preauthorization requirements list effective … · 2020. 12. 22. · 70482 ct orbit/ear/fossa...

ServiceElective or Emergency Inpatient

Dialysis Treatment (Out-of-network services only)

Home Health, Hospice Care

Home Infusion

Elective surgery at a Hospital or Ambulatory

Surgical Facility (Out-of-Network services only)

Other Procedures Requiring Prior Authorization

Specialty Pharmacy

Service Category Procedure Code Code DescriptionMedical Policy No/

GuidelineMedical Policy Title

Advanced Imaging- Advanced Imaging Services:

MRI, MRA, PET, PET-CT, CT, CTA, Nuclear

Medicine (excludes Cardiac Advanced Imaging)

70336 Magnetic Image Jaw Joint AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70450 Ct Head/Brain W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70460 Ct Head/Brain W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70470 Ct Head/Brain W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70480 Ct Orbit/Ear/Fossa W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70481 Ct Orbit/Ear/Fossa W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70482 Ct Orbit/Ear/Fossa W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70486 Ct Maxillofacial W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70487 Ct Maxillofacial W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70488 Ct Maxillofacial W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com

Admission to a licensed Acute Care Facility, Skilled Nursing Facility, Long Term Care Facility inpatient Admissions.

PREAUTHORIZATION REQUIREMENTS LIST EFFECTIVE 01/01/2021

• Preauthorization is required by BCBSMT for certain services to determine in advance the Medical Necessity or Experiment Investigational and/or Unproven nature of certain care and services based on MCG Criteria,

Medical Policy and Member benefits. The list below describes the services that require preauthorization.

• Predetermination is a process used to submit requests for review of coverage decisions in accordance with medical policy and member contracts for a service (i.e., procedure, supply, drug or device) used to diagnose or

treat an illness or condition. A predetermination is recommended if a provider is uncertain if the service meets medical policy criteria. Contact Provider Customer Service to determine if a service not on this list is subject to

medical necessity review.

• Not all requirements apply to each product in these networks (Blue Preferred PPOSM, Blue OptionsSM, Blue Focus POSSM, Managed CareSM or TraditionalSM). It is imperative that providers check eligibility and benefits

and verify preauthorization requirements through Availity®.

Medical/Surgical Services Requiring Preauthorization

Service Description

MEDICAL SURGICAL SERVICES

2021 Commercial Outpatient Benefit Preauthorization Procedure Code List

This list includes Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes related to services/categories for which benefit preauthorization may be required as of 01/01/2021 for

commercial, fully insured, standard plans/networks,

This is not an exhaustive listing of all codes. Codes may change, and this list may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract.

Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply. Benefit preauthorization for some

services/categories must be obtained through Blue Cross and Blue Shield of Montana (BCBSMT). Benefit preauthorization for other services/categories must be obtained through a utilization management vendor.

It is imperative that providers check eligibility and benefits for each patient prior to rendering services to confirm benefits, benefit preauthorization/pre-notification requirements and utilization management vendors that must be

used, if applicable. Providers may submit online eligibility and benefits inquiries (electronic 270 transactions) via the Availity® Provider Portal or other preferred web vendor portal. Services performed without benefit

preauthorization, if required, may be denied for payment and providers may not seek reimbursement from BCBSMT members. Obtaining benefit preauthorization/pre-notification is not a substitute for confirming eligibility and

benefits.

PRESS "CTRL" AND "F" KEYS AT THE SAME TIME TO BRING UP THE SEARCH BOX. ENTER A PROCEDURE CODE OR DESCRIPTION OF THE SERVICE.

Dialysis Treatment provided by an Out-of-network provider.

Skilled home health care provided by a lincensed home health or hospice agency.

Outpatient Infusion therapy provided by a licensed home infusion agency.

Outpatient elective surgery performed at an out of network hospital or ambulatory surgery facility. Specific service requiring preauthorization are listed in the table below.

