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

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

Transmittal 4383 Date: August 30, 2019

Change Request 11412 SUBJECT: October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3 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: October 1, 2019 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: October 7, 2019 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: 4383 Date: August 30, 2019 Change Request: 11412 SUBJECT: October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3 EFFECTIVE DATE: October 1, 2019 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: October 7, 2019 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 October 1, 2019. 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

11412.1 The Shared System Maintainer shall install the Integrated OCE (I/OCE) into their systems.

X

11412.2 Medicare contractors shall identify the I/OCE specifications on the CMS Website at http://www.cms.gov/OutpatientCodeEdit/.

X X X

III. PROVIDER EDUCATION TABLE Number Requirement Responsibility

A/B

MAC DME

CED

A B HHH

MAC

I

11412.3 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, Yvonne.Young@cms.hhs.gov , Marina Kushnirova, Marina.Kushnirova@cms.hhs.gov , Fred Rooke, Fred.Rooke@cms.hhs.gov 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: 0

1

FINAL

Summary of Data Changes

Integrated OCE v20.3

Effective October 1, 2019

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Table of Contents

CPT codes, descriptions, and material only are Copyright 2018 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes

no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. DEFINITIONS ............................................................................................................................................ 3

DIAGNOSIS CODE CHANGES ............................................................................................................... 4

Added Diagnosis Codes .......................................................................................................................... 4

Deleted Diagnosis Codes ........................................................................................................................ 9

Diagnosis Edit Changes ........................................................................... Error! Bookmark not defined.

APC CHANGES ....................................................................................................................................... 10

Added APCs ......................................................................................................................................... 10

Deleted APCs ........................................................................................................................................ 11

APC Description Changes .................................................................................................................... 11

APC Status Indicator Changes .............................................................................................................. 11

HCPCS/CPT PROCEDURE CODE CHANGES ..................................................................................... 12

Added HCPCS/CPT Procedure Codes .................................................................................................. 12

Deleted HCPCS/CPT Procedure Codes ................................................................................................ 13

HCPCS Description Changes ............................................................................................................... 14

HCPCS Changes- APC, Status Indicator and/or Edit Assignments ..................................................... 14

Comprehensive APC Procedure Exclusion Changes ............................................................................ 15

HCPCS Approval and/or Termination Date Changes........................................................................... 15

Edit Assignments .................................................................................................................................. 15

Device Dependent Procedure Changes ................................................................................................. 15

Skin Substitute Low Cost Product Procedure Changes ........................................................................ 17

FQHC PPS Procedure Changes ............................................................................................................ 17

Add-On Procedure Code Changes ........................................................................................................ 18

MODIFIERS ............................................................................................................................................. 19

Deleted Modifiers ................................................................................................................................. 19

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DEFINITIONS

• A blank in a field indicates ‘no change’

• The “old” column describes the attribute prior to the change being made in the current update, which is indicated in the “new” column. If the effective date of the change is the same as the effective date of the new update, ‘old’ describes the attribute up to the last day of the previous quarter. If the effective date is retroactive, then ‘old’ describes the attribute for the same date in the previous release of the software.

• “Unassigned”, “Pre-defined” or “Placeholder” in APC or HCPCS descriptions indicates that the APC or

HCPCS code is inactive. When the APC or HCPCS code is activated, it becomes valid for use in the OCE, and a new description appears in the “new description” column, with the appropriate effective date.

• Activation Date (ActivDate) indicates the mid-quarter date of FDA approval for a drug, or the mid-

quarter date of a new or changed code resulting from a National Coverage Determination (NCD). The Activation Date is the date the code becomes valid for use in the OCE. If the Activation Date is blank, then the effective date takes precedence.

• Termination Date (TermDate) indicates the mid-quarter date when a code or change becomes inactive. A

code is not valid for use in the OCE after its termination date.

• For codes with SI of “Q1, Q2, and Q3”, the APC assignment is the standard APC to which the code would be assigned if it is paid separately.

