Transcript
Page 1: HCPCS Level II - cdn.optumcoding.com · Organization of HCPCS The Optum360 2019 HCPCS Level II Expert con tains mandated changes and new codes for use as of January 1, 2 019. Deleted

Power up your codingoptum360coding.com

2019

HCPCS Level IIA resourceful compilation of HCPCS codes

Supports HIPAA compliance

EXPERT

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© 2017 Optum360, LLC

ContentsIntroduction ..................................................................... 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 ...........................................................................97

Temporary Codes................................................................................97

L Codes .........................................................................101

Orthotic Devices and Procedures ................................................ 101

Prosthetic Procedures..................................................................... 113

M Codes ........................................................................125

Medical Services............................................................................... 125

P Codes .........................................................................126

Pathology and Laboratory Services .............................................126

Q Codes.........................................................................128

Q Codes (Temporary) .......................................................................128

R Codes .........................................................................135

Diagnostic Radiology Services.......................................................135

S Codes .........................................................................137

Temporary National Codes (Non-Medicare) ..............................137

T Codes .........................................................................147

National T Codes Established for State Medicaid Agencies ...147

V Codes .........................................................................149

Vision Services ...................................................................................149

Hearing Services................................................................................151

Appendixes

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

Appendix 2 — Modifiers......................................Appendixes — 27

Appendix 3 — Abbreviations and Acronyms.........................................................Appendixes — 33

Appendix 4 — Internet-only Manuals (IOMs)................................................................Appendixes — 35

Appendix 5 — HCPCS Changes for 2019...... Appendixes — 175

Appendix 6 — Place of Service and Type of Service...................................................... Appendixes — 179

Appendix 7 — Deleted Code Crosswalk....... Appendixes — 183

Appendix 8 — Glossary .................................... Appendixes — 185

Appendix 9 — Quality Payment Program (QPP)............................................................... Appendixes — 189

Page 3: HCPCS Level II - cdn.optumcoding.com · Organization of HCPCS The Optum360 2019 HCPCS Level II Expert con tains mandated changes and new codes for use as of January 1, 2 019. Deleted

© 2017 Optum360, LLC Introduction — i

IntroductionOrganization of HCPCS The Optum360 2019 HCPCS Level II Expert contains mandated changes and new codes for use as of January 1, 2019. Deleted codes have also been indicated and cross-referenced to active codes when possible. New codes have been added to the appropriate sections, eliminating the time-consuming step of looking in two places for a code. However, keep in mind that the information in this book is a reproduction of the 2019 HCPCS; additional information on coverage issues may have been provided to Medicare contractors after publication. All contractors periodically update their systems and records throughout the year. If this book does not agree with your contractor, it is either because of a mid-year update or correction, or a specific local, or regional coverage policy.

IndexBecause HCPCS is organized by code number rather than by service or supply name, the index enables the coder to locate any code without looking through individual ranges of codes. Just look up the medical or surgical supply, service, orthotic, or prosthetic in question to find the appropriate codes. This index also refers to many of the brand names by which these items are known.

Table of Drugs and BiologicalsThe brand names of drugs and biologicals listed are examples only and may not include all products available for that type. The table lists HCPCS codes from any available section including A codes, C codes, J codes, S codes, and Q codes under brand and generic names with amount, route of administration, and code numbers. While every effort is made to make the table comprehensive, it is not all-inclusive.

Quality Payment ProgramPreviously, this appendix contained lists of the numerators and denominators applicable to Medicare PQRS. However, with the implementation of the Quality Payment Program (QPP) mandated by passage of the Medicare Access and Chip Reauthorization Act (MACRA) of 2015, the PQRS system will be obsolete. This appendix now contains information pertinent to that legislation as well as a comprehensive overview of the QPP.

Color-coded Coverage InstructionsThe Optum360 HCPCS Level II book provides colored symbols for each coverage and reimbursement instruction. A legend to these symbols is provided on the bottom of each two-page spread.

Yellow Color Bar—Carrier DiscretionIssues that are left to “carrier discretion” are covered with a yellow bar. Contact the carrier for specific coverage information on those codes.

Green Color Bar—Special Coverage InstructionsA green bar for “special coverage instructions” over a code means that special coverage instructions apply to that code. These special instructions are also typically given in the form of Medicare Internet Only Manuals (IOM) reference numbers. The appendixes provide the full text of the cited Medicare IOM.

Pink Color Bar—Not Covered by or Invalid for MedicareCodes that are not covered by or are invalid for Medicare are covered by a pink bar. The pertinent Medicare Internet-only Manuals (Pub. 100) reference numbers are also given explaining why a particular code is not covered. These numbers refer to the appendixes, where the Medicare references are listed.

Codes in the Optum360 HCPCS Level II follow the AMA CPT book conventions to indicate new, revised, and deleted codes.

• A black circle (●) precedes a new code.

• A black triangle (▲) precedes a code with revised terminology or rules.

• A circle (❍) precedes a recycled/reinstated code.

• Codes deleted from the current active codes appear with a strike-out.

@ Quantity AlertMany codes in HCPCS report quantities that may not coincide with quantities available in the marketplace. For instance, a HCPCS code for an ostomy pouch with skin barrier reports each pouch, but the product is generally sold in a package of 10; “10” must be indicated in the quantity box on the CMS claim form to ensure proper reimbursement. This symbol indicates that care should be taken to verify quantities in this code. These quantity alerts do not represent Medicare Unlikely Edits (MUEs) and should not be used for MUEs.

HOW TO USE OPTUM360 HCPCS LEVEL II BOOKS

A4336 Incontinence supply, urethral insert, any type, each

A9581 Injection, gadoxetate disodium, 1 ml

A4264 Permanent implantable contraceptive intratubal occlusion device(s) and delivery system

● C9014 Injection, cerliponase alfa, 1 mg

▲ Q4163 WoundEx, BioSkin, per sq cm

❍ J7345 Aminolevulinic acid HCl for topical administration, 10% gel, 10 mg

Q9987 Pathogen(s) test for platelets

@ J0120 Injection, tetracycline, up to 250 mg

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AAbdomen/abdominal

dressing holder/binder, A4461, A4463pad, low profile, L1270

Abductioncontrol, each, L2624pillow, E1399rotation bar, foot, L3140-L3170

Ablationprostate, transrectal

high intensity focused ultrasound,C9747

ultrasound, C9734Abortion, S0199, S2260-S2267Absorption dressing, A6251-A6256Accessories

ambulation devices, E0153-E0159artificial kidney and machine (see also ES-

RD), E1510-E1699beds, E0271-E0280Medicare IVIG demonstration, Q2052oxygen, E1352, E1354-E1358ventricular assist device, Q0477, Q0501-

