 05163 05164 44390 2020-01-01 Colonoscopy for foreign body 05311 05312 45337 2020-01-01 Sigmoidoscopy & decompress 05311 05312 45341 2020-01-01 Sigmoidoscopy w/ultrasound 05311 05312 45349 2020-01-01 Sigmoidoscopy w/resection 05313 05312 J1 T 45390 2020-01-01 Colonoscopy w/resection 05313 05312 J1 T 50433 2020-01-01 Plmt nephroureteral catheter 05374 05373 50555 2020-01-01 Kidney endoscopy & biopsy 05376 05375 50693 2020-01-01 Plmt ureteral stent prq 05374 05373 50951 2020-01-01 Endoscopy of ureter 05374 05373 50970 2020-01-01 Ureter endoscopy 05374 05373 51020 2020-01-01 Incise & treat bladder 05374 05373 51520 2020-01-01 Removal of bladder lesion 05374 05373 52341 2020-01-01 Cysto w/ureter stricture tx 05374 05373 52351 2020-01-01 Cystouretero & or pyeloscope 05374 05373 53240 2020-01-01 Surgery for urethra pouch 05374 05373 53450 2020-01-01 Revision of urethra 05374 05373 53460 2020-01-01 Revision of urethra 05374 05373 54000 2020-01-01 Slitting of prepuce 05374 05373 54435 2020-01-01 Revision of penis 05374 05373 54520 2020-01-01 Removal of testis 05374 05373 54522 2020-01-01 Orchiectomy partial 05374 05373 54600 2020-01-01 Reduce testis torsion 05374 05373 54680 2020-01-01 Relocation of testis(es) 05374 05373 54865 2020-01-01 Explore epididymis 05374 05373 55060 2020-01-01 Repair of hydrocele 05374 05373 55150 2020-01-01 Removal of scrotum 05374 05373 55200 2020-01-01 Incision of sperm duct 05374 05373 55500 2020-01-01 Removal of hydrocele 05374 05373 55520 2020-01-01 Removal of sperm cord lesion 05374 05373 55706 2020-01-01 Prostate saturation sampling 05374 05373 55970 2020-01-01 Sex transformation m to f 05415 05414 57020 2020-01-01 Drainage of pelvic fluid 05415 05414 57022 2020-01-01 I & d vaginal hematoma pp 05073 05072 57150 2020-01-01 Treat vagina infection 05733 05734 57155 2020-01-01 Insert uteri tandem/ovoids 05415 05414 57268 2020-01-01 Repair of bowel bulge 05415 05414 57291 2020-01-01 Construction of vagina 05415 05414 57335 2020-01-01 Repair vagina 05415 05414 57530 2020-01-01 Removal of cervix 05415 05414 57550 2020-01-01 Removal of residual cervix 05415 05414 58301 2020-01-01 Remove intrauterine device 05412 05411 12 12 58346 2020-01-01 Insert heyman uteri capsule 05415 05414 59100 2020-01-01 Remove uterus lesion 05415 05414 61880 2020-01-01 Revise/remove neuroelectrode J1 Q2 62287 2020-01-01 Percutaneous diskectomy 05431 05432 63265 2020-01-01 Excise intraspinl lesion crv 05114 00000 J1 C 63266 2020-01-01 Excise intrspinl lesion thrc 05114 00000 J1 C 63267 2020-01-01 Excise intrspinl lesion lmbr 05114 00000 J1 C 63268 2020-01-01 Excise intrspinl lesion scrl 05114 00000 J1 C 63662 2020-01-01 Remove spine eltrd plate J1 Q2 63688 2020-01-01 Revise/remove neuroreceiver J1 Q2 64585 2020-01-01 Revise/remove neuroelectrode J1 Q2 64595 2020-01-01 Revise/rmv pn/gastr stimul J1 Q2 64612 2020-01-01 Destroy nerve face muscle 12 64615 2020-01-01 Chemodenerv musc migraine 12 64766 2020-01-01 Incise hip/thigh nerve 05431 05432 64831 2020-01-01 Repair of digit nerve 05431 05432 64858 2020-01-01 Repair sciatic nerve 05431 05432 64861 2020-01-01 Repair of arm nerves 05431 05432 67900 2020-01-01 Repair brow defect 12 69610 2020-01-01 Repair of eardrum 05163 05164 74230 2020-01-01 X-ray xm swlng funcj c+ 05571 05522 74250 2020-01-01 X-ray xm sm int 1cntrst std 05571 05522 74251 2020-01-01 X-ray xm sm int 2cntrst std 05571 05523 Q1 S 74280 2020-01-01 X-ray xm colon 2cntrst std Q1 S 75731 2020-01-01 Artery x-rays adrenal gland J1 Q2 75746 2020-01-01 Artery x-rays lung J1 Q2 75803 2020-01-01 Lymph vessel x-ray arms/legs J1 Q2 75805 2020-01-01 Lymph vessel x-ray trunk J1 Q2 75810 2020-01-01 Vein x-ray spleen/liver J1 Q2 75822 2020-01-01 Vein x-ray arms/legs J1 Q2


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Edits Current

Edits Previous

75870 2020-01-01 Vein x-ray skull J1 Q2 75887 2020-01-01 Vein x-ray liver w/o hemodyn J1 Q2 75898 2020-01-01 Follow-up angiography J1 Q2 78803 2020-01-01 Rp loclzj tum spect 1 area 05593 05592 81508 2020-01-01 Ftl cgen abnor two proteins Q4 E1 9 81509 2020-01-01 Ftl cgen abnor 3 proteins Q4 E1 9 81510 2020-01-01 Ftl cgen abnor three anal Q4 E1 9 81511 2020-01-01 Ftl cgen abnor four anal Q4 E1 9 81512 2020-01-01 Ftl cgen abnor five anal Q4 E1 9 86077 2020-01-01 Phys blood bank serv xmatch 05731 05732 86485 2020-01-01 Skin test candida 05731 05732 86975 2020-01-01 Rbc serum pretx incubj drugs 05734 05732 87490 2020-01-01 Chylmd trach dna dir probe Q4 A 87491 2020-01-01 Chylmd trach dna amp probe Q4 A 87590 2020-01-01 N.gonorrhoeae dna dir prob Q4 A 87591 2020-01-01 N.gonorrhoeae dna amp prob Q4 A 87800 2020-01-01 Detect agnt mult dna direc Q4 A 88161 2020-01-01 Cytopath smear other source 05731 05732 88302 2020-01-01 Tissue exam by pathologist 05731 05732 88358 2020-01-01 Analysis tumor 05672 05673 89251 2020-01-01 Cultr oocyte/embryo <4 days 05672 05673 90296 2020-01-01 Diphtheria antitoxin 09315 00000 K N 90634 2020-01-01 Hepa vacc ped/adol 3 dose 00000 09086 N K 92228 2020-01-01 Remote retinal imaging mgmt 05732 05735 92283 2020-01-01 Color vision examination 05733 05734 92326 2020-01-01 Replacement of contact lens 05733 05734 93050 2020-01-01 Art pressure waveform analys 05731 05732 93503 2020-01-01 Insert/place heart catheter J1 T 94200 2020-01-01 Lung function test (mbc/mvv) 05733 05734 95017 2020-01-01 Perq & icut allg test venoms 05731 05732 95933 2020-01-01 Blink reflex test 05733 05734 95983 2020-01-01 Alys brn npgt prgrmg 15 min 05742 05741 96932 2020-01-01 Rcm celulr subcelulr img skn 00000 05731 N Q1 A9587 2020-01-01 Gallium ga-68 00000 09056 N G A9588 2020-01-01 Fluciclovine f-18 00000 09052 N G C9248 2020-01-01 Inj, clevidipine butyrate 00000 09087 N K 55 55 C9293 2020-01-01 Injection, glucarpidase 00000 09293 N K 55 55 C9754 2020-01-01 Perc av fistula, direct 05194 05193 55 55 C9755 2020-01-01 Rf magnetic-guide av fistula 05194 05193 55 55 G0117 2020-01-01 Glaucoma scrn hgh risk direc 05731 05732 G0237 2020-01-01 Therapeutic procd strg endur 05731 05732 G0238 2020-01-01 Oth resp proc, indiv 05731 05732 G0413 2020-01-01 Pelvic ring fracture uni/bil 05114 05113 G0473 2020-01-01 Group behave couns 2-10 05821 05822 J0380 2020-01-01 Inj metaraminol bitartrate E2 N 13 J0520 2020-01-01 Bethanechol chloride inject E2 N 13 J0570 2020-01-01 Buprenorphine implant 74.2mg K G J0585 2020-01-01 Injection,onabotulinumtoxina 12 J0586 2020-01-01 Abobotulinumtoxina 12 J0587 2020-01-01 Inj, rimabotulinumtoxinb 12 J0588 2020-01-01 Incobotulinumtoxin a 12 J0637 2020-01-01 Caspofungin acetate 00000 09019 N K J0641 2019-10-01 Inj levoleucovorin nos 0.5mg 01236 09323 K G J0725 2020-01-01 Chorionic gonadotropin/1000u 00000 09098 N K J0800 2020-01-01 Corticotropin injection 09316 00000 K N J1267 2020-01-01 Doripenem injection 09317 00000 K N J1364 2020-01-01 Erythro lactobionate /500 mg 00000 01669 N K J1556 2020-01-01 Inj, imm glob bivigam, 500mg 00000 09130 N K J1729 2020-01-01 Inj hydroxyprogst capoat nos 09318 00000 K N J2062 2020-01-01 Loxapine for inhalation 1 mg 00000 09497 N K J2320 2020-01-01 Nandrolone decanoate 50 mg 00000 01743 N K J2469 2020-01-01 Palonosetron hcl 00000 09210 N K J2793 2020-01-01 Rilonacept injection E2 N 13 J2941 2020-01-01 Somatropin injection 09319 00000 K N J2993 2020-01-01 Reteplase injection 00000 09005 N K J3300 2020-01-01 Triamcinolone a inj prs-free 00000 01253 N K J3350 2020-01-01 Urea injection E2 N 13 J7179 2020-01-01 Vonvendi inj 1 iu vwf:rco K G J7210 2020-01-01 Inj, afstyla, 1 i.u. K G J7211 2020-01-01 Inj, kovaltry, 1 i.u. 00000 09075 N K J7321 2020-01-01 Hyalgan supartz visco-3 dose 00000 00873 N K J7331 2020-01-01 Synojoynt, inj., 1 mg 09337 00000 K E2 13 J7332 2020-01-01 Inj., triluron, 1 mg 09338 00000 K E2 13 J7340 2020-01-01 Carbidopa levodopa ent 100ml 09320 00000 K N J8510 2020-01-01 Oral busulfan 09335 00000 K N J8562 2020-01-01 Oral fludarabine phosphate 00000 09089 N K


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Edits Current

Edits Previous

J8600 2020-01-01 Melphalan oral 2 mg 00000 09090 N K J9034 2020-01-01 Inj., bendeka 1 mg K G J9151 2020-01-01 Daunorubicin citrate inj 00000 09091 N K J9215 2020-01-01 Interferon alfa-n3 inj E2 N 13 J9270 2020-01-01 Plicamycin (mithramycin) inj 00000 09093 N K P9100 2020-01-01 Pathogen test for platelets 01494 01493 Q2009 2020-01-01 Fosphenytoin inj pe 09321 00000 K N Q5107 2020-01-01 Inj mvasi 10 mg G K Q5115 2019-10-01 Inj truxima 10 mg 09336 00000 K E2 13 Q5117 2020-01-01 Inj., kanjinti, 10 mg G K


Page 28 of 84


The following HCPCS code(s) were added to Mid-Quarter edit 67, 68, 69, 83, or 110. Mid Quarter Edits Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description Approval Date Edit R* Q5115 2019-10-01 Inj truxima 10 mg 2019-11-11 110 A


Page 29 of 84

Male Only HCPCS Additions

The following HCPCS code(s) were added to the list of male procedures. Male Only HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0582T 2020-01-01 Trurl abltj mal prst8 tiss N 81542 2020-01-01 Onc prostate mrna 22 cnt gen N


Page 30 of 84

Female Only HCPCS Additions

The following HCPCS code(s) were added to the list of female procedures. Female Only HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0567T 2020-01-01 Perm flp tube occls w/implt N 0568T 2020-01-01 Intro mix saline&air f/ssg N


Page 31 of 84

Female Only HCPCS Removals

The following HCPCS code(s) were removed from the list of female procedures. Female Only HCPCS Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 0357T 2020-01-01 Cryopreservation oocyte(s) D


Page 32 of 84

Conditional Bilateral Additions

The following HCPCS were added to the Conditional Bilateral list. Conditional Bilateral Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 35702 2020-01-01 Expl n/flwd surg uxtr art N 35703 2020-01-01 Expl n/flwd surg lxtr art N 64420 2020-01-01 Njx aa&/strd ntrcost nrv 1 A 64451 2020-01-01 Njx aa&/strd nrv nrvtg si jt N 64454 2020-01-01 Njx aa&/strd gnclr nrv brnch N 64624 2020-01-01 Dstrj nulyt agt gnclr nrv N 64625 2020-01-01 Rf abltj nrv nrvtg si jt N 66987 2020-01-01 Xcapsl ctrc rmvl cplx w/ecp N 66988 2020-01-01 Xcapsl ctrc rmvl w/ecp N


Page 33 of 84

Conditional Bilateral Removals

The following HCPCS were removed from the Conditional Bilateral list. Conditional Bilateral Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 19304 2020-01-01 Mast subq D 35721 2020-01-01 Exploration femoral artery D 35741 2020-01-01 Exploration popliteal artery D 35761 2020-01-01 Exploration of artery/vein D 64402 2020-01-01 N block inj facial D 64410 2020-01-01 N block inj phrenic D 64413 2020-01-01 N block inj cervical plexus D


Page 34 of 84

Independent Bilateral Removals

The following HCPCS were removed from the Independent Bilateral list. Independent Bilateral Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 92225 2020-01-01 Special eye exam initial D 92226 2020-01-01 Special eye exam subsequent D


Page 35 of 84

Inherent Bilateral Additions

The following HCPCS were added to the Inherent Bilateral list. Inherent Bilateral Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 92201 2020-01-01 Opscpy extnd rta draw uni/bi N 92202 2020-01-01 Opscpy extnd on/mac draw N 93985 2020-01-01 Dup-scan hemo compl bi std N


Page 36 of 84

Deductible Coinsurance Not Applicable Additions

The following HCPCS were added to the Deductible Coinsurance Not Applicable list. Deductible Coinsurance Not Applicable Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* G0404 2020-01-01 Ekg tracing for initial prev A


Page 37 of 84


The following HCPCS were removed from the Deductible Coinsurance Not Applicable list. Deductible Coinsurance Not Applicable Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 86780 2018-01-01 Treponema pallidum R


Page 38 of 84

Non-Standard CT Scan Equipment Procedure Additions

The following code(s) were added to the Non-Standard (NEMA) CT scan procedure list when reported with modifier CT. Non-Standard CT Scan Equipment Procedure Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 78429 2020-01-01 Myocrd img pet 1 std w/ct N 78430 2020-01-01 Myocrd img pet rst/strs w/ct N 78431 2020-01-01 Myocrd img pet rst&strs ct N 78433 2020-01-01 Myocrd img pet 2rtracer ct N 78830 2020-01-01 Rp loclzj tum spect w/ct 1 N 78832 2020-01-01 Rp loclzj tum spect w/ct 2 N


Page 39 of 84

Non-Standard CT Scan Equipment Procedure Removals

The following code(s) were removed from the Non-Standard (NEMA) CT scan procedure list when reported with modifier CT. Non-Standard CT Scan Equipment Procedure Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 74263 2016-01-01 Ct colonography screening R


Page 40 of 84

Radiology Procedure For Payment Adjustment Additions

The following HCPCS were added to the Radiology Payment adjustment procedure list when reported with modifier FX or FY. Radiology Procedure For Payment Adjustment Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 74221 2020-01-01 X-ray xm esophagus 2cntrst N 74248 2020-01-01 X-ray sm int f-thru std N 78429 2020-01-01 Myocrd img pet 1 std w/ct N 78430 2020-01-01 Myocrd img pet rst/strs w/ct N 78431 2020-01-01 Myocrd img pet rst&strs ct N 78432 2020-01-01 Myocrd img pet 2rtracer N 78433 2020-01-01 Myocrd img pet 2rtracer ct N 78434 2020-01-01 Aqmbf pet rest & rx stress N 78830 2020-01-01 Rp loclzj tum spect w/ct 1 N 78831 2020-01-01 Rp loclzj tum spect 2 areas N 78832 2020-01-01 Rp loclzj tum spect w/ct 2 N 78835 2020-01-01 Rp quan meas single area N


Page 41 of 84

Radiology Procedure For Payment Adjustment Removals

The following HCPCS were added to the Radiology Payment adjustment procedure list when reported with modifier FX or FY. Radiology Procedure For Payment Adjustment Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 74241 2020-01-01 X-ray upper gi delay w/kub D 74245 2020-01-01 X-ray upper gi&small intest D 74247 2020-01-01 Contrst x-ray uppr gi tract D 74249 2020-01-01 Contrst x-ray uppr gi tract D 74260 2020-01-01 X-ray exam of small bowel D 76930 2020-01-01 Echo guide cardiocentesis D 78205 2020-01-01 Liver imaging (3d) D 78206 2020-01-01 Liver image (3d) with flow D 78320 2020-01-01 Bone imaging (3d) D 78607 2020-01-01 Brain imaging (3d) D 78647 2020-01-01 Cerebrospinal fluid scan D 78710 2020-01-01 Kidney imaging (3d) D 78805 2020-01-01 Abscess imaging ltd area D 78806 2020-01-01 Abscess imaging whole body D 78807 2020-01-01 Nuclear localization/abscess D


Page 42 of 84


The following HCPCS were assigned an SI = J1 Comprehensive APC, Comprehensive APC HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0267T 2020-01-01 Implt/rpl crtd sns dev lead A 0270T 2020-01-01 Rev/remvl crtd sns dev lead A 0271T 2020-01-01 Rev/remvl crtd sns dev gen A 0313T 2020-01-01 Laps rmvl nstim array vagus A 0314T 2020-01-01 Laps rmvl vgl arry&pls gen A 0315T 2020-01-01 Rmvl vagus nerve pls gen A 0428T 2020-01-01 Rmvl nstim apnea pls gen A 0429T 2020-01-01 Rmvl nstim apnea sen ld A 0430T 2020-01-01 Rmvl nstim apnea stimj ld A 0432T 2020-01-01 Repos nstim apnea stimj ld A 0433T 2020-01-01 Repos nstim apnea sensing ld A 0467T 2020-01-01 Revj/rplmnt ch respir eltrd A 0468T 2020-01-01 Rmvl ch wal respir eltrd/ra A 21601 2020-01-01 Exc chest wall tumor w/ribs N 22633 2020-01-01 Lumbar spine fusion combined A 27130 2020-01-01 Total hip arthroplasty A 32551 2020-01-01 Insertion of chest tube A 32557 2020-01-01 Insert cath pleura w/ image A 33016 2020-01-01 Pericardiocentesis w/imaging N 36555 2020-01-01 Insert non-tunnel cv cath A 36556 2020-01-01 Insert non-tunnel cv cath A 36569 2020-01-01 Insj picc 5 yr+ w/o imaging A 36573 2020-01-01 Insj picc rs&i 5 yr+ A 36576 2020-01-01 Repair tunneled cv cath A 36580 2020-01-01 Replace cvad cath A 36584 2020-01-01 Compl rplcmt picc rs&i A 36596 2020-01-01 Mech remov tunneled cv cath A 36597 2020-01-01 Reposition venous catheter A 36901 2020-01-01 Intro cath dialysis circuit A 37213 2020-01-01 Thromblytic art/ven therapy A 37214 2020-01-01 Cessj therapy cath removal A 37565 2020-01-01 Ligation of neck vein A 37615 2020-01-01 Ligation of neck artery A 37761 2020-01-01 Ligate leg veins open A 37780 2020-01-01 Revision of leg vein A 45349 2020-01-01 Sigmoidoscopy w/resection A 45390 2020-01-01 Colonoscopy w/resection A 46948 2020-01-01 Int hrhc tranal dartlzj 2+ N 61880 2020-01-01 Revise/remove neuroelectrode A 63265 2020-01-01 Excise intraspinl lesion crv A 63266 2020-01-01 Excise intrspinl lesion thrc A 63267 2020-01-01 Excise intrspinl lesion lmbr A 63268 2020-01-01 Excise intrspinl lesion scrl A 63662 2020-01-01 Remove spine eltrd plate A 63688 2020-01-01 Revise/remove neuroreceiver A 64585 2020-01-01 Revise/remove neuroelectrode A 64595 2020-01-01 Revise/rmv pn/gastr stimul A 64624 2020-01-01 Dstrj nulyt agt gnclr nrv N 64625 2020-01-01 Rf abltj nrv nrvtg si jt N 66987 2020-01-01 Xcapsl ctrc rmvl cplx w/ecp N 66988 2020-01-01 Xcapsl ctrc rmvl w/ecp N 75731 2020-01-01 Artery x-rays adrenal gland A 75746 2020-01-01 Artery x-rays lung A 75803 2020-01-01 Lymph vessel x-ray arms/legs A 75805 2020-01-01 Lymph vessel x-ray trunk A 75810 2020-01-01 Vein x-ray spleen/liver A 75822 2020-01-01 Vein x-ray arms/legs A 75870 2020-01-01 Vein x-ray skull A 75887 2020-01-01 Vein x-ray liver w/o hemodyn A 75898 2020-01-01 Follow-up angiography A 93503 2020-01-01 Insert/place heart catheter A C9757 2020-01-01 Spine/lumbar disk surgery N


Page 43 of 84

Comprehensive APC HCPCS Removals

The following HCPCS were removed from being assigned an SI = J1 Comprehensive APC. Comprehensive APC HCPCS Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 0249T 2020-01-01 Ligation hemorrhoid w/us D 0377T 2020-01-01 Anoscpy inj agent for incont D 19260 2020-01-01 Removal of chest wall lesion D 19304 2020-01-01 Mast subq D 35761 2020-01-01 Exploration of artery/vein D


Page 44 of 84

Complexity Adjusted Code Pair Additions

The following Comprehensive APC code pairs were added for complexity adjustment. Complexity Adjusted Code Pair Additions Reason Key: A=Added To List, N=New Code Code 1 Code 2 Eff Date R* 0191T 65820 2020-01-01 A 0449T 66984 2020-01-01 A 11406 11424 2020-01-01 A 11644 11623 2020-01-01 A 19370 19370 2020-01-01 A 20220 32405 2020-01-01 A 21012 21012 2020-01-01 A 22514 22510 2020-01-01 A 23071 21931 2020-01-01 A 23630 23430 2020-01-01 A 25447 25000 2020-01-01 A 25447 25111 2020-01-01 A 25447 26055 2020-01-01 A 25447 29846 2020-01-01 A 25447 29848 2020-01-01 A 25608 25545 2020-01-01 A 25608 25605 2020-01-01 A 25609 20690 2020-01-01 A 26455 26455 2020-01-01 A 26615 11012 2020-01-01 A 27652 28119 2020-01-01 A 27823 27829 2020-01-01 A 28108 28108 2020-01-01 A 28118 28200 2020-01-01 A 28122 11044 2020-01-01 A 28289 28285 2020-01-01 A 28291 28291 2020-01-01 A 28296 28104 2020-01-01 A 28296 28270 2020-01-01 A 28297 28285 2020-01-01 A 28297 28313 2020-01-01 A 28300 27698 2020-01-01 A 28300 28306 2020-01-01 A 28308 28288 2020-01-01 A 28645 28285 2020-01-01 A 28740 27687 2020-01-01 A 28740 27691 2020-01-01 A 28740 28292 2020-01-01 A 28750 28112 2020-01-01 A 29806 29828 2020-01-01 A 29819 29822 2020-01-01 A 29819 29823 2020-01-01 A 29823 23120 2020-01-01 A 29823 29824 2020-01-01 A 29837 29834 2020-01-01 A 29848 26145 2020-01-01 A 29882 29879 2020-01-01 A 29916 29914 2020-01-01 A 30630 30520 2020-01-01 A 31630 31628 2020-01-01 A 31630 31652 2020-01-01 A 31640 31652 2020-01-01 A 31641 31630 2020-01-01 A 31653 31640 2020-01-01 A 32405 20206 2020-01-01 A 32405 47000 2020-01-01 A 32550 32550 2020-01-01 A 32551 32551 2020-01-01 A 32556 32405 2020-01-01 A 32557 32405 2020-01-01 A 32557 32557 2020-01-01 A 33207 93650 2020-01-01 A 33285 93619 2020-01-01 A 36475 37785 2020-01-01 A 36556 32551 2020-01-01 A 36556 33016 2020-01-01 N 36556 36556 2020-01-01 A 36556 36569 2020-01-01 A 36556 36901 2020-01-01 A 36558 36556 2020-01-01 A 36558 38222 2020-01-01 A


Page 45 of 84

Complexity Adjusted Code Pair Additions Reason Key: A=Added To List, N=New Code Code 1 Code 2 Eff Date R* 36561 32557 2020-01-01 A 36561 36569 2020-01-01 A 36569 11044 2020-01-01 A 36569 36569 2020-01-01 A 36569 36584 2020-01-01 A 36569 43246 2020-01-01 A 36821 10140 2020-01-01 A 36821 36556 2020-01-01 A 36821 75822 2020-01-01 A 36904 36556 2020-01-01 A 37184 37221 2020-01-01 A 37184 37228 2020-01-01 A 37193 36561 2020-01-01 A 37221 37236 2020-01-01 A 37221 37246 2020-01-01 A 37225 93458 2020-01-01 A 37236 37224 2020-01-01 A 37241 37241 2020-01-01 A 37246 37220 2020-01-01 A 38220 38221 2020-01-01 A 38500 11623 2020-01-01 A 38500 11644 2020-01-01 A 38500 56620 2020-01-01 A 38510 11606 2020-01-01 A 38510 31535 2020-01-01 A 38525 19371 2020-01-01 A 38525 24073 2020-01-01 A 38570 58661 2020-01-01 A 43262 43242 2020-01-01 A 43264 43278 2020-01-01 A 43277 43262 2020-01-01 A 44366 44369 2020-01-01 A 44378 44377 2020-01-01 A 49423 20500 2020-01-01 A 49507 55040 2020-01-01 A 49520 54520 2020-01-01 A 49560 11406 2020-01-01 A 49560 49561 2020-01-01 A 49651 49329 2020-01-01 A 49652 49650 2020-01-01 A 49653 49651 2020-01-01 A 50200 38505 2020-01-01 A 50200 47000 2020-01-01 A 50382 50382 2020-01-01 A 50434 50387 2020-01-01 A 50434 50434 2020-01-01 A 50434 50435 2020-01-01 A 50693 50432 2020-01-01 A 50949 58661 2020-01-01 A 51040 52281 2020-01-01 A 51040 52310 2020-01-01 A 52005 51102 2020-01-01 A 52204 51102 2020-01-01 A 52204 52005 2020-01-01 A 52214 52260 2020-01-01 A 52214 C9738 2020-01-01 A 52224 52005 2020-01-01 A 52224 52214 2020-01-01 A 52224 55700 2020-01-01 A 52235 50432 2020-01-01 A 52276 54161 2020-01-01 A 52318 50590 2020-01-01 A 52332 50432 2020-01-01 A 52649 52356 2020-01-01 A 54001 52281 2020-01-01 A 54161 52005 2020-01-01 A 54161 55700 2020-01-01 A 55700 52310 2020-01-01 A 56620 58558 2020-01-01 A 58558 57520 2020-01-01 A 61626 75898 2020-01-01 A 63663 63688 2020-01-01 A 64708 64708 2020-01-01 A 64718 64719 2020-01-01 A 65730 66982 2020-01-01 A 65730 66984 2020-01-01 A


Page 46 of 84

Complexity Adjusted Code Pair Additions Reason Key: A=Added To List, N=New Code Code 1 Code 2 Eff Date R* 65756 66986 2020-01-01 A 66180 67036 2020-01-01 A 66180 67040 2020-01-01 A 66982 66982 2020-01-01 A 66986 67121 2020-01-01 A 67108 66984 2020-01-01 A 67113 66984 2020-01-01 A 67314 67311 2020-01-01 A 67911 67911 2020-01-01 A 69801 69801 2020-01-01 A 75898 75898 2020-01-01 A 92920 93456 2020-01-01 A 92924 92920 2020-01-01 A 92937 92928 2020-01-01 A 92937 92937 2020-01-01 A 92943 C9600 2020-01-01 A 93451 75822 2020-01-01 A 93454 93571 2020-01-01 A 93455 93454 2020-01-01 A 93458 36556 2020-01-01 A 93458 36569 2020-01-01 A 93458 93455 2020-01-01 A 93460 93458 2020-01-01 A 93461 92978 2020-01-01 A 93505 93505 2020-01-01 A


Page 47 of 84

Complexity Adjusted Code Pair Removals

The following Comprehensive APC code pairs were removed for complexity adjustment. Complexity Adjusted Code Pair Removals Reason Key: R=Removed From List, D=Code Terminated Code 1 Code 2 Eff Date R* 11404 11422 2020-01-01 R 11406 11422 2020-01-01 R 11406 11423 2020-01-01 R 11624 11643 2020-01-01 R 11644 11624 2020-01-01 R 19300 19300 2020-01-01 R 19301 19125 2020-01-01 R 19301 19499 2020-01-01 R 19304 19304 2020-01-01 D 21031 21031 2020-01-01 R 22513 20225 2020-01-01 R 22513 38221 2020-01-01 R 22514 20225 2020-01-01 R 22514 63030 2020-01-01 R 22612 38220 2020-01-01 R 25071 25071 2020-01-01 R 26535 26535 2020-01-01 R 26536 26536 2020-01-01 R 27650 27687 2020-01-01 R 27650 28119 2020-01-01 R 27650 28120 2020-01-01 R 28010 28010 2020-01-01 R 28118 27650 2020-01-01 R 28232 28232 2020-01-01 R 28292 28110 2020-01-01 R 28297 27687 2020-01-01 R 28297 28110 2020-01-01 R 28299 28110 2020-01-01 R 28299 28270 2020-01-01 R 28299 28285 2020-01-01 R 28299 28288 2020-01-01 R 28299 28308 2020-01-01 R 28299 28313 2020-01-01 R 28740 20900 2020-01-01 R 28740 28296 2020-01-01 R 28750 20902 2020-01-01 R 28750 27687 2020-01-01 R 28750 27691 2020-01-01 R 28750 28755 2020-01-01 R 28750 38220 2020-01-01 R 28805 27687 2020-01-01 R 29823 29819 2020-01-01 R 29823 29821 2020-01-01 R 29823 29825 2020-01-01 R 29824 29825 2020-01-01 R 29825 29822 2020-01-01 R 29827 23412 2020-01-01 R 29827 24340 2020-01-01 R 29855 27509 2020-01-01 R 29891 29898 2020-01-01 R 30117 31238 2020-01-01 R 30520 30130 2020-01-01 R 30520 30140 2020-01-01 R 30520 30630 2020-01-01 R 30520 30802 2020-01-01 R 30520 31238 2020-01-01 R 30520 31240 2020-01-01 R 31020 31020 2020-01-01 R 31600 43246 2020-01-01 R 31624 31622 2020-01-01 R 31624 31624 2020-01-01 R 31630 31641 2020-01-01 R 31641 43191 2020-01-01 R 31652 31640 2020-01-01 R 32609 32550 2020-01-01 R 33285 93460 2020-01-01 R 36558 36558 2020-01-01 R 36558 38221 2020-01-01 R 36821 36821 2020-01-01 R 36902 36830 2020-01-01 R 36904 37248 2020-01-01 R


