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  • Power up your codingoptum360coding.com

    2019

    HCPCS Level IIA resourceful compilation of HCPCS codes

    Supports HIPAA compliance

    EXPERT

  • © 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

  • © 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

  • 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

  • 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 [email protected]

    Syringe with needle, sterile 2 cc, each [email protected]

    Syringe with needle, sterile 3 cc, each [email protected]

    Syringe with needle, sterile 5 cc or greater, each [email protected]

    Needle-free injection device, each [email protected] 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 [email protected]

    Needle, sterile, any size, each NA4215

    Sterile water, saline and/or dextrose, diluent/flush, 10ml [email protected]

    A4216

    Sterile water/saline, 500ml [email protected](AU)A4217CMS: 100-04,20,30.9

    Sterile saline or water, metered dose dispenser, 10ml [email protected]

    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) [email protected]

    A4223

    Supplies for maintenance of insulin infusion catheter, perweek N7

    A4224

    s Revised Codem Recycled/Reinstatedl New [email protected] Quantity AlertCarrier DiscretionNoncovered by MedicareSpecial Coverage Instructions

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

    2019 HCPCS Level IIA0426M

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    A0426

    —A4224

  • 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 [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    B4087

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

    Gastrostomy/jejunostomy tube, low-profile, anymaterial, anytype, each [email protected]

    B4088

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

    Food thickener, administered orally, per oz [email protected]: 100-03,180.2

    Enteral formula, foradults,usedtoreplacefluidsandelectrolytes(e.g., clear liquids), 500ml = 1 unit [email protected]

    B4102

    CMS: 100-03,180.2

    Enteral formula, for pediatrics, used to replace fluids andelectrolytes (e.g., clear liquids), 500ml = 1 unit [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    B4160

    CMS: 100-03,180.2

    s Revised Codem Recycled/Reinstatedl New [email protected] 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

  • Humanplasma fibrin sealant, vapor-heated, solvent-detergent(Artiss), 2 ml [email protected]

    C9250

    Injection, lacosamide, 1 mg [email protected] this code for VIMPAT.

    Injection, bevacizumab, 0.25mg [email protected] this code for Avastin.CMS: 100-03,110.17AHA: 3Q, '13, 9

    Injection, hexaminolevulinate HCl, 100mg, per studydose [email protected]

    C9275

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

    Lidocaine 70mg/tetracaine 70mg, per patch [email protected] this code for SYNERA.AHA: 3Q, '11, 9

    Injection, bupivacaine liposome, 1mg [email protected] this code for EXPAREL.AHA: 2Q, '12, 7

    Injection, glucarpidase, 10 units [email protected] this code for Voraxaze.

    Microporouscollagenimplantabletube(NeuraGenNerveGuide),per cm length [email protected]

    C9352

    AHA: 1Q, '08, 6

    Microporous collagen implantable slit tube (NeuraWrap NerveProtector), per cm length [email protected]

    C9353

    AHA: 1Q, '08, 6

    Acellularpericardial tissuematrixofnonhumanorigin (Veritas),per sq cm [email protected]

    C9354

    AHA: 1Q, '08, 6

    Collagen nerve cuff (NeuroMatrix), per 0.5 cm length [email protected]: 1Q, '08, 6

    Tendon, porousmatrix of cross-linked collagen andglycosaminoglycanmatrix (TenoGlideTendonProtectorSheet),per sq cm [email protected]

    C9356

    AHA: 3Q, '08, 6

    Dermal substitute,native,nondenaturedcollagen, fetalbovineorigin (SurgiMend CollagenMatrix), per 0.5 sq cm [email protected]

    C9358

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

    Porouspurifiedcollagenmatrixbonevoid filler (IntegraMozaikOsteoconductive Scaffold Putty, Integra OS OsteoconductiveScaffold Putty), per 0.5 cc [email protected]

    C9359

    AHA: 3Q, '15, 2

    Dermal substitute, native, nondenatured collagen, neonatalbovine origin (SurgiMend CollagenMatrix), per 0.5 sqcm [email protected]

    C9360

    AHA: 2Q, '12, 7

    Collagenmatrixnervewrap (NeuroMendCollagenNerveWrap),per 0.5 cm length [email protected]

    C9361

    Porouspurifiedcollagenmatrixbonevoid filler (IntegraMozaikOsteoconductive Scaffold Strip), per 0.5 cc [email protected]

    C9362

    AHA: 2Q, '10, 8

    Skin substitute (Integra Meshed Bilayer WoundMatrix), per sqcm [email protected]

    C9363

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

    Porcine implant, Permacol, per sq cm [email protected]

    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 [email protected] this code for Omidria.

    Injection, cangrelor, 1 mg [email protected] this code for Kengreal.AHA: 1Q, '16, 6-8

    Injection, sotalol hydrochloride, 1 mg [email protected]: 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 [email protected] 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 [email protected]: 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 [email protected] 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

  • 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 [email protected] 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

  • 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 [email protected],

    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 [email protected],

    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 [email protected]

    G0293

    AHA: 4Q, '02, 9-10

    Noncovered procedure(s) using either no anesthesia or localanesthesia only, in a Medicare qualifying clinical trial, perday [email protected]

    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 [email protected]

    G0302

    Preoperative pulmonary surgery services for preparation forLVRS, 10 to 15 days of services [email protected]

    G0303

    Preoperative pulmonary surgery services for preparation forLVRS, 1 to 9 days of services [email protected]

    G0304

    PostdischargepulmonarysurgeryservicesafterLVRS,minimumof 6 days of services [email protected]

    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 [email protected] 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

  • Injection, mannitol, 25% in 50ml [email protected] this code for Osmitrol.CMS: 100-04,4,20.6.4

    Injection, mecasermin, 1 mg [email protected] this code for Iplex, Increlex.CMS: 100-04,4,20.6.4

    Injection, meperidine HCl, per 100mg [email protected] this code for Demerol.CMS: 100-04,4,20.6.4

    Injection, meperidine and promethazine HCl, up to 50mg [email protected]

    J2180

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

    Injection, mepolizumab, 1mg [email protected] this code for Nucala.