Q0509wheelchairs, E0950-E1012, E1050-E1298,

E2201-E2231, E2295, E2300-E2367,K0001-K0108

Access system, A4301AccuChek

blood glucose meter, E0607test strips, box of 50, A4253

Accurateprosthetic sock, L8420-L8435stump sock, L8470-L8485

Acetate concentrate for hemodialysis, A4708Acid concentrate for hemodialysis, A4709Action Patriot manual wheelchair, K0004ActionXtra,ActionMVP,ActionPro-T,manual

wheelchair, K0005Active Life

convex one-piece urostomypouch, A4421flush away, A5051one-piece

drainable custom pouch, A5061pre-cut closed-end pouch, A5051stoma cap, A5055

Activity therapy, G0176Adaptor

electric/pneumatic ventricular assistdevice,Q0478

neurostimulator, C1883pacing lead, C1883

Additioncushion AK, L5648cushion BK, L5646harness upper extremity, L6675-L6676to halo procedure, L0861to lower extremity orthotic, K0672, L2750-

L2760, L2780-L2861to lower extremityprosthesis, L5970-L5990to upper extremity orthotic, L3891wrist, flexion, extension, L6620

Adhesivebarrier, C1765catheter, A4364disc or foam pad, A5126medical, A4364Nu-Hope

1 oz bottle with applicator, A43643 oz bottle with applicator, A4364

ostomy, A4364pads, A6203-A6205, A6212-A6214, A6219-

A6221,A6237-A6239,A6245-A6247,A6254-A6256

remover, A4455, A4456support, breast prosthesis, A4280tape, A4450, A4452tissue, G0168

Adjunctive blue light cystoscopy, C9738Adjustabrace 3, L2999Adjustment

bariatric band, S2083Administration

aerosolized drug therapy, home, S9061chemotherapy infusion

continued in community, G0498

Administration— continuedhepatitis B vaccine, G0010influenza virus vaccine, G0008medication, T1502-T1503

direct observation, H0033pneumococcal vaccine, G0009

Adoptive immunotherapy, S2107Adrenal transplant, S2103AdvantaJet, A4210AFO, E1815, E1830, L1900-L1990, L4392, L4396AimscoUltraThin syringe, 1 ccor1/2 cc, each,

A4206Air bubble detector, dialysis, E1530Aircast air stirrup ankle brace, L1906Air fluidized bed, E0194Airlife BrandMisty-Neb nebulizer, E0580Air pressure pad/mattress, E0186, E0197AirSep, E0601Air travelandnonemergency transportation,

A0140Airway device, E0485-E0486Alarm

device, A9280enuresis, S8270pressure, dialysis, E1540

Albumarc, P9041Albumin, human, P9041, P9045-P9047Alcohol

abuse service, G0396, G0397, H0047assessment, H0001pint, A4244testing, H0048wipes, A4245

Alert device, A9280Algiderm, alginate dressing, A6196-A6199Alginate dressing, A6196-A6199Algosteril, alginate dressing, A6196-A6199Alkaline battery for blood glucosemonitor,

A4233-A4236Allogenic cord blood harvest, S2140Allograft

small intestine and liver, S2053Alternating pressuremattress/pad, E0181,

E0277pump, E0182

Alternative communicationdevice, i.e., com-munication board, E1902

Ambulance, A0021-A0999air, A0436disposable supplies, A0382-A0398non-emergency, S9960-S9961oxygen, A0422response, treatment, no transport, A0998

Ambulation device, E0100-E0159Ambulation stimulator

spinal cord injured, E0762Aminaid, enteral nutrition, B4154Amirosyn-RF, parenteral nutrition, B5000Ammonia test paper, A4774AmnioBand woundmatrix, Q4168AmnioGen-A woundmatrix, Q4162AmnioGen-C woundmatrix, Q4162AmnioPro Flowwoundmatrix, Q4162AmnioPro woundmatrix, Q4163Amputee

adapter, wheelchair, E0959prosthesis, L5000-L7510, L7520, L8400-

L8465stump sock, L8470wheelchair, E1170-E1190, E1200

Analysisdose optimization, S3722gene sequence

hypertrophic cardiomyopathy,S3865, S3866

semen, G0027Anchor, screw, C1713Anesthesia

dialysis, A4736-A4737monitored (MAC), G9654

Angiographyfluorescent

nonocular, C9733iliac artery, G0278magnetic resonance, C8901-C8914, C8918-

C8920

Angiography— continuedreconstruction, G0288

Ankle foot system, L5973Ankle orthrosis, L1902, L1904, L1907Ankle–footorthotic (AFO), L1900, L1906, L1910-

L1940, L2106-L2116Dorsiwedge Night Splint, A4570, L2999,

L4398Specialist

Ankle Foot Orthotic, L1930Tibial Pre-formed Fracture Brace,

L2116Surround Ankle Stirrup Braces with Foam,

L1906Annual wellness visit, G0438-G0439Antenna

replacementdiaphragmatic/phrenic nerve stimu-

lator, L8696Anterior-posterior orthotic

lateral orthotic, L0700, L0710Antibiotichomeinfusiontherapy, S9494-S9504Antibiotic regimen, G9286-G9287Antibody testing, HIV-1, S3645Anticoagulation clinic, S9401Antifungal home infusion therapy, S9494-

S9504Antimicrobial prophylaxis, G9196-G9198Antiseptic

chlorhexidine, A4248Antisperm antibodies, S3655Antiviralhome infusion therapy, S9494-S9504Apheresis

low density lipid, S2120Apneamonitor, E0618-E0619

with recording feature, E0619electrodes, A4556lead wires, A4557

Appliancecleaner, A5131pneumatic, E0655-E0673

Applicationskin substitute, C5271-C5278tantalum rings, S8030

AquaPedic sectional gel flotation, E0196Aqueous

shunt, L8612Arch support, L3040-L3100Arm

slingdeluxe, A4565mesh cradle, A4565universal

arm, A4565elevator, A4565

wheelchair, E0973Arrow, power wheelchair, K0014Artacent woundmatrix, Q4169Arthroereisis

subtalar, S2117Arthroscopy

kneeharvest of cartilage, S2112removal loose body, FB, G0289

shoulderwith capsulorrhaphy, S2300

Artificialkidney machines and accessories (see also

Dialysis), E1510-E1699larynx, L8500saliva, A9155

Assertivecommunitytreatment, H0039-H0040Assessment

alcohol and/or substance, G0396-G0397,H0001

audiologic, V5008-V5020chronic care management services

comprehensive, G0506family, H1011functional outcome, G9227geriatric, S0250mental health, H0031pain, G8442speech, V5362-V5364wellness, S5190

Assisted living, T2030-T2031

Assistive listening device, V5268-V5274alerting device, V5269cochlear implant assistive device, V5273FM/DM, V5281

accessories, V5283-V5290system, V5281-V5282

supplies and accessories, V5267TDD, V5272telephone amplifier, V5268television caption decoder, V5271

Asthmaeducation, S9441kit, S8097

Attendant care, S5125-S5126Attends, adult diapers, A4335Audiologic assessment, V5008-V5020Audiometry, S0618Auditoryosseointegrateddevice, L8690, L8691,

L8692-L8693Autoclix lancet device, A4258Auto-Glide folding walker, E0143Autolance lancet device, A4258Autolet lancet device, A4258Autolet Lite lancet device, A4258Autolet Mark II lancet device, A4258

BBabysitter, child of parents in treatment,

T1009Back school, S9117Back supports, L0450-L0710Bacterial sensitivity study, P7001Bag

drainage, A4357irrigation supply, A4398resuscitation bag, S8999spacer, for metered dose inhaler, A4627urinary, A4358, A5112

Balken, fracture frame, E0946Ballistocardiogram, S3902Bandage

adhesive, A6413compression

high, A6452light, A6448-A6450medium, A6451padding, S8430roll, S8431

conforming, A6442-A6447Orthoflex elastic plastic bandages, A4580padding, A6441self-adherent, A6413, A6453-A6455specialist plaster bandages, A4580zinc paste impregnated, A6456

Bariatricbed, E0302-E0304brief/diaper, T4543surgery, S2083

Barium enema, G0106cancer screening, G0120

Barrierwith flange, A43734 x 4, A4372adhesion, C1765

Baseball finger splint, A4570Bath chair, E0240Bathtub

chair, E0240heat unit, E0249stool or bench, E0245transfer bench, E0247, E0248transfer rail, E0246wall rail, E0241, E0242

Battery, L7360, L7364blood glucose monitor, A4233-A4236charger, L7362, L7366, L7368, L8695,

L8699, Q0495cochlear implant device

alkaline, L8622lithium, L8623-L8624zinc, L8621

hearing device, V5266infusion pump, external, A4602, K0601-

K0605lithium, A4601-A4602, L7367, Q0506

charger, L7368

Index — 1© 2017 Optum360, LLC

Battery2019 HCPCS Level IIAbdom

en/abdominal—

Battery

Index

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Ambulance service, advanced life support, nonemergencytransport, level 1 (ALS 1) A

A0426

CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,30;100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1; 100-04,15,40AHA: 4Q, '12, 1

Ambulanceservice,advanced lifesupport,emergencytransport,level 1 (ALS 1 - emergency) A

A0427

CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,30;100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1; 100-04,15,40AHA: 4Q, '12, 1

Ambulanceservice,basic life support,nonemergency transport,(BLS) A

A0428

CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,20.6;100-04,15,30; 100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1;100-04,15,40AHA: 4Q, '12, 1

Ambulanceservice,basic lifesupport,emergencytransport (BLS,emergency) A

A0429

CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,30;100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1; 100-04,15,40AHA: 4Q, '12, 1

Ambulance service, conventional air services, transport, oneway (fixed wing) A

A0430

CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,20.3;100-04,15,30; 100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1;100-04,15,40AHA: 4Q, '12, 1

Ambulance service, conventional air services, transport, oneway (rotary wing) A

A0431

CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,20.3;100-04,15,30; 100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1;100-04,15,40AHA: 4Q, '12, 1

Paramedic intercept (PI), rural area, transport furnished by avolunteer ambulance companywhich isprohibitedby state lawfrom billing third-party payers A

A0432

CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,30;100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1; 100-04,15,40AHA: 4Q, '12, 1

Advanced life support, level 2 (ALS 2) AA0433CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,30;100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1; 100-04,15,40AHA: 4Q, '12, 1

Specialty care transport (SCT) AA0434CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,30;100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1; 100-04,15,40AHA: 4Q, '12, 1

Fixed wing air mileage, per statute mile AA0435CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,20.3;100-04,15,30; 100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1;100-04,15,40AHA: 4Q, '12, 1

Rotary wing air mileage, per statute mile AA0436CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,10.2.2;100-02,10,10.3.3; 100-02,10,20; 100-02,10,30.1; 100-02,10,30.1.1;100-02,10.20; 100-04,15,10.3; 100-04,15,20.1.4; 100-04,15,20.3;100-04,15,30; 100-04,15,30.1.2; 100-04,15,30.2; 100-04,15,30.2.1;100-04,15,40AHA: 4Q, '12, 1

Noncoveredambulancemileage,permile (e.g., formiles traveledbeyond closest appropriate facility) E

A0888

CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,20; 100-02,10,30.1;100-02,10,30.1.1; 100-04,15,30.1.2; 100-04,15,30.2.4

Ambulance response and treatment, no transport EA0998CMS: 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,30.1; 100-02,10,30.1.1

Unlisted ambulance service AA0999CMS: 100-02,10,10.1; 100-02,10,10.1.2; 100-02,10,10.2.1; 100-02,10,20;100-02,10,30.1; 100-02,10,30.1.1

Medical and Surgical Supplies A4206-A9999This section covers a wide variety of medical, surgical, and some durable medicalequipment (DME) related supplies and accessories. DME-related supplies, accessories,maintenance, and repair required to ensure the proper functioning of this equipment isgenerally covered by Medicare under the prosthetic devices provision.

Injection Supplies

Syringe with needle, sterile, 1 cc or less, each N@A4206

Syringe with needle, sterile 2 cc, each N@A4207

Syringe with needle, sterile 3 cc, each N@A4208

Syringe with needle, sterile 5 cc or greater, each N@A4209

Needle-free injection device, each E@A4210Sometimes covered by commercial payers with preauthorization andphysician letter stating need (e.g., for insulin injection in young children).

Supplies for self-administered injections NA4211When a drug that is usually injected by the patient (e.g., insulin orcalcitonin) is injected by the physician, it is excluded from Medicarecoverage unless administered in an emergency situation (e.g., diabeticcoma).

Noncoring needle or stylet with or without catheter NA4212

Syringe, sterile, 20 cc or greater, each N@A4213

Needle, sterile, any size, each NA4215

Sterile water, saline and/or dextrose, diluent/flush, 10ml Nq@7

A4216

Sterile water/saline, 500ml Nq@7(AU)A4217CMS: 100-04,20,30.9

Sterile saline or water, metered dose dispenser, 10ml Nq@A4218

Refill kit for implantable infusion pump NqA4220

Supplies formaintenanceofnon-insulindrug infusioncatheter,per week (list drugs separately) N7

A4221

Infusion supplies for external drug infusion pump, per cassetteor bag (list drugs separately) N7

A4222

Infusion supplies not used with external infusion pump, percassette or bag (list drugs separately) N@

A4223

Supplies for maintenance of insulin infusion catheter, perweek N7

A4224

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

© 2017 Optum360, LLCA-Y OPPS Status Indicators: Male Only; Female Onlyx Maternity Edity Age Edit2—A Codes

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Enteral and Parenteral Therapy B4034-B9999This section includes codes for supplies, formulae, nutritional solutions, and infusionpumps.

Enteral Formulae and Enteral Medical Supplies

Enteral feedingsupplykit; syringe fed,perday, includesbutnotlimited to feeding/flushing syringe, administration set tubing,dressings, tape Y@

B4034

CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Enteral feeding supply kit; pump fed, per day, includes but notlimited to feeding/flushing syringe, administration set tubing,dressings, tape Y@

B4035

CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Enteral feedingsupplykit; gravity fed,perday, includesbutnotlimited to feeding/flushing syringe, administration set tubing,dressings, tape Y@

B4036

CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Nasogastric tubing with stylet YB4081CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Nasogastric tubing without stylet YB4082CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Stomach tube - Levine type YB4083CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Gastrostomy/jejunostomy tube, standard, anymaterial, anytype, each A@

B4087

CMS: 100-03,180.2; 100-04,23,60.3

Gastrostomy/jejunostomy tube, low-profile, anymaterial, anytype, each A@

B4088

CMS: 100-03,180.2; 100-04,23,60.3

Food thickener, administered orally, per oz E@B4100CMS: 100-03,180.2

Enteral formula, foradults,usedtoreplacefluidsandelectrolytes(e.g., clear liquids), 500ml = 1 unit Y@

B4102

CMS: 100-03,180.2

Enteral formula, for pediatrics, used to replace fluids andelectrolytes (e.g., clear liquids), 500ml = 1 unit Y@

B4103

CMS: 100-03,180.2

Additive for enteral formula (e.g., fiber) EB4104CMS: 100-03,180.2

Enteral formula, manufactured blenderized natural foods withintactnutrients, includesproteins, fats, carbohydrates, vitaminsandminerals,mayincludefiber,administeredthroughanenteralfeeding tube, 100 calories = 1 unit Y@

B4149

CMS: 100-03,180.2; 100-04,23,60.3

Enteral formula, nutritionally complete with intact nutrients,includes proteins, fats, carbohydrates, vitamins andminerals,may include fiber, administered through an enteral feedingtube, 100 calories = 1 unit Y@

B4150

Use this code for Enrich, Ensure, EnsureHN, Ensure Powder, Isocal, LonalacPowder, Meritene, Meritene Powder, Osmolite, Osmolite HN, PortagenPowder, Sustacal, Renu, Sustagen Powder, Travasorb.CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Enteral formula,nutritionally complete, caloricallydense (equalto or greater than 1.5 kcal/ml) with intact nutrients, includesproteins, fats, carbohydrates,vitaminsandminerals,mayincludefiber,administeredthroughanenteral feedingtube,100calories= 1 unit Y@

B4152

Use this code for Magnacal, Isocal HCN, Sustacal HC, Ensure Plus, EnsurePlus HN.CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Enteral formula, nutritionally complete, hydrolyzed proteins(amino acids and peptide chain), includes fats, carbohydrates,vitaminsandminerals,may include fiber, administered throughan enteral feeding tube, 100 calories = 1 unit Y@

B4153

Use this code for Criticare HN, Vivonex t.e.n. (Total Enteral Nutrition),Vivonex HN, Vital (Vital HN), Travasorb HN, Isotein HN, Precision HN,Precision Isotonic.CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Enteral formula, nutritionally complete, for special metabolicneeds, excludes inherited disease of metabolism, includesaltered composition of proteins, fats, carbohydrates, vitaminsand/or minerals, may include fiber, administered through anenteral feeding tube, 100 calories = 1 unit Y@

B4154

Use this code forHepatic-aid, TravasorbHepatic, TravasorbMCT, TravasorbRenal, Traum-aid, Tramacal, Aminaid.CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Enteral formula, nutritionally incomplete/modular nutrients,includes specific nutrients, carbohydrates (e.g., glucosepolymers), proteins/amino acids (e.g., glutamine, arginine), fat(e.g.,mediumchain triglycerides)or combination,administeredthrough an enteral feeding tube, 100 calories = 1 unit Y@

B4155

Use this code for Propac, Gerval Protein, Promix, Casec, Moducal,Controlyte, Polycose Liquid or Powder, Sumacal, Microlipids, MCT Oil,Nutri-source.CMS: 100-03,180.2; 100-04,20,160.2; 100-04,23,60.3

Enteral formula, nutritionally complete, for special metabolicneeds for inherited disease of metabolism, includes proteins,fats, carbohydrates, vitamins andminerals, may include fiber,administered through an enteral feeding tube, 100 calories = 1unit Y@

B4157

CMS: 100-03,180.2

Enteral formula, forpediatrics,nutritionallycompletewith intactnutrients, includes proteins, fats, carbohydrates, vitamins andminerals, may include fiber and/or iron, administered throughan enteral feeding tube, 100 calories = 1 unit Y@

B4158

CMS: 100-03,180.2

Enteral formula, forpediatrics,nutritionally complete soybasedwith intact nutrients, includes proteins, fats, carbohydrates,vitamins andminerals, may include fiber and/or iron,administered through an enteral feeding tube, 100 calories = 1unit Y@

B4159

CMS: 100-03,180.2

Enteral formula, forpediatrics,nutritionally completecaloricallydense (equal toorgreater than0.7kcal/ml)with intactnutrients,includes proteins, fats, carbohydrates, vitamins andminerals,may include fiber, administered through an enteral feedingtube, 100 calories = 1 unit Y@

B4160

CMS: 100-03,180.2

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

B Codes— 17, SNF Excluded7 DMEPOS PaidAHA: Coding ClinicCMS: IOMg-w ASC Pmt© 2017 Optum360, LLC

B41602019 HCPCS Level IIB4034

—B4160

EnteralandParenteralTherapy

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Humanplasma fibrin sealant, vapor-heated, solvent-detergent(Artiss), 2 ml Kn@

C9250

Injection, lacosamide, 1 mg Nq@C9254Use this code for VIMPAT.

Injection, bevacizumab, 0.25mg Kn@C9257Use this code for Avastin.CMS: 100-03,110.17AHA: 3Q, '13, 9

Injection, hexaminolevulinate HCl, 100mg, per studydose Nq@

C9275

Use this code for Cysview.AHA: 2Q, '15, 9

Lidocaine 70mg/tetracaine 70mg, per patch Nq@C9285Use this code for SYNERA.AHA: 3Q, '11, 9

Injection, bupivacaine liposome, 1mg Nq@C9290Use this code for EXPAREL.AHA: 2Q, '12, 7

Injection, glucarpidase, 10 units Kn@C9293Use this code for Voraxaze.

Microporouscollagenimplantabletube(NeuraGenNerveGuide),per cm length Nq@

C9352

AHA: 1Q, '08, 6

Microporous collagen implantable slit tube (NeuraWrap NerveProtector), per cm length Nq@

C9353

AHA: 1Q, '08, 6

Acellularpericardial tissuematrixofnonhumanorigin (Veritas),per sq cm Nq@

C9354

AHA: 1Q, '08, 6

Collagen nerve cuff (NeuroMatrix), per 0.5 cm length Nq@C9355AHA: 1Q, '08, 6

Tendon, porousmatrix of cross-linked collagen andglycosaminoglycanmatrix (TenoGlideTendonProtectorSheet),per sq cm Nq@

C9356

AHA: 3Q, '08, 6

Dermal substitute,native,nondenaturedcollagen, fetalbovineorigin (SurgiMend CollagenMatrix), per 0.5 sq cm Nq@

C9358

AHA: 2Q, '12, 7; 3Q, '08, 6

Porouspurifiedcollagenmatrixbonevoid filler (IntegraMozaikOsteoconductive Scaffold Putty, Integra OS OsteoconductiveScaffold Putty), per 0.5 cc Nq@

C9359

AHA: 3Q, '15, 2

Dermal substitute, native, nondenatured collagen, neonatalbovine origin (SurgiMend CollagenMatrix), per 0.5 sqcm Nq@

C9360

AHA: 2Q, '12, 7

Collagenmatrixnervewrap (NeuroMendCollagenNerveWrap),per 0.5 cm length Nq@

C9361

Porouspurifiedcollagenmatrixbonevoid filler (IntegraMozaikOsteoconductive Scaffold Strip), per 0.5 cc Nq@

C9362

AHA: 2Q, '10, 8

Skin substitute (Integra Meshed Bilayer WoundMatrix), per sqcm Nq@

C9363

AHA: 2Q, '12, 7; 2Q, '10, 8

Porcine implant, Permacol, per sq cm Nq@C9364

Unclassified drugs or biologicals AoC9399CMS: 100-04,17,90.3AHA: 1Q, '17, 8; 1Q, '17, 1-3; 4Q, '16, 10; 4Q, '14, 5; 2Q, '14, 8; 2Q, '13, 5;1Q, '13, 9; 1Q, '08, 6; 4Q, '05, 7, 9; 4Q, '04, 3

Injection, phenylephrine and ketorolac, 4 ml vial Gn@C9447Use this code for Omidria.

Injection, cangrelor, 1 mg Gn@C9460Use this code for Kengreal.AHA: 1Q, '16, 6-8

Injection, sotalol hydrochloride, 1 mg Gn@C9482AHA: 4Q, '16, 9

Injection, atezolizumab, 10mgC9483Jan

To report, see ~J9022

Injection, eteplirsen, 10mgC9484Jan

To report, see ~J1428

Injection, olaratumab, 10mgC9485Jan

To report, see ~J9285

Injection, granisetron extended release, 0.1 mgC9486Jan

To report, see ~J1627

Ustekinumab, for intravenous injection, 1 mgC9487Jan

To report, see ~Q9989

Injection, conivaptan hydrochloride, 1 mg Gn@C9488JanlUse this code for Vaprisol.

Injection, nusinersen, 0.1 mgC9489Jan

To report, see ~J2326

Injection, bezlotoxumab, 10mgC9490Jan

To report, see ~J0565

Injection, avelumab, 10mgC9491Jan

To report, see ~J9023

Injection, durvalumab, 10mg GnC9492JanlUse this code for Imfinzi.

Injection, edaravone, 1 mg GnC9493JanlUse this code for Radicava.

Injection, ocrelizumab, 1mgC9494Jan

To report, see ~J2350

Loxapine, inhalation powder, 10mg Kn@C9497AHA: 1Q, '14, 6

Percutaneous transcatheter placement of drug elutingintracoronary stent(s), with coronary angioplasty whenperformed; single major coronary artery or branch J

C9600

Jan January Update

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

© 2017 Optum360, LLCA-Y OPPS Status Indicators: Male Only; Female Onlyx Maternity Edity Age Edit24—C Codes

2019 HCPCS Level IIC9250Outpa

tient

PPS

C9250—

C9600

Page 8: HCPCS Level II - cdn.optumcoding.com · Organization of HCPCS The Optum360 2019 HCPCS Level II Expert con tains mandated changes and new codes for use as of January 1, 2 019. Deleted

Transfer bench for tub or toilet with or without commodeopening E

E0247

Transfer bench, heavy-duty, for tub or toilet with or withoutcommode opening E

E0248

Pad for water circulating heat unit, for replacementonly Y7(NU,RR,UE)

E0249

Hospital Beds and Accessories

Hospital bed, fixed height, with any type side rails, withmattress Y7(RR)

E0250

CMS: 100-04,23,60.3

Hospital bed, fixed height, with any type side rails, withoutmattress Y7(RR)

E0251

CMS: 100-04,23,60.3

Hospitalbed, variableheight,hi-lo,withany typeside rails,withmattress Y7(RR)

E0255

CMS: 100-04,23,60.3

Hospital bed, variable height, hi-lo, with any type side rails,without mattress Y7(RR)

E0256

CMS: 100-04,23,60.3

Hospital bed, semi-electric (head and foot adjustment), withany type side rails, withmattress Y7(RR)

E0260

CMS: 100-04,23,60.3

Hospital bed, semi-electric (head and foot adjustment), withany type side rails, without mattress Y7(RR)

E0261

CMS: 100-04,23,60.3

Hospitalbed, total electric (head, foot, andheightadjustments),with any type side rails, withmattress Y7(RR)

E0265

CMS: 100-04,23,60.3

Hospitalbed, total electric (head, foot, andheightadjustments),with any type side rails, without mattress Y7(RR)

E0266

CMS: 100-04,23,60.3

Hospital bed, institutional type includes: oscillating, circulatingand Stryker frame, withmattress E

E0270

Mattress, innerspring Y7(NU,RR,UE)E0271CMS: 100-04,23,60.3; 100-04,36,50.14

Mattress, foam rubber Y7(NU,RR,UE)E0272CMS: 100-04,23,60.3; 100-04,36,50.14

Bed board EE0273

Over-bed table EE0274

Bed pan, standard, metal or plastic Y7(NU,RR,UE)E0275Reusable, autoclavablebedpansare coveredbyMedicare forbed-confinedpatients.

Bed pan, fracture, metal or plastic Y7(NU,RR,UE)E0276Reusable, autoclavablebedpansare coveredbyMedicare forbed-confinedpatients.

Powered pressure-reducing air mattress Y7(RR)E0277CMS: 100-04,23,60.3

Bed cradle, any type Y7(NU,RR,UE)E0280CMS: 100-04,23,60.3; 100-04,36,50.14

Hospital bed, fixed height, without side rails, withmattress Y7(RR)

E0290

CMS: 100-04,23,60.3

Hospital bed, fixed height, without side rails, withoutmattress Y7(RR)

E0291

CMS: 100-04,23,60.3

Hospital bed, variable height, hi-lo, without side rails, withmattress Y7(RR)

E0292

CMS: 100-04,23,60.3

Hospital bed, variable height, hi-lo, without side rails, withoutmattress Y7(RR)

E0293

CMS: 100-04,23,60.3

Hospitalbed, semi-electric (headand footadjustment),withoutside rails, withmattress Y7(RR)

E0294

CMS: 100-04,23,60.3

Hospitalbed, semi-electric (headand footadjustment),withoutside rails, without mattress Y7(RR)

E0295

CMS: 100-04,23,60.3

Hospitalbed, total electric (head, foot, andheightadjustments),without side rails, withmattress Y7(RR)

E0296

CMS: 100-04,23,60.3

Hospitalbed, total electric (head, foot, andheightadjustments),without side rails, without mattress Y7(RR)

E0297

CMS: 100-04,23,60.3

Pediatric crib, hospital grade, fully enclosed, with or withouttop enclosure Y7(RR)

E0300

CMS: 100-04,23,60.3

Hospital bed, heavy-duty, extra wide, with weight capacitygreater than 350 pounds, but less than or equal to 600 pounds,with any type side rails, without mattress Y7(RR)

E0301

CMS: 100-04,23,60.3

Hospitalbed,extraheavy-duty,extrawide,withweightcapacitygreater than 600 pounds, with any type side rails, withoutmattress Y7(RR)

E0302

CMS: 100-04,23,60.3

Hospital bed, heavy-duty, extra wide, with weight capacitygreater than 350 pounds, but less than or equal to 600 pounds,with any type side rails, withmattress Y7(RR)

E0303

CMS: 100-04,23,60.3

Hospitalbed,extraheavy-duty,extrawide,withweightcapacitygreater than 600 pounds, with any type side rails, withmattress Y7(RR)

E0304

CMS: 100-04,23,60.3

Bedside rails, half-length Y7(RR)E0305CMS: 100-04,23,60.3

Bedside rails, full-length Y7(NU,RR,UE)E0310CMS: 100-04,23,60.3; 100-04,36,50.14

Bed accessory: board, table, or support device, any type EE0315

Safety enclosure frame/canopy for use with hospital bed, anytype Y7(RR)

E0316

CMS: 100-04,23,60.3AHA: 1Q, '02, 5

Urinal; male, jug-type, anymaterial :Y7(NU,RR,UE)E0325

Urinal; female, jug-type, anymaterial y ;Y7(NU,RR,UE)E0326

Hospital bed, pediatric, manual, 360 degree side enclosures,topofheadboard, footboardandside rails up to24 inabove thespring, includes mattress Y

E0328

Hospitalbed,pediatric, electricor semi-electric, 360degree sideenclosures, top of headboard, footboard and side rails up to 24in above the spring, includes mattress Y

E0329

Control unit for electronic bowel irrigation/evacuationsystem E

E0350

Disposable pack (water reservoir bag, speculum, valvingmechanism, and collection bag/box) for usewith the electronicbowel irrigation/evacuation system E

E0352

Air pressure elevator for heel EE0370

E0247—

E0370Durable

MedicalEquipm

ent

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

E Codes— 29, SNF Excluded7 DMEPOS PaidAHA: Coding ClinicCMS: IOMg-w ASC Pmt© 2017 Optum360, LLC

E03702019 HCPCS Level II

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Medical nutrition therapy; reassessment and subsequentintervention(s) followingsecondreferral insameyear forchangeindiagnosis,medical conditionor treatment regimen (includingadditional hours needed for renal disease), individual,face-to-face with the patient, each 15minutes A@,

G0270

CMS: 100-04,12,190.3;100-04,12,190.6;100-04,12,190.6.1; 100-04,12,190.7

Medical nutrition therapy, reassessment and subsequentintervention(s) followingsecondreferral insameyear forchangeindiagnosis,medical condition,or treatment regimen(includingadditional hours needed for renal disease), group (2 or moreindividuals), each 30minutes A@,

G0271

Blinded procedure for lumbar stenosis, percutaneousimage-guided lumbardecompression (PILD)orplacebo-control,performedinanapprovedcoveragewithevidencedevelopment(CED) clinical trial Ji

G0276

CMS: 100-03,150.13; 100-04,32,330.1; 100-04,32,330.2

Hyperbaric oxygen under pressure, full body chamber, per 30minute interval S

G0277

AHA: 3Q, '15, 7

Iliac and/or femoral artery angiography, nonselective, bilateralor ipsilateral to catheter insertion, performed at the same timeascardiaccatheterizationand/orcoronaryangiography, includespositioning or placement of the catheter in the distal aorta oripsilateral femoral or iliac artery, injection of dye, productionof permanent images, and radiologic supervision andinterpretation (List separately in addition to primaryprocedure) N,

G0278

AHA: 3Q, '11, 3; 4Q, '06, 8

Diagnostic digital breast tomosynthesis, unilateral or bilateral(list separately in addition to 77065-77067) A

G0279Janm

CMS: 100-04,18,20.2; 100-04,18,20.2.2

Electrical stimulation, (unattended), to one or more areas, forchronic Stage III and Stage IV pressure ulcers, arterial ulcers,diabetic ulcers, and venous stasis ulcers not demonstratingmeasurable signs of healing after 30 days of conventional care,as part of a therapy plan of care A

G0281

CMS: 100-04,32,11.1AHA: 2Q, '03, 7; 1Q, '03, 7

Electrical stimulation, (unattended), to one or more areas, forwound care other than described in G0281 E

G0282

CMS: 100-04,32,11.1AHA: 2Q, '03, 7; 1Q, '03, 7

Electrical stimulation (unattended), to one or more areas forindication(s) other than wound care, as part of a therapy planof care A

G0283

AHA: 2Q, '09, 1; 2Q, '03, 7; 1Q, '03, 7

Reconstruction, computed tomographic angiography of aortafor surgical planning for vascular surgery N

G0288

Arthroscopy, knee, surgical, for removal of loose body, foreignbody,debridement/shavingofarticularcartilage(chondroplasty)at the time of other surgical knee arthroscopy in a differentcompartment of the same knee N,

G0289

AHA: 2Q, '03, 9

Noncovered surgical procedure(s) using conscious sedation,regional, general, or spinal anesthesia in aMedicare qualifyingclinical trial, per day Z@

G0293

AHA: 4Q, '02, 9-10

Noncovered procedure(s) using either no anesthesia or localanesthesia only, in a Medicare qualifying clinical trial, perday Z@

G0294

AHA: 4Q, '02, 9-10

Electromagnetic therapy, to one ormore areas, for wound careother than described in G0329 or for other uses E

G0295

AHA: 1Q, '03, 7

Counselingvisit todiscussneed for lung cancer screeningusinglow dose CT scan (LDCT) (service is for eligibility determinationand shared decisionmaking) S

G0296

CMS: 100-02,13,220; 100-02,13,220.1; 100-02,13,220.3; 100-04,18,220;100-04,18,220.1; 100-04,18,220.2; 100-04,18,220.3; 100-04,18,220.5;1004-04,13,220.1

Low dose CT scan (LDCT) for lung cancer screening SG0297CMS: 100-04,18,220; 100-04,18,220.1; 100-04,18,220.2; 100-04,18,220.3;100-04,18,220.5

Direct skilled nursing services of a registered nurse (RN) in thehome health or hospice setting, each 15minutes B

G0299

CMS: 100-01,3,30.3; 100-04,10,40.2; 100-04,11,30.3

Direct skilled nursing services of a licensedpractical nurse (lpn)in the home health or hospice setting, each 15minutes B

G0300

CMS: 100-01,3,30.3; 100-04,10,40.2; 100-04,11,30.3

Preoperative pulmonary surgery services for preparation forLVRS, complete course of services, to include aminimum of 16days of services S@

G0302

Preoperative pulmonary surgery services for preparation forLVRS, 10 to 15 days of services S@

G0303

Preoperative pulmonary surgery services for preparation forLVRS, 1 to 9 days of services S@

G0304

PostdischargepulmonarysurgeryservicesafterLVRS,minimumof 6 days of services S@

G0305

CompleteCBC,automated(HgB,HCT,RBC,WBC,withoutplateletcount) and automatedWBC differential count Q

G0306

CMS: 100-02,11,20.2

Complete (CBC), automated (HgB, Hct, RBC, WBC; withoutplatelet count) Q

G0307

CMS: 100-02,11,20.2

Colorectal cancer screening; fecal occult blood test,immunoassay, 1-3 simultaneous determinations A

G0328

CMS: 100-02,15,280.2.2; 100-04,16,70.8; 100-04,18,60; 100-04,18,60.1;100-04,18,60.1.1; 100-04,18,60.2; 100-04,18,60.2.1; 100-04,18,60.6;100-04,18,60.7AHA: 2Q, '12, 9

Electromagnetic therapy, tooneormoreareas for chronicStageIII and Stage IV pressure ulcers, arterial ulcers, diabetic ulcersand venous stasis ulcers not demonstratingmeasurable signsofhealingafter30daysof conventional careaspartof 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

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

G0339

AHA: 4Q, '13, 8-10; 1Q, '04, 6

Image guided robotic linear accelerator-based stereotacticradiosurgery,delivery includingcollimator changesandcustomplugging, fractionatedtreatment,all lesions,persession, secondthrough fifth sessions, maximum 5 sessions per course oftreatment B,

G0340

AHA: 4Q, '13, 8-10; 1Q, '04, 6

Jan January Update

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

© 2017 Optum360, LLCA-Y OPPS Status Indicators: Male Only; Female Onlyx Maternity Edity Age Edit44—G Codes

2019 HCPCS Level IIG0270Proc

edures

/Professiona

lService

s(Tem

porary)

G0270

—G0340

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Injection, mannitol, 25% in 50ml Nq@J2150Use this code for Osmitrol.CMS: 100-04,4,20.6.4

Injection, mecasermin, 1 mg Nq@J2170Use this code for Iplex, Increlex.CMS: 100-04,4,20.6.4

Injection, meperidine HCl, per 100mg Nq@J2175Use this code for Demerol.CMS: 100-04,4,20.6.4

Injection, meperidine and promethazine HCl, up to 50mg Nq@

J2180

Use this code for Mepergan Injection.CMS: 100-04,4,20.6.4

Injection, mepolizumab, 1mg Gn@J2182Use this code for Nucala.

Injection, meropenem, 100mg Nq@J2185Use this code for Merrem.CMS: 100-04,4,20.6.4AHA: 2Q, '05, 11

Injection, methylergonovinemaleate, up to 0.2 mg Nq@J2210Use this code for Methergine.CMS: 100-04,4,20.6.4

Injection, methylnaltrexone, 0.1 mg Nq@J2212Use this code for Relistor.

Injection, micafungin sodium, 1mg Nq@J2248Use this code for Mycamine.

Injection, midazolam HCl, per 1mg Nq@J2250Use this code for Versed.CMS: 100-04,4,20.6.4

Injection, milrinone lactate, 5 mg Kn@J2260Use this code for Primacor.CMS: 100-04,4,20.6.4

Injection, minocycline HCl, 1 mg Kn@J2265Use this code for MINOCIN.

Injection, morphine sulfate, up to 10mg Nq@J2270Use this code for Depodur, Infumorph.CMS: 100-04,4,20.6.4AHA: 2Q, '13, 5; 4Q, '05, 1-6; 3Q, '04, 1-10

Injection, morphine sulfate, preservative free for epidural orintrathecal use, 10mg Nq@

J2274

Use this code for DepoDur, Astromorph PF, Durarmorph PF.AHA: 1Q, '15, 6

Injection, ziconotide, 1 mcg Kn@J2278Use this code for Prialt.

Injection, moxifloxacin, 100mg Nq@J2280Use this code for Avelox.CMS: 100-04,4,20.6.4AHA: 2Q, '05, 11

Injection, nalbuphine HCl, per 10mg Nq@J2300Use this code for Nubain.CMS: 100-04,4,20.6.4

Injection, naloxone HCl, per 1mg Nq@J2310Use this code for Narcan.

Injection, naltrexone, depot form, 1mg Kn@J2315Use this code for Vivitrol.

Injection, nandrolone decanoate, up to 50mg Kn@J2320

Injection, natalizumab, 1mg Kn@J2323Use this code for Tysabri.AHA: 1Q, '08, 6

Injection, nesiritide, 0.1 mg Kn@J2325Use this code for Natrecor.CMS: 100-03,200.1

Injection, nusinersen, 0.1 mgJ2326JanlUse this code for Spinraza.

Injection, ocrelizumab, 1mgJ2350JanmUse this code for Ocrevus.

Injection, octreotide, depot form for intramuscular injection, 1mg Kn@

J2353

Use this code for Sandostatin LAR.

Injection, octreotide, nondepot form for subcutaneous orintravenous injection, 25mcg Nq@

J2354

Use this code for Sandostatin.

Injection, oprelvekin, 5 mg Kn@J2355Use this code for Neumega.AHA: 2Q, '05, 11

Injection, omalizumab, 5mg Kn@J2357Use this code for Xolair.AHA: 2Q, '05, 11

Injection, olanzapine, long-acting, 1 mg Kn@J2358Use this code for ZYPREXA RELPREVV.

Injection, orphenadrine citrate, up to 60mg Nq@J2360Use this code for Norflex.

Injection, phenylephrine HCl, up to 1ml Nq@J2370

Injection, chloroprocaine HCl, per 30ml Nq@J2400Use this code for Nesacaine, Nesacaine-MPF.

Injection, ondansetron HCl, per 1mg Nq@J2405Use this code for Zofran.

Injection, oritavancin, 10mg Gn@J2407Use this code for Orbactiv.

Injection, oxymorphone HCl, up to 1mg Nq@J2410Use this code for Numorphan, Oxymorphone HCl.

Injection, palifermin, 50mcg Kn@J2425Use this code for Kepivance.

Injection, paliperidone palmitate extended release, 1mg Kn@

J2426

Use this code for INVEGA SUSTENNA.

Injection, pamidronate disodium, per 30mg Nq@J2430Use this code for Aredia.

Injection, papaverine HCl, up to 60mg Nq@J2440

Injection, oxytetracycline HCl, up to 50mg Nq@J2460Use this code for Terramycin IM.

Injection, palonosetron HCl, 25mcg Kn@J2469Use this code for Aloxi.AHA: 2Q, '05, 11; 1Q, '05, 7, 9-10

Injection, paricalcitol, 1 mcg Nq@J2501Use this code For Zemplar.

Injection, pasireotide long acting, 1 mg Gn@J2502Use this code for Signifor LAR.

Injection, pegaptanib sodium, 0.3 mg Kn@J2503Use this code for Macugen.

Injection, pegademase bovine, 25 IU Kn@J2504Use this code for Adagen.

J2150—

J2504Drugs

Adm

inisteredOtherThan

OralM

ethod

Jan January Update

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

J Codes— 85, SNF Excluded7 DMEPOS PaidAHA: Coding ClinicCMS: IOMg-w ASC Pmt© 2017 Optum360, LLC

J25042019 HCPCS Level II

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All lower extremity prostheses, foot, multiaxialankle/foot A,7

L5978

All lower extremity prostheses, multiaxial ankle, dynamicresponse foot, one piece system A,7

L5979

All lower extremity prostheses, flex-foot system A,7L5980

All lower extremity prostheses, flex-walk system orequal A,7

L5981

All exoskeletal lower extremity prostheses, axial rotationunit A,7

L5982

All endoskeletal lowerextremityprostheses, axial rotationunit,with or without adjustability A,7

L5984

Allendoskeletal lowerextremityprostheses,dynamicprostheticpylon A,7

L5985

All lowerextremityprostheses,multiaxial rotationunit (MCPorequal) A,7

L5986

All lower extremity prostheses, shank foot systemwith verticalloading pylon A7

L5987

Addition to lower limbprosthesis, vertical shock reducingpylonfeature A,7

L5988

Addition to lower extremity prosthesis, user adjustable heelheight A,7

L5990

AHA: 1Q, '02, 5

Lower extremity prosthesis, not otherwise specified AL5999Determine if an alternative HCPCS Level II or a CPT code better describesthe servicebeing reported. This code shouldbeusedonly if amore specificcode is unavailable.

Partial Hand

Partial hand, thumb remaining A7L6000

Partial hand, little and/or ring finger remaining A7L6010

Partial hand, no finger remaining A7L6020

Transcarpal/metacarpal or partial hand disarticulationprosthesis, external power, self-suspended, inner socket withremovable forearmsection,electrodesandcables, twobatteries,charger, myoelectric control of terminal device, excludesterminal device(s) A7

L6026

Wrist Disarticulation

Wrist disarticulation, molded socket, flexible elbow hinges,triceps pad A,7

L6050

Wristdisarticulation,moldedsocketwithexpandable interface,flexible elbow hinges, triceps pad A,7

L6055

Below Elbow

Below elbow, molded socket, flexible elbow hinge, tricepspad A,7

L6100

Below elbow, molded socket (Muenster or Northwesternsuspension types) A,7

L6110

Below elbow, molded double wall split socket, step-up hinges,half cuff A,7

L6120

Belowelbow,moldeddoublewall split socket, stumpactivatedlocking hinge, half cuff A,7

L6130

ElbowDisarticulation

Elbow disarticulation, molded socket, outside locking hinge,forearm A,7

L6200

Elbowdisarticulation,moldedsocketwithexpandable interface,outside locking hinges, forearm A,7

L6205

Above Elbow

Aboveelbow,moldeddoublewall socket, internal lockingelbow,forearm A,7

L6250

Shoulder Disarticulation

Shoulder disarticulation, molded socket, shoulder bulkhead,humeral section, internal locking elbow, forearm A,7

L6300

Shoulder disarticulation, passive restoration (completeprosthesis) A,7

L6310

Shoulder disarticulation, passive restoration (shoulder caponly) A,7

L6320

Interscapular Thoracic

Interscapular thoracic, molded socket, shoulder bulkhead,humeral section, internal locking elbow, forearm A,7

L6350

Interscapular thoracic, passive restoration (completeprosthesis) A,7

L6360

Interscapular thoracic, passive restoration (shoulder caponly) A,7

L6370

Immediate and Early Postsurgical Procedures

Immediate postsurgical or early fitting, application of initialrigid dressing, including fitting alignment and suspension ofcomponents,andonecast change,wristdisarticulationorbelowelbow A7

L6380

Immediate postsurgical or early fitting, application of initialrigid dressing including fitting alignment and suspension ofcomponents, and one cast change, elbow disarticulation orabove elbow A@7

L6382

Immediate postsurgical or early fitting, application of initialrigid dressing including fitting alignment and suspension ofcomponents, and one cast change, shoulder disarticulation orinterscapular thoracic A@7

L6384

Immediate postsurgical or early fitting, each additional castchange and realignment A@7

L6386

Immediate postsurgical or early fitting, application of rigiddressing only A7

L6388

Molded Socket

Below elbow, molded socket, endoskeletal system, includingsoft prosthetic tissue shaping A,7

L6400

Elbow disarticulation, molded socket, endoskeletal system,including soft prosthetic tissue shaping A,7

L6450

Above elbow, molded socket, endoskeletal system, includingsoft prosthetic tissue shaping A,7

L6500

Shoulder disarticulation, molded socket, endoskeletal system,including soft prosthetic tissue shaping A,7

L6550

Interscapular thoracic, molded socket, endoskeletal system,including soft prosthetic tissue shaping A,7

L6570

L5978—

L6570Prosthetic Procedures=

=

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

L Codes— 117, SNF Excluded7 DMEPOS PaidAHA: Coding ClinicCMS: IOMg-w ASC Pmt© 2017 Optum360, LLC

L65702019 HCPCS Level II

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Perphenazine,4mg,oral,FDAapprovedprescriptionantiemetic,foruseasa complete therapeutic substitute foran IVantiemeticat the timeof chemotherapy treatment, not toexceeda48hourdosage 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, 25mg, 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

Dolasetronmesylate, 100mg, 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

Powermodule patient cable for use with electric orelectric/pneumatic ventricular assist device, replacementonly

Q0477Janl

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

Q0478

Powermodule 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/displaymodule for use with electric ventricular assistdevice, replacement only A7

Q0483

AHA: 3Q, '05, 1-2

Monitor/displaymodule 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

Monitorcontrol cable forusewithelectric/pneumaticventricularassist 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 usewith 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 usewith electric ventricularassist device, replacement only A7

Q0492

AHA: 3Q, '05, 1-2

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

Q0493

AHA: 3Q, '05, 1-2

Emergencyhandpumpforusewithelectricorelectric/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

Q0175

—Q0503

Temporary

Codes

Jan January Update

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

Q Codes (Temporary)—, SNF Excluded7 DMEPOS PaidAHA: Coding ClinicCMS: IOMg-w ASC Pmt© 2017 Optum360, LLC 129

Q05032019 HCPCS Level II


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