Specific service requiring preauthorization are listed in the table below.

Refer to 2021 Specialty Drugs Preauthorization List for Infusion Site of Care on Claims and Eligibility, Predetermination and Preauthorization section on bcbsmt.com/provider.

12/20/2020 2021 Commercial Outpatient Benefit Preauthorization Procedure Code List 1/24




70490 Ct Soft Tissue Neck W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70491 Ct Soft Tissue Neck W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70492 Ct Sft Tsue Nck W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70496 Ct Angiography Head AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70498 Ct Angiography Neck AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70540 Mri Orbit/Face/Neck W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70542 Mri Orbit/Face/Neck W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70543 Mri Orbt/Fac/Nck W/O &W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70544 Mr Angiography Head W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70545 Mr Angiography Head W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70546 Mr Angiograph Head W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70547 Mr Angiography Neck W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70548 Mr Angiography Neck W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70549 Mr Angiograph Neck W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70551 Mri Brain Stem W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70552 Mri Brain Stem W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70553 Mri Brain Stem W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70554 Fmri Brain By Tech AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




70555 Fmri Brain By Phys/Psych AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




71250 Ct Thorax W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




71260 Ct Thorax W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




71270 Ct Thorax W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




71271 Ct Thorax Lung Cancer Scr C- AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




71275 Ct Angiography Chest AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




71550 Mri Chest W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




71551 Mri Chest W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





71552 Mri Chest W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




71555 Mri Angio Chest W Or W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72125 Ct Neck Spine W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72126 Ct Neck Spine W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72127 Ct Neck Spine W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72128 Ct Chest Spine W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72129 Ct Chest Spine W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72130 Ct Chest Spine W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72131 Ct Lumbar Spine W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72132 Ct Lumbar Spine W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72133 Ct Lumbar Spine W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72141 Mri Neck Spine W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72142 Mri Neck Spine W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72146 Mri Chest Spine W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72147 Mri Chest Spine W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72148 Mri Lumbar Spine W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72149 Mri Lumbar Spine W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72156 Mri Neck Spine W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72157 Mri Chest Spine W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72158 Mri Lumbar Spine W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72159 Mr Angio Spine W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72191 Ct Angiograph Pelv W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72192 Ct Pelvis W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72193 Ct Pelvis W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72194 Ct Pelvis W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72195 Mri Pelvis W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





72196 Mri Pelvis W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72197 Mri Pelvis W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




72198 Mr Angio Pelvis W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73200 Ct Upper Extremity W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73201 Ct Upper Extremity W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73202 Ct Uppr Extremity W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73206 Ct Angio Upr Extrm W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73218 Mri Upper Extremity W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73219 Mri Upper Extremity W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73220 Mri Uppr Extremity W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73221 Mri Joint Upr Extrem W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73222 Mri Joint Upr Extrem W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73223 Mri Joint Upr Extr W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73225 Mr Angio Upr Extr W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73700 Ct Lower Extremity W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73701 Ct Lower Extremity W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73702 Ct Lwr Extremity W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73706 Ct Angio Lwr Extr W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73718 Mri Lower Extremity W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73719 Mri Lower Extremity W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73720 Mri Lwr Extremity W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73721 Mri Jnt Of Lwr Extre W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73722 Mri Joint Of Lwr Extr W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73723 Mri Joint Lwr Extr W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




73725 Mr Ang Lwr Ext W Or W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74150 Ct Abdomen W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





74160 Ct Abdomen W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74170 Ct Abdomen W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74174 Ct Angio Abd&Pelv W/O&W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74175 Ct Angio Abdom W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74176 Ct Abd & Pelvis W/O Contrast AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74177 Ct Abd & Pelv W/Contrast AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74178 Ct Abd & Pelv 1/> Regns AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74181 Mri Abdomen W/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74182 Mri Abdomen W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74183 Mri Abdomen W/O & W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74185 Mri Angio Abdom W Orw/O Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74261 Ct Colonography Dx AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74262 Ct Colonography Dx W/Dye AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74263 Ct Colonography Screening AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74712 Mri Fetal Sngl/1St Gestation AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




