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2018

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HCPCS Level IIA resourceful compilation of HCPCS codes

Supports HIPAA Compliance

E X P E R T

HCPCS.book Page i Wednesday, November 25, 2015 5:55 PM

© 2016 Optum360, LLC

ContentsIntroduction ........................................... Introduction — i

Index.................................................................. Index — 1

A Codes............................................................................. 1

Transportation Services Including Ambulance ............................. 1

Medical and Surgical Supplies........................................................... 2

B Codes ...........................................................................17

Enternal and Parenteral Therapy ....................................................17

C Codes ...........................................................................19

Outpatient PPS ....................................................................................19

E Codes ...........................................................................27

Durable Medical Equipment ............................................................27

G Codes...........................................................................41

Procedures/Professional Services (Temporary)...........................41

H Codes...........................................................................77

Alcohol and Drug Abuse Treatment Services ..............................77

J Codes............................................................................79

J Codes Drugs.......................................................................................79

J Codes Chemotherapy Drugs .........................................................92

K Codes ...........................................................................95

Temporary Codes................................................................................95

L Codes ...........................................................................99

Orthotic Devices and Procedures....................................................99

Prosthetic Procedures..................................................................... 111

M Codes ........................................................................123

Medical Services............................................................................... 123

P Codes .........................................................................124

Pathology and Laboratory Services .............................................124

Q Codes.........................................................................126

Q Codes (Temporary) .......................................................................126

R Codes .........................................................................133

Diagnostic Radiology Services ......................................................133

S Codes .........................................................................135

Temporary National Codes (Non-Medicare) ..............................135

T Codes .........................................................................145

National T Codes Established for State Medicaid Agencies ...145

V Codes .........................................................................147

Vision Services ...................................................................................147

Hearing Services ...............................................................................149

Appendixes

Appendix 1 — Table of Drugs .............................. Appendixes — 1

Appendix 2 — Modifiers......................................Appendixes — 29

Appendix 3 — Abbreviations and Acronyms .........................................................Appendixes — 35

Appendix 4 — Internet-only Manuals (IOMs)................................................................Appendixes — 39

Appendix 5 — HCPCS Changes for 2017...... Appendixes — 173

Appendix 6 — Place of Service and Type of Service...................................................... Appendixes — 183

Appendix 7 — Deleted Code Crosswalk....... Appendixes — 187

Appendix 8 — Glossary .................................... Appendixes — 189

Appendix 9 — Physician Quality Reporting System (PQRS) ............................................. Appendixes — 193

Implant — continuedyttrium 90, S2095Zoladex, J9202

Implantable radiation dosimeter, ea, A4650Impregnated gauze dressing, A6222-A6230Incontinence

appliances and supplies, A4310, A4336,A5051-A5093, A5102-A5114, A5120-A5200

brief or diaper, T4521-T4528, T4543-T4544disposable/liner, T4535garment, A4520pediatric

brief or diaper, T4529-T4530pull-on protection, T4531-T4532

rectal insert, A4337reusable

diaper or brief, T4539pull-on protection, T4536underpad, A4553

underpaddisposable, T4541, T4542reusable, A4553, T4537, T4540

youthbrief or diaper, T4533pull-on protection, T4534

Indium 111capromab pendetide, A9507ibritumomab tiuxetan, A9542labeled

platelets, A9571white blood cells, A9570

oxyguinoline, A9547pentetate, A9548, A9572pentetreotide, A9572satumomab pendetide, A4642

Infant safety, CPR, training, S9447Infection, G9311-G9312Infusion

catheter, C1751dose optimization, for infusion, S3722IV, OPPS, C8957pump, C1772, C2626

ambulatory, with administrative equip-ment, E0781

epoprostenol, K0455heparin, dialysis, E1520implantable, E0782, E0783implantable, refill kit, A4220insulin, E0784mechanical, reusable, E0779, E0780nonprogrammable, C1891supplies, A4221, A4222, A4230-A4232Versa-Pole IV, E0776

Sipuleucel-T autologous CD54+, Q2043supplies, A4222, A4223

syringe cartridge, non-insulin pump,K0552

therapy, home, S9347, S9351, S9497-S9504Inhalation drugs

acetylcysteine, J7608albuterol, J7609, J7610, J7611Alupent, J7668-J7669atropine, J7635-J7636Atrovent, J7644Azmacort, J7684beclomethasone, J7622betamethasone, J7624bitolterol mesylate, J7628-J7629Brcanyl, J7680-J7681Brethine, J7680-J7681budesonide, J7626-J7627, J7633-J7634colistimethate sodium, S0142cromolyn sodium, J7631dexamethasone, J7637-J7638dornase alpha, J7639flunisolide, J7641formoterol, J7606, J7640Gastrocrom, J7631glycopyrolate, J7642-J7643iloprost, Q4074Intal, J7631ipratropium bromide, J7644-J7645isoetharine HCl, J7647-J7650isoproterenol HCl, J7657-J7660levalbuterol, J7607, J7614, J7615

Inhalation drugs — continuedmetaproterenol sulfate, J7667-J7670methacholine chloride, J7674Mucomyst, J7608Mucosil, J7608Nasalcrom, J7631NOC, J7699pentamidine isethionate, J7676Pulmicort Respules, J7627terbutaline sulfate, J7680-J7681Tobi, J7682tobramycin, J7682, J7685Tornalate, J7628-J7629triamcinolone, J7683-J7684

InitialECG, Medicare, G0403-G0405physical exam, Medicare, G0402

Injectablebulking agent

urinary tract, L8603-L8606vocal cord, L8607

Injection — see also Table of Drugsadjustment, bariatric band, S2083bulking agent

urinary tract, L8603-L8606vocal cord, L8607

contrast material, during MRI, A9576-A9579,Q9953

dermal filler for LDS, G0429sacroiliac joint, G0259-G0260supplies for self-administered, A4211,

A4224-A4225Inpatient telehealth pharmacologic manage-

ment, G0459Insert

convex, for ostomy, A5093diabetic, for shoe, A5512-A5513foot insert/plate, L3031implant

soft palate, C9727Insertion

cardioverter-defibrillator system, G0448intrauterine system, S4981tray, A4310-A4316

Instillation fecal microbiota, G0455Integra

bilayer matrix wound dressing, Q4104dermal regeneration template, Q4105flowable wound matrix, Q4114matrix, Q4108meshed bilayer wound matrix, C9363osteoconductive scaffold putty, C9359osteoconductive scaffold strip, C9362

Interfacecough stimulating device, A7020oral with suction pump, A7047

Interfyl wound matrix, Q4171Intermittent

limb compression device, E0676peritoneal dialysis system, E1592positive pressure breathing (IPPB) machine,

E0500Interphalangeal joint, prosthetic implant,

L8658Interscapular thoracic prosthesis

endoskeletal, L6570upper limb, L6350-L6370

Interspinous process distraction device,C1821

Interventionalcohol and/or drug, H0050leak of endoluminal contents, G9305-G9306

Intrafallopian transfercomplete cycle, gamete, S4013complete cycle, zygote, S4014donor egg cycle, S4023incomplete cycle, S4017

Intraocular lenses, C1780, C1840, Q1004-Q1005, S0596, V2630-V2632

new technologycategory 4, Q1004category 5, Q1005

presbyopia correcting function, V2788refractive correcting, S0596telescopic, C1840

Intratubal occlusion device, A4264

Intrauterine devicecopper contraceptive, J7300other, S4989Progestacert, S4989

Introducer sheathguiding, C1766, C1892, C1893other than guiding, C1894, C2629

Inversion device, A9285In vitro fertilization, S4011Iodine 125, A9527, A9532, C2638-C2639Iodine I-131

albumin, A9524iobenguane sulfate, A9508sodium iodide, A9517

Iodine swabs/wipes, A4247IPD

system, E1592IPPB machine, E0500

delivery device, A9274, E0784, S5560-S5561,S5565-S5571

home infusion administration, S9353intermediate acting, S5552long acting, S5553NPH, J1815, S5552outpatient IV treatment, G9147rapid onset, S5550-S5551

Ipratropium bromideadministered through DME, J7644-J7645

Iris Preventix pressure relief/reduction mat-tress, E0184

Iris therapeutic overlays, E0199IRM ankle-foot orthotic, L1950Iron

sucrose, J1756Irrigation/evacuation system, bowel

control unit, E0350disposable supplies for, E0352

Irrigation supplies, A4320, A4322, A4355,A4397-A4400

Surfitirrigation sleeve, A4397night drainage container set, A5102

Visi-flow irrigator, A4398, A4399Islet cell transplant

laparoscopy, G0342laparotomy, G0343percutaneous, G0341

Isocal, enteral nutrition, B4150HCN, B4152

Isoetharineinhalation solution

concentrated, J7647unit dose, J7649-J7650

Isolates, B4150, B4152Isoproterenol HCl

administered through DME, J7657-J7660Isosulfan blue, Q9968Isotein, enteral nutrition, B4153IV, G0459

administration set, non-PVC, S1016infusion, OPPS, C8957pole, E0776, K0105solution

5% dextrose/normal saline, J704210% LMD, J7100D-5-W, J7070dextran, J7100, J7110Gentran, J7100, J7110normal saline, A4217, J7030-J7040,