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DIAGNOSIS CODE CHANGES

Added Diagnosis Codes The following new ICD-10 diagnosis codes were added to the IOCE, effective 10-01-19 Diagnosis CodeDesc Low Age High Age D75A Glucose-6-phosphate dehydrgnse (G6PD) defic without anemia 0 124 D8130 Adenosine deaminase deficiency, unspecified 0 124 D8131 Severe combined immunodef due to adenosine deaminase defic 0 124 D8132 Adenosine deaminase 2 deficiency 0 124 D8139 Other adenosine deaminase deficiency 0 124 H814 Vertigo of central origin 0 124 I2693 Single subsegmental pulmon emblsm w/o acute cor pulmonale 0 124 I2694 Mult subsegmental pulmon emboli without acute cor pulmonale 0 124 I4811 Longstanding persistent atrial fibrillation 0 124 I4819 Other persistent atrial fibrillation 0 124 I4820 Chronic atrial fibrillation, unspecified 0 124 I4821 Permanent atrial fibrillation 0 124 I80241 Phlebitis and thrombophlebitis of right peroneal vein 0 124 I80242 Phlebitis and thrombophlebitis of left peroneal vein 0 124 I80243 Phlebitis and thrombophlebitis of peroneal vein, bilateral 0 124 I80249 Phlebitis and thrombophlebitis of unspecified peroneal vein 0 124 I80251 Phlebitis and thrombophlebitis of right calf muscular vein 0 124 I80252 Phlebitis and thrombophlebitis of left calf muscular vein 0 124 I80253 Phlebitis and thombophlb of calf muscular vein, bilateral 0 124 I80259 Phlebitis and thombophlb of unspecified calf muscular vein 0 124 I82451 Acute embolism and thrombosis of right peroneal vein 0 124 I82452 Acute embolism and thrombosis of left peroneal vein 0 124 I82453 Acute embolism and thrombosis of peroneal vein, bilateral 0 124 I82459 Acute embolism and thrombosis of unspecified peroneal vein 0 124 I82461 Acute embolism and thrombosis of right calf muscular vein 0 124 I82462 Acute embolism and thrombosis of left calf muscular vein 0 124 I82463 Acute embolism and thombos of calf muscular vein, bilateral 0 124 I82469 Acute embolism and thombos unsp calf muscular vein 0 124 I82551 Chronic embolism and thrombosis of right peroneal vein 0 124 I82552 Chronic embolism and thrombosis of left peroneal vein 0 124 I82553 Chronic embolism and thrombosis of peroneal vein, bilateral 0 124 I82559 Chronic embolism and thrombosis of unspecified peroneal vein 0 124 I82561 Chronic embolism and thrombosis of right calf muscular vein 0 124 I82562 Chronic embolism and thrombosis of left calf muscular vein 0 124 I82563 Chronic embolism and thombos of calf muscular vein, bi 0 124 I82569 Chronic embolism and thombos unsp calf muscular vein 0 124 L89006 Pressure-induced deep tissue damage of unspecified elbow 0 124 L89016 Pressure-induced deep tissue damage of right elbow 0 124 L89026 Pressure-induced deep tissue damage of left elbow 0 124 L89106 Pressr-induc deep tissue damage of unspecified part of back 0 124 L89116 Pressure-induced deep tissue damage of right upper back 0 124 L89126 Pressure-induced deep tissue damage of left upper back 0 124

5

Diagnosis CodeDesc Low Age High Age L89136 Pressure-induced deep tissue damage of right lower back 0 124 L89146 Pressure-induced deep tissue damage of left lower back 0 124 L89156 Pressure-induced deep tissue damage of sacral region 0 124 L89206 Pressure-induced deep tissue damage of unspecified hip 0 124 L89216 Pressure-induced deep tissue damage of right hip 0 124 L89226 Pressure-induced deep tissue damage of left hip 0 124 L89306 Pressure-induced deep tissue damage of unspecified buttock 0 124 L89316 Pressure-induced deep tissue damage of right buttock 0 124 L89326 Pressure-induced deep tissue damage of left buttock 0 124 L8946 Pressr-induc dp tiss damag of contig site of back, butt & hp 0 124 L89506 Pressure-induced deep tissue damage of unspecified ankle 0 124 L89516 Pressure-induced deep tissue damage of right ankle 0 124 L89526 Pressure-induced deep tissue damage of left ankle 0 124 L89606 Pressure-induced deep tissue damage of unspecified heel 0 124 L89616 Pressure-induced deep tissue damage of right heel 0 124 L89626 Pressure-induced deep tissue damage of left heel 0 124 L89816 Pressure-induced deep tissue damage of head 0 124 L89896 Pressure-induced deep tissue damage of other site 0 124 L8996 Pressure-induced deep tissue damage of unspecified site 0 124 N6315 Unspecified lump in the right breast, overlapping quadrants 0 124 N6325 Unspecified lump in the left breast, overlapping quadrants 0 124 N9985 Post endometrial ablation syndrome 0 124 Q6600 Congenital talipes equinovarus, unspecified foot 0 124 Q6601 Congenital talipes equinovarus, right foot 0 124 Q6602 Congenital talipes equinovarus, left foot 0 124 Q6610 Congenital talipes calcaneovarus, unspecified foot 0 124 Q6611 Congenital talipes calcaneovarus, right foot 0 124 Q6612 Congenital talipes calcaneovarus, left foot 0 124 Q66211 Congenital metatarsus primus varus, right foot 0 124 Q66212 Congenital metatarsus primus varus, left foot 0 124 Q66219 Congenital metatarsus primus varus, unspecified foot 0 124 Q66221 Congenital metatarsus adductus, right foot 0 124 Q66222 Congenital metatarsus adductus, left foot 0 124 Q66229 Congenital metatarsus adductus, unspecified foot 0 124 Q6630 Other congenital varus deformities of feet, unspecified foot 0 124 Q6631 Other congenital varus deformities of feet, right foot 0 124 Q6632 Other congenital varus deformities of feet, left foot 0 124 Q6640 Congenital talipes calcaneovalgus, unspecified foot 0 124 Q6641 Congenital talipes calcaneovalgus, right foot 0 124 Q6642 Congenital talipes calcaneovalgus, left foot 0 124 Q6670 Congenital pes cavus, unspecified foot 0 124 Q6671 Congenital pes cavus, right foot 0 124 Q6672 Congenital pes cavus, left foot 0 124 Q6690 Congenital deformity of feet, unspecified, unspecified foot 0 124 Q6691 Congenital deformity of feet, unspecified, right foot 0 124 Q6692 Congenital deformity of feet, unspecified, left foot 0 124 Q7960 Ehlers-Danlos syndrome, unspecified 0 124 Q7961 Classical Ehlers-Danlos syndrome 0 124 Q7962 Hypermobile Ehlers-Danlos syndrome 0 124 Q7963 Vascular Ehlers-Danlos syndrome 0 124 Q7969 Other Ehlers-Danlos syndromes 0 124