74713 Mri Fetal Ea Addl Gestation AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




75635 Ct Angio Abdominal Arteries AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




76376 3D Render W/Intrp Postproces AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




76377 3D Render W/Intrp Postproces AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




76380 Cat Scan Follow-Up Study AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




76390 Mr Spectroscopy AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




76391 Mr Elastography AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




76497 Ct Procedure AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




76498 Mri Procedure AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




76975 Gi Endoscopic Ultrasound AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




77021 Mri Guidance Ndl Plmt Rs&I AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





77022 Mri Gdn Parnchyma Tiss Abltj AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




77046 Mri Breast C- Unilateral AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




77047 Mri Breast C- Bilateral AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




77048 Mri Breast C-+ W/Cad Uni AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




77049 Mri Breast C-+ W/Cad Bi AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




77078 Ct Bone Density Axial AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




77084 Magnetic Image Bone Marrow AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78012 Thyroid Uptake Measurement AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78013 Thyroid Imaging W/Blood Flow AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78014 Thyroid Imaging W/Blood Flow AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78015 Thyroid Met Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78016 Thyroid Met Imaging/Studies AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78018 Thyroid Met Imaging Body AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78020 Thyroid Met Uptake AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78070 Parathyroid Planar Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78071 Parathyrd Planar W/Wo Subtrj AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78072 Parathyrd Planar W/Spect&Ct AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78075 Adrenal Cortex & Medulla Img AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78102 Bone Marrow Imaging Ltd AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78103 Bone Marrow Imaging Mult AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78104 Bone Marrow Imaging Body AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78185 Spleen Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78195 Lymph System Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78201 Liver Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78202 Liver Imaging With Flow AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78215 Liver And Spleen Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





78216 Liver & Spleen Image/Flow AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78226 Hepatobiliary System Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78227 Hepatobil Syst Image W/Drug AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78230 Salivary Gland Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78231 Serial Salivary Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78232 Salivary Gland Function Exam AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78258 Esophageal Motility Study AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78261 Gastric Mucosa Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78262 Gastroesophageal Reflux Exam AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78264 Gastric Emptying Imag Study AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com












78278 Acute Gi Blood Loss Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78290 Meckels Divert Exam AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78291 Leveen/Shunt Patency Exam AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78300 Bone Imaging Limited Area AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78305 Bone Imaging Multiple Areas AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78306 Bone Imaging Whole Body AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78315 Bone Imaging 3 Phase AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78445 Vascular Flow Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78456 Acute Venous Thrombus Image AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78457 Venous Thrombosis Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78458 Ven Thrombosis Images Bilat AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78579 Lung Ventilation Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78580 Lung Perfusion Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78582 Lung Ventilat&Perfus Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





78597 Lung Perfusion Differential AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78598 Lung Perf&Ventilat Diferentl AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78600 Brain Image < 4 Views AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78601 Brain Image W/Flow < 4 Views AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78605 Brain Image 4+ Views AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78606 Brain Image W/Flow 4 + Views AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78608 Brain Imaging (Pet) AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78609 Brain Imaging (Pet) AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78610 Brain Flow Imaging Only AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78630 Cerebrospinal Fluid Scan AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78635 Csf Ventriculography AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78645 Csf Shunt Evaluation AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78650 Csf Leakage Imaging AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78660 Nuclear Exam Of Tear Flow AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78700 Kidney Imaging Morphol AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78701 Kidney Imaging With Flow AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78707 K Flow/Funct Image W/O Drug AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78708 K Flow/Funct Image W/Drug AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78709 K Flow/Funct Image Multiple AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78725 Kidney Function Study AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78730 Urinary Bladder Retention AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78740 Ureteral Reflux Study AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78761 Testicular Imaging W/Flow AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78800 Rp Loclzj Tum 1 Area 1 D Img AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78801 Rp Loclzj Tum 2+Area 1+D Img AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78802 Rp Loclzj Tum Whbdy 1 D Img AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





