Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter CHC-89 February 2011 TO: Community Health Centers Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Community Health Center Manual (2011 HCPCS) This letter transmits revisions to the service codes and descriptions in the Community Health Center Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) for 2011. The revised Subchapter 6 is effective for dates of service on or after January 1, 2011. Please Note: MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 405.000 and 450.000. A community health center (CHC) may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5), for a MassHealth Standard or CommonHealth member younger than 21 years of age even if it is not designated as covered or payable in the Community Health Center Manual. For more information about payment, you may download the Division of Health Care Finance and Policy (DHCFP) regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of the DHCFP regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The regulation titles are as follows: 114.3 CMR 18.00: Radiology, 114.3 CMR 20.00: Clinical Laboratory Services, 114.3 CMR 4.00: Rates for Community Health Centers, and 114.3 CMR 17.00: Medicine. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp Reminder to Use a Modifier When Billing for Behavioral Health Screening Tools The administration and scoring of standardized behavioral-health screening tools, selected from the approved menu of tools found in Appendix W of your MassHealth provider manual, is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code 96110 must be accompanied by one of the modifiers listed in Section 612 to indicate whether a behavioral-health need was identified. “Behavioral-health need identified” means the provider administering the screening tool, in his or her professional judgment, identifies a child with a potential behavioral health services need. Digital Mammography Effective January 1, 2011, digital mammography Service Codes G0202, G0204, and G0206 are payable under MassHealth. Providers are reminded to bill the professional and technical components individually on separate claim lines with the appropriate modifier 26 or TC. Any claims for such services that are not billed with modifier 26 or TC will be denied. MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. Questions If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language) Community Health Center Manual Pages vi and 6-1 through 6-74 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Community Health Center Manual Pages vi and 6-1 through 6-74 — transmitted by Transmittal Letter CHC-87 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page vi Community Health Center Manual Transmittal Letter CHC-89 Date 01/01/11 6. Service Codes and Descriptions Introduction and Explanation of Abbreviations............................................................................ 6-1 Radiology Service Codes and Descriptions.................................................................................. 6-1 Laboratory Service Codes and Descriptions................................................................................. 6-23 Visit Service Codes and Descriptions........................................................................................... 6-62 Obstetrics and Surgery Service Codes and Descriptions.............................................................. 6-69 Nurse-Midwife Service Codes and Descriptions.......................................................................... 6-70 Audiology Service Codes and Descriptions................................................................................. 6-71 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service Codes and Descriptions............................................................................. 6-71 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Tests Service Codes and Descriptions....................................................... 6-72 Tobacco Cessation Service Codes and Descriptions.................................................................... 6-72 Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes and Descriptions................................................................................................ 6-73 Behavioral Health Screening Tool Service Codes and Descriptions............................................ 6-74 Appendix A. Directory.................................................................................................................... A-1 Appendix B. Enrollment Centers..................................................................................................... B-1 Appendix C. Third-Party-Liability Codes....................................................................................... C-1 Appendix D. Supplemental Instructions for TPL Exceptions........................................................... D-1 Appendix E. Utilization Management Program.............................................................................. E-1 Appendix F. Admission Guidelines................................................................................................ F-1 Appendix W. EPSDT Services Medical and Dental Protocol and Periodicity Schedule................. W-1 Appendix X. Family Assistance Copayment and Deductibles........................................................ X-1 Appendix Y. EVS/Codes Messages................................................................................................. Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes................................................................ Z-1 601 Introduction and Explanation of Abbreviations MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 405.000 and 450.000. A community health center may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. § 1396d(a), and 42 U.S.C. § 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age even if it is not designated as covered or payable in Subchapter 6 of the Community Health Center Manual. The following abbreviations are used in Subchapter 6. (A) P.A. indicates that service-specific prior authorization is required (see 130 CMR 450.303). (B) I.C. indicates that the claim will receive individual consideration to determine payment. A descriptive report must accompany the claim (see 130 CMR 450.271). (C) S.P. indicates that the procedure is commonly performed as part of a total service and does not usually warrant a separate fee. The procedure must be performed separately to receive the separate fee. 602 Radiology Service Codes and Descriptions Service Code Service Description DIAGNOSTIC RADIOLOGY (DIAGNOSTIC IMAGING) HEAD AND NECK 70010 Myelography, posterior fossa, radiological supervision and interpretation 70015 Cisternography, positive contrast, radiological supervision and interpretation 70030 Radiologic examination, eye, for detection of foreign body 70100 Radiologic examination, mandible; partial, less than four views 70110 complete, minimum of four views 70120 Radiologic examination, mastoids; less than three views per side 70130 complete, minimum of three views per side 70134 Radiologic examination, internal auditory meati, complete 70140 Radiologic examination, facial bones; less than three views 70150 complete, minimum of three views 70160 Radiologic examination, nasal bones, complete, minimum of three views 70170 Dacryocystography, nasolacrimal duct, radiological supervision and interpretation 70190 Radiologic examination; optic foramina 70200 orbits, complete, minimum of four views 70210 Radiologic examination, sinuses, paranasal, less than three views 70220 Radiologic examination, sinuses, paranasal, complete, minimum of three views 70240 Radiologic examination, sella turcica 70250 Radiologic examination, skull; less than four views Service Code Service Description 70260 complete, minimum of four views 70300 Radiologic examination, teeth; single view 70310 partial examination, less than full mouth 70320 complete, full mouth 70328 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral 70330 bilateral 70332 Temporomandibular joint arthrography, radiological supervision and interpretation 70336 Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s) 70350 Cephalogram, orthodontic 70355 Orthopantogram 70360 Radiologic examination; neck, soft tissue 70370 pharynx or larynx, including fluoroscopy and/or magnification technique 70371 Complex dynamic pharyngeal and speech evaluation by cine or video recording 70373 Laryngography, contrast, radiological supervision and interpretation 70380 Radiologic examination, salivary gland for calculus 70390 Sialography, radiological supervision and interpretation 70450 Computed tomography, head or brain; without contrast material 70460 with contrast material(s) 70470 without contrast material, followed by contrast material(s) and further sections 70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material 70481 with contrast material(s) 70482 without contrast material, followed by contrast material(s) and further sections 70486 Computed tomography, maxillofacial area; without contrast material 70487 with contrast material(s) 70488 without contrast material, followed by contrast material(s) and further sections 70490 Computed tomography, soft tissue neck; without contrast material 70491 with contrast material(s) 70492 without contrast material followed by contrast material(s) and further sections 70540 Magnetic resonance (e.g., proton) imaging, orbit, face, and neck; without contrast material(s) 70542 with contrast material(s) 70543 without contrast material(s), followed by contrast material(s) and further sequences 70551 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material 70552 with contrast material(s) (professional component only) 70553 without contrast material, followed by contrast material(s) and further sequences 70554 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration 70555 requiring physician or psychologist administration of entire neurofunctional testing 70557 Magnetic resonance (e.g., proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (e.g., to assess for residual tumor or residual vascular malformation); without contrast material 70558 with contrast material(s) 70559 without contrast material(s), followed by contrast material(s) and further sequences Service Code Service Description CHEST 71010 Radiologic examination, chest; single view, frontal 71015 stereo, frontal 71020 Radiologic examination, chest, two views, frontal and lateral 71021 with apical lordotic procedure 71022 with oblique projections 71023 with fluoroscopy 71030 Radiologic examination, chest, complete, minimum of four views 71034 with fluoroscopy 71035 Radiologic examination, chest, special views (e.g., lateral decubitus, Bucky studies) 71040 Bronchography, unilateral, radiological supervision and interpretation 71060 Bronchography, bilateral, radiological supervision and interpretation 71090 Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation 71100 Radiologic examination, ribs, unilateral; two views 71101 including posteroanterior chest, minimum of three views 71110 Radiologic examination, ribs, bilateral; three views 71111 including posteroanterior chest, minimum of four views 71120 Radiologic examination; sternum, minimum of two views 71130 sternoclavicular joint or joints, minimum of three views 71250 Computed tomography, thorax; without contrast material 71260 with contrast material(s) 71270 without contrast material, followed by contrast material(s) and further sections 71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) SPINE AND PELVIS 72010 Radiologic examination, spine, entire, survey study, anteroposterior and lateral 72020 Radiologic examination, spine, single view, specify level 72040 Radiologic examination, spine, cervical; two or three views 72050 minimum of four views 72052 complete, including oblique and flexion and/or extension studies 72069 Radiological examination, spine, thoracolumbar, standing (scoliosis) 72070 Radiologic examination, spine; thoracic, two views 72072 thoracic, three views 72074 thoracic, minimum of four views 72080 thoracolumbar, two views 72090 scoliosis study, including supine and erect studies 72100 Radiologic examination, spine, lumbosacral; two or three views 72110 minimum of four views 72114 complete, including bending views 72120 Radiologic examination, spine, lumbosacral, bending views only, minimum of four views 72125 Computed tomography, cervical spine; without contrast material 72126 with contrast material Service Code Service Description 72127 without contrast material, followed by contrast material(s) and further sections 72128 Computed tomography, thoracic spine; without contrast material 72129 with contrast material 72130 without contrast material, followed by contrast material(s) and further sections 72131 Computed tomography, lumbar spine; without contrast material 72132 with contrast material 72133 without contrast material, followed by contrast material(s) and further sections 72141 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; without contrast material 72142 with contrast material(s) 72146 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; without contrast material 72147 with contrast material(s) 72148 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material 72149 with contrast material(s) 72156 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical 72157 thoracic 72158 lumbar 72170 Radiologic examination, pelvis; one or two views 72190 complete, minimum of three views 72192 Computed tomography, pelvis; without contrast material 72193 with contrast material(s) 72194 without contrast material, followed by contrast material(s) and further sections 72196 Magnetic resonance (e.g., proton) imaging, pelvis; with contrast material(s) 72200 Radiologic examination, sacroiliac joints; less than three views 72202 three or more views 72220 Radiologic examination, sacrum and coccyx, minimum of two views 72240 Myelography, cervical, radiological supervision and interpretation 72255 Myelography, thoracic, radiological supervision and interpretation 72265 Myelography, lumbosacral, radiological supervision and interpretation 72270 Myelography, two or more regions (e.g., lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological supervision and interpretation 72275 Epidurography, radiological supervision and interpretation 72285 Diskography, cervical or thoracic, radiological supervision and interpretation 72291 Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance 72292 under CT guidance 72295 Diskography, lumbar, radiological supervision and interpretation Service Code Service Description UPPER EXTREMITIES 73000 Radiologic examination; clavicle, complete 73010 scapula, complete 73020 Radiologic examination, shoulder; one view 73030 complete, minimum of two views 73040 Radiologic examination, shoulder, arthrography, radiological supervision and interpretation 73050 Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction 73060 humerus, minimum of two views 73070 Radiologic examination, elbow; two views 73080 complete, minimum of three views 73085 Radiologic examination, elbow, arthrography, radiological supervision and interpretation 73090 Radiologic examination; forearm, two views 73092 upper extremity, infant, minimum of two views 73100 Radiologic examination, wrist; two views 73110 complete, minimum of three views 73115 Radiologic examination, wrist, arthrography, radiological supervision and interpretation 73120 Radiologic examination, hand; two views 73130 minimum of three views 73140 Radiologic examination, finger(s), minimum of two views 73200 Computed tomography, upper extremity; without contrast material 73201 with contrast material(s) 73202 without contrast material, followed by contrast material(s) and further sections 73220 Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences 73221 Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s) LOWER EXTREMITIES 73500 Radiologic examination, hip, unilateral; one view 73510 complete, minimum of two views 73520 Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis 73525 Radiologic examination, hip, arthrography, radiological supervision and interpretation 73530 Radiologic examination, hip, during operative procedure 73540 Radiologic examination, pelvis and hips, infant or child, minimum of two views 73542 Radiological examination, sacroliac joint arthrography, radiological supervision and interpretation 73550 Radiologic examination, femur, two views 73560 Radiologic examination, knee; one or two views 73562 three views 73564 complete, four or more views 73565 both knees, standing, anteroposterior Service Code Service Description 73580 Radiologic examination, knee, arthrography, radiological supervision and interpretation 73590 Radiologic examination; tibia and fibula, two views 73592 lower extremity, infant, minimum of two views 73600 Radiologic examination, ankle; two views 73610 complete, minimum of three views 73615 Radiologic examination, ankle, arthrography, radiological supervision and interpretation 73620 Radiologic examination, foot; two views 73630 complete, minimum of three views 73650 Radiologic examination; calcaneus, minimum of two views 73660 toe(s), minimum of two views 73700 Computed tomography, lower extremity; without contrast material 73701 with contrast material(s) 73702 without contrast material, followed by contrast material(s) and further sections 73720 Magnetic resonance (e.g., proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences 73721 Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material 73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s) ABDOMEN 74000 Radiologic examination, abdomen; single anteroposterior view 74010 anteroposterior and additional oblique and cone views 74020 complete, including decubitus and/or erect views 74022 complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest 74150 Computed tomography, abdomen; without contrast material 74160 with contrast material(s) 74170 without contrast material, followed by contrast material(s) and further sections 74176 Computed tomography, abdomen and pelvis; without contrast material 74177 with contrast material(s) 74178 without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions 74181 Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s) 74185 Magnetic resonance angiography, abdomen, with or without contrast material(s) 74190 Peritoneogram (e.g., after injection of air or contrast), radiological supervision and interpretation GASTROINTESTINAL TRACT 74210 Radiologic examination; pharynx and/or cervical esophagus 74220 esophagus 74230 Swallowing function, with cineradiography/videoradiography 74235 Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and interpretation 74240 Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB 74241 with or without delayed films, with KUB Service Code Service Description 74245 with small intestine, includes multiple serial films 74246 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, without KUB 74247 with or without delayed films, with KUB 74249 with small intestine follow-through 74250 Radiologic examination, small intestine, includes multiple serial films 74251 via enteroclysis tube 74260 Duodenography, hypotonic 74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material (P.A.) 74262 with contrast material(s) including non-contrast images, if performed (P.A.) 74270 Radiologic examination, colon; contrast (e.g., barium) enema, with or without KUB 74280 air contrast with specific high density barium, with or without glucagon 74283 Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (e.g., meconium ileus) 74290 Cholecystography, oral contrast 74291 additional or repeat examination or multiple day examination 74300 Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation 74301 additional set intraoperative, radiological supervision and interpretation (List separately in addition to code for primary procedure.) 