Page 48 of 84

Complexity Adjusted Code Pair Removals Reason Key: R=Removed From List, D=Code Terminated Code 1 Code 2 Eff Date R* 36905 36905 2020-01-01 R 37184 37224 2020-01-01 R 37220 37222 2020-01-01 R 37221 37184 2020-01-01 R 37224 36902 2020-01-01 R 37224 37211 2020-01-01 R 37228 37184 2020-01-01 R 37236 37221 2020-01-01 R 37236 37236 2020-01-01 R 37238 37248 2020-01-01 R 37243 50593 2020-01-01 R 37722 36475 2020-01-01 R 37722 37722 2020-01-01 R 38221 20206 2020-01-01 R 38221 32405 2020-01-01 R 38221 49180 2020-01-01 R 38500 11643 2020-01-01 R 38500 36561 2020-01-01 R 38505 38505 2020-01-01 R 38510 69110 2020-01-01 R 38525 11406 2020-01-01 R 38525 19304 2020-01-01 D 38525 24071 2020-01-01 R 41820 41820 2020-01-01 R 41874 41874 2020-01-01 R 43238 43249 2020-01-01 R 43242 43245 2020-01-01 R 43254 43237 2020-01-01 R 43255 43245 2020-01-01 R 44970 58662 2020-01-01 R 47534 47536 2020-01-01 R 49406 49180 2020-01-01 R 49423 49406 2020-01-01 R 49446 43246 2020-01-01 R 49505 49585 2020-01-01 R 49505 49587 2020-01-01 R 49560 49587 2020-01-01 R 49652 49505 2020-01-01 R 49652 49659 2020-01-01 R 50200 49180 2020-01-01 R 50200 50200 2020-01-01 R 50433 50432 2020-01-01 R 50433 50433 2020-01-01 R 50433 50435 2020-01-01 R 50693 50435 2020-01-01 R 50693 50693 2020-01-01 R 51102 52310 2020-01-01 R 52204 54161 2020-01-01 R 52214 52224 2020-01-01 R 52276 51102 2020-01-01 R 52287 52276 2020-01-01 R 52351 52204 2020-01-01 R 52351 52214 2020-01-01 R 52351 52224 2020-01-01 R 52356 50432 2020-01-01 R 52356 52648 2020-01-01 R 54520 54520 2020-01-01 R 55500 54840 2020-01-01 R 55500 55500 2020-01-01 R 55700 52281 2020-01-01 R 57265 57267 2020-01-01 R 57410 92018 2020-01-01 R 58263 57260 2020-01-01 R 58263 57265 2020-01-01 R 58270 57265 2020-01-01 R 63075 63076 2020-01-01 R 67900 67917 2020-01-01 R 67950 67900 2020-01-01 R 92928 92928 2020-01-01 R 92943 92928 2020-01-01 R 92986 93453 2020-01-01 R 93458 93451 2020-01-01 R 93459 93459 2020-01-01 R 93460 93454 2020-01-01 R 93460 93460 2020-01-01 R 93620 93613 2020-01-01 R


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Complexity Adjusted Code Pair Removals Reason Key: R=Removed From List, D=Code Terminated Code 1 Code 2 Eff Date R* 93620 93650 2020-01-01 R C9600 33210 2020-01-01 R C9600 92937 2020-01-01 R C9600 92986 2020-01-01 R


Page 50 of 84

Complexity Adjusted Code Pair Modifications

The following Comprehensive APC code pairs were modified for complexity adjusted APC assignment. Complexity Adjusted Code Pair Modifications Code 1 Code 2 Eff Date Current CAPC Previous CAPC 26530 26530 2020-01-01 5115 5114 52351 50432 2020-01-01 5375 5374 57155 57155 2020-01-01 5416 5415


Page 51 of 84


The following HCPCS were added to the CAPC Exclusion list. CAPC Exclusion Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 78431 2020-01-01 Myocrd img pet rst&strs ct N 78432 2020-01-01 Myocrd img pet 2rtracer N 78433 2020-01-01 Myocrd img pet 2rtracer ct N C9758 2020-01-01 Interatrial shunt ide N G2082 2020-01-01 Visit esketamine 56m or less N G2083 2020-01-01 Visit esketamine, > 56m N


Page 52 of 84

Device Additions

The following HCPCS were added to the Device list. Device Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* A4648 2019-01-01 Implantable tissue marker A C1734 2020-01-01 Orth/devic/drug bn/bn,tis/bn N C1824 2020-01-01 Generator, ccm, implant N C1839 2020-01-01 Iris prosthesis N C1982 2020-01-01 Cath, pressure,valve-occlu N C2596 2020-01-01 Probe, robotic, water-jet N


Page 53 of 84

Device Removals

The following HCPCS were removed from the Device list. Device Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* C1842 2017-01-01 Retinal prosth, add-on R L8680 2015-01-01 Implt neurostim elctr each R L8685 2015-01-01 Implt nrostm pls gen sng rec R L8686 2015-01-01 Implt nrostm pls gen sng non R L8687 2015-01-01 Implt nrostm pls gen dua rec R L8688 2015-01-01 Implt nrostm pls gen dua non R


Page 54 of 84

Device Procedure Additions

The following HCPCS were added to the Device Procedure list. Device Procedure Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0200T 2020-01-01 Perq sacral augmt unilat inj A 0313T 2020-01-01 Laps rmvl nstim array vagus A 0431T 2020-01-01 Rmvl/rplc nstim apnea pls gn A 0442T 2020-01-01 Abltj perc plex/trncl nrv A 0505T 2020-01-01 Ev fempop artl revsc A 0587T 2020-01-01 Perq impltj/rplcmt isdns ptn N 20983 2020-01-01 Ablate bone tumor(s) perq A 21208 2020-01-01 Augmentation of facial bones A 21245 2020-01-01 Reconstruction of jaw A 21346 2020-01-01 Opn tx nasomax fx w/fixj A 21742 2020-01-01 Repair stern/nuss w/o scope A 21812 2020-01-01 Treatment of rib fracture A 22612 2020-01-01 Lumbar spine fusion A 22633 2020-01-01 Lumbar spine fusion combined A 23406 2020-01-01 Incise tendon(s) & muscle(s) A 23630 2020-01-01 Treat humerus fracture A 24365 2020-01-01 Reconstruct head of radius A 24575 2020-01-01 Treat humerus fracture A 25136 2020-01-01 Remove & graft wrist lesion A 25350 2020-01-01 Revision of radius A 25545 2020-01-01 Treat fracture of ulna A 25670 2020-01-01 Treat wrist dislocation A 25800 2020-01-01 Fusion of wrist joint A 26390 2020-01-01 Revise hand/finger tendon A 27130 2020-01-01 Total hip arthroplasty A 27400 2020-01-01 Revise thigh muscles/tendons A 27477 2020-01-01 Surgery to stop leg growth A 27826 2020-01-01 Treat lower leg fracture A 28130 2020-01-01 Removal of ankle bone A 28302 2020-01-01 Incision of ankle bone A 28446 2020-01-01 Osteochondral talus autogrft A 31647 2020-01-01 Bronchial valve init insert A 33220 2020-01-01 Repair lead pace-defib dual A 33226 2020-01-01 Reposition l ventric lead A 33233 2020-01-01 Removal of pm generator A 33235 2020-01-01 Removal pacemaker electrode A 36583 2020-01-01 Replace tunneled cv cath A 36904 2020-01-01 Thrmbc/nfs dialysis circuit A 37244 2020-01-01 Vasc embolize/occlude bleed A 43773 2020-01-01 Lap replace gastr adj device A 45327 2020-01-01 Proctosigmoidoscopy w/stent A 59072 2020-01-01 Umbilical cord occlud w/us A 64448 2020-01-01 Njx aa&/strd fem nerve nfs A 64912 2020-01-01 Nrv rpr w/nrv algrft 1st A 65779 2020-01-01 Cover eye w/membrane suture A 66987 2020-01-01 Xcapsl ctrc rmvl cplx w/ecp N 66988 2020-01-01 Xcapsl ctrc rmvl w/ecp N 92920 2020-01-01 Prq cardiac angioplast 1 art A 92924 2020-01-01 Prq card angio/athrect 1 art A 93024 2020-01-01 Cardiac drug stress test A 93612 2020-01-01 Intraventricular pacing A 93619 2020-01-01 Electrophysiology evaluation A 95928 2020-01-01 C motor evoked uppr limbs A 95961 2020-01-01 Electrode stimulation brain A C9757 2020-01-01 Spine/lumbar disk surgery N


Page 55 of 84

Device Procedure Removals

The following HCPCS were removed from the Device Procedure list. Device Procedure Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 0467T 2020-01-01 Revj/rplmnt ch respir eltrd R 19105 2020-01-01 Cryosurg ablate fa each R 19342 2020-01-01 Delayed breast prosthesis R 21125 2020-01-01 Augmentation lower jaw bone R 21454 2020-01-01 Treat lower jaw fracture R 23532 2020-01-01 Treat clavicle dislocation R 24115 2020-01-01 Remove/graft bone lesion R 24344 2020-01-01 Reconstruct elbow lat ligmnt R 24360 2020-01-01 Reconstruct elbow joint R 25126 2020-01-01 Remove/graft forearm lesion R 25525 2020-01-01 Treat fracture of radius R 26843 2020-01-01 Fusion of hand joint R 27357 2020-01-01 Remove femur lesion/graft R 27396 2020-01-01 Transplant of thigh tendon R 27407 2020-01-01 Repair of knee ligament R 27416 2020-01-01 Osteochondral knee autograft R 27652 2020-01-01 Repair/graft achilles tendon R 27696 2020-01-01 Repair of ankle ligaments R 27832 2020-01-01 Treat lower leg dislocation R 28102 2020-01-01 Remove/graft foot lesion R 28103 2020-01-01 Remove/graft foot lesion R 28309 2020-01-01 Incision of metatarsals R 29905 2020-01-01 Subtalar arthro w/exc R 36260 2020-01-01 Insertion of infusion pump R 36580 2020-01-01 Replace cvad cath R 36581 2020-01-01 Replace tunneled cv cath R 36595 2020-01-01 Mech remov tunneled cv cath R 37606 2020-01-01 Ligation of neck artery R 47539 2020-01-01 Perq plmt bile duct stent R 63075 2020-01-01 Neck spine disk surgery R 63744 2020-01-01 Revision of spinal shunt R 64595 2020-01-01 Revise/rmv pn/gastr stimul R 64885 2020-01-01 Nerve graft head/neck </4 cm R 64886 2020-01-01 Nerve graft head/neck >4 cm R 75733 2020-01-01 Artery x-rays adrenals R 75746 2020-01-01 Artery x-rays lung R 75870 2020-01-01 Vein x-ray skull R 93610 2020-01-01 Intra-atrial pacing R C9728 2020-01-01 Place device/marker, non pro R


Page 56 of 84

Device Procedure Edit 92 Bypass Additions

The following HCPCS were added to the Device Procedure Bypass Edit 92 list. Device Procedure Edit 92 Bypass Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0200T 2020-01-01 Perq sacral augmt unilat inj A 23630 2020-01-01 Treat humerus fracture A 24575 2020-01-01 Treat humerus fracture A 25545 2020-01-01 Treat fracture of ulna A 27826 2020-01-01 Treat lower leg fracture A 33220 2020-01-01 Repair lead pace-defib dual A 33226 2020-01-01 Reposition l ventric lead A 33233 2020-01-01 Removal of pm generator A 33235 2020-01-01 Removal pacemaker electrode A 36904 2020-01-01 Thrmbc/nfs dialysis circuit A 37244 2020-01-01 Vasc embolize/occlude bleed A 43773 2020-01-01 Lap replace gastr adj device A 45327 2020-01-01 Proctosigmoidoscopy w/stent A 59072 2020-01-01 Umbilical cord occlud w/us A 64448 2020-01-01 Njx aa&/strd fem nerve nfs A 64912 2020-01-01 Nrv rpr w/nrv algrft 1st A 65779 2020-01-01 Cover eye w/membrane suture A


Page 57 of 84

Daily Mental Health Additions

The following HCPCS were added to the Daily Mental Health list. Daily Mental Health Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 96156 2020-01-01 Hlth bhv assmt/reassessment N 96158 2020-01-01 Hlth bhv ivntj indiv 1st 30 N 96164 2020-01-01 Hlth bhv ivntj grp 1st 30 N 96167 2020-01-01 Hlth bhv ivntj fam 1st 30 N


Page 58 of 84

Daily Mental Health Removals

The following HCPCS were removed from the Daily Mental Health list. Daily Mental Health Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 96150 2020-01-01 Assess hlth/behave init D 96151 2020-01-01 Assess hlth/behave subseq D 96152 2020-01-01 Intervene hlth/behave indiv D 96153 2020-01-01 Intervene hlth/behave group D 96154 2020-01-01 Interv hlth/behav fam w/pt D


Page 59 of 84

Mental Health Not Billable Under PHP Edit 80 Additions

The following HCPCS were added to the mental health list not billable under the PHP program. Mental Health Not Billable Under PHP Edit 80 Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 96156 2020-01-01 Hlth bhv assmt/reassessment N 96158 2020-01-01 Hlth bhv ivntj indiv 1st 30 N 96164 2020-01-01 Hlth bhv ivntj grp 1st 30 N 96167 2020-01-01 Hlth bhv ivntj fam 1st 30 N


Page 60 of 84

Mental Health Not Billable Under PHP Edit 80 Removals

The following HCPCS were removed from the mental health list not billable under the PHP program. Mental Health Not Billable Under PHP Edit 80 Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 96150 2020-01-01 Assess hlth/behave init D 96151 2020-01-01 Assess hlth/behave subseq D 96152 2020-01-01 Intervene hlth/behave indiv D 96153 2020-01-01 Intervene hlth/behave group D 96154 2020-01-01 Interv hlth/behav fam w/pt D


Page 61 of 84

FQHC Non-Covered Additions

The following HCPCS were added to the FQHC Non-Covered list. FQHC Non-Covered Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0139U 2020-01-01 Neuro austm meas 6 c metablt N 0140U 2020-01-01 Nfct ds fungi dna 15 trgt N 0141U 2020-01-01 Nfct ds bact&fng gram pos N 0142U 2020-01-01 Nfct ds bact&fng gram neg N 0143U 2020-01-01 Drug assay 120+ rx/metablt N 0144U 2020-01-01 Drug assay 160+ rx/metablt N 0145U 2020-01-01 Drug assay 65+ rx/metablt N 0146U 2020-01-01 Drug assay 80+ rx/metablt N 0147U 2020-01-01 Drug assay 85+ rx/metablt N 0148U 2020-01-01 Drug assay 100+ rx/metablt N 0149U 2020-01-01 Drug assay 60+ rx/metablt N 0150U 2020-01-01 Drug assay 120+ rx/metablt N 0151U 2020-01-01 Nfct bct/vir resp nfctj 33 N 0152U 2020-01-01 Nfct bct fng prst dna >1000 N 0153U 2020-01-01 Onc breast mrna 101 genes N 0154U 2020-01-01 Fgfr3 gene analysis N 0155U 2020-01-01 Pik3ca gene analysis N 0156U 2020-01-01 Copy number sequence alys N 0157U 2020-01-01 Apc mrna seq alys N 0158U 2020-01-01 Mlh1 mrna seq alys N 0159U 2020-01-01 Msh2 mrna seq alys N 0160U 2020-01-01 Msh6 mrna seq alys N 0161U 2020-01-01 Pms2 mrna seq alys N 0162U 2020-01-01 Hered colon ca trgt mrna pnl N 80145 2020-01-01 Drug assay adalimumab N 80187 2020-01-01 Drug assay posaconazole N 80230 2020-01-01 Drug assay infliximab N 80235 2020-01-01 Drug assay lacosamide N 80280 2020-01-01 Drug assay vedolizumab N 80285 2020-01-01 Drug assay voriconazole N 81277 2020-01-01 Cytogenomic neo microra alys N 81307 2020-01-01 Palb2 gene full gene seq N 81308 2020-01-01 Palb2 gene known famil vrnt N 81309 2020-01-01 Pik3ca gene trgt seq alys N 81522 2020-01-01 Onc breast mrna 12 genes N 81542 2020-01-01 Onc prostate mrna 22 cnt gen N 81552 2020-01-01 Onc uveal mlnma mrna 15 gene N 87563 2020-01-01 M. genitalium amp probe N


Page 62 of 84

FQHC Non-Covered Removals

The following HCPCS were removed from the FQHC Non-Covered list. FQHC Non-Covered Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 0009M 2020-01-01 Fetal aneuploidy trisom risk D 0081U 2020-01-01 Onc uveal mlnma mrna 15 gene D 0085U 2020-01-01 Cdtb&vinculin igg antb ia D 96153 2020-01-01 Intervene hlth/behave group D 96154 2020-01-01 Interv hlth/behav fam w/pt D 96155 2020-01-01 Interv hlth/behav fam no pt D 99444 2020-01-01 Online e/m by phys/qhp D


Page 63 of 84

RHC Modifier HCPCS Conflict Additions

The following HCPCS modifier pairing for RHC conflict were added. RHC Modifier HCPCS Conflict Additions Reason Key: A=Added To List, N=New Code HCPCS Modifier Eff Date R* 11750 CG 2020-01-01 A 11765 CG 2020-01-01 A 20600 CG 2020-01-01 A 69210 CG 2020-01-01 A


Page 64 of 84

Pass-Through Device HCPCS Additions

The following HCPCS were added to the Pass-Through Device HCPCS list. Pass-Through Device HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* C1734 2020-01-01 Orth/devic/drug bn/bn,tis/bn N C1824 2020-01-01 Generator, ccm, implant N C1839 2020-01-01 Iris prosthesis N C1982 2020-01-01 Cath, pressure,valve-occlu N C2596 2020-01-01 Probe, robotic, water-jet N


Page 65 of 84


The following HCPCS were added to the Pass-Through Radiopharm HCPCS list. Pass-Through Radiopharm HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* A9590 2020-01-01 Iodine i-131 iobenguane 1mci N


Page 66 of 84

Pass-Through Radiopharm HCPCS Removals

The following HCPCS were removed from the Pass-Through Radiopharm HCPCS list. Pass-Through Radiopharm HCPCS Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* A9587 2020-01-01 Gallium ga-68 R A9588 2020-01-01 Fluciclovine f-18 R C9407 2020-01-01 Iodine i-131 iobenguane, dx D C9408 2020-01-01 Iodine i-131 iobenguane, tx D


Page 67 of 84

Skin Substitute High Cost Product Additions

The following HCPCS were added to the Skin Substitute High Cost Product list. Skin Substitute High Cost Product Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* Q4179 2020-01-01 Flowerderm, per sq cm A Q4208 2020-01-01 Novafix per sq cm A


Page 68 of 84

Skin Substitute Low Cost Product Removals

The following HCPCS were removed from the Skin Substitute Low Cost Product list. Skin Substitute Low Cost Product Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* Q4168 2020-01-01 Amnioband, 1 mg R Q4179 2020-01-01 Flowerderm, per sq cm R Q4206 2020-01-01 Fluid flow or fluid gf 1 cc R Q4208 2020-01-01 Novafix per sq cm R Q4212 2020-01-01 Allogen, per cc R Q4213 2020-01-01 Ascent, 0.5 mg R Q4215 2020-01-01 Axolotl ambient, cryo 0.1 mg R


Page 69 of 84

Pass-Through Device Credit Procedure Additions

The following HCPCS were added to the list of pass-through device code pairs subject to a payment credit. Pass-Through Device Credit Procedure Additions Code1 Code2 Eff Date Amount C1734 27870 2020-01-01 $5,805.17 C1734 28705 2020-01-01 $8,354.15 C1734 28715 2020-01-01 $6,096.73 C1734 28725 2020-01-01 $5,291.06 C1824 0408T 2020-01-01 $13,019.03 C1839 66999 2020-01-01 $149.82 C1982 37243 2020-01-01 $2,124.38 C2596 0421T 2020-01-01 $0.00


Page 70 of 84

Pass-Through Device Credit Procedure Modifications

The following HCPCS on the list of pass-through device code pairs subject to payment offset had a modified credit amount Pass-Through Device Credit Procedure Modifications Code1 Code2 Eff Date Current Amount Previous Amount C1823 0424T 2020-01-01 $22,092.39 $20,626.59


Page 71 of 84

Terminated Device Procedure Additions

The following HCPCS were added to the terminated device procedure list, that may be subject to device credit when the procedure is terminated early. Terminated Device Procedure Additions HCPCS Eff Date Amount 0200T 2020-01-01 $2,201.96 0313T 2020-01-01 $2,790.20 0431T 2020-01-01 $25,668.17 0442T 2020-01-01 $2,414.05 0505T 2020-01-01 $4,672.84 0587T 2020-01-01 $193.77 20983 2020-01-01 $1,811.93 21208 2020-01-01 $1,693.81 21245 2020-01-01 $1,822.83 21346 2020-01-01 $1,530.34 21742 2020-01-01 $1,865.57 21812 2020-01-01 $4,281.88 22612 2020-01-01 $5,227.98 22633 2020-01-01 $5,906.32 23406 2020-01-01 $2,645.82 23630 2020-01-01 $1,929.78 24365 2020-01-01 $6,589.42 24575 2020-01-01 $3,717.78 25136 2020-01-01 $1,984.81 25350 2020-01-01 $2,663.16 25545 2020-01-01 $1,901.66 25670 2020-01-01 $1,923.80 25800 2020-01-01 $2,675.13 26390 2020-01-01 $1,816.12 27130 2020-01-01 $5,717.10 27400 2020-01-01 $1,822.70 27477 2020-01-01 $2,962.86 27826 2020-01-01 $2,320.40 28130 2020-01-01 $2,786.39 28302 2020-01-01 $2,200.76 28446 2020-01-01 $2,233.66 31647 2020-01-01 $3,106.45 33220 2020-01-01 $1,251.49 33226 2020-01-01 $876.56 33233 2020-01-01 $3,401.39 33235 2020-01-01 $898.19 36583 2020-01-01 $2,144.12 36904 2020-01-01 $1,505.49 37244 2020-01-01 $3,051.81 43773 2020-01-01 $1,642.49 45327 2020-01-01 $1,436.64 59072 2020-01-01 $110.02 64448 2020-01-01 $253.03 64912 2020-01-01 $2,923.08 65779 2020-01-01 $1,010.67 66987 2020-01-01 $1,183.68 66988 2020-01-01 $1,183.68 92920 2020-01-01 $1,487.66 92924 2020-01-01 $4,989.91 93024 2020-01-01 $110.31 93612 2020-01-01 $1,806.32 93619 2020-01-01 $1,796.32 95928 2020-01-01 $739.79 95961 2020-01-01 $330.31 C9757 2020-01-01 $3,689.22


Page 72 of 84

Terminated Device Procedure Removals

The following HCPCS were removed from the terminated device procedure list, that may be subject to device credit when the procedure is terminated early. Terminated Device Procedure Removals HCPCS Eff Date Amount 0467T 2020-01-01 $1,050.55 19105 2020-01-01 $1,315.36 19342 2020-01-01 $2,339.68 21125 2020-01-01 $1,723.24 21454 2020-01-01 $1,753.76 23532 2020-01-01 $2,288.96 24115 2020-01-01 $2,687.36 24344 2020-01-01 $1,992.01 24360 2020-01-01 $1,992.58 25126 2020-01-01 $1,024.68 25525 2020-01-01 $1,753.19 26843 2020-01-01 $1,994.29 27357 2020-01-01 $2,353.93 27396 2020-01-01 $1,972.63 27407 2020-01-01 $2,523.21 27416 2020-01-01 $1,821.02 27652 2020-01-01 $1,899.10 27696 2020-01-01 $1,939.57 27832 2020-01-01 $2,623.52 28102 2020-01-01 $2,514.66 28103 2020-01-01 $1,923.04 28309 2020-01-01 $1,717.29 29905 2020-01-01 $812.19 36260 2020-01-01 $1,353.66 36580 2020-01-01 $357.29 36581 2020-01-01 $819.66 36595 2020-01-01 $795.36 37606 2020-01-01 $1,315.21 47539 2020-01-01 $1,385.19 63075 2020-01-01 $1,713.30 63744 2020-01-01 $1,597.66 64595 2020-01-01 $1,006.49 64885 2020-01-01 $3,265.65 64886 2020-01-01 $1,674.37 75733 2020-01-01 $836.83 75746 2020-01-01 $984.38 75870 2020-01-01 $396.77 86891 2020-01-01 $334.76 93610 2020-01-01 $1,777.46 C9728 2020-01-01 $413.95


Page 73 of 84

Terminated Device Procedure Modifications

The following HCPCS have a modified device credit amount for device procedures that may be terminated early. Terminated Device Procedure Modifications HCPCS Eff Date Description Current


0100T 2020-01-01 Prosth retina receive&gen $143,014.97 $144,616.22 0191T 2020-01-01 Insert ant segment drain int $2,103.52 $2,001.05 0221T 2020-01-01 Plmt post facet implt lumb $2,773.23 $3,029.33 0234T 2020-01-01 Trluml perip athrc renal art $5,494.25 $5,361.48 0236T 2020-01-01 Trluml perip athrc abd aorta $3,571.02 $3,484.72 0237T 2020-01-01 Trluml perip athrc brchiocph $4,458.82 $4,565.72 0238T 2020-01-01 Trluml perip athrc iliac art $7,388.18 $7,006.26 0253T 2020-01-01 Insert aqueous drain device $2,122.99 $1,958.46 0268T 2020-01-01 Implt/rpl crtd sns dev gen $26,294.22 $17,369.60 0308T 2020-01-01 Insj ocular telescope prosth $16,997.43 $12,485.74 0312T 2020-01-01 Laps impltj nstim vagus $26,093.30 $24,820.04 0316T 2020-01-01 Replc vagus nerve pls gen $27,429.85 $17,184.40 0335T 2020-01-01 Insj sinus tarsi implant $2,431.66 $2,889.12 0408T 2020-01-01 Insj/rplc cardiac modulj sys $13,019.03 $15,613.09 0409T 2020-01-01 Insj/rplc car modulj pls gn $7,041.00 $6,818.90 0410T 2020-01-01 Insj/rplc car modulj atr elt $2,368.97 $2,295.27 0411T 2020-01-01 Insj/rplc car modulj vnt elt $2,368.97 $2,295.27 0414T 2020-01-01 Rmvl & rpl car modulj pls gn $7,041.00 $6,818.90 0424T 2020-01-01 Insj/rplc nstim apnea compl $22,092.39 $20,626.59 0449T 2020-01-01 Insj aqueous drain dev 1st $2,084.04 $1,911.50 0511T 2020-01-01 Rmvl&rinsj sinus tarsi implt $1,854.40 $1,766.87 0515T 2020-01-01 Insj wcs lv compl sys $7,041.00 $6,818.90 0516T 2020-01-01 Insj wcs lv eltrd only $2,368.97 $2,295.27 0517T 2020-01-01 Insj wcs lv pg compnt $2,368.97 $2,295.27 0519T 2020-01-01 Rmvl & rplcmt pg compnt wcs $925.04 $970.46 0520T 2020-01-01 Rmvl&rplcmt pg wcs new eltrd $7,041.00 $6,818.90 0525T 2020-01-01 Insj/rplcmt compl iims $3,178.10 $3,062.60 0526T 2020-01-01 Insj/rplcmt iims eltrd only $2,368.97 $2,295.27 0527T 2020-01-01 Insj/rplcmt iims implt mntr $6,591.10 $6,386.04 0548T 2020-01-01 Tprnl balo cntnc dev bi $2,501.06 $5,059.06 0549T 2020-01-01 Tprnl balo cntnc dev uni $1,311.80 $1,246.37 11970 2020-01-01 Replace tissue expander $1,871.75 $1,806.77 19296 2020-01-01 Place po breast cath for rad $3,789.54 $3,512.87 19357 2020-01-01 Breast reconstruction $4,218.34 $3,746.07 20690 2020-01-01 Apply bone fixation device $1,839.45 $1,836.98 20692 2020-01-01 Apply bone fixation device $5,299.39 $4,765.53 20696 2020-01-01 Comp multiplane ext fixation $7,229.95 $5,777.46 21243 2020-01-01 Reconstruction of jaw joint $9,111.59 $8,822.53 21244 2020-01-01 Reconstruction of lower jaw $2,022.19 $1,716.16 21338 2020-01-01 Open nasoethmoid fx w/o fixj $1,683.13 $1,809.51 21365 2020-01-01 Opn tx complx malar fx $1,592.91 $1,482.12 21461 2020-01-01 Treat lower jaw fracture $1,899.95 $1,438.32 21462 2020-01-01 Treat lower jaw fracture $1,743.77 $1,676.78 21470 2020-01-01 Treat lower jaw fracture $1,890.25 $1,705.98 21811 2020-01-01 Optx of rib fx w/fixj scope $3,262.56 $1,210.15 21813 2020-01-01 Treatment of rib fracture $715.65 $693.44 22551 2020-01-01 Neck spine fuse&remov bel c2 $5,530.26 $4,969.10 22554 2020-01-01 Neck spine fusion $5,481.47 $4,721.61 22856 2020-01-01 Cerv artific diskectomy $8,942.56 $8,309.63 22867 2020-01-01 Insj stablj dev w/dcmprn $9,409.78 $8,606.89 22869 2020-01-01 Insj stablj dev w/o dcmprn $8,730.36 $10,932.67 23156 2020-01-01 Removal of humerus lesion $1,845.43 $2,223.41 23470 2020-01-01 Reconstruct shoulder joint $6,288.34 $5,704.07 23473 2020-01-01 Revis reconst shoulder joint $5,025.67 $4,723.75 23485 2020-01-01 Revision of collar bone $4,712.68 $4,515.90 23491 2020-01-01 Reinforce shoulder bones $4,273.54 $3,345.94 23515 2020-01-01 Treat clavicle fracture $2,231.27 $2,058.69 23552 2020-01-01 Treat clavicle dislocation $2,051.81 $1,818.74 23615 2020-01-01 Treat humerus fracture $5,194.66 $4,623.04 23616 2020-01-01 Treat humerus fracture $8,362.12 $7,380.86 23680 2020-01-01 Treat dislocation/fracture $5,164.91 $4,656.25 24126 2020-01-01 Remove/graft bone lesion $1,902.86 $1,813.04 24361 2020-01-01 Reconstruct elbow joint $8,696.99 $9,968.47 24362 2020-01-01 Reconstruct elbow joint $3,942.71 $5,954.77 24363 2020-01-01 Replace elbow joint $9,774.95 $9,458.65 24366 2020-01-01 Reconstruct head of radius $6,840.53 $6,116.55 24370 2020-01-01 Revise reconst elbow joint $5,466.00 $5,412.65 24371 2020-01-01 Revise reconst elbow joint $8,196.29 $8,303.47 24430 2020-01-01 Repair of humerus $4,831.69 $4,388.41 24435 2020-01-01 Repair humerus with graft $4,862.63 $4,332.69 24498 2020-01-01 Reinforce humerus $4,168.82 $3,687.72 24515 2020-01-01 Treat humerus fracture $4,362.80 $3,834.50


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Terminated Device Procedure Modifications HCPCS Eff Date Description Current


