all procedures carved out of apgs (individual codes carved ... · apg description all procedures...

All Procedures Carved out of APGs (individual codes carved out & codes that group to carved out APGs) Inclusion on this list indicates that service should not be billed using APGs; it does not guarantee alternative payment. See codes removed from the Carve out list below.

*The following optional carved-out procedures may be billed as ordered ambulatory services when an APG visit is not billed for the clinic patient on the same date of service. Effective Date

Alternative Payment Source/Notes

*J1055 Medrxyprogester acetate inj 435 Class I Pharmacotherapy Procedure carve out 9/1/2008 Ordered Ambulatory Fee Schedule

*86580 TB intradermal test 394 Level I Immunology Tests Procedure carve out 4/1/2010 Laboratory Fee Schedule

*81025 Urine pregnancy test 410 Urinalysis Procedure carve out 9/1/2008 Laboratory Fee Schedule

Select rate codes carved out of the APG reimbursement methodology: 1604, 1695, 1802, 1850, 2961, 2983, 3107, 3109, 3111, 3139. See list of subsumed rate codes for a complete list of rate codes carved out of the APG reimbursement methodology.

HCPCS Description APG APG Description v3.5 APG v3.5 APG Description Carve out Type Effective

Date 58565 Hysteroscopy, sterilization 200 HYSTEROSCOPY 200 HYSTEROSCOPY Procedure carve out 1/1/2011

83655 Lead screen 404 Toxicology Tests 404 Toxicology Tests Procedure carve out 1/1/2010 83890 Molecule isolate 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83891 Molecule isolate nucleic 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 83892 Molecular diagnostics 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

8389383893 Molecule dot/slot/blot Molecule dot/slot/blot 395395 Level II Immunology Tests Level II Immunology Tests 395395 Level II Immunology Tests Level II Immunology Tests Procedure carve out Procedure carve out 1/1/20101/1/2010

83894 Molecule gel electrophor 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83896 Molecular diagnostics 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83897 Molecule nucleic transfer 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83898 Molecule nucleic ampli, each 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83900 Molecule nucleic ampli 2 seq 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83901 Molecule nucleic ampli addon 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83902 Molecular diagnostics 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83903 Molecule mutation scan 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83904 Molecule mutation identify 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 83905 Molecule mutation identify 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 83906 Molecule mutation identify 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83907 Lyse cells for nucleic ext 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

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Date 83908 Nucleic acid, signal ampli 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83909 Nucleic acid, high resolute 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010

83912 Genetic examination 400 Level I Chemistry Tests 400 Level I Chemistry Tests Procedure carve out 1/1/2010

83913 Molecular, rna stabilization 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 83914 Mutation ident ola/sbce/aspe 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 85004 Automated diff wbc count 408 Level I Hematology Tests 408 Level I Hematology Tests Procedure carve out 1/1/2010 85610 Prothrombin time 406 Level I Clotting Tests 406 Level I Clotting Tests Procedure carve out 1/1/2010 87536 HIV viral load testing 397 Level II Microbiology Tests 397 Level II Microbiology Tests Procedure carve out 1/1/2010 87900 Virtual phenotype 397 Level II Microbiology Tests 397 Level II Microbiology Tests Procedure carve out 1/1/2010 87901 HIV genotype, drug resistance test 393 Blood And Tissue Typing 393 Blood And Tissue Typing Procedure carve out 1/1/2010 87902 Hepatitis C virus, genotype test 397 Level II Microbiology Tests 397 Level II Microbiology Tests Procedure carve out 1/1/2010 87903 HIV drug resistance 393 Blood And Tissue Typing 393 Blood And Tissue Typing Procedure carve out 1/1/2010 87904 Phenotype, dna hiv w/clt add 393 Blood And Tissue Typing 393 Blood And Tissue Typing Procedure carve out 1/1/2010 87999 Microbiology procedure 396 Level I Microbiology Tests 396 Level I Microbiology Tests Procedure carve out 1/1/2010 88230 Tissue culture, lymphocyte 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88233 Tissue culture, skin/biopsy 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88235 Tissue culture, placenta 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88237 Tissue culture, bone marrow 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88239 Tissue culture, tumor 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88240 Cell cryopreserve/storage 390 Level I Pathology 390 Level I Pathology Procedure carve out 1/1/2010 8824188241 F ll iFrozen cell preparation 390390 L l I P h lLevel I Pathology 390390 L l I P h lLevel I Pathology P dProcedure carve out 1/1/20101/1/2010 88245 Chromosome analysis, 20-25 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88248 Chromosome analysis, 50-100 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88249 Chromosome analysis, 100 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 88261 Chromosome analysis, 5 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88262 Chromosome analysis, 15-20 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88263 Chromosome analysis, 45 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88264 Chromosome analysis, 20-25 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 88267 Chromosome analys, placenta 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88269 Chromosome analys, amniotic 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88271 Cytogenetics, dna probe 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 88272 Cytogenetics, 3-5 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 88273 Cytogenetics, 10-30 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 88274 Cytogenetics, 25-99 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 88275 Cytogenetics, 100-300 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 88280 Chromosome karyotype study 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88283 Chromosome banding study 391 Level II Pathology 391 Level II Pathology Procedure carve out 1/1/2010 88285 Chromosome count, additional 390 Level I Pathology 390 Level I Pathology Procedure carve out 1/1/2010 88289 Chromosome study, additional 390 Level I Pathology 390 Level I Pathology Procedure carve out 1/1/2010 88291 Cyto/molecular report 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 90470 Immune admin H1N1 im/nasal 414 Level I Immunization And Allergy 414 Level I Immunization And Allergy Procedure carve out 9/1/2009 90473 Immune admin oral/nasal 490 Incidental To Medical, Significant 490 Incidental To Medical, Significant Procedure carve out 9/1/2009 90655 Flu vaccine no preserv 6-35m 414 Level I Immunization And Allergy 414 Level I Immunization And Allergy Procedure carve out 9/1/2009