78803 Rp Loclzj Tum Spect 1 Area AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78804 Rp Loclzj Tum Whbdy 2+D Img AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78811 Pet Image Ltd Area AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78812 Pet Image Skull-Thigh AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78813 Pet Image Full Body AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78814 Pet Image W/Ct Lmtd AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78815 Pet Image W/Ct Skull-Thigh AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78816 Pet Image W/Ct Full Body AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78830 Rp Loclzj Tum Spect W/Ct 1 AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78831 Rp Loclzj Tum Spect 2 Areas AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




78832 Rp Loclzj Tum Spect W/Ct 2 AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




0042T Ct Perfusion W/Contrast Cbf AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




C8900Magnetic Resonance Angiography With Contrast

AbdomenAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




C8901Magnetic Resonance Angiography Without Contrast

AbdomenAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Followed By With Contrast AbdomenAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




C8903Magnetic Resonance Imaging With Contrast Breast;

UnilateralAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




C8905Magnetic Resonance Imaging Without Contrast

Followed By With Contrast Breast; UnilateralAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




C8906Magnetic Resonance Imaging With Contrast Breast;

BilateralAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




C8908Magnetic Resonance Imaging Without Contrast

Followed By With Contrast Breast; BilateralAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Chest (Excluding Myocardium)AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Chest (Excluding Myocardium)AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




C8911

Magnetic Resonance Angiography Without Contrast

Followed By With Contrast Chest (Excluding

Myocardium)

AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Lower ExtremityAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Lower ExtremityAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Followed By With Contrast Lower ExtremityAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





PelvisAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com






PelvisAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Followed By With Contrast PelvisAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Spinal Canal And ContentsAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Spinal Canal And ContentsAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Followed By With Contrast Spinal Canal And ContentsAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Upper ExtremityAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Upper ExtremityAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com





Followed By With Contrast Upper ExtremityAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




G0219Pet Imaging Whole Body; Melanoma For Non-Covered

IndicationsAIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




G0235 Pet Imaging Any Site Not Otherwise Specified AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




G0252

Pet Imaging Full And Partial-Ring Pet Scanners Only

For Initial Diagnosis Of Breast Cancer And/Or Surgical

Planning For Breast Cancer (E. G. Initial Staging Of

Axillary Lymph Nodes)





G0297 Low Dose Ct Scan (Ldct) For Lung Cancer Screening AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




S8037Magnetic Resonance Cholangiopancreatography

(Mrcp)AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




S8042 Magnetic Resonance Imaging (Mri) Low-Field AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com




S8085

Fluorine-18 Fluorodeoxyglucose (F-18 Fdg) Imaging

Using Dual-Head Coincidence Detection System (Non-

Dedicated Pet Scan)





S8092Electron Beam Computed Tomography (Also Known

As Ultrafast Ct Cine Ct)AIM Clinical Guidelines Call 1-844-377-1285 or Access Website https://aimspecialtyhealth.com

Air Ambulance (fixed wing & rotary) for non-

emergent medical transportationA0430

Ambulance Service Conventional Air Services

Transport One Way (Fixed Wing)ADM1001.005 Ambulance and Medical Transport Services


emergent medical transportationA0431

Ambulance Service Conventional Air Services

Transport One Way (Rotary Wing)ADM1001.005 Ambulance and Medical Transport Services


emergent medical transportationA0435 Fixed Wing Air Mileage Per Statute Mile ADM1001.005 Ambulance and Medical Transport Services


emergent medical transportationA0436 Rotary Wing Air Mileage Per Statute Mile ADM1001.005 Ambulance and Medical Transport Services