24516 2020-01-01 Treat humerus fracture $4,598.43 $4,153.77 24545 2020-01-01 Treat humerus fracture $5,188.71 $4,708.75 24546 2020-01-01 Treat humerus fracture $7,186.90 $6,834.07 24579 2020-01-01 Treat humerus fracture $4,114.08 $3,351.30 24587 2020-01-01 Treat elbow fracture $6,081.26 $5,654.79 24635 2020-01-01 Treat elbow fracture $2,400.56 $2,041.02 24666 2020-01-01 Treat radius fracture $6,808.40 $6,035.13 24685 2020-01-01 Treat ulnar fracture $1,888.50 $1,719.57 25390 2020-01-01 Shorten radius or ulna $2,127.18 $1,892.83 25391 2020-01-01 Lengthen radius or ulna $5,539.78 $5,208.02 25400 2020-01-01 Repair radius or ulna $2,429.27 $2,259.32 25405 2020-01-01 Repair/graft radius or ulna $2,393.38 $2,167.55 25415 2020-01-01 Repair radius & ulna $2,058.39 $2,185.79 25420 2020-01-01 Repair/graft radius & ulna $2,198.37 $2,349.37 25425 2020-01-01 Repair/graft radius or ulna $2,146.32 $2,767.15 25441 2020-01-01 Reconstruct wrist joint $7,299.90 $6,411.19 25442 2020-01-01 Reconstruct wrist joint $9,220.02 $9,377.02 25443 2020-01-01 Reconstruct wrist joint $3,580.80 $3,027.05 25444 2020-01-01 Reconstruct wrist joint $7,916.35 $7,688.28 25445 2020-01-01 Reconstruct wrist joint $2,341.93 $2,223.41 25446 2020-01-01 Wrist replacement $10,840.15 $10,402.82 25515 2020-01-01 Treat fracture of radius $1,997.37 $1,882.57 25526 2020-01-01 Treat fracture of radius $2,100.86 $1,794.80 25574 2020-01-01 Treat fracture radius & ulna $2,158.89 $2,238.23 25575 2020-01-01 Treat fracture radius/ulna $2,184.61 $2,178.95 25607 2020-01-01 Treat fx rad extra-articul $2,629.07 $2,459.37 25608 2020-01-01 Treat fx rad intra-articul $2,587.19 $2,466.21 25609 2020-01-01 Treat fx radial 3+ frag $2,645.22 $2,537.46 25805 2020-01-01 Fusion/graft of wrist joint $2,431.66 $2,465.64 25810 2020-01-01 Fusion/graft of wrist joint $4,863.82 $4,091.63 25820 2020-01-01 Fusion of hand bones $2,227.68 $2,156.15 25825 2020-01-01 Fuse hand bones with graft $2,027.88 $2,022.78 25830 2020-01-01 Fusion radioulnar jnt/ulna $1,963.28 $2,054.70 26531 2020-01-01 Revise knuckle with implant $2,563.27 $2,576.78 26536 2020-01-01 Revise/implant finger joint $2,230.67 $2,062.11 26820 2020-01-01 Thumb fusion with graft $2,679.32 $1,811.90 26844 2020-01-01 Fusion/graft of hand joint $2,005.75 $1,957.24 27279 2020-01-01 Arthrodesis sacroiliac joint $11,104.85 $10,713.95 27403 2020-01-01 Repair of knee cartilage $1,902.26 $1,124.36 27415 2020-01-01 Osteochondral knee allograft $7,305.85 $6,238.69 27427 2020-01-01 Reconstruction knee $2,051.21 $1,866.62 27428 2020-01-01 Reconstruction knee $4,073.61 $3,412.37 27429 2020-01-01 Reconstruction knee $5,214.89 $3,948.06 27438 2020-01-01 Revise kneecap with implant $4,440.15 $3,989.85 27440 2020-01-01 Revision of knee joint $5,563.58 $4,661.61 27442 2020-01-01 Revision of knee joint $5,600.47 $4,878.03 27443 2020-01-01 Revision of knee joint $4,973.31 $3,579.51 27446 2020-01-01 Revision of knee joint $5,526.69 $5,023.74 27447 2020-01-01 Total knee arthroplasty $5,792.08 $4,615.54 27485 2020-01-01 Surgery to stop leg growth $3,590.96 $1,408.47 27509 2020-01-01 Treatment of thigh fracture $2,767.85 $2,908.50 27705 2020-01-01 Incision of tibia $2,106.84 $2,124.81 27709 2020-01-01 Incision of tibia & fibula $4,760.28 $4,025.20 27720 2020-01-01 Repair of tibia $2,236.05 $2,318.59 27722 2020-01-01 Repair/graft of tibia $2,764.26 $1,847.81 27726 2020-01-01 Repair fibula nonunion $2,242.03 $2,074.08 27745 2020-01-01 Reinforce tibia $2,196.57 $1,994.29 27756 2020-01-01 Treatment of tibia fracture $2,450.80 $2,302.06 27758 2020-01-01 Treatment of tibia fracture $5,004.25 $4,076.63 27759 2020-01-01 Treatment of tibia fracture $4,411.59 $3,873.07 27792 2020-01-01 Treatment of ankle fracture $1,954.90 $1,765.73 27814 2020-01-01 Treatment of ankle fracture $2,017.71 $1,832.99 27822 2020-01-01 Treatment of ankle fracture $1,996.77 $1,856.36 27823 2020-01-01 Treatment of ankle fracture $1,908.24 $1,843.25 27827 2020-01-01 Treat lower leg fracture $4,494.90 $4,148.41 27828 2020-01-01 Treat lower leg fracture $4,741.24 $4,255.55 27848 2020-01-01 Treat ankle dislocation $2,203.15 $2,121.39 27870 2020-01-01 Fusion of ankle joint open $5,805.17 $5,001.24 27871 2020-01-01 Fusion of tibiofibular joint $4,749.57 $3,942.71 28262 2020-01-01 Revision of foot and ankle $2,501.05 $1,935.58 28291 2020-01-01 Corrj halux rigdus w/implt $3,105.83 $2,645.18 28297 2020-01-01 Correction hallux valgus $2,605.14 $2,333.41 28300 2020-01-01 Incision of heel bone $2,035.66 $1,889.98 28305 2020-01-01 Incise/graft midfoot bones $2,222.29 $2,192.06 28320 2020-01-01 Repair of foot bones $5,413.63 $4,446.26 28322 2020-01-01 Repair of metatarsals $2,254.00 $2,087.76 28415 2020-01-01 Treat heel fracture $2,152.31 $2,079.78


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28420 2020-01-01 Treat/graft heel fracture $4,637.71 $4,615.54 28445 2020-01-01 Treat ankle fracture $1,891.49 $1,774.28 28465 2020-01-01 Treat midfoot fracture each $2,278.52 $1,973.20 28485 2020-01-01 Treat metatarsal fracture $2,039.25 $1,782.26 28555 2020-01-01 Repair foot dislocation $2,030.87 $2,416.63 28585 2020-01-01 Repair foot dislocation $2,224.69 $2,603.00 28615 2020-01-01 Repair foot dislocation $2,103.85 $1,913.35 28705 2020-01-01 Fusion of foot bones $8,354.15 $7,878.36 28715 2020-01-01 Fusion of foot bones $6,096.73 $5,268.01 28725 2020-01-01 Fusion of foot bones $5,291.06 $4,488.04 28730 2020-01-01 Fusion of foot bones $6,120.54 $5,328.01 28735 2020-01-01 Fusion of foot bones $5,890.85 $5,257.30 28737 2020-01-01 Revision of foot bones $6,285.96 $5,555.15 28740 2020-01-01 Fusion of foot bones $2,783.40 $2,593.31 28750 2020-01-01 Fusion of big toe joint $2,727.17 $2,490.72 29855 2020-01-01 Tibial arthroscopy/surgery $3,093.27 $3,025.34 29856 2020-01-01 Tibial arthroscopy/surgery $6,103.87 $6,182.98 29867 2020-01-01 Allgrft implnt knee w/scope $5,401.73 $5,046.24 29888 2020-01-01 Knee arthroscopy/surgery $2,184.01 $1,963.51 29889 2020-01-01 Knee arthroscopy/surgery $4,578.20 $3,956.64 29899 2020-01-01 Ankle arthroscopy/surgery $1,944.13 $1,719.00 29907 2020-01-01 Subtalar arthro w/fusion $4,149.78 $4,188.06 31636 2020-01-01 Bronchoscopy bronch stents $2,279.51 $2,222.72 31660 2020-01-01 Bronch thermoplsty 1 lobe $3,037.90 $2,899.63 31661 2020-01-01 Bronch thermoplsty 2/> lobes $3,113.52 $2,940.81 33206 2020-01-01 Insert heart pm atrial $5,995.33 $5,924.64 33207 2020-01-01 Insert heart pm ventricular $6,172.69 $5,958.23 33208 2020-01-01 Insrt heart pm atrial & vent $6,558.17 $6,363.28 33211 2020-01-01 Insert card electrodes dual $3,545.05 $4,696.43 33212 2020-01-01 Insert pulse gen sngl lead $4,860.98 $4,475.04 33213 2020-01-01 Insert pulse gen dual leads $6,248.56 $6,258.56 33214 2020-01-01 Upgrade of pacemaker system $6,333.65 $6,196.32 33216 2020-01-01 Insert 1 electrode pm-defib $2,912.31 $2,895.75 33217 2020-01-01 Insert 2 electrode pm-defib $3,758.26 $3,746.48 33221 2020-01-01 Insert pulse gen mult leads $11,665.52 $11,567.38 33224 2020-01-01 Insert pacing lead & connect $5,547.32 $5,307.18 33227 2020-01-01 Remove&replace pm gen singl $4,641.66 $4,512.06 33228 2020-01-01 Remv&replc pm gen dual lead $6,368.51 $6,239.79 33229 2020-01-01 Remv&replc pm gen mult leads $12,117.86 $11,859.08 33230 2020-01-01 Insrt pulse gen w/dual leads $17,461.67 $16,400.56 33231 2020-01-01 Insrt pulse gen w/mult leads $23,469.48 $22,189.09 33240 2020-01-01 Insrt pulse gen w/singl lead $16,816.62 $17,260.62 33249 2020-01-01 Insj/rplcmt defib w/lead(s) $24,302.37 $23,117.98 33262 2020-01-01 Rmvl& replc pulse gen 1 lead $16,471.39 $15,872.65 33263 2020-01-01 Rmvl & rplcmt dfb gen 2 lead $17,066.47 $16,490.75 33264 2020-01-01 Rmvl & rplcmt dfb gen mlt ld $24,757.56 $23,197.68 33270 2020-01-01 Ins/rep subq defibrillator $24,434.73 $23,335.64 33271 2020-01-01 Insj subq impltbl dfb elctrd $4,736.42 $5,354.65 33274 2020-01-01 Tcat insj/rpl perm ldls pm $10,370.54 $9,989.64 33285 2020-01-01 Insj subq car rhythm mntr $5,857.48 $5,675.25 33289 2020-01-01 Tcat impl wrls p-art prs snr $25,175.95 $25,899.06 36253 2020-01-01 Ins cath ren art 2nd+ unilat $1,641.76 $1,417.99 36261 2020-01-01 Revision of infusion pump $2,264.86 $2,376.07 36835 2020-01-01 Artery to vein shunt $1,369.84 $926.38 36903 2020-01-01 Intro cath dialysis circuit $5,040.44 $4,832.59 36906 2020-01-01 Thrmbc/nfs dialysis circuit $7,697.41 $7,291.85 37183 2020-01-01 Remove hepatic shunt (tips) $1,774.99 $1,741.82 37184 2020-01-01 Prim art m-thrmbc 1st vsl $3,999.06 $1,889.19 37187 2020-01-01 Venous mech thrombectomy $1,934.50 $1,589.30 37191 2020-01-01 Ins endovas vena cava filtr $1,883.98 $1,775.12 37192 2020-01-01 Redo endovas vena cava filtr $918.13 $1,025.17 37221 2020-01-01 Iliac revasc w/stent $3,923.76 $3,711.94 37224 2020-01-01 Fem/popl revas w/tla $1,996.43 $1,876.09 37225 2020-01-01 Fem/popl revas w/ather $5,617.12 $5,450.44 37226 2020-01-01 Fem/popl revasc w/stent $4,896.77 $4,731.06 37227 2020-01-01 Fem/popl revasc stnt & ather $8,931.17 $8,440.37 37228 2020-01-01 Tib/per revasc w/tla $3,259.89 $3,136.64 37229 2020-01-01 Tib/per revasc w/ather $7,687.85 $7,353.27 37230 2020-01-01 Tib/per revasc w/stent $7,305.29 $7,066.14 37231 2020-01-01 Tib/per revasc stent & ather $8,178.80 $7,568.23 37236 2020-01-01 Open/perq place stent 1st $3,728.56 $3,634.59 37238 2020-01-01 Open/perq place stent same $4,148.68 $4,259.21 37242 2020-01-01 Vasc embolize/occlude artery $3,754.32 $3,503.09 43212 2020-01-01 Esophagoscop stent placement $2,679.18 $2,495.32 43240 2020-01-01 Egd w/transmural drain cyst $1,427.86 $1,334.95 43266 2020-01-01 Egd endoscopic stent place $2,776.71 $2,592.88 43284 2020-01-01 Laps esophgl sphnctr agmntj $3,839.74 $3,937.39


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43647 2020-01-01 Lap impl electrode antrum $4,418.85 $4,012.26 43770 2020-01-01 Lap place gastr adj device $3,690.83 $3,571.21 44370 2020-01-01 Small bowel endoscopy/stent $2,419.58 $2,260.17 44402 2020-01-01 Colonoscopy w/stent plcmt $2,448.26 $2,417.09 45347 2020-01-01 Sigmoidoscopy w/plcmt stent $3,094.15 $2,982.24 45389 2020-01-01 Colonoscopy w/stent plcmt $2,774.79 $2,761.04 47383 2020-01-01 Perq abltj lvr cryoablation $1,903.03 $1,712.41 47538 2020-01-01 Perq plmt bile duct stent $2,365.62 $2,183.49 47540 2020-01-01 Perq plmt bile duct stent $2,001.64 $2,025.85 47556 2020-01-01 Biliary endoscopy thru skin $2,133.60 $2,012.06 50434 2020-01-01 Convert nephrostomy catheter $568.31 $561.59 50593 2020-01-01 Perc cryo ablate renal tum $3,123.79 $2,615.90 51715 2020-01-01 Endoscopic injection/implant $962.31 $945.96 51992 2020-01-01 Laparo sling operation $1,503.28 $1,494.57 52327 2020-01-01 Cystoscopy inject material $1,397.70 $1,649.63 53440 2020-01-01 Male sling procedure $5,173.16 $4,796.89 53444 2020-01-01 Insert tandem cuff $9,844.93 $9,994.09 53445 2020-01-01 Insert uro/ves nck sphincter $12,512.66 $11,418.79 53447 2020-01-01 Remove/replace ur sphincter $11,516.22 $10,668.09 54400 2020-01-01 Insert semi-rigid prosthesis $11,526.76 $10,591.39 54401 2020-01-01 Insert self-contd prosthesis $12,361.52 $11,294.76 54405 2020-01-01 Insert multi-comp penis pros $12,563.62 $11,557.51 54410 2020-01-01 Remove/replace penis prosth $12,052.22 $11,095.66 54411 2020-01-01 Remov/replc penis pros comp $11,551.36 $10,668.09 54416 2020-01-01 Remv/repl penis contain pros $11,804.43 $10,919.41 54417 2020-01-01 Remv/replc penis pros compl $10,971.42 $9,217.28 54660 2020-01-01 Revision of testis $1,617.33 $1,822.11 55873 2020-01-01 Cryoablate prostate $3,699.15 $3,465.70 57288 2020-01-01 Repair bladder defect $1,331.87 $1,315.31 58565 2020-01-01 Hysteroscopy sterilization $1,317.34 $1,392.88 61623 2020-01-01 Endovasc tempory vessel occl $4,964.15 $3,413.17 61626 2020-01-01 Transcath occlusion non-cns $3,037.94 $2,979.03 61885 2020-01-01 Insrt/redo neurostim 1 array $16,505.11 $16,048.87 61886 2020-01-01 Implant neurostim arrays $24,916.91 $23,853.39 61888 2020-01-01 Revise/remove neuroreceiver $2,745.85 $2,564.02 62350 2020-01-01 Implant spinal canal cath $1,854.88 $1,406.35 62360 2020-01-01 Insert spine infusion device $12,142.89 $11,716.34 62361 2020-01-01 Implant spine infusion pump $11,852.20 $12,026.44 62362 2020-01-01 Implant spine infusion pump $12,380.72 $12,167.83 63610 2020-01-01 Stimulation of spinal cord $839.21 $796.33 63650 2020-01-01 Implant neuroelectrodes $3,099.75 $3,037.60 63655 2020-01-01 Implant neuroelectrodes $13,270.02 $12,926.65 63663 2020-01-01 Revise spine eltrd perq aray $2,923.42 $2,970.63 63664 2020-01-01 Revise spine eltrd plate $10,983.49 $10,685.53 63685 2020-01-01 Insrt/redo spine n generator $24,054.99 $22,961.52 63741 2020-01-01 Install spinal shunt $1,844.42 $1,850.62 64553 2020-01-01 Implant neuroelectrodes $4,733.77 $3,495.63 64555 2020-01-01 Implant neuroelectrodes $3,563.79 $3,100.98 64561 2020-01-01 Implant neuroelectrodes $3,295.88 $3,175.13 64568 2020-01-01 Inc for vagus n elect impl $25,126.56 $23,745.37 64569 2020-01-01 Revise/repl vagus n eltrd $5,056.74 $4,528.90 64575 2020-01-01 Implant neuroelectrodes $13,752.01 $12,473.93 64580 2020-01-01 Implant neuroelectrodes $15,302.08 $15,609.25 64581 2020-01-01 Implant neuroelectrodes $3,987.61 $3,863.37 64590 2020-01-01 Insrt/redo pn/gastr stimul $16,306.53 $15,837.48 64890 2020-01-01 Nerve graft hand/foot </4 cm $2,223.44 $2,144.68 64891 2020-01-01 Nerve graft hand/foot >4 cm $3,538.44 $1,774.83 64910 2020-01-01 Nerve repair w/allograft $2,075.79 $1,532.83 65770 2020-01-01 Revise cornea with implant $2,940.33 $4,665.36 66180 2020-01-01 Aqueous shunt eye w/graft $1,307.40 $1,259.17 66183 2020-01-01 Insert ant drainage device $1,820.96 $1,500.88 69714 2020-01-01 Implant temple bone w/stimul $7,742.60 $7,091.52 69715 2020-01-01 Temple bne implnt w/stimulat $8,457.80 $9,344.67 69717 2020-01-01 Temple bone implant revision $3,196.75 $3,226.54 69930 2020-01-01 Implant cochlear device $27,009.77 $26,053.73 75898 2020-01-01 Follow-up angiography $658.49 $759.85 92928 2020-01-01 Prq card stent w/angio 1 vsl $3,660.19 $3,382.23 92933 2020-01-01 Prq card stent/ath/angio $8,790.89 $8,309.86 92937 2020-01-01 Prq revasc byp graft 1 vsl $3,495.71 $3,358.06 92943 2020-01-01 Prq card revasc chronic 1vsl $4,214.08 $3,902.42 92986 2020-01-01 Revision of aortic valve $1,871.59 $1,734.80 92987 2020-01-01 Revision of mitral valve $3,400.59 $3,161.78 93532 2020-01-01 R & l heart cath congenital $966.70 $879.94 93580 2020-01-01 Transcath closure of asd $10,732.38 $9,922.08 93581 2020-01-01 Transcath closure of vsd $11,352.45 $8,011.98 93582 2020-01-01 Perq transcath closure pda $6,396.71 $6,035.85 93590 2020-01-01 Perq transcath cls mitral $7,246.31 $6,075.78


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93591 2020-01-01 Perq transcath cls aortic $6,063.56 $5,888.45 93600 2020-01-01 Bundle of his recording $2,686.24 $1,734.64 93602 2020-01-01 Intra-atrial recording $1,995.84 $1,665.32 93603 2020-01-01 Right ventricular recording $425.64 $314.23 93650 2020-01-01 Ablate heart dysrhythm focus $2,569.70 $2,113.89 93653 2020-01-01 Ep & ablate supravent arrhyt $7,371.00 $6,609.53 93654 2020-01-01 Ep & ablate ventric tachy $8,787.17 $7,673.97 93656 2020-01-01 Tx atrial fib pulm vein isol $9,543.27 $8,628.89 C9600 2020-01-01 Perc drug-el cor stent sing $3,941.59 $3,894.69 C9602 2020-01-01 Perc d-e cor stent ather s $9,130.41 $8,733.64 C9604 2020-01-01 Perc d-e cor revasc t cabg s $4,107.06 $3,976.88 C9607 2020-01-01 Perc d-e cor revasc chro sin $8,880.16 $8,425.01 C9739 2020-01-01 Cystoscopy prostatic imp 1-3 $2,801.33 $2,648.33 C9740 2020-01-01 Cysto impl 4 or more $5,921.05 $5,558.89 C9745 2020-01-01 Nasal endo eustachian tube $2,099.79 $1,742.70 C9749 2020-01-01 Repair nasal stenosis w/imp $2,010.06 $1,371.51 C9752 2020-01-01 Intraosseous des lumb/sacrum $3,689.22 $3,321.30 C9754 2020-01-01 Perc av fistula, direct $4,941.39 $2,997.40 C9755 2020-01-01 Rf magnetic-guide av fistula $4,941.39 $2,997.40


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Drug Administration Addon Procedure Code List Additions

The following HCPCS were added to the Drug Administration Addon Procedure code list (edit 106). Drug Administration Addon Procedure Code List Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 96361 2018-04-01 Hydrate iv infusion add-on A 96366 2018-04-01 Ther/proph/diag iv inf addon A 96367 2018-04-01 Tx/proph/dg addl seq iv inf A 96368 2018-04-01 Ther/diag concurrent inf A 96370 2018-04-01 Sc ther infusion addl hr A 96371 2018-04-01 Sc ther infusion reset pump A 96375 2018-04-01 Tx/pro/dx inj new drug addon A 96376 2018-04-01 Tx/pro/dx inj same drug adon A 96411 2018-04-01 Chemo iv push addl drug A 96415 2018-04-01 Chemo iv infusion addl hr A 96417 2018-04-01 Chemo iv infus each addl seq A 96423 2018-04-01 Chemo ia infuse each addl hr A


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Type One Addon Procedure Code List Additions

The following HCPCS were added to the Type One Addon Procedure code list (edit 106). Type One Addon Procedure Code List Additions Reason Key: A=Added To List, N=New Code Addon Primary Eff Date R* 34714 33440 2019-10-01 A 34716 33440 2019-10-01 A 34812 34710 2019-10-01 A 34833 33440 2019-10-01 A 64787 64776 2018-04-01 A


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Type One Addon Procedure Code List Removals

The following HCPCS were removed from the Type One Addon Procedure code list (edit 106). Type One Addon Procedure Code List Removals Reason Key: R=Removed From List, D=Code Terminated Addon Primary Eff Date R* 0205T 92920 2020-01-01 D 0205T 92924 2020-01-01 D 0205T 92928 2020-01-01 D 0205T 92933 2020-01-01 D 0205T 92937 2020-01-01 D 0205T 92941 2020-01-01 D 0205T 92943 2020-01-01 D 0205T 92975 2020-01-01 D 0205T 93454 2020-01-01 D 0205T 93455 2020-01-01 D 0205T 93456 2020-01-01 D 0205T 93457 2020-01-01 D 0205T 93458 2020-01-01 D 0205T 93459 2020-01-01 D 0205T 93460 2020-01-01 D 0205T 93461 2020-01-01 D 0205T 93563 2020-01-01 D 0205T 93564 2020-01-01 D 0205T C9600 2020-01-01 D 0205T C9602 2020-01-01 D 0205T C9604 2020-01-01 D 0205T C9606 2020-01-01 D 0205T C9607 2020-01-01 D 0399T 93303 2020-01-01 D 0399T 93304 2020-01-01 D 0399T 93306 2020-01-01 D 0399T 93307 2020-01-01 D 0399T 93308 2020-01-01 D 0399T 93312 2020-01-01 D 0399T 93314 2020-01-01 D 0399T 93315 2020-01-01 D 0399T 93317 2020-01-01 D 0399T 93350 2020-01-01 D 0399T 93351 2020-01-01 D 0399T 93355 2020-01-01 D 0482T 78491 2020-01-01 D 0482T 78492 2020-01-01 D 32674 19260 2020-01-01 D 33257 33860 2020-01-01 D 33257 33870 2020-01-01 D 33259 33860 2020-01-01 D 33259 33870 2020-01-01 D 33866 33860 2020-01-01 D 34714 0254T 2020-01-01 D 34714 33860 2020-01-01 D 34714 33870 2020-01-01 D 34715 0254T 2020-01-01 D 34716 0254T 2020-01-01 D 34716 33860 2020-01-01 D 34716 33870 2020-01-01 D 34812 0254T 2020-01-01 D 34820 0254T 2020-01-01 D 34833 0254T 2020-01-01 D 34833 33860 2020-01-01 D 34833 33870 2020-01-01 D 34834 0254T 2020-01-01 D 37222 0254T 2020-01-01 D 37223 0254T 2020-01-01 D 37252 0254T 2020-01-01 D 37253 0254T 2020-01-01 D 38746 19260 2020-01-01 D 96367 96360 2018-04-01 R 96367 96365 2018-04-01 R 96367 96374 2018-04-01 R 96367 96409 2018-04-01 R 96367 96413 2018-04-01 R 96368 96360 2018-04-01 R 96368 96365 2018-04-01 R 96368 96366 2018-04-01 R 96368 96413 2018-04-01 R 96368 96415 2018-04-01 R 96368 96416 2018-04-01 R


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Type One Addon Procedure Code List Removals Reason Key: R=Removed From List, D=Code Terminated Addon Primary Eff Date R* 96368 C8957 2018-04-01 R 96370 96369 2018-04-01 R 96371 96369 2018-04-01 R 96375 96360 2018-04-01 R 96375 96365 2018-04-01 R 96375 96374 2018-04-01 R 96375 96409 2018-04-01 R 96375 96413 2018-04-01 R 96376 96365 2018-04-01 R 96376 96374 2018-04-01 R 96376 96409 2018-04-01 R 96376 96413 2018-04-01 R 96411 96409 2018-04-01 R 96411 96413 2018-04-01 R 96415 96413 2018-04-01 R 96417 96413 2018-04-01 R 96423 96422 2018-04-01 R


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Modifier Changes

Added Modifiers

The following modifier(s) were added to the list of valid modifiers (edit 22). Added Modifiers Modifier Eff Date Description CB 2019-07-01 Esrd bene part a snf-sep pay MA 2020-01-01 Emer med cond susp/confirm MB 2020-01-01 Auc hardship, insuf internet MC 2020-01-01 Auc hardship, vendor issues MD 2020-01-01 Auc hardship, extreme circ ME 2020-01-01 Order adheres to auc MF 2020-01-01 Order does not adhere to auc MG 2020-01-01 Auc not applicable to order MH 2020-01-01 Auc consult not provided


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Deleted Modifiers

The following modifier(s) were removed from the list of valid modifiers (edit 22). Deleted Modifiers Modifier Eff Date Description GD 2020-01-01 Unit of service > mue value


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Final


IOCE v21.0 January 2020


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Added APCs ..................................................................................................................................................................................................... 5 Deleted APCs ................................................................................................................................................................................................... 6 Modified APC Descriptions ............................................................................................................................................................................. 7 Modified APC Status Indicators ...................................................................................................................................................................... 8 Added Comprehensive APCs ........................................................................................................................................................................... 9 APC Payment Offsets Modified ..................................................................................................................................................................... 10

HCPCS Procedure Code Changes ...................................................................................................................................................................... 11 Added HCPCS Codes .................................................................................................................................................................................... 11 Deleted HCPCS CPT Codes .......................................................................................................................................................................... 17 Modified HCPCS Code Descriptions ............................................................................................................................................................. 20 Modified HCPCS Code APC/Status Indicators/Edit Assignments ................................................................................................................ 23 Mid Quarter Edits Additions .......................................................................................................................................................................... 28 Male Only HCPCS Additions ........................................................................................................................................................................ 29 Female Only HCPCS Additions ..................................................................................................................................................................... 30 Female Only HCPCS Removals .................................................................................................................................................................... 31 Conditional Bilateral Additions ..................................................................................................................................................................... 32 Conditional Bilateral Removals ..................................................................................................................................................................... 33 Independent Bilateral Removals .................................................................................................................................................................... 34 Inherent Bilateral Additions ........................................................................................................................................................................... 35 Deductible Coinsurance Not Applicable Additions ....................................................................................................................................... 36 Deductible Coinsurance Not Applicable Removals ....................................................................................................................................... 37 Non-Standard CT Scan Equipment Procedure Additions .............................................................................................................................. 38 Non-Standard CT Scan Equipment Procedure Removals .............................................................................................................................. 39 Radiology Procedure For Payment Adjustment Additions ............................................................................................................................ 40 Radiology Procedure For Payment Adjustment Removals ............................................................................................................................ 41 Comprehensive APC HCPCS Additions ........................................................................................................................................................ 42 Comprehensive APC HCPCS Removals ....................................................................................................................................................... 43 Complexity Adjusted Code Pair Additions .................................................................................................................................................... 44 Complexity Adjusted Code Pair Removals .................................................................................................................................................... 47 CAPC Exclusion Additions ............................................................................................................................................................................ 50 Device Additions............................................................................................................................................................................................ 52 Device Removals ........................................................................................................................................................................................... 53 Device Procedure Additions .......................................................................................................................................................................... 54 Device Procedure Removals .......................................................................................................................................................................... 55 Device Procedure Edit 92 Bypass Additions ................................................................................................................................................. 56 Daily Mental Health Additions ...................................................................................................................................................................... 57 Daily Mental Health Removals ...................................................................................................................................................................... 58 Mental Health Not Billable Under PHP Edit 80 Additions ............................................................................................................................ 59 Mental Health Not Billable Under PHP Edit 80 Removals ........................................................................................................................... 60 FQHC Non-Covered Additions ...................................................................................................................................................................... 61 FQHC Non-Covered Removals ..................................................................................................................................................................... 62 RHC Modifier HCPCS Conflict Additions .................................................................................................................................................... 63 Pass-Through Device HCPCS Additions ....................................................................................................................................................... 64 Pass-Through Radiopharm HCPCS Additions ............................................................................................................................................... 65


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Pass-Through Radiopharm HCPCS Removals .............................................................................................................................................. 66 Skin Substitute High Cost Product Additions ................................................................................................................................................ 67 Skin Substitute Low Cost Product Removals................................................................................................................................................. 68 Pass-Through Device Credit Procedure Additions......................................................................................................................................... 69 Pass-Through Device Credit Procedure Modifications .................................................................................................................................. 70 Terminated Device Procedure Additions ....................................................................................................................................................... 71 Terminated Device Procedure Removals ....................................................................................................................................................... 72 Terminated Device Procedure Modifications ................................................................................................................................................. 73 Drug Administration Addon Procedure Code List Additions ........................................................................................................................ 78 Type One Addon Procedure Code List Additions .......................................................................................................................................... 79 Type One Addon Procedure Code List Removals ......................................................................................................................................... 80

Modifier Changes ............................................................................................................................................................................................... 82 Added Modifiers ............................................................................................................................................................................................ 82 Deleted Modifiers .......................................................................................................................................................................................... 83


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Page 5 of 84

APC Changes

Added APCs

The following APC(s) were added. Added APCs APC Eff Date Description Status Indicator Payment 01236 2019-10-01 Inj levoleucovorin nos 0.5mg K $0.58 02024 2020-01-01 Generator, CCM, implant H $0.00 02025 2020-01-01 Cath, pressure,valve-occlu H $0.00 02026 2020-01-01 Orth/devic/drug bn/bn,tis/bn H $0.00 02027 2020-01-01 Probe, robotic, water-jet H $0.00 02028 2020-01-01 Iris prosthesis H $0.00 05495 2020-01-01 Level 5 Intraocular Procedures J1 $20,675.62 09303 2019-10-01 Injection, levoleucovorin G $4.12 09315 2020-01-01 Diphtheria antitoxin K $12.68 09316 2020-01-01 Corticotropin injection K $3,946.50 09317 2020-01-01 Doripenem injection K $0.89 09318 2020-01-01 Inj hydroxyprogst capoat nos K $10.81 09319 2020-01-01 Somatropin injection K $1.67 09320 2020-01-01 Carbidopa levodopa ent 100ml K $219.45 09321 2020-01-01 Fosphenytoin inj pe K $1.73 09331 2020-01-01 Inj, polatuzumab vedotin 1mg G $110.36 09332 2020-01-01 Injection, lefamulin G $0.70 09333 2020-01-01 Inj, brexanolone G $76.74 09334 2020-01-01 Injection, khapzory, 0.5 mg G $2.04 09335 2020-01-01 Oral busulfan K $24.18 09336 2019-10-01 Inj truxima 10 mg K $0.00 09337 2020-01-01 Synojoynt, inj., 1 mg K $6.13 09338 2020-01-01 Inj., triluron, 1 mg K $25.18 09339 2020-01-01 Iodine i-131 iobenguane 1mci G $311.06 09340 2020-01-01 Inj, brolucizumab-dbll, 1 mg K $317.58


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Deleted APCs

The following APC(s) were deleted. Deleted APCs APC Eff Date Description 00873 2020-01-01 Hyalgan supartz visco-3 dose 01253 2020-01-01 Triamcinolone A inj PRS-free 01669 2020-01-01 Erythro lactobionate /500 mg 01743 2020-01-01 Nandrolone decanoate 50 mg 09005 2020-01-01 Reteplase injection 09019 2020-01-01 Caspofungin acetate 09052 2020-01-01 Fluciciovine F-18 09056 2020-01-01 Gallium Ga-68 09075 2020-01-01 Inj, kovaltry, 1 i.u. 09086 2020-01-01 Hepa vacc ped/adol 3 dose 09087 2020-01-01 Inj, clevidipine butyrate 09089 2020-01-01 Oral fludarabine phosphate 09090 2020-01-01 Melphalan oral 2 mg 09091 2020-01-01 Daunorubicin citrate inj 09093 2020-01-01 Plicamycin (mithramycin) inj 09098 2020-01-01 Chorionic gonadotropin/1000u 09130 2020-01-01 Inj, Imm Glob Bivigam, 500mg 09184 2020-01-01 Iodine i-131 iobenguane, dx 09185 2020-01-01 Iodine i-131 iobenguane, tx 09210 2020-01-01 Palonosetron hcl 09293 2020-01-01 Injection, glucarpidase 09323 2019-10-01 Inj., levoleucovorin, 0.5 mg 09497 2020-01-01 Loxapine for inhalation 1 mg


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Modified APC Descriptions

The following APC(s) had a description change. Modified APC Descriptions APC Eff Date Description Current Description Previous 01491 2020-01-01 New Technology - Level 1A ($0-$10) New Technology - Level 1A ($0-$10) 01492 2020-01-01 New Technology - Level 1B ($11-$20) New Technology - Level 1B ($11-$20) 01493 2020-01-01 New Technology - Level 1C ($21-$30) New Technology - Level 1C ($21-$30) 01494 2020-01-01 New Technology - Level 1D ($31-$40) New Technology - Level 1D ($31-$40) 01495 2020-01-01 New Technology - Level 1E ($41-$50) New Technology - Level 1E ($41-$50) 01496 2020-01-01 New Technology - Level 1A ($0-$10) New Technology - Level 1A ($0-$10) 01497 2020-01-01 New Technology - Level 1B ($11-$20) New Technology - Level 1B ($11-$20) 01498 2020-01-01 New Technology - Level 1C ($21-$30) New Technology - Level 1C ($21-$30) 01499 2020-01-01 New Technology - Level 1D ($31-$40) New Technology - Level 1D ($31-$40) 01500 2020-01-01 New Technology - Level 1E ($41-$50) New Technology - Level 1E ($41-$50) 01516 2020-01-01 New Technology - Level 16 ($1401 - $1500) New Technology - Level 16 ($1401 - $1500) 09125 2020-01-01 Risperidone, long acting Inj., risperdal consta, 0.5 mg 09179 2020-01-01 Injection, Aristada Initio Inj., aristada initio, 1 mg 09182 2020-01-01 Inj mogamulizumab-kpkc, 1 mg Inj, mogamulizumab-kpkc, 1 mg 09225 2020-01-01 Fluocinolone acetonide implt Inj., retisert, 0.01 mg 09450 2020-01-01 Fluocinol acet intravit imp Inj., iluvien, 0.01 mg


Page 8 of 84

Modified APC Status Indicators

The following APC(s) had status indicator changes. Modified APC Status Indicators APC Eff Date Description Status Indicator Current Status Indicator Previous 01861 2020-01-01 Inj., bendeka 1 mg K G 05182 2020-01-01 Level 2 Vascular Procedures J1 T 05461 2020-01-01 Level 1 Neurostimulator and Related Procedures J1 T 09043 2020-01-01 Inj, afstyla, 1 i.u. K G 09058 2020-01-01 Buprenorphine implant 74.2mg K G 09059 2020-01-01 Vonvendi inj 1 iu vwf:rco K G 09329 2020-01-01 Inj mvasi 10 mg G K 09330 2020-01-01 Inj., kanjinti, 10 mg G K


Page 9 of 84

Added Comprehensive APCs

The following Comprehensive APC(s) were added. Added Comprehensive APCs APC Eff Date Description Status Indicator 05495 2020-01-01 Level 5 Intraocular Procedures J1


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05054 2020-01-01 Level 4 Skin Procedures $759.60 $737.11 05055 2020-01-01 Level 5 Skin Procedures $269.44 $185.54 05571 2020-01-01 Level 1 Imaging with Contrast $40.14 $47.13 05572 2020-01-01 Level 2 Imaging with Contrast $71.94 $67.34 05573 2020-01-01 Level 3 Imaging with Contrast $103.89 $96.84 05591 2020-01-01 Level 1 Nuclear Medicine and Related Services $51.65 $49.81 05592 2020-01-01 Level 2 Nuclear Medicine and Related Services $92.41 $92.85 05593 2020-01-01 Level 3 Nuclear Medicine and Related Services $338.91 $335.42 05594 2020-01-01 Level 4 Nuclear Medicine and Related Services $269.87 $329.24 05722 2020-01-01 Level 2 Diagnostic Tests and Related Services $3.57 $3.59


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Added HCPCS Codes

The following HCPCS code(s) were added. Added HCPCS Codes HCPCS Eff Date Description Status


0139U 2020-01-01 Neuro austm meas 6 c metablt Q4 00000 0140U 2020-01-01 Nfct ds fungi dna 15 trgt A 00000 0141U 2020-01-01 Nfct ds bact&fng gram pos A 00000 0142U 2020-01-01 Nfct ds bact&fng gram neg A 00000 0143U 2020-01-01 Drug assay 120+ rx/metablt Q4 00000 0144U 2020-01-01 Drug assay 160+ rx/metablt Q4 00000 0145U 2020-01-01 Drug assay 65+ rx/metablt Q4 00000 0146U 2020-01-01 Drug assay 80+ rx/metablt Q4 00000 0147U 2020-01-01 Drug assay 85+ rx/metablt Q4 00000 0148U 2020-01-01 Drug assay 100+ rx/metablt Q4 00000 0149U 2020-01-01 Drug assay 60+ rx/metablt Q4 00000 0150U 2020-01-01 Drug assay 120+ rx/metablt Q4 00000 0151U 2020-01-01 Nfct bct/vir resp nfctj 33 A 00000 0152U 2020-01-01 Nfct bct fng prst dna >1000 A 00000 0153U 2020-01-01 Onc breast mrna 101 genes A 00000 0154U 2020-01-01 Fgfr3 gene analysis A 00000 0155U 2020-01-01 Pik3ca gene analysis A 00000 0156U 2020-01-01 Copy number sequence alys A 00000 0157U 2020-01-01 Apc mrna seq alys A 00000 0158U 2020-01-01 Mlh1 mrna seq alys A 00000 0159U 2020-01-01 Msh2 mrna seq alys A 00000 0160U 2020-01-01 Msh6 mrna seq alys A 00000 0161U 2020-01-01 Pms2 mrna seq alys A 00000 0162U 2020-01-01 Hered colon ca trgt mrna pnl A 00000 0563T 2020-01-01 Evac meibomian glnd heat bi Q1 05733 0564T 2020-01-01 Onc chemo rx cytotox csc 14 Q1 05671 0565T 2020-01-01 Autol cell implt adps hrvg Q1 05733 0566T 2020-01-01 Autol cell implt adps njx T 05441 0567T 2020-01-01 Perm flp tube occls w/implt E1 00000 9 0568T 2020-01-01 Intro mix saline&air f/ssg E1 00000 9 0569T 2020-01-01 Ttvr perq appr 1st prosth C 00000 0570T 2020-01-01 Ttvr perq ea addl prosth C 00000 0571T 2020-01-01 Insj/rplcmt icds ss eltrd E1 00000 9 0572T 2020-01-01 Insertion ss dfb electrode E1 00000 9 0573T 2020-01-01 Removal ss dfb electrode E1 00000 9 0574T 2020-01-01 Repos prev ss impl dfb eltrd E1 00000 9 0575T 2020-01-01 Prgrmg dev eval icds ss ip E1 00000 9 0576T 2020-01-01 Interrog dev eval icds ss ip E1 00000 9 0577T 2020-01-01 Ephys eval icds ss E1 00000 9 0578T 2020-01-01 Rem interrog dev icds phys E1 00000 9 0579T 2020-01-01 Rem interrog dev icds tech E1 00000 9 0580T 2020-01-01 Rmvl ss impl dfb pg only E1 00000 9 0581T 2020-01-01 Abltj mal brst tum perq crtx E1 00000 9 0582T 2020-01-01 Trurl abltj mal prst8 tiss E1 00000 9 0583T 2020-01-01 Tmpst auto tube dlvr sys E1 00000 9 0584T 2020-01-01 Perq islet cell transplant C 00000 0585T 2020-01-01 Laps islet cell transplant C 00000 0586T 2020-01-01 Open islet cell transplant C 00000 0587T 2020-01-01 Perq impltj/rplcmt isdns ptn T 05442 0588T 2020-01-01 Revision/removal isdns ptn T 05441 0589T 2020-01-01 Elec alys smpl prgrmg iins S 05742 0590T 2020-01-01 Elec alys cplx prgrmg iins S 05742 0591T 2020-01-01 Hlth&wb coaching indiv 1st E1 00000 9 0592T 2020-01-01 Hlth&wb coaching indiv f-up E1 00000 9 0593T 2020-01-01 Hlth&wb coaching group E1 00000 9 15769 2020-01-01 Grfg autol soft tiss dir exc T 05055 15771 2020-01-01 Grfg autol fat lipo 50 cc/< T 05055 15772 2020-01-01 Grfg autol fat lipo ea addl N 00000 15773 2020-01-01 Grfg autol fat lipo 25 cc/< T 05054 15774 2020-01-01 Gfrg autol fat lipo ea addl N 00000 20560 2020-01-01 Ndl insj w/o njx 1 or 2 musc E1 00000 9 20561 2020-01-01 Ndl insj w/o njx 3+ musc E1 00000 9 20700 2020-01-01 Mnl prep&insj dp rx dlvr dev N 00000 20701 2020-01-01 Rmvl deep rx delivery device N 00000 20702 2020-01-01 Mnl prep&insj imed rx dev N 00000 20703 2020-01-01 Rmvl imed rx delivery device N 00000 20704 2020-01-01 Mnl prep&insj i-artic rx dev N 00000 20705 2020-01-01 Rmvl i-artic rx delivery dev N 00000 21601 2020-01-01 Exc chest wall tumor w/ribs J1 05073


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21602 2020-01-01 Exc ch wal tum w/o lymphadec C 00000 21603 2020-01-01 Exc ch wal tum w/lymphadec C 00000 3045F 2019-10-01 Hg a1c level 7.0-9.0% M 00000 72 3051F 2020-01-01 Hg a1c>equal 7.0%<8.0% E1 00000 28 3052F 2020-01-01 Hg a1c>equal 8.0%<equal 9.0% E1 00000 28 33016 2020-01-01 Pericardiocentesis w/imaging J1 05182 33017 2020-01-01 Prcrd drg 6yr+ w/o cgen car C 00000 33018 2020-01-01 Prcrd drg 0-5yr or w/anomly C 00000 33019 2020-01-01 Perq prcrd drg insj cath ct C 00000 33858 2020-01-01 As-aort grf f/aortic dsj C 00000 33859 2020-01-01 As-aort grf f/ds oth/thn dsj C 00000 33871 2020-01-01 Transvrs a-arch grf hypthrm C 00000 34717 2020-01-01 Evasc rpr a-iliac ndgft C 00000 34718 2020-01-01 Evasc rpr n/a a-iliac ndgft C 00000 35702 2020-01-01 Expl n/flwd surg uxtr art C 00000 35703 2020-01-01 Expl n/flwd surg lxtr art C 00000 46948 2020-01-01 Int hrhc tranal dartlzj 2+ J1 05313 49013 2020-01-01 Prpertl pel pack hemrrg trma C 00000 49014 2020-01-01 Reexploration pelvic wound C 00000 62328 2020-01-01 Dx lmbr spi pnxr w/fluor/ct T 05442 62329 2020-01-01 Ther spi pnxr csf fluor/ct T 05442 64451 2020-01-01 Njx aa&/strd nrv nrvtg si jt T 05442 64454 2020-01-01 Njx aa&/strd gnclr nrv brnch T 05442 64624 2020-01-01 Dstrj nulyt agt gnclr nrv J1 05431 64625 2020-01-01 Rf abltj nrv nrvtg si jt J1 05431 66987 2020-01-01 Xcapsl ctrc rmvl cplx w/ecp J1 05492 66988 2020-01-01 Xcapsl ctrc rmvl w/ecp J1 05492 74221 2020-01-01 X-ray xm esophagus 2cntrst Q1 05571 74248 2020-01-01 X-ray sm int f-thru std N 00000 78429 2020-01-01 Myocrd img pet 1 std w/ct S 05594 78430 2020-01-01 Myocrd img pet rst/strs w/ct S 05594 78431 2020-01-01 Myocrd img pet rst&strs ct S 01522 78432 2020-01-01 Myocrd img pet 2rtracer S 01523 78433 2020-01-01 Myocrd img pet 2rtracer ct S 01523 78434 2020-01-01 Aqmbf pet rest & rx stress N 00000 78830 2020-01-01 Rp loclzj tum spect w/ct 1 S 05593 78831 2020-01-01 Rp loclzj tum spect 2 areas S 05593 78832 2020-01-01 Rp loclzj tum spect w/ct 2 S 05594 78835 2020-01-01 Rp quan meas single area N 00000 80145 2020-01-01 Drug assay adalimumab Q4 00000 80187 2020-01-01 Drug assay posaconazole Q4 00000 80230 2020-01-01 Drug assay infliximab Q4 00000 80235 2020-01-01 Drug assay lacosamide Q4 00000 80280 2020-01-01 Drug assay vedolizumab Q4 00000 80285 2020-01-01 Drug assay voriconazole Q4 00000 81277 2020-01-01 Cytogenomic neo microra alys A 00000 81307 2020-01-01 Palb2 gene full gene seq A 00000 81308 2020-01-01 Palb2 gene known famil vrnt A 00000 81309 2020-01-01 Pik3ca gene trgt seq alys A 00000 81522 2020-01-01 Onc breast mrna 12 genes A 00000 81542 2020-01-01 Onc prostate mrna 22 cnt gen A 00000 81552 2020-01-01 Onc uveal mlnma mrna 15 gene A 00000 87563 2020-01-01 M. genitalium amp probe Q4 00000 90694 2020-01-01 Vacc aiiv4 no prsrv 0.5ml im E1 00000 9 90912 2020-01-01 Bfb training 1st 15 min A 00000 90913 2020-01-01 Bfb training ea addl 15 min A 00000 92201 2020-01-01 Opscpy extnd rta draw uni/bi Q1 05733 92202 2020-01-01 Opscpy extnd on/mac draw Q1 05733 92549 2020-01-01 Cdp-sot 6 cond w/i&r mct&adt Q1 05734 93356 2020-01-01 Myocrd strain img spckl trck N 00000 93985 2020-01-01 Dup-scan hemo compl bi std S 05523 93986 2020-01-01 Dup-scan hemo compl uni std S 05522 95700 2020-01-01 Eeg cont rec w/vid eeg tech S 05722 95705 2020-01-01 Eeg w/o vid 2-12 hr unmntr S 05722 95706 2020-01-01 Eeg wo vid 2-12hr intmt mntr S 05722 95707 2020-01-01 Eeg w/o vid 2-12hr cont mntr S 05722 95708 2020-01-01 Eeg wo vid ea 12-26hr unmntr S 05723 95709 2020-01-01 Eeg w/o vid ea 12-26hr intmt S 05723 95710 2020-01-01 Eeg w/o vid ea 12-26hr cont S 05723 95711 2020-01-01 Veeg 2-12 hr unmonitored S 05722 95712 2020-01-01 Veeg 2-12 hr intmt mntr S 05722 95713 2020-01-01 Veeg 2-12 hr cont mntr S 05723 95714 2020-01-01 Veeg ea 12-26 hr unmntr S 05723 95715 2020-01-01 Veeg ea 12-26hr intmt mntr S 05723 95716 2020-01-01 Veeg ea 12-26hr cont mntr S 05724 95717 2020-01-01 Eeg phys/qhp 2-12 hr w/o vid M 00000 72 95718 2020-01-01 Eeg phys/qhp 2-12 hr w/veeg M 00000 72


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95719 2020-01-01 Eeg phys/qhp ea incr w/o vid M 00000 72 95720 2020-01-01 Eeg phy/qhp ea incr w/veeg M 00000 72 95721 2020-01-01 Eeg phy/qhp>36<60 hr w/o vid M 00000 72 95722 2020-01-01 Eeg phy/qhp>36<60 hr w/veeg M 00000 72 95723 2020-01-01 Eeg phy/qhp>60<84 hr w/o vid M 00000 72 95724 2020-01-01 Eeg phy/qhp>60<84 hr w/veeg M 00000 72 95725 2020-01-01 Eeg phy/qhp>84 hr w/o vid M 00000 72 95726 2020-01-01 Eeg phy/qhp>84 hr w/veeg M 00000 72 96156 2020-01-01 Hlth bhv assmt/reassessment Q3 05822 96158 2020-01-01 Hlth bhv ivntj indiv 1st 30 Q3 05822 96159 2020-01-01 Hlth bhv ivntj indiv ea addl N 00000 96164 2020-01-01 Hlth bhv ivntj grp 1st 30 Q3 05821 96165 2020-01-01 Hlth bhv ivntj grp ea addl N 00000 96167 2020-01-01 Hlth bhv ivntj fam 1st 30 Q3 05821 96168 2020-01-01 Hlth bhv ivntj fam ea addl N 00000 96170 2020-01-01 Hlth bhv ivntj fam wo pt 1st E1 00000 9 96171 2020-01-01 Hlth bhv ivntj fam w/o pt ea E1 00000 9 97129 2020-01-01 Ther ivntj 1st 15 min A 00000 97130 2020-01-01 Ther ivntj ea addl 15 min A 00000 98970 2020-01-01 Qnhp ol dig e/m svc 5-10min B 00000 62 98971 2020-01-01 Qnhp ol dig em svc 11-20min B 00000 62 98972 2020-01-01 Qnhp ol dig e/m svc 21+ min B 00000 62 99421 2020-01-01 Ol dig e/m svc 5-10 min M 00000 72 99422 2020-01-01 Ol dig e/m svc 11-20 min M 00000 72 99423 2020-01-01 Ol dig e/m svc 21+ min M 00000 72 99458 2020-01-01 Rem physiol mntr ea addl 20 N 00000 99473 2020-01-01 Self-meas bp pt educaj/train Q1 05731 99474 2020-01-01 Self-meas bp 2 readg bid 30d M 00000 72 A4226 2020-01-01 Weekly supply maint cgs pump N 00000 A9590 2020-01-01 Iodine i-131 iobenguane 1mci G 09339 B4187 2020-01-01 Omegaven, 10 grams lipids B 00000 62 C1734 2020-01-01 Orth/devic/drug bn/bn,tis/bn H 02026 55 C1824 2020-01-01 Generator, ccm, implant H 02024 55 C1839 2020-01-01 Iris prosthesis H 02028 55 C1982 2020-01-01 Cath, pressure,valve-occlu H 02025 55 C2596 2020-01-01 Probe, robotic, water-jet H 02027 55 C9043 2019-10-01 Injection, levoleucovorin G 09303 55 C9054 2020-01-01 Injection, lefamulin G 09332 55 C9055 2020-01-01 Inj, brexanolone G 09333 55 C9757 2020-01-01 Spine/lumbar disk surgery J1 05115 55 C9758 2020-01-01 Interatrial shunt ide T 01589 55 D0419 2020-01-01 Assess of salivary flow E1 00000 9 D1551 2020-01-01 Recement space maint - max S 05871 D1552 2020-01-01 Recement space maint - man S 05871 D1553 2020-01-01 Recement unilat space maint S 05871 D1556 2020-01-01 Rem fixed unilat space maint E1 00000 50 D1557 2020-01-01 Remove fixed bilat maint max E1 00000 50 D1558 2020-01-01 Remove fixed bilat man E1 00000 50 D2753 2020-01-01 Crown porc fused to titanium E1 00000 50 D5284 2020-01-01 Rem unilat dent flex base E1 00000 50 D5286 2020-01-01 Rem unilat dent 1 pc resin E1 00000 50 D6082 2020-01-01 Imp crown porc to base alloy E1 00000 28 D6083 2020-01-01 Imp crown porc to noble allo E1 00000 28 D6084 2020-01-01 Imp crown porc to titanium E1 00000 28 D6086 2020-01-01 Imp crown base alloys E1 00000 28 D6087 2020-01-01 Implant crown noble alloys E1 00000 28 D6088 2020-01-01 Imp crown titanium alloys E1 00000 28 D6097 2020-01-01 Abut crown porc to titanium E1 00000 28 D6098 2020-01-01 Imp retain porc to base allo E1 00000 9 D6099 2020-01-01 Imp retainer for fpd E1 00000 9 D6120 2020-01-01 Imp retain porc to titanium E1 00000 9 D6121 2020-01-01 Retain metal fpd base alloys E1 00000 9 D6122 2020-01-01 Retain metal fpd noble alloy E1 00000 9 D6123 2020-01-01 Retain metal fpd titanium E1 00000 9 D6195 2020-01-01 Abut retain porc to titanium E1 00000 9 D6243 2020-01-01 Pontic porcelain to titanium E1 00000 50 D6753 2020-01-01 Retain crown porc to titaniu E1 00000 50 D6784 2020-01-01 Retainer crown 3/4 titanium E1 00000 9 D7922 2020-01-01 Place intra-socket bio dress E1 00000 28 D8696 2020-01-01 Rep of ortho appliance max E1 00000 50 D8697 2020-01-01 Rep of ortho appliance man E1 00000 50 D8698 2020-01-01 Recement fixed retainer max E1 00000 50 D8699 2020-01-01 Recement fixed retainer man E1 00000 50 D8701 2020-01-01 Repair fixed retainer max E1 00000 50 D8702 2020-01-01 Repair of fixed retainer man E1 00000 50 D8703 2020-01-01 Replace broken retainer max E1 00000 50 D8704 2020-01-01 Replace broken retainer man E1 00000 50


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D9997 2020-01-01 Dent case mgmt special needs E1 00000 28 E0787 2020-01-01 Cgs dose adj insulin inf pmp Y 00000 61 E2398 2020-01-01 Wc dynamic pos back hardware Y 00000 61 G1000 2020-01-01 Cdsm applied pathways E1 00000 112 G1001 2020-01-01 Cdsm evicore E1 00000 112 G1002 2020-01-01 Cdsm medcurrent E1 00000 112 G1003 2020-01-01 Cdsm medicalis E1 00000 112 G1004 2020-01-01 Cdsm ndsc E1 00000 112 G1005 2020-01-01 Cdsm nia E1 00000 112 G1006 2020-01-01 Cdsm test approp E1 00000 112 G1007 2020-01-01 Cdsm aim E1 00000 112 G1008 2020-01-01 Cdsm cranberry pk E1 00000 112 G1009 2020-01-01 Cdsm sage health E1 00000 112 G1010 2020-01-01 Cdsm stanson E1 00000 112 G1011 2020-01-01 Cdsm qualified nos E1 00000 112 G2021 2020-01-01 Hea care pract tx in place E1 00000 112 G2022 2020-01-01 Benef refuses service, mod E1 00000 112 G2058 2020-01-01 Ccm add 20min N 00000 G2061 2020-01-01 Qual nonmd est pt 5-10m M 00000 72 G2062 2020-01-01 Qual nonmd est pt 11-20m M 00000 72 G2063 2020-01-01 Qual nonmd est pt 21>min M 00000 72 G2064 2020-01-01 Md mang high risk dx 30 M 00000 72 G2065 2020-01-01 Clin mang h risk dx 30 S 05822 G2066 2020-01-01 Inter devc remote 30d Q1 05741 G2067 2020-01-01 Med assist tx meth wk E1 00000 112 G2068 2020-01-01 Med assist tx bupre oral E1 00000 112 G2069 2020-01-01 Med assist tx inject E1 00000 112 G2070 2020-01-01 Med assist tx implant E1 00000 112 G2071 2020-01-01 Med tx remove implant E1 00000 112 G2072 2020-01-01 Med tx insert/remove imp E1 00000 112 G2073 2020-01-01 Med tx naltrexone E1 00000 112 G2074 2020-01-01 Med assist tx no drug E1 00000 112 G2075 2020-01-01 Med tx meds nos E1 00000 112 G2076 2020-01-01 Intake act w/med exam E1 00000 112 G2077 2020-01-01 Periodic assessment E1 00000 112 G2078 2020-01-01 Take-home meth E1 00000 112 G2079 2020-01-01 Take-hom buprenorphine E1 00000 112 G2080 2020-01-01 Add 30 mins counsel E1 00000 112 G2081 2020-01-01 Pt 66+ snp or ltc pos > 90d M 00000 72 G2082 2020-01-01 Visit esketamine 56m or less S 01508 G2083 2020-01-01 Visit esketamine, > 56m S 01511 G2086 2020-01-01 Off base opioid tx 70min S 05823 G2087 2020-01-01 Off base opioid tx, 60 m S 05823 G2088 2020-01-01 Off base opioid tx, add30 N 00000 G2089 2020-01-01 A1c level 7 to 9% M 00000 72 G2090 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2091 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2092 2020-01-01 Ace arb arni M 00000 72 G2093 2020-01-01 Med doc rsn no ace arn arni M 00000 72 G2094 2020-01-01 Pt rsn no ace arn arni M 00000 72 G2095 2020-01-01 Sys rsn no ace arn arni M 00000 72 G2096 2020-01-01 No rsn ace arb arni M 00000 72 G2097 2020-01-01 Child dx uri 3d of other dx M 00000 72 G2098 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2099 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2100 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2101 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2102 2020-01-01 Dil retinal eye exam M 00000 72 G2103 2020-01-01 7 stereo photos interpret M 00000 72 G2104 2020-01-01 Eye img valid w/7 stereo M 00000 72 G2105 2020-01-01 Pt 66+ lt ints > 90 M 00000 72 G2106 2020-01-01 Pt 66+ lt ints > 90 M 00000 72 G2107 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2108 2020-01-01 Pt 66+ lt ints > 90 M 00000 72 G2109 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2110 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2112 2020-01-01 Pred<=5 mg ra glu <6m M 00000 72 G2113 2020-01-01 Pred>5 mg >6m, no chg da M 00000 72 G2114 2020-01-01 Pt 66-80 frailty and med dem M 00000 72 G2115 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2116 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2117 2020-01-01 Pt 66-80 frailty and adv ill M 00000 72 G2118 2020-01-01 Pt 81+ frailty M 00000 72 G2119 2020-01-01 Calc vitd opt M 00000 72 G2120 2020-01-01 No calc vitd opt M 00000 72 G2121 2020-01-01 Psy dep anx ap and icd asse M 00000 72 G2122 2020-01-01 Psy/dep/anx/apandicd noasse M 00000 72


Page 15 of 84



G2123 2020-01-01 Pt 66-80 frailty med dem M 00000 72 G2124 2020-01-01 Pt 66-80 frailty adv ill M 00000 72 G2125 2020-01-01 Pt 81+ frailty M 00000 72 G2126 2020-01-01 Pt 66+ frailty adv ill M 00000 72 G2127 2020-01-01 Pt 66+ frailty med dem M 00000 72 G2128 2020-01-01 No aspirin med rsn M 00000 72 G2129 2020-01-01 No bp outpt M 00000 72 G2130 2020-01-01 Pt 66+ lt inst > 90 M 00000 72 G2131 2020-01-01 Pt 81+ frailty M 00000 72 G2132 2020-01-01 Pt 66-80 frailty and med dem M 00000 72 G2133 2020-01-01 Pt 66-80 frailty and adv ill M 00000 72 G2134 2020-01-01 Pt 66+ frailty and med dem M 00000 72 G2135 2020-01-01 Pt 66+ frailty and adv ill M 00000 72 G2136 2020-01-01 Bk pain vas 6-20wk = 3 M 00000 72 G2137 2020-01-01 Bk pain vas 6-20wk > 3 M 00000 72 G2138 2020-01-01 Bk pain vas 9-15mo = 3 M 00000 72 G2139 2020-01-01 Bk pain vas 9-20mo > 3 M 00000 72 G2140 2020-01-01 Leg pain vas 6-20wk = 3 M 00000 72 G2141 2020-01-01 Leg pain vas 6-20wk > 3 M 00000 72 G2142 2020-01-01 Fs odi 9-15mo postop<= 22 M 00000 72 G2143 2020-01-01 Fs odi 9-15mo > 22 M 00000 72 G2144 2020-01-01 Fs odi 6-20wk postop > 22 M 00000 72 G2145 2020-01-01 Fsodi 6-20wk >22 or chg 30pt M 00000 72 G2146 2020-01-01 Leg pain vas 9-15mo <= 3 M 00000 72 G2147 2020-01-01 Leg pain vas 9-15mo > 3 M 00000 72 G2148 2020-01-01 Mpm used M 00000 72 G2149 2020-01-01 No mpm med rsn M 00000 72 G2150 2020-01-01 No mpm M 00000 72 G2151 2020-01-01 Dx degen neuro M 00000 72 G2152 2020-01-01 Res change sc =0 M 00000 72 G2153 2020-01-01 Hosp dur meas pd M 00000 72 G2154 2020-01-01 Td 9 yrs start end meas M 00000 72 G2155 2020-01-01 Hist contraindications M 00000 72 G2156 2020-01-01 No prior td or hx contra M 00000 72 G2157 2020-01-01 Pneum vacc 12 mo 60+ M 00000 72 G2158 2020-01-01 Pneum vacc adv rx M 00000 72 G2159 2020-01-01 No pneum vacc 12 mo 60+ M 00000 72 G2160 2020-01-01 Herpzos 50+ M 00000 72 G2161 2020-01-01 Adv rx zos M 00000 72 G2162 2020-01-01 No herpzos 50+ M 00000 72 G2163 2020-01-01 Infl vacc 07/01 to 06/30 M 00000 72 G2164 2020-01-01 Adv rx infl vacc M 00000 72 G2165 2020-01-01 No infl vacc 07/01 to 06/30 M 00000 72 G2166 2020-01-01 No pt adm dx no neck fs prom M 00000 72 G2167 2020-01-01 Res change sc < 0 M 00000 72 J0179 2020-01-01 Inj, brolucizumab-dbll, 1 mg K 09340 J0642 2019-10-01 Injection, khapzory, 0.5 mg B 00000 62 J0642 2020-01-01 Injection, khapzory, 0.5 mg G 09334 J9199 2020-01-01 Injection, infugem, 200 mg N 00000 J9309 2020-01-01 Inj, polatuzumab vedotin 1mg G 09331 K1001 2020-01-01 Electronic posa treatment Y 00000 61 K1002 2020-01-01 Ces system w/supplies access E1 00000 9 K1003 2020-01-01 Whirlpool tub walkin portabl Y 00000 61 K1004 2020-01-01 Lo freq us diathermy device Y 00000 61 K1005 2020-01-01 Disp col sto bag breast milk Y 00000 61 L2006 2020-01-01 Kaf sng/dbl swg/stn mcpr cus A 00000 L8033 2020-01-01 Nipple prosthesis custom, ea A 00000 M1106 2020-01-01 Start eoc doc med rec M 00000 72 M1107 2020-01-01 Docu dx degen neuro M 00000 72 M1108 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1109 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1110 2020-01-01 Oc ni pt selfdc 1-2 vis M 00000 72 M1111 2020-01-01 Start eoc doc med rec M 00000 72 M1112 2020-01-01 Docu dx degen neuro M 00000 72 M1113 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1114 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1115 2020-01-01 Oc ni pt selfdc 1-2 vis M 00000 72 M1116 2020-01-01 Start eoc doc med rec M 00000 72 M1117 2020-01-01 Docu dx degen neuro M 00000 72 M1118 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1119 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1120 2020-01-01 Oc ni pt selfdc 1-2 vis M 00000 72 M1121 2020-01-01 Start eoc doc med rec M 00000 72 M1122 2020-01-01 Docu dx degen neuro M 00000 72 M1123 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1124 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1125 2020-01-01 Oc ni pt selfdc 1-2 vis M 00000 72