6

Diagnosis CodeDesc Low Age High Age Q8711 Prader-Willi syndrome 0 124 Q8719 Other congen malform synd predom assoc with short stature 0 124 R1115 Cyclical vomiting syndrome unrelated to migraine 0 124 R8281 Pyuria 0 124 R8289 Other abn findings on cytolog and histolog exam of urine 0 124 S02121A Fracture of orbital roof, right side, init 0 124 S02121B Fracture of orbital roof, right side, 7thB 0 124 S02121D Fracture of orbital roof, right side, 7thD 0 124 S02121G Fracture of orbital roof, right side, 7thG 0 124 S02121K Fracture of orbital roof, right side, 7thK 0 124 S02121S Fracture of orbital roof, right side, sequela 0 124 S02122A Fracture of orbital roof, left side, init 0 124 S02122B Fracture of orbital roof, left side, 7thB 0 124 S02122D Fracture of orbital roof, left side, 7thD 0 124 S02122G Fracture of orbital roof, left side, 7thG 0 124 S02122K Fracture of orbital roof, left side, 7thK 0 124 S02122S Fracture of orbital roof, left side, sequela 0 124 S02129A Fracture of orbital roof, unspecified side, init 0 124 S02129B Fracture of orbital roof, unspecified side, 7thB 0 124 S02129D Fracture of orbital roof, unspecified side, 7thD 0 124 S02129G Fracture of orbital roof, unspecified side, 7thG 0 124 S02129K Fracture of orbital roof, unspecified side, 7thK 0 124 S02129S Fracture of orbital roof, unspecified side, sequela 0 124 S02831A Fracture of medial orbital wall, right side, init 0 124 S02831B Fracture of medial orbital wall, right side, 7thB 0 124 S02831D Fracture of medial orbital wall, right side, 7thD 0 124 S02831G Fracture of medial orbital wall, right side, 7thG 0 124 S02831K Fracture of medial orbital wall, right side, 7thK 0 124 S02831S Fracture of medial orbital wall, right side, sequela 0 124 S02832A Fracture of medial orbital wall, left side, init 0 124 S02832B Fracture of medial orbital wall, left side, 7thB 0 124 S02832D Fracture of medial orbital wall, left side, 7thD 0 124 S02832G Fracture of medial orbital wall, left side, 7thG 0 124 S02832K Fracture of medial orbital wall, left side, 7thK 0 124 S02832S Fracture of medial orbital wall, left side, sequela 0 124 S02839A Fracture of medial orbital wall, unspecified side, init 0 124 S02839B Fracture of medial orbital wall, unspecified side, 7thB 0 124 S02839D Fracture of medial orbital wall, unspecified side, 7thD 0 124 S02839G Fracture of medial orbital wall, unspecified side, 7thG 0 124 S02839K Fracture of medial orbital wall, unspecified side, 7thK 0 124 S02839S Fracture of medial orbital wall, unspecified side, sequela 0 124 S02841A Fracture of lateral orbital wall, right side, init 0 124 S02841B Fracture of lateral orbital wall, right side, 7thB 0 124 S02841D Fracture of lateral orbital wall, right side, 7thD 0 124 S02841G Fracture of lateral orbital wall, right side, 7thG 0 124 S02841K Fracture of lateral orbital wall, right side, 7thK 0 124 S02841S Fracture of lateral orbital wall, right side, sequela 0 124 S02842A Fracture of lateral orbital wall, left side, init 0 124 S02842B Fracture of lateral orbital wall, left side, 7thB 0 124 S02842D Fracture of lateral orbital wall, left side, 7thD 0 124 S02842G Fracture of lateral orbital wall, left side, 7thG 0 124