Home Health, Hospice Care 99500 Home Visit PrenatalMCG

OB401.017

Clinical Guidelines

Home Uterine Activity MonitoringHome Health, Hospice Care 99501 Home Visit Postnatal MCG Clinical GuidelinesHome Health, Hospice Care 99502 Home Visit Nb Care MCG Clinical GuidelinesHome Health, Hospice Care 99503 Home Visit Resp Therapy MCG Clinical GuidelinesHome Health, Hospice Care 99504 Hhome Visit Mech Ventilator MCG Clinical GuidelinesHome Health, Hospice Care 99505 Home Visit Stoma Care MCG Clinical Guidelines

Home Health, Hospice Care 99506 Home Visit Im InjectionMCG

RX501.062

Clinical Guidelines

Progesterone Therapy as a Technique to Reduce Preterm Delivery in High-Risk Pregnancies

Home Health, Hospice Care 99507 Home Visit Cath Maintain MCG Clinical Guidelines

Home Health, Hospice Care 99509 Home Visit Day Life ActivityMCG

ADM1001.014

Clinical Guidelines

Custodial CareHome Health, Hospice Care 99511 Home Visit Fecal/Enema Mgmt MCG Clinical GuidelinesHome Health, Hospice Care 99600 Home Visit Nos MCG Clinical Guidelines

Home Health, Hospice Care G0151

Services Performed By A Qualified Physical Therapist

In The Home Health Or Hospice Setting Each 15

Minutes

MCG

PSY301.014

THE803.010

Guidelines

Autism Spectrum Disorders (ASD)

Physical Therapy (PT) and Occupational Therapy (OT) Services


Services Performed By A Qualified Occupational

Therapist In The Home Health Or Hospice Setting

Each 15 Minutes

MCG

PSY301.014

THE803.010

Clinical Guidelines




Services Performed By A Qualified Speech-Language

Pathologist In The Home Health Or Hospice Setting

Each 15 Minutes

MCG

PSY301.014

THE803.014

Clinical Guidelines

PSY301.014

THE803.014

Home Health, Hospice Care G0155Services Of Clinical Social Worker In Home Health Or

Hospice Settings, Each 15 MinutesMCG Clinical Guidelines

Home Health, Hospice Care G0156Services Of Home Health/Hospice Aide In Home

Health Or Hospice Settings, Each 15 MinutesMCG Clinical Guidelines



Assistant In The Home Health Or Hospice Setting

Each 15 Minutes

MCG

PSY301.014

THE803.010

Guidelines






Therapist Assistant In The Home Health Or Hospice

Setting Each 15 Minutes

MCG

PSY301.014

THE803.010

Clinical Guidelines





In The Home Health Setting In The Establishment Or

Delivery Of A Safe And Effective Physical Therapy

Maintenance Program Each 15 Minutes

MCG

PSY301.014

THE803.010

Guidelines





Therapist In The Home Health Setting In The

Establishment Or Delivery Of A Safe And Effective

Occupational Therapy Maintenance Program Each 15

Minutes

MCG

PSY301.014

THE803.010

Clinical Guidelines




Services Performed By A Qualified Speech-Language

Pathologist In The Home Health Setting In The

Establishment Or Delivery Of A Safe And Effective

Speech-Language Pathology Maintenance Program

Each 15 Minutes

MCG

PSY301.014

THE803.014

Clinical Guidelines


Speech-Language Therapy (SLT)


Skilled Services By A Registered Nurse (Rn) In The

Delivery Of Management & Evaluation Of The Plan Of

Care; Each 15 Minutes (The Patient'S Underlying

Condition Or Complication Requires An Rn To Ensure

That Essential Non-Skilled Care Achieve Its Purpose In

The Home Health Or Hospice Setting)

MCG Clinical Guidelines


Direct Skilled Nursing Services Of A Registered Nurse

(Rn) In The Home Health Or Hospice Setting Each 15

Minutes



Direct Skilled Nursing Services Of A License Practical

Nurse (Lpn) In The Home Health Or Hospice Setting

Each 15 Minutes



Face-To-Face Home Health Nursing Visit By A Rural

Health Clinic (Rhc) Or Federally Qualified Health

Center (Fqhc) In An Area With A Shortage Of Home

Health Agencies. (Services Limited To Rn Or Lpn Only).