Page 16 of 84



M1126 2020-01-01 Start eoc doc med rec M 00000 72 M1127 2020-01-01 Docu dx degen neuro M 00000 72 M1128 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1129 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1130 2020-01-01 Oc ni pt self dc 1-2 vis M 00000 72 M1131 2020-01-01 Docu dx degen neuro M 00000 72 M1132 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1133 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1134 2020-01-01 Oc ni pt self dc 1-2 vis M 00000 72 M1135 2020-01-01 Start eoc doc med rec M 00000 72 M1136 2020-01-01 Start eoc doc med rec M 00000 72 M1137 2020-01-01 Docu dx degen neuro M 00000 72 M1138 2020-01-01 Oc ni pt 1-2 vis M 00000 72 M1139 2020-01-01 Oc ni pt self dc 1-2 vis M 00000 72 M1140 2020-01-01 Oc ni pt dc 1-2 vis M 00000 72 M1141 2020-01-01 Fs no oks M 00000 72 M1142 2020-01-01 Emerge cases M 00000 72 M1143 2020-01-01 Ni rehab med chiro M 00000 72 M1144 2020-01-01 Oc no ind pt 1-2 vis M 00000 72 P9099 2020-01-01 Blood component/product noc E2 00000 13


Page 17 of 84

Deleted HCPCS CPT Codes

The following HCPCS code(s) were deleted. Deleted HCPCS CPT Codes HCPCS Eff Date Description 0009M 2020-01-01 Fetal aneuploidy trisom risk 0081U 2020-01-01 Onc uveal mlnma mrna 15 gene 0085U 2020-01-01 Cdtb&vinculin igg antb ia 0205T 2020-01-01 Inirs each vessel add-on 0206T 2020-01-01 Cptr dbs alys car elec dta 0249T 2020-01-01 Ligation hemorrhoid w/us 0254T 2020-01-01 Evasc rpr iliac art bifur 0341T 2020-01-01 Quant pupillometry w/ rprt 0357T 2020-01-01 Cryopreservation oocyte(s) 0375T 2020-01-01 Total disc arthrp ant appr 0377T 2020-01-01 Anoscpy inj agent for incont 0380T 2020-01-01 Comp animat ret imag series 0399T 2020-01-01 Myocardial strain imaging 0482T 2020-01-01 Absl quan myocrd bld flo pet 19260 2020-01-01 Removal of chest wall lesion 19271 2020-01-01 Revision of chest wall 19272 2020-01-01 Extensive chest wall surgery 19304 2020-01-01 Mast subq 20926 2020-01-01 Removal of tissue for graft 3051F 2019-10-01 Hg a1c>equal 7.0%<8.0% 3052F 2019-10-01 Hg a1c>equal 8.0%<equal 9.0% 33010 2020-01-01 Drainage of heart sac 33011 2020-01-01 Repeat drainage of heart sac 33015 2020-01-01 Incision of heart sac 33860 2020-01-01 Ascending aortic graft 33870 2020-01-01 Transverse aortic arch graft 35721 2020-01-01 Exploration femoral artery 35741 2020-01-01 Exploration popliteal artery 35761 2020-01-01 Exploration of artery/vein 43401 2020-01-01 Esophagus surgery for veins 64402 2020-01-01 N block inj facial 64410 2020-01-01 N block inj phrenic 64413 2020-01-01 N block inj cervical plexus 74241 2020-01-01 X-ray upper gi delay w/kub 74245 2020-01-01 X-ray upper gi&small intest 74247 2020-01-01 Contrst x-ray uppr gi tract 74249 2020-01-01 Contrst x-ray uppr gi tract 74260 2020-01-01 X-ray exam of small bowel 76930 2020-01-01 Echo guide cardiocentesis 78205 2020-01-01 Liver imaging (3d) 78206 2020-01-01 Liver image (3d) with flow 78320 2020-01-01 Bone imaging (3d) 78607 2020-01-01 Brain imaging (3d) 78647 2020-01-01 Cerebrospinal fluid scan 78710 2020-01-01 Kidney imaging (3d) 78805 2020-01-01 Abscess imaging ltd area 78806 2020-01-01 Abscess imaging whole body 78807 2020-01-01 Nuclear localization/abscess 90911 2020-01-01 Biofeedback peri/uro/rectal 92225 2020-01-01 Special eye exam initial 92226 2020-01-01 Special eye exam subsequent 93299 2020-01-01 Interrog eval icpms/scrms 95827 2020-01-01 Eeg all night recording 95831 2020-01-01 Limb muscle testing manual 95832 2020-01-01 Hand muscle testing manual 95833 2020-01-01 Body muscle testing manual 95834 2020-01-01 Body muscle testing manual 95950 2020-01-01 Ambulatory eeg monitoring 95951 2020-01-01 Eeg monitoring/videorecord 95953 2020-01-01 Eeg monitoring/computer 95956 2020-01-01 Eeg monitor technol attended 96150 2020-01-01 Assess hlth/behave init 96151 2020-01-01 Assess hlth/behave subseq 96152 2020-01-01 Intervene hlth/behave indiv 96153 2020-01-01 Intervene hlth/behave group 96154 2020-01-01 Interv hlth/behav fam w/pt 96155 2020-01-01 Interv hlth/behav fam no pt 97127 2020-01-01 Ther ivntj w/focus cog funcj 98969 2020-01-01 Online service by hc pro 99444 2020-01-01 Online e/m by phys/qhp C9407 2020-01-01 Iodine i-131 iobenguane, dx C9408 2020-01-01 Iodine i-131 iobenguane, tx D1550 2020-01-01 Recement space maintainer


Page 18 of 84

Deleted HCPCS CPT Codes HCPCS Eff Date Description D1555 2020-01-01 Remove fix space maintainer D8691 2020-01-01 Repair ortho appliance D8692 2020-01-01 Replacement retainer D8693 2020-01-01 Rebond/recement retainers D8694 2020-01-01 Repair fixed retainers G0365 2020-01-01 Vessel mapping hemo access G0515 2020-01-01 Cognitive skills development G8649 2020-01-01 Rafscrs ki no scor G8653 2020-01-01 Rafscrs hi no scor G8657 2020-01-01 Rafscrs llfai no scor G8665 2020-01-01 Rafscrs si no scor G8669 2020-01-01 Rafscrs G8673 2020-01-01 Rafscrs goi no scor G8861 2020-01-01 Dxa ordered for osteo G8978 2020-01-01 Mobility current status G8979 2020-01-01 Mobility goal status G8980 2020-01-01 Mobility d/c status G8981 2020-01-01 Body pos current status G8982 2020-01-01 Body pos goal status G8983 2020-01-01 Body pos d/c status G8984 2020-01-01 Carry current status G8985 2020-01-01 Carry goal status G8986 2020-01-01 Carry d/c status G8987 2020-01-01 Self care current status G8988 2020-01-01 Self care goal status G8989 2020-01-01 Self care d/c status G8990 2020-01-01 Other pt/ot current status G8991 2020-01-01 Other pt/ot goal status G8992 2020-01-01 Other pt/ot d/c status G8993 2020-01-01 Sub pt/ot current status G8994 2020-01-01 Sub pt/ot goal status G8995 2020-01-01 Sub pt/ot d/c status G8996 2020-01-01 Swallow current status G8997 2020-01-01 Swallow goal status G8998 2020-01-01 Swallow d/c status G8999 2020-01-01 Motor speech current status G9017 2020-01-01 Amantadine hcl 100mg oral G9018 2020-01-01 Zanamivir,inhalation pwd 10m G9019 2020-01-01 Oseltamivir phosphate 75mg G9020 2020-01-01 Rimantadine hcl 100mg oral G9033 2020-01-01 Amantadine hcl oral brand G9034 2020-01-01 Zanamivir, inh pwdr, brand G9035 2020-01-01 Oseltamivir phosp, brand G9036 2020-01-01 Rimantadine hcl, brand G9158 2020-01-01 Motor speech d/c status G9159 2020-01-01 Lang comp current status G9160 2020-01-01 Lang comp goal status G9161 2020-01-01 Lang comp d/c status G9162 2020-01-01 Lang express current status G9163 2020-01-01 Lang express goal status G9164 2020-01-01 Lang express d/c status G9165 2020-01-01 Atten current status G9166 2020-01-01 Atten goal status G9167 2020-01-01 Atten d/c status G9168 2020-01-01 Memory current status G9169 2020-01-01 Memory goal status G9170 2020-01-01 Memory d/c status G9171 2020-01-01 Voice current status G9172 2020-01-01 Voice goal status G9173 2020-01-01 Voice d/c status G9174 2020-01-01 Speech lang current status G9175 2020-01-01 Speech lang goal status G9176 2020-01-01 Speech lang d/c status G9186 2020-01-01 Motor speech goal status G9472 2020-01-01 No dxa no med hx no rv sx G9742 2020-01-01 Psych sympt assessed G9743 2020-01-01 Psych symp not assessed, rns G9941 2020-01-01 Pre and post vas wthn 3 mos G9944 2020-01-01 Vas 3 mon pre and 1 yr post G9947 2020-01-01 Pre and post vas wthn 3 mos M1000 2020-01-01 Pain scr as mod to sevr M1001 2020-01-01 Pln to adrs pain doc M1002 2020-01-01 Pln to adrs pain not doc M1030 2020-01-01 Pt clin ind img hd M1042 2020-01-01 Ftl st mea sco ot odi 3 mo M1044 2020-01-01 Ftl st mea odi 3 mo M1047 2020-01-01 Fs msrd oks pre and post M1048 2020-01-01 Fsm wth scr odi pre and post


Page 19 of 84

Deleted HCPCS CPT Codes HCPCS Eff Date Description M1050 2020-01-01 Fs msrd odi pre and post M1053 2020-01-01 Pre and post vas wthn 3 mos 3045F 2020-01-01 Hg a1c level 7.0-9.0%


Page 20 of 84

Modified HCPCS Code Descriptions

The following HCPCS code(s) had a description change. Modified HCPCS Code Descriptions HCPCS Eff Date Description Current Description Previous 0124U 2020-01-01 Ftl cgen abnor 3 analytes Ftl cgen abnor 3 analtyes 0402T 2019-01-01 Colgn cross-link crn med sep Collagen crosslinking cornea 0409T 2016-01-01 Insj/rplc car modulj pls gn Insj/rplc cardiac modulj pls gn 0423T 2016-01-01 Assay secretory type ii pla2 Assay secretory type ii pla2` 0434T 2016-01-01 Interro eval npgs apnea Interro eval npgs sleep apnea 11921 2015-01-01 Correct skn color 6.1-20.0cm Correct skn color 6.1-20.0cm 2022F 2020-01-01 Dilat rta xm evc rtnopthy Dil retina exam interp rev 2024F 2020-01-01 7 fld rta photo evc rtnopthy 7 field photo interp doc rev 3084F 2020-01-01 Kt/v >= 1.7 Kt/v >/= 1.7 31233 2020-01-01 Nsl/sins ndsc dx max sinusc Nasal/sinus endoscopy dx 31235 2020-01-01 Nsl/sins ndsc dx sphn sinusc Nasal/sinus endoscopy dx 31292 2020-01-01 Nsl/sins ndsc med/inf dcmprn Nasal/sinus endoscopy surg 31293 2020-01-01 Nsl/sins ndsc med&inf dcmprn Nasal/sinus endoscopy surg 31294 2020-01-01 Nsl/sins ndsc surg on dcmprn Nasal/sinus endoscopy surg 31295 2020-01-01 Nsl/sins ndsc surg max sins Sinus endo w/balloon dil 31296 2020-01-01 Nsl/sins ndsc surg frnt sins Sinus endo w/balloon dil 31297 2020-01-01 Nsl/sins ndsc surg sphn sins Sinus endo w/balloon dil 31298 2020-01-01 Nsl/sins ndsc surg frnt&sphn Nsl/sins ndsc w/sins dilat 33275 2020-01-01 Tcat rmvl perm ldls pm w/img Tcat rmvl perm ldls pm 35701 2020-01-01 Expl n/flwd surg neck art Exploration carotid artery 43763 2019-01-01 Rplc gtube revj gstrst trc Rplc gtube revj gstrst trc 46945 2020-01-01 Int hrhc lig 1 hroid w/o img Remove by ligat int hem grp 46946 2020-01-01 Int hrhc lig 2+hroid w/o img Remove by ligat int hem grps 54640 2020-01-01 Orchiopexy ingun/scrot appr Suspension of testis 62270 2020-01-01 Dx lmbr spi pnxr Spinal fluid tap diagnostic 62272 2020-01-01 Ther spi pnxr drg csf Drain cerebro spinal fluid 64400 2020-01-01 Njx aa&/strd trigeminal nrv N block inj trigeminal 64405 2020-01-01 Njx aa&/strd gr ocpl nrv N block inj occipital 64408 2020-01-01 Njx aa&/strd vagus nrv N block inj vagus 64415 2020-01-01 Njx aa&/strd brach plexus N block inj brachial plexus 64416 2020-01-01 Njx aa&/strd brach plex nfs N block cont infuse b plex 64417 2020-01-01 Njx aa&/strd axillary nrv N block inj axillary 64418 2020-01-01 Njx aa&/strd sprscap nrv N block inj suprascapular 64420 2020-01-01 Njx aa&/strd ntrcost nrv 1 N block inj intercost sng 64421 2020-01-01 Njx aa&/strd ntrcost nrv ea N block inj intercost mlt 64425 2020-01-01 Njx aa&/strd ii ih nerves N block inj ilio-ing/hypogi 64430 2020-01-01 Njx aa&/strd pudendal nerve N block inj pudendal 64435 2020-01-01 Njx aa&/strd paracrv nrv N block inj paracervical 64445 2020-01-01 Njx aa&/strd sciatic nerve N block inj sciatic sng 64446 2020-01-01 Njx aa&/strd sciatic nrv nfs N blk inj sciatic cont inf 64447 2020-01-01 Njx aa&/strd femoral nerve N block inj fem single 64448 2020-01-01 Njx aa&/strd fem nerve nfs N block inj fem cont inf 64449 2020-01-01 Njx aa&/strd lmbr plex nfs N block inj lumbar plexus 64450 2020-01-01 Njx aa&/strd other pn/branch N block other peripheral 66711 2020-01-01 Ecp ciliary body destruction Ciliary endoscopic ablation 66982 2020-01-01 Xcapsl ctrc rmvl cplx wo ecp Cataract surgery complex 66984 2020-01-01 Xcapsl ctrc rmvl w/o ecp Cataract surg w/iol 1 stage 74022 2020-01-01 X-ray exam complete abdomen X-ray exam series abdomen 74210 2020-01-01 X-ray xm phrnx&/crv esoph c+ Contrst x-ray exam of throat 74220 2020-01-01 X-ray xm esophagus 1cntrst Contrast x-ray esophagus 74230 2020-01-01 X-ray xm swlng funcj c+ Cine/vid x-ray throat/esoph 74240 2020-01-01 X-ray xm upr gi trc 1cntrst X-ray upper gi delay w/o kub 74246 2020-01-01 X-ray xm upr gi trc 2cntrst Contrst x-ray uppr gi tract 74250 2020-01-01 X-ray xm sm int 1cntrst std X-ray exam of small bowel 74251 2020-01-01 X-ray xm sm int 2cntrst std X-ray exam of small bowel 74270 2020-01-01 X-ray xm colon 1cntrst std Contrast x-ray exam of colon 74280 2020-01-01 X-ray xm colon 2cntrst std Contrast x-ray exam of colon 76805 2020-01-01 Ob us >= 14 wks sngl fetus Ob us >/= 14 wks sngl fetus 76810 2020-01-01 Ob us >= 14 wks addl fetus Ob us >/= 14 wks addl fetus 78459 2020-01-01 Myocrd img pet single study Heart muscle imaging (pet) 78491 2020-01-01 Myocrd img pet 1std rst/strs Heart image (pet) single 78492 2020-01-01 Myocrd img pet mlt rst&strs Heart image (pet) multiple 78800 2020-01-01 Rp loclzj tum 1 area 1 d img Tumor imaging limited area 78801 2020-01-01 Rp loclzj tum 2+area 1+d img Tumor imaging mult areas 78802 2020-01-01 Rp loclzj tum whbdy 1 d img Tumor imaging whole body 78803 2020-01-01 Rp loclzj tum spect 1 area Tumor imaging (3d) 78804 2020-01-01 Rp loclzj tum whbdy 2+d img Tumor imaging whole body 81350 2020-01-01 Ugt1a1 gene common variants Ugt1a1 gene 90734 2020-01-01 Menacwyd/menacwycrm vacc im Mcv4 menacwy vaccine im 92548 2020-01-01 Cdp-sot 6 cond w/i&r Posturography 92626 2020-01-01 Eval aud funcj 1st hour Eval aud rehab status 92627 2020-01-01 Eval aud funcj ea addl 15 Eval aud status rehab add-on 93784 2020-01-01 Ambl bp mntr w/software Ambulatory bp monitoring


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Modified HCPCS Code Descriptions HCPCS Eff Date Description Current Description Previous 93786 2020-01-01 Ambl bp mntr w/sw rec only Ambulatory bp recording 93788 2020-01-01 Ambl bp mntr w/sw a/r Ambulatory bp analysis 93790 2020-01-01 Ambl bp mntr w/sw i&r Review/report bp recording 93792 2020-01-01 Pt/caregiver traing home inr Pt/caregiver trainj home inr 94728 2020-01-01 Airwy resist by oscillometry Pulm funct test oscillometry 95813 2020-01-01 Eeg extnd mntr 61-119 min Eeg over 1 hour 95836 2020-01-01 Ecog impltd brn npgt <30 d Ecog impltd brn npgt </30 d 97605 2020-01-01 Neg press wound tx <=50 cm Neg press wound tx </=50 cm 97607 2020-01-01 Neg press wnd tx <=50 sq cm Neg press wnd tx </=50 sq cm 97760 2020-01-01 Orthotic mgmt&traing 1st enc Orthotic mgmt&trainj 1st enc 97761 2020-01-01 Prosthetic traing 1st enc Prosthetic trainj 1st enc 99457 2020-01-01 Rem physiol mntr 1st 20 min Rem physiol mntr 20 min mo A4407 2019-10-01 Ext wear ost skn barr <=4sq" Ext wear ost skn barr <=4sq A4408 2019-10-01 Ext wear ost skn barr >4sq" Ext wear ost skn barr >4sq A4719 2019-10-01 "y set" tubing y set tubing B4185 2020-01-01 Pn soln nos 10 grams lipids Parenteral sol 10 gm lipids C8903 2020-01-01 Mri w/cont, breast, uni Mri w/cont, breast, uni C8906 2020-01-01 Mri w/cont, breast, bi Mri w/cont, breast, bi C8937 2019-01-01 Cad breast mri CAD breast MRI C9041 2019-04-01 Inj, coagulation factor xa Inj, coagulation factor Xa C9756 2019-07-01 Fluorescence lymph map w/icg Fluorescence lymph map w/ICG E2201 2019-10-01 Man w/ch acc seat w>=20"<24" Man w/ch acc seat w>=20"<24 G0108 2020-01-01 Diab manage trn per indiv Diab manage trn per indiv G2000 2018-10-01 Blinded conv. tx mdd clin tr Blinded conv. Tx MDD clin tr G2012 2019-01-01 Brief check in by md/qhp Brief check in by MD/QHP G8650 2020-01-01 Rafs crs ki no scor no surv Rafscrs ki no scor no surv G8654 2020-01-01 Rafs crs hi no scor no surv Rafscrs hi no scor no surv G8662 2020-01-01 Rafs crs lbi no scor no surv Rafscrs lbi no scor no surv G8666 2020-01-01 Rafs crs si no scor no surv Rafscrs si no scor no surv G8670 2020-01-01 Rafs crs ewh no scor no surv Rafscrs ewh no scor no surv G9349 2020-01-01 Ct within 28 days Doc sinus ct 28d G9359 2020-01-01 Neg mgd pos tb notact Doc of neg or man pos tb scn G9405 2020-01-01 Recd f/u w/in 7d dc Recd f/u w/in 7d disch G9469 2020-01-01 Rec cortico>90d or 1rx 900mg Rec cortico>60d or 1rx 600mg G9510 2020-01-01 Remis12m not phq-9 score <5 Remis 12m not phq-9 score <5 G9519 2020-01-01 Final ref +/- 1.0 w/in 90d Final ref +/- 0.5 w/in 90d G9520 2020-01-01 Refract not +/- 1.0 w/in 90d Refract not +/- 0.5 w/in 90d G9547 2020-01-01 Cys ren les or adren Incid finding liver/kid/adre G9548 2020-01-01 No f/u rec image study Abd imag and followup rec G9549 2020-01-01 Doc med rsn for f/u imag Doc med rsn for follow imag G9550 2020-01-01 Imag rec Abd imag and followup no rec G9551 2020-01-01 Imag no les Abd imag no les,kid/livr/adr G9595 2020-01-01 Doc shnt/tum/coag Doc shnt/tum/coag/thrombocyt G9663 2020-01-01 Fast/dir ldl <= 190 mg/dl Fast/dir ldl = 190 mg/dl G9695 2017-01-01 Long act inhal bronchdil pre Long act inhal bronchdil pres G9699 2017-01-01 Long inhal bronchdil no pres Long inhal bronchdil no presc G9785 2020-01-01 Path report sent Pathology report sent G9786 2020-01-01 Path report not sent Pathology report not sent G9798 2020-01-01 D/c ami btw 7/1-6/30 meas pd D/c ami btw 7/1-6/30 mst per G9898 2020-01-01 Pt 66+ snp or ltc pos Snp/lg trm cre pt w/pos cde G9901 2020-01-01 Pt 66+ snp or ltc pos Snp/lg trm cre pt w/pos cde G9910 2020-01-01 Pt 66+ snp or ltc pos Snp/lg trm cre pt w/pos cde G9917 2020-01-01 Adv dem crgvr limited Doc med rsn no funct status G9927 2020-01-01 Doc no warf /fda pt trial Doc no warf /fda pt trial G9938 2020-01-01 Pt 66+ snp or ltc pos Snp/lg trm cre pt w/pos cde G9945 2020-01-01 Pt w/cancer scoliosis Pt w/cancer scoliosis G9946 2020-01-01 Bk pain no vas Bk pn nt msr vas pre-pst 1y G9949 2020-01-01 Leg pain no vas Lg pn nt msr vas scl pre/pst G9984 2020-01-01 Remote e/m est. pt 15mins Remote e/m est. pt 15mins J0641 2019-10-01 Inj levoleucovorin nos 0.5mg Inj., levoleucovorin, 0.5 mg J2794 2019-10-01 Inj risperdal consta, 0.5 mg Inj., risperdal consta, 0.5 mg J9201 2020-01-01 In gemcitabine hcl nos 200mg Gemcitabine hcl injection J9204 2019-10-01 Inj mogamulizumab-kpkc, 1 mg Inj, mogamulizumab-kpkc, 1 mg L8608 2019-01-01 Arg ii ext com/sup/acc misc Arg II ext com/sup/acc misc M1009 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1010 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1011 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1012 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1013 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1014 2020-01-01 Dc epi care doc medrec Pt tx and final eval comp M1015 2020-01-01 Dc eoc doc med rec Pt tx and final eval comp M1043 2020-01-01 Fs no odi 9-15mo Ftl st mea sco no ot odi M1045 2020-01-01 Fs oks 9-15mo = 37 Fsm wth scr oks pre and post M1046 2020-01-01 Fs oks 9-15mo = 37 Fsm wth scr no oks pre and p M1049 2020-01-01 Fs wth scr no odi pre and p Fsm wth scr no odi pre and p M1052 2020-01-01 Lg pn not meas w/ vas 1yr po Lg pn nt msr vas scl pre/pst Q4220 2019-10-01 Bellacell hd, surederm sq cm Bellacell HD, Surederm sq cm Q5114 2019-07-01 Inj ogivri 10 mg Inj ogivri 10 mg


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Modified HCPCS Code Descriptions HCPCS Eff Date Description Current Description Previous Q9985 2017-07-01 Inj hydroxyprogesterone, NOS Inj, hydroxyprogesterone, NOS Q9988 2017-07-01 Platelet pheresis path reduc Platelets pheresis path reduc S0285 2016-07-01 Cnslt before screen colonosc Cnslt before screen colonoscop S1036 2014-07-01 Art pancreas ext transmitter Art pancreas ext transmitter. V5190 2019-01-01 Hearing aid monaural glasses Hearing aid monaural glasses


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0002M 2020-01-01 Liver dis 10 assays w/ash Q4 E1 9 0003M 2020-01-01 Liver dis 10 assays w/nash Q4 E1 9 0071U 2020-01-01 Cyp2d6 full gene sequence A N 0072U 2020-01-01 Cyp2d6 gen cyp2d6-2d7 hybrid A N 0073U 2020-01-01 Cyp2d6 gen cyp2d7-2d6 hybrid A N 0074U 2020-01-01 Cyp2d6 nonduplicated gene A N 0075U 2020-01-01 Cyp2d6 5' gene dup/mlt A N 0076U 2020-01-01 Cyp2d6 3' gene dup/mlt A N 00802 2020-01-01 Anesth fat layer removal N C 00865 2020-01-01 Anesth removal of prostate N C 00944 2020-01-01 Anesth vaginal hysterectomy N C 01214 2020-01-01 Anesth hip arthroplasty N C 0126T 2020-01-01 Chd risk imt study 05731 05732 0130U 2020-01-01 Hered colon ca do mrna pnl A N 0131U 2020-01-01 Hered brst ca rltd do pnl 13 A N 0132U 2020-01-01 Hered ova ca rltd do pnl 17 A N 0133U 2020-01-01 Hered prst8 ca rltd do 11 A N 0134U 2020-01-01 Hered pan ca mrna pnl 18 gen A N 0135U 2020-01-01 Hered gyn ca mrna pnl 12 gen A N 0136U 2020-01-01 Atm mrna seq alys A N 0137U 2020-01-01 Palb2 mrna seq alys A N 0138U 2020-01-01 Brca1 brca2 mrna seq alys A N 0266T 2020-01-01 Implt/rpl crtd sns dev total 05464 05463 0267T 2020-01-01 Implt/rpl crtd sns dev lead J1 T 0268T 2020-01-01 Implt/rpl crtd sns dev gen 05464 05463 0270T 2020-01-01 Rev/remvl crtd sns dev lead J1 Q2 0271T 2020-01-01 Rev/remvl crtd sns dev gen J1 Q2 0296T 2020-01-01 Ext ecg recording 05733 05734 0308T 2020-01-01 Insj ocular telescope prosth 05495 05494 0313T 2020-01-01 Laps rmvl nstim array vagus J1 T 0314T 2020-01-01 Laps rmvl vgl arry&pls gen J1 Q2 0315T 2020-01-01 Rmvl vagus nerve pls gen J1 Q2 0316T 2020-01-01 Replc vagus nerve pls gen 05464 05463 0356T 2020-01-01 Insrt drug device for iop 05692 05733 0358T 2020-01-01 Bia whole body 05731 05732 0421T 2020-01-01 Waterjet prostate abltj cmpl 05376 05375 0427T 2020-01-01 Insj/rplc nstim apnea pls gn 05464 05463 0428T 2020-01-01 Rmvl nstim apnea pls gen J1 Q2 0429T 2020-01-01 Rmvl nstim apnea sen ld J1 Q2 0430T 2020-01-01 Rmvl nstim apnea stimj ld J1 Q2 0431T 2020-01-01 Rmvl/rplc nstim apnea pls gn 05464 05463 0432T 2020-01-01 Repos nstim apnea stimj ld J1 T 0433T 2020-01-01 Repos nstim apnea sensing ld J1 T 0440T 2020-01-01 Abltj perc uxtr/perph nrv 05431 05432 0441T 2020-01-01 Abltj perc lxtr/perph nrv 05431 05432 0467T 2020-01-01 Revj/rplmnt ch respir eltrd J1 Q2 0468T 2020-01-01 Rmvl ch wal respir eltrd/ra J1 Q2 0499T 2020-01-01 Cysto f/urtl strix/stenosis 05374 05373 0503T 2020-01-01 Cor ffr alys gnrj ffr mdl 01511 01516 0541T 2020-01-01 Myocardial imaging mcg 05723 05722 0548T 2020-01-01 Tprnl balo cntnc dev bi 05376 05377 15782 2020-01-01 Dermabrasion other than face 05073 05072 12 12 15830 2020-01-01 Exc skin abd 12 15847 2020-01-01 Exc skin abd add-on 12 15931 2020-01-01 Remove sacrum pressure sore 05073 05072 2023F 2020-01-01 Dilat rta xm w/o rtnopthy E1 M 9 72 2025F 2020-01-01 7 fld rta photo w/o rtnopthy E1 M 9 72 2033F 2020-01-01 Eye img valid w/o rtnopthy E1 M 9 72 20912 2020-01-01 Remove cartilage for graft 12 21210 2020-01-01 Face bone graft 12 21235 2020-01-01 Ear cartilage graft 12 21700 2020-01-01 Revision of neck muscle 05114 05113 21811 2020-01-01 Optx of rib fx w/fixj scope 05114 05113 21812 2020-01-01 Treatment of rib fracture 05114 05113 22101 2020-01-01 Remove part thorax vertebra 05114 05113 22633 2020-01-01 Lumbar spine fusion combined 05115 00000 J1 C 22634 2020-01-01 Spine fusion extra segment N C 22869 2020-01-01 Insj stablj dev w/o dcmprn 05115 05116 23031 2020-01-01 Drain shoulder bursa 05073 05072 23174 2020-01-01 Remove humerus lesion 05114 05113 23180 2020-01-01 Remove collar bone lesion 05114 05113


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23182 2020-01-01 Remove shoulder blade lesion 05114 05113 23333 2020-01-01 Remove shoulder fb deep 05073 05072 23406 2020-01-01 Incise tendon(s) & muscle(s) 05114 05113 23440 2020-01-01 Remove/transplant tendon 05114 05113 23930 2020-01-01 Drainage of arm lesion 05073 05072 24330 2020-01-01 Revision of arm muscles 05114 05113 24582 2020-01-01 Treat humerus fracture 05114 05113 25077 2020-01-01 Resect forearm/wrist tum<3cm 05073 05072 25135 2020-01-01 Remove & graft wrist lesion 05114 05113 25263 2020-01-01 Repair forearm tendon/muscle 05114 05113 25392 2020-01-01 Shorten radius & ulna 05114 05113 25393 2020-01-01 Lengthen radius & ulna 05114 05113 25670 2020-01-01 Treat wrist dislocation 05114 05113 25685 2020-01-01 Treat wrist fracture 05114 05113 25909 2020-01-01 Amputation follow-up surgery 05114 05113 26352 2020-01-01 Repair/graft hand tendon 05114 05113 26358 2020-01-01 Repair/graft hand tendon 05114 05113 26518 2020-01-01 Fusion of knuckle joints 05114 05113 26530 2020-01-01 Revise knuckle joint 05114 05113 27033 2020-01-01 Exploration of hip joint 05114 05113 27060 2020-01-01 Removal of ischial bursa 05114 05113 27065 2020-01-01 Remove hip bone les super 05114 05113 27086 2020-01-01 Remove hip foreign body 05073 05072 27130 2020-01-01 Total hip arthroplasty 05115 00000 J1 C 27350 2020-01-01 Removal of kneecap 05114 05113 27393 2020-01-01 Lengthening of thigh tendon 05114 05113 27403 2020-01-01 Repair of knee cartilage 05114 05113 27477 2020-01-01 Surgery to stop leg growth 05114 05113 27485 2020-01-01 Surgery to stop leg growth 05114 05113 27499 2020-01-01 Decompression of thigh/knee 05114 05113 27650 2020-01-01 Repair achilles tendon 05114 05113 28070 2020-01-01 Removal of foot joint lining 05114 05113 28130 2020-01-01 Removal of ankle bone 05114 05113 28299 2020-01-01 Correction hallux valgus 05114 05113 28307 2020-01-01 Incision of metatarsal 05114 05113 28310 2020-01-01 Revision of big toe 05114 05113 28576 2020-01-01 Treat foot dislocation 05114 05113 29861 2020-01-01 Hip arthro w/fb removal 05114 05113 29905 2020-01-01 Subtalar arthro w/exc 05114 05113 30460 2020-01-01 Revision of nose 12 30462 2020-01-01 Revision of nose 12 30465 2020-01-01 Repair nasal stenosis 12 3051F 2020-01-01 Hg a1c>equal 7.0%<8.0% E1 M 28 72 30520 2020-01-01 Repair of nasal septum 12 3052F 2020-01-01 Hg a1c>equal 8.0%<equal 9.0% E1 M 28 72 31201 2020-01-01 Removal of ethmoid sinus 05163 05164 32551 2020-01-01 Insertion of chest tube J1 T 32557 2020-01-01 Insert cath pleura w/ image J1 T 36473 2020-01-01 Endovenous mchnchem 1st vein 12 36474 2020-01-01 Endovenous mchnchem add-on 12 36475 2020-01-01 Endovenous rf 1st vein 12 36476 2020-01-01 Endovenous rf vein add-on 12 36478 2020-01-01 Endovenous laser 1st vein 12 36479 2020-01-01 Endovenous laser vein addon 12 36482 2020-01-01 Endoven ther chem adhes 1st 12 36483 2020-01-01 Endoven ther chem adhes sbsq 12 36555 2020-01-01 Insert non-tunnel cv cath J1 T 36556 2020-01-01 Insert non-tunnel cv cath J1 T 36569 2020-01-01 Insj picc 5 yr+ w/o imaging J1 T 36573 2020-01-01 Insj picc rs&i 5 yr+ J1 T 36576 2020-01-01 Repair tunneled cv cath J1 T 36580 2020-01-01 Replace cvad cath J1 T 36584 2020-01-01 Compl rplcmt picc rs&i J1 T 36596 2020-01-01 Mech remov tunneled cv cath J1 T 36597 2020-01-01 Reposition venous catheter J1 T 36901 2020-01-01 Intro cath dialysis circuit J1 T 37184 2020-01-01 Prim art m-thrmbc 1st vsl 05193 05192 37213 2020-01-01 Thromblytic art/ven therapy J1 T 37214 2020-01-01 Cessj therapy cath removal J1 T 37565 2020-01-01 Ligation of neck vein J1 T 37615 2020-01-01 Ligation of neck artery J1 T 37761 2020-01-01 Ligate leg veins open J1 T 37780 2020-01-01 Revision of leg vein J1 T 38222 2020-01-01 Dx bone marrow bx & aspir 05073 05072 38300 2020-01-01 Drainage lymph node lesion 05073 05072 38305 2020-01-01 Drainage lymph node lesion 05073 05072


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40812 2020-01-01 Excise/repair mouth lesion 05163 05164 41828 2020-01-01 Excision of gum lesion 05163 05164 12 12 41870 2020-01-01 Gum graft 05163 05164 42405 2020-01-01 Biopsy of salivary gland 05163 05164 42800 2020-01-01 Biopsy of throat 05163 05164 44390 2020-01-01 Colonoscopy for foreign body 05311 05312 45337 2020-01-01 Sigmoidoscopy & decompress 05311 05312 45341 2020-01-01 Sigmoidoscopy w/ultrasound 05311 05312 45349 2020-01-01 Sigmoidoscopy w/resection 05313 05312 J1 T 45390 2020-01-01 Colonoscopy w/resection 05313 05312 J1 T 50433 2020-01-01 Plmt nephroureteral catheter 05374 05373 50555 2020-01-01 Kidney endoscopy & biopsy 05376 05375 50693 2020-01-01 Plmt ureteral stent prq 05374 05373 50951 2020-01-01 Endoscopy of ureter 05374 05373 50970 2020-01-01 Ureter endoscopy 05374 05373 51020 2020-01-01 Incise & treat bladder 05374 05373 51520 2020-01-01 Removal of bladder lesion 05374 05373 52341 2020-01-01 Cysto w/ureter stricture tx 05374 05373 52351 2020-01-01 Cystouretero & or pyeloscope 05374 05373 53240 2020-01-01 Surgery for urethra pouch 05374 05373 53450 2020-01-01 Revision of urethra 05374 05373 53460 2020-01-01 Revision of urethra 05374 05373 54000 2020-01-01 Slitting of prepuce 05374 05373 54435 2020-01-01 Revision of penis 05374 05373 54520 2020-01-01 Removal of testis 05374 05373 54522 2020-01-01 Orchiectomy partial 05374 05373 54600 2020-01-01 Reduce testis torsion 05374 05373 54680 2020-01-01 Relocation of testis(es) 05374 05373 54865 2020-01-01 Explore epididymis 05374 05373 55060 2020-01-01 Repair of hydrocele 05374 05373 55150 2020-01-01 Removal of scrotum 05374 05373 55200 2020-01-01 Incision of sperm duct 05374 05373 55500 2020-01-01 Removal of hydrocele 05374 05373 55520 2020-01-01 Removal of sperm cord lesion 05374 05373 55706 2020-01-01 Prostate saturation sampling 05374 05373 55970 2020-01-01 Sex transformation m to f 05415 05414 57020 2020-01-01 Drainage of pelvic fluid 05415 05414 57022 2020-01-01 I & d vaginal hematoma pp 05073 05072 57150 2020-01-01 Treat vagina infection 05733 05734 57155 2020-01-01 Insert uteri tandem/ovoids 05415 05414 57268 2020-01-01 Repair of bowel bulge 05415 05414 57291 2020-01-01 Construction of vagina 05415 05414 57335 2020-01-01 Repair vagina 05415 05414 57530 2020-01-01 Removal of cervix 05415 05414 57550 2020-01-01 Removal of residual cervix 05415 05414 58301 2020-01-01 Remove intrauterine device 05412 05411 12 12 58346 2020-01-01 Insert heyman uteri capsule 05415 05414 59100 2020-01-01 Remove uterus lesion 05415 05414 61880 2020-01-01 Revise/remove neuroelectrode J1 Q2 62287 2020-01-01 Percutaneous diskectomy 05431 05432 63265 2020-01-01 Excise intraspinl lesion crv 05114 00000 J1 C 63266 2020-01-01 Excise intrspinl lesion thrc 05114 00000 J1 C 63267 2020-01-01 Excise intrspinl lesion lmbr 05114 00000 J1 C 63268 2020-01-01 Excise intrspinl lesion scrl 05114 00000 J1 C 63662 2020-01-01 Remove spine eltrd plate J1 Q2 63688 2020-01-01 Revise/remove neuroreceiver J1 Q2 64585 2020-01-01 Revise/remove neuroelectrode J1 Q2 64595 2020-01-01 Revise/rmv pn/gastr stimul J1 Q2 64612 2020-01-01 Destroy nerve face muscle 12 64615 2020-01-01 Chemodenerv musc migraine 12 64766 2020-01-01 Incise hip/thigh nerve 05431 05432 64831 2020-01-01 Repair of digit nerve 05431 05432 64858 2020-01-01 Repair sciatic nerve 05431 05432 64861 2020-01-01 Repair of arm nerves 05431 05432 67900 2020-01-01 Repair brow defect 12 69610 2020-01-01 Repair of eardrum 05163 05164 74230 2020-01-01 X-ray xm swlng funcj c+ 05571 05522 74250 2020-01-01 X-ray xm sm int 1cntrst std 05571 05522 74251 2020-01-01 X-ray xm sm int 2cntrst std 05571 05523 Q1 S 74280 2020-01-01 X-ray xm colon 2cntrst std Q1 S 75731 2020-01-01 Artery x-rays adrenal gland J1 Q2 75746 2020-01-01 Artery x-rays lung J1 Q2 75803 2020-01-01 Lymph vessel x-ray arms/legs J1 Q2 75805 2020-01-01 Lymph vessel x-ray trunk J1 Q2 75810 2020-01-01 Vein x-ray spleen/liver J1 Q2 75822 2020-01-01 Vein x-ray arms/legs J1 Q2


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Edits Current

Edits Previous

75870 2020-01-01 Vein x-ray skull J1 Q2 75887 2020-01-01 Vein x-ray liver w/o hemodyn J1 Q2 75898 2020-01-01 Follow-up angiography J1 Q2 78803 2020-01-01 Rp loclzj tum spect 1 area 05593 05592 81508 2020-01-01 Ftl cgen abnor two proteins Q4 E1 9 81509 2020-01-01 Ftl cgen abnor 3 proteins Q4 E1 9 81510 2020-01-01 Ftl cgen abnor three anal Q4 E1 9 81511 2020-01-01 Ftl cgen abnor four anal Q4 E1 9 81512 2020-01-01 Ftl cgen abnor five anal Q4 E1 9 86077 2020-01-01 Phys blood bank serv xmatch 05731 05732 86485 2020-01-01 Skin test candida 05731 05732 86975 2020-01-01 Rbc serum pretx incubj drugs 05734 05732 87490 2020-01-01 Chylmd trach dna dir probe Q4 A 87491 2020-01-01 Chylmd trach dna amp probe Q4 A 87590 2020-01-01 N.gonorrhoeae dna dir prob Q4 A 87591 2020-01-01 N.gonorrhoeae dna amp prob Q4 A 87800 2020-01-01 Detect agnt mult dna direc Q4 A 88161 2020-01-01 Cytopath smear other source 05731 05732 88302 2020-01-01 Tissue exam by pathologist 05731 05732 88358 2020-01-01 Analysis tumor 05672 05673 89251 2020-01-01 Cultr oocyte/embryo <4 days 05672 05673 90296 2020-01-01 Diphtheria antitoxin 09315 00000 K N 90634 2020-01-01 Hepa vacc ped/adol 3 dose 00000 09086 N K 92228 2020-01-01 Remote retinal imaging mgmt 05732 05735 92283 2020-01-01 Color vision examination 05733 05734 92326 2020-01-01 Replacement of contact lens 05733 05734 93050 2020-01-01 Art pressure waveform analys 05731 05732 93503 2020-01-01 Insert/place heart catheter J1 T 94200 2020-01-01 Lung function test (mbc/mvv) 05733 05734 95017 2020-01-01 Perq & icut allg test venoms 05731 05732 95933 2020-01-01 Blink reflex test 05733 05734 95983 2020-01-01 Alys brn npgt prgrmg 15 min 05742 05741 96932 2020-01-01 Rcm celulr subcelulr img skn 00000 05731 N Q1 A9587 2020-01-01 Gallium ga-68 00000 09056 N G A9588 2020-01-01 Fluciclovine f-18 00000 09052 N G C9248 2020-01-01 Inj, clevidipine butyrate 00000 09087 N K 55 55 C9293 2020-01-01 Injection, glucarpidase 00000 09293 N K 55 55 C9754 2020-01-01 Perc av fistula, direct 05194 05193 55 55 C9755 2020-01-01 Rf magnetic-guide av fistula 05194 05193 55 55 G0117 2020-01-01 Glaucoma scrn hgh risk direc 05731 05732 G0237 2020-01-01 Therapeutic procd strg endur 05731 05732 G0238 2020-01-01 Oth resp proc, indiv 05731 05732 G0413 2020-01-01 Pelvic ring fracture uni/bil 05114 05113 G0473 2020-01-01 Group behave couns 2-10 05821 05822 J0380 2020-01-01 Inj metaraminol bitartrate E2 N 13 J0520 2020-01-01 Bethanechol chloride inject E2 N 13 J0570 2020-01-01 Buprenorphine implant 74.2mg K G J0585 2020-01-01 Injection,onabotulinumtoxina 12 J0586 2020-01-01 Abobotulinumtoxina 12 J0587 2020-01-01 Inj, rimabotulinumtoxinb 12 J0588 2020-01-01 Incobotulinumtoxin a 12 J0637 2020-01-01 Caspofungin acetate 00000 09019 N K J0641 2019-10-01 Inj levoleucovorin nos 0.5mg 01236 09323 K G J0725 2020-01-01 Chorionic gonadotropin/1000u 00000 09098 N K J0800 2020-01-01 Corticotropin injection 09316 00000 K N J1267 2020-01-01 Doripenem injection 09317 00000 K N J1364 2020-01-01 Erythro lactobionate /500 mg 00000 01669 N K J1556 2020-01-01 Inj, imm glob bivigam, 500mg 00000 09130 N K J1729 2020-01-01 Inj hydroxyprogst capoat nos 09318 00000 K N J2062 2020-01-01 Loxapine for inhalation 1 mg 00000 09497 N K J2320 2020-01-01 Nandrolone decanoate 50 mg 00000 01743 N K J2469 2020-01-01 Palonosetron hcl 00000 09210 N K J2793 2020-01-01 Rilonacept injection E2 N 13 J2941 2020-01-01 Somatropin injection 09319 00000 K N J2993 2020-01-01 Reteplase injection 00000 09005 N K J3300 2020-01-01 Triamcinolone a inj prs-free 00000 01253 N K J3350 2020-01-01 Urea injection E2 N 13 J7179 2020-01-01 Vonvendi inj 1 iu vwf:rco K G J7210 2020-01-01 Inj, afstyla, 1 i.u. K G J7211 2020-01-01 Inj, kovaltry, 1 i.u. 00000 09075 N K J7321 2020-01-01 Hyalgan supartz visco-3 dose 00000 00873 N K J7331 2020-01-01 Synojoynt, inj., 1 mg 09337 00000 K E2 13 J7332 2020-01-01 Inj., triluron, 1 mg 09338 00000 K E2 13 J7340 2020-01-01 Carbidopa levodopa ent 100ml 09320 00000 K N J8510 2020-01-01 Oral busulfan 09335 00000 K N J8562 2020-01-01 Oral fludarabine phosphate 00000 09089 N K


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Edits Current

Edits Previous

J8600 2020-01-01 Melphalan oral 2 mg 00000 09090 N K J9034 2020-01-01 Inj., bendeka 1 mg K G J9151 2020-01-01 Daunorubicin citrate inj 00000 09091 N K J9215 2020-01-01 Interferon alfa-n3 inj E2 N 13 J9270 2020-01-01 Plicamycin (mithramycin) inj 00000 09093 N K P9100 2020-01-01 Pathogen test for platelets 01494 01493 Q2009 2020-01-01 Fosphenytoin inj pe 09321 00000 K N Q5107 2020-01-01 Inj mvasi 10 mg G K Q5115 2019-10-01 Inj truxima 10 mg 09336 00000 K E2 13 Q5117 2020-01-01 Inj., kanjinti, 10 mg G K


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The following HCPCS code(s) were added to Mid-Quarter edit 67, 68, 69, 83, or 110. Mid Quarter Edits Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description Approval Date Edit R* Q5115 2019-10-01 Inj truxima 10 mg 2019-11-11 110 A


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Male Only HCPCS Additions

The following HCPCS code(s) were added to the list of male procedures. Male Only HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0582T 2020-01-01 Trurl abltj mal prst8 tiss N 81542 2020-01-01 Onc prostate mrna 22 cnt gen N


Page 30 of 84

Female Only HCPCS Additions

The following HCPCS code(s) were added to the list of female procedures. Female Only HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0567T 2020-01-01 Perm flp tube occls w/implt N 0568T 2020-01-01 Intro mix saline&air f/ssg N


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Female Only HCPCS Removals

The following HCPCS code(s) were removed from the list of female procedures. Female Only HCPCS Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 0357T 2020-01-01 Cryopreservation oocyte(s) D


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Conditional Bilateral Additions

The following HCPCS were added to the Conditional Bilateral list. Conditional Bilateral Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 35702 2020-01-01 Expl n/flwd surg uxtr art N 35703 2020-01-01 Expl n/flwd surg lxtr art N 64420 2020-01-01 Njx aa&/strd ntrcost nrv 1 A 64451 2020-01-01 Njx aa&/strd nrv nrvtg si jt N 64454 2020-01-01 Njx aa&/strd gnclr nrv brnch N 64624 2020-01-01 Dstrj nulyt agt gnclr nrv N 64625 2020-01-01 Rf abltj nrv nrvtg si jt N 66987 2020-01-01 Xcapsl ctrc rmvl cplx w/ecp N 66988 2020-01-01 Xcapsl ctrc rmvl w/ecp N


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Conditional Bilateral Removals

The following HCPCS were removed from the Conditional Bilateral list. Conditional Bilateral Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 19304 2020-01-01 Mast subq D 35721 2020-01-01 Exploration femoral artery D 35741 2020-01-01 Exploration popliteal artery D 35761 2020-01-01 Exploration of artery/vein D 64402 2020-01-01 N block inj facial D 64410 2020-01-01 N block inj phrenic D 64413 2020-01-01 N block inj cervical plexus D


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Independent Bilateral Removals

The following HCPCS were removed from the Independent Bilateral list. Independent Bilateral Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 92225 2020-01-01 Special eye exam initial D 92226 2020-01-01 Special eye exam subsequent D


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Inherent Bilateral Additions

The following HCPCS were added to the Inherent Bilateral list. Inherent Bilateral Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 92201 2020-01-01 Opscpy extnd rta draw uni/bi N 92202 2020-01-01 Opscpy extnd on/mac draw N 93985 2020-01-01 Dup-scan hemo compl bi std N


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Deductible Coinsurance Not Applicable Additions

The following HCPCS were added to the Deductible Coinsurance Not Applicable list. Deductible Coinsurance Not Applicable Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* G0404 2020-01-01 Ekg tracing for initial prev A


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The following HCPCS were removed from the Deductible Coinsurance Not Applicable list. Deductible Coinsurance Not Applicable Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 86780 2018-01-01 Treponema pallidum R


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Non-Standard CT Scan Equipment Procedure Additions

The following code(s) were added to the Non-Standard (NEMA) CT scan procedure list when reported with modifier CT. Non-Standard CT Scan Equipment Procedure Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 78429 2020-01-01 Myocrd img pet 1 std w/ct N 78430 2020-01-01 Myocrd img pet rst/strs w/ct N 78431 2020-01-01 Myocrd img pet rst&strs ct N 78433 2020-01-01 Myocrd img pet 2rtracer ct N 78830 2020-01-01 Rp loclzj tum spect w/ct 1 N 78832 2020-01-01 Rp loclzj tum spect w/ct 2 N


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Non-Standard CT Scan Equipment Procedure Removals

The following code(s) were removed from the Non-Standard (NEMA) CT scan procedure list when reported with modifier CT. Non-Standard CT Scan Equipment Procedure Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 74263 2016-01-01 Ct colonography screening R


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Radiology Procedure For Payment Adjustment Additions

The following HCPCS were added to the Radiology Payment adjustment procedure list when reported with modifier FX or FY. Radiology Procedure For Payment Adjustment Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 74221 2020-01-01 X-ray xm esophagus 2cntrst N 74248 2020-01-01 X-ray sm int f-thru std N 78429 2020-01-01 Myocrd img pet 1 std w/ct N 78430 2020-01-01 Myocrd img pet rst/strs w/ct N 78431 2020-01-01 Myocrd img pet rst&strs ct N 78432 2020-01-01 Myocrd img pet 2rtracer N 78433 2020-01-01 Myocrd img pet 2rtracer ct N 78434 2020-01-01 Aqmbf pet rest & rx stress N 78830 2020-01-01 Rp loclzj tum spect w/ct 1 N 78831 2020-01-01 Rp loclzj tum spect 2 areas N 78832 2020-01-01 Rp loclzj tum spect w/ct 2 N 78835 2020-01-01 Rp quan meas single area N


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Radiology Procedure For Payment Adjustment Removals

The following HCPCS were added to the Radiology Payment adjustment procedure list when reported with modifier FX or FY. Radiology Procedure For Payment Adjustment Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 74241 2020-01-01 X-ray upper gi delay w/kub D 74245 2020-01-01 X-ray upper gi&small intest D 74247 2020-01-01 Contrst x-ray uppr gi tract D 74249 2020-01-01 Contrst x-ray uppr gi tract D 74260 2020-01-01 X-ray exam of small bowel D 76930 2020-01-01 Echo guide cardiocentesis D 78205 2020-01-01 Liver imaging (3d) D 78206 2020-01-01 Liver image (3d) with flow D 78320 2020-01-01 Bone imaging (3d) D 78607 2020-01-01 Brain imaging (3d) D 78647 2020-01-01 Cerebrospinal fluid scan D 78710 2020-01-01 Kidney imaging (3d) D 78805 2020-01-01 Abscess imaging ltd area D 78806 2020-01-01 Abscess imaging whole body D 78807 2020-01-01 Nuclear localization/abscess D


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The following HCPCS were assigned an SI = J1 Comprehensive APC, Comprehensive APC HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0267T 2020-01-01 Implt/rpl crtd sns dev lead A 0270T 2020-01-01 Rev/remvl crtd sns dev lead A 0271T 2020-01-01 Rev/remvl crtd sns dev gen A 0313T 2020-01-01 Laps rmvl nstim array vagus A 0314T 2020-01-01 Laps rmvl vgl arry&pls gen A 0315T 2020-01-01 Rmvl vagus nerve pls gen A 0428T 2020-01-01 Rmvl nstim apnea pls gen A 0429T 2020-01-01 Rmvl nstim apnea sen ld A 0430T 2020-01-01 Rmvl nstim apnea stimj ld A 0432T 2020-01-01 Repos nstim apnea stimj ld A 0433T 2020-01-01 Repos nstim apnea sensing ld A 0467T 2020-01-01 Revj/rplmnt ch respir eltrd A 0468T 2020-01-01 Rmvl ch wal respir eltrd/ra A 21601 2020-01-01 Exc chest wall tumor w/ribs N 22633 2020-01-01 Lumbar spine fusion combined A 27130 2020-01-01 Total hip arthroplasty A 32551 2020-01-01 Insertion of chest tube A 32557 2020-01-01 Insert cath pleura w/ image A 33016 2020-01-01 Pericardiocentesis w/imaging N 36555 2020-01-01 Insert non-tunnel cv cath A 36556 2020-01-01 Insert non-tunnel cv cath A 36569 2020-01-01 Insj picc 5 yr+ w/o imaging A 36573 2020-01-01 Insj picc rs&i 5 yr+ A 36576 2020-01-01 Repair tunneled cv cath A 36580 2020-01-01 Replace cvad cath A 36584 2020-01-01 Compl rplcmt picc rs&i A 36596 2020-01-01 Mech remov tunneled cv cath A 36597 2020-01-01 Reposition venous catheter A 36901 2020-01-01 Intro cath dialysis circuit A 37213 2020-01-01 Thromblytic art/ven therapy A 37214 2020-01-01 Cessj therapy cath removal A 37565 2020-01-01 Ligation of neck vein A 37615 2020-01-01 Ligation of neck artery A 37761 2020-01-01 Ligate leg veins open A 37780 2020-01-01 Revision of leg vein A 45349 2020-01-01 Sigmoidoscopy w/resection A 45390 2020-01-01 Colonoscopy w/resection A 46948 2020-01-01 Int hrhc tranal dartlzj 2+ N 61880 2020-01-01 Revise/remove neuroelectrode A 63265 2020-01-01 Excise intraspinl lesion crv A 63266 2020-01-01 Excise intrspinl lesion thrc A 63267 2020-01-01 Excise intrspinl lesion lmbr A 63268 2020-01-01 Excise intrspinl lesion scrl A 63662 2020-01-01 Remove spine eltrd plate A 63688 2020-01-01 Revise/remove neuroreceiver A 64585 2020-01-01 Revise/remove neuroelectrode A 64595 2020-01-01 Revise/rmv pn/gastr stimul A 64624 2020-01-01 Dstrj nulyt agt gnclr nrv N 64625 2020-01-01 Rf abltj nrv nrvtg si jt N 66987 2020-01-01 Xcapsl ctrc rmvl cplx w/ecp N 66988 2020-01-01 Xcapsl ctrc rmvl w/ecp N 75731 2020-01-01 Artery x-rays adrenal gland A 75746 2020-01-01 Artery x-rays lung A 75803 2020-01-01 Lymph vessel x-ray arms/legs A 75805 2020-01-01 Lymph vessel x-ray trunk A 75810 2020-01-01 Vein x-ray spleen/liver A 75822 2020-01-01 Vein x-ray arms/legs A 75870 2020-01-01 Vein x-ray skull A 75887 2020-01-01 Vein x-ray liver w/o hemodyn A 75898 2020-01-01 Follow-up angiography A 93503 2020-01-01 Insert/place heart catheter A C9757 2020-01-01 Spine/lumbar disk surgery N


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Comprehensive APC HCPCS Removals

The following HCPCS were removed from being assigned an SI = J1 Comprehensive APC. Comprehensive APC HCPCS Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 0249T 2020-01-01 Ligation hemorrhoid w/us D 0377T 2020-01-01 Anoscpy inj agent for incont D 19260 2020-01-01 Removal of chest wall lesion D 19304 2020-01-01 Mast subq D 35761 2020-01-01 Exploration of artery/vein D


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Complexity Adjusted Code Pair Additions

The following Comprehensive APC code pairs were added for complexity adjustment. Complexity Adjusted Code Pair Additions Reason Key: A=Added To List, N=New Code Code 1 Code 2 Eff Date R* 0191T 65820 2020-01-01 A 0449T 66984 2020-01-01 A 11406 11424 2020-01-01 A 11644 11623 2020-01-01 A 19370 19370 2020-01-01 A 20220 32405 2020-01-01 A 21012 21012 2020-01-01 A 22514 22510 2020-01-01 A 23071 21931 2020-01-01 A 23630 23430 2020-01-01 A 25447 25000 2020-01-01 A 25447 25111 2020-01-01 A 25447 26055 2020-01-01 A 25447 29846 2020-01-01 A 25447 29848 2020-01-01 A 25608 25545 2020-01-01 A 25608 25605 2020-01-01 A 25609 20690 2020-01-01 A 26455 26455 2020-01-01 A 26615 11012 2020-01-01 A 27652 28119 2020-01-01 A 27823 27829 2020-01-01 A 28108 28108 2020-01-01 A 28118 28200 2020-01-01 A 28122 11044 2020-01-01 A 28289 28285 2020-01-01 A 28291 28291 2020-01-01 A 28296 28104 2020-01-01 A 28296 28270 2020-01-01 A 28297 28285 2020-01-01 A 28297 28313 2020-01-01 A 28300 27698 2020-01-01 A 28300 28306 2020-01-01 A 28308 28288 2020-01-01 A 28645 28285 2020-01-01 A 28740 27687 2020-01-01 A 28740 27691 2020-01-01 A 28740 28292 2020-01-01 A 28750 28112 2020-01-01 A 29806 29828 2020-01-01 A 29819 29822 2020-01-01 A 29819 29823 2020-01-01 A 29823 23120 2020-01-01 A 29823 29824 2020-01-01 A 29837 29834 2020-01-01 A 29848 26145 2020-01-01 A 29882 29879 2020-01-01 A 29916 29914 2020-01-01 A 30630 30520 2020-01-01 A 31630 31628 2020-01-01 A 31630 31652 2020-01-01 A 31640 31652 2020-01-01 A 31641 31630 2020-01-01 A 31653 31640 2020-01-01 A 32405 20206 2020-01-01 A 32405 47000 2020-01-01 A 32550 32550 2020-01-01 A 32551 32551 2020-01-01 A 32556 32405 2020-01-01 A 32557 32405 2020-01-01 A 32557 32557 2020-01-01 A 33207 93650 2020-01-01 A 33285 93619 2020-01-01 A 36475 37785 2020-01-01 A 36556 32551 2020-01-01 A 36556 33016 2020-01-01 N 36556 36556 2020-01-01 A 36556 36569 2020-01-01 A 36556 36901 2020-01-01 A 36558 36556 2020-01-01 A 36558 38222 2020-01-01 A


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Complexity Adjusted Code Pair Additions Reason Key: A=Added To List, N=New Code Code 1 Code 2 Eff Date R* 36561 32557 2020-01-01 A 36561 36569 2020-01-01 A 36569 11044 2020-01-01 A 36569 36569 2020-01-01 A 36569 36584 2020-01-01 A 36569 43246 2020-01-01 A 36821 10140 2020-01-01 A 36821 36556 2020-01-01 A 36821 75822 2020-01-01 A 36904 36556 2020-01-01 A 37184 37221 2020-01-01 A 37184 37228 2020-01-01 A 37193 36561 2020-01-01 A 37221 37236 2020-01-01 A 37221 37246 2020-01-01 A 37225 93458 2020-01-01 A 37236 37224 2020-01-01 A 37241 37241 2020-01-01 A 37246 37220 2020-01-01 A 38220 38221 2020-01-01 A 38500 11623 2020-01-01 A 38500 11644 2020-01-01 A 38500 56620 2020-01-01 A 38510 11606 2020-01-01 A 38510 31535 2020-01-01 A 38525 19371 2020-01-01 A 38525 24073 2020-01-01 A 38570 58661 2020-01-01 A 43262 43242 2020-01-01 A 43264 43278 2020-01-01 A 43277 43262 2020-01-01 A 44366 44369 2020-01-01 A 44378 44377 2020-01-01 A 49423 20500 2020-01-01 A 49507 55040 2020-01-01 A 49520 54520 2020-01-01 A 49560 11406 2020-01-01 A 49560 49561 2020-01-01 A 49651 49329 2020-01-01 A 49652 49650 2020-01-01 A 49653 49651 2020-01-01 A 50200 38505 2020-01-01 A 50200 47000 2020-01-01 A 50382 50382 2020-01-01 A 50434 50387 2020-01-01 A 50434 50434 2020-01-01 A 50434 50435 2020-01-01 A 50693 50432 2020-01-01 A 50949 58661 2020-01-01 A 51040 52281 2020-01-01 A 51040 52310 2020-01-01 A 52005 51102 2020-01-01 A 52204 51102 2020-01-01 A 52204 52005 2020-01-01 A 52214 52260 2020-01-01 A 52214 C9738 2020-01-01 A 52224 52005 2020-01-01 A 52224 52214 2020-01-01 A 52224 55700 2020-01-01 A 52235 50432 2020-01-01 A 52276 54161 2020-01-01 A 52318 50590 2020-01-01 A 52332 50432 2020-01-01 A 52649 52356 2020-01-01 A 54001 52281 2020-01-01 A 54161 52005 2020-01-01 A 54161 55700 2020-01-01 A 55700 52310 2020-01-01 A 56620 58558 2020-01-01 A 58558 57520 2020-01-01 A 61626 75898 2020-01-01 A 63663 63688 2020-01-01 A 64708 64708 2020-01-01 A 64718 64719 2020-01-01 A 65730 66982 2020-01-01 A 65730 66984 2020-01-01 A