74305 through existing catheter, radiological supervision and interpretation 74320 Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation 74327 Postoperative biliary duct calculus removal, percutaneous via T-tube tract, basket, or snare (e.g., Burhenne technique), radiological supervision and interpretation 74328 Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation 74329 Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation 74330 Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation 74340 Introduction of long gastrointestinal tube (e.g., Miller-Abbott), including multiple fluoroscopies and films, radiological supervision and interpretation 74355 Percutaneous placement of enteroclysis tube, radiological supervision and interpretation 74360 Intraluminal dilation of strictures and/or obstructions (e.g., esophagus), radiological supervision and interpretation 74363 Percutaneous transhepatic dilatation of biliary duct stricture with or without placement of stent, radiological supervision and interpretation URINARY TRACT 74400 Urography (pyelography), intravenous, with or without KUB, with or without tomography 74410 Urography, infusion, drip technique and/or bolus technique 74415 with nephrotomography 74420 Urography, retrograde, with or without KUB Service Code Service Description 74425 Urography, antegrade (pyelostogram, nephrostogram, loopogram), radiological supervision and interpretation 74430 Cystography, minimum of three views, radiological supervision and interpretation 74440 Vasography, vesiculography, or epididymography, radiological supervision and interpretation 74445 Corpora cavernosography, radiological supervision and interpretation 74450 Urethrocystography, retrograde, radiological supervision and interpretation 74455 Urethrocystography, voiding, radiological supervision and interpretation 74470 Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and interpretation 74475 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation 74480 Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation 74485 Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation GYNECOLOGICAL AND OBSTETRICAL 74710 Pelvimetry, with or without placental localization 74740 Hysterosalpingography, radiological supervision and interpretation 74742 Transcervical catheterization of fallopian tube, radiological supervision and interpretation 74775 Perineogram (e.g., vaginogram, for sex determination or extent of anomalies) HEART 75557 Cardiac magnetic resonance imaging for morphology and function without contrast material 75559 with stress imaging 75561 Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences 75563 with stress imaging 75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure.) 75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) 75573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed) 75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) Service Code Service Description AORTA AND ARTERIES 75600 Aortography, thoracic, without serialography, radiological supervision and interpretation 75605 Aortography, thoracic, by serialography, radiological supervision and interpretation 75625 Aortography, abdominal, by serialography, radiological supervision and interpretation 75630 Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation 75650 Angiography, cervicocerebral, catheter, including vessel origin, radiological supervision and interpretation 75658 Angiography, brachial, retrograde, radiological supervision and interpretation 75660 Angiography, external carotid, unilateral, selective, radiological supervision and interpretation 75662 Angiography, external carotid, bilateral, selective, radiological supervision and interpretation 75665 Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation 75671 Angiography, carotid, cerebral, bilateral, radiological supervision and interpretation 75676 Angiography, carotid, cervical, unilateral, radiological supervision and interpretation 75680 Angiography, carotid, cervical, bilateral, radiological supervision and interpretation 75685 Angiography, vertebral, cervical, and/or intracranial, radiological supervision and interpretation 75705 Angiography, spinal, selective, radiological supervision and interpretation 75710 Angiography, extremity, unilateral, radiological supervision and interpretation 75716 Angiography, extremity, bilateral, radiological supervision and interpretation 75722 Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and interpretation 75724 Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation 75726 Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation 75731 Angiography, adrenal, unilateral, selective, radiological supervision and interpretation 75733 Angiography, adrenal, bilateral, selective, radiological supervision and interpretation 75736 Angiography, pelvic, selective or supraselective, radiological supervision and interpretation 75741 Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation 75743 Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation 75746 Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation 75756 Angiography, internal mammary, radiological supervision and interpretation 75774 Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure.) 75791 Angiography, arteriovenous shunt (e.g., dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava), radiological supervision and interpretation Service Code Service Description VEINS AND LYMPHATICS 75801 Lymphangiography, extremity only, unilateral, radiological supervision and interpretation 75803 Lymphangiography, extremity only, bilateral, radiological supervision and interpretation 75805 Lymphangiography, pelvic/abdominal, unilateral, radiological supervision and interpretation 75807 Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation 75809 Shuntogram for investigation of previously placed indwelling nonvascular shunt (e.g., LeVeen shunt, ventriculoperitoneal shunt, indwelling infusion pump), radiological supervision and interpretation 75810 Splenoportography, radiological supervision and interpretation 75820 Venography, extremity, unilateral, radiological supervision and interpretation 75822 Venography, extremity, bilateral, radiological supervision and interpretation 75825 Venography, caval, inferior, with serialography, radiological supervision and interpretation 75827 Venography, caval, superior, with serialography, radiological supervision and interpretation 75831 Venography, renal, unilateral, selective, radiological supervision and interpretation 75833 Venography, renal, bilateral, selective, radiological supervision and interpretation 75840 Venography, adrenal, unilateral, selective, radiological supervision and interpretation 75842 Venography, adrenal, bilateral, selective, radiological supervision and interpretation 75860 Venography, venous sinus (e.g., petrosal and inferior saggital) or jugular, catheter, radiological supervision and interpretation 75870 Venography, superior sagittal sinus, radiological supervision and interpretation 75872 Venography, epidural, radiological supervision and interpretation 75880 Venography, orbital, radiological supervision and interpretation 75885 Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation 75887 Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision and interpretation 75889 Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and interpretation 75891 Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation 75893 Venous sampling through catheter, with or without angiography (e.g., for parathyroid hormone, renin), radiological supervision and interpretation Transcatheter Procedures 75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation 75896 Transcatheter therapy, infusion, any method (e.g., thrombolysis other than coronary), radiological supervision and interpretation 75898 Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion 75900 Exchange of a previously placed intravascular catheter during thrombolytic therapy with contrast monitoring, radiological supervision and interpretation Service Code Service Description 75901 Mechanical removal of pericatheter obstructive material (e.g., fibrin sheath) from central venous device via separate venous access, radiologic supervision and interpretation 75902 Mechanical removal of intraluminal (intracathether) obstructive material from central venous device through device lumen, radiologic supervision and interpretation 75940 Percutaneous placement of IVC filter, radiological supervision and interpretation 75945 Intravascular ultrasound (non-coronary vessel), radiological supervision and interpretation; initial vessel 75946 each additional non-coronary vessel (List separately in addition to code for primary procedure.) 75952 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation 75953 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm, or dissection, radiological supervision and interpretation 75954 Endovascular repair of iliac artery aneurysm, pseudoaneurysm, arteriovenous malformation, or trauma, using ilio-iliac tube endoprosthesis, radiological supervision and interpretation 75956 Endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprothesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation 75957 not involving coverage of left subclavian artery origin, initial endoprothesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation 75958 Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption), radiological supervision and interpretation 75959 Placement of distal extension prosthesis(s) (delayed) after endovascular repair of descending thoracic aorta, as needed, to level of celiac origin, radiological supervision and interpretation 75960 Transcatheter introduction of intravascular stent(s), (except coronary, carotid, vertebral, iliac, and lower extremity artery), percutaneous and/or open, radiological supervision and interpretation, each vessel 75961 Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g., fractured venous or arterial catheter), radiological supervision and interpretation 75962 Transluminal balloon angioplasty, peripheral artery other than cervical carotid, renal or other visceral artery, iliac or lower extremity, radiological supervision and interpretation 75964 Transluminal balloon angioplasty, each additional peripheral artery, other than cervical carotid, renal or other visceral artery, iliac and lower extremity, radiological supervision and interpretation (List separately in addition to code for primary procedure.) 75966 Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation 75968 Transluminal balloon angioplasty, each additional visceral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure.) 75970 Transcatheter biopsy, radiological supervision and interpretation 75978 Transluminal balloon angioplasty, venous (e.g., subclavian stenosis), radiological supervision and interpretation Service Code Service Description 75980 Percutaneous transhepatic biliary drainage with contrast monitoring, radiological supervision and interpretation 75982 Percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation 75984 Change of percutaneous tube or drainage catheter with contrast monitoring (e.g., genitourinary system, abscess), radiological supervision and interpretation 75989 Radiological guidance (i.e., fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (e.g., abscess, specimen collection), with placement of catheter, radiological supervision and interpretation Other Procedures R0070 Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen 76000 Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (e.g., cardiac fluoroscopy) 76001 Fluoroscopy, physician time more than one hour, assisting a nonradiologic physician (e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy) 76010 Radiologic examination from nose to rectum for foreign body, single view, child 76080 Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation 76098 Radiological examination, surgical specimen 76100 Radiologic examination, single plane body section (e.g., tomography), other than with urography 76101 Radiologic examination, complex motion (i.e., hypercycloidal) body section (e.g., mastoid polytomography), other than with urography; unilateral 76102 bilateral 76120 Cineradiography/videoradiography, except where specifically included 76125 Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure.) 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation 76377 requiring image postprocessing on an independent workstation 76380 Computed tomography, limited or localized follow-up study 76499 Unlisted diagnostic radiographic procedure (I.C.) DIAGNOSTIC ULTRASOUND HEAD AND NECK 76506 Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated Service Code Service Description 76510 Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter 76511 quantitative A-scan only 76512 B-scan (with or without superimposed non-quantitative A-scan) 76513 anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy 76514 corneal pachymetry, unilateral or bilateral (determination of corneal thickness) 76516 Ophthalmic biometry by ultrasound echography, A-scan 76519 with intraocular lens power calculation 76529 Ophthalmic ultrasonic foreign body localization 76536 Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation CHEST 76604 Ultrasound, chest, (includes mediastinum), real time with image documentation 76645 Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation ABDOMEN AND RETROPERITONEUM 76700 Ultrasound, abdominal, real time with image documentation; complete 76705 limited (e.g., single organ, quadrant, follow-up) 76770 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete 76775 limited 76776 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation SPINAL CANAL 76800 Ultrasound, spinal canal and contents PELVIS 76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach; single or first gestation 76802 each additional gestation (List separately in addition to code for primary procedure.) 76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation 76810 each additional gestation (List separately in addition to code for primary procedure) 76811 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach, single or first gestation 76812 each additional gestation (List separately in addition to code for primary procedure.) 76813 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation 76814 each additional gestation (List separately in addition to code for primary procedure) Service Code Service Description 76815 Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses 76816 Ultrasound, pregnant uterus, real time with image documentation, follow-up (e.g., reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, reevaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal 76818 Fetal biophysical profile; with non-stress testing 76820 Doppler velocimetry, fetal; umbilical artery 76821 middle cerebral artery 76825 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording 76826 follow-up or repeat study 76827 Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete 76828 follow-up or repeat study NONOBSTETRICAL 76830 Ultrasound, transvaginal 76831 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed 76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete 76857 limited or follow-up (e.g., for follicles) GENITALIA 76870 Ultrasound, scrotum and contents 76872 Ultrasound, transrectal 76873 prostate volume study for brachytherapy treatment planning (separate procedure) EXTREMITIES 76881 Ultrasound, extremity, nonvascular, real-time with image documentation; complete 76882 limited, anatomic specific 76885 Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician manipulation) 76886 limited, static (not requiring physician manipulation) ULTRASONIC GUIDANCE PROCEDURES 76930 Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation 76932 Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation 76936 Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging) 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description 76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure.) 76940 Ultrasonic guidance for, and monitoring of, parenchymal tissue ablation 76941 Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation 76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation 76945 Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation 76946 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation 76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation 76950 Ultrasonic guidance for placement of radiation therapy fields 76965 Ultrasonic guidance for interstitial radioelement application Other Procedures 76970 Ultrasound study follow-up (specify) 76975 Gastrointestinal endoscopic ultrasound, supervision and interpretation 76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method 76998 Ultrasonic guidance, intraoperative 76999 Unlisted ultrasound procedure (e.g., diagnostic, interventional) (I.C.) RADIATION ONCOLOGY CLINICAL TREATMENT PLANNING (EXTERNAL AND INTERNAL SOURCES) 77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) 77002 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction 77011 Computed tomography guidance for stereotactic localization 77012 Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation 77013 Computerized tomography guidance for, and monitoring of, parenchymal tissue ablation 77014 Computed tomography guidance for placement of radiation therapy fields 77021 Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation 77022 Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description 77031 Stereotactic localization guidance for breast biopsy or needle placement (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation 77032 Mammographic guidance for needle placement, breast (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation 77051 Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure.) 77052 screening mammography (List separately in addition to code for primary procedure.) 77053 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation 77054 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 77055 Mammography; unilateral 77056 bilateral 77057 Screening mammography, bilateral (two-view film study of each breast) 77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral (P.A.) 77059 bilateral (P.A.) 77071 Manual application of stress performed by physician for joint radiography, including contralateral joint if indicated 77072 Bone age studies 77073 Bone length studies (orthoroentgenogram, scanogram) 77074 Radiologic examination, osseous survey; limited (e.g., for metastases) 77075 complete (axial and appendicular skeleton) 77076 Radiologic examination, osseous survey, infant 77077 Joint survey, single view, 2 or more joints (specify) 77078 Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) 77079 appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) 77081 appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 77082 vertebral fracture assessment 77083 Radiographic absorptiometry (e.g., photodensitometry, radiogrammetry), 1 or more sites 77084 Magnetic resonance (e.g., proton) imaging, bone marrow blood supply 77261 Therapeutic radiology treatment planning; simple 77262 intermediate 77263 complex 77280 Therapeutic radiology simulation-aided field setting; simple 77285 intermediate 77290 complex 77295 three-dimensional 77299 Unlisted procedure, therapeutic radiology clinical treatment planning (I.C.) 77338 Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan 77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services (I.C.) 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description RADIATION TREATMENT MANAGEMENT 77427 Radiation treatment management, five treatments 77431 Radiation therapy management with complete course of therapy consisting of one or two fractions only 77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of one session) 77435 Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed five fractions 77470 Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavitary, or intraoperative cone irradiation) 77499 Unlisted procedure, therapeutic radiology treatment management (I.C.) Hyperthermia Hyperthermia is used only as an adjunct to radiation therapy or chemotherapy. 77600 Hyperthermia, externally generated; superficial (i.e., heating to a depth of four cm or less) 77605 deep (i.e., heating to depths greater than four cm) 77610 Hyperthermia generated by interstitial probe(s); five or fewer interstitial applicators 77615 more than five interstitial applicators Clinical Intracavitary Hyperthermia Clinical intracavitary hyperthermia is used only as an adjunct to radiation therapy or chemotherapy. 77620 Hyperthermia generated by intracavitary probe(s) Clinical Brachytherapy 77750 Infusion or instillation of radioelement solution (includes three-month follow-up care) 77761 Intracavitary radiation source application; simple 77762 intermediate 77763 complex 77776 Interstitial radiation source application; simple 77777 intermediate 77778 complex 77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel 77786 2-12 channels 77787 over 12 channels 77789 Surface application of radiation source 77799 Unlisted procedure, clinical brachytherapy (I.C.) 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description NUCLEAR MEDICINE DIAGNOSTIC Endocrine System 78000 Thyroid uptake; single determination 78001 multiple determinations 78003 stimulation, suppression or discharge (not including initial uptake studies) 78006 Thyroid imaging, with uptake; single determination 78007 multiple determinations 78010 Thyroid imaging; only 78011 with vascular flow 78015 Thyroid carcinoma metastases imaging; limited area (e.g., neck and chest only) 78016 with additional studies (e.g., urinary recovery) 78018 whole body 78020 Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure.) 78070 Parathyroid imaging 78075 Adrenal imaging, cortex and/or medulla 78099 Unlisted endocrine procedure, diagnostic nuclear medicine (I.C.) Hematopoietic, Reticuloendothelial and Lymphatic System 78102 Bone marrow imaging; limited area 78103 multiple areas 78104 whole body 78110 Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling 78111 multiple samplings 78120 Red cell volume determination (separate procedure); single sampling 78121 multiple samplings 78122 Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique) 78130 Red cell survival study 78135 differential organ/tissue kinetics (e.g., splenic and/or hepatic sequestration) 78140 Labeled red cell sequestration, differential organ/tissue (e.g., splenic and/or hepatic) 78185 Spleen imaging only, with or without vascular flow 78190 Kinetics, study of platelet survival, with or without differential organ/tissue localization 78191 Platelet survival study 78195 Lymphatics and lymph nodes imaging 78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine (I.C.) 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description Gastrointestinal System 78201 Liver imaging; static only 78202 with vascular flow 78205 Liver imaging (SPECT) 78206 with vascular flow 78215 Liver and spleen imaging; static only 78216 with vascular flow 78220 Liver function study with hepatobiliary agents, with serial images 78223 Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function 78230 Salivary gland imaging 78231 with serial images 78232 Salivary gland function study 78258 Esophageal motility 78261 Gastric mucosa imaging 78262 Gastroesophageal reflux study 78264 Gastric emptying study 78270 Vitamin B-12 absorption study (e.g., Schilling test); without intrinsic factor 78271 with intrinsic factor 78272 Vitamin B-12 absorption studies combined, with and without intrinsic factor 78278 Acute gastrointestinal blood loss imaging 78282 Gastrointestinal protein loss 78290 Intestine imaging (e.g., ectopic gastric mucosa, Meckel's localization, volvulus) 78291 Peritoneal-venous shunt patency test (e.g., for LeVeen, Denver shunt) 78299 Unlisted gastrointestinal procedure, diagnostic nuclear medicine (I.C.) Musculoskeletal System 78300 Bone and/or joint imaging; limited area 78305 multiple areas 78306 whole body 78315 three phase study 78320 tomographic (SPECT) 78350 Bone density (bone mineral content) study, one or more sites; single photon absorptiometry 78399 Unlisted musculoskeletal procedure, diagnostic nuclear medicine (I.C.) Cardiovascular System 78414 Determination of central c-v hemodynamics (non-imaging) (e.g., ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations 78428 Cardiac shunt detection 78445 Non-cardiac vascular flow imaging (i.e., angiography, venography) 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description 78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) 78452 multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection 78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) 78454 multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection 78456 Acute venous thrombosis imaging, peptide 78457 Venous thrombosis imaging, venogram; unilateral 78458 bilateral 78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation 78466 Myocardial imaging, infarct avid, planar; qualitative or quantitative 78468 with ejection fraction by first pass technique 78469 tomographic SPECT with or without quantification 78472 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing 78473 multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification 78481 Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification 78483 multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification 78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress 78492 multiple studies at rest and/or stress 78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing 78496 Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List separately in addition to code for primary procedure.) 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine (I.C.) Respiratory System 78580 Pulmonary perfusion imaging; particulate 78584 Pulmonary perfusion imaging, particulate, with ventilation; single breath 78585 rebreathing and washout, with or without single breath 78586 Pulmonary ventilation imaging, aerosol; single projection 78587 multiple projections (e.g., anterior, posterior, lateral views) 78588 Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, one or multiple projections 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description 78591 Pulmonary ventilation imaging, gaseous, single breath, single projection 78593 Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; single projection 78594 multiple projections (e.g., anterior, posterior, lateral views) 78596 Pulmonary quantitative differential function (ventilation/perfusion) study 78599 Unlisted respiratory procedure, diagnostic nuclear medicine (I.C.) Nervous System 78600 Brain imaging, less than four static views 78601 with vascular flow 78605 Brain imaging, minimum four static views 78607 Brain imaging, tomographic (SPECT) 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation 78609 perfusion evaluation 78610 Brain imaging, vascular flow only 78630 Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography 78635 ventriculography 78645 shunt evaluation 78647 tomographic (SPECT) 78650 Cerebrospinal fluid leakage detection and localization 78660 Radiopharmaceutical dacryocystography 78699 Unlisted nervous system procedure, diagnostic nuclear medicine (I.C.) Genitourinary System 78700 Kidney imaging morphology 78701 with vascular flow 78707 with vascular flow and function, single study without pharmacological intervention 78708 with vascular flow and function, single study, with pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic) 78709 with vascular flow and function, multiple studies, with and without pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic) 78710 tomographic (SPECT) 78725 Kidney function study, non-imaging radioisotopic study 78730 Urinary bladder residual study (List separately in adition to code for primary procedure.) 78740 Ureteral reflux study (radiopharmaceutical voiding cystogram) 78761 Testicular imaging with vascular flow 78799 Unlisted genitourinary procedure, diagnostic nuclear medicine (I.C.) Other Procedures 78800 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area 78801 multiple areas 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description 78802 whole body, single day imaging 78803 tomographic (SPECT) 78804 whole body, requiring two or more days imaging 78805 Radiopharmaceutical localization of inflammatory process; limited area 78806 whole body 78807 tomographic (SPECT) 78808 Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (e.g., parathyroid adenoma) 78811 Positron emission tomography (PET) imaging; limited area (e.g., chest, head/neck) 78812 skull base to mid-thigh 78813 whole body 78814 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (e.g., chest, head/neck) 78815 skull base to mid-thigh 78816 whole body 78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine (I.C.) THERAPEUTIC 79005 Radiopharmaceutical therapy, by oral administration 79101 Radiopharmaceutical therapy, by intravenous administration 79200 Radiopharmaceutical therapy, by intracavitary administration 79300 Radiopharmaceutical therapy, by interstitial radioactive colloid administration 79403 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion 79440 Radiopharmaceutical therapy, by intra-articular administration 79999 Radiopharmaceutical therapy, unlisted procedure (I.C.) SCREENING SERVICES G0202 Screening mammography, producing direct digital image, bilateral, all views G0204 Diagnostic mammography, producing direct digital image, bilateral, all views G0206 Diagnostic mammography, producing direct digital image, unilateral, all views 603 Laboratory Service Codes and Descriptions Service Code Service Description PATHOLOGY AND LABORATORY ORGAN OR DISEASE-ORIENTED PANELS These panels were developed for coding purposes only and should not be interpreted as clinical parameters. The tests listed with each panel identify the defined components of that panel. These panel components are not intended to limit the performance of other tests. If one performs tests in addition to those specifically indicated for a particular panel, those tests should be reported separately in addition to the panel code. 80047 Basic metabolic panel (Calcium, ionized) (This panel must include the following: Calcium, ionized (82330), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), Sodium (84295), and Urea nitrogen (BUN) (84520).) 80048 Basic metabolic panel (Calcium, total) (This panel must include the following: Calcium (82310), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), Sodium (84295), and Urea nitrogen (BUN) (84520).) 80050 General health panel (This panel must include the following: Comprehensive metabolic panel (80053), blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) or blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) and Thyroid stimulating hormone (TSH) (84443).) 80051 Electrolyte panel (This panel must include the following: Carbon dioxide (82374), Chloride (82435), Potassium (84132), and Sodium (84295).) 80053 Comprehensive metabolic panel (This panel must include the following: Albumin (82040), Bilirubin, total (82247), Calcium, total (82310), Carbon dioxide (bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphatase, alkaline (84075), Potassium (84132), Protein, total (84155), Sodium (84295), Transferase, alanine amino (ALT) (SGPT) (84460), Transferase, aspartate amino (AST) (SGOT) (84450), and Urea nitrogen (BUN) (84520).) 80055 Obstetric panel (This panel must include the following: blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) or blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009), Hepatitis B surface antigen (HbsAg) (87340), Antibody, rubella (86762), Syphilis test, non- treponemal antibody;qualitative (e.g., VDRL, RPR, ART) (86592), Antibody screen, RBC, each serum technique (86850), Blood typing, ABO (86900), and Blood typing, Rh (D) (86901).) 80061 Lipid panel (This panel must include the following: Cholesterol, serum, total (82465), Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718), and Triglycerides (84478).) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 80069 Renal function panel (This panel must include the following: Albumin (82040), Calcium, total (82310), Carbon dioxide (bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphorus inorganic (phosphate) (84100), Potassium (84132), Sodium (84295), and Urea nitrogen (BUN) (84520).) 80074 Acute hepatitis panel (This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709), Hepatitis B core antibody (HBcAb), IgM antibody (86705), Hepatitis B surface antigen (HBsAg) (87340), and Hepatitis C antibody (86803).) 80076 Hepatic function panel (This panel must include the following: Albumin (82040), Bilirubin, total (82247), Bilirubin, direct (82248), Phosphatase, alkaline (84075), Protein, total (84155), Transferase, alanine amino (ALT) (SGPT) (84460), and Transferase, aspartate amino (AST) (SGOT) (84450).) DRUG TESTING The following list contains examples of drugs or classes of drugs that are commonly assayed by qualitative screen, followed by confirmation with a second method. Alcohols Amphetamines Barbiturates Benzodiazepines Cocaine and metabolites Methadones Methaqualones Opiates Phencyclidines Phenothiazines Propoxyphenes Tetrahydrocannabinoids Tricyclic antidepressants Confirmed drugs may also be quantitated. Use 80100 for each multiple drug class chromatographic procedure. Use 80102 for each procedure necessary for confirmation. For chromatography, each combination of stationary and mobile phase is to be counted as one procedure. For example, if detection of three drugs by chromatography requires one stationary phase with three mobile phases, use 80100 three times. However, if multiple drugs can be detected using a single analysis (e.g., one stationary phase with one mobile phase), use 80100 only once. For quantitation of drugs screened, use appropriate code in Chemistry section (82000-84999) or Therapeutic Drug Assay section (0150-80299). 80100 Drug screen, qualitative; multiple drug classes chromatographic method, each procedure (P.A. for tests with greater than 8 units) 80101 single drug class method (e.g., immunoassay, enzyme assay), each drug class (P.A. for tests with greater than 8 units) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 80102 Drug confirmation, each procedure 80103 Tissue preparation for drug analysis 80104 Drug screen, qualitative; multiple drug classes other than chromatographic method, each procedure THERAPEUTIC DRUG ASSAYS The material for examination may be from any source. Examination is quantitative. For nonquantitative testing, see Drug Testing (80100-80103). 80150 Amikacin 80152 Amitriptyline 80154 Benzodiazepines 80156 Carbamazepine; total 80157 free 80158 Cyclosporine 80160 Desipramine 80162 Digoxin 80164 Dipropylacetic acid (valproic acid) 80166 Doxepin 80168 Ethosuximide 80170 Gentamicin 80172 Gold 80173 Haloperidol 80174 Imipramine 80176 Lidocaine 80178 Lithium 80182 Nortriptyline 80184 Phenobarbital 80185 Phenytoin; total 80186 free 80188 Primidone 80190 Procainamide 80192 with metabolites (e.g., n-acetyl procainamide) 80194 Quinidine 80195 Sirolimus 80196 Salicylate 80197 Tacrolimus 80198 Theophylline 80200 Tobramycin 80201 Topiramate 80202 Vancomycin 80299 Quantitation of drug, not elsewhere specified 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description EVOCATIVE/SUPPRESSION TESTING 80400 ACTH stimulation panel; for adrenal insufficiency (This panel must include the following: Cortisol (82533 x 2).) 80402 for 21 hydroxylase deficiency (This panel must include the following: Cortisol (82533 x 2) and 17 hydroxyprogesterone (83498 x 2).) 80406 for 3 beta-hydroxydehydrogenase deficiency (This panel must include the following: Cortisol (82533 x 2) and 17 hydroxypregnenolone (84143 x 2).) 80408 Aldosterone suppression evaluation panel (e.g., saline infusion) (This panel must include the following: Aldosterone (82088 x 2) and Renin (84244 x 2).) 80410 Calcitonin stimulation panel (e.g., calcium, pentagastrin) (This panel must include the following: Calcitonin (82308 x 3).) 80412 Corticotropic releasing hormone (CRH) stimulation panel (This panel must include the following: Cortisol (82533 x 6) and Adrenocorticotropic hormone (ACTH) (82024 x 6).) 80414 Chorionic gonadotropin stimulation panel; testosterone response (This panel must include the following: Testosterone (84403 x 2 on three pooled blood samples).) 80415 estradiol response (This panel must include the following: Estradiol (82670 x 2 on three pooled blood samples).) 80416 Renal vein renin stimulation panel (e.g., captopril) (This panel must include the following: Renin (84244 x 6).) 80417 Peripheral vein renin stimulation panel (e.g., captopril) (This panel must include the following: Renin (84244 x 2).) 80418 Combined rapid anterior pituitary evaluation panel (This panel must include the following: Adrenocorticotropic hormone (ACTH) (82024 x 4), Luteinizing hormone (LH) (83002 x 4), Follicle stimulating hormone (FSH) (83001 x 4), Prolactin (84146 x 4), Human growth hormone (HGH) (83003 x 4), Cortisol (82533 x 4), and Thyroid stimulating hormone (TSH) (84443 x 4).) 80420 Dexamethasone suppression panel, 48 hour (This panel must include the following: Free cortisol, urine (82530 x 2), Cortisol (82533 x 2), and Volume measurement for timed collection (81050 x 2).) (For single dose dexamethasone, use 82533.) 80422 Glucagon tolerance panel; for insulinoma (This panel must include the following: Glucose (82947 x 3) and Insulin (83525 x 3).) 80424 for pheochromocytoma (This panel must include the following: Catecholamines, fractionated (82384 x 2).) 80426 Gonadatropin releasing hormone stimulation panel (This panel must include the following: Follicle stimulating hormone (FSH) (83001 x 4) and Luteinizing hormone (LH) (83002 x 4).) 80428 Growth hormone stimulation panel (e.g., arginine infusion, l-dopa administration). (This panel must include the following: Human growth hormone (HGH) (83003 x 4).) 80430 Growth hormone suppression panel (glucose administration) (This panel must include the following: Glucose (82947 x 3) and Human growth hormone (HGH) (83003 x 4).) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 80432 Insulin-induced C-peptide suppression panel (This panel must include the following: Insulin (83525), C-peptide (84681 x 5), and Glucose (82947 x 5).) 80434 Insulin tolerance panel; for ACTH insufficiency (This panel must include the following: Cortisol (82533 x 5) and Glucose (82947 x 5).) 80435 for growth hormone deficiency (This panel must include the following: Glucose (82947 x 5) and Human growth hormone (HGH) (83003 x 5).) 80436 Metyrapone panel (This panel must include the following: Cortisol (82533 x 2) and 11 deoxycortisol (82634 x 2).) 80438 Thyrotropin releasing hormone (TRH) stimulation panel; one hour (This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 3).) 80439 two hour (This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 4).) 80440 for hyperprolactinemia (This panel must include the following: Prolactin (84146 x 3).) URINALYSIS 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non- automated, with microscopy 81001 automated, with microscopy 81002 non-automated, without microscopy 81003 automated, without microscopy 81005 Urinalysis; qualitative or semiquantitative, except immunoassays 81007 bacteriuria screen, except by culture or dipstick (specify type) 81015 microscopic only 81020 two or three glass test 81025 Urine pregnancy test, by visual color comparison methods 81050 Volume measurement for timed collection, each 81099 Unlisted urinalysis procedure (I.C.) CHEMISTRY The material for examination may be from any source. Examination is quantitative unless specified. Clinical information derived from the results of laboratory data that is mathematically calculated (e.g., free thyroxine index (T7)) is considered part of the test procedure and therefore is not a separately reportable service. 82000 Acetaldehyde, blood 82003 Acetaminophen 82009 Acetone or other ketone bodies, serum; qualitative 82010 quantitative 82013 Acetylcholinesterase 82016 Acylcarnitines; qualitative, each specimen 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 82017 quantitative, each specimen 82024 Adrenocorticotropic hormone (ACTH) 82030 Adenosine; 5-monophosphate, cyclic (cyclic AMP) 82040 Albumin; serum, plasma or whole blood 82042 urine or other source, quantitative, each specimen 82043 urine, microalbumin, quantitative 82044 urine, microalbumin, semiquantitative (e.g., reagent strip assay) 82045 ischemia modified 82055 Alcohol (ethanol); any specimen except breath 82085 Aldolase 82088 Aldosterone 82101 Alkaloids, urine, quantitative 82103 Alpha-1-antitrypsin; total 82104 phenotype 82105 Alpha-fetoprotein (AFP); serum 82106 amniotic fluid 82108 Aluminum 82120 Amines, vaginal fluid, qualitative 82127 Amino acids; single, qualitative, each specimen 82128 multiple, qualitative, each specimen 82131 single, quantitative, each specimen 82135 Aminolevulinic acid, delta (ALA) 82136 Amino acids, two to five amino acids, quantitative, each specimen 82139 Amino acids, six or more amino acids, quantitative, each specimen 82140 Ammonia 82143 Amniotic fluid scan (spectrophotometric) 82145 Amphetamine or methamphetamine 82150 Amylase 82154 Androstanediol glucuronide 82157 Androstenedione 82160 Androsterone 82163 Angiotensin II 82164 Angiotensin I - converting enzyme (ACE) 82172 Apolipoprotein, each 82175 Arsenic 82180 Ascorbic acid (vitamin C), blood 82190 Atomic absorption spectroscopy, each analyte 82205 Barbiturates, not elsewhere specified 82232 Beta-2 microglobulin 82239 Bile acids; total 82240 cholylglycine 82247 Bilirubin; total 82248 direct 82252 feces, qualitative 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 82261 Biotinidase, each specimen 82270 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection) 82271 other sources 82272 Blood, occult, by perioxidase activity (e.g., guaiac), qualitative, feces, one to three simultaneous determinations, performed for other than colorectal neoplasm screening 82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, one to three simultaneous determinations 82286 Bradykinin 82300 Cadmium 82306 Vitamin D; 25 hydroxy, include fraction(s), if performed 82308 Calcitonin 82310 Calcium; total 82330 ionized 82331 after calcium infusion test 82340 urine quantitative, timed specimen 82355 Calculus; qualitative analysis 82360 quantitative analysis, chemical 82365 infrared spectroscopy 82370 X-ray diffraction 82373 Carbohydrate deficient transferrin 82374 Carbon dioxide (bicarbonate) 82375 Carboxyhemoglobin; quantitative 82376 qualitative 82378 Carcinoembryonic antigen (CEA) 82379 Carnitine (total and free), quantitative, each specimen 82380 Carotene 82382 Catecholamines; total urine 82383 blood 82384 fractionated 82387 Cathepsin-D 82390 Ceruloplasmin 82397 Chemiluminescent assay 82415 Chloramphenicol 82435 Chloride; blood 82436 urine 82438 other source 82441 Chlorinated hydrocarbons, screen 82465 Cholesterol, serum or whole blood, total 82480 Cholinesterase; serum 82482 RBC 82485 Chondroitin B sulfate, quantitative 82486 Chromatography, qualitative; column (e.g., gas liquid or HPLC), analyte not elsewhere specified 82487 paper, one-dimensional, analyte not elsewhere specified 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 82488 paper, two-dimensional, analyte not elsewhere specified 82489 thin layer, analyte not elsewhere specified 82491 Chromatography, quantitative, column (e.g., gas liquid or HPLC); single analyte not elsewhere specified, single stationary and mobile phase 82492 multiple analytes, single stationary and mobile phase 82495 Chromium 82507 Citrate 82520 Cocaine or metabolite 82523 Collagen cross links, any method 82525 Copper 82528 Corticosterone 82530 Cortisol; free 82533 total 82540 Creatine 82541 Column chromatography/mass spectrometry (e.g., GC/MS, or HPLC/MS), analyte not elsewhere specified; qualitative, single stationary and mobile phase 82542 quantitative, single stationary and mobile phase 82543 stable isotope dilution, single analyte, quantitative, single stationary and mobile phase 82544 stable isotope dilution, multiple analytes, quantitative, single stationary and mobile phase 82550 Creatine kinase (CK), (CPK); total 82552 isoenzymes 82553 MB fraction only 82554 isoforms 82565 Creatinine; blood 82570 other source 82575 clearance 82585 Cryofibrinogen 82595 Cryoglobulin, qualitative or semi-quantitative (e.g., cryocrit) 82600 Cyanide 82607 Cyanocobalamin (vitamin B-12) 82608 unsaturated binding capacity 82610 Cystatin C 82615 Cystine and homocystine, urine, qualitative 82626 Dehydroepiandrosterone (DHEA) 82627 Dehydroepiandrosterone-sulfate (DHEA-S) 82633 Desoxycorticosterone, 11- 82634 Deoxycortisol, 11- 82638 Dibucaine number 82646 Dihydrocodeinone 82649 Dihydromorphinone 82651 Dihydrotestosterone (DHT) 82652 Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed 82654 Dimethadione 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 82656 Elastase, pancreatic (EL-1), fecal, qualitative or semiquantitative 82657 Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; nonradioactive substrate, each specimen 82658 radioactive substrate, each specimen 82664 Electrophoretic technique, not elsewhere specified 82666 Epiandrosterone 82668 Erythropoietin 82670 Estradiol 82671 Estrogens; fractionated 82672 total 82677 Estriol 82679 Estrone 82690 Ethchlorvynol 82693 Ethylene glycol 82696 Etiocholanolone 82705 Fat or lipids, feces; qualitative 82710 quantitative 82715 Fat differential, feces, quantitative 82725 Fatty acids, nonesterified 82726 Very long chain fatty acids 82728 Ferritin 82731 Fetal fibronectin, cervicovaginal secretions, semi-quantitative 82735 Fluoride 82742 Flurazepam 82746 Folic acid; serum 82747 RBC 82757 Fructose, semen 82759 Galactokinase, RBC 82760 Galactose 82775 Galactose-1-phosphate uridyl transferase; quantitative 82776 screen 82784 Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each 82785 IgE 82787 immunoglobulin subclasses (e.g., IgG1, 2, 3, or 4), each 82800 Gases, blood, pH only 82803 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation) 82805 with O2 saturation, by direct measurement, except pulse oximetry 82810 Gases, blood, O2 saturation only, by direct measurement, except pulse oximetry 82820 Hemoglobin-oxygen affinity (pO2 for 50% hemoglobin saturation with oxygen) 82930 Gastric acid analysis, includes pH if performed, each specimen 82938 Gastrin after secretin stimulation 82941 Gastrin 82943 Glucagon 82945 Glucose, body fluid, other than blood 82946 Glucagon tolerance test 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 82947 Glucose; quantitative, blood (except reagent strip) 82948 blood, reagent strip 82950 postglucose dose (includes glucose) 82951 tolerance test (GTT), three specimens (includes glucose) 82952 tolerance test, each additional beyond three specimens (List separately in addition to code for primary procedure.) 82953 tolbutamide tolerance test 82955 Glucose-6-phosphate dehydrogenase (G6PD); quantitative 82960 screen 82963 Glucosidase, beta 82965 Glutamate dehydrogenase 82975 Glutamine (glutamic acid amide) 82977 Glutamyltransferase, gamma (GGT) 82978 Glutathione 82979 Glutathione reductase, RBC 82980 Glutethimide 82985 Glycated protein 83001 Gonadotropin; follicle-stimulating hormone (FSH) 83002 luteinizing hormone (LH) 83003 Growth hormone, human (HGH) (somatotropin) 83008 Guanosine monophosphate (GMP), cyclic 83009 Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (e.g., C-13) 83010 Haptoglobin; quantitative 83012 phenotypes 83013 Helicobacter pylori; breath test analysis for urease acitivity, non-radioactive isotope (e.g., C-13) 83014 drug administration 83015 Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen 83018 quantitative, each 83020 Hemoglobin fractionation and quantitation; electrophoresis (e.g., A2, S, C, and/or F) 83021 chromatography (e.g., A2, S, C, and/or F) 83026 Hemoglobin; by copper sulfate method, non-automated 83030 F (fetal), chemical 83033 F (fetal), qualitative 83036 glycosylated (A1C) 83037 glycosylated (A1C) by device cleared by FDA for home use 83045 methemoglobin, qualitative 83050 methemoglobin, quantitative 83051 plasma 83055 sulfhemoglobin, qualitative 83060 sulfhemoglobin, quantitative 83065 thermolabile 83068 unstable, screen 83069 urine 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 83070 Hemosiderin; qualitative 83071 quantitative 83080 b-Hexosaminidase, each assay 83088 Histamine 83090 Homocystine 83150 Homovanillic acid (HVA) 83491 Hydroxycorticosteroids, 17- (17-OHCS) 83497 Hydroxyindolacetic acid, 5- (HIAA) 83498 Hydroxyprogesterone, 17-d 83499 Hydroxyprogesterone, 20- 83500 Hydroxyproline; free 83505 total 83516 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative, multiple step method 83518 qualitative or semiquantitative, single step method (e.g., reagent strip) 83519 quantitative, by radioammunoassay (e.g., RIA) 83520 quantitative, not otherwise specified 83525 Insulin; total 83527 free 83528 Intrinsic factor 83540 Iron 83550 Ironbinding capacity 83570 Isocitric dehydrogenase (IDH) 83582 Ketogenic steroids, fractionation 83586 Ketosteroids, 17- (17-KS); total 83593 fractionation 83605 Lactate (lactic acid) 83615 Lactate dehydrogenase (LD), (LDH) 83625 isoenzymes, separation and quantitation 83630 Lactoferrin, fecal; qualitative 83631 quantitative 83632 Lactogen, human placental (HPL) human chorionic somatomammotropin 83633 Lactose, urine; qualitative 83634 quantitative 83655 Lead 83661 Fetal lung maturity assessment; lecithin sphingomyelin (L/S) ratio 83662 foam stability test 83663 fluorescence polarization 83664 lamellar body density 83670 Leucine aminopeptidase (LAP) 83690 Lipase 83695 Lipoprotein (a) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 83700 Lipoprotein, blood, electrophoretic separation and quantitation 83701 high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (e.g., electrophoresis, ultracentrifugation) 83704 quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (e.g., by nuclear magnetic resonance spectroscopy) 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 83719 VLDL cholesterol 83721 LDL cholesterol 83727 Luteinizing releasing factor (LRH) 83735 Magnesium 83775 Malate dehydrogenase 83785 Manganese 83788 Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; qualitative, each specimen 83789 quantitative, each specimen 83805 Meprobamate 83825 Mercury, quantitative 83835 Metanephrines 83840 Methadone 83857 Methemalbumin 83858 Methsuximide 83861 Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity 83864 Mucopolysaccharides, acid; quantitative 83866 screen 83872 Mucin, synovial fluid (Ropes test) 83873 Myelin basic protein, cerebrospinal fluid 83874 Myoglobin 83876 Myeloperoxidase (MPO) 83880 Natriuretic peptide 83883 Nephelometry, each analyte not elsewhere specified 83885 Nickel 83887 Nicotine Molecular Diagnostics The series of codes 83890-83912 is intended for use with molecular diagnostic techniques for analysis of nucleic acids. These services are coded by procedure rather than analyte. Code separately for each procedure used in an analysis. For example, a procedure requiring isolation of DNA, restriction endonuclease digestion, electrophoresis, and nucleic acid probe amplification would be coded 83890, 83892, 83894, and 83898. 83890 Molecular diagnostics; molecular isolation or extraction, each nucleic acid type (i.e., DNA or RNA) 83891 isolation or extraction of highly purified nucleic acid, each nucleic acid type (i.e., DNA or RNA) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 83892 enzymatic digestion, each enzyme treatment 83893 dot/slot blot production, each nucleic acid preparation 83894 separation by gel electrophoresis (e.g., agarose, polyacrylamide), each nucleic acid preparation 83896 nucleic acid probe, each 83897 nucleic acid transfer (e.g., Southern, Northern), each nucleic acid preparation 83898 amplification, target, each nucleic acid sequence 83900 amplification, target, multiplex, first two nucleic acid sequences 83901 amplification, target, multiplex, each additional nucleic acid sequence beyond two (List separately in addition to code for primary procedure.) 83902 reverse transcription 83903 mutation scanning, by physical properties (e.g., single strand conformational polymorphisms (SSCP), heteroduplex, denaturing gradient gel electrophoresis (DGGE), RNA’ase A), single segment, each 83904 mutation identification by sequencing, single segment, each segment 83905 mutation identification by allele specific transcription, single segment, each segment 83906 mutation identification by allele specific translation, single segment, each segment 83907 lysis of cells prior to nucleic acid extraction (e.g., stool specimens, paraffin embedded tissue), each specimen 83908 amplification, signal, each nucleic acid sequence 83909 separation and identification by high resolution technique (e.g., capillary electrophoresis), each nucleic acid preparation 83912 interpretation and report 83914 Mutation identification by enzymatic ligation or primer extension, single segment, each segment (e.g., oligonucleotide ligation assay (OLA), single base chain extension (SBCE), or allele- specific primer extension (ASPE)) 83915 Nucleotidase 5’- 83916 Oligoclonal immune (oligoclonal bands) 83918 Organic acids; total, quantitative, each specimen 83919 qualitative, each specimen 83921 Organic acid, single, quantitative 83925 Opiate(s), drug and metabolites, each procedure 83930 Osmolality; blood 83935 urine 83937 Osteocalcin (bone g1a protein) 83945 Oxalate 83950 Oncoprotein, HER-2/neu 83951 des-gamma-carboxy-prothrombin (DCP) 83970 Parathormone (parathyroid hormone) 83986 pH, body fluid, not otherwise specified 83992 Phencyclidine (PCP) 83993 Calprotectin, fecal 84022 Phenothiazine 84030 Phenylalanine (PKU), blood 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 84035 Phenylketones, qualitative 84060 Phosphatase, acid; total 84066 prostatic 84075 Phosphatase, alkaline 84078 heat stable (total not included) 84080 isoenzymes 84081 Phosphatidylglycerol 84085 Phosphogluconate, 6-, dehydrogenase, RBC 84087 Phosphohexose isomerase 84100 Phosphorus inorganic (phosphate) 84105 urine 84106 Porphobilinogen, urine; qualitative 84110 quantitative 84112 Placental alpha microglobulin-1 (PAMG-1), cervicovaginal secretion, qualitative 84119 Porphyrins, urine; qualitative 84120 quantitation and fractionation 84126 Porphyrins, feces; quantitative 84127 qualitative 84132 Potassium; serum, plasma or whole blood 84133 urine 84134 Prealbumin 84135 Pregnanediol 84138 Pregnanetriol 84140 Pregnenolone 84143 17-hydroxypregnenolone 84144 Progesterone 84146 Prolactin 84150 Prostaglandin, each 84152 Prostate specific antigen (PSA); complexed (direct measurement) 84153 total 84154 free 84155 Protein, total, except by refractometry; serum, plasma or whole blood 84156 urine 84157 other source (e.g., synovial fluid, cerebrospinal fluid) 84160 Protein, total, by refractometry, any source 84163 Pregnancy-associated plasma protein-A (PAPP-A) (I.C.) 84165 Protein, electrophoretic fractionation and quantitation, serum 84166 electrophoretic fractionation and quantitation, other fluids with concentration (e.g., urine, CSF) 84181 Western Blot, with interpretation and report, blood or other body fluid 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 84182 Western Blot, with interpretation and report, blood or other body fluid, immunological probe for band identification, each 84202 Protoporphyrin, RBC; quantitative 84203 screen 84206 Proinsulin 84207 Pyridoxal phosphate (vitamin B-6) 84210 Pyruvate 84220 Pyruvate kinase 84228 Quinine 84233 Receptor assay; estrogen 84234 progesterone 84235 endocrine, other than estrogen or progesterone (specify hormone) 84238 non-endocrine (specify receptor) 84244 Renin 84252 Riboflavin (vitamin B-2) 84255 Selenium 84260 Serotonin 84270 Sex hormone binding globulin (SHBG) 84275 Sialic acid 84285 Silica 84295 Sodium; serum, plasma or whole blood 84300 urine 84302 other source 84305 Somatomedin 84307 Somatostatin 84311 Spectrophotometry, analyte not elsewhere specified 84315 Specific gravity (except urine) 84375 Sugars, chromatographic, TLC or paper chromatography 84376 Sugars (mono-, di, and oligosaccharides); single qualitative, each specimen 84377 multiple qualitative, each specimen 84378 single quantitative, each specimen 84379 multiple quantitative, each specimen 84392 Sulfate, urine 84402 Testosterone; free 84403 total 84425 Thiamine (vitamin B-1) 84430 Thiocyanate 84432 Thyroglobulin 84436 Thyroxine; total 84437 requiring elution (e.g., neonatal) 84439 free 84442 Thyroxine binding globulin (TBG) 84443 Thyroid stimulating hormone (TSH) 84445 Thyroid stimulating immune globulins (TSI) 84446 Tocopherol alpha (vitamin E) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 84449 Transcortin (cortisol binding globulin) 84450 Transferase; aspartate amino (AST) (SGOT) 84460 alanine amino (ALT) (SGPT) 84466 Transferrin 84478 Triglycerides 84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) 84480 Triiodothyronine T3; total (TT-3) 84481 free 84482 reverse 84484 Troponin, quantitative 84485 Trypsin; duodenal fluid 84488 feces, qualitative 84490 feces, quantitative, 24-hour collection 84510 Tyrosine 84512 Troponin, qualitative 84520 Urea nitrogen; quantitative 84525 semiquantitative (e.g., reagent strip test) 84540 Urea nitrogen, urine 84545 Urea nitrogen, clearance 84550 Uric acid; blood 84560 other source 84577 Urobilinogen, feces, quantitative 84578 Urobilinogen, urine; qualitative 84580 quantitative, timed specimen 84583 semiquantitative 84585 Vanillylmandelic acid (VMA), urine 84586 Vasoactive intestinal peptide (VIP) 84588 Vasopressin (antidiuretic hormone, ADH) 84590 Vitamin A 84591 Vitamin, not otherwise specified 84597 Vitamin K 84600 Volatiles (e.g., acetic anhydride, carbon tetrachloride, dichloroethane, dichloromethane, diethylether, isopropyl alcohol, methanol) 84620 Xylose absorption test, blood and/or urine 84630 Zinc 84681 C-peptide 84702 Gonadotropin, chorionic (hCG); quantitative 84703 qualitative 84704 free beta chain 84999 Unlisted chemistry procedure (I.C.) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description HEMATOLOGY AND COAGULATION 85002 Bleeding time 85004 Blood count; automated differential WBC count 85007 blood smear, microscopic examination with manual differential WBC count 85008 blood smear, microscopic examination without manual differential WBC count 85009 manual differential WBC count, buffy coat 85013 spun microhematocrit 85014 hematocrit (Hct) 85018 hemoglobin (Hgb) 85025 complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count 85027 complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) 85032 manual cell count (erythrocyte, leukocyte, or platelet) each 85041 red blood cell (RBC), automated 85044 reticulocyte, manual 85045 reticulocyte, automated 85046 reticulocytes, automated, including one or more cellular parameters (e.g., reticulocyte hemoglobin content (CHr), immature reticulocyte fraction (IRF), reticulocyte volume (MRV), RNA content), direct measurement 85048 leukocyte (WBC), automated 85049 platelet, automated 85055 Reticulated platelet assay 85060 Blood smear, peripheral, interpretation by physician with written report 85097 Bone marrow, smear interpretation 85130 Chromogenic substrate assay 85170 Clot retraction 85175 Clot lysis time, whole blood dilution 85210 Clotting; factor II, prothrombin, specific 85220 factor V (AcG or proaccelerin), labile factor 85230 factor VII (proconvertin, stable factor) 85240 factor VIII (AHG), one stage 85244 factor VIII related antigen 85245 factor VIII, VW factor, ristocetin cofactor 85246 factor VIII, VW factor antigen 85247 factor VIII, von Willebrand factor, multimetric analysis 85250 factor IX (PTC or Christmas) 85260 factor X (Stuart-Prower) 85270 factor XI (PTA) 85280 factor XII (Hageman) 85290 factor XIII (fibrin stabilizing) 85291 factor XIII (fibrin stabilizing), screen solubility 85292 prekallikrein assay (Fletcher factor assay) 85293 high molecular weight kininogen assay (Fitzgerald factor assay) 85300 Clotting inhibitors or anticoagulants; antithrombin III, activity 85301 antithrombin III, antigen assay 85302 protein C, antigen 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 85303 protein C, activity 85305 protein S, total 85306 protein S, free 85307 Activated Protein C (APC) resistance assay 85335 Factor inhibitor test 85337 Thrombomodulin 85345 Coagulation time; Lee and White 85347 activated 85348 other methods 85360 Euglobulin lysis 85362 Fibrin(ogen) degradation (split) products (FDP) (FSP); agglutination slide; semiquantitative 85366 paracoagulation 85370 quantitative 85378 Fibrin degradation products, D-dimer; qualitative or semiquantitative 85379 quantitative 85380 ultrasensitive (e.g., for evaluation for venous thromboembolism), qualitative or semiquantitative 85384 Fibrinogen; activity 85385 antigen 85390 Fibrinolysins or coagulopathy screen, interpretation and report 85396 Coagulation/fibrinolysis assay, whole blood (e.g., viscoelastic clot assessment), including use of any pharmacologic additive(s), as indicated, including interpretation and written report, per day 85397 Coagulation and fibrinolysis, functional activity, not otherwise specified (e.g., ADAMTS-13), each analyte 85400 Fibrinolytic factors and inhibitors; plasmin 85410 alpha-2 antiplasmin 85415 plasminogen activator 85420 plasminogen, except antigenic assay 85421 plasminogen, antigenic assay 85441 Heinz bodies; direct 85445 induced, acetyl phenylhydrazine 85460 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke) 85461 rosette 85475 Hemolysin, acid 85520 Heparin assay 85525 Heparin neutralization 85530 Heparin-protamine tolerance test 85536 Iron stain, peripheral blood 85540 Leukocyte alkaline phosphatase with count 85547 Mechanical fragility, RBC 85549 Muramidase 85555 Osmotic fragility, RBC; unincubated 85557 incubated 85576 Platelet; aggregation (in vitro), each agent 85597 Phospholipid neutralization; platelet 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 85598 hexagonal phospholipid 85610 Prothrombin time 85611 substitution, plasma fractions, each 85612 Russell viper venom time (includes venom); undiluted 85613 diluted 85635 Reptilase test 85651 Sedimentation rate, erythrocyte; non-automated 85652 automated 85660 Sickling of RBC, reduction 85670 Thrombin time; plasma 85675 titer 85705 Thromboplastin inhibition; tissue 85730 Thromboplastin time, partial (PTT); plasma or whole blood 85732 substitution, plasma fractions, each 85810 Viscosity 85999 Unlisted hematology and coagulation procedure (I.C.) IMMUNOLOGY 86000 Agglutinins, febrile (e.g., Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain spotted fever, scrub typhus), each antigen 86001 Allergen specific IgG; quantitative or semiquantitative, each allergen 86003 Allergen specific IgE; quantitative or semiquantitative, each allergen 86005 qualitative, multiallergen screen (dipstick, paddle, or disk) 86021 Antibody identification; leukocyte antibodies 86022 platelet antibodies 86023 platelet-associated immunoglobulin assay 86038 Antinuclear antibodies (ANA) 86039 titer 86060 Antistreptolysin 0; titer 86063 screen 86140 C-reactive protein 86141 high sensitivity (hsCRP) 86146 Beta 2 Glycoprotein I antibody, each 86147 Cardiolipin (phospholipid) antibody, each Ig class 86148 Anti-phosphatidylserine (phospholipid) antibody 86155 Chemotaxis assay, specify method 86156 Cold agglutinin; screen 86157 titer 86160 Complement; antigen, each component 86161 functional activity, each component 86162 total hemolytic (CH50) 86171 Complement fixation tests, each antigen 86185 Counterimmunoelectrophoresis, each antigen 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 86200 Cyclic citrullinated peptide (CCP), antibody 86215 Deoxyribonuclease, antibody 86225 Deoxyribonucleic acid (DNA), antibody; native or double stranded 86226 single stranded 86235 Extractable nuclear antigen, antibody to, any method (e.g., nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody 86243 Fc receptor 86255 Fluorescent noninfectious agent antibody; screen, each antibody 86256 titer, each antibody 86277 Growth hormone, human (HGH), antibody 86280 Hemagglutination inhibition test (HAI) 86294 Immunoassay for tumor antigen, qualitative or semiquantitative (e.g., bladder tumor antigen) 86300 Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29) 86301 CA 19-9 86304 CA 125 86308 Heterophile antibodies; screening 86309 titer 86310 titers after absorption with beef cells and guinea pig kidney 86316 Immunoassay for tumor antigen; other antigen, quantitative (e.g., CA 50, 72-4, 549), each 86317 Immunoassay for infectious agent antibody, quantitative, not otherwise specified 86318 Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (e.g., reagent strip) 86320 Immunoelectrophoresis; serum 86325 other fluids (e.g., urine, cerobrospinal fluid) with concentration 86327 crossed (two-dimensional assay) 86329 Immunodiffusion; not elsewhere specified 86331 gel diffusion, qualitative (Ouchterlony), each antigen or antibody 86332 Immune complex assay 86334 Immunofixation electrophoresis; serum 86335 other fluids with concentration (e.g., urine, CSF) 86336 Inhibin A 86337 Insulin antibodies 86340 Intrinsic factor antibodies 86341 Islet cell antibody 86343 Leukocyte histamine release test (LHR) 86344 Leukocyte phagocytosis 86352 Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP) 86353 Lymphocyte transformation, mitogen (phytomitogen) or antigen-induced blastogenesis 86355 B cells, total count 86356 Mononuclear cell antigen, quantitative (e.g., flow cytometry), not otherwise specified, each antigen 86357 Natural killer (NK) cells, total count 86359 T cells; total count 86360 absolute CD4 and CD8 count, including ratio 86361 absolute CD4 count 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 86367 Stem cells (i.e., CD34), total count 86376 Microsomal antibodies (e.g., thyroid or liver-kidney), each 86378 Migration inhibitory factor test (MIF) 86382 Neutralization test, viral 86384 Nitroblue tetrazolium dye test (NTD) 86403 Particle agglutination; screen, each antibody 86406 titer, each antibody 86430 Rheumatoid factor; qualitative 86431 quantitative 86480 Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon 86481 enumeration of gamma interferon-producing T-cells in cell suspension 86485 Skin test; candida 86486 unlisted antigen, each 86490 coccidioidomycosis 86510 histoplasmosis 86590 Streptokinase, antibody 86592 Syphilis test (non-treponemal antibody); qualitative (e.g., VDRL, RPR, ART) 86593 quantitative The following codes (86602-86804) are qualitative or semiquantitative immunoassays performed by multiple step methods for the detection of antibodies to infectious agents. For immunoassays by single step method (e.g., reagent strips), use code 86318. Procedures for the identification of antibodies should be coded as precisely as possible. For example, an antibody to a virus could be coded with increasing specificity for virus, family, genus, species, or type. In some cases, further precision may be added to codes by specifying the class of immunoglobulin being detected. When multiple tests are done to detect antibodies to organisms classified more precisely than the specificity allowed by available codes, it is appropriate to code each as a separate service. For example, a test for antibody to an enterovirus is coded as 86658. Coxsackieviruses are enteroviruses, but there are no codes for the individual species of enterovirus. If assays are performed for antibodies to coxsackie A and B species, each assay should be separately coded. Similarly, if multiple assays are performed for antibodies of different immunoglobulin classes, each assay should be coded separately. When a coding option exists for reporting IgM specific antibodies (e.g., 86632) the corresponding ono-specific code (e.g., 86631) may be reported for performance of either an antibody analysis not specific for a particular immunoglobulin class or an IgG analysis. 86602 Antibody; actinomyces 86603 adenovirus 86606 Aspergillus 86609 bacterium, not elsewhere specified 86611 Bartonella 86612 Blastomyces 86615 Bordetella 86617 Borrelia burgdorferi (Lyme disease) confirmatory test (e.g., Western blot or immunoblot) 86618 Borrelia burgdorferi (Lyme disease) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 86619 Borrelia (relapsing fever) 86622 Brucella 86625 Campylobacter 86628 Candida 86631 Chlamydia 86632 Chlamydia, IgM 86635 Coccidioides 86638 Coxiella burnetii (Q fever) 86641 Cryptococcus 86644 cytomegalovirus (CMV) 86645 cytomegalovirus (CMV), IgM 86648 Diphtheria 86651 encephalitis, California (La Crosse) 86652 encephalitis, Eastern equine 86653 encephalitis, St. Louis 86654 encephalitis, Western equine 86658 enterovirus (e.g., coxsackie, echo, polio) 86663 Epstein-Barr (EB) virus, early antigen (EA) 86664 Epstein-Barr (EB) virus, nuclear antigen (EBNA) 86665 Epstein-Barr (EB) virus, viral capsid (VCA) 86666 Ehrlichia 86668 Francisella tularensis 86671 fungus, not elsewhere specified 86674 Giardia lamblia 86677 Helicobacter pylori 86682 helminth, not elsewhere specified 86684 Haemophilus influenza 86687 HTLV-I 86688 HTLV-II 86689 HTLV or HIV antibody, confirmatory test (e.g., Western Blot) 86692 hepatitis, delta agent 86694 herpes simplex, non-specific type test 86695 herpes simplex, type 1 86696 herpes simplex, type 2 86698 histoplasma 86701 HIV-1 86702 HIV-2 86703 HIV-1 and HIV-2, single assay 86704 Hepatitis B core antibody (HBcAb); total 86705 IgM antibody 86706 Hepatitis B surface antibody (HBsAb) 86707 Hepatitis Be antibody (HBeAb) 86708 Hepatitis A antibody (HAAb); total 86709 IgM antibody 86710 Antibody; influenza virus 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 86713 Legionella 86717 Leishmania 86720 Leptospira 86723 Listeria monocytogenes 86727 lymphocytic choriomeningitis 86729 lymphogranuloma venereum 86732 mucormycosis 86735 mumps 86738 mycoplasma 86741 Neisseria meningitidis 86744 Nocardia 86747 parvovirus 86750 Plasmodium (malaria) 86753 protozoa, not elsewhere specified 86756 respiratory syncytial virus 86757 Rickettsia 86759 rotavirus 86762 rubella 86765 rubeola 86768 Salmonella 86771 Shigella 86774 tetanus 86777 Toxoplasma 86778 Toxoplasma, IgM 86780 Treponema pallidum 86784 Trichinella 86787 varicella-zoster 86790 virus, not elsewhere specified 86793 Yersinia 86800 Thyroglobulin antibody 86803 Hepatitis C antibody 86804 confirmatory test (e.g., immunoblot) Tissue Typing 86805 Lymphocytotoxicity assay, visual crossmatch; with titration 86806 without titration 86807 Serum screening for cytotoxic percent reactive antibody (PRA); standard method 86808 quick method 86812 HLA typing; A, B, or C (e.g., A10, B7, B27), single antigen 86813 A, B, or C, multiple antigens 86816 DR/DQ, single antigen 86817 DR/DQ, multiple antigens 86821 lymphocyte culture, mixed (MLC) 86822 lymphocyte culture, primed (PLC) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 86825 Human leukocyte antigen (HLA) crossmatch, non-cytotoxic (e.g., using flow cytometry); first serum sample or dilution 86826 each additional serum sample or sample dilution (List separately in addition to primary procedure.) 86849 Unlisted immunology procedure (I.C.) TRANSFUSION MEDICINE 86850 Antibody screen, RBC, each serum technique 86860 Antibody elution (RBC), each elution 86870 Antibody identification, RBC antibodies, each panel for each serum technique 86880 Antihuman globulin test (Coombs test); direct, each antiserum 86885 indirect, qualitative, each reagent red cell 86886 indirect, each antibody titer 86900 Blood typing; ABO 86901 Rh (D) 86902 antigen testing of donor blood using reagent serum, each antigen test 86904 antigen screening for compatible unit using patient serum, per unit screened 86905 RBC antigens, other than ABO or Rh (D), each 86906 Rh phenotyping, complete 86920 Compatibility test each unit; immediate spin technique (I.C.) 86921 incubation technique (I.C.) 86922 antiglobulin technique (I.C.) 86923 electronic (I.C.) 86940 Hemolysins and agglutinins; auto, screen, each 86941 incubated 86970 Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with chemical agents or drugs, each 86971 incubation with enzymes, each 86972 by density gradient separation 86975 Pretreatment of serum for use in RBC antibody identification; incubation with drugs, each 86976 by dilution 86977 incubation with inhibitors, each 86978 by differential red-cell absorption using patient RBCs or RBCs of known phenotype, each absorption 86999 Unlisted transfusion medicine procedure (I.C.) MICROBIOLOGY 87001 Animal inoculation, small animal; with observation 87003 with observation and dissection 87015 Concentration (any type), for infectious agents 87040 Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 87045 stool, aerobic, with isolation and preliminary examination (e.g., KIA, LIA), Salmonella and Shigella species 87046 stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate 87070 any other source except urine, blood, or stool, aerobic, with isolation and presumptive identification of isolates 87071 quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood, or stool 87073 quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood, or stool 87075 any source, except blood, anaerobic with isolation and presumptive identification of isolates 87076 anaerobic isolate, additional methods required for definitive identification, each isolate 87077 aerobic isolate, additional methods required for definitive identification, each isolate 87081 Culture, presumptive, pathogenic organisms, screening only 87084 with colony estimation from density chart 87086 Culture, bacterial; quantitative colony count, urine 87088 with isolation and presumptive identification of each isolate, urine 87101 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail 87102 other source (except blood) 87103 blood 87106 Culture, fungi, definitive identification, each organism; yeast (Use in addition to codes 87101, 87102, or 87103 when appropriate.) 87107 mold 87109 Culture, mycoplasma, any source 87110 Culture, chlamydia, any source 87116 Culture, tubercle or other acid-fast bacilli (e.g., TB, AFB, mycobacteria) any source, with isolation and presumptive identification of isolates 87118 Culture, mycobacteria, definitive identification, each isolate 87140 Culture, typing; immunofluorescent method, each antiserum 87143 gas liquid chromatography (GLC) or high pressure liquid chromatography (HPLC) method 87147 immunologic method, other than immunofluorescence (e.g., agglutination grouping), per antiserum 87149 identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed 87152 identification by pulse field gel typing 87158 other methods 87164 Dark field examination, any source (e.g., penile, vaginal, oral, skin); includes specimen collection 87166 without collection 87168 Macroscopic examination; arthropod 87169 parasite 87172 Pinworm exam (e.g., cellophane tape prep) 87176 Homogenization, tissue, for culture 87177 Ova and parasites, direct smears, concentration and identification 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 87181 Susceptibility studies, antimicrobial agent; agar dilution method, per agent (e.g., antibiotic gradient strip) 87184 disk method, per plate (12 or fewer agents) 87185 enzyme detection (e.g., beta lactamase), per enzyme 87186 microdilution or agar dilution (minimum inhibitory concentration (MIC) or breakpoint), each multiantimicrobial, per plate 87187 microdilution or agar dilution, minimum lethal concentration (MLC), each plate (List separately in addition to code for primary procedure.) 87188 macrobroth dilution method, each agent 87190 mycobacteria, proportion method, each agent 87197 Serum bactericidal titer (Schlicter test) 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 87206 fluorescent and/or acid-fast stain for bacteria, fungi, parasites, viruses, or cell types 87207 special stain for inclusion bodies or parasites (e.g., malaria, coccidia, microsporidia, trypanosomes, herpes viruses) 87209 complex special stain (e.g., trichrome, iron hemotoxylin) for ova and parasites (I.C.) 87210 wet mount for infectious agents (e.g., saline, India ink, KOH preps) 87220 Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (e.g., scabies) 87230 Toxin or antitoxin assay, tissue culture (e.g., Clostridium difficile toxin) 87250 Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection 87252 tissue culture inoculation, observation, and presumptive identification by cytopathic effect 87253 tissue culture, additional studies or definitive identification (e.g., hemabsorption, neutralization, immunofluorescence stain), each isolate 87254 centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus 87255 including identification by non-immunologic method, other than by cytopathic effect (e.g., virus specific enzymatic activity) Infectious agents by antigen detection, immunofluorescence microscopy; or nucleic acid probe techniques should be reported as precisely as possible. The most specific code possible should be reported. If there is no specific agent code, the general methodology code (e.g., 87299, 87449, 87450, 87797, 87798, 87799, 87899) should be used. For identification of antibodies to many of the listed infectious agents, see 86602-86804. 87260 Infectious agent antigen detection by immunofluorescent technique; adenovirus 87265 Bordetella pertussis/parapertussis 87267 Enterovirus, direct fluorescent antibody (DFA) 87269 giardia 87270 Chlamydia trachomatis 87271 Cytomegalovirus, direct fluorescent antibody (DFA) 87272 cryptosporidium 87273 Herpes simplex virus type 2 87274 Herpes simplex virus type 1 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 87275 influenza B virus 87276 influenza A virus 87277 Legionella micdadei 87278 Legionella pneumophila 87279 Parainfluenza virus, each type 87280 respiratory syncytial virus 87281 Pneumocystis carinii 87283 Rubeola 87285 Treponema pallidum 87290 Varicella zoster virus 87299 not otherwise specified, each organism 87300 Infectious agent antigen detection by immunofluorescent technique, polyvalent for multiple organisms, each polyvalent antiserum 87301 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; adenovirus enteric types 40/41 87305 Aspergillus 87320 Chlamydia trachomatis 87324 Clostridium difficile toxin(s) 87327 Cryptococcus neoformans 87328 cryptosporidium 87329 giardia 87332 cytomegalovirus 87335 Escherichia coli 0157 87336 Entamoeba histolytica dispar group 87337 Entamoeba histolytica group 87338 Helicobacter pylori, stool 87339 Helicobacter pylori 87340 hepatitis B surface antigen (HBsAg) 87341 hepatitis B surface antigen (HBsAg) neutralization 87350 hepatitis Be antigen (HBeAg) 87380 hepatitis, delta agent 87385 Histoplasma capsulatum 87390 HIV-1 87391 HIV-2 87400 influenza, A or B, each 87420 respiratory syncytial virus 87425 rotavirus 87427 Shiga-like toxin 87430 Streptococcus, group A 87449 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative; multiple step method, not otherwise specified, each organism 87450 single step method, not otherwise specified, each organism 87451 multiple step method, polyvalent for multiple organisms, each polyvalent antiserum 87470 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, direct probe technique 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 87471 Bartonella henselae and Bartonella quintana, amplified probe technique 87472 Bartonella henselae and Bartonella quintana, quantification 87475 Borrelia burgdorferi, direct probe technique 87476 Borrelia burgdorferi, amplified probe technique 87477 Borrelia burgdorferi, quantification 87480 Candida species, direct probe technique 87481 Candida species, amplified probe technique 87482 Candida species, quantification 87485 Chlamydia pneumoniae, direct probe technique 87486 Chlamydia pneumoniae, amplified probe technique 87487 Chlamydia pneumoniae, quantification 87490 Chlamydia trachomatis, direct probe technique 87491 Chlamydia trachomatis, amplified probe technique 87492 Chlamydia trachomatis, quantification 87495 cytomegalovirus, direct probe technique 87496 cytomegalovirus, amplified probe technique 87497 cytomegalovirus, quantification 87498 enterovirus, amplified probe technique 87500 vancomycin resistance (e.g., enterococcus species van A, van B), amplified probe technique 87501 influenza virus, reverse transcription and amplified probe technique, each type or subtype 87502 influenza virus, for multiple types or sub-types, reverse transcription and amplified probe technique, first 2 types or sub-types 87503 influenza virus, for multiple types or sub-types, multiple reverse transcription and amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure.) 87510 Gardnerella vaginalis, direct probe technique 87511 Gardnerella vaginalis, amplified probe technique 87512 Gardnerella vaginalis, quantification 87515 hepatitis B virus, direct probe technique 87516 hepatitis B virus, amplified probe technique 87517 hepatitis B virus, quantification 87520 hepatitis C, direct probe technique 87521 hepatitis C, amplified probe technique 87522 hepatitis C, quantification 87525 hepatitis G, direct probe technique 87526 hepatitis G, amplified probe technique 87527 hepatitis G, quantification 87528 herpes simplex virus, direct probe technique 87529 herpes simplex virus, amplified probe technique 87530 herpes simplex virus, quantification 87531 herpes virus-6, direct probe technique 87532 herpes virus-6, amplified probe technique 87533 herpes virus-6, quantification 87534 HIV-1, direct probe technique 87535 HIV-1, amplified probe technique 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 87536 HIV-1, quantification 87537 HIV-2, direct probe technique 87538 HIV-2, amplified probe technique 87539 HIV-2, quantification 87540 Legionella pneumophila, direct probe technique 87541 Legionella pneumophila, amplified probe technique 87542 Legionella pneumophila, quantification 87550 Mycobacteria species, direct probe technique 87551 Mycobacteria species, amplified probe technique 87552 Mycobacteria species, quantification 87555 Mycobacteria tuberculosis, direct probe technique 87556 Mycobacteria tuberculosis, amplified probe technique 87557 Mycobacteria tuberculosis, quantification 87560 Mycobacteria avium-intracellulare, direct probe technique 87561 Mycobacteria avium-intracellulare, amplified probe technique 87562 Mycobacteria avium-intracellulare, quantification 87580 Mycoplasma pneumoniae, direct probe technique 87581 Mycoplasma pneumoniae, amplified probe technique 87582 Mycoplasma pneumoniae, quantification 87590 Neisseria gonorrhoeae, direct probe technique 87591 Neisseria gonorrhoeae, amplified probe technique 87592 Neisseria gonorrhoeae, quantification 87620 papillomavirus, human, direct probe technique 87621 papillomavirus, human, amplified probe technique 87622 papillomavirus, human, quantification 87650 Streptococcus, group A, direct probe technique 87651 Streptococcus, group A, amplified probe technique 87652 Streptococcus, group A, quantification 87660 Trichomonas vaginalis, direct probe technique 87797 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism 87798 amplified probe technique, each organism 87799 quantification, each organism 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87801 amplified probe(s) technique 87802 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group B 87803 Clostridium difficile toxin A 87804 Influenza 87807 respiratory syncytial virus 87809 adenovirus 87810 Chlamydia trachomatis 87850 Neisseria gonorrhoeae 87880 Streptococcus, group A 87899 not otherwise specified 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 87900 Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics 87901 Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase and protease regions 87902 Hepatitis C virus 87903 Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; first through 10 drugs tested 87904 each additional drug tested (List separately in addition to code for primary procedure.) 87905 Infectious agent enzymatic activity other than virus (e.g., sialidase activity in vaginal fluid) 87906 Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (e.g., integrase, fusion) 87999 Unlisted microbiology procedure (I.C.) ANATOMIC PATHOLOGY Cytopathology 88104 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation 88106 simple filter method with interpretation 88107 smears and simple filter preparation with interpretation 88108 Cytopathology, concentration technique, smears and interpretation (e.g., Saccomanno technique) 88112 Cytopathology, selective cellular enhancement technique with interpretation (e.g., liquid based slide preparation method), except cervical or vaginal 88120 Cytopathology, in situ hybridization (e.g., FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual 88121 using computer-assisted technology 88130 Sex chromatin identification; Barr bodies 88140 peripheral blood smear, polymorphonuclear drumsticks Codes 88141-88155 and 88164-88167 are used to report cervical or vaginal screening by various methods and to report physician interpretation services. Use codes 88150-88154 to report Pap smears that are examined using non-Bethesda reporting. Use codes 88164-88167 to report Pap smears that are examined using the Bethesda System of reporting. Use codes 88142-88143 to report specimens collected in fluid medium with automated thin layer preparation that are examined using any system of reporting (Bethesda or non-Bethesda). Within each of these three code families choose the one code that describes the screening method(s) used. Codes 88141 and 88155 should be reported in addition to the screening code chosen when the additional services are provided. 88141 Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician 88142 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision 88143 with manual screening and rescreening under physician supervision 88147 Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision 88148 screening by automated system with manual rescreening under physician supervision 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 88150 Cytopathology, slides, cervical or vaginal; manual screening under physician supervision 88152 with manual screening and computer-assisted rescreening under physician supervision 88153 with manual screening and rescreening under physician supervision 88154 with manual screening and computer-assisted rescreening using cell selection and review under physician supervision 88155 Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (e.g., maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code(s) for other technical and interpretation services.) 88160 Cytopathology, smears, any other source; screening and interpretation 88161 preparation, screening, and interpretation 88162 extended study involving over five slides and/or multiple stains 88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision 88165 with manual screening and rescreening under physician supervision 88166 with manual screening and computer-assisted rescreening under physician supervision 86167 with manual screening and computer-assisted rescreening using cell selection and review under physician supervision 88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site 88173 interpretation and report 88174 Cytopathology, cervical or vaginal (any reported system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision 88175 with screening by automated system and manual rescreening or review, under physician supervision 88177 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure.) 88182 cell cycle or DNA analysis 88184 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker 88185 each additional marker (List separately in addition to code for first marker.) 88187 Flow cytometry, interpretation; two to 8 markers 88188 nine to 15 markers 88189 16 or more markers 88199 Unlisted cytopathology procedure (I.C.) Cytogenetic Studies 88230 Tissue culture for non-neoplastic disorders; lymphocyte 88233 skin or other solid tissue biopsy 88235 amniotic fluid or chorionic villus cells 88237 Tissue culture for neoplastic disorders; bone marrow, blood cells 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 88239 solid tumor 88240 Cryopreservation, freezing and storage of cells, each cell line 88241 Thawing and expansion of frozen cells, each aliquot 88245 Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells 88248 baseline breakage, score 50-100 cells, count 20 cells, two karyotypes, (e.g., for ataxia telangiectasia, Fanconi anemia, fragile X) 88249 score 100 cells, clastogen stress (e.g., diepoxybutane, mitomycin C, ionizing radiation, UV radiation) 88261 Chromosome analysis; count five cells, one karyotype, with banding 88262 count 15-20 cells, two karyotypes, with banding 88263 count 45 cells for mosaicism, two karyotypes, with banding 88264 analyze 20-25 cells 88267 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, one karyotype, with banding 88269 Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, one karyotype, with banding 88271 Molecular cytogenetics; DNA probe, each (e.g., FISH) 88272 chromosomal in situ hybridization, analyze three to five cells (e.g., for derivatives and markers) 88273 chromosomal in situ hybridization, analyze 10-30 cells (e.g., for microdeletions) 88274 interphase in situ hybridization, analyze 25-99 cells 88275 interphase in situ hybridization, analyze 100-300 cells 88280 Chromosome analysis; additional karyotypes, each study 88283 additional specialized banding technique (e.g., NOR, C-banding) 88285 additional cells counted, each study 88289 additional high resolution study 88291 Cytogenetics and molecular cytogenetics, interpretation and report 88299 Unlisted cytogenetic study (I.C.) SURGICAL PATHOLOGY Complete descriptions for codes 88300 through 88309 are listed in the American Medical Association’s Current Procedural Terminology (CPT) code book. 88300 Level I - surgical pathology, gross examination only 88302 Level II - surgical pathology, gross and microscopic examination 88304 Level III - surgical pathology, gross and microscopic examination 88305 Level IV - surgical pathology, gross and microscopic examination 88307 Level V - surgical pathology, gross and microscopic examination 88309 Level VI - surgical pathology, gross and microscopic examination 88311 Decalcification procedure (List separately in addition to code for surgical pathology examination.) 88312 Special stains; Group I for microorganisms (e.g., Gridley, acid fast, methenamine silver), including interpretation and report, each 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 88313 Group II, all other (e.g., iron, trichrome), except immunocytochemistry and immunoperoxidase stains, including interpretation and report, each 88314 histochemical staining with frozen section(s), including interpretation and report (List separately in addition to code for primary procedure.) 88318 Determinative histochemistry to identify chemical components (e.g., copper, zinc) 88319 Determinative histochemistry or cytochemistry to identify enzyme constituents, each 88342 Immunohistochemistry (including tissue immunoperoxidase), each antibody 88346 Immunofluorescent study, each antibody; direct method 88347 indirect method 88348 Electron microscopy; diagnostic 88349 scanning 88355 Morphometric analysis; skeletal muscle 88356 nerve 88358 tumor (e.g., DNA ploidy) 88360 Morphometric analysis, tumor immunohistochemistry (e.g., Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody; manual 88361 using computer-assisted technology 88362 Nerve teasing preparations 88363 Examination and selection of retrieved archival (i.e., previously diagnosed) tissue(s) for molecular analysis (e.g., KRAS mutational analysis) 88365 In situ hybridization, (e.g., FISH), each probe 88367 Morphometric analysis, in situ hybridization, (quantitative or semi-quantitative) each probe; using computer-assisted technology 88368 manual 88371 Protein analysis of tissue by Western Blot, with interpretation and report 88372 immunological probe for band identification, each 88380 Microdissection (i.e., sample preparation of microscopically identified target); laser capture 88381 manual 88384 Array-based evaluation of multiple molecular probes; 11 through 50 probes (I.C.) 88385 51 through 250 probes 88386 251 through 500 probes 88387 Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (e.g., nucleic acid-based molecular studies); each tissue preparation (e.g., a single lymph node) 88388 in conjunction with a touch imprint, intraoperative consultation, or frozen section, each tissue preparation (e.g., a single lymph node) (List separately in addition to code for primary procedure.) 88399 Unlisted surgical pathology procedure (I.C.) 88720 Bilirubin, total, transcutaneous 88740 Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin 88741 methemoglobin 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description OTHER PROCEDURES 89049 Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report 89050 Cell count, miscellaneous body fluids (e.g., cerebrospinal fluid, joint fluid), except blood 89051 with differential count 89055 Leukocyte assessment, fecal, qualitative or semiquantitative 89060 Crystal identification by light microscopy with or without polarizing lens analysis, any body fluid (except urine) 89125 Fat stain, feces, urine, or respiratory secretions 89160 Meat fibers, feces 89190 Nasal smear for eosinophils 89220 Sputum, obtaining specimen, aerosol induced technique (Separate procedure) 89230 Sweat collection by iontopheresis 89240 Unlisted miscellaneous pathology test (I.C.) MEDICINE CARDIOVASCULAR Cardiography 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 tracing only, without interpretation and report 93010 interpretation and report only 93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report 93018 interpretation and report only 93024 Ergonovine provocation test 93040 Rhythm ECG, one to three leads; with interpretation and report 93041 tracing only without interpretation and report 93042 interpretation and report only 93224 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, physician review and interpretation 93225 recording (includes connection, recording, and disconnection) 93226 scanning analysis with report 93227 physician review and interpretation 93228 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 93229 technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports (I.C.) 93268 External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, physician review and interpretation 93278 Signal-averaged electrocardiography (SAECG), with or without ECG 93279 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and selected optimal permanent programmed values with physician analysis, review and report; single lead pacemaker system 93280 dual lead pacemaker system 93281 multiple lead pacemaker system 93282 single lead implantable cardioverter-defibrillator system 93283 dual lead implantable cardioverter-defibrillator system 93284 multiple lead implantable cardioverter-defibrillator system 93285 implantable loop recorder system 93286 Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with physician analysis, review and report; single, dual, or multiple lead pacemaker system 93287 single, dual, or multiple lead implantable cardioverter-defibrillator system 93288 Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead pacemaker system 93289 single, dual, or multiple lead implantable cardioverter-defibrillator system, including analysis of heart rhythm derived data elements 93290 implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors 93291 implantable loop recorder system, including heart rhythm derived data analysis 93292 wearable defibrillator system 93293 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with or without magnet application with physician analysis, review and report(s), up to 90 days 93294 Interrogation device evaluation(s) (remote) up to 90 days; single, dual, or multiple lead pacemaker system with interim physician analysis, review(s) and report(s) 93295 single, dual, or multiple lead implantable cardioverter-defibrillator system with interim physician analysis, review(s) and report(s) 93296 single, dual, or multiple lead pacemaker system or implantable cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results 93297 Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system, including analysis of 1 or more recorder physiologic cardiovascular data elements from all internal and external sensors, physician analysis, review(s) and report(s) 93298 implantable loop recorder system, including analysis of recorded heart rhythm data, physician analysis, review(s) and report(s) 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 93299 implantable cardiovascular monitor system or implantable loop recorder system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results (I.C.) 93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography 93351 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically reduced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision 93352 Use of echocardiographic contrast agent during stress echocardipgraphy (List separately in addition to code for primary procedure.) Other Vascular Studies 93701 Bioimpedance-derived physiologic cardiovascular analysis 93724 Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings) 93745 Initial set-up and programming by a physician of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events (I.C.) 93750 Interrogation of ventricular assist device (VAD), in person, with physician analysis of device parameters (e.g., drivelines, alarms, power surges), review of device function (e.g., flow and volume status, septum status, recovery), with programming, if performed, and report Other Procedures 93797 Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) 93798 with continuous ECG monitoring (per session) 93799 Unlisted cardiovascular service or procedure (I.C.) NONINVASIVE VASCULAR DIAGNOSTIC STUDIES Cerebrovascular Arterial Studies 93875 Noninvasive physiologic studies of extracranial arteries, complete bilateral study (e.g., periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis) (S.P. to 93880 and 93882) 93880 Duplex scan of extracranial arteries; complete bilateral study 93882 unilateral or limited study 93886 Transcranial Doppler study of the intracranial arteries; complete study 93888 limited study 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description Extremity Arterial Studies (Including Digits) 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 93926 unilateral or limited study 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93931 unilateral or limited study Extremity Venous Studies (Including Digits) 93965 Noninvasive physiologic studies of extremity veins, complete bilateral study (e.g., Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography) (S.P. to 93970 and 93976) 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study 93971 unilateral or limited study Visceral and Penile Vascular Studies 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study 93976 limited study (S.P. to 93975) 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study (S.P. to 93975) 93979 unilateral or limited study (S.P. to 93975) 93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study 93981 follow-up or limited study (S.P. to 93980) Extremity Arterial—Venous Studies 93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) PULMONARY 94002 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day 94003 hospital inpatient/observation, each subsequent day 94004 nursing facility, per day 94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation (S.P. to 94060, 94070, and 94620) 94011 Measurement of spirometric forced expiratory flows in an infant or child through 2 years of age 94012 Measurement of spirometric forced expiratory flows, before and after bronchodilator, in an infant or child through 2 years of age 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 94013 Measurement of lung volumes (i.e., functional residual capacity (FRC), forced vital capacity (FVC), and expiratory reserve volume (ERV) in an infant or child through 2 years of age 94014 Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration, and physician review and interpretation 94016 physician review and interpretation only 94060 Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration (S.P. to 94070 and 94620) 94070 Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010,with administered agents (e.g., antigen(s), cold air, methacholine) 94150 Vital capacity, total (separate procedure) (S.P. to 94010, 94060, 94070, and 94620) 94200 Maximum breathing capacity, maximal voluntary ventilation (S.P. to 94010, 94060, 94070, and 94620) 94240 Functional residual capacity or residual volume: helium method, nitrogen open circuit method, or other method 94250 Expired gas collection, quantitative, single procedure (separate procedure) 94260 Thoracic gas volume 94350 Determination of maldistribution of inspired gas: multiple breath nitrogen washout curve including alveolar nitrogen or helium equilibration time 94360 Determination of resistance to airflow, oscillatory or plethysmographic methods 94370 Determination of airway closing volume, single breath tests 94375 Respiratory flow volume loop (S.P. to 94010, 94060, and 94070) 94400 Breathing response to CO2 (CO2 response curve) 94450 Breathing response to hypoxia (hypoxia response curve) 94620 Pulmonary stress testing; simple (e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry) 94621 complex (including measurements of CO2 production, O2 uptake, and electrocardiographic recordings) 94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) 94642 Aerosol inhalation of pentamidine for pneumocystis carinii pneumonia treatment or prophylaxis 94660 Continuous positive airway pressure ventilation (CPAP), initiation and management 94662 Continuous negative pressure ventilation (CNP), initiation and management 94664 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device 94667 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation 94668 subsequent 94680 Oxygen uptake, expired gas analysis; rest and exercise, direct, simple (S.P. to 94620) 94681 including CO2 output, percentage oxygen extracted (S.P. to 94620 and 94680) 94690 rest, indirect (separate procedure) (S.P. to 94620) 94720 Carbon monoxide diffusing capacity (e.g., single breath, steady state) (S.P. to 94725) 94725 Membrane diffusion capacity 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 94750 Pulmonary compliance study (e.g., plethysmography, volume and pressure measurements) (with report only) (S.P. to 94010, 94060, 94070, and 94620) 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination (no professional component) (S.P. to 94620) 94761 multiple determinations (e.g., during exercise) (no professional component) (S.P. to 94620) 94762 by continuous overnight monitoring (separate procedure) (no professional component) (S.P. to 94620) 94770 Carbon dioxide, expired gas determination by infrared analyzer (with report only) (S.P. to 94620) 94772 Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour continuous recording, infant (I.C.) 94774 Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; includes monitor attachment, download of data, physician review, interpretation, and preparation of a report (I.C.) 94775 monitor attachment only (includes hook-up, initiation of recording and disconnection) (I.C.) 94776 monitoring, download of information, receipt of transmission(s) and analyses by computer only (I.C.) 94777 physician review, interpretation, and preparation of report only (I.C.) 94799 Unlisted pulmonary service or procedure (I.C.) SUPPLEMENTARY 99000 Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory When claiming payment for visits, a CHC must bill according to the following service codes. A visit during which a member sees more than one professional for the same medical problem or general purpose must be claimed as only one visit. (See 130 CMR 405.421 for other requirements.) 604 Visit Service Codes and Descriptions Service Code Modifier Service Description CHC Visits D1206 Topical fluoride varnish; therapeutic application for moderate-to-high caries risk patients. D9450 Case presentation, detailed and extensive treatment planning (use only for dental enhancement fee. This code may only be billed once per date of service for each member receiving dental services on that date.) J3490 Unclassified drugs (Use for injectable and infusible drugs and devices supplied in the clinic. Do not use for medications and injectables related to family planning services.) (I.C.) T1015 Clinic visit/encounter, all-inclusive (Use for individual medical visit.) T1015 HQ Clinic visit/encounter, all-inclusive, group setting (Use for group clinic visit.) 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 90632 Hepatitis A vaccine, adult dosage, for intramuscular use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90746 Hepatitis B vaccine, adult dosage, for intramuscular use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90899 Unlisted psychiatric service or procedure (Use for individual mental health visit.) (I.C.) 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g.. holidays, Saturday, and Sunday), in addition to basic service (Use for urgent care Monday through Friday from 5:00 P.M. to 6:59 A.M., and Saturday 7:00 A.M. to Monday 6:59 A.M. This code may be billed in addition to the individual medical visit.) 99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes (Use for HIV counseling visits.) Hospital Inpatient Services 99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - detailed or comprehensive history; - detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity. 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity. 99460 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant Subsequent Hospital Care 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a problem focused interval history; - a problem focused examination; - medical decision making that is straightforward or of low complexity. 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - an expanded problem focused interval history; - an expanded problem focused examination; - medical decision making of moderate complexity. 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a detailed interval history; - a detailed examination; - medical decision making of high complexity. 99462 Subsequent hospital care, per day, for evaluation and management of normal newborn HOSPITAL OBSERVATION SERVICES Initial Observation Care (New or Established Patient) 99218 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: - a detailed or comprehensive history; - a detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. 99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity. 99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity. Subsequent Observation Care 99224 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - problem focused interval history; - problem focused examination; - Medical decision making that is straightforward or of low complexity. 99225 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - an expanded problem focused interval history; - an expanded problem focused examination; - Medical decision making of moderate complexity. 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 99226 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a detailed interval history; - a detailed examination; - Medical decision making of high complexity. Nursing Facility Services 99304 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: - a detailed or comprehensive history; - a detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 35 minutes with the patient and/or family or caregiver. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver. 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description Subsequent Nursing Facility Care 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a problem focused interval history; - a problem focused examination; - straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the patient is stable, recovering, or improving. Physicians typically spend 10 minutes with the patient and/or family or caregiver. 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - an expanded problem-focused interval history; - an expanded problem-focused examination; - medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 15 minutes with the patient and/or family or caregiver. 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a detailed interval history; - a detailed examination; - medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes with the patient and/or family or caregiver. 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a comprehensive interval history; - a comprehensive examination; - medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes with the patient and/or family or caregiver. 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description DOMICILIARY, REST HOME (E.G., BOARDING HOME), OR CUSTODIAL CARE SERVICES New Patient 99324 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three key components: - a problem-focused history; - a problem-focused examination; and - straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of low severity. Physicians typically spend 20 minutes with the patient and/or family or caregiver. 99325 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three components: - an expanded problem-focused history; - an expanded problem-focused examination; and - medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes with the patient and/or family or caregiver. 99326 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three key components: - a detailed history; - a detailed examination; and - medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver. 99327 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of high severity. Physicians typically spend 60 minutes with the patient and/or family or caregiver. 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description Established Patient 99334 Domicillary or rest home visit for the evaluation and management of an established patient, which requires at least two these three key components: - a problem-focused interval history; - a problem-focused examination; - straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of self-limited or minor. Physicians typically spend 15 minutes with the patient and/or family or caregiver. 99335 Domicillary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three components: - an expanded problem-focused interval history; - an expanded problem-focused examination; - medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver. 99336 Domicillary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three components: - a detailed interval history; - a detailed examination; - medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes with the patient and/or family or caregiver. 99337 Domicillary or rest home visit for the evaluation and management of an established patient, which requires these three components: - a comprehensive interval history; - a comprehensive examination; - medical decision making of moderate to high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 60 minutes with the patient and/or family or caregiver. 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description HOME SERVICES New Patient 99341 Home visit for the evaluation and management of a new patient, which requires these three key components: - a problem focused history; - a problem focused examination; and - straightforward medical decision making. 99342 Home visit for the evaluation and management of a new patient, which requires these three key components: - an expanded problem focused history; - an expanded problem focused examination; and - medical decision making of low complexity. 99343 Home visit for the evaluation and management of a new patient, which requires these three key components: - a detailed history; - a detailed examination; and - medical decision making of moderate complexity. 99345 Home visit for the evaluation and management of a new patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity. (I.C.) Established Patient 99347 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a problem focused interval history; - a problem focused examination; - straightforward medical decision making. 99348 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: - an expanded problem focused interval history; - an expanded problem focused examination; - medical decision making of low complexity. 99349 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a detailed interval history; - a detailed examination; - medical decision making of moderate complexity. 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 99350 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a comprehensive interval history; - a comprehensive examination; - medical decision making of moderate to high complexity. (I.C.) 605 Obstetrics and Surgery Service Codes and Descriptions See 130 CMR 405.422 through 405.426 for other requirements. Service Code Service Description Fee-for-Service Deliveries 59409 Vaginal delivery only (with or without episiotomy and /or forceps 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59414 Delivery of placenta (separate procedure) 59515 Cesarean delivery only; including postpartum care 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to 59510 or 59515.) (Hysterectomy Information (HI-1) form required) 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 including postpartum care 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59622 including postpartum care Global Deliveries 59400 Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery 59618 Routine obstetric care, including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery Surgery Services 54150 Circumcision, using clamp or other device; newborn 54160 Circumcision, surgical excision other than clamp, device or dorsal slit; newborn 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) (Consent for Sterilization Form (CS-18 or CS-21) required) (S.P.) 55450 Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) (Consent for Sterilization Form (CS-18 or CS-21) required) (S.P.) 605 Obstetrics and Surgery Service Codes and Descriptions (cont.) Service Code Service Description 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral (Consent for Sterilization Form (CS-18 or CS-21) required) 58605 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) (Consent for Sterilization Form (CS-18 or CS-21) required) (S.P.) 58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean section or intra- abdominal surgery (not a separate procedure) (Consent for Sterilization Form (CS-18 or CS- 21) required) (List separately in addition to code for primary procedure.) 58615 Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring), vaginal or suprapubic approach (Consent for Sterilization Form (CS-18 or CS-21) required) 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) (Consent for Sterilization Form (CS-18 or CS-21) required) 58671 with occlusion of oviducts by device (e.g., band, clip, or Falope ring) (Consent for Sterilization Form (CS-18 or CS-21) required) 59000 Amniocentesis, any method 59012 Cordocentesis (intrauterine), any method 59015 Chorionic villus sampling, any method 59025 Fetal non-stress test 606 Nurse-Midwife Service Codes and Descriptions See 130 CMR 405.427 for requirements. When billing for delivery services performed by a nurse midwife, the provider must use a modifier. Service Code Modifier Service Description T1015 TH Clinic visit/encounter, all-inclusive – obstetrical treatment/services, prenatal or postpartum (use for a medical visit with a nurse midwife for a prenatal or postpartum service) 59400 Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care (Hysterectomy Information (HI-1) form required) 59414 Delivery of placenta (separate procedure) 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 including postpartum care 607 Audiology Service Codes and Descriptions See 130 CMR 405.461 through 405.463 for other requirements. Service Code Service Description 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92553 air and bone 92567 Tympanometry (impedance testing) 608 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service Codes and Descriptions See 130 CMR 450.140 through 450.149 for other requirements. Service Code Service Description New Patient 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; infant (age younger than one year) 99382 early childhood (age one through four years) 99383 late childhood (age five through 11 years) 99384 adolescent (age 12 through 17 years) 99385 18 through 39 years Established Patient 99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; infant (age younger than one year) 99392 early childhood (age one through four years) 99393 late childhood (age five through 11 years) 99394 adolescent (age 12 through 17 years) 99395 18 through 39 years 609 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Tests Service Codes and Descriptions Service Code Service Description 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92587 Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) 99173 Screening test of visual acuity, quantitative, bilateral. 610 Tobacco Cessation Service Codes and Descriptions Service Code Modifier Service Description 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are physicians employed by community health centers.) 99407 HN Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are physicians employed by community health centers.) 99407 HQ Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (for an individual in a group setting, 60-90 minutes). (Eligible providers are physicians employed by community health centers.) 99407 SA Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are nurse practitioners employed by community health centers.) 99407 SB Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are nurse midwives employed by community health centers.) 99407 TD Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are registered nurses employed by community health centers.) 99407 TF Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (intake assessment for an individual, at least 45 minutes). (Eligible providers are physicians employed by community health centers.) 99407 U1 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). Eligible providers are tobacco cessation counselors employed by community health centers.) 99407 U2 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (intake assessment for an individual, at least 45 minutes). (Eligible providers are nurse practitioner, nurse midwife, physician assistant, registered nurse, and tobacco cessation counselor.) 99407 U3 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (for an individual in a group setting, 60-90 minutes). (Eligible providers are nurse practitioners, nurse midwives, physician assistants, registered nurses, and tobacco cessation counselors.) 611 Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes and Descriptions Service Code Service Description G0108 Diabetes self-management training services, individual, per 30 minutes G0109 Diabetes outpatient self-management training services, group session (two or more), per 30 minutes G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes G0271 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (two or more individuals), each 30 minutes 97802 Medical nutrition therapy, initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 reassessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 group (two or more individuals), each 30 minutes 612 Behavioral Health Screening Tool Service Codes and Descriptions Service Code Modifier Service Description The administration and scoring of standardized behavioral-health screening tools selected from the approved menu of tools found in Appendix W of your provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. 96110 U1 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W with no behavioral health need identified* (eligible providers are physicians employed by community health centers) 96110 U2 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W and behavioral health need identified* (eligible providers are physicians employed by community health centers) 96110 U3 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W with no behavioral health need identified* (eligible providers are nurse midwives employed by community health centers) 96110 U4 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W and behavioral health need identified* (eligible providers are nurse midwives employed by community health centers) 96110 U5 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W with no behavioral health need identified* (eligible providers are nurse practitioners employed by community health centers) 612 Behavioral Health Screening Tool Service Codes and Descriptions (cont.) Service Code Modifier Service Description 96110 U6 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W and behavioral health need identified* (eligible providers are nurse practitioners employed by community health centers) 96110 U7 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W with no behavioral health need identified* (eligible providers are physician assistants employed by community health centers) 96110 U8 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W and behavioral health need identified* (eligible providers are physician assistants employed by community health centers) * "Behavioral health need identified" means the provider administering the screening tool, in his or her professional judgment identifies a child with a potential behavioral health services need. This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS codes are defined in the Current Procedural Terminology (CPT) code book.