J7050Rheomacrodex, J7100Ringer’s lactate, J7120

tubing extension set, S1015

JJace tribrace, L1832Jacket

scoliosis, L1300, L1310J-cell battery, replacement for blood glucose

monitor, A4234Jejunostomy tube, B4087-B4088Joint device, C1776

transcutaneous electrical stimulation, E0762

KKaltostat, alginate dressing, A6196-A6199Kartop Patient Lift, toilet or bathroom (see

also Lift), E0625Keramatrix skin substitute, Q4165Keratectomy photorefractive, S0810Keratoprosthesis, C1818Keto-Diastix, box of 100 glucose/ketone

urine test strips, A4250Key-Pred

-25,-50, J2650Kidney

ESRD supply, A4651-A4913system, E1510wearable artificial, E1632

Kingsley gloves, above hands, L6890Kits

asthma, S8097enteral feeding supply (syringe) (pump)

(gravity), B4034-B4036fistula cannulation (set), A4730parenteral nutrition, B4220-B4224surgical dressing (tray), A4550tracheostomy, A4625

KneeAdjustabrace 3, L2999disarticulation, prosthesis, L5150-L5160,

L5312extension/flexion device, E1812immobilizer, L1830joint, miniature, L5826Knee-O-Prene Hinged Wraparound Knee

Support, L1810locks, L2405-L2425Masterbrace 3, L2999Masterhinge Adjustabrace 3, L2999orthotic (KO), E1810, L1810, L1820, L1830-

L1860, L1851-L1852Knee-O-Prene Hinged Knee Sleeve, L1810Knee-O-Prene Hinged Wraparound Knee

Support, L1810Knee Support, L2000-L2038, L2126-L2136KnitRite

prostheticsheath, L8400-L8415sock, L8420-L8435

stump sock, L8470-L8485K-Y Lubricating Jelly, A4332, A4402Kyphosis pad, L1020, L1025

LLaboratory tests

chemistry, P2028-P2038miscellaneous, Q0111-Q0115

Labor care (not resulting in delivery), S4005Lacrimal duct implant

permanent, A4263temporary, A4262

Lancet, A4258, A4259Laparoscopy, surgical

esophagomyotomy, S2079Laryngectomy

tube, A7520-A7522Larynx, artifcial, L8500Laser

application, S8948assisted uvulopalatoplasty (LAUP), S2080in situ keratomileusis, S0800myringotomy, S2225

Laser skin piercing device, for blood collec-tion, E0620

replacement lens, A4257LAUP, S2080Lead

adaptorneurostimulator, C1883pacing, C1883

cardioverter, defibrillator, C1777, C1895,C1896

environmental, home evaluation, T1029neurostimulator, C1778neurostimulator/test kit, C1897pacemaker, C1779, C1898, C1899ventricular, C1900

Implant—

LeadIndex

Index — 7© 2016 Optum360, LLC

LeadHCPCS Level II

Legbag, A4358, A5112extensions for walker, E0158Nextep Contour Lower Leg Walker, L2999Nextep Low Silhouette Lower Leg Walkers,

L2999rest, elevating, K0195rest, wheelchair, E0990strap, A5113, A5114, K0038, K0039

Legg Perthes orthotic, A4565, L1700-L1755Lens

aniseikonic, V2118, V2318contact, V2500-V2599deluxe feature, V2702eye, S0504-S0508, S0580-S0590, S0596,

V2100-V2615, V2700-V2799intraocular, C1780, C1840, V2630-V2632low vision, V2600-V2615mirror coating, V2761occupational multifocal, V2786polarization, V2762polycarbonate, V2784progressive, V2781skin piercing device, replacement, A4257telescopic, C1840tint, V2744

addition, V2745Lenticular lens

bifocal, V2221single vision, V2121trifocal, V2321

Lerman Minerva spinal orthotic, L0174Lesion

destruction, G0186Leukocyte

poor blood, each unit, P9016Levine, stomach tube, B4087-B4088Levonorgestrel, contraceptive implants and

supplies, J7297-J7298, J7301, J7306Lice infestation treatment, A9180Lifescan lancets, box of 100, A4259Lifestand manual wheelchair, K0009Lifestyle modification program, coronary

heart disease, S0340-S0342Lift

combination, E0637patient, and seat, E0621-E0635

HoyerHome Care, E0621Partner All-Purpose, hydraulic,

E0630Partner Power Multifunction, E0625

separate seat mechanism, any type, E0627,E0629

shoe, L3300-L3334standing frame system, E0638

Lift-Aid patient lifts, E0621Light box, E0203Lispro insulin, S5551Lithium battery for blood glucose monitor,

A4233-A4236Lithrotripsy, gallstones, S9034Little Ones

drainable pouch, A5063mini-pouch, A5054one-piece custom drainable pouch, A5061one-piece custom urostomy pouch, A5071pediatric belt, A4367pediatric urine collector, A4335urostomy pouch, transparent, A5073

Lively, knee-ankle-foot orthotic, L2038Lobectomy, lung, donor, S2061Lodging

recipient, escort nonemergency transport,A0180, A0200

transplant-related, S9975NOS, S9976

Lomustine, S0178Lonalac powder, enteral nutrition, B4150Lower limb, prosthesis, addition, L5968Low osmolar contrast

100-199 mgs iodine, Q9965200-299 mgs iodine, Q9966300-399 mgs iodine, Q9967400 or greater mgs iodine, Q9951

LPN services, T1003

Lubricant, A4332, A4402Lumbar

orthotic, L0625-L0627pad, L1030, L1040sacral orthotic (LSO), L0628-L0640

Lung biopsy plug, C2613Lung volume reduction surgery services,

G0302-G0305LVRS services, G0302-G0305Lymphedema therapy, S8950

MMadamist II medication compressor/nebuliz-

er, E0570Magnacal, enteral nutrition, B4152Magnetic

resonance angiography, C8900, C8901-C8914, C8918-C8920, C8931-C8936

resonance cholangiopancreatography,S8037

resonance imaging, low field, S8042source imaging, S8035

Maintenance contract, ESRD, A4890Male erection system, L7900Malibu cervical turtleneck safety collar, L0150Mammography, G0202-G0206Management

advanced illness, S0311disease, S0316-S0317

Mappingtopographic brain, S8040vessels, G0365

Markertissue, A4648

Maskburn compression, A6513CPAP, A7027oxygen, A4620surgical, for dialysis, A4928

Mastectomybra, L8002camisole, S8460form, L8020prosthesis, L8000-L8039, L8600sleeve, L8010

Masterbrace 3, L2999Masterfoot Walking Cast Sole, L3649Masterhinge Adjustabrace 3, L2999Masterhinge Elbow Brace 3, L3999Masterhinge Hip Hinge 3, L2999Masterhinge Shoulder Brace 3, L3999Masters 2 step, S3904Mattress

air pressure, E0186, E0197alternating pressure, E0277

pad, Bio Flote, E0181pad, KoalaKair, E0181

AquaPedic Sectional, E0196decubitus care, E0196dry pressure, E0184flotation, E0184gel pressure, E0196hospital bed, E0271, E0272

non-powered, pressure reducing, E0373Iris Preventix pressure relief/reduction,

E0184Overlay, E0371-E0372pressure reducing, E0181TenderFlor II, E0187TenderGel II, E0196water pressure, E0187, E0198

powered, pressure reducing, E0277MCCM, G9480MCP, multi-axial rotation unit, L5986MCT Oil, enteral nutrition, B4155Meals

adults in treatment, T1010per diem NOS, S9977

Mechanicalhand, L6708-L6709hook, L6706-L6707wound suction, A9272

Medialization material for vocal cord, C1878Medical and surgical supplies, A4206-A6404Medical conference, S0220-S0221Medical food, S9435

Medical home program, S0280-S0281Medical records copying fee, S9981-S9982Medical visit, G0463, G9246-G9247Medicare Care Choice Model (MCCM), G9480Medicare “welcome”

ECG, G0403-G0405physical, G0402

Medication management device, T1505Medication services

comprehensive, H2010reminder, S5185

Medi-Jector injection device, A4210MediSense 2 Pen blood glucose monitor,

E0607Medralone

40, J103080, J1040

Menotropins, S0122Mental health

assessment, H0031education, G0177hospitalization, H0035peer services, H0038self-help, H0038service plan, H0032services, NOS, H0046supportive treatment, H0026-H0037training, G0177

Meritene, enteral nutrition, B4150powder, B4150

MESA, S4028Mesh, C1781Metabolism error, food supplement, S9434Metacarpophalangeal joint prosthesis, L8630Metatarsal joint, prosthetic implant, L8641Meter, bath conductivity, dialysis, E1550Methylene blue injection, Q9968Methylprednisolone

acetate, J1020-J1040oral, J7509sodium succinate, J2920, J2930

Meunster Suspension, socket prosthesis,L6110

Microbiology test, P7001Microcapillary tube, A4651

sealant, A4652Micro-Fine

disposable insulin syringes, up to 1 cc, persyringe, A4206

lancets, box of 100, A4259Microlipids, enteral nutrition, B4155Mileage, ambulance, A0380, A0390Milk, breast

processing, T2101Milwaukee spinal orthotic, L1000Minerva, spinal orthotic, L0700, L0710Mini-bus, nonemergency transportation,