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Complexity Adjusted Code Pair Additions Reason Key: A=Added To List, N=New Code Code 1 Code 2 Eff Date R* 65756 66986 2020-01-01 A 66180 67036 2020-01-01 A 66180 67040 2020-01-01 A 66982 66982 2020-01-01 A 66986 67121 2020-01-01 A 67108 66984 2020-01-01 A 67113 66984 2020-01-01 A 67314 67311 2020-01-01 A 67911 67911 2020-01-01 A 69801 69801 2020-01-01 A 75898 75898 2020-01-01 A 92920 93456 2020-01-01 A 92924 92920 2020-01-01 A 92937 92928 2020-01-01 A 92937 92937 2020-01-01 A 92943 C9600 2020-01-01 A 93451 75822 2020-01-01 A 93454 93571 2020-01-01 A 93455 93454 2020-01-01 A 93458 36556 2020-01-01 A 93458 36569 2020-01-01 A 93458 93455 2020-01-01 A 93460 93458 2020-01-01 A 93461 92978 2020-01-01 A 93505 93505 2020-01-01 A


Page 47 of 84

Complexity Adjusted Code Pair Removals

The following Comprehensive APC code pairs were removed for complexity adjustment. Complexity Adjusted Code Pair Removals Reason Key: R=Removed From List, D=Code Terminated Code 1 Code 2 Eff Date R* 11404 11422 2020-01-01 R 11406 11422 2020-01-01 R 11406 11423 2020-01-01 R 11624 11643 2020-01-01 R 11644 11624 2020-01-01 R 19300 19300 2020-01-01 R 19301 19125 2020-01-01 R 19301 19499 2020-01-01 R 19304 19304 2020-01-01 D 21031 21031 2020-01-01 R 22513 20225 2020-01-01 R 22513 38221 2020-01-01 R 22514 20225 2020-01-01 R 22514 63030 2020-01-01 R 22612 38220 2020-01-01 R 25071 25071 2020-01-01 R 26535 26535 2020-01-01 R 26536 26536 2020-01-01 R 27650 27687 2020-01-01 R 27650 28119 2020-01-01 R 27650 28120 2020-01-01 R 28010 28010 2020-01-01 R 28118 27650 2020-01-01 R 28232 28232 2020-01-01 R 28292 28110 2020-01-01 R 28297 27687 2020-01-01 R 28297 28110 2020-01-01 R 28299 28110 2020-01-01 R 28299 28270 2020-01-01 R 28299 28285 2020-01-01 R 28299 28288 2020-01-01 R 28299 28308 2020-01-01 R 28299 28313 2020-01-01 R 28740 20900 2020-01-01 R 28740 28296 2020-01-01 R 28750 20902 2020-01-01 R 28750 27687 2020-01-01 R 28750 27691 2020-01-01 R 28750 28755 2020-01-01 R 28750 38220 2020-01-01 R 28805 27687 2020-01-01 R 29823 29819 2020-01-01 R 29823 29821 2020-01-01 R 29823 29825 2020-01-01 R 29824 29825 2020-01-01 R 29825 29822 2020-01-01 R 29827 23412 2020-01-01 R 29827 24340 2020-01-01 R 29855 27509 2020-01-01 R 29891 29898 2020-01-01 R 30117 31238 2020-01-01 R 30520 30130 2020-01-01 R 30520 30140 2020-01-01 R 30520 30630 2020-01-01 R 30520 30802 2020-01-01 R 30520 31238 2020-01-01 R 30520 31240 2020-01-01 R 31020 31020 2020-01-01 R 31600 43246 2020-01-01 R 31624 31622 2020-01-01 R 31624 31624 2020-01-01 R 31630 31641 2020-01-01 R 31641 43191 2020-01-01 R 31652 31640 2020-01-01 R 32609 32550 2020-01-01 R 33285 93460 2020-01-01 R 36558 36558 2020-01-01 R 36558 38221 2020-01-01 R 36821 36821 2020-01-01 R 36902 36830 2020-01-01 R 36904 37248 2020-01-01 R


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Complexity Adjusted Code Pair Removals Reason Key: R=Removed From List, D=Code Terminated Code 1 Code 2 Eff Date R* 36905 36905 2020-01-01 R 37184 37224 2020-01-01 R 37220 37222 2020-01-01 R 37221 37184 2020-01-01 R 37224 36902 2020-01-01 R 37224 37211 2020-01-01 R 37228 37184 2020-01-01 R 37236 37221 2020-01-01 R 37236 37236 2020-01-01 R 37238 37248 2020-01-01 R 37243 50593 2020-01-01 R 37722 36475 2020-01-01 R 37722 37722 2020-01-01 R 38221 20206 2020-01-01 R 38221 32405 2020-01-01 R 38221 49180 2020-01-01 R 38500 11643 2020-01-01 R 38500 36561 2020-01-01 R 38505 38505 2020-01-01 R 38510 69110 2020-01-01 R 38525 11406 2020-01-01 R 38525 19304 2020-01-01 D 38525 24071 2020-01-01 R 41820 41820 2020-01-01 R 41874 41874 2020-01-01 R 43238 43249 2020-01-01 R 43242 43245 2020-01-01 R 43254 43237 2020-01-01 R 43255 43245 2020-01-01 R 44970 58662 2020-01-01 R 47534 47536 2020-01-01 R 49406 49180 2020-01-01 R 49423 49406 2020-01-01 R 49446 43246 2020-01-01 R 49505 49585 2020-01-01 R 49505 49587 2020-01-01 R 49560 49587 2020-01-01 R 49652 49505 2020-01-01 R 49652 49659 2020-01-01 R 50200 49180 2020-01-01 R 50200 50200 2020-01-01 R 50433 50432 2020-01-01 R 50433 50433 2020-01-01 R 50433 50435 2020-01-01 R 50693 50435 2020-01-01 R 50693 50693 2020-01-01 R 51102 52310 2020-01-01 R 52204 54161 2020-01-01 R 52214 52224 2020-01-01 R 52276 51102 2020-01-01 R 52287 52276 2020-01-01 R 52351 52204 2020-01-01 R 52351 52214 2020-01-01 R 52351 52224 2020-01-01 R 52356 50432 2020-01-01 R 52356 52648 2020-01-01 R 54520 54520 2020-01-01 R 55500 54840 2020-01-01 R 55500 55500 2020-01-01 R 55700 52281 2020-01-01 R 57265 57267 2020-01-01 R 57410 92018 2020-01-01 R 58263 57260 2020-01-01 R 58263 57265 2020-01-01 R 58270 57265 2020-01-01 R 63075 63076 2020-01-01 R 67900 67917 2020-01-01 R 67950 67900 2020-01-01 R 92928 92928 2020-01-01 R 92943 92928 2020-01-01 R 92986 93453 2020-01-01 R 93458 93451 2020-01-01 R 93459 93459 2020-01-01 R 93460 93454 2020-01-01 R 93460 93460 2020-01-01 R 93620 93613 2020-01-01 R


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Complexity Adjusted Code Pair Removals Reason Key: R=Removed From List, D=Code Terminated Code 1 Code 2 Eff Date R* 93620 93650 2020-01-01 R C9600 33210 2020-01-01 R C9600 92937 2020-01-01 R C9600 92986 2020-01-01 R


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Complexity Adjusted Code Pair Modifications

The following Comprehensive APC code pairs were modified for complexity adjusted APC assignment. Complexity Adjusted Code Pair Modifications Code 1 Code 2 Eff Date Current CAPC Previous CAPC 26530 26530 2020-01-01 5115 5114 52351 50432 2020-01-01 5375 5374 57155 57155 2020-01-01 5416 5415


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The following HCPCS were added to the CAPC Exclusion list. CAPC Exclusion Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 78431 2020-01-01 Myocrd img pet rst&strs ct N 78432 2020-01-01 Myocrd img pet 2rtracer N 78433 2020-01-01 Myocrd img pet 2rtracer ct N C9758 2020-01-01 Interatrial shunt ide N G2082 2020-01-01 Visit esketamine 56m or less N G2083 2020-01-01 Visit esketamine, > 56m N


Page 52 of 84

Device Additions

The following HCPCS were added to the Device list. Device Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* A4648 2019-01-01 Implantable tissue marker A C1734 2020-01-01 Orth/devic/drug bn/bn,tis/bn N C1824 2020-01-01 Generator, ccm, implant N C1839 2020-01-01 Iris prosthesis N C1982 2020-01-01 Cath, pressure,valve-occlu N C2596 2020-01-01 Probe, robotic, water-jet N


Page 53 of 84

Device Removals

The following HCPCS were removed from the Device list. Device Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* C1842 2017-01-01 Retinal prosth, add-on R L8680 2015-01-01 Implt neurostim elctr each R L8685 2015-01-01 Implt nrostm pls gen sng rec R L8686 2015-01-01 Implt nrostm pls gen sng non R L8687 2015-01-01 Implt nrostm pls gen dua rec R L8688 2015-01-01 Implt nrostm pls gen dua non R


Page 54 of 84

Device Procedure Additions

The following HCPCS were added to the Device Procedure list. Device Procedure Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0200T 2020-01-01 Perq sacral augmt unilat inj A 0313T 2020-01-01 Laps rmvl nstim array vagus A 0431T 2020-01-01 Rmvl/rplc nstim apnea pls gn A 0442T 2020-01-01 Abltj perc plex/trncl nrv A 0505T 2020-01-01 Ev fempop artl revsc A 0587T 2020-01-01 Perq impltj/rplcmt isdns ptn N 20983 2020-01-01 Ablate bone tumor(s) perq A 21208 2020-01-01 Augmentation of facial bones A 21245 2020-01-01 Reconstruction of jaw A 21346 2020-01-01 Opn tx nasomax fx w/fixj A 21742 2020-01-01 Repair stern/nuss w/o scope A 21812 2020-01-01 Treatment of rib fracture A 22612 2020-01-01 Lumbar spine fusion A 22633 2020-01-01 Lumbar spine fusion combined A 23406 2020-01-01 Incise tendon(s) & muscle(s) A 23630 2020-01-01 Treat humerus fracture A 24365 2020-01-01 Reconstruct head of radius A 24575 2020-01-01 Treat humerus fracture A 25136 2020-01-01 Remove & graft wrist lesion A 25350 2020-01-01 Revision of radius A 25545 2020-01-01 Treat fracture of ulna A 25670 2020-01-01 Treat wrist dislocation A 25800 2020-01-01 Fusion of wrist joint A 26390 2020-01-01 Revise hand/finger tendon A 27130 2020-01-01 Total hip arthroplasty A 27400 2020-01-01 Revise thigh muscles/tendons A 27477 2020-01-01 Surgery to stop leg growth A 27826 2020-01-01 Treat lower leg fracture A 28130 2020-01-01 Removal of ankle bone A 28302 2020-01-01 Incision of ankle bone A 28446 2020-01-01 Osteochondral talus autogrft A 31647 2020-01-01 Bronchial valve init insert A 33220 2020-01-01 Repair lead pace-defib dual A 33226 2020-01-01 Reposition l ventric lead A 33233 2020-01-01 Removal of pm generator A 33235 2020-01-01 Removal pacemaker electrode A 36583 2020-01-01 Replace tunneled cv cath A 36904 2020-01-01 Thrmbc/nfs dialysis circuit A 37244 2020-01-01 Vasc embolize/occlude bleed A 43773 2020-01-01 Lap replace gastr adj device A 45327 2020-01-01 Proctosigmoidoscopy w/stent A 59072 2020-01-01 Umbilical cord occlud w/us A 64448 2020-01-01 Njx aa&/strd fem nerve nfs A 64912 2020-01-01 Nrv rpr w/nrv algrft 1st A 65779 2020-01-01 Cover eye w/membrane suture A 66987 2020-01-01 Xcapsl ctrc rmvl cplx w/ecp N 66988 2020-01-01 Xcapsl ctrc rmvl w/ecp N 92920 2020-01-01 Prq cardiac angioplast 1 art A 92924 2020-01-01 Prq card angio/athrect 1 art A 93024 2020-01-01 Cardiac drug stress test A 93612 2020-01-01 Intraventricular pacing A 93619 2020-01-01 Electrophysiology evaluation A 95928 2020-01-01 C motor evoked uppr limbs A 95961 2020-01-01 Electrode stimulation brain A C9757 2020-01-01 Spine/lumbar disk surgery N


Page 55 of 84

Device Procedure Removals

The following HCPCS were removed from the Device Procedure list. Device Procedure Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 0467T 2020-01-01 Revj/rplmnt ch respir eltrd R 19105 2020-01-01 Cryosurg ablate fa each R 19342 2020-01-01 Delayed breast prosthesis R 21125 2020-01-01 Augmentation lower jaw bone R 21454 2020-01-01 Treat lower jaw fracture R 23532 2020-01-01 Treat clavicle dislocation R 24115 2020-01-01 Remove/graft bone lesion R 24344 2020-01-01 Reconstruct elbow lat ligmnt R 24360 2020-01-01 Reconstruct elbow joint R 25126 2020-01-01 Remove/graft forearm lesion R 25525 2020-01-01 Treat fracture of radius R 26843 2020-01-01 Fusion of hand joint R 27357 2020-01-01 Remove femur lesion/graft R 27396 2020-01-01 Transplant of thigh tendon R 27407 2020-01-01 Repair of knee ligament R 27416 2020-01-01 Osteochondral knee autograft R 27652 2020-01-01 Repair/graft achilles tendon R 27696 2020-01-01 Repair of ankle ligaments R 27832 2020-01-01 Treat lower leg dislocation R 28102 2020-01-01 Remove/graft foot lesion R 28103 2020-01-01 Remove/graft foot lesion R 28309 2020-01-01 Incision of metatarsals R 29905 2020-01-01 Subtalar arthro w/exc R 36260 2020-01-01 Insertion of infusion pump R 36580 2020-01-01 Replace cvad cath R 36581 2020-01-01 Replace tunneled cv cath R 36595 2020-01-01 Mech remov tunneled cv cath R 37606 2020-01-01 Ligation of neck artery R 47539 2020-01-01 Perq plmt bile duct stent R 63075 2020-01-01 Neck spine disk surgery R 63744 2020-01-01 Revision of spinal shunt R 64595 2020-01-01 Revise/rmv pn/gastr stimul R 64885 2020-01-01 Nerve graft head/neck </4 cm R 64886 2020-01-01 Nerve graft head/neck >4 cm R 75733 2020-01-01 Artery x-rays adrenals R 75746 2020-01-01 Artery x-rays lung R 75870 2020-01-01 Vein x-ray skull R 93610 2020-01-01 Intra-atrial pacing R C9728 2020-01-01 Place device/marker, non pro R


Page 56 of 84

Device Procedure Edit 92 Bypass Additions

The following HCPCS were added to the Device Procedure Bypass Edit 92 list. Device Procedure Edit 92 Bypass Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0200T 2020-01-01 Perq sacral augmt unilat inj A 23630 2020-01-01 Treat humerus fracture A 24575 2020-01-01 Treat humerus fracture A 25545 2020-01-01 Treat fracture of ulna A 27826 2020-01-01 Treat lower leg fracture A 33220 2020-01-01 Repair lead pace-defib dual A 33226 2020-01-01 Reposition l ventric lead A 33233 2020-01-01 Removal of pm generator A 33235 2020-01-01 Removal pacemaker electrode A 36904 2020-01-01 Thrmbc/nfs dialysis circuit A 37244 2020-01-01 Vasc embolize/occlude bleed A 43773 2020-01-01 Lap replace gastr adj device A 45327 2020-01-01 Proctosigmoidoscopy w/stent A 59072 2020-01-01 Umbilical cord occlud w/us A 64448 2020-01-01 Njx aa&/strd fem nerve nfs A 64912 2020-01-01 Nrv rpr w/nrv algrft 1st A 65779 2020-01-01 Cover eye w/membrane suture A


Page 57 of 84

Daily Mental Health Additions

The following HCPCS were added to the Daily Mental Health list. Daily Mental Health Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 96156 2020-01-01 Hlth bhv assmt/reassessment N 96158 2020-01-01 Hlth bhv ivntj indiv 1st 30 N 96164 2020-01-01 Hlth bhv ivntj grp 1st 30 N 96167 2020-01-01 Hlth bhv ivntj fam 1st 30 N


Page 58 of 84

Daily Mental Health Removals

The following HCPCS were removed from the Daily Mental Health list. Daily Mental Health Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 96150 2020-01-01 Assess hlth/behave init D 96151 2020-01-01 Assess hlth/behave subseq D 96152 2020-01-01 Intervene hlth/behave indiv D 96153 2020-01-01 Intervene hlth/behave group D 96154 2020-01-01 Interv hlth/behav fam w/pt D


Page 59 of 84

Mental Health Not Billable Under PHP Edit 80 Additions

The following HCPCS were added to the mental health list not billable under the PHP program. Mental Health Not Billable Under PHP Edit 80 Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 96156 2020-01-01 Hlth bhv assmt/reassessment N 96158 2020-01-01 Hlth bhv ivntj indiv 1st 30 N 96164 2020-01-01 Hlth bhv ivntj grp 1st 30 N 96167 2020-01-01 Hlth bhv ivntj fam 1st 30 N


Page 60 of 84

Mental Health Not Billable Under PHP Edit 80 Removals

The following HCPCS were removed from the mental health list not billable under the PHP program. Mental Health Not Billable Under PHP Edit 80 Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 96150 2020-01-01 Assess hlth/behave init D 96151 2020-01-01 Assess hlth/behave subseq D 96152 2020-01-01 Intervene hlth/behave indiv D 96153 2020-01-01 Intervene hlth/behave group D 96154 2020-01-01 Interv hlth/behav fam w/pt D


Page 61 of 84

FQHC Non-Covered Additions

The following HCPCS were added to the FQHC Non-Covered list. FQHC Non-Covered Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 0139U 2020-01-01 Neuro austm meas 6 c metablt N 0140U 2020-01-01 Nfct ds fungi dna 15 trgt N 0141U 2020-01-01 Nfct ds bact&fng gram pos N 0142U 2020-01-01 Nfct ds bact&fng gram neg N 0143U 2020-01-01 Drug assay 120+ rx/metablt N 0144U 2020-01-01 Drug assay 160+ rx/metablt N 0145U 2020-01-01 Drug assay 65+ rx/metablt N 0146U 2020-01-01 Drug assay 80+ rx/metablt N 0147U 2020-01-01 Drug assay 85+ rx/metablt N 0148U 2020-01-01 Drug assay 100+ rx/metablt N 0149U 2020-01-01 Drug assay 60+ rx/metablt N 0150U 2020-01-01 Drug assay 120+ rx/metablt N 0151U 2020-01-01 Nfct bct/vir resp nfctj 33 N 0152U 2020-01-01 Nfct bct fng prst dna >1000 N 0153U 2020-01-01 Onc breast mrna 101 genes N 0154U 2020-01-01 Fgfr3 gene analysis N 0155U 2020-01-01 Pik3ca gene analysis N 0156U 2020-01-01 Copy number sequence alys N 0157U 2020-01-01 Apc mrna seq alys N 0158U 2020-01-01 Mlh1 mrna seq alys N 0159U 2020-01-01 Msh2 mrna seq alys N 0160U 2020-01-01 Msh6 mrna seq alys N 0161U 2020-01-01 Pms2 mrna seq alys N 0162U 2020-01-01 Hered colon ca trgt mrna pnl N 80145 2020-01-01 Drug assay adalimumab N 80187 2020-01-01 Drug assay posaconazole N 80230 2020-01-01 Drug assay infliximab N 80235 2020-01-01 Drug assay lacosamide N 80280 2020-01-01 Drug assay vedolizumab N 80285 2020-01-01 Drug assay voriconazole N 81277 2020-01-01 Cytogenomic neo microra alys N 81307 2020-01-01 Palb2 gene full gene seq N 81308 2020-01-01 Palb2 gene known famil vrnt N 81309 2020-01-01 Pik3ca gene trgt seq alys N 81522 2020-01-01 Onc breast mrna 12 genes N 81542 2020-01-01 Onc prostate mrna 22 cnt gen N 81552 2020-01-01 Onc uveal mlnma mrna 15 gene N 87563 2020-01-01 M. genitalium amp probe N


Page 62 of 84

FQHC Non-Covered Removals

The following HCPCS were removed from the FQHC Non-Covered list. FQHC Non-Covered Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* 0009M 2020-01-01 Fetal aneuploidy trisom risk D 0081U 2020-01-01 Onc uveal mlnma mrna 15 gene D 0085U 2020-01-01 Cdtb&vinculin igg antb ia D 96153 2020-01-01 Intervene hlth/behave group D 96154 2020-01-01 Interv hlth/behav fam w/pt D 96155 2020-01-01 Interv hlth/behav fam no pt D 99444 2020-01-01 Online e/m by phys/qhp D


Page 63 of 84

RHC Modifier HCPCS Conflict Additions

The following HCPCS modifier pairing for RHC conflict were added. RHC Modifier HCPCS Conflict Additions Reason Key: A=Added To List, N=New Code HCPCS Modifier Eff Date R* 11750 CG 2020-01-01 A 11765 CG 2020-01-01 A 20600 CG 2020-01-01 A 69210 CG 2020-01-01 A


Page 64 of 84

Pass-Through Device HCPCS Additions

The following HCPCS were added to the Pass-Through Device HCPCS list. Pass-Through Device HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* C1734 2020-01-01 Orth/devic/drug bn/bn,tis/bn N C1824 2020-01-01 Generator, ccm, implant N C1839 2020-01-01 Iris prosthesis N C1982 2020-01-01 Cath, pressure,valve-occlu N C2596 2020-01-01 Probe, robotic, water-jet N


Page 65 of 84


The following HCPCS were added to the Pass-Through Radiopharm HCPCS list. Pass-Through Radiopharm HCPCS Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* A9590 2020-01-01 Iodine i-131 iobenguane 1mci N


Page 66 of 84

Pass-Through Radiopharm HCPCS Removals

The following HCPCS were removed from the Pass-Through Radiopharm HCPCS list. Pass-Through Radiopharm HCPCS Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* A9587 2020-01-01 Gallium ga-68 R A9588 2020-01-01 Fluciclovine f-18 R C9407 2020-01-01 Iodine i-131 iobenguane, dx D C9408 2020-01-01 Iodine i-131 iobenguane, tx D


Page 67 of 84

Skin Substitute High Cost Product Additions

The following HCPCS were added to the Skin Substitute High Cost Product list. Skin Substitute High Cost Product Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* Q4179 2020-01-01 Flowerderm, per sq cm A Q4208 2020-01-01 Novafix per sq cm A


Page 68 of 84

Skin Substitute Low Cost Product Removals

The following HCPCS were removed from the Skin Substitute Low Cost Product list. Skin Substitute Low Cost Product Removals Reason Key: R=Removed From List, D=Code Terminated HCPCS Eff Date Description R* Q4168 2020-01-01 Amnioband, 1 mg R Q4179 2020-01-01 Flowerderm, per sq cm R Q4206 2020-01-01 Fluid flow or fluid gf 1 cc R Q4208 2020-01-01 Novafix per sq cm R Q4212 2020-01-01 Allogen, per cc R Q4213 2020-01-01 Ascent, 0.5 mg R Q4215 2020-01-01 Axolotl ambient, cryo 0.1 mg R


Page 69 of 84

Pass-Through Device Credit Procedure Additions

The following HCPCS were added to the list of pass-through device code pairs subject to a payment credit. Pass-Through Device Credit Procedure Additions Code1 Code2 Eff Date Amount C1734 27870 2020-01-01 $5,805.17 C1734 28705 2020-01-01 $8,354.15 C1734 28715 2020-01-01 $6,096.73 C1734 28725 2020-01-01 $5,291.06 C1824 0408T 2020-01-01 $13,019.03 C1839 66999 2020-01-01 $149.82 C1982 37243 2020-01-01 $2,124.38 C2596 0421T 2020-01-01 $0.00


Page 70 of 84

Pass-Through Device Credit Procedure Modifications

The following HCPCS on the list of pass-through device code pairs subject to payment offset had a modified credit amount Pass-Through Device Credit Procedure Modifications Code1 Code2 Eff Date Current Amount Previous Amount C1823 0424T 2020-01-01 $22,092.39 $20,626.59


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Terminated Device Procedure Additions

The following HCPCS were added to the terminated device procedure list, that may be subject to device credit when the procedure is terminated early. Terminated Device Procedure Additions HCPCS Eff Date Amount 0200T 2020-01-01 $2,201.96 0313T 2020-01-01 $2,790.20 0431T 2020-01-01 $25,668.17 0442T 2020-01-01 $2,414.05 0505T 2020-01-01 $4,672.84 0587T 2020-01-01 $193.77 20983 2020-01-01 $1,811.93 21208 2020-01-01 $1,693.81 21245 2020-01-01 $1,822.83 21346 2020-01-01 $1,530.34 21742 2020-01-01 $1,865.57 21812 2020-01-01 $4,281.88 22612 2020-01-01 $5,227.98 22633 2020-01-01 $5,906.32 23406 2020-01-01 $2,645.82 23630 2020-01-01 $1,929.78 24365 2020-01-01 $6,589.42 24575 2020-01-01 $3,717.78 25136 2020-01-01 $1,984.81 25350 2020-01-01 $2,663.16 25545 2020-01-01 $1,901.66 25670 2020-01-01 $1,923.80 25800 2020-01-01 $2,675.13 26390 2020-01-01 $1,816.12 27130 2020-01-01 $5,717.10 27400 2020-01-01 $1,822.70 27477 2020-01-01 $2,962.86 27826 2020-01-01 $2,320.40 28130 2020-01-01 $2,786.39 28302 2020-01-01 $2,200.76 28446 2020-01-01 $2,233.66 31647 2020-01-01 $3,106.45 33220 2020-01-01 $1,251.49 33226 2020-01-01 $876.56 33233 2020-01-01 $3,401.39 33235 2020-01-01 $898.19 36583 2020-01-01 $2,144.12 36904 2020-01-01 $1,505.49 37244 2020-01-01 $3,051.81 43773 2020-01-01 $1,642.49 45327 2020-01-01 $1,436.64 59072 2020-01-01 $110.02 64448 2020-01-01 $253.03 64912 2020-01-01 $2,923.08 65779 2020-01-01 $1,010.67 66987 2020-01-01 $1,183.68 66988 2020-01-01 $1,183.68 92920 2020-01-01 $1,487.66 92924 2020-01-01 $4,989.91 93024 2020-01-01 $110.31 93612 2020-01-01 $1,806.32 93619 2020-01-01 $1,796.32 95928 2020-01-01 $739.79 95961 2020-01-01 $330.31 C9757 2020-01-01 $3,689.22


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Terminated Device Procedure Removals

The following HCPCS were removed from the terminated device procedure list, that may be subject to device credit when the procedure is terminated early. Terminated Device Procedure Removals HCPCS Eff Date Amount 0467T 2020-01-01 $1,050.55 19105 2020-01-01 $1,315.36 19342 2020-01-01 $2,339.68 21125 2020-01-01 $1,723.24 21454 2020-01-01 $1,753.76 23532 2020-01-01 $2,288.96 24115 2020-01-01 $2,687.36 24344 2020-01-01 $1,992.01 24360 2020-01-01 $1,992.58 25126 2020-01-01 $1,024.68 25525 2020-01-01 $1,753.19 26843 2020-01-01 $1,994.29 27357 2020-01-01 $2,353.93 27396 2020-01-01 $1,972.63 27407 2020-01-01 $2,523.21 27416 2020-01-01 $1,821.02 27652 2020-01-01 $1,899.10 27696 2020-01-01 $1,939.57 27832 2020-01-01 $2,623.52 28102 2020-01-01 $2,514.66 28103 2020-01-01 $1,923.04 28309 2020-01-01 $1,717.29 29905 2020-01-01 $812.19 36260 2020-01-01 $1,353.66 36580 2020-01-01 $357.29 36581 2020-01-01 $819.66 36595 2020-01-01 $795.36 37606 2020-01-01 $1,315.21 47539 2020-01-01 $1,385.19 63075 2020-01-01 $1,713.30 63744 2020-01-01 $1,597.66 64595 2020-01-01 $1,006.49 64885 2020-01-01 $3,265.65 64886 2020-01-01 $1,674.37 75733 2020-01-01 $836.83 75746 2020-01-01 $984.38 75870 2020-01-01 $396.77 86891 2020-01-01 $334.76 93610 2020-01-01 $1,777.46 C9728 2020-01-01 $413.95


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Terminated Device Procedure Modifications

The following HCPCS have a modified device credit amount for device procedures that may be terminated early. Terminated Device Procedure Modifications HCPCS Eff Date Description Current