Skilled Services Of A Registered Nurse (Rn) For The

Observation And Assessment Of The Patient'S

Condition Each 15 Minutes (The Change In The

Patient'S Condition Requires Skilled Nursing Personnel

To Identify And Evaluate The Patient'S Need For

Possible Modification Of Treatment In The Home

Health Or Hospice Setting)



Skilled Services Of A Licensed Practical Nurse (Lpn)

For The Observation And Assessment Of The Patient'S

Condition Each 15 Minutes (The Change In The

Patient'S Condition Requires Skilled Nursing Personnel

To Identify And Evaluate The Patient'S Need For

Possible Modification Of Treatment In The Home

Health Or Hospice Setting)



Skilled Services Of A Registered Nurse (Rn) In The

Training And/Or Education Of A Patient Or Family

Member In The Home Health Or Hospice Setting

Each 15 Minutes



Skilled Services Of A Licensed Practical Nurse (Lpn) In

The Training And/Or Education Of A Patient Or Family

Member In The Home Health Or Hospice Setting

Each 15 Minutes


Home Health, Hospice Care G9473Services Performed By Chaplain In The Hospice

Setting Each 15 MinutesMCG Clinical Guidelines

Home Health, Hospice Care G9474Services Performed By Dietary Counselor In The

Hospice Setting Each 15 MinutesMCG Clinical Guidelines

Home Health, Hospice Care G9475Services Performed By Other Counselor In The

Hospice Setting Each 15 MinutesMCG Clinical Guidelines

Home Health, Hospice Care G9478Services Performed By Other Qualified Therapist In

The Hospice Setting Each 15 MinutesMCG Clinical Guidelines

Home Health, Hospice Care Q5001Hospice Or Home Health Care Provided In Patient'S

Home/ResidenceMCG Clinical Guidelines

Home Health, Hospice Care Q5002Hospice Or Home Health Care Provided In Assisted

Living FacilityMCG Clinical Guidelines

Home Health, Hospice Care Q5003Hospice Care Provided In Nursing Long Term Care

Facility (Ltc) Or Non-Skilled Nursing Facility (Nf)MCG Clinical Guidelines

Home Health, Hospice Care Q5004 Hospice Care Provided In Skilled Nursing Facility (Snf) MCG Clinical Guidelines

Home Health, Hospice Care Q5005 Hospice Care Provided In Inpatient Hospital MCG Clinical Guidelines

Home Health, Hospice Care Q5006 Hospice Care Provided In Inpatient Hospice Facility MCG Clinical Guidelines

Home Health, Hospice Care Q5007 Hospice Care Provided In Long Term Care Facility MCG Clinical Guidelines

Home Health, Hospice Care Q5008 Hospice Care Provided In Inpatient Psychiatric Facility MCG Clinical Guidelines

Home Health, Hospice Care Q5009Hospice Or Home Health Care Provided In Place Not

Otherwise Specified (Nos)MCG Clinical Guidelines

Home Health, Hospice Care Q5010 Hospice Home Care Provided In A Hospice Facility MCG Clinical Guidelines

Home Health, Hospice Care S5108Home Care Training To Home Care Client, Per 15

Minutes

MCG

PSY301.021

Clinical Guidelines

Applied Behavior Analysis (ABA) for Autism Spectrum Disorder (ASD) Diagnosis

Home Health, Hospice Care S5109 Home Care Training To Home Care Client, Per Session MCG Clinical Guidelines