7

Diagnosis CodeDesc Low Age High Age S02842K Fracture of lateral orbital wall, left side, 7thK 0 124 S02842S Fracture of lateral orbital wall, left side, sequela 0 124 S02849A Fracture of lateral orbital wall, unspecified side, init 0 124 S02849B Fracture of lateral orbital wall, unspecified side, 7thB 0 124 S02849D Fracture of lateral orbital wall, unspecified side, 7thD 0 124 S02849G Fracture of lateral orbital wall, unspecified side, 7thG 0 124 S02849K Fracture of lateral orbital wall, unspecified side, 7thK 0 124 S02849S Fracture of lateral orbital wall, unspecified side, sequela 0 124 S0285XA Fracture of orbit, unspecified, init 0 124 S0285XB Fracture of orbit, unspecified, 7thB 0 124 S0285XD Fracture of orbit, unspecified, 7thD 0 124 S0285XG Fracture of orbit, unspecified, 7thG 0 124 S0285XK Fracture of orbit, unspecified, 7thK 0 124 S0285XS Fracture of orbit, unspecified, sequela 0 124 T50911A Poisoning by multiple unsp drug/meds/biol subst, acc, init 0 124 T50911D Poisoning by multiple unsp drug/meds/biol subst, acc, subs 0 124 T50911S Poisn by multiple unsp drug/meds/biol subst, acc, sequela 0 124 T50912A Poisn by multiple unsp drug/meds/biol subst, self-harm, init 0 124 T50912D Poisn by multiple unsp drug/meds/biol subst, self-harm, subs 0 124 T50912S Poisn by mult unsp drug/meds/biol subst, slf-hrm, sequela 0 124 T50913A Poisn by multiple unsp drug/meds/biol subst, assault, init 0 124 T50913D Poisn by multiple unsp drug/meds/biol subst, assault, subs 0 124 T50913S Poisn by mult unsp drug/meds/biol subst, assault, sequela 0 124 T50914A Poisoning by multiple unsp drug/meds/biol subst, undet, init 0 124 T50914D Poisoning by multiple unsp drug/meds/biol subst, undet, subs 0 124 T50914S Poisn by multiple unsp drug/meds/biol subst, undet, sequela 0 124 T50915A Adverse effect of multiple unsp drug/meds/biol subst, init 0 124 T50915D Adverse effect of multiple unsp drug/meds/biol subst, subs 0 124 T50915S Adverse effect of mult unsp drug/meds/biol subst, sequela 0 124 T50916A Undrdose of multiple unspecified drug/meds/biol subst, init 0 124 T50916D Undrdose of multiple unspecified drug/meds/biol subst, subs 0 124 T50916S Undrdose of multiple unsp drug/meds/biol subst, sequela 0 124 T6701XA Heatstroke and sunstroke, initial encounter 0 124 T6701XD Heatstroke and sunstroke, subsequent encounter 0 124 T6701XS Heatstroke and sunstroke, sequela 0 124 T6702XA Exertional heatstroke, initial encounter 0 124 T6702XD Exertional heatstroke, subsequent encounter 0 124 T6702XS Exertional heatstroke, sequela 0 124 T6709XA Other heatstroke and sunstroke, initial encounter 0 124 T6709XD Other heatstroke and sunstroke, subsequent encounter 0 124 T6709XS Other heatstroke and sunstroke, sequela 0 124 Y35009A Legal intrvnt w unsp firearm disch, unsp person inj, init 0 124 Y35009D Legal intrvnt w unsp firearm disch, unsp person inj, subs 0 124 Y35009S Legal intrvnt w unsp firearm disch, unsp person inj, sequela 0 124 Y35019A Legal intrvnt w injury by mch gun, unsp person injured, init 0 124 Y35019D Legal intrvnt w injury by mch gun, unsp person injured, subs 0 124 Y35019S Legal intrvnt w injury by mch gun, unsp person inj, sequela 0 124 Y35029A Legal intrvnt w injury by handgun, unsp person injured, init 0 124 Y35029D Legal intrvnt w injury by handgun, unsp person injured, subs 0 124 Y35029S Legal intrvnt w injury by handgun, unsp person inj, sequela 0 124 Y35039A Legal intrvnt w injury by rifl pelet, unsp person inj, init 0 124

8

Diagnosis CodeDesc Low Age High Age Y35039D Legal intrvnt w injury by rifl pelet, unsp person inj, subs 0 124 Y35039S Legal intrvnt w injury by rifl pelet, unsp person inj, sqla 0 124 Y35049A Legal intrvnt w injury by rubr bulet, unsp person inj, init 0 124 Y35049D Legal intrvnt w injury by rubr bulet, unsp person inj, subs 0 124 Y35049S Legal intrvnt w injury by rubr bulet, unsp person inj, sqla 0 124 Y35099A Legal intervnt w firearm disch, unsp person injured, init 0 124 Y35099D Legal intervnt w firearm disch, unsp person injured, subs 0 124 Y35099S Legal intervnt w firearm disch, unsp person injured, sequela 0 124 Y35109A Legal intervnt w unsp explosv, unsp person injured, init 0 124 Y35109D Legal intervnt w unsp explosv, unsp person injured, subs 0 124 Y35109S Legal intervnt w unsp explosv, unsp person injured, sequela 0 124 Y35119A Legal intrvnt w injury by dynamite, unsp person inj, init 0 124 Y35119D Legal intrvnt w injury by dynamite, unsp person inj, subs 0 124 Y35119S Legal intrvnt w injury by dynamite, unsp person inj, sequela 0 124 Y35129A Legal intrvnt w inj by explosv shell, unsp person inj, init 0 124 Y35129D Legal intrvnt w inj by explosv shell, unsp person inj, subs 0 124 Y35129S Legal intrvnt w inj by explosv shell, unsp person inj, sqla 0 124 Y35199A Legal intervnt w other explosv, unsp person injured, init 0 124 Y35199D Legal intervnt w other explosv, unsp person injured, subs 0 124 Y35199S Legal intervnt w other explosv, unsp person injured, sequela 0 124 Y35209A Legal intervnt involving unsp gas, unsp person injured, init 0 124 Y35209D Legal intervnt involving unsp gas, unsp person injured, subs 0 124 Y35209S Legal intervnt w unsp gas, unsp person injured, sequela 0 124 Y35219A Legal intrvnt w injury by tear gas, unsp person inj, init 0 124 Y35219D Legal intrvnt w injury by tear gas, unsp person inj, subs 0 124 Y35219S Legal intrvnt w injury by tear gas, unsp person inj, sequela 0 124 Y35299A Legal intervnt w other gas, unsp person injured, init 0 124 Y35299D Legal intervnt w other gas, unsp person injured, subs 0 124 Y35299S Legal intervnt w other gas, unsp person injured, sequela 0 124 Y35309A Legal intrvnt w unsp blunt objects, unsp person inj, init 0 124 Y35309D Legal intrvnt w unsp blunt objects, unsp person inj, subs 0 124 Y35309S Legal intrvnt w unsp blunt objects, unsp person inj, sequela 0 124 Y35319A Legal intervnt involving baton, unsp person injured, init 0 124 Y35319D Legal intervnt involving baton, unsp person injured, subs 0 124 Y35319S Legal intervnt involving baton, unsp person injured, sequela 0 124 Y35399A Legal intrvnt w other blunt objects, unsp person inj, init 0 124 Y35399D Legal intrvnt w other blunt objects, unsp person inj, subs 0 124 Y35399S Legal intrvnt w other blunt obj, unsp person inj, sequela 0 124 Y35409A Legal intrvnt w unsp sharp objects, unsp person inj, init 0 124 Y35409D Legal intrvnt w unsp sharp objects, unsp person inj, subs 0 124 Y35409S Legal intrvnt w unsp sharp objects, unsp person inj, sequela 0 124 Y35419A Legal intervnt involving bayonet, unsp person injured, init 0 124 Y35419D Legal intervnt involving bayonet, unsp person injured, subs 0 124 Y35419S Legal intervnt w bayonet, unsp person injured, sequela 0 124 Y35499A Legal intrvnt w other sharp objects, unsp person inj, init 0 124 Y35499D Legal intrvnt w other sharp objects, unsp person inj, subs 0 124 Y35499S Legal intrvnt w other sharp obj, unsp person inj, sequela 0 124 Y35819A Legal intervnt w manhandling, unsp person injured, init 0 124 Y35819D Legal intervnt w manhandling, unsp person injured, subs 0 124 Y35819S Legal intervnt w manhandling, unsp person injured, sequela 0 124 Y35831A Legal intrvnt w a cond energy device, law enforc inj, init 0 124

9

Diagnosis CodeDesc Low Age High Age Y35831D Legal intrvnt w a cond energy device, law enforc inj, subs 0 124 Y35831S Legal intrvnt w a cond energy device, law enforc inj, sqla 0 124 Y35832A Legal intervnt w a cond energy device, bystand injured, init 0 124 Y35832D Legal intervnt w a cond energy device, bystand injured, subs 0 124 Y35832S Legal intrvnt w a cond energy device, bystand inj, sequela 0 124 Y35833A Legal intervnt w a cond energy device, suspect injured, init 0 124 Y35833D Legal intervnt w a cond energy device, suspect injured, subs 0 124 Y35833S Legal intrvnt w a cond energy device, suspect inj, sequela 0 124 Y35839A Legal intrvnt w a cond energy device, unsp person inj, init 0 124 Y35839D Legal intrvnt w a cond energy device, unsp person inj, subs 0 124 Y35839S Legal intrvnt w a cond energy device, unsp person inj, sqla 0 124 Y3599XA Legal intervnt, means unsp, unspecified person injured, init 0 124 Y3599XD Legal intervnt, means unsp, unspecified person injured, subs 0 124 Y3599XS Legal intervnt, means unsp, unsp person injured, sequela 0 124 Z01020 Enctr for ex of eyes and vis fol fail vis scrn w/o abn find 0 124 Z01021 Enctr for exam of eyes and vis fol fail vis scrn wbn find 0 124 Z117 Encounter for testing for latent tuberculosis infection 0 124 Z227 Latent tuberculosis 0 124 Z7184 Encounter for health counseling related to travel 0 124 Z86002 Pers hx of in-situ neoplasm of other and unsp genital organs 0 124 Z86003 Pers hx of in-situ neoplm of oral cavity, esoph and stomach 0 124 Z86004 Pers hx of in-situ neoplasm of other and unsp dgstv orgs 0 124 Z86005 Pers hx of in-situ neoplasm of middle ear and resp sys 0 124 Z86006 Personal history of melanoma in-situ 0 124 Z86007 Personal history of in-situ neoplasm of skin 0 124 Z8615 Personal history of latent tuberculosis infection 0 124 Z9682 Presence of neurostimulator 0 124

Deleted Diagnosis Codes The following deleted ICD-10 diagnosis codes were removed from the IOCE, effective 10-01-19 Diagnosis CodeDesc D813 Adenosine deaminase [ADA] deficiency H8141 Vertigo of central origin, right ear H8142 Vertigo of central origin, left ear H8143 Vertigo of central origin, bilateral H8149 Vertigo of central origin, unspecified ear I481 Persistent atrial fibrillation I482 Chronic atrial fibrillation Q660 Congenital talipes equinovarus Q661 Congenital talipes calcaneovarus Q6621 Congenital metatarsus primus varus Q6622 Congenital metatarsus adductus Q663 Other congenital varus deformities of feet Q664 Congenital talipes calcaneovalgus Q667 Congenital pes cavus Q669 Congenital deformity of feet, unspecified Q796 Ehlers-Danlos syndrome Q871 Congenital malform syndromes predom assoc w short stature

10

Diagnosis CodeDesc R828 Abnormal findings on cytolog and histolog exam of urine T670XXA Heatstroke and sunstroke, initial encounter T670XXD Heatstroke and sunstroke, subsequent encounter T670XXS Heatstroke and sunstroke, sequela The following ICD-10 code(s) were added to the list of female diagnoses, effective 10-01-19 DIAGNOSIS N9985 The following ICD-10 code(s) were added to the list of code first diagnoses, effective 10-01-19 DIAGNOSIS T50912A T50912D T50912S T50913A T50913D T50913S T50914A T50914D T50914S

APC CHANGES

Added APCs The following APC(s) were added to the IOCE, effective 04-01-19 APC APCDesc StatusIndicator 09313 Inj., belrapzo 1 mg G The following APC(s) were added to the IOCE, effective 07-01-19 APC APCDesc StatusIndicator 09322 Bcg live intravesical 1mg K 09329 Inj mvasi 10 mg K The following APC(s) were added to the IOCE, effective 10-01-19 APC APCDesc StatusIndicator 09323 Inj., levoleucovorin, 0.5 mg G 09324 Phenylep ketorolac opth soln G 09325 Inj., eravacycline, 1 mg K 09326 Inj., lanadelumab-flyo, 1 mg K 09327 Inj. romosozumab-aqqg 1 mg G 09328 Inj., yutiq, 0.01 mg K 09330 Inj., kanjinti, 10 mg K

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Deleted APCs The following APC(s) were removed from the IOCE, effective 07-01-19 APC APCDesc 00809 Bcg live intravesical 1mg The following APC(s) were removed from the IOCE, effective 10-01-19 APC APCDesc 01236 Levoleucovorin injection 09083 Inj, phenylephrine ketorolac 09303 Injection, levoleucovorin

APC Description Changes The following APC(s) had description changes, effective 07-01-19 APC Old Description New Description 09313 Inj., belrapzo, 1 mg Inj. belrapzo/bendamustine The following APC(s) had description changes, effective 10-01-19 APC Old Description New Description 09125 Risperidone, long acting Inj., risperdal consta, 0.5 mg 09179 Injection, Aristada Initio Inj., aristada initio, 1 mg 09180 Injection, patisiran Inj., patisiran, 0.1 mg 09181 Injection, risperidone Inj., perseris, 0.5 mg 09182 Inj mogamulizumab-kpkc Inj, mogamulizumab-kpkc, 1 mg 09183 Injection, plazomicin Inj., plazomicin, 5 mg 09197 Injection, fremanezumab-vfrm Inj., fremanezumab-vfrm 1 mg 09225 Fluocinolone acetonide implt Inj., retisert, 0.01 mg 09304 Injection, cemiplimab-rwlc Inj., cemiplimab-rwlc, 1 mg 09305 Moxetumomab pasudotox-tdfk Inj., lumoxiti, 0.01 mg 09308 Dexamethasone ophth insert Dexametha opth insert 0.1 mg 09309 Injection, tagraxofusp-erzs Inj. tagraxofusp-erzs 10 mcg 09310 Injection, emapalumab-lzsg Inj., emapalumab-lzsg, 1 mg 09311 Injection, omadacycline Inj., omadacycline, 1 mg 09312 Injection, ravulizumab-cwv Inj., ravulizumab-cwvz 10 mg 09450 Fluocinol acet intravit imp Inj., iluvien, 0.01 mg 09470 Aripiprazole lauroxil 1mg Aripirazole lauroxil 1 mg

APC Status Indicator Changes The following APC(s) had Status Indicator changes, effective 10-01-19 APC Old SI New SI 09314 K G

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HCPCS/CPT PROCEDURE CODE CHANGES

Added HCPCS/CPT Procedure Codes The following new HCPCS/CPT code(s) were added to the IOCE, effective 10-01-19 HCPCS CodeDesc SI APC Edit ActivDate TermDate 0105U Neph ckd mult eclia tum nec Q4 00000 0106U Gstr emptg 7 timed brth spec Q4 00000 0107U C diff tox ag detcj ia stool Q4 00000 0108U Gi barrett esoph 9 prtn bmrk Q4 00000 0109U Id aspergillus dna 4 species A 00000 0110U Rx mntr 1+oral onc rx&sbsts Q4 00000 0111U Onc colon ca kras&nras alys A 00000 0112U Iadi 16s&18s rrna genes A 00000 0113U Onc prst8 pca3&tmprss2-erg A 00000 0114U Gi barretts esoph vim&ccna1 A 00000 0115U Respir iadna 18 viral&2 bact A 00000 0116U Rx mntr nzm ia 35+oral flu Q4 00000 0117U Pain mgmt 11 endogenous anal Q4 00000 0118U Trnsplj don-drv cll-fr dna A 00000 0119U Crd ceramides liq chrom plsm Q4 00000 0120U Onc b cll lymphm mrna 58 gen A 00000 0121U Sc dis vcam-1 whole blood Q4 00000 0122U Sc dis p-selectin whl blood Q4 00000 0123U Mchnl fragility rbc prflg Q4 00000 0124U Ftl cgen abnor 3 analtyes E1 00000 9 0125U Ftl cgen abnor prnt comp 5 Q4 00000 0126U Ftl cgen abnor prnt comp 5 y Q4 00000 0127U Ob pe 3 analytes Q4 00000 0128U Ob pe 3 analytes y chrmsm Q4 00000 0129U Hered brst ca rltd do panel A 00000 0130U Hered colon ca do mrna pnl N 00000 0131U Hered brst ca rltd do pnl 13 N 00000 0132U Hered ova ca rltd do pnl 17 N 00000 0133U Hered prst8 ca rltd do 11 N 00000 0134U Hered pan ca mrna pnl 18 gen N 00000 0135U Hered gyn ca mrna pnl 12 gen N 00000 0136U Atm mrna seq alys N 00000 0137U Palb2 mrna seq alys N 00000 0138U Brca1 brca2 mrna seq alys N 00000 2023F Dilat rta xm w/o rtnopthy M 00000 72 2025F 7 fld rta photo w/o rtnopthy M 00000 72 2033F Eye img valid w/o rtnopthy M 00000 72 3051F Hg a1c>equal 7.0%<8.0% M 00000 72 3052F Hg a1c>equal 8.0%<equal 9.0% M 00000 72 J0121 Inj., omadacycline, 1 mg G 09311 J0122 Inj., eravacycline, 1 mg K 09325 J0222 Inj., patisiran, 0.1 mg G 09180 J0291 Inj., plazomicin, 5 mg G 09183 J0593 Inj., lanadelumab-flyo, 1 mg K 09326

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HCPCS CodeDesc SI APC Edit ActivDate TermDate J1096 Dexametha opth insert 0.1 mg G 09308 J1097 Phenylep ketorolac opth soln G 09324 J1303 Inj., ravulizumab-cwvz 10 mg G 09312 J1943 Inj., aristada initio, 1 mg G 09179 J1944 Aripirazole lauroxil 1 mg K 09470 J2798 Inj., perseris, 0.5 mg G 09181 J3031 Inj., fremanezumab-vfrm 1 mg G 09197 J3111 Inj. romosozumab-aqqg 1 mg G 09327 J7314 Inj., yutiq, 0.01 mg K 09328 J7331 Synojoynt, inj., 1 mg E2 00000 13 J7332 Inj., triluron, 1 mg E2 00000 13 J7401 Mometasone furoate sinus imp N 00000 J9118 Inj. calaspargase pegol-mknl E2 00000 13 J9119 Inj., cemiplimab-rwlc, 1 mg G 09304 J9204 Inj, mogamulizumab-kpkc, 1 mg G 09182 J9210 Inj., emapalumab-lzsg, 1 mg G 09310 J9269 Inj. tagraxofusp-erzs 10 mcg G 09309 J9313 Inj., lumoxiti, 0.01 mg G 09305 Q4205 Membrane graft or wrap sq cm N 00000 Q4206 Fluid flow or fluid gf 1 cc N 00000 Q4208 Novafix per sq cm N 00000 Q4209 Surgraft per sq cm N 00000 Q4210 Axolotl graf dualgraf sq cm N 00000 Q4211 Amnion bio or axobio sq cm N 00000 Q4212 Allogen, per cc N 00000 Q4213 Ascent, 0.5 mg N 00000 Q4214 Cellesta cord per sq cm N 00000 Q4215 Axolotl ambient, cryo 0.1 mg N 00000 Q4216 Artacent cord per sq cm N 00000 Q4217 Woundfix biowound plus xplus N 00000 Q4218 Surgicord per sq cm N 00000 Q4219 Surgigraft dual per sq cm N 00000 Q4220 Bellacell HD, Surederm sq cm N 00000 Q4221 Amniowrap2 per sq cm N 00000 Q4222 Progenamatrix, per sq cm N 00000 Q4226 Myown harv prep proc sq cm N 00000 Q5116 Inj., trazimera, 10 mg E2 00000 13 Q5117 Inj., kanjinti, 10 mg K 09330 Q5118 Inj., zirabev, 10 mg E2 00000 13

Deleted HCPCS/CPT Procedure Codes The following HCPCS/CPT code(s) were removed from the IOCE, effective 10-01-19 HCPCS CodeDesc 0104U Hered pan ca pnl 32 genes 3045F Hg a1c level 7.0-9.0% C9035 Injection, Aristada Initio C9036 Injection, patisiran C9037 Injection, risperidone

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HCPCS CodeDesc C9038 Inj mogamulizumab-kpkc C9039 Injection, plazomicin C9040 Injection, fremanezumab-vfrm C9043 Injection, levoleucovorin C9044 Injection, cemiplimab-rwlc C9045 Moxetumomab pasudotox-tdfk C9048 Dexamethasone ophth insert C9049 Injection, tagraxofusp-erzs C9050 Injection, emapalumab-lzsg C9051 Injection, omadacycline C9052 Injection, ravulizumab-cwv C9447 Inj, phenylephrine ketorolac J1942 Aripiprazole lauroxil 1mg S1090 Mometasone sinus implant

HCPCS Description Changes The following code descriptions were changed, effective 07-01-19 HCPCS Old Description New Description J9036 Inj., belrapzo, 1 mg Inj. belrapzo/bendamustine Q5115 Inj rituximab-abbs bio 10 mg Inj truxima 10 mg The following code descriptions were changed, effective 10-01-19 HCPCS Old Description New Description 2026F Eye image valid to dx rev Eye img valid evc rtnopthy A4407 Ext wear ost skn barr <=4sq" Ext wear ost skn barr <=4sq A4408 Ext wear ost skn barr >4sq" Ext wear ost skn barr >4sq A4719 "y set" tubing y set tubing E2201 Man w/ch acc seat w>=20"<24" Man w/ch acc seat w>=20"<24 J0641 Levoleucovorin injection Inj., levoleucovorin, 0.5 mg J2794 Risperidone, long acting Inj., risperdal consta, 0.5 mg J7311 Fluocinolone acetonide implt Inj., retisert, 0.01 mg J7313 Fluocinol acet intravit imp Inj., iluvien, 0.01 mg Q4122 Dermacell Dermacell, awm, porous sq cm Q4165 Keramatrix, per square cm Keramatrix, kerasorb sq cm Q4184 Cellesta, 1 sq cm Cellesta or duo per sq cm

HCPCS Changes- APC, Status Indicator and/or Edit Assignments The following code(s) had an APC and/or SI and/or edit change, effective 04-01-19 **A blank in the field indicates no change. HCPCS CodeDesc Old APC New APC Old SI New SI Old Edit New Edit C9042 Inj., belrapzo 1 mg 00000 09313 E2 G 13 N/A

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The following code(s) had an APC and/or SI and/or edit change, effective 07-01-19 **A blank in the field indicates no change. HCPCS CodeDesc Old APC New APC Old SI New SI Old Edit New Edit 0080U Onc lng 5 clin rsk factr alg Q4 A 0559T Antmc mdl 3d print 1st

cmpnt S Q1

0561T Antmc guide 3d print 1st gd S Q1 81599 Unlisted maaa E1 A 9 N/A J9030 Bcg live intravesical 1mg 00809 09322 Q5107 Inj mvasi 10 mg 00000 09329 E2 K 13 N/A The following code(s) had an APC and/or SI and/or edit change, effective 10-01-19 **A blank in the field indicates no change. HCPCS CodeDesc Old APC New APC Old SI New SI Old Edit New Edit J0641 Inj., levoleucovorin, 0.5 mg 01236 09323 K G J9356 Inj. herceptin hylecta, 10mg K G

Comprehensive APC Procedure Exclusion Changes The following codes were added to the comprehensive APC exclusion list, effective 01-01-15 HCPCS G0279

HCPCS Approval and/or Termination Date Changes The following code(s) had approval and /or termination date changes HCPCS Old ApprovalDt New ApprovalDt Old TerminationDt New TerminationDt Edit Q5107 0 20190718 110

Edit Assignments The following drug or biological code(s) were added to the list of exclusions for not requiring an OPPS payable procedure for edit 99, effective 07-01-19 HCPCS J7208

Device Dependent Procedure Changes The following code(s) were removed from the device dependent procedure list (edit 92), effective 01-01-19 HCPCS 86891

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The following device procedures were added to the edit 92 modifier bypass list, effective 01-01-19 HCPCS 23473 23515 23615 23616 23680 24370 24371 24545 24546 24579 24635 24666 24685 25515 25525 25526 25574 25575 27792 27814 27822 27823 27827 27828 27832 28415 28420 28445 28465 28485 28555 28585 28615 29855 29856 37192 61888 62350 63663 63664 64595

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Skin Substitute Low Cost Product Procedure Changes The following code(s) were added to the skin substitute low cost product list, effective 10-01-19 HCPCS Q4205 Q4206 Q4208 Q4209 Q4210 Q4211 Q4212 Q4213 Q4214 Q4215 Q4216 Q4217 Q4218 Q4219 Q4220 Q4221 Q4222 Q4226

FQHC PPS Procedure Changes The following FQHC PPS non-covered procedure codes are added, effective 10-01-19 HCPCS 0105U 0106U 0107U 0108U 0109U 0110U 0111U 0112U 0113U 0114U 0115U 0116U 0117U 0118U 0119U 0120U 0121U 0122U 0123U 0125U 0126U 0127U

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HCPCS 0128U 0129U 0130U 0131U 0132U 0133U 0134U 0135U 0136U 0137U 0138U

Add-On Procedure Code Changes The following code(s) were added to the Type I Add-on Code Procedure list, effective 10-01-19 Addon Primary 0130U 0101U 0130U 81435 0131U 0102U 0131U 81162 0131U 81432 0132U 0103U 0132U 81162 0132U 81432 0133U 81162 0134U 81162 0134U 81432 0134U 81435 0135U 81162 0136U 81408 0137U 81406 0138U 81162 The following code(s) were removed from the Type I Add on Code Procedure list, effective 04-01-18 Addon Primary 96361 96360 96361 96365 96361 96374 96361 96409 96361 96413 96366 96360 96366 96365 96366 96367 96366 96413

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MODIFIERS

Deleted Modifiers The following modifier(s) were removed from the list of valid modifiers, effective 07-01-19 modif ACTIVATIONDATE CB 0