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Date 90656 Flu vaccine no preserv 3 & > 414 Level I Immunization And Allergy 414 Level I Immunization And Allergy Procedure carve out 9/1/2009 90657 Flu vaccine, 3 yrs, im 414 Level I Immunization And Allergy 414 Level I Immunization And Allergy Procedure carve out 9/1/2009 90658 Flu vaccine, 3 yrs & >, im 414 Level I Immunization And Allergy 414 Level I Immunization And Allergy Procedure carve out 9/1/2009 90660 Flu vaccine, nasal 414 Level I Immunization And Allergy 414 Level I Immunization And Allergy Procedure carve out 9/1/2009 90663 Flu vacc pandemic 414 Level I Immunization And Allergy 414 Level I Immunization And Allergy Procedure carve out 9/1/2009 90669 Pneumococcal vacc, ped <5 415 Level II Immunization 415 Level II Immunization Procedure carve out 9/1/2009 90732 Pneumococcal vaccine 414 Level I Immunization And Allergy 414 Level I Immunization And Allergy Procedure carve out 9/1/2009 B4164 Parenteral 50% dextrose solu 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B4168 Parenteral sol amino acid 3. 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B4172 Parenteral sol amino acid 5. 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B4176 Parenteral sol amino acid 7- 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B4178 Parenteral sol amino acid > 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B4180 Parenteral sol carb > 50% 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B4185 Parenteral sol 10 gm lipids 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B4189 Parenteral sol amino acid & 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008

B4193 Parenteral sol 52-73 gm prot 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008

B4197 Parenteral sol 74-100 gm pro 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008

B4199 Parenteral sol > 100gm prote 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008

B4216 Parenteral nutrition additiv 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008

B4220 B4220 Parenteral supply kit premix Parenteral supply kit premix 454454 Tpn Formulae Tpn Formulae 454454 Tpn Formulae Tpn Formulae APG carve out APG carve out 12/1/200812/1/2008

B4222 Parenteral supply kit homemi 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008

B4224 Parenteral administration ki 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B5000 Parenteral sol renal-amirosy 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008

B5100 Parenteral sol hepatic-fream 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B5200 Parenteral sol stres-brnch c 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B9000 Enter infusion pump w/o alrm 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B9002 Enteral infusion pump w/ ala 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B9004 Parenteral infus pump portab 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B9006 Parenteral infus pump statio 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B9998 Enteral supp not otherwise c 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 B9999 Parenteral supp not othrws c 454 Tpn Formulae 454 Tpn Formulae APG carve out 12/1/2008 C9259 Injection, pralatrexate, 1 mg 432 Class III Chemotherapy Drugs 463 CLASS XI COMBINED Procedure carve out 1/1/2011 D7650 Open red simp malar/zygom fx 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8050 Intercep dental tx primary 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8060 Intercep dental tx transitn 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8070 Compre dental tx transition 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8080 Compre dental tx adolescent 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8090 Compre dental tx adult 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8210 Orthodontic rem appliance tx 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008

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Date D8660 Preorthodontic tx visit 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8670 Periodic orthodontc tx visit 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8680 Orthodontic retention 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8690 Orthodontic treatment 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8692 Replacement retainer 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 D8999 Orthodontic procedure 371 Orthodontics 371 Orthodontics APG carve out 12/1/2008 E1220 Whlchr special size/constrc 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 E2227 Gear reduction drive wheel 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 E2228 Mwc acc, wheelchair brake 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 E2300 Pwr seat elevation sys 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2301 Pwr standing 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2310 Electro connect btw control 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2311 Electro connect btw 2 sys 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2312 Mini-prop remote joystick 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 E2313 PWC harness, expand control 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 E2321 Hand interface joystick 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2322 Mult mech switches 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2323 Special joystick handle 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2324 Chin cup interface 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2325 Sip and puff interface 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2326 Breath tube kit 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2327 Head control interface mech 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2328 Head/extremity control inter 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2329 Head control nonproportional 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2330 Head control proximity switc 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2331 Attendant control 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2340 W/c wdth 20-23 in seat frame 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2341 W/c wdth 24-27 in seat frame 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2342 W/c dpth 20-21 in seat frame 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2343 W/c dpth 22-25 in seat frame 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2351 Electronic SGD interface 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2360 22nf nonsealed leadacid 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2361 22nf sealed leadacid battery 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2362 Gr24 nonsealed leadacid 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2363 Gr24 sealed leadacid battery 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2364 U1nonsealed leadacid battery 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2365 U1 sealed leadacid battery 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2366 Battery charger, single mode 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2367 Battery charger, dual mode 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2368 Power wc motor replacement 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2369 Pwr wc gear box replacement 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2370 Pwr wc motor/gear box combo 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2371 Gr27 sealed leadacid battery 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

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Date E2372 Gr27 non-sealed leadacid 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2373 Hand/chin ctrl spec joystick 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2374 Hand/chin ctrl std joystick 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2375 Non-expandable controller 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2376 Expandable controller, repl 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2377 Expandable controller, initl 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2381 Pneum drive wheel tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2382 Tube, pneum wheel drive tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2383 Insert, pneum wheel drive 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2384 Pneumatic caster tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2385 Tube, pneumatic caster tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2386 Foam filled drive wheel tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2387 Foam filled caster tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2388 Foam drive wheel tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2389 Foam caster tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2390 Solid drive wheel tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2391 Solid caster tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2392 Solid caster tire, integrate 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2394 Drive wheel excludes tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2395 Caster wheel excludes tire 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008 E2396 Caster fork 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

E2397 Pwc acc, lith-based battery 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 G0008 Admin influenza virus vac 490 Incidental To Medical, Significant

Procedure Or Therapy Visit 490 Incidental To Medical, Significant

Procedure Or Therapy Visit Procedure carve out 9/1/2009

G0009 Admin pneumococcal vaccine 490 Incidental To Medical, Significant 490 Incidental To Medical, Significant Procedure carve out 9/1/2009 J0128 Abarelix injection 434 Class V Chemotherapy Drugs 461 CLASS IX COMBINED procedure carve out 12/1/2008 J0135 Adalimumab injection 433 Class IV Chemotherapy Drugs 441 CLASS VI CHEMOTHERAPY APG carve out 12/1/2008 J0180 Agalsidase beta injection 442 Class VII Combined 464 CLASS XII COMBINED APG carve out 12/1/2008 J0207 Amifostine 433 Class IV Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J0365 Aprotonin, 10,000 kiu 434 Class V Chemotherapy Drugs 461 CLASS IX COMBINED procedure carve out 12/1/2008 J0480 Basiliximab 433 Class IV Chemotherapy Drugs 460 CLASS VIII COMBINED procedure carve out 12/1/2008 J0585 Botulinum toxin a per unit 438 Class IV Pharmacotherapy 439 CLASS V PHARMACOTHERAPY Procedure carve out 12/1/2008 J0587 Botulinum toxin type B 436 Class II Pharmacotherapy 439 CLASS V PHARMACOTHERAPY Procedure carve out 12/1/2008

J0640 Leucovorin calcium injection 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008

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J1300

HCPCS J0641

J0740

J0795

J0878 J0882 J0886 J1190

J1325 J1327 J1440 J1441 J1451

J1457 J1458 J1566 J1620 J1626J1626

J1675 J1742 J1785 J1825 J1931 J1945 Lepirudin J1950 Leuprolide acetate /3.75 MG J2278 Ziconotide injection J2323 Natalizumab injection J2425 Palifermin injection J2430 Pamidronate disodium /30 MG J2469 Palonosetron hcl J2504 Pegademase bovine, 25 iu J2505 Injection, pegfilgrastim 6mg J2513 Pentastarch 10% solution J2562 Injection, plerixafor, 1 mg J2770 Quinupristin/dalfopristin J2794 Risperidone, long acting J2805 Sincalide injection J2997 Alteplase recombinant J3110 Teriparatide injection

Eculizumab injection

Description Levoleucovorin injection

Cidofovir injection

Corticorelin ovine triflutal

Daptomycin injection Darbepoetin alfa, esrd use Epoetin alfa 1000 units ESRD Dexrazoxane HCl injection

Epoprostenol injection Eptifibatide injection Filgrastim 300 mcg injection Filgrastim 480 mcg injection Fomepizole, 15 mg

Gallium nitrate injection Galsulfase injection Immune globulin, powder Gonadorelin hydroch/ 100 mcg Granisetron hcl injectionGranisetron hcl injection

Histrelin acetate Ibutilide fumarate injection Injection imiglucerase /unit Interferon beta-1a Laronidase injection

442

APG 431

432

433

431 432 431 431

430 432 437 437 433

433 442 433 430 431431

434 432 442 431 434 431 434 441 439 433 431 431 431 439 431 437 430 436 430 437 434

Class VII Combined Chemotherapy & Pharmacotherapy

APG Description Class II Chemotherapy Drugs

Class III Chemotherapy Drugs

Class IV Chemotherapy Drugs

Class II Chemotherapy Drugs Class III Chemotherapy Drugs Class II Chemotherapy Drugs Class II Chemotherapy Drugs

Class I Chemotherapy Drugs Class III Chemotherapy Drugs Class III Pharmacotherapy Class III Pharmacotherapy Class IV Chemotherapy Drugs

Class IV Chemotherapy Drugs Class VII Combined Class IV Chemotherapy Drugs Class I Chemotherapy Drugs Class II Chemotherapy DrugsClass II Chemotherapy Drugs

Class V Chemotherapy Drugs Class III Chemotherapy Drugs Class VII Combined Class II Chemotherapy Drugs Class V Chemotherapy Drugs Class II Chemotherapy Drugs Class V Chemotherapy Drugs Class VI Chemotherapy Drugs Class V Pharmacotherapy Class IV Chemotherapy Drugs Class II Chemotherapy Drugs Class II Chemotherapy Drugs Class II Chemotherapy Drugs Class V Pharmacotherapy Class II Chemotherapy Drugs Class III Pharmacotherapy Class I Chemotherapy Drugs Class II Pharmacotherapy Class I Chemotherapy Drugs Class III Pharmacotherapy Class V Chemotherapy Drugs

465

v3.5 APG 433

460

434

433 439 439 434

430 431 438 438 443

443 464 462 430 430430

460 441 465 432 464 432 443 430 461 441 438 432 433 462 432 463 432 438 431 436 461

CLASS XIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

v3.5 APG Description CLASS IV CHEMOTHERAPY DRUGS CLASS VIII COMBINED CHEMOTHERAPY AND CLASS V CHEMOTHERAPY DRUGS CLASS IV CHEMOTHERAPY CLASS V PHARMACOTHERAPY CLASS V PHARMACOTHERAPY CLASS V CHEMOTHERAPY DRUGS

CLASS I CHEMOTHERAPY CLASS II CHEMOTHERAPY CLASS IV PHARMACOTHERAPY CLASS IV PHARMACOTHERAPY CLASS VII CHEMOTHERAPY DRUGS CLASS VII CHEMOTHERAPY CLASS XII COMBINEDCLASS X COMBINED CLASS I CHEMOTHERAPY CLASS I CHEMOTHERAPYCLASS I CHEMOTHERAPY DRUGS CLASS VIII COMBINED CLASS VI CHEMOTHERAPY CLASS XIII COMBINED CLASS III CHEMOTHERAPY CLASS XII COMBINED CLASS III CHEMOTHERAPY CLASS VII CHEMOTHERAPY CLASS I CHEMOTHERAPY CLASS IX COMBINED CLASS VI CHEMOTHERAPY CLASS IV PHARMACOTHERAPY CLASS III CHEMOTHERAPY CLASS IV CHEMOTHERAPY CLASS X COMBINED CLASS III CHEMOTHERAPY CLASS XI COMBINED CLASS III CHEMOTHERAPY CLASS IV PHARMACOTHERAPY CLASS II CHEMOTHERAPY CLASS II PHARMACOTHERAPY CLASS IX COMBINED

APG carve out

Carve out Type APG carve out

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APG carve out

APG carve out APG carve Now a APG carve Now a APG carve out

APG carve out APG carve out Procedure carve out Procedure carve out APG carve out

APG carve out

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carve out procedure carve out APG carve out APG car outAPG carvvee out

procedure carve out APG carve out APG carve out APG carve out procedure carve out APG carve out APG carve out APG carve out Procedure carve out -APG carve out APG carve out APG carve out APG carve out Procedure carve out APG carve out Procedure carve out APG carve out Procedure carve out -APG carve out Procedure carve out procedure carve out

1/1/2010

Effective Date

1/1/2009

12/1/2008

12/1/2008

12/1/2008 12/1/2008 12/1/2008 12/1/2008

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008

12/1/2008 1/1/2010 12/1/2008 12/1/2008 12/1/200812/1/2008

12/1/2008 12/1/2008 1/1/2010

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2010

12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 12/1/2008 1/1/2011

12/1/2008 4/1/2009

12/1/2008 1/1/2010

12/1/2008

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Date J3246 Tirofiban HCl 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J3285 Treprostinil injection 432 Class III Chemotherapy Drugs 461 CLASS IX COMBINED procedure carve out 12/1/2008 J3315 Triptorelin pamoate 433 Class IV Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J3396 Verteporfin injection 433 Class IV Chemotherapy Drugs 443 CLASS VII CHEMOTHERAPY APG carve out 12/1/2008 J3487 Zoledronic acid 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J3490 Drugs unclassified injection 435 Class I Pharmacotherapy 435 CLASS I PHARMACOTHERAPY Procedure carve out 4/1/2010 J3590 Unclassified biologics 435 Class I Pharmacotherapy 435 CLASS I PHARMACOTHERAPY Procedure carve out 4/1/2010 J7187 Humate-P, inj 438 Class IV Pharmacotherapy 460 CLASS VIII COMBINED

CHEMOTHERAPY AND PHARMACOTHERAPY

Procedure carve out 12/1/2008

J7189 Factor viia 438 Class IV Pharmacotherapy 465 CLASS XIII COMBINED Procedure carve out 12/1/2008 J7190 Factor viii 439 Class V Pharmacotherapy 465 CLASS XIII COMBINED

CHEMOTHERAPY AND Procedure carve out 12/1/2008

J7191 Factor VIII (porcine) 439 Class V Pharmacotherapy 465 CLASS XIII COMBINED Procedure carve out 12/1/2008 J7192 Factor viii recombinant 439 Class V Pharmacotherapy 465 CLASS XIII COMBINED Procedure carve out 12/1/2008 J7193 Factor IX non-recombinant 439 Class V Pharmacotherapy 465 CLASS XIII COMBINED Procedure carve out 12/1/2008 J7194 Factor ix complex 437 Class III Pharmacotherapy 465 CLASS XIII COMBINED Procedure carve out 12/1/2008 J7195 Factor IX recombinant 439 Class V Pharmacotherapy 465 CLASS XIII COMBINED Procedure carve out 12/1/2008 J7197 Antithrombin iii injection 436 Class II Pharmacotherapy 438 CLASS IV PHARMACOTHERAPY Procedure carve out 12/1/2008

J7198 Anti-inhibitor 439 Class V Pharmacotherapy 460 CLASS VIII COMBINED Procedure carve out 12/1/2008 J7199 Hemophilia clot factor noc 436 Class II Pharmacotherapy 437 CLASS III PHARMACOTHERAPY Procedure carve out 12/1/2008 J7300 Intraut copper contraceptive 490 Incidental To Medical, Significant 490 Incidental To Medical, Significant Procedure carve out 12/1/2008 J7302 Levonorgestrel iu contracept 436 Class II Pharmacotherapy 439 CLASS V PHARMACOTHERAPY Procedure carve out 12/1/2008 J7307J7307 Et l i lEtonogestrel implant system 436436 Cl II Ph thClass II Pharmacotherapy 439439 CLASS V PHARMACOTHERAPY CLASS V PHARMACOTHERAPY P dProcedure carve out 12/1/200812/1/2008 J7501 Azathioprine parenteral 433 Class IV Chemotherapy Drugs 431 CLASS II CHEMOTHERAPY APG carve out 12/1/2008 J7504 Lymphocyte immune globulin 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J7505 Monoclonal antibodies 433 Class IV Chemotherapy Drugs 443 CLASS VII CHEMOTHERAPY APG carve out 12/1/2008 J7520 Sirolimus, oral 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY APG carve out 12/1/2008 J8498 Antiemetic rectal/supp NOS 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J8501 Oral aprepitant 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY APG carve out 12/1/2008 J8510 Oral busulfan 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J8515 Cabergoline, oral 0.25mg 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY

DRUGS APG carve out 12/1/2008

J8520 Capecitabine, oral, 150 mg 432 Class III Chemotherapy Drugs 461 CLASS IX COMBINED procedure carve out 12/1/2008 J8521 Capecitabine, oral, 500 mg 433 Class IV Chemotherapy Drugs 443 CLASS VII CHEMOTHERAPY APG carve out 12/1/2008 J8530 Cyclophosphamide oral 25 MG 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J8540 Oral dexamethasone 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J8560 Etoposide oral 50 MG 431 Class II Chemotherapy Drugs 433 CLASS IV CHEMOTHERAPY APG carve out 12/1/2008 J8565 Gefitinib oral 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J8597 Antiemetic drug oral NOS 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J8600 Melphalan oral 2 MG 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J8610 Methotrexate oral 2.5 MG 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J8650 Nabilone oral 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J8700 Temozolomide 432 Class III Chemotherapy Drugs 433 CLASS IV CHEMOTHERAPY APG carve out 12/1/2008 J8705 Topotecan oral 433 Class IV Chemotherapy Drugs 443 CLASS VII CHEMOTHERAPY APG carve out 12/1/2008

page 7 of 14


Date J9000 Doxorubicin hcl injection 431 Class II Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9001 Doxorubicin hcl liposome inj 434 Class V Chemotherapy Drugs 462 CLASS X COMBINED procedure carve out 12/1/2008 J9010 Alemtuzumab injection 434 Class V Chemotherapy Drugs 443 CLASS VII CHEMOTHERAPY


J9015 Aldesleukin injection 432 Class III Chemotherapy Drugs 441 CLASS VI CHEMOTHERAPY APG carve out 12/1/2008 J9017 Arsenic trioxide injection 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY


J9020 Asparaginase injection 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY APG carve out 12/1/2008 J9025 Azacitidine injection 433 Class IV Chemotherapy Drugs 441 CLASS VI CHEMOTHERAPY APG carve out 12/1/2008 J9027 Clofarabine injection 433 Class IV Chemotherapy Drugs 465 CLASS XIII COMBINED APG Carve out 12/1/2008 J9031 Bcg live intravesical vac 431 Class II Chemotherapy Drugs 431 CLASS II CHEMOTHERAPY APG carve out 12/1/2008 J9033 Bendamustine injection 441 Class VI Chemotherapy Drugs 462 CLASS X COMBINED procedure carve out 1/1/2010 J9035 Bevacizumab injection 441 Class VI Chemotherapy Drugs 461 CLASS IX COMBINED procedure carve out 1/1/2010 J9040 Bleomycin sulfate injection 431 Class II Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9041 Bortezomib injection 433 Class IV Chemotherapy Drugs 443 CLASS VII CHEMOTHERAPY APG carve out 12/1/2008 J9045 Carboplatin injection 432 Class III Chemotherapy Drugs 431 CLASS II CHEMOTHERAPY APG carve out 12/1/2008 J9050 Carmustine injection 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J9055 Cetuximab injection 441 Class VI Chemotherapy Drugs 461 CLASS IX COMBINED procedure carve out 1/1/2010 J9060 Cisplatin 10 MG injection 431 Class II Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9062 Cisplatin 50 MG injection 431 Class II Chemotherapy Drugs 431 CLASS II CHEMOTHERAPY APG carve out 12/1/2008 J9065 Inj cladribine per 1 MG 432 Class III Chemotherapy Drugs 433 CLASS IV CHEMOTHERAPY APG carve out 12/1/2008 J9070 Cyclophosphamide 100 MG inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9080 Cyclophosphamide 200 MG inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9090 Cyclophosphamide 500 MG inj 431 Class II Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9091 Cyclophosphamide 1.0 grm inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY


J9092 Cyclophosphamide 2.0 grm inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS

APG carve out 12/1/2008

J9093 Cyclophosphamide lyophilized 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9094 Cyclophosphamide lyophilized 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY


J9095 Cyclophosphamide lyophilized 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9096 Cyclophosphamide lyophilized 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9097 Cyclophosphamide lyophilized 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9098 Cytarabine liposome inj 434 Class V Chemotherapy Drugs 464 CLASS XII COMBINED procedure carve out 12/1/2008 J9100 Cytarabine hcl 100 MG inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9110 Cytarabine hcl 500 MG inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9120 Dactinomycin injection 433 Class IV Chemotherapy Drugs 461 CLASS IX COMBINED procedure carve out 12/1/2008 J9130 Dacarbazine 100 mg inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY


J9140 Dacarbazine 200 MG inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS


J9150 Daunorubicin injection 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY DRUGS


page 8 of 14


Date J9151 Daunorubicin citrate inj 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY


J9155 Degarelix injection 434 Class V Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY DRUG APG carve out 1/1/2010

J9160 Denileukin diftitox inj 434 Class V Chemotherapy Drugs 463 CLASS XI COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY

procedure carve out 12/1/2008

J9171 Docetaxel injection 432 Class III Chemotherapy Drugs 443 CLASS VII CHEMOTHERAPY DRU APG carve out 1/1/2010 J9178 Inj, epirubicin hcl, 2 mg 433 Class IV Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY


J9181 Etoposide injection 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9185 Fludarabine phosphate inj 432 Class III Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY


J9190 Fluorouracil injection 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS


J9200 Floxuridine injection 432 Class III Chemotherapy Drugs 431 CLASS II CHEMOTHERAPY DRUGS


J9201 Gemcitabine hcl injection 433 Class IV Chemotherapy Drugs 443 CLASS VII CHEMOTHERAPY APG carve out 12/1/2008 J9202 Goserelin acetate implant 432 Class III Chemotherapy Drugs 433 CLASS IV CHEMOTHERAPY


J9206 Irinotecan injection 433 Class IV Chemotherapy Drugs 433 CLASS IV CHEMOTHERAPY APG carve out 12/1/2008 J9207 Ixabepilone injection 432 Class III Chemotherapy Drugs 463 CLASS XI COMBINED procedure carve out 12/1/2008 J9208 Ifosfomide injection j 432 Class III Chemotherapy Drugs py g 432 CLASS III CHEMOTHERAPY APG carve out 12/1/2008 J9209 Mesna injection 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY APG carve out 12/1/2008 J9211 Idarubicin hcl injection 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY APG carve out 12/1/2008 J9212 Interferon alfacon-1 inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9213 Interferon alfa-2a inj 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J9214 Interferon alfa-2b inj 432 Class III Chemotherapy Drugs 433 CLASS IV CHEMOTHERAPY APG carve out 12/1/2008 J9215 Interferon alfa-n3 inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9216 Interferon gamma 1-b inj 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J9217 Leuprolide acetate suspnsion 434 Class V Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J9218 Leuprolide acetate injeciton 434 Class V Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9219 Leuprolide acetate implant 434 Class V Chemotherapy Drugs 463 CLASS XI COMBINED procedure carve out 12/1/2008 J9225 Vantas implant 434 Class V Chemotherapy Drugs 460 CLASS VIII COMBINED procedure carve out 12/1/2008 J9230 Mechlorethamine hcl inj 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY APG carve out 12/1/2008 J9245 Inj melphalan hydrochl 50 MG 441 Class VI Chemotherapy Drugs 460 CLASS VIII COMBINED procedure carve out 1/1/2010 J9250 Methotrexate sodium inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9260 Methotrexate sodium inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9261 Nelarabine injection 434 Class V Chemotherapy Drugs 441 CLASS VI CHEMOTHERAPY APG carve out 12/1/2008 J9263 Oxaliplatin 441 Class VI Chemotherapy Drugs 461 CLASS IX COMBINED

CHEMOTHERAPY AND PHARMACOTHERAPY


J9264 Paclitaxel protein bound 433 Class IV Chemotherapy Drugs 461 CLASS IX COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY


J9265 Paclitaxel injection 432 Class III Chemotherapy Drugs 431 CLASS II CHEMOTHERAPY APG carve out 12/1/2008

page 9 of 14


Date J9266 Pegaspargase injection 441 Class VI Chemotherapy Drugs 462 CLASS X COMBINED procedure carve out 1/1/2010 J9268 Pentostatin injection 434 Class V Chemotherapy Drugs 463 CLASS XI COMBINED procedure carve out 12/1/2008 J9270 Plicamycin (mithramycin) inj 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J9280 Mitomycin 5 MG inj 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY APG carve out 12/1/2008 J9290 Mitomycin 20 MG inj 431 Class II Chemotherapy Drugs 433 CLASS IV CHEMOTHERAPY APG carve out 12/1/2008 J9291 Mitomycin 40 MG inj 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY APG carve out 12/1/2008 J9293 Mitoxantrone hydrochl / 5 MG 433 Class IV Chemotherapy Drugs 433 CLASS IV CHEMOTHERAPY APG carve out 12/1/2008 J9300 Gemtuzumab ozogamicin inj 442 Class VII Combined 465 CLASS XIII COMBINED APG carve out 1/1/2010 J9303 Injection, panitumumab, 10 mg 440 CLASS VI PHARMACOTHERAPY 462 CLASS X COMBINED Procedure carve out 1/1/2011 J9305 Pemetrexed injection 441 Class VI Chemotherapy Drugs 463 CLASS XI COMBINED procedure carve out 1/1/2010 J9310 Injection, rituximab, 100 mg 440 CLASS VI PHARMACOTHERAPY 463 CLASS XI COMBINED Procedure carve out 1/1/2011 J9320 Streptozocin injection 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J9328 Temozolomide injection 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY DRUG APG carve out 1/1/2010 J9330 Temsirolimus injection 434 Class V Chemotherapy Drugs 443 CLASS VII CHEMOTHERAPY APG carve out 12/1/2008 J9340 Thiotepa injection 431 Class II Chemotherapy Drugs 433 CLASS IV CHEMOTHERAPY APG carve out 12/1/2008 J9350 Topotecan injection 433 Class IV Chemotherapy Drugs 460 CLASS VIII COMBINED procedure carve out 12/1/2008 J9355 Trastuzumab injection 434 Class V Chemotherapy Drugs 460 CLASS VIII COMBINED procedure carve out 12/1/2008 J9357 Valrubicin injection 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY APG carve out 12/1/2008 J9360 Vinblastine sulfate inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9370 Vincristine sulfate 1 MG inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9375 Vincristine sulfate 2 MG inj 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9380 Vincristine sulfate 5 MG inj 431 Class II Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9390 Vinorelbine tartrate inj 431 Class II Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 J9395J9395 Injection, Fulvestrant Injection, Fulvestrant 433433 Class IV Chemotherapy DrugsClass IV Chemotherapy Drugs 441441 CLASS VI CHEMOTHERAPY CLASS VI CHEMOTHERAPY APG carve out APG carve out 12/1/200812/1/2008 J9600 Porfimer sodium injection 441 Class VI Chemotherapy Drugs 463 CLASS XI COMBINED procedure carve out 1/1/2010 J9999 Chemotherapy drug 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY APG carve out 12/1/2008 K0800 POV group 1 std up to 300lbs 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0801 POV group 1 hd 301-450 lbs 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0802 POV group 1 vhd 451-600 lbs 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0806 POV group 2 std up to 300lbs 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0807 POV group 2 hd 301-450 lbs 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0808 POV group 2 vhd 451-600 lbs 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0812 Power operated vehicle NOC 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0813 PWC gp 1 std port seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0814 PWC gp 1 std port cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0815 PWC gp 1 std seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0816 PWC gp 1 std cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0820 PWC gp 2 std port seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0821 PWC gp 2 std port cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0822 PWC gp 2 std seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0823 PWC gp 2 std cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0824 PWC gp 2 hd seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0825 PWC gp 2 hd cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0826 PWC gp 2 vhd seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0827 PWC gp vhd cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0828 PWC gp 2 xtra hd seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

page 10 of 14


Date K0829 PWC gp 2 xtra hd cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0830 PWC gp2 std seat elevate s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0831 PWC gp2 std seat elevate cap 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0835 PWC gp2 std sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0836 PWC gp2 std sing pow opt cap 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0837 PWC gp 2 hd sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0838 PWC gp 2 hd sing pow opt cap 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0839 PWC gp2 vhd sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0840 PWC gp2 xhd sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0841 PWC gp2 std mult pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0842 PWC gp2 std mult pow opt cap 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0843 PWC gp2 hd mult pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0848 PWC gp 3 std seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0849 PWC gp 3 std cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0850 PWC gp 3 hd seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0851 PWC gp 3 hd cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0852 PWC gp 3 vhd seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0853 PWC gp 3 vhd cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0854 PWC gp 3 xhd seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0855 PWC gp 3 xhd cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0856 PWC gp3 std sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0857 PWC gp3 std sing pow opt cap 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0858 PWC gp3 hd sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0859 K0859 PWC gp3 hd sing pow opt capPWC gp3 hd sing pow opt cap 453453 Motorized Wheelchair Motorized Wheelchair 453453 Motorized Wheelchair Motorized Wheelchair APG carve out APG carve out 12/1/200812/1/2008 K0860 PWC gp3 vhd sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0861 PWC gp3 std mult pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0862 PWC gp3 hd mult pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0863 PWC gp3 vhd mult pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0864 PWC gp3 xhd mult pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0868 PWC gp 4 std seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0869 PWC gp 4 std cap chair 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0870 PWC gp 4 hd seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008 K0871 PWC gp 4 vhd seat/back 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0877 PWC gp4 std sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0878 PWC gp4 std sing pow opt cap 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0879 PWC gp4 hd sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0880 PWC gp4 vhd sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

page 11 of 14


Date K0884 PWC gp4 std mult pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0885 PWC gp4 std mult pow opt cap 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0886 PWC gp4 hd mult pow s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0890 PWC gp5 ped sing pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0891 PWC gp5 ped mult pow opt s/b 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0898 Power wheelchair NOC 453 Motorized Wheelchair 453 Motorized Wheelchair APG carve out 12/1/2008

K0899 Pow mobil dev no SADMERC 456 Motorized Wheelchair Accessories 456 Motorized Wheelchair Accessories APG carve out 12/1/2008

Q0166 Granisetron hcl 1 mg oral 431 Class II Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUG APG carve out 1/1/2010

Q0515 Sermorelin acetate injection 433 Class IV Chemotherapy Drugs 443 CLASS VII CHEMOTHERAPY DRUGS


Q4074 Iloprost non-comp unit dose 434 Class V Chemotherapy Drugs 461 CLASS IX COMBINED CHEMOTHERAPY AND


Q9955 Inj perflexane lip micros,ml 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS


Q9956 Inj octafluoropropane mic,ml 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS


Q9957 Inj perflutren lip micros,ml 430 Class I Chemotherapy Drugs 431 CLASS II CHEMOTHERAPY DRUGSDRUGS


S0091 Granisetron 1mg 431 Class II Chemotherapy Drugs 431 CLASS II CHEMOTHERAPY DRUG APG carve out 1/1/2010

S0108 Mercaptopurine 50 mg 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS


S0156 Exemestane, 25 mg 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUG APG carve out 1/1/2010

S0170 Anastrozole 1 mg 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS


S0172 Chlorambucil 2 mg 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS


S0175 Flutamide 125 mg 431 Class II Chemotherapy Drugs 432 CLASS III CHEMOTHERAPY DRUGS


S0176 Hydroxyurea 500 mg 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS


S0178 Lomustine 10 mg 432 Class III Chemotherapy Drugs 434 CLASS V CHEMOTHERAPY DRUGS


S0179 Megestrol 20 mg 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS


S0182 Procarbazine 5 mg 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUGS


S0187 Tamoxifen 10 mg 430 Class I Chemotherapy Drugs 430 CLASS I CHEMOTHERAPY DRUG APG carve out 1/1/2010

page 12 of 14


Date S0190 Mifepristone, oral, 200 mg 435 Class I Pharmacotherapy 436 CLASS II PHARMACOTHERAPY Procedure carve out 12/1/2008

S0191 Misoprostol, oral, 200 mcg 435 Class I Pharmacotherapy 435 CLASS I PHARMACOTHERAPY Procedure carve out 12/1/2008 S3818 BRCA1 gene anal 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3819 BRCA2 gene anal 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3820 Comp BRCA1/BRCA2 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3822 Sing mutation brst/ovar 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3823 3 mutation brst/ovar 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3828 Comp MLH1 gene 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3829 Comp MLH2 gene 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3830 Gene test HNPCC comp 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3831 Gene test HNPCC single 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3833 Comp APC sequence 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3834 Sing mutation APC 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3835 Gene test cystic fibrosis 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3840 DNA analysis RET-oncogene 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3842 Gene test Hippel-Lindau 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3843 DNA analysis factor v 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3844 DNA analysis deafness 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3845 Gene test alpha-thalassemia 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3846 Gene test beta-thalassemia 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3847 Gene test Tay-Sachs 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3848 Gene test Gaucher 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3849 Gene test Niemann-Pick 395 Level II Immunology Tests gy 395 Level II Immunology Tests gy Procedure carve out 1/1/2010 S3850 Gene test sickle cell 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3851 Gene test canavan 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3852 DNA analysis APOE alzheimer 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S3853 Gene test myo musclr dyst 395 Level II Immunology Tests 395 Level II Immunology Tests Procedure carve out 1/1/2010 S4989 Contracept IUD 417 Minor Reproductive Procedures 417 Minor Reproductive Procedures Procedure carve out 12/1/2008 S5550 Insulin rapid 5 u 452 Diabetes Supplies 452 Diabetes Supplies APG carve out 12/1/2008

S5551 Insulin most rapid 5 u 452 Diabetes Supplies 452 Diabetes Supplies APG carve out 12/1/2008

S5552 Insulin intermed 5 u 452 Diabetes Supplies 452 Diabetes Supplies APG carve out 12/1/2008

S5553 Insulin long acting 5 u 452 Diabetes Supplies 452 Diabetes Supplies APG carve out 12/1/2008

S5560 Insulin reuse pen 1.5 ml 452 Diabetes Supplies 452 Diabetes Supplies APG carve out 12/1/2008

S5561 Insulin reuse pen 3 ml 452 Diabetes Supplies 452 Diabetes Supplies APG carve out 12/1/2008

S5565 Insulin cartridge 150 u 452 Diabetes Supplies 452 Diabetes Supplies APG carve out 12/1/2008 S5566 Insulin cartridge 300 u 452 Diabetes Supplies 452 Diabetes Supplies APG carve out 12/1/2008

S5570 Insulin dispos pen 1.5 ml 452 Diabetes Supplies 452 Diabetes Supplies APG carve out 12/1/2008 S5571 Insulin dispos pen 3 ml 452 Diabetes Supplies 452 Diabetes Supplies APG carve out 12/1/2008

page 13 of 14


Date Procedures Removed from the Procedure Carve out List

HCPCS Description APG APG Description

APG - updated w/ v3.5 2011 drug

groupings APG Description - updated w/

v3.5 2011 drug groupings

Date Added to Carve out

List Q4080 Iloprost non-comp unit dose 434 Class V Chemotherapy Drugs NA NA APG carve out 12/1/2008

J3472 Ovine, 1000 USP units 433 Class IV Chemotherapy Drugs 437 CLASS III PHARMACOTHERAPY APG carve out 1/1/2011 J0885 Epoetin alfa, non-esrd 432 Class III Chemotherapy Drugs 439 CLASS V PHARMACOTHERAPY APG carve out 1/1/2011 J9170 Docetaxel injection 433 Class IV Chemotherapy Drugs NA NA APG carve out 12/1/2008

E2393 Valve, pneumatic tire tube 456 Motorized Wheelchair Accessories NA NA APG carve out 12/1/2008

E2399 Noc interface 456 Motorized Wheelchair Accessories NA NA APG carve out 12/1/2008

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all procedures carved out of apgs (individual codes carved ... · apg description all procedures...

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