Home Health, Hospice Care S5110 Home Care Training, Family; Per 15 MinutesMCG

PSY301.021

Clinical Guidelines


Home Health, Hospice Care S5111 Home Care Training, Family; Per SessionMCG

PSY301.021

Clinical Guidelines


Home Health, Hospice Care S5115 Home Care Training, Non-Family; Per 15 Minutes MCG Clinical Guidelines

Home Health, Hospice Care S5116 Home Care Training, Non-Family; Per Session MCG Clinical GuidelinesHome Health, Hospice Care S5125 Attendant Care Services; Per 15 Minutes MCG Clinical GuidelinesHome Health, Hospice Care S5126 Attendant Care Services; Per Diem MCG Clinical Guidelines

Home Health, Hospice Care S5180 Home Health Respiratory Therapy, Initial Evaluation MCG Clinical Guidelines


Home Health, Hospice Care S5181 Home Health Respiratory Therapy, Nos, Per Diem MCG Clinical Guidelines

Home Health, Hospice Care S9097 Home Visit Wound Care MCG Clinical Guidelines

Home Health, Hospice Care S9098

Home Visit Phototherapy Services (E. G. Bili-Lite)

Including Equipment Rental Nursing Services Blood

Draw Supplies And Other Services Per Diem


Home Health, Hospice Care S9122Home Health Aide Or Certified Nurse Assistant,

Providing Care In The Home; Per HourMCG Clinical Guidelines


Nursing Care In The Home; By Registered Nurse Per

Hour (Use For General Nursing Care Only Not To Be

Used When Cpt Codes 99500-99602 Can Be Used)

MCG

RX501.062

Clinical Guidelines


Home Health, Hospice Care S9124Nursing Care In The Home; By Licensed Practical

Nurse Per Hour

MCG

RX501.062

Clinical Guidelines


Home Health, Hospice Care S9126 Hospice Care, In The Home, Per Diem MCG Clinical Guidelines


Home Management Of Preterm Labor Including

Administrative Services Professional Pharmacy

Services Care Coordination And All Necessary

Supplies Or Equipment (Drugs And Nursing Visits

Coded Separately) Per Diem (Do Not Use This Code

With Any Home Infusion Per Diem Code)

MCG

RX501.062

Clinical Guidelines



Home Management Of Preterm Premature Rupture

Of Membranes (Pprom) Including Administrative

Services Professional Pharmacy Services Care

Coordination And All Necessary Supplies Or

Equipment (Drugs And Nursing Visits Coded

Separately) Per Diem (Do Not Use This Code With

Any Home Infusion Per Diem Code)


Home Health, Hospice Care T1004Services Of A Qualified Nursing Aide, Up To 15

MinutesMCG Clinical Guidelines

Home Health, Hospice Care T1502

Administration Of Oral, Intramuscular And/Or

Subcutaneous Medication By Health Care

Agency/Professional, Per Visit


Home Health, Hospice Care T1503

Administration Of Medication, Other Than Oral

And/Or Injectable, By A Health Care

Agency/Professional, Per Visit


Home Hemodialysis 99512 Home Visit For Hemodialysis THE802.002 Daily Hemodialysis and Hemodialysis in the Home Setting

Home Hemodialysis S9335

Home Therapy Hemodialysis; Administrative Services

Professional Pharmacy Services Care Coordination

And All Necessary Supplies And Equipment (Drugs

And Nursing Services Coded Separately) Per Diem

THE802.002 Daily Hemodialysis and Hemodialysis in the Home Setting

Home Infusion Therapy (HIT) 99601 Home Infusion/Visit 2 Hrs MCG Clinical GuidelinesHome Infusion Therapy (HIT) 99602 Home Infusion Each Addtl Hr MCG Clinical Guidelines

Home Infusion Therapy (HIT) B4034

Enteral Feeding Supply Kit; Syringe Fed Per Day

Includes But Not Limited To Feeding/Flushing Syringe

Administration Set Tubing Dressings Tape

MCG

MