MASTER PRECERTIFICATION LIST

Transcription

1 MASTER PRECERTIFICATION LIST For Providers January 2018, updated Code Code Description Addition / Removal Radiology-Therapeutic and/or Chemotherapy Administration- Radiation Therapy Revenue Code 0333 Revenue Code 0905 Revenue Code 0906 Revenue Code 0907 Revenue Code 0912 Revenue Code M 0007M 0008M 0009M 0011M 0051T 0052T 0053T ; Added 02/27/2016 Intensive outpatient services-psychiatric Added 08/27/2015 Intensive outpatient services-chemical dependency Added 08/27/2015 Community behavioral health program (day treatment) Added 08/27/2015 Partial hospitalization-less intensive Added 08/27/2015 Partial hospitalization- intensive Added 08/27/2015 Scoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithm reported as a risk score Oncology (gastrointestinal neuroendocrine tumors), realtime PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index Oncology (breast), mrna analysis of 58 genes using hybrid capture, on formalin-fixed paraffin-embedded (FFPE) tissue, prognostic algorithm reported as a risk score Fetal aneuploidy (trisomy 21, and 18) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy Oncology, prostate cancer, mrna expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and/or urine, algorithms to predict high-grade prostate cancer risk Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy Replacement or repair of thoracic unit of a total replacement heart system (artificial heart) Replacement or repair of implantable or components of total replacement heart system (artificial heart), excluding thoracic unit Added 07/01/2013 Added 07/01/2014 New Code Added 07/01/2014 New Code Added 01/01/2015; Removed 02/17/2017 Added 01/01/2018 1

2 0058T Cryopreservation; reproductive tissue, ovarian Added 07/01/ T Cryopreservation; oocyte(s) Added 07/01/ T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue 0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue 0073T Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator convergent beam Removed 02/26/2016 modulated fields, per treatment session 0085T Breath test for heart transplant rejection 0092T Total disc arthroplasty (artificial disc), anterior approach, including diskectomy to prepare interspace (other than for decompression); each additional interspace (List Removed 02/26/2016 separately in addition to code for primary procedure) 0098T Revision of total disc arthroplasty, anterior approach; each additional interspace (List separately in addition to code for primary procedure) 0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy 0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle 0111T Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes 0159T Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure) 0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace 0165T Revision of total disc arthroplasty, anterior approach, lumbar, each additional interspace 0174T Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation 0175T Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation 0181T Corneal hysteresis determination, by air impulse stimulation, bilateral, with interpretation and report Removed 02/26/2016 2

3 0190T 0191T 0195T 0196T 0197T 0198T 0199T 0200T 0201T 0202T 0207T 0208T 0209T 0210T 0211T 0212T 0213T 0214T Placement intraocular radiation source Insertion aqueous drainage device internal approach Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L5-S1 interspace Arthrodesis, pre-sacral interbody technique, disc space preparation, discectomy, without instrumentation, with image guidance, includes bone graft when performed; L4-L5 interspace (List separately in addition to code for primary procedure) Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report Physiologic recording of tremor using accelerometer(s) and gyroscope(s), (inc frequency and amplitude) inc interpretation and report Percutaneous sacral augmentation (sacroplasty) unilateral injection(s), inc the use of a balloon or mechanical device (if utilized), one or more needles Percutaneous sacral augmentation (sacroplasty) unilateral injection(s), inc the use of a balloon or mechanical device (if utilized), two or more needles Posterior vertebral joint(s) arthroplasty (e.g. facet joint(s) replacement) inc facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, inc fluoroscopy, single level, lumbar spine Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral Pure tone audiometry (threshold), automated; air only Pure tone audiometry (threshold), automated; air and bone Speech audiometry threshold, automated Speech audiometry threshold, automated; with speech recognition Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) Removed 02/26/2016 Removed 02/26/2016 3

4 0215T 0216T 0217T 0218T 0219T 0220T 0221T 0222T 0226T 0227T 0228T 0229T 0230T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (List separately in addition to code for primary procedure) Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); diagnostic, including collection of specimen(s) by brushing or washing when performed Anoscopy, high resolution (HRA) (with magnification and chemical agent enhancement); with biopsy(ies) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level Removed 02/26/2016 Removed 02/26/2016 4

5 0231T 0232T 0239T 0249T 0253T 0254T 0255T 0263T 0264T 0265T 0266T 0267T Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure) Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed Bioimpedance spectroscopy (BIS), measuring 100 frequencies or greater, direct measurement of extracellular fluid differences between the limbs Ligation, hemorrhoidal vascular bundle(s), including ultrasound guidance Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space Endovascular repair of iliac artery bifurcation (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery, unilateral; Endovascular repair of iliac artery bifurcation (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery, unilateral; radiological supervision and interpretation Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest. Complete procedure excluding bone marrow harvest Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest. Unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intraoperative interrogation, programming, and repositioning, when performed) Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intraoperative interrogation, programming, and repositioning, when performed) Lead only, unilateral (includes intra- Removed 02/26/2016 Added 07/01/2011 Added 07/01/2011 Added 07/01/2011 Added 07/01/2011 Added 07/01/2011 5

6 operative interrogation, programming, and repositioning, when performed) 0268T 0269T 0270T 0271T 0272T 0273T 0274T Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intraoperative interrogation, programming, and repositioning, when performed) Pulse generator only (includes intraoperative interrogation, programming, and repositioning, when performed) Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (eg, battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (eg, battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day);with programming Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; cervical or thoracic Added 07/01/2011 Added 07/01/2011 Added 07/01/2011 Added 07/01/2011 Added 07/01/2011 Added 07/01/2011 Added 07/01/2011 6

7 0275T 0278T 0284T 0290T 0293T 0294T 0295T 0296T 0297T 0298T 0299T 0300T 0301T Percutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (eg, fluoroscopic, CT), with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar Transcutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes) Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed Corneal incisions in the recipient cornea created using a laser, in preparation for penetrating or lamellar keratoplasty (List separately in addition to code for primary procedure) Insertion of left atrial hemodynamic monitor; complete system, includes implanted communication module and pressure sensor lead in left atrium including transseptal access, radiological supervision and interpretation, and associated injection procedures, Insertion of left atrial hemodynamic monitor; pressure sensor lead at time of insertion of pacing cardioverterdefibrillator pulse generator including radiological supervision and interpretation and associated injection procedures, when performed (List se External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; recording (includes connection and initial recording) External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; scanning analysis with report External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage; review and interpretation Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure) Destruction/reduction of malignant breast tumor with externally applied focused microwave, including interstitial placement of disposable catheter with combined temperature monitoring probe and microwave focusing sensocatheter under ultrasound thermothera Added 07/01/2011 Added 01/01/2012; Removed from Precert 02/17/2017 Added 01/01/2012 Added 01/01/2012 Added 01/01/2012 Added 01/01/2012 Added 01/01/2012; *Removed 02/26/2016 Added 01/01/2012; *Removed 02/26/2016 Added 01/01/2012; *Removed 02/26/2016 Added 01/01/2012; *Removed 02/26/2016 Added 01/01/2012 Added 01/01/2012 Added 01/01/2012 7

8 0302T 0303T 0304T 0305T 0306T 0307T 0308T 0309T 0310T 0311T 0312T 0313T 0314T 0315T 0316T Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intraoperative interrogation and programming when performed; complete system (includes device and electrode) Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intraoperative interrogation and programming when performed; electrode only Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation when performed and intraoperative interrogation and programming when performed; device only Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report Added 07/01/2012; *Removed from Precert 3/31/2016 Added 07/01/2012; *Removed from Precert 3/31/2016 Added 07/01/2012; *Removed from Precert 3/31/2016 Added 07/01/2012; *Removed from Precert 3/31/2016 Added 07/01/2012; *Removed from Precert 3/31/2016 Removal of intracardiac ischemia monitoring device Added 07/01/2012; *Removed from Precert 3/31/2016 Insertion of ocular telescope prosthesis including removal of crystalline lens Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (List separately in addition to code for primary procedure) Motor function mapping using non-invasive navigated transcranial magnetic stimulation (ntms) for therapeutic treatment planning, upper and lower extremity Non-invasive calculation and analysis of central arterial pressure waveforms with interpretation and report Vagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming Vagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator Vagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator Vagus nerve blocking therapy (morbid obesity); removal of pulse generator Vagus nerve blocking therapy (morbid obesity); replacement of pulse generator Added 07/01/2012 Added 01/01/2013 Added 01/01/2013 Added 01/01/2013; *Removed 02/26/2016 Added 01/01/2013 Added 01/01/2013 Added 01/01/2013 Added 01/01/2013 Added 01/01/2013 8

9 0317T 0319T 0320T 0321T 0323T 0325T 0326T 0327T 0328T 0329T 0330T 0331T 0332T 0333T 0334T 0335T 0337T Vagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, Added 01/01/2013 includes reprogramming when performed Insertion or replacement of subcutaneous implantable Added 01/01/2013; defibrillator system with subcutaneous electrode *Removed 02/26/2016 Insertion of subcutaneous defibrillator electrode Added 01/01/2013; Removed 02/26/2016 Insertion of subcutaneous implantable defibrillator pulse Added 01/01/2013; generator only with existing subcutaneous electrode Removed 02/26/2016 Removal of subcutaneous implantable defibrillator pulse generator with replacement of subcutaneous implantable defibrillator pulse generator only Repositioning of subcutaneous implantable defibrillator electrode and/or pulse generator Electrophysiologic evaluation of subcutaneous implantable defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters) Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable subcutaneous lead defibrillator system Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis; implantable subcutaneous lead defibrillator system Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report Tear film imaging, unilateral or bilateral, with interpretation and report Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT Visual evoked potential, screening of visual acuity, automated Sacroiliac joint stabilization for arthrodesis, percutaneous or minimally invasive (indirect visualization), includes obtaining and applying autograft or allograft (structural or morselized), when performed, includes image guidance when performed (eg, CT or fluoroscopic) Extra-osseous subtalar joint implant for talotarsal stabilization Endothelial function assessment, using peripheral vascular response to reactive hyperemia, non-invasive (eg, brachial artery ultrasound, peripheral artery Added 01/01/2013; Removed 02/26/2016 Added 01/01/2013; Removed 02/26/2016 Added 01/01/2013; Removed 02/26/2016 Added 01/01/2013; Removed 02/26/2016 Added 01/01/2013; Removed 02/26/2016 Added 07/01/2013 Added 07/01/2013 Added 07/01/2013 Added 07/01/2013; Removed 02/26/2016 Added 01/01/2014 New Code Added 01/01/2014 New Code 9

10 tonometry), unilateral or bilateral 0338T 0339T 0340T 0341T 0342T 0343T 0344T 0345T 0346T Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance Quantitative pupillometry with interpretation and report, unilateral or bilateral Therapeutic apheresis with selective HDL delipidation and plasma reinfusion Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; initial prosthesis Transcatheter mitral valve repair percutaneous approach including transseptal puncture when performed; additional prosthesis (es) during same session (List separately in addition to code for primary procedure) Transcatheter mitral valve repair percutaneous approach via the coronary sinus Added 01/01/2014 New Code Added 01/01/2014 New Code Added 01/01/2014 New Code Added 01/01/2014 New Code Added 01/01/2014 New Code Added 01/01/2014 New Code; Removed 02/26/2016 Added 01/01/2014 New Code; Removed 02/26/2016 Added 01/01/2014 New Code; Ultrasound, elastography (List separately in addition to code for primary procedure) Added 01/01/2014 New Code; *Removed 10/01/ T 0348T 0349T 0350T 0351T Placement of interstitial device(s) in bone for radiostereometric analysis (RSA) Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when performed) Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow and wrist, when performed) Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee and ankle, when performed) Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code 10

11 0352T 0353T 0354T 0355T 0356T 0357T 0358T 0359T 0360T 0361T 0362T 0363T 0364T Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real time or referred Optical coherence tomography of breast, surgical cavity; real time intraoperative Optical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report Insertion of drug-eluting implant (including punctal dilation and implant removal when performed) into lacrimal canaliculus, each Cryopreservation; immature oocyte(s) Bioelectrical impedance analysis whole body composition assessment, supine position, with interpretation and report Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/caregiver(s), and preparation of report Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; first 30 minutes of technician time, faceto-face with the patient Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by one technician; each additional 30 minutes of technician time, face-to-face with the patient (List separately in addition to code for primary service) Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; first 30 minutes of technician(s) time, face-to-face with the patient Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with interpretation and report, administered by physician or other qualified health care professional with the assistance of one or more technicians; each additional 30 minutes of technician(s) time, face-to-face with the patient (List separately in addition to code for primary procedure) Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of technician time Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code 01/01/2015 Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code 11

12 0365T 0366T 0367T 0368T 0369T 0370T 0371T 0372T 0373T 0374T 0375T 0376T 0377T 0378T Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; each additional 30 minutes of technician time (List separately in addition to code for primary procedure) Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; first 30 minutes of technician time Group adaptive behavior treatment by protocol, administered by technician, face-to-face with two or more patients; each additional 30 minutes of technician time (List separately in addition to code for primary procedure) Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; first 30 minutes of patient face-to-face time Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; each additional 30 minutes of patient face-to-face time (List separately in addition to code for primary procedure) Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present) Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional face-to-face with multiple patients Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); first 60 minutes of technicians' time, face-to-face with patient Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive behavior(s); each additional 30 minutes of technicians' time face-to-face with patient (List separately in addition to code for primary procedure) Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), cervical, three or more levels Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in addition to code for primary procedure) Anoscopy with directed submucosal injection of bulking agent for fecal incontinence Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code Added 07/01/2014 New Code 01/01/ /01/ /01/ /01/

13 0379T 0380T 0381T 0382T 0383T 0384T 0385T 0386T 0387T 0388T Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional Computer-aided animation and analysis of time series retinal images for the monitoring of disease progression, unilateral or bilateral, with interpretation and report External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional External heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional External heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional External heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; review and interpretation only Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular Transcatheter removal of permanent leadless pacemaker, ventricular 01/01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/

14 0389T 0390T 0391T 0394T 0395T 0397T 0402T 0404T 0405T 0406T 0407T 0408T 0409T Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed Endoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure) Collagen cross-linking of cornea (including removal of the corneal epithelium and intraoperative pachymetry when performed) Transcervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency Oversight of the care of an extracorporeal liver assist system patient requiring review of status, review of laboratories and other studies, and revision of orders and liver assist care plan (as appropriate), within a calendar month, 30 minutes or more of non-face-to-face time Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant; Nasal endoscopy, surgical, ethmoid sinus, placement of drug eluting implant; with biopsy, polypectomy or debridement Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only 01/01/ /01/ /01/ /01/2016; 01/01/2016; Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/ T Insertion or replacement of permanent cardiac Add to Precert 14

15 0411T 0412T 0413T 0414T 0415T 0416T 0417T 0418T 0421T 0422T 0423T 0424T contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only Removal of permanent cardiac contractility modulation system; pulse generator only Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular) Removal and replacement of permanent cardiac contractility modulation system pulse generator only Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead) Relocation of skin pocket for implanted cardiac contractility modulation pulse generator Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation system Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiac contractility modulation system Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) Tactile breast imaging by computer-aided tactile sensors, unilateral or bilateral Secretory type II phospholipase A2 (spla2-iia) Insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator) 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/2016 Add to Precert 01/01/ T Insertion or replacement of neurostimulator system for Add to Precert treatment of central sleep apnea; sensing lead only 01/01/ T Insertion or replacement of neurostimulator system for Add to Precert treatment of central sleep apnea; stimulation lead only 01/01/ T Insertion or replacement of neurostimulator system for Add to Precert treatment of central sleep apnea; pulse generator only 01/01/ T Removal of neurostimulator system for treatment of Add to Precert central sleep apnea; pulse generator only 01/01/ T Removal of neurostimulator system for treatment of Add to Precert central sleep apnea; sensing lead only 01/01/ T Removal of neurostimulator system for treatment of Add to Precert central sleep apnea; stimulation lead only 01/01/ T Removal and replacement of neurostimulator system for Add to Precert 15

16 0432T 0433T 0434T 0435T 0436T 0438T 0439T 0440T 0441T 0442T 0443T 0444T 0445T 0446T 0447T 0448T 0449T 0450T treatment of central sleep apnea, pulse generator only 01/01/2016 Repositioning of neurostimulator system for treatment of Add to Precert central sleep apnea; stimulation lead only 01/01/2016 Repositioning of neurostimulator system for treatment of Add to Precert central sleep apnea; sensing lead only 01/01/2016 Interrogation device evaluation implanted neurostimulator Add to Precert pulse generator system for central sleep apnea 01/01/2016 Programming device evaluation of implanted Add to Precert neurostimulator pulse generator system for central sleep 01/01/2016 apnea; single session Programming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; during sleep study Transperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple, includes image guidance Myocardial contrast perfusion echocardiography; at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure) Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve) Real time spectral analysis of prostate tissue by fluorescence spectroscopy Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the Add to Precert 01/01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/

17 0451T 0452T 0453T 0454T 0455T 0456T 0457T 0458T 0459T 0460T 0461T 0462T subconjunctival space; each additional device (List separately in addition to code for primary procedure) Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; complete system (counterpulsation device, vascular graft, implantable vascular hemostatic seal, mechano-electrical skin interface and subcutaneous electrodes) Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; aortic counterpulsation device and vascular hemostatic seal Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; mechano-electrical skin interface Insertion or replacement of a permanently implantable aortic counterpulsation ventricular assist system, endovascular approach, and programming of sensing and therapeutic parameters; subcutaneous electrode Removal of permanently implantable aortic counterpulsation ventricular assist system; complete system (aortic counterpulsation device, vascular hemostatic seal, mechano-electrical skin interface and electrodes) Removal of permanently implantable aortic counterpulsation ventricular assist system; aortic counterpulsation device and vascular hemostatic seal Removal of permanently implantable aortic counterpulsation ventricular assist system; mechanoelectrical skin interface Removal of permanently implantable aortic counterpulsation ventricular assist system; subcutaneous electrode Relocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device, mechano- electrical skin interface and electrodes Repositioning of previously implanted aortic counterpulsation ventricular assist device; subcutaneous electrode Repositioning of previously implanted aortic counterpulsation ventricular assist device, subcutaneous electrode; aortic counterpulsation device Programming device evaluation (in person) with 01/01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/ /01/

18 0463T 0464T 0465T 0466T 0467T 0468T 0472T 0473T 0474T 0475T 0476T iterative adjustment of the implantable mechanoelectrical skin interface and/or external driver to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable aortic counterpulsation ventricular assist system, per day Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day Visual evoked potential, testing for glaucoma, with interpretation and report Suprachoroidal injection of a pharmacologic agent (does not include supply of medication) Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator (List separately in addition to code for primary procedure) Revision or replacement of chest wall respiratory sensor electrode or electrode array, including connection to existing pulse generator Removal of chest wall respiratory sensor electrode or electrode array Device evaluation, interrogation, and initial programming of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, with iterative adjustment of the implantable device to test functionality, select optimal permanent programmed values with analysis, including visual training, with review and report by a qualified health care professional Device evaluation and interrogation of intra-ocular retinal electrode array (eg, retinal prosthesis), in person, including reprogramming and visual training, when performed, with review and report by a qualified health care professional Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space Recording of fetal magnetic cardiac signal using at least 3 channels; patient recording and storage, data scanning with signal extraction, technical analysis and result, as well as supervision, review, and interpretation of report by a physician or other qualified health care professional Recording of fetal magnetic cardiac signal using at least 3 channels; patient recording, data scanning, with raw electronic signal transfer of data and storage 01/01/ /01/ /01/ /01/ /01/ /01/ /01/2017 New Code 07/01/2017 New Code 07/01/2017 New Code 07/01/2017 New Code 07/01/2017 New Code 0477T Recording of fetal magnetic cardiac signal using at least 07/01/2017 New Code 18

19 3 channels; signal extraction, technical analysis, and result 0478T Recording of fetal magnetic cardiac signal using at least 3 channels; review, interpretation, report by physician or Added 07/01/2017 New Code other qualified health care professional 0479T Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of Added 01/01/2018 infants and children Fractional ablative laser fenestration of burn and Added 01/01/ T traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof (List separately in addition to code for primary procedure) Injection(s), autologous white blood cell concentrate Added 01/01/ T (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed Absolute quantitation of myocardial blood flow, positron Added 01/01/ T emission tomography (PET), rest and stress (List separately in addition to code for primary procedure) Transcatheter mitral valve implantation/replacement Added 01/01/ T (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed 0484T Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) Added 01/01/ T Optical coherence tomography (OCT) of middle ear, with Added 01/01/2018 interpretation and report; unilateral 0486T Optical coherence tomography (OCT) of middle ear, with Added 01/01/2018 interpretation and report; bilateral 0487T Biomechanical mapping, transvaginal, with report Added 01/01/2018 Autologous adipose-derived regenerative cell therapy Added 01/01/ T for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells 0490T Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one Added 01/01/2018 or both hands 0491T Ablative laser treatment, non-contact, full field and fractional ablation, open wound, per day, total Added 01/01/2018 treatment surface area; first 20 sq cm or less 0492T Ablative laser treatment, non-contact, full field and fractional ablation, open wound, per day, total treatment surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for Added 01/01/