A0120Minimed

3 cc syringe, A4232506 insulin pump, E0784insulin infusion set with bent needle wings,

each, A4231Sof-Set 24” insulin infusion set, each, A4230

Miroderm wound matrix, Q4175Mitotic rate, G9292-G9294Mobilite hospital beds, E0293, E0295, E0297Moderate sedation, G0500Moducal, enteral nutrition, B4155Moisture exchanger for use with invasive

mechanical ventilation, A4483Moisturizer, skin, A6250Monitor

apnea, E0618blood glucose, E0607

Accu-Check, E0607Tracer II, E0607

blood pressure, A4670device, A9279pacemaker, E0610, E0615ultrafiltration, S9007

Monoject disposable insulin syringes, up to1 cc, per syringe, A4206

Monojector lancet device, A4258Morcellator, C1782

Mouthpiece (for respiratory equipment),A4617

MRCP, S8037MRI

contrast material, A9576-A9579, Q9954low field, S8042

Mucoprotein, blood, P2038Mucus trap, S8210Multidisciplinary services, children, T1026Multifetal pregnancy reduction, ultrasound

guidance, S8055Multiple post collar, cervical, L0180-L0200Multipositional patient support system,

E0636Muscular dystrophy, genetic test, S3853Myotonic muscular dystrophy, genetic test,

S3853Myringotomy, S2225

NNail trim, G0127, S0390Narrowing device, wheelchair, E0969Nasal

application device (for CPAP device), A7032-A7034

endoscopy, S2342vaccine inhalation, J3530

Nasogastric tubing, B4081, B4082Nebulizer, E0570-E0585

aerosol mask, A7015aerosols, E0580

Airlife Brand Misty-Neb, E0580Power-Mist, E0580Up-Draft Neb-U-Mist, E0580Up-Mist hand-held nebulizer, E0580

compressor, with, E0570Madamist II medication compressor/neb-

ulizer, E0570Pulmo-Aide compressor/nebulizer,

E0570Schuco Mist nebulizer system, E0570

corrugated tubingdisposable, A7010, A7018

distilled water, A7018filter

disposable, A7013non-disposable, A7014

heater, E1372large volume

disposable, prefilled, A7008disposable, unfilled, A7007

not used with oxygendurable glass, A7017

pneumatic, administration set, A7003,A7005, A7006

pneumatic, nonfiltered, A7004portable, E0570small volume, E0574spacer or nebulizer, S8100

with mask, S8101ultrasonic, dome and mouthpiece, A7016ultrasonic, reservoir bottle

nondisposable, A7009water, A7018water collection device large volume nebu-

lizer, A7012distilled water, A7018

Needle, A4215with syringe, A4206-A4209biopsy

bone marrow, C1830brachytherapy, C1715non-coring, A4212

Negative pressure wound therapydressing set, A6550pump, E2402

NephrAmine, parenteral nutrition, B5000Neuromuscular stimulator, E0745

ambulation of spinal cord injured, E0762Neurophysiology monitoring, G0453Neuro-Pulse, E0720Neurostimulator

functional transcutaneous, E0764generator

nonrechargeable, C1767

© 2016 Optum360, LLC8 — Index

HCPCS Level IILegIn

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Leg

— N

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or

Transtracheal oxygen catheter, each N@7A4608CMS: 100-04,23,60.3

Supplies for Oxygen and Related Respiratory Equipment

Battery, heavy-duty; replacement for patient-ownedventilator E

A4611

Battery cables; replacement for patient-owned ventilator EA4612

Battery charger; replacement for patient-ownedventilator E@

A4613

Peak expiratory flow rate meter, hand held N7A4614

Cannula, nasal N7A4615CMS: 100-04,20,100.2; 100-04,23,60.3

Tubing (oxygen), per foot N@7A4616CMS: 100-04,20,100.2; 100-04,23,60.3

Mouthpiece N7A4617CMS: 100-04,20,100.2; 100-04,23,60.3

Breathing circuits N7(NU,RR,UE)A4618CMS: 100-04,20,100.2

Face tent N7(NU)A4619CMS: 100-04,20,100.2

Variable concentration mask N7A4620CMS: 100-04,20,100.2; 100-04,23,60.3

Tracheostomy, inner cannula N7A4623

Tracheal suction catheter, any type other than closed system,each N@7(NU)

A4624

Tracheostomy care kit for new tracheostomy N7A4625

Tracheostomy cleaning brush, each N@7A4626

Spacer, bag or reservoir, with or without mask, for use withmetered dose inhaler E

A4627

CMS: 100-02,15,110

Oropharyngeal suction catheter, each N@7(NU)A4628

Tracheostomy care kit for established tracheostomy N7A4629

Replacement Supplies for DME

Replacement batteries, medically necessary, transcutaneouselectrical stimulator, owned by patient E@7(NU)

A4630

Replacement bulb/lamp for ultraviolet light therapy system,each E@7(NU)

A4633

Replacement bulb for therapeutic light box, tabletopmodel N

A4634

Underarm pad, crutch, replacement, each E@7(NU,RR,UE)A4635

Replacement, handgrip, cane, crutch, or walker,each E@7(NU,RR,UE)

A4636

CMS: 100-04,23,60.3; 100-04,36,50.15

Replacement, tip, cane, crutch, walker, each E@7(NU,RR,UE)A4637CMS: 100-04,23,60.3; 100-04,36,50.15

Replacement battery for patient-owned ear pulse generator,each E@7(NU,RR,UE)

A4638

Replacement pad for infrared heating pad system,each E@7(RR)

A4639

Replacement pad for use with medically necessary alternatingpressure pad owned by patient E7(NU,RR,UE)

A4640

Radiopharmaceuticals

Radiopharmaceutical, diagnostic, not otherwiseclassified Nq

A4641

CMS: 100-04,13,60.3; 100-04,13,60.3.1; 100-04,13,60.3.2AHA: 4Q, '05, 1-6; 3Q, '04, 1-10

Indium In-111 satumomab pendetide, diagnostic, per studydose, up to 6 millicuries Nq@

A4642

Use this code for Oncoscint.AHA: 4Q, '05, 1-6; 3Q, '04, 1-10; 2Q, '02, 8-9

Miscellaneous Supplies

Tissue marker, implantable, any type, each Nq@,A4648AHA: 3Q, '13

Surgical supply; miscellaneous NA4649Determine if an alternative HCPCS Level II or a CPT code better describesthe service being reported. This code should be used only if a more specificcode is unavailable.

Implantable radiation dosimeter, each Nq@,A4650

Calibrated microcapillary tube, each N@,A4651AHA: 1Q, '02, 5

Microcapillary tube sealant N,A4652AHA: 1Q, '02, 5

Dialysis Supplies

Peritoneal dialysis catheter anchoring device, belt,each N@,

A4653

Syringe, with or without needle, each N@,A4657CMS: 100-04,13,60.7.1; 100-04,8,60.4.4; 100-04,8,60.4.6.3; 100-04,8,60.7;100-04,8,60.7.3AHA: 1Q, '02, 5

Sphygmomanometer/blood pressure apparatus with cuff andstethoscope N,

A4660

Blood pressure cuff only N,A4663

Automatic blood pressure monitor EA4670

Disposable cycler set used with cycler dialysis machine,each B@,

A4671

Drainage extension line, sterile, for dialysis, each B@,A4672

Extension line with easy lock connectors, used withdialysis B,

A4673

Chemicals/antiseptics solution used to clean/sterilize dialysisequipment, per 8 oz B@,

A4674

Activated carbon filter for hemodialysis, each N@,A4680

Dialyzer (artificial kidneys), all types, all sizes, for hemodialysis,each N@,

A4690

Bicarbonate concentrate, solution, for hemodialysis, pergallon N@,

A4706

AHA: 1Q, '02, 5

Bicarbonate concentrate, powder, for hemodialysis, perpacket N@,

A4707

AHA: 1Q, '02, 5

Acetate concentrate solution, for hemodialysis, pergallon N@,

A4708

AHA: 1Q, '02, 5

Acid concentrate, solution, for hemodialysis, pergallon N@,

A4709

AHA: 1Q, '02, 5

Treated water (deionized, distilled, or reverse osmosis) forperitoneal dialysis, per gallon N@,

A4714

A4608

— A

4714Transportation Services Including A

mbulance

s Revised Codem Recycled/Reinstatedl New Code@ Quantity AlertCarrier DiscretionNoncovered by MedicareSpecial Coverage Instructions

A Codes — 7, SNF Excluded7 DMEPOS PaidAHA: Coding ClinicCMS: Pub 100g-w ASC Pmt© 2016 Optum360, LLC

A4714HCPCS Level II

Commode chair, mobile or stationary, with detachablearms Y7(RR)

E0165

Medicare covers commodes for patients confined to their beds or rooms,for patients without indoor bathroom facilities, and to patients who cannotclimb or descend the stairs necessary to reach the bathrooms in theirhomes.

Pail or pan for use with commode chair, replacementonly Y7(NU,RR,UE)

E0167

Medicare covers commodes for patients confined to their beds or rooms,for patients without indoor bathroom facilities, and to patients who cannotclimb or descend the stairs necessary to reach the bathrooms in theirhomes.

Commode chair, extra wide and/or heavy-duty, stationary ormobile, with or without arms, any type,each Y@7(NU,RR,UE)

E0168

Commode chair with integrated seat lift mechanism, electric,any type Y7(RR)

E0170

Commode chair with integrated seat lift mechanism, nonelectric,any type Y7(RR)

E0171

Seat lift mechanism placed over or on top of toilet, anytype E

E0172

Footrest, for use with commode chair, each Y@7(NU,RR,UE)E0175

Decubitus Care Equipment

Powered pressure reducing mattress overlay/pad, alternating,with pump, includes heavy-duty Y7(RR)

E0181

For Medicare coverage, a detailed written order must be received by thesupplier before a claim is submitted.

Pump for alternating pressure pad, for replacementonly Y7(RR)

E0182


Dry pressure mattress Y7(NU,RR,UE)E0184For Medicare coverage, a detailed written order must be received by thesupplier before a claim is submitted.

Gel or gel-like pressure pad for mattress, standard mattresslength and width Y7(NU,RR,UE)

E0185


Air pressure mattress Y7(RR)E0186For Medicare coverage, a detailed written order must be received by thesupplier before a claim is submitted.

Water pressure mattress Y7(RR)E0187For Medicare coverage, a detailed written order must be received by thesupplier before a claim is submitted.

Synthetic sheepskin pad Y7(NU,RR,UE)E0188For Medicare coverage, a detailed written order must be received by thesupplier before a claim is submitted.

Lambswool sheepskin pad, any size Y7(NU,RR,UE)E0189For Medicare coverage, a detailed written order must be received by thesupplier before a claim is submitted.

Positioning cushion/pillow/wedge, any shape or size, includesall components and accessories E

E0190

Heel or elbow protector, each Y@7(NU,RR,UE)E0191

Powered air flotation bed (low air loss therapy) Y7(RR)E0193CMS: 100-04,23,60.3

Air fluidized bed Y7(RR)E0194An air fluidized bed is covered by Medicare if the patient has a stage 3 orstage 4 pressure sore and, without the bed, would requireinstitutionalization. For Medicare coverage, a detailed written order mustbe received by the supplier before a claim is submitted.

Gel pressure mattress Y7(RR)E0196Medicare covers pads if physicians supervise their use in patients whohave decubitus ulcers or susceptibility to them. For Medicare coverage,a detailed written order must be received by the supplier before a claimis submitted.

Air pressure pad for mattress, standard mattress length andwidth Y7(RR)

E0197

Medicare covers pads if physicians supervise their use in patients whohave decubitus ulcers or susceptibility to them. For Medicare coverage,a detailed written order must be received by the supplier before a claimis submitted.

Water pressure pad for mattress, standard mattress length andwidth Y7(RR)

E0198

Medicare covers pads if physicians supervise their use in patients whohave decubitus ulcers or susceptibility to them.For Medicare coverage, adetailed written order must be received by the supplier before a claim issubmitted.

Dry pressure pad for mattress, standard mattress length andwidth Y7(NU,RR,UE)

E0199

Medicare covers pads if physicians supervise their use in patients whohave decubitus ulcers or susceptibility to them. For Medicare coverage,a detailed written order must be received by the supplier before a claimis submitted.

Heat/Cold Application

Heat lamp, without stand (table model), includes bulb, orinfrared element Y7(NU,RR,UE)

E0200

Phototherapy (bilirubin) light with photometer Y7(RR)E0202

Therapeutic lightbox, minimum 10,000 lux, table topmodel E

E0203

Heat lamp, with stand, includes bulb, or infraredelement Y7(NU,RR,UE)

E0205

Electric heat pad, standard Y7(NU,RR,UE)E0210

Electric heat pad, moist Y7(NU,RR,UE)E0215

Water circulating heat pad with pump Y7(NU,RR,UE)E0217

Water circulating cold pad with pump YE0218

Infrared heating pad system YE0221AHA: 1Q, '02, 5

Hydrocollator unit, includes pads Y7(NU,RR,UE)E0225

Noncontact wound-warming device (temperature control unit,AC adapter and power cord) for use with warming card andwound cover E

E0231

AHA: 1Q, '02, 5

Warming card for use with the noncontact wound-warmingdevice and noncontact wound-warming wound cover E

E0232

AHA: 1Q, '02, 5

Paraffin bath unit, portable (see medical supply code A4265 forparaffin) Y7(RR)

E0235

Pump for water circulating pad Y7(RR)E0236

Hydrocollator unit, portable Y7(NU,RR,UE)E0239

Bath and Toilet Aids

Bath/shower chair, with or without wheels, any size EE0240

Bathtub wall rail, each E@E0241

Bathtub rail, floor base EE0242

Toilet rail, each E@E0243

Raised toilet seat EE0244

Tub stool or bench EE0245

Transfer tub rail attachment EE0246


© 2016 Optum360, LLCA-Y OPPS Status Indicators: Male Only; Female Onlyx Maternity Edity Age Edit28 — E Codes

HCPCS Level IIE0165D

urab

le M

edic

al E

quip

men

tE0

165

— E

0246

Electromagnetic therapy, to one or more areas for chronic StageIII and Stage IV pressure ulcers, arterial ulcers, diabetic ulcersand venous stasis ulcers not demonstrating measurable signsof healing after 30 days of conventional care as part of a therapyplan of care A

G0329

CMS: 100-04,32,11.2

Pharmacy dispensing fee for inhalation drug(s); initial 30-daysupply as a beneficiary M

G0333

Hospice evaluation and counseling services, preelection BG0337CMS: 100-04,11,10; 100-04,11,10.1

Image guided robotic linear accelerator-based stereotacticradiosurgery, complete course of therapy in one session or firstsession of fractionated treatment B,

G0339

AHA: 4Q, '13; 1Q, '04, 6

Image guided robotic linear accelerator-based stereotacticradiosurgery, delivery including collimator changes and customplugging, fractionated treatment, all lesions, per session, secondthrough fifth sessions, maximum 5 sessions per course oftreatment B,

G0340

AHA: 4Q, '13; 1Q, '04, 6

Percutaneous islet cell transplant, includes portal veincatheterization and infusion C,

G0341

CMS: 100-04,32,70

Laparoscopy for islet cell transplant, includes portal veincatheterization and infusion C,

G0342

CMS: 100-04,32,70

Laparotomy for islet cell transplant, includes portal veincatheterization and infusion C,

G0343

CMS: 100-04,32,70

Bone marrow aspiration performed with bone marrow biopsythrough the same incision on the same date of service N,

G0364

AHA: 3Q, '12, 6

Vessel mapping of vessels for hemodialysis access (services forpreoperative vessel mapping prior to creation of hemodialysisaccess using an autogenous hemodialysis conduit, includingarterial inflow and venous outflow) Sr

G0365

Physician service required to establish and document the needfor a power mobility device M,

G0372

CMS: 100-04,12,30.6.15.4

Observation/Emergency Department Services

Hospital observation service, per hour NG0378CMS: 100-02,6,20.6; 100-04,01,50.3.2; 100-04,4,290.1; 100-04,4,290.2.2;100-04,4,290.4.1; 100-04,4,290.4.2; 100-04,4,290.4.3; 100-04,4,290.5.1;100-04,4,290.5.2; 100-04,4,290.5.3AHA: 4Q, '05, 7, 9

Direct admission of patient for hospital observation care JG0379CMS: 100-02,6,20.6; 100-04,4,290.4.1; 100-04,4,290.4.2; 100-04,4,290.4.3;100-04,4,290.5.1; 100-04,4,290.5.2; 100-04,4,290.5.3AHA: 4Q, '05, 7, 9

Level 1 hospital emergency department visit provided in a typeB emergency department; (the ED must meet at least one of thefollowing requirements: (1) it is licensed by the state in whichit is located under applicable state law as an emergency roomor emergency department; (2) it is held out to the public (byname, posted signs, advertising, or other means) as a place thatprovides care for emergency medical conditions on an urgentbasis without requiring a previously scheduled appointment;or (3) during the calendar year immediately preceding thecalendar year in which a determination under 42 CFR 489.24 isbeing made, based on a representative sample of patient visitsthat occurred during that calendar year, it provides at leastone-third of all of its outpatient visits for the treatment ofemergency medical conditions on an urgent basis withoutrequiring a previously scheduled appointment) J

G0380

CMS: 100-04,4,160AHA: 4Q, '13; 1Q, '09, 1; 4Q, '07, 1


G0381

CMS: 100-04,4,160AHA: 4Q, '13; 1Q, '09, 1; 4Q, '07, 1


G0382

CMS: 100-04,4,160AHA: 4Q, '13; 1Q, '09, 1; 4Q, '07, 1


G0383

CMS: 100-04,4,160AHA: 4Q, '13; 1Q, '09, 1; 4Q, '07, 1

G0329

— G

0383Procedures/Professional Services (Tem

porary)


G Codes — 45, SNF Excluded7 DMEPOS PaidAHA: Coding ClinicCMS: Pub 100g-w ASC Pmt© 2016 Optum360, LLC

G0383HCPCS Level II

Lymphocyte immune globulin, antithymocyte globulin, equine,parenteral, 250 mg Kn@

J7504

Use this code for Atgam.CMS: 100-03,260.7; 100-04,17,80.3

Muromonab-CD3, parenteral, 5 mg E@J7505Use this code for Orthoclone OKT3.CMS: 100-04,17,80.3

Tacrolimus, immediate release, oral, 1 mg Nq@J7507Use this code for Prograf.CMS: 100-02,15,50.5; 100-04,17,80.3

Tacrolimus, extended release, (Astagraf XL), oral, 0.1mg Gn@

J7508

AHA: 1Q, '16, 6-8; 1Q, '14

Methylprednisolone, oral, per 4 mg Nq@J7509Use this code for Medrol, Methylpred.CMS: 100-02,15,50.5; 100-04,17,80.3

Prednisolone, oral, per 5 mg Nq@J7510Use this code for Delta-Cortef, Cotolone, Pediapred, Prednoral, Prelone.CMS: 100-02,15,50.5; 100-04,17,80.3

Lymphocyte immune globulin, antithymocyte globulin, rabbit,parenteral, 25 mg Kn@

J7511

Use this code for Thymoglobulin.CMS: 100-04,17,80.3AHA: 2Q, '02, 8-9; 1Q, '02, 5

Prednisone, immediate release or delayed release, oral, 1mg N

J7512

AHA: 1Q, '16, 6-8

Daclizumab, parenteral, 25 mg Kn@J7513Use this code for Zenapax.CMS: 100-02,15,50.5; 100-04,17,80.3AHA: 2Q, '05, 11

Cyclosporine, oral, 25 mg Nq@J7515Use this code for Neoral, Sandimmune, Gengraf, Sangcya.CMS: 100-04,17,80.3

Cyclosporine, parenteral, 250 mg Nq@J7516Use this code for Neoral, Sandimmune, Gengraf, Sangcya.CMS: 100-04,17,80.3

Mycophenolate mofetil, oral, 250 mg Nq@J7517Use this code for CellCept.CMS: 100-04,17,80.3

Mycophenolic acid, oral, 180 mg Nq@J7518Use this code for Myfortic Delayed Release.CMS: 100-04,17,80.3.1AHA: 2Q, '05, 11

Sirolimus, oral, 1 mg Nq@J7520Use this code for Rapamune.CMS: 100-02,15,50.5; 100-04,17,80.3

Tacrolimus, parenteral, 5 mg Kn@J7525Use this code for Prograf.CMS: 100-02,15,50.5; 100-04,17,80.3

Everolimus, oral, 0.25 mg Nq@J7527Use this code for Zortress, Afinitor.

Immunosuppressive drug, not otherwise classified NqJ7599Determine if an alternative HCPCS Level II or a CPT code better describesthe service being reported. This code should be used only if a more specificcode is unavailable.CMS: 100-02,15,50.5; 100-04,17,80.3AHA: 2Q, '13

Inhalation Drugs

Acetylcysteine, inhalation solution, compounded product,administered through DME, unit dose form, per g M@

J7604

Arformoterol, inhalation solution, FDA approved final product,noncompounded, administered through DME, unit dose form,15 mcg M@

J7605

Formoterol fumarate, inhalation solution, FDA approved finalproduct, noncompounded, administered through DME, unitdose form, 20 mcg M

J7606

Use this code for PERFOROMIST.

Levalbuterol, inhalation solution, compounded product,administered through DME, concentrated form, 0.5 mg M@

J7607

CMS: 100-03,200.2

Acetylcysteine, inhalation solution, FDA-approved final product,noncompounded, administered through DME, unit dose form,per g M@

J7608

Use this code for Acetadote, Mucomyst, Mucosil.

Albuterol, inhalation solution, compounded product,administered through DME, unit dose, 1 mg M@

J7609

Albuterol, inhalation solution, compounded product,administered through DME, concentrated form, 1 mg M@

J7610

Albuterol, inhalation solution, FDA-approved final product,noncompounded, administered through DME, concentratedform, 1 mg M@

J7611

Use this code for Accuneb, Proventil, Respirol, Ventolin.AHA: 2Q, '08, 10; 2Q, '07, 10

Levalbuterol, inhalation solution, FDA-approved final product,noncompounded, administered through DME, concentratedform, 0.5 mg M@

J7612

Use this code for Xopenex HFA.CMS: 100-03,200.2AHA: 2Q, '08, 10; 2Q, '07, 10

Albuterol, inhalation solution, FDA-approved final product,noncompounded, administered through DME, unit dose, 1mg M@

J7613

Use this code for Accuneb, Proventil, Respirol, Ventolin.AHA: 2Q, '08, 10; 2Q, '07, 10

Levalbuterol, inhalation solution, FDA-approved final product,noncompounded, administered through DME, unit dose, 0.5mg M@

J7614

Use this code for Xopenex.CMS: 100-03,200.2AHA: 2Q, '08, 10; 2Q, '07, 10

Levalbuterol, inhalation solution, compounded product,administered through DME, unit dose, 0.5 mg M@

J7615

CMS: 100-03,200.2

Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg,FDA-approved final product, noncompounded, administeredthrough DME M@

J7620

Beclomethasone, inhalation solution, compounded product,administered through DME, unit dose form, per mg M@

J7622

Use this code for Beclovent, Beconase.AHA: 1Q, '02, 5

Betamethasone, inhalation solution, compounded product,administered through DME, unit dose form, per mg M@

J7624

AHA: 1Q, '02, 5


© 2016 Optum360, LLCA-Y OPPS Status Indicators: Male Only; Female Onlyx Maternity Edity Age Edit90 — J Codes

HCPCS Level IIJ7504D

rugs

Adm

inis

tere

d O

ther

Tha

n O

ral M

etho

dJ7

504

— J

7624

Sacroiliac orthotic, flexible, provides pelvic-sacral support,reduces motion about the sacroiliac joint, includes straps,closures, may include pendulous abdomen design, customfabricated A7

L0622

Sacroiliac orthosis, provides pelvic-sacral support, with rigid orsemi-rigid panels over the sacrum and abdomen, reduces motionabout the sacroiliac joint, includes straps, closures, may includependulous abdomen design, prefabricated, off-the-shelf A7

L0623

Sacroiliac orthotic, provides pelvic-sacral support, with rigid orsemi-rigid panels placed over the sacrum and abdomen, reducesmotion about the sacroiliac joint, includes straps, closures, mayinclude pendulous abdomen design, custom fabricated A7

L0624

Lumbar orthosis, flexible, provides lumbar support, posteriorextends from L-1 to below L-5 vertebra, produces intracavitarypressure to reduce load on the intervertebral discs, includesstraps, closures, may include pendulous abdomen design,shoulder straps, stays, prefabricated, off-the-shelf A7

L0625

Lumbar orthosis, sagittal control, with rigid posterior panel(s),posterior extends from L-1 to below L-5 vertebra, producesintracavitary pressure to reduce load on the intervertebral discs,includes straps, closures, may include padding, stays, shoulderstraps, pendulous abdomen design, prefabricated item that hasbeen trimmed, bent, molded, assembled, or otherwisecustomized to fit a specific patient by an individual withexpertise A7

L0626

Lumbar orthosis, sagittal control, with rigid anterior andposterior panels, posterior extends from L-1 to below L-5vertebra, produces intracavitary pressure to reduce load on theintervertebral discs, includes straps, closures, may includepadding, shoulder straps, pendulous abdomen design,prefabricated item that has been trimmed, bent, molded,assembled, or otherwise customized to fit a specific patient byan individual with expertise A7

L0627

Lumbar-sacral orthosis, flexible, provides lumbo-sacral support,posterior extends from sacrococcygeal junction to T-9 vertebra,produces intracavitary pressure to reduce load on theintervertebral discs, includes straps, closures, may include stays,shoulder straps, pendulous abdomen design, prefabricated,off-the-shelf A7

L0628

Lumbar-sacral orthotic, flexible, provides lumbo-sacral support,posterior extends from sacrococcygeal junction to T-9 vertebra,produces intracavitary pressure to reduce load on theintervertebral discs, includes straps, closures, may include stays,shoulder straps, pendulous abdomen design, customfabricated A7

L0629

Lumbar-sacral orthosis, sagittal control, with rigid posteriorpanel(s), posterior extends from sacrococcygeal junction to T-9vertebra, produces intracavitary pressure to reduce load on theintervertebral discs, includes straps, closures, may includepadding, stays, shoulder straps, pendulous abdomen design,prefabricated item that has been trimmed, bent, molded,assembled, or otherwise customized to fit a specific patient byan individual with expertise A7

L0630

Lumbar-sacral orthosis, sagittal control, with rigid anterior andposterior panels, posterior extends from sacrococcygeal junctionto T-9 vertebra, produces intracavitary pressure to reduce loadon the intervertebral discs, includes straps, closures, may includepadding, shoulder straps, pendulous abdomen design,prefabricated item that has been trimmed, bent, molded,assembled, or otherwise customized to fit a specific patient byan individual with expertise A7

L0631

Lumbar-sacral orthotic (LSO), sagittal control, with rigid anteriorand posterior panels, posterior extends from sacrococcygealjunction to T-9 vertebra, produces intracavitary pressure toreduce load on the intervertebral discs, includes straps, closures,may include padding, shoulder straps, pendulous abdomendesign, custom fabricated A7

L0632

Lumbar-sacral orthosis, sagittal-coronal control, with rigidposterior frame/panel(s), posterior extends from sacrococcygealjunction to T-9 vertebra, lateral strength provided by rigid lateralframe/panels, produces intracavitary pressure to reduce loadon intervertebral discs, includes straps, closures, may includepadding, stays, shoulder straps, pendulous abdomen design,prefabricated item that has been trimmed, bent, molded,assembled, or otherwise customized to fit a specific patient byan individual with expertise A7

L0633

Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigidposterior frame/panel(s), posterior extends from sacrococcygealjunction to T-9 vertebra, lateral strength provided by rigid lateralframe/panel(s), produces intracavitary pressure to reduce loadon intervertebral discs, includes straps, closures, may includepadding, stays, shoulder straps, pendulous abdomen design,custom fabricated A7

L0634

Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbarflexion, rigid posterior frame/panel(s), lateral articulating designto flex the lumbar spine, posterior extends from sacrococcygealjunction to T-9 vertebra, lateral strength provided by rigid lateralframe/panel(s), produces intracavitary pressure to reduce loadon intervertebral discs, includes straps, closures, may includepadding, anterior panel, pendulous abdomen design,prefabricated, includes fitting and adjustment A7

L0635

Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbarflexion, rigid posterior frame/panels, lateral articulating designto flex the lumbar spine, posterior extends from sacrococcygealjunction to T-9 vertebra, lateral strength provided by rigid lateralframe/panels, produces intracavitary pressure to reduce loadon intervertebral discs, includes straps, closures, may includepadding, anterior panel, pendulous abdomen design, customfabricated A7

L0636

Lumbar-sacral orthosis, sagittal-coronal control, with rigidanterior and posterior frame/panels, posterior extends fromsacrococcygeal junction to T-9 vertebra, lateral strengthprovided by rigid lateral frame/panels, produces intracavitarypressure to reduce load on intervertebral discs, includes straps,closures, may include padding, shoulder straps, pendulousabdomen design, prefabricated item that has been trimmed,bent, molded, assembled, or otherwise customized to fit aspecific patient by an individual with expertise A7

L0637

Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigidanterior and posterior frame/panels, posterior extends fromsacrococcygeal junction to T-9 vertebra, lateral strengthprovided by rigid lateral frame/panels, produces intracavitarypressure to reduce load on intervertebral discs, includes straps,closures, may include padding, shoulder straps, pendulousabdomen design, custom fabricated A7

L0638

Lumbar-sacral orthosis, sagittal-coronal control, rigidshell(s)/panel(s), posterior extends from sacrococcygeal junctionto T-9 vertebra, anterior extends from symphysis pubis toxyphoid, produces intracavitary pressure to reduce load on theintervertebral discs, overall strength is provided by overlappingrigid material and stabilizing closures, includes straps, closures,may include soft interface, pendulous abdomen design,prefabricated item that has been trimmed, bent, molded,assembled, or otherwise customized to fit a specific patient byan individual with expertise A7

L0639

L0622—

L0639O

rthotic Devices and Procedures


L Codes — 101, SNF Excluded7 DMEPOS PaidAHA: Coding ClinicCMS: Pub 100g-w ASC Pmt© 2016 Optum360, LLC

L0639HCPCS Level II

Perphenazine, 4 mg, oral, FDA approved prescription antiemetic,for use as a complete therapeutic substitute for an IV antiemeticat the time of chemotherapy treatment, not to exceed a 48 hourdosage regimen Nq@

Q0175

Medicare covers at the time of chemotherapy if regimen doesn't exceed48 hours. Submit on the same claim as the chemotherapy. Use this codefor Trilifon.CMS: 100-02,15,50.5.4; 100-03,110.18; 100-04,17,80.2.1AHA: 1Q, '08, 1

Hydroxyzine pamoate, 25 mg, oral, FDA approved prescriptionantiemetic, for use as a complete therapeutic substitute for anIV antiemetic at the time of chemotherapy treatment, not toexceed a 48-hour dosage regimen Nq@

Q0177

Medicare covers at the time of chemotherapy if regimen doesn't exceed48 hours. Submit on the same claim as the chemotherapy. Use this codefor Vistaril.CMS: 100-02,15,50.5.4; 100-03,110.18; 100-04,17,80.2.1AHA: 1Q, '08, 1

Dolasetron mesylate, 100 mg, oral, FDA approved prescriptionantiemetic, for use as a complete therapeutic substitute for anIV antiemetic at the time of chemotherapy treatment, not toexceed a 24-hour dosage regimen Nq@

Q0180

Medicare covers at the time of chemotherapy if regimen doesn't exceed24 hours. Submit on the same claim as the chemotherapy. Use this codefor Anzemet.CMS: 100-02,15,50.5.4; 100-03,110.18; 100-04,17,80.2.1AHA: 1Q, '08, 1

Unspecified oral dosage form, FDA approved prescriptionantiemetic, for use as a complete therapeutic substitute for anIV antiemetic at the time of chemotherapy treatment, not toexceed a 48-hour dosage regimen Nq

Q0181

Medicare covers at the time of chemotherapy if regimen doesn't exceed48-hours. Submit on the same claim as the chemotherapy.CMS: 100-02,15,50.5.4; 100-03,110.18; 100-04,17,80.2.1AHA: 2Q, '12, 9; 1Q, '08, 1

Power adapter for use with electric or electric/pneumaticventricular assist device, vehicle type A7

Q0478

Power module for use with electric or electric/pneumaticventricular assist device, replacement only A7

Q0479

Driver for use with pneumatic ventricular assist device,replacement only A7

Q0480

AHA: 3Q, '05, 1-2

Microprocessor control unit for use with electric ventricularassist device, replacement only A7

Q0481

AHA: 3Q, '05, 1-2

Microprocessor control unit for use with electric/pneumaticcombination ventricular assist device, replacement only A7

Q0482

AHA: 3Q, '05, 1-2

Monitor/display module for use with electric ventricular assistdevice, replacement only A7

Q0483

AHA: 3Q, '05, 1-2

Monitor/display module for use with electric orelectric/pneumatic ventricular assist device, replacementonly A7

Q0484

AHA: 3Q, '05, 1-2

Monitor control cable for use with electric ventricular assistdevice, replacement only A7

Q0485

AHA: 3Q, '05, 1-2

Monitor control cable for use with electric/pneumatic ventricularassist device, replacement only A7

Q0486

AHA: 3Q, '05, 1-2

Leads (pneumatic/electrical) for use with any typeelectric/pneumatic ventricular assist device, replacementonly A7

Q0487

AHA: 3Q, '05, 1-2

Power pack base for use with electric ventricular assist device,replacement only A

Q0488

AHA: 3Q, '05, 1-2

Power pack base for use with electric/pneumatic ventricularassist device, replacement only A7

Q0489

AHA: 3Q, '05, 1-2

Emergency power source for use with electric ventricular assistdevice, replacement only A7

Q0490

AHA: 3Q, '05, 1-2

Emergency power source for use with electric/pneumaticventricular assist device, replacement only A7

Q0491

AHA: 3Q, '05, 1-2

Emergency power supply cable for use with electric ventricularassist device, replacement only A7

Q0492

AHA: 3Q, '05, 1-2

Emergency power supply cable for use with electric/pneumaticventricular assist device, replacement only A7

Q0493

AHA: 3Q, '05, 1-2

Emergency hand pump for use with electric or electric/pneumaticventricular assist device, replacement only A7

Q0494

AHA: 3Q, '05, 1-2

Battery/power pack charger for use with electric orelectric/pneumatic ventricular assist device, replacementonly A7

Q0495

AHA: 3Q, '05, 1-2

Battery, other than lithium-ion, for use with electric orelectric/pneumatic ventricular assist device, replacementonly A7

Q0496

AHA: 3Q, '05, 1-2

Battery clips for use with electric or electric/pneumaticventricular assist device, replacement only A7

Q0497

AHA: 3Q, '05, 1-2

Holster for use with electric or electric/pneumatic ventricularassist device, replacement only A7

Q0498

AHA: 3Q, '05, 1-2

Belt/vest/bag for use to carry external peripheral componentsof any type ventricular assist device, replacement only A7

Q0499

AHA: 3Q, '05, 1-2

Filters for use with electric or electric/pneumatic ventricularassist device, replacement only A@7

Q0500

The base unit for this code is for each filter.AHA: 3Q, '05, 1-2

Shower cover for use with electric or electric/pneumaticventricular assist device, replacement only A7

Q0501

AHA: 3Q, '05, 1-2

Mobility cart for pneumatic ventricular assist device,replacement only A7

Q0502

AHA: 3Q, '05, 1-2

Battery for pneumatic ventricular assist device, replacementonly, each A@7

Q0503

AHA: 3Q, '05, 1-2

Power adapter for pneumatic ventricular assist device,replacement only, vehicle type A7

Q0504

AHA: 3Q, '05, 1-2

Battery, lithium-ion, for use with electric or electric/pneumaticventricular assist device, replacement only A7

Q0506

Q0175

— Q

0506Tem

porary Codes


Q Codes (Temporary) —, SNF Excluded7 DMEPOS PaidAHA: Coding ClinicCMS: Pub 100g-w ASC Pmt© 2016 Optum360, LLC127

Q0506HCPCS Level II

HCPCS Level II Appendix 1 — Table of Drugs and Biologicals

© 2016 Optum360, LLC Appendixes — 5

Appendix 1 —

Table of Drugs and B

iologicals

BUNAVAIL 6.3 MG ORAL J0574

BUPIVACAINE HCL 30 ML VAR S0020

BUPIVACAINE LIPOSOME 1 MG VAR C9290

BUPRENEX 0.1 MG IM, IV J0592

BUPRENORPHIN/NALOXONE UP TO 3 MG ORAL J0572

BUPRENORPHIN/NALOXONE > 10 MG ORAL J0575

BUPRENORPHINE HCL 0.1 MG IM, IV J0592

BUPRENORPHINE IMPLANT 74.2 MG OTH J0570

BUPRENORPHINE ORAL 1 MG ORAL J0571

BUPRENORPHINE/NALOXONE 3.1 TO 6 MG ORAL J0573

BUPRENORPHINE/NALOXONE 6.1 TO 10 MG ORAL J0574

BUPROPION HCL 150 MG ORAL S0106

BUSULFAN 2 MG ORAL J8510

BUSULFAN 1 MG IV J0594

BUSULFEX 2 MG ORAL J8510

BUTORPHANOL TARTRATE 2 MG IM, IV J0595

BUTORPHANOL TARTRATE 25 MG OTH S0012

C 1 ESTERASE INHIBITOR (HUMAN) (BERINERT)

10 UNITS IV J0597

C1 ESTERASE INHIBITOR (HUMAN) (CINRYZE)

10 UNITS IV J0598

C1 ESTERASE INHIBITOR (RECOMBINANT)

10 UNITS IV J0596

CABAZITAXEL 1 MG IV J9043

CABERGOLINE 0.25 MG ORAL J8515

CAFCIT 5 MG IV J0706

CAFFEINE CITRATE 5 MG IV J0706

CALCIJEX 0.1 MCG IM J0636

CALCIJEX 0.25 MCG INJ S0169

CALCIMAR UP TO 400 U SC, IM J0630

CALCITONIN SALMON 400 U SC, IM J0630

CALCITRIOL 0.1 MCG IM J0636

CALCITROL 0.25 MCG IM S0169

CALCIUM DISODIUM VERSENATE 1,000 MG IV, SC, IM J0600

CALCIUM GLUCONATE 10 ML IV J0610

CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE

10 ML IM, SC J0620

CALDOLOR 100 MG IV J1741

CAMPTOSAR 20 MG IV J9206

CANAKINUMAB 1 MG SC J0638

CANCIDAS 5 MG IV J0637

CAPECITABINE 150 MG ORAL J8520

CAPROMAB PENDETIDE STUDY DOSE UP TO 10 MCI

IV A9507

CAPSAICIN 8% PATCH 1 SQ CM OTH J7336

CARBIDOPA/LEVODOPA 5 MG/20 MG ORAL J7340

CARBOCAINE 10 ML VAR J0670

CARBOPLATIN 50 MG IV J9045

CARDIOGEN 82 STUDY DOSE UP TO 60 MCI

IV A9555

CARDIOLITE STUDY DOSE IV A9500

CARFILZOMIB 1 MG IV J9047

Drug Name Unit Per Route Code

CARIMUNE 500 MG IV J1566

CARMUSTINE 100 MG IV J9050

CARNITOR 1 G IV J1955

CARTICEL OTH J7330

CASPOFUNGIN ACETATE 5 MG IV J0637

CATAPRES 1 MG OTH J0735

CATHFLO 1 MG IV J2997

CAVERJECT 1.25 MCG VAR J0270

CEA SCAN STUDY DOSE UP TO 45 MCI

IV A9568

CEENU 10 MG ORAL S0178

CEFAZOLIN SODIUM 500 MG IM, IV J0690

CEFEPIME HCL 500 MG IV J0692

CEFIZOX 500 MG IV, IM J0715

CEFOBID 1 G IV S0021

CEFOPERAZONE SODIUM 1 G IV S0021

CEFOTAN 500 MG IM, IV S0074

CEFOTAXIME SODIUM 1 GM IV, IM J0698

CEFOTETAN DISODIUM 500 MG IM. IV S0074

CEFOXITIN SODIUM 1 GM IV, IM J0694

CEFTAROLINE FOSAMIL 10 MG IV J0712

CEFTAZIDIME 500 MG IM, IV J0713

CEFTAZIDIME AND AVIBACTAM 0.5 G/0.125 G

IV J0714

CEFTIZOXIME SODIUM 500 MG IV, IM J0715

CEFTOLOZANE AND TAZOBACTAM

50 MG/25 MG

IV J0695

CEFTRIAXONE SODIUM 250 MG IV, IM J0696

CEFUROXIME 750 MG IM, IV J0697

CEFUROXIME SODIUM STERILE 750 MG IM, IV J0697

CELESTONE SOLUSPAN 3 MG IM J0702

CELLCEPT 250 MG ORAL J7517

CENACORT A-40 10 MG IM J3301

CENACORT FORTE 5 MG IM J3302

CENTRUROIDES (SCORPION) IMMUNE F(AB)2 (EQUINE)

UP TO 120 MG

IV J0716

CEPHALOTHIN SODIUM UP TO 1 G INJ J1890

CEPHAPIRIN SODIUM 1 G IV J0710

CEPTAZ 500 MG IM, IV J0713

CEREBRYX 50 MG IM, IV Q2009

CEREBRYX 750 MG IM, IV S0078

CEREDASE 10 U IV J0205

CERETEC STUDY DOSE UP TO 25 MCI

IV A9521

CEREZYME 10 U IV J1786

CERTOLIZUMAB PEGOL 1 MG SC J0717

CERUBIDINE 10 MG IV J9150

CESAMET 1 MG ORAL J8650

CETUXIMAB 10 MG IV J9055

CHEALAMIDE 150 MG IV J3520

CHLORAMBUCIL 2 MG ORAL S0172

Drug Name Unit Per Route Code

Appendix 4 — Internet-only Manuals (IOMs) HCPCS Level II

104 — Appendixes © 2016 Optum360, LLC

App

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Teaching physicians submitting claims under this exception must:

• Not have other responsibilities (including the supervision of other personnel) at the time the service was provided by the resident;

• Have the primary medical responsibility for patients cared for by the residents;

• Ensure that the care provided was reasonable and necessary;

• Review the care provided by the resident during or immediately after each visit. This must include a review of the patient’s medical history, the resident’s findings on physical examination, the patient’s diagnosis, and treatment plan (i.e., record of tests and therapies); and

• Document the extent of his/her own participation in the review and direction of the services furnished to each patient.

Patients under this exception should consider the center to be their primary location for health care services. The residents must be expected to generally provide care to the same group of established patients during their residency training. The types of services furnished by residents under this exception include:

• Acute care for undifferentiated problems or chronic care for ongoingconditions including chronic mental illness;

• Coordination of care furnished by other physicians and providers; and,

• Comprehensive care not limited by organ system or diagnosis.

Residency programs most likely qualifying for this exception include family practice, general internal medicine, geriatric medicine, pediatrics, and obstetrics/gynecology.

Certain GME programs in psychiatry may qualify in special situations such as when the program furnishes comprehensive care for chronically mentally ill patients. These would be centers in which the range of services the residents are trained to furnish, and actually do furnish, include comprehensive medical care as well as psychiatric care. For example, antibiotics are being prescribed as well as psychotropic drugs.

100-04, 12, 180Care Plan Oversight ServicesThe Medicare Benefit Policy Manual, Chapter 15, contains requirements for coverage for medical and other health services including those of physicians and non-physician practitioners.

Care plan oversight (CPO) is the physician supervision of a patient receiving complex and/or multidisciplinary care as part of Medicare-covered services provided by a participating home health agency or Medicare approved hospice.

CPO services require complex or multidisciplinary care modalities involving: Regular physician development and/or revision of care plans; Review of subsequent reports of patient status; Review of related laboratory and other studies; Communication with other health professionals not employed in the same practice who are involved in the patient's care; Integration of new information into the medical treatment plan; and/or Adjustment of medical therapy.

The CPO services require recurrent physician supervision of a patient involving 30 or more minutes of the physician's time per month. Services not countable toward the 30 minutes threshold that must be provided in order to bill for CPO include, but are not limited to: Time associated with discussions with the patient, his or her family or friends to adjust medication or treatment; Time spent by staff getting or filing charts; Travel time; and/or Physician's time spent telephoning prescriptions into the pharmacist unless the telephone conversation involves discussions of pharmaceutical therapies.

Implicit in the concept of CPO is the expectation that the physician has coordinated an aspect of the patient's care with the home health agency or hospice during the month for which CPO services were billed. The physician who bills for CPO must be the same physician who signs the plan of care.

Nurse practitioners, physician assistants, and clinical nurse specialists, practicing within the scope of State law, may bill for care plan oversight. These non-physician practitioners must have been providing ongoing care for the beneficiary through evaluation and management services. These non-physician practitioners may not bill for CPO if they have been involved only with the delivery of the Medicare-covered home health or hospice service.

A. Home Health CPO Non-physician practitioners can perform CPO only if the physician signing the plan of care provides regular ongoing care under the same plan of care as does the NPP billing for CPO and either: The physician and NPP are part of the same group practice; or If the NPP is a nurse practitioner or clinical nurse specialist, the physician signing the plan of care also has a collaborative agreement with the NPP; or If the NPP is a physician assistant, the physician signing the plan of care is also the physician who provides general supervision of physician assistant services for the practice.

Billing may be made for care plan oversight services furnished by an NPP when: The NPP providing the care plan oversight has seen and examined the patient; The NPP

providing care plan oversight is not functioning as a consultant whose participation is limited to a single medical condition rather than multidisciplinary coordination of care; and The NPP providing care plan oversight integrates his or her care with that of the physician who signed the plan of care.

NPPs may not certify the beneficiary for home health care.

B. Hospice CPO The attending physician or nurse practitioner (who has been designated as the attending physician) may bill for hospice CPO when they are acting as an "attending physician".

An "attending physician" is one who has been identified by the individual, at the time he/she elects hospice coverage, as having the most significant role in the determination and delivery of their medical care. They are not employed nor paid by the hospice. The care plan oversight services are billed using Form CMS-1500 or electronic equivalent.

For additional information on hospice CPO, see Chapter 11, 40.1.3.1 of this manual.

100-04, 12, 180.1Care Plan Oversight Billing Requirements

A. Codes for Which Separate Payment May Be Made Effective January 1, 1995, separate payment may be made for CPO oversight services for 30 minutes or more if the requirements specified in the Medicare Benefits Policy Manual, Chapter 15 are met.

Providers billing for CPO must submit the claim with no other services billed on that claim and may bill only after the end of the month in which the CPO services were rendered. CPO services may not be billed across calendar months and should be submitted (and paid) only for one unit of service.

Physicians may bill and be paid separately for CPO services only if all the criteria in the Medicare Benefit Policy Manual, Chapter 15 are met.

B. Physician Certification and Recertification of Home Health Plans of Care Effective 2001, two new HCPCS codes for the certification and recertification and development of plans of care for Medicare-covered home health services were created.

See the Medicare General Information, Eligibility, and Entitlement Manual, Pub. 100-01, Chapter 4, “Physician Certification and Recertification of Services,” 10-60, and the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 7, “Home Health Services”, 30.

The home health agency certification code can be billed only when the patient has not received Medicare-covered home health services for at least 60 days. The home health agency recertification code is used after a patient has received services for at least 60 days (or one certification period) when the physician signs the certification after the initial certification period. The home health agency recertification code will be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.

C. Provider Number of Home Health Agency (HHA) or HospiceFor claims for CPO submitted on or after January 1, 1997, physicians must enter on the Medicare claim form the 6-character Medicare provider number of the HHA or hospice providing Medicare-covered services to the beneficiary for the period during which CPO services was furnished and for which the physician signed the plan of care. Physicians are responsible for obtaining the HHA or hospice Medicare provider numbers.

Additionally, physicians should provide their UPIN to the HHA or hospice furnishing services to their patient.

NOTE: There is currently no place on the HIPAA standard ASC X12N 837 professional format to specifically include the HHA or hospice provider number required for a care plan oversight claim. For this reason, the requirement to include the HHA or hospice provider number on a care plan oversight claim is temporarily waived until a new version of this electronic standard format is adopted under HIPAA and includes a place to provide the HHA and hospice provider numbers for care plan oversight claims.

100-04, 12, 190.3List of Medicare Telehealth ServicesThe use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services. The various services and corresponding current procedure terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes are listed below.

• Consultations (CPT codes 99241 - 99275) - Effective October 1, 2001 – December31, 2005;

HCPCS Level II Appendix 8 — Glossary

© 2016 Optum360, LLC Appendixes — 191

Appendix 8 —

Glossary

ocular implant. Implant inside muscular cone.

omnicardiogram. Method of mathematically interpreting the usual linear form of the electrocardiogram in a different, roughly circular shape. This interpretation is then compared to a normal template and an analysis is performed on two randomly selected cycles from leads I, II, V4, V, and/or V6.

oral. Pertaining to the mouth.

ordering physician. Physician who orders nonphysician services (e.g., laboratory services, pharmaceutical services, imaging services, or durable medical equipment) for a patient.

orphan drugs. Drugs that treat diseases that affect fewer than 200,000 people in the United States, as designated by the FDA. Orphan drugs follow a varied process from other drugs regulated by the FDA.

orthosis. Derived from a Greek word meaning "to make straight," it is an artificial appliance that supports, aligns, or corrects an anatomical deformity or improves the use of a moveable body part. Unlike a prosthesis, an orthotic device is always functional in nature.

orthotic. Associated with the making and fitting of an orthosis(es).

osteo-. Having to do with bone.

osteogenesis stimulator. Device used to stimulate the growth of bone by electrical impulses or ultrasound.

ostomy. Artificial (surgical) opening in the body used for drainage or for delivery of medications or nutrients.

pacemaker. Implantable cardiac device that controls the heart's rhythm and maintains regular beats by artificial electric discharges. This device consists of the pulse generator with a battery and the electrodes, or leads, which are placed in single or dual chambers of the heart, usually transvenously.

parenteral. Other than the alimentary canal and is usually used in a method of delivery context: total parenteral nutrition (TPN) and parenteral nutrition therapy (PNT) formulas, kits, and devices.

parenteral nutrition. Nutrients provided subcutaneously, intravenously, intramuscularly, or intradermally for patients during the postoperative period and in other conditions, such as shock, coma, and renal failure.

partial hospitalization. Situation in which the patient only stays part of each day over a long period. Cardiac, rehabilitation, and chronic pain patients, for example, could use this service.

passive mobilization. Pressure, movement, or pulling of a limb or body part utilizing an apparatus or device.

periradicular. Surrounding part of the tooth's root.

peritoneal. Space between the lining of the abdominal wall, or parietal peritoneum, and the surface layer of the abdominal organs, or visceral peritoneum. It contains a thin, watery fluid that keeps the peritoneal surfaces moist.

peritoneal dialysis. Dialysis that filters waste from blood inside the body using the peritoneum, the natural lining of the abdomen, as the semipermeable membrane across which ultrafiltration is accomplished. A special catheter is inserted into the abdomen and a dialysis solution is drained into the abdomen. This solution extracts fluids and wastes, which are then discarded when the fluid is drained. Various forms of peritoneal dialysis include CAPD, CCPD, and NIDP.

peritoneal effusion. Persistent escape of fluid within the peritoneal cavity.

pessary. Device placed in the vagina to support and reposition a prolapsing or retropositioned uterus, rectum, or vagina.

photocoagulation. Application of an intense laser beam of light to disrupt tissue and condense protein material to a residual mass, used especially for treating ocular conditions.

physician. Legally authorized practitioners including a doctor of medicine or osteopathy, a doctor of dental surgery or of dental medicine, a doctor of podiatric medicine, a doctor of optometry, and a chiropractor only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation).

PICC. Peripherally inserted central catheter. PICC is inserted into one of the large veins of the arm and threaded through the vein until the tip sits in a large vein just above the heart.

PQRS. Physician Quality Reporting System. Voluntary CMS reporting mechanism used to measure physician quality that will be mandatory as of January 1, 2015. Eligible providers submit quality data for set measures through approved reporting options.

prehensile. Ability to grasp, seize, or hold.

prodrug. Inactive drug that goes through a metabolic process when given resulting in a chemical conversion that changes the drug into an active pharmacological agent.

prophylaxis. Intervention or protective therapy intended to prevent a disease.

prostate cancer screening tests. Test that consists of any (or all) of the procedures provided for the early detection of prostate cancer to a man 50 years of age or older who has not had a test during the preceding year. The procedures are as follows: A digital rectal examination; A prostate-specific antigen blood test. After 2002, the list of procedures may be expanded as appropriate for the early detection of prostate cancer, taking into account changes in technology and standards of medical practice, availability, effectiveness, costs, and other factors.

prosthetic. Device that replaces all or part of an internal body organ or body part, or that replaces part of the function of a permanently inoperable or malfunctioning internal body organ or body part.

pulse generator. Component of a pacemaker or an implantable cardioverter defibrillator that contains the battery and the electronics for producing the electrical discharge sent to the heart to control cardiac rhythm. Insertion or replacement of the pulse generator may be done alone, not in conjunction with insertion or replacement of the entire pacemaker system.

residual limb. Portion of an arm or leg that remains attached to the body after an amputation.

screening mammography. Radiologic images taken of the female breast for the early detection of breast cancer.

screening pap smear. Diagnostic laboratory test consisting of a routine exfoliative cytology test (Papanicolaou test) provided to a woman for the early detection of cervical or vaginal cancer. The exam includes a clinical breast examination and a physician's interpretation of the results.

sialodochoplasty. Surgical repair of a salivary gland duct.

single-lead device. Implantable cardiac device (pacemaker or implantable cardioverter-defibrillator [ICD]) in which pacing and sensing components are placed in only one chamber of the heart.

skin substitute. Non-autologous human or non-human skin that forms a base for skin growth, often considered a graft dressing.

speech prosthetic. Electronic speech aid device for patient who has had a laryngectomy. One operates by placing a vibrating head against the throat; the other amplifies sound waves through a tube which is inserted into the user's mouth.

splint. Brace or support. 1) dynamic splint: brace that permits movement of an anatomical structure such as a hand, wrist, foot, or other part of the body after surgery or injury. 2) static splint: brace that prevents movement and maintains support and position for an anatomical structure after surgery or injury.

stent. Tube to provide support in a body cavity or lumen.

stereotactic radiosurgery. Delivery of externally-generated ionizing radiation to specific targets for destruction or inactivation. Most often utilized in the treatment of brain or spinal tumors, high-resolution stereotactic imaging is used to identify the target and then deliver the treatment. Computer-assisted planning may also be employed. Simple and complex cranial lesions and spinal lesions are typically treated in a single planning and treatment session, although a maximum of five sessions may be required. No incision is made for stereotactic radiosurgery procedures.

subcutaneous. Below the skin.

TENS. Transcutaneous electrical nerve stimulator. TENS is applied by placing electrode pads over the area to be stimulated and connecting the electrodes to a transmitter box, which sends a current through the skin to sensory nerve fibers to help decrease pain in that nerve distribution.

terminal device. Addition to an upper limb prosthesis that replaces the function and/or appearance of a missing hand.

TLSO. Thoracolumbosacral orthosis.

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