    Injection, meropenem, 100mg [email protected] this code for Merrem.CMS: 100-04,4,20.6.4AHA: 2Q, '05, 11

    Injection, methylergonovinemaleate, up to 0.2 mg [email protected] this code for Methergine.CMS: 100-04,4,20.6.4

    Injection, methylnaltrexone, 0.1 mg [email protected] this code for Relistor.

    Injection, micafungin sodium, 1mg [email protected] this code for Mycamine.

    Injection, midazolam HCl, per 1mg [email protected] this code for Versed.CMS: 100-04,4,20.6.4

    Injection, milrinone lactate, 5 mg [email protected] this code for Primacor.CMS: 100-04,4,20.6.4

    Injection, minocycline HCl, 1 mg [email protected] this code for MINOCIN.

    Injection, morphine sulfate, up to 10mg [email protected] 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 [email protected]

    J2274

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

    Injection, ziconotide, 1 mcg [email protected] this code for Prialt.

    Injection, moxifloxacin, 100mg [email protected] this code for Avelox.CMS: 100-04,4,20.6.4AHA: 2Q, '05, 11

    Injection, nalbuphine HCl, per 10mg [email protected] this code for Nubain.CMS: 100-04,4,20.6.4

    Injection, naloxone HCl, per 1mg [email protected] this code for Narcan.

    Injection, naltrexone, depot form, 1mg [email protected] this code for Vivitrol.

    Injection, nandrolone decanoate, up to 50mg [email protected]

    Injection, natalizumab, 1mg [email protected] this code for Tysabri.AHA: 1Q, '08, 6

    Injection, nesiritide, 0.1 mg [email protected] 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 [email protected]

    J2353

    Use this code for Sandostatin LAR.

    Injection, octreotide, nondepot form for subcutaneous orintravenous injection, 25mcg [email protected]

    J2354

    Use this code for Sandostatin.

    Injection, oprelvekin, 5 mg [email protected] this code for Neumega.AHA: 2Q, '05, 11

    Injection, omalizumab, 5mg [email protected] this code for Xolair.AHA: 2Q, '05, 11

    Injection, olanzapine, long-acting, 1 mg [email protected] this code for ZYPREXA RELPREVV.

    Injection, orphenadrine citrate, up to 60mg [email protected] this code for Norflex.

    Injection, phenylephrine HCl, up to 1ml [email protected]

    Injection, chloroprocaine HCl, per 30ml [email protected] this code for Nesacaine, Nesacaine-MPF.

    Injection, ondansetron HCl, per 1mg [email protected] this code for Zofran.

    Injection, oritavancin, 10mg [email protected] this code for Orbactiv.

    Injection, oxymorphone HCl, up to 1mg [email protected] this code for Numorphan, Oxymorphone HCl.

    Injection, palifermin, 50mcg [email protected] this code for Kepivance.

    Injection, paliperidone palmitate extended release, 1mg [email protected]

    J2426

    Use this code for INVEGA SUSTENNA.

    Injection, pamidronate disodium, per 30mg [email protected] this code for Aredia.

    Injection, papaverine HCl, up to 60mg [email protected]

    Injection, oxytetracycline HCl, up to 50mg [email protected] this code for Terramycin IM.

    Injection, palonosetron HCl, 25mcg [email protected] this code for Aloxi.AHA: 2Q, '05, 11; 1Q, '05, 7, 9-10

    Injection, paricalcitol, 1 mcg [email protected] this code For Zemplar.

    Injection, pasireotide long acting, 1 mg [email protected] this code for Signifor LAR.

    Injection, pegaptanib sodium, 0.3 mg [email protected] this code for Macugen.

    Injection, pegademase bovine, 25 IU [email protected] this code for Adagen.

    J2150—

    J2504Drugs

    Adm

    inisteredOtherThan

    OralM

    ethod

    Jan January Update

    s Revised Codem Recycled/Reinstatedl New [email protected] 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

  • 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 [email protected]

    L6382

    Immediate postsurgical or early fitting, application of initialrigid dressing including fitting alignment and suspension ofcomponents, and one cast change, shoulder disarticulation orinterscapular thoracic [email protected]

    L6384

    Immediate postsurgical or early fitting, each additional castchange and realignment [email protected]

    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 [email protected] 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

  • Perphenazine,4mg,oral,FDAapprovedprescriptionantiemetic,foruseasa complete therapeutic substitute foran IVantiemeticat the timeof chemotherapy treatment, not toexceeda48hourdosage regimen [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    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 [email protected]

    Q0503

    AHA: 3Q, '05, 1-2

    Q0175

    —Q0503

    Temporary

    Codes

    Jan January Update

    s Revised Codem Recycled/Reinstatedl New [email protected] 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