0100T 2020-01-01 Prosth retina receive&gen $143,014.97 $144,616.22 0191T 2020-01-01 Insert ant segment drain int $2,103.52 $2,001.05 0221T 2020-01-01 Plmt post facet implt lumb $2,773.23 $3,029.33 0234T 2020-01-01 Trluml perip athrc renal art $5,494.25 $5,361.48 0236T 2020-01-01 Trluml perip athrc abd aorta $3,571.02 $3,484.72 0237T 2020-01-01 Trluml perip athrc brchiocph $4,458.82 $4,565.72 0238T 2020-01-01 Trluml perip athrc iliac art $7,388.18 $7,006.26 0253T 2020-01-01 Insert aqueous drain device $2,122.99 $1,958.46 0268T 2020-01-01 Implt/rpl crtd sns dev gen $26,294.22 $17,369.60 0308T 2020-01-01 Insj ocular telescope prosth $16,997.43 $12,485.74 0312T 2020-01-01 Laps impltj nstim vagus $26,093.30 $24,820.04 0316T 2020-01-01 Replc vagus nerve pls gen $27,429.85 $17,184.40 0335T 2020-01-01 Insj sinus tarsi implant $2,431.66 $2,889.12 0408T 2020-01-01 Insj/rplc cardiac modulj sys $13,019.03 $15,613.09 0409T 2020-01-01 Insj/rplc car modulj pls gn $7,041.00 $6,818.90 0410T 2020-01-01 Insj/rplc car modulj atr elt $2,368.97 $2,295.27 0411T 2020-01-01 Insj/rplc car modulj vnt elt $2,368.97 $2,295.27 0414T 2020-01-01 Rmvl & rpl car modulj pls gn $7,041.00 $6,818.90 0424T 2020-01-01 Insj/rplc nstim apnea compl $22,092.39 $20,626.59 0449T 2020-01-01 Insj aqueous drain dev 1st $2,084.04 $1,911.50 0511T 2020-01-01 Rmvl&rinsj sinus tarsi implt $1,854.40 $1,766.87 0515T 2020-01-01 Insj wcs lv compl sys $7,041.00 $6,818.90 0516T 2020-01-01 Insj wcs lv eltrd only $2,368.97 $2,295.27 0517T 2020-01-01 Insj wcs lv pg compnt $2,368.97 $2,295.27 0519T 2020-01-01 Rmvl & rplcmt pg compnt wcs $925.04 $970.46 0520T 2020-01-01 Rmvl&rplcmt pg wcs new eltrd $7,041.00 $6,818.90 0525T 2020-01-01 Insj/rplcmt compl iims $3,178.10 $3,062.60 0526T 2020-01-01 Insj/rplcmt iims eltrd only $2,368.97 $2,295.27 0527T 2020-01-01 Insj/rplcmt iims implt mntr $6,591.10 $6,386.04 0548T 2020-01-01 Tprnl balo cntnc dev bi $2,501.06 $5,059.06 0549T 2020-01-01 Tprnl balo cntnc dev uni $1,311.80 $1,246.37 11970 2020-01-01 Replace tissue expander $1,871.75 $1,806.77 19296 2020-01-01 Place po breast cath for rad $3,789.54 $3,512.87 19357 2020-01-01 Breast reconstruction $4,218.34 $3,746.07 20690 2020-01-01 Apply bone fixation device $1,839.45 $1,836.98 20692 2020-01-01 Apply bone fixation device $5,299.39 $4,765.53 20696 2020-01-01 Comp multiplane ext fixation $7,229.95 $5,777.46 21243 2020-01-01 Reconstruction of jaw joint $9,111.59 $8,822.53 21244 2020-01-01 Reconstruction of lower jaw $2,022.19 $1,716.16 21338 2020-01-01 Open nasoethmoid fx w/o fixj $1,683.13 $1,809.51 21365 2020-01-01 Opn tx complx malar fx $1,592.91 $1,482.12 21461 2020-01-01 Treat lower jaw fracture $1,899.95 $1,438.32 21462 2020-01-01 Treat lower jaw fracture $1,743.77 $1,676.78 21470 2020-01-01 Treat lower jaw fracture $1,890.25 $1,705.98 21811 2020-01-01 Optx of rib fx w/fixj scope $3,262.56 $1,210.15 21813 2020-01-01 Treatment of rib fracture $715.65 $693.44 22551 2020-01-01 Neck spine fuse&remov bel c2 $5,530.26 $4,969.10 22554 2020-01-01 Neck spine fusion $5,481.47 $4,721.61 22856 2020-01-01 Cerv artific diskectomy $8,942.56 $8,309.63 22867 2020-01-01 Insj stablj dev w/dcmprn $9,409.78 $8,606.89 22869 2020-01-01 Insj stablj dev w/o dcmprn $8,730.36 $10,932.67 23156 2020-01-01 Removal of humerus lesion $1,845.43 $2,223.41 23470 2020-01-01 Reconstruct shoulder joint $6,288.34 $5,704.07 23473 2020-01-01 Revis reconst shoulder joint $5,025.67 $4,723.75 23485 2020-01-01 Revision of collar bone $4,712.68 $4,515.90 23491 2020-01-01 Reinforce shoulder bones $4,273.54 $3,345.94 23515 2020-01-01 Treat clavicle fracture $2,231.27 $2,058.69 23552 2020-01-01 Treat clavicle dislocation $2,051.81 $1,818.74 23615 2020-01-01 Treat humerus fracture $5,194.66 $4,623.04 23616 2020-01-01 Treat humerus fracture $8,362.12 $7,380.86 23680 2020-01-01 Treat dislocation/fracture $5,164.91 $4,656.25 24126 2020-01-01 Remove/graft bone lesion $1,902.86 $1,813.04 24361 2020-01-01 Reconstruct elbow joint $8,696.99 $9,968.47 24362 2020-01-01 Reconstruct elbow joint $3,942.71 $5,954.77 24363 2020-01-01 Replace elbow joint $9,774.95 $9,458.65 24366 2020-01-01 Reconstruct head of radius $6,840.53 $6,116.55 24370 2020-01-01 Revise reconst elbow joint $5,466.00 $5,412.65 24371 2020-01-01 Revise reconst elbow joint $8,196.29 $8,303.47 24430 2020-01-01 Repair of humerus $4,831.69 $4,388.41 24435 2020-01-01 Repair humerus with graft $4,862.63 $4,332.69 24498 2020-01-01 Reinforce humerus $4,168.82 $3,687.72 24515 2020-01-01 Treat humerus fracture $4,362.80 $3,834.50


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24516 2020-01-01 Treat humerus fracture $4,598.43 $4,153.77 24545 2020-01-01 Treat humerus fracture $5,188.71 $4,708.75 24546 2020-01-01 Treat humerus fracture $7,186.90 $6,834.07 24579 2020-01-01 Treat humerus fracture $4,114.08 $3,351.30 24587 2020-01-01 Treat elbow fracture $6,081.26 $5,654.79 24635 2020-01-01 Treat elbow fracture $2,400.56 $2,041.02 24666 2020-01-01 Treat radius fracture $6,808.40 $6,035.13 24685 2020-01-01 Treat ulnar fracture $1,888.50 $1,719.57 25390 2020-01-01 Shorten radius or ulna $2,127.18 $1,892.83 25391 2020-01-01 Lengthen radius or ulna $5,539.78 $5,208.02 25400 2020-01-01 Repair radius or ulna $2,429.27 $2,259.32 25405 2020-01-01 Repair/graft radius or ulna $2,393.38 $2,167.55 25415 2020-01-01 Repair radius & ulna $2,058.39 $2,185.79 25420 2020-01-01 Repair/graft radius & ulna $2,198.37 $2,349.37 25425 2020-01-01 Repair/graft radius or ulna $2,146.32 $2,767.15 25441 2020-01-01 Reconstruct wrist joint $7,299.90 $6,411.19 25442 2020-01-01 Reconstruct wrist joint $9,220.02 $9,377.02 25443 2020-01-01 Reconstruct wrist joint $3,580.80 $3,027.05 25444 2020-01-01 Reconstruct wrist joint $7,916.35 $7,688.28 25445 2020-01-01 Reconstruct wrist joint $2,341.93 $2,223.41 25446 2020-01-01 Wrist replacement $10,840.15 $10,402.82 25515 2020-01-01 Treat fracture of radius $1,997.37 $1,882.57 25526 2020-01-01 Treat fracture of radius $2,100.86 $1,794.80 25574 2020-01-01 Treat fracture radius & ulna $2,158.89 $2,238.23 25575 2020-01-01 Treat fracture radius/ulna $2,184.61 $2,178.95 25607 2020-01-01 Treat fx rad extra-articul $2,629.07 $2,459.37 25608 2020-01-01 Treat fx rad intra-articul $2,587.19 $2,466.21 25609 2020-01-01 Treat fx radial 3+ frag $2,645.22 $2,537.46 25805 2020-01-01 Fusion/graft of wrist joint $2,431.66 $2,465.64 25810 2020-01-01 Fusion/graft of wrist joint $4,863.82 $4,091.63 25820 2020-01-01 Fusion of hand bones $2,227.68 $2,156.15 25825 2020-01-01 Fuse hand bones with graft $2,027.88 $2,022.78 25830 2020-01-01 Fusion radioulnar jnt/ulna $1,963.28 $2,054.70 26531 2020-01-01 Revise knuckle with implant $2,563.27 $2,576.78 26536 2020-01-01 Revise/implant finger joint $2,230.67 $2,062.11 26820 2020-01-01 Thumb fusion with graft $2,679.32 $1,811.90 26844 2020-01-01 Fusion/graft of hand joint $2,005.75 $1,957.24 27279 2020-01-01 Arthrodesis sacroiliac joint $11,104.85 $10,713.95 27403 2020-01-01 Repair of knee cartilage $1,902.26 $1,124.36 27415 2020-01-01 Osteochondral knee allograft $7,305.85 $6,238.69 27427 2020-01-01 Reconstruction knee $2,051.21 $1,866.62 27428 2020-01-01 Reconstruction knee $4,073.61 $3,412.37 27429 2020-01-01 Reconstruction knee $5,214.89 $3,948.06 27438 2020-01-01 Revise kneecap with implant $4,440.15 $3,989.85 27440 2020-01-01 Revision of knee joint $5,563.58 $4,661.61 27442 2020-01-01 Revision of knee joint $5,600.47 $4,878.03 27443 2020-01-01 Revision of knee joint $4,973.31 $3,579.51 27446 2020-01-01 Revision of knee joint $5,526.69 $5,023.74 27447 2020-01-01 Total knee arthroplasty $5,792.08 $4,615.54 27485 2020-01-01 Surgery to stop leg growth $3,590.96 $1,408.47 27509 2020-01-01 Treatment of thigh fracture $2,767.85 $2,908.50 27705 2020-01-01 Incision of tibia $2,106.84 $2,124.81 27709 2020-01-01 Incision of tibia & fibula $4,760.28 $4,025.20 27720 2020-01-01 Repair of tibia $2,236.05 $2,318.59 27722 2020-01-01 Repair/graft of tibia $2,764.26 $1,847.81 27726 2020-01-01 Repair fibula nonunion $2,242.03 $2,074.08 27745 2020-01-01 Reinforce tibia $2,196.57 $1,994.29 27756 2020-01-01 Treatment of tibia fracture $2,450.80 $2,302.06 27758 2020-01-01 Treatment of tibia fracture $5,004.25 $4,076.63 27759 2020-01-01 Treatment of tibia fracture $4,411.59 $3,873.07 27792 2020-01-01 Treatment of ankle fracture $1,954.90 $1,765.73 27814 2020-01-01 Treatment of ankle fracture $2,017.71 $1,832.99 27822 2020-01-01 Treatment of ankle fracture $1,996.77 $1,856.36 27823 2020-01-01 Treatment of ankle fracture $1,908.24 $1,843.25 27827 2020-01-01 Treat lower leg fracture $4,494.90 $4,148.41 27828 2020-01-01 Treat lower leg fracture $4,741.24 $4,255.55 27848 2020-01-01 Treat ankle dislocation $2,203.15 $2,121.39 27870 2020-01-01 Fusion of ankle joint open $5,805.17 $5,001.24 27871 2020-01-01 Fusion of tibiofibular joint $4,749.57 $3,942.71 28262 2020-01-01 Revision of foot and ankle $2,501.05 $1,935.58 28291 2020-01-01 Corrj halux rigdus w/implt $3,105.83 $2,645.18 28297 2020-01-01 Correction hallux valgus $2,605.14 $2,333.41 28300 2020-01-01 Incision of heel bone $2,035.66 $1,889.98 28305 2020-01-01 Incise/graft midfoot bones $2,222.29 $2,192.06 28320 2020-01-01 Repair of foot bones $5,413.63 $4,446.26 28322 2020-01-01 Repair of metatarsals $2,254.00 $2,087.76 28415 2020-01-01 Treat heel fracture $2,152.31 $2,079.78


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28420 2020-01-01 Treat/graft heel fracture $4,637.71 $4,615.54 28445 2020-01-01 Treat ankle fracture $1,891.49 $1,774.28 28465 2020-01-01 Treat midfoot fracture each $2,278.52 $1,973.20 28485 2020-01-01 Treat metatarsal fracture $2,039.25 $1,782.26 28555 2020-01-01 Repair foot dislocation $2,030.87 $2,416.63 28585 2020-01-01 Repair foot dislocation $2,224.69 $2,603.00 28615 2020-01-01 Repair foot dislocation $2,103.85 $1,913.35 28705 2020-01-01 Fusion of foot bones $8,354.15 $7,878.36 28715 2020-01-01 Fusion of foot bones $6,096.73 $5,268.01 28725 2020-01-01 Fusion of foot bones $5,291.06 $4,488.04 28730 2020-01-01 Fusion of foot bones $6,120.54 $5,328.01 28735 2020-01-01 Fusion of foot bones $5,890.85 $5,257.30 28737 2020-01-01 Revision of foot bones $6,285.96 $5,555.15 28740 2020-01-01 Fusion of foot bones $2,783.40 $2,593.31 28750 2020-01-01 Fusion of big toe joint $2,727.17 $2,490.72 29855 2020-01-01 Tibial arthroscopy/surgery $3,093.27 $3,025.34 29856 2020-01-01 Tibial arthroscopy/surgery $6,103.87 $6,182.98 29867 2020-01-01 Allgrft implnt knee w/scope $5,401.73 $5,046.24 29888 2020-01-01 Knee arthroscopy/surgery $2,184.01 $1,963.51 29889 2020-01-01 Knee arthroscopy/surgery $4,578.20 $3,956.64 29899 2020-01-01 Ankle arthroscopy/surgery $1,944.13 $1,719.00 29907 2020-01-01 Subtalar arthro w/fusion $4,149.78 $4,188.06 31636 2020-01-01 Bronchoscopy bronch stents $2,279.51 $2,222.72 31660 2020-01-01 Bronch thermoplsty 1 lobe $3,037.90 $2,899.63 31661 2020-01-01 Bronch thermoplsty 2/> lobes $3,113.52 $2,940.81 33206 2020-01-01 Insert heart pm atrial $5,995.33 $5,924.64 33207 2020-01-01 Insert heart pm ventricular $6,172.69 $5,958.23 33208 2020-01-01 Insrt heart pm atrial & vent $6,558.17 $6,363.28 33211 2020-01-01 Insert card electrodes dual $3,545.05 $4,696.43 33212 2020-01-01 Insert pulse gen sngl lead $4,860.98 $4,475.04 33213 2020-01-01 Insert pulse gen dual leads $6,248.56 $6,258.56 33214 2020-01-01 Upgrade of pacemaker system $6,333.65 $6,196.32 33216 2020-01-01 Insert 1 electrode pm-defib $2,912.31 $2,895.75 33217 2020-01-01 Insert 2 electrode pm-defib $3,758.26 $3,746.48 33221 2020-01-01 Insert pulse gen mult leads $11,665.52 $11,567.38 33224 2020-01-01 Insert pacing lead & connect $5,547.32 $5,307.18 33227 2020-01-01 Remove&replace pm gen singl $4,641.66 $4,512.06 33228 2020-01-01 Remv&replc pm gen dual lead $6,368.51 $6,239.79 33229 2020-01-01 Remv&replc pm gen mult leads $12,117.86 $11,859.08 33230 2020-01-01 Insrt pulse gen w/dual leads $17,461.67 $16,400.56 33231 2020-01-01 Insrt pulse gen w/mult leads $23,469.48 $22,189.09 33240 2020-01-01 Insrt pulse gen w/singl lead $16,816.62 $17,260.62 33249 2020-01-01 Insj/rplcmt defib w/lead(s) $24,302.37 $23,117.98 33262 2020-01-01 Rmvl& replc pulse gen 1 lead $16,471.39 $15,872.65 33263 2020-01-01 Rmvl & rplcmt dfb gen 2 lead $17,066.47 $16,490.75 33264 2020-01-01 Rmvl & rplcmt dfb gen mlt ld $24,757.56 $23,197.68 33270 2020-01-01 Ins/rep subq defibrillator $24,434.73 $23,335.64 33271 2020-01-01 Insj subq impltbl dfb elctrd $4,736.42 $5,354.65 33274 2020-01-01 Tcat insj/rpl perm ldls pm $10,370.54 $9,989.64 33285 2020-01-01 Insj subq car rhythm mntr $5,857.48 $5,675.25 33289 2020-01-01 Tcat impl wrls p-art prs snr $25,175.95 $25,899.06 36253 2020-01-01 Ins cath ren art 2nd+ unilat $1,641.76 $1,417.99 36261 2020-01-01 Revision of infusion pump $2,264.86 $2,376.07 36835 2020-01-01 Artery to vein shunt $1,369.84 $926.38 36903 2020-01-01 Intro cath dialysis circuit $5,040.44 $4,832.59 36906 2020-01-01 Thrmbc/nfs dialysis circuit $7,697.41 $7,291.85 37183 2020-01-01 Remove hepatic shunt (tips) $1,774.99 $1,741.82 37184 2020-01-01 Prim art m-thrmbc 1st vsl $3,999.06 $1,889.19 37187 2020-01-01 Venous mech thrombectomy $1,934.50 $1,589.30 37191 2020-01-01 Ins endovas vena cava filtr $1,883.98 $1,775.12 37192 2020-01-01 Redo endovas vena cava filtr $918.13 $1,025.17 37221 2020-01-01 Iliac revasc w/stent $3,923.76 $3,711.94 37224 2020-01-01 Fem/popl revas w/tla $1,996.43 $1,876.09 37225 2020-01-01 Fem/popl revas w/ather $5,617.12 $5,450.44 37226 2020-01-01 Fem/popl revasc w/stent $4,896.77 $4,731.06 37227 2020-01-01 Fem/popl revasc stnt & ather $8,931.17 $8,440.37 37228 2020-01-01 Tib/per revasc w/tla $3,259.89 $3,136.64 37229 2020-01-01 Tib/per revasc w/ather $7,687.85 $7,353.27 37230 2020-01-01 Tib/per revasc w/stent $7,305.29 $7,066.14 37231 2020-01-01 Tib/per revasc stent & ather $8,178.80 $7,568.23 37236 2020-01-01 Open/perq place stent 1st $3,728.56 $3,634.59 37238 2020-01-01 Open/perq place stent same $4,148.68 $4,259.21 37242 2020-01-01 Vasc embolize/occlude artery $3,754.32 $3,503.09 43212 2020-01-01 Esophagoscop stent placement $2,679.18 $2,495.32 43240 2020-01-01 Egd w/transmural drain cyst $1,427.86 $1,334.95 43266 2020-01-01 Egd endoscopic stent place $2,776.71 $2,592.88 43284 2020-01-01 Laps esophgl sphnctr agmntj $3,839.74 $3,937.39


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43647 2020-01-01 Lap impl electrode antrum $4,418.85 $4,012.26 43770 2020-01-01 Lap place gastr adj device $3,690.83 $3,571.21 44370 2020-01-01 Small bowel endoscopy/stent $2,419.58 $2,260.17 44402 2020-01-01 Colonoscopy w/stent plcmt $2,448.26 $2,417.09 45347 2020-01-01 Sigmoidoscopy w/plcmt stent $3,094.15 $2,982.24 45389 2020-01-01 Colonoscopy w/stent plcmt $2,774.79 $2,761.04 47383 2020-01-01 Perq abltj lvr cryoablation $1,903.03 $1,712.41 47538 2020-01-01 Perq plmt bile duct stent $2,365.62 $2,183.49 47540 2020-01-01 Perq plmt bile duct stent $2,001.64 $2,025.85 47556 2020-01-01 Biliary endoscopy thru skin $2,133.60 $2,012.06 50434 2020-01-01 Convert nephrostomy catheter $568.31 $561.59 50593 2020-01-01 Perc cryo ablate renal tum $3,123.79 $2,615.90 51715 2020-01-01 Endoscopic injection/implant $962.31 $945.96 51992 2020-01-01 Laparo sling operation $1,503.28 $1,494.57 52327 2020-01-01 Cystoscopy inject material $1,397.70 $1,649.63 53440 2020-01-01 Male sling procedure $5,173.16 $4,796.89 53444 2020-01-01 Insert tandem cuff $9,844.93 $9,994.09 53445 2020-01-01 Insert uro/ves nck sphincter $12,512.66 $11,418.79 53447 2020-01-01 Remove/replace ur sphincter $11,516.22 $10,668.09 54400 2020-01-01 Insert semi-rigid prosthesis $11,526.76 $10,591.39 54401 2020-01-01 Insert self-contd prosthesis $12,361.52 $11,294.76 54405 2020-01-01 Insert multi-comp penis pros $12,563.62 $11,557.51 54410 2020-01-01 Remove/replace penis prosth $12,052.22 $11,095.66 54411 2020-01-01 Remov/replc penis pros comp $11,551.36 $10,668.09 54416 2020-01-01 Remv/repl penis contain pros $11,804.43 $10,919.41 54417 2020-01-01 Remv/replc penis pros compl $10,971.42 $9,217.28 54660 2020-01-01 Revision of testis $1,617.33 $1,822.11 55873 2020-01-01 Cryoablate prostate $3,699.15 $3,465.70 57288 2020-01-01 Repair bladder defect $1,331.87 $1,315.31 58565 2020-01-01 Hysteroscopy sterilization $1,317.34 $1,392.88 61623 2020-01-01 Endovasc tempory vessel occl $4,964.15 $3,413.17 61626 2020-01-01 Transcath occlusion non-cns $3,037.94 $2,979.03 61885 2020-01-01 Insrt/redo neurostim 1 array $16,505.11 $16,048.87 61886 2020-01-01 Implant neurostim arrays $24,916.91 $23,853.39 61888 2020-01-01 Revise/remove neuroreceiver $2,745.85 $2,564.02 62350 2020-01-01 Implant spinal canal cath $1,854.88 $1,406.35 62360 2020-01-01 Insert spine infusion device $12,142.89 $11,716.34 62361 2020-01-01 Implant spine infusion pump $11,852.20 $12,026.44 62362 2020-01-01 Implant spine infusion pump $12,380.72 $12,167.83 63610 2020-01-01 Stimulation of spinal cord $839.21 $796.33 63650 2020-01-01 Implant neuroelectrodes $3,099.75 $3,037.60 63655 2020-01-01 Implant neuroelectrodes $13,270.02 $12,926.65 63663 2020-01-01 Revise spine eltrd perq aray $2,923.42 $2,970.63 63664 2020-01-01 Revise spine eltrd plate $10,983.49 $10,685.53 63685 2020-01-01 Insrt/redo spine n generator $24,054.99 $22,961.52 63741 2020-01-01 Install spinal shunt $1,844.42 $1,850.62 64553 2020-01-01 Implant neuroelectrodes $4,733.77 $3,495.63 64555 2020-01-01 Implant neuroelectrodes $3,563.79 $3,100.98 64561 2020-01-01 Implant neuroelectrodes $3,295.88 $3,175.13 64568 2020-01-01 Inc for vagus n elect impl $25,126.56 $23,745.37 64569 2020-01-01 Revise/repl vagus n eltrd $5,056.74 $4,528.90 64575 2020-01-01 Implant neuroelectrodes $13,752.01 $12,473.93 64580 2020-01-01 Implant neuroelectrodes $15,302.08 $15,609.25 64581 2020-01-01 Implant neuroelectrodes $3,987.61 $3,863.37 64590 2020-01-01 Insrt/redo pn/gastr stimul $16,306.53 $15,837.48 64890 2020-01-01 Nerve graft hand/foot </4 cm $2,223.44 $2,144.68 64891 2020-01-01 Nerve graft hand/foot >4 cm $3,538.44 $1,774.83 64910 2020-01-01 Nerve repair w/allograft $2,075.79 $1,532.83 65770 2020-01-01 Revise cornea with implant $2,940.33 $4,665.36 66180 2020-01-01 Aqueous shunt eye w/graft $1,307.40 $1,259.17 66183 2020-01-01 Insert ant drainage device $1,820.96 $1,500.88 69714 2020-01-01 Implant temple bone w/stimul $7,742.60 $7,091.52 69715 2020-01-01 Temple bne implnt w/stimulat $8,457.80 $9,344.67 69717 2020-01-01 Temple bone implant revision $3,196.75 $3,226.54 69930 2020-01-01 Implant cochlear device $27,009.77 $26,053.73 75898 2020-01-01 Follow-up angiography $658.49 $759.85 92928 2020-01-01 Prq card stent w/angio 1 vsl $3,660.19 $3,382.23 92933 2020-01-01 Prq card stent/ath/angio $8,790.89 $8,309.86 92937 2020-01-01 Prq revasc byp graft 1 vsl $3,495.71 $3,358.06 92943 2020-01-01 Prq card revasc chronic 1vsl $4,214.08 $3,902.42 92986 2020-01-01 Revision of aortic valve $1,871.59 $1,734.80 92987 2020-01-01 Revision of mitral valve $3,400.59 $3,161.78 93532 2020-01-01 R & l heart cath congenital $966.70 $879.94 93580 2020-01-01 Transcath closure of asd $10,732.38 $9,922.08 93581 2020-01-01 Transcath closure of vsd $11,352.45 $8,011.98 93582 2020-01-01 Perq transcath closure pda $6,396.71 $6,035.85 93590 2020-01-01 Perq transcath cls mitral $7,246.31 $6,075.78


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93591 2020-01-01 Perq transcath cls aortic $6,063.56 $5,888.45 93600 2020-01-01 Bundle of his recording $2,686.24 $1,734.64 93602 2020-01-01 Intra-atrial recording $1,995.84 $1,665.32 93603 2020-01-01 Right ventricular recording $425.64 $314.23 93650 2020-01-01 Ablate heart dysrhythm focus $2,569.70 $2,113.89 93653 2020-01-01 Ep & ablate supravent arrhyt $7,371.00 $6,609.53 93654 2020-01-01 Ep & ablate ventric tachy $8,787.17 $7,673.97 93656 2020-01-01 Tx atrial fib pulm vein isol $9,543.27 $8,628.89 C9600 2020-01-01 Perc drug-el cor stent sing $3,941.59 $3,894.69 C9602 2020-01-01 Perc d-e cor stent ather s $9,130.41 $8,733.64 C9604 2020-01-01 Perc d-e cor revasc t cabg s $4,107.06 $3,976.88 C9607 2020-01-01 Perc d-e cor revasc chro sin $8,880.16 $8,425.01 C9739 2020-01-01 Cystoscopy prostatic imp 1-3 $2,801.33 $2,648.33 C9740 2020-01-01 Cysto impl 4 or more $5,921.05 $5,558.89 C9745 2020-01-01 Nasal endo eustachian tube $2,099.79 $1,742.70 C9749 2020-01-01 Repair nasal stenosis w/imp $2,010.06 $1,371.51 C9752 2020-01-01 Intraosseous des lumb/sacrum $3,689.22 $3,321.30 C9754 2020-01-01 Perc av fistula, direct $4,941.39 $2,997.40 C9755 2020-01-01 Rf magnetic-guide av fistula $4,941.39 $2,997.40


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Drug Administration Addon Procedure Code List Additions

The following HCPCS were added to the Drug Administration Addon Procedure code list (edit 106). Drug Administration Addon Procedure Code List Additions Reason Key: A=Added To List, N=New Code HCPCS Eff Date Description R* 96361 2018-04-01 Hydrate iv infusion add-on A 96366 2018-04-01 Ther/proph/diag iv inf addon A 96367 2018-04-01 Tx/proph/dg addl seq iv inf A 96368 2018-04-01 Ther/diag concurrent inf A 96370 2018-04-01 Sc ther infusion addl hr A 96371 2018-04-01 Sc ther infusion reset pump A 96375 2018-04-01 Tx/pro/dx inj new drug addon A 96376 2018-04-01 Tx/pro/dx inj same drug adon A 96411 2018-04-01 Chemo iv push addl drug A 96415 2018-04-01 Chemo iv infusion addl hr A 96417 2018-04-01 Chemo iv infus each addl seq A 96423 2018-04-01 Chemo ia infuse each addl hr A


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Type One Addon Procedure Code List Additions

The following HCPCS were added to the Type One Addon Procedure code list (edit 106). Type One Addon Procedure Code List Additions Reason Key: A=Added To List, N=New Code Addon Primary Eff Date R* 34714 33440 2019-10-01 A 34716 33440 2019-10-01 A 34812 34710 2019-10-01 A 34833 33440 2019-10-01 A 64787 64776 2018-04-01 A


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Type One Addon Procedure Code List Removals

The following HCPCS were removed from the Type One Addon Procedure code list (edit 106). Type One Addon Procedure Code List Removals Reason Key: R=Removed From List, D=Code Terminated Addon Primary Eff Date R* 0205T 92920 2020-01-01 D 0205T 92924 2020-01-01 D 0205T 92928 2020-01-01 D 0205T 92933 2020-01-01 D 0205T 92937 2020-01-01 D 0205T 92941 2020-01-01 D 0205T 92943 2020-01-01 D 0205T 92975 2020-01-01 D 0205T 93454 2020-01-01 D 0205T 93455 2020-01-01 D 0205T 93456 2020-01-01 D 0205T 93457 2020-01-01 D 0205T 93458 2020-01-01 D 0205T 93459 2020-01-01 D 0205T 93460 2020-01-01 D 0205T 93461 2020-01-01 D 0205T 93563 2020-01-01 D 0205T 93564 2020-01-01 D 0205T C9600 2020-01-01 D 0205T C9602 2020-01-01 D 0205T C9604 2020-01-01 D 0205T C9606 2020-01-01 D 0205T C9607 2020-01-01 D 0399T 93303 2020-01-01 D 0399T 93304 2020-01-01 D 0399T 93306 2020-01-01 D 0399T 93307 2020-01-01 D 0399T 93308 2020-01-01 D 0399T 93312 2020-01-01 D 0399T 93314 2020-01-01 D 0399T 93315 2020-01-01 D 0399T 93317 2020-01-01 D 0399T 93350 2020-01-01 D 0399T 93351 2020-01-01 D 0399T 93355 2020-01-01 D 0482T 78491 2020-01-01 D 0482T 78492 2020-01-01 D 32674 19260 2020-01-01 D 33257 33860 2020-01-01 D 33257 33870 2020-01-01 D 33259 33860 2020-01-01 D 33259 33870 2020-01-01 D 33866 33860 2020-01-01 D 34714 0254T 2020-01-01 D 34714 33860 2020-01-01 D 34714 33870 2020-01-01 D 34715 0254T 2020-01-01 D 34716 0254T 2020-01-01 D 34716 33860 2020-01-01 D 34716 33870 2020-01-01 D 34812 0254T 2020-01-01 D 34820 0254T 2020-01-01 D 34833 0254T 2020-01-01 D 34833 33860 2020-01-01 D 34833 33870 2020-01-01 D 34834 0254T 2020-01-01 D 37222 0254T 2020-01-01 D 37223 0254T 2020-01-01 D 37252 0254T 2020-01-01 D 37253 0254T 2020-01-01 D 38746 19260 2020-01-01 D 96367 96360 2018-04-01 R 96367 96365 2018-04-01 R 96367 96374 2018-04-01 R 96367 96409 2018-04-01 R 96367 96413 2018-04-01 R 96368 96360 2018-04-01 R 96368 96365 2018-04-01 R 96368 96366 2018-04-01 R 96368 96413 2018-04-01 R 96368 96415 2018-04-01 R 96368 96416 2018-04-01 R


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Type One Addon Procedure Code List Removals Reason Key: R=Removed From List, D=Code Terminated Addon Primary Eff Date R* 96368 C8957 2018-04-01 R 96370 96369 2018-04-01 R 96371 96369 2018-04-01 R 96375 96360 2018-04-01 R 96375 96365 2018-04-01 R 96375 96374 2018-04-01 R 96375 96409 2018-04-01 R 96375 96413 2018-04-01 R 96376 96365 2018-04-01 R 96376 96374 2018-04-01 R 96376 96409 2018-04-01 R 96376 96413 2018-04-01 R 96411 96409 2018-04-01 R 96411 96413 2018-04-01 R 96415 96413 2018-04-01 R 96417 96413 2018-04-01 R 96423 96422 2018-04-01 R


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Modifier Changes

Added Modifiers

The following modifier(s) were added to the list of valid modifiers (edit 22). Added Modifiers Modifier Eff Date Description CB 2019-07-01 Esrd bene part a snf-sep pay MA 2020-01-01 Emer med cond susp/confirm MB 2020-01-01 Auc hardship, insuf internet MC 2020-01-01 Auc hardship, vendor issues MD 2020-01-01 Auc hardship, extreme circ ME 2020-01-01 Order adheres to auc MF 2020-01-01 Order does not adhere to auc MG 2020-01-01 Auc not applicable to order MH 2020-01-01 Auc consult not provided


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Deleted Modifiers

The following modifier(s) were removed from the list of valid modifiers (edit 22). Deleted Modifiers Modifier Eff Date Description GD 2020-01-01 Unit of service > mue value


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Documents

CMS Manual System · 0575T 2020-01-01 Prgrmg dev eval icds ss ip 05741 00000 Q1 E1 9 0576T 2020-01-01 Interrog dev eval icds ss ip 05741 00000 Q1 E1 9 0577T 2020-01-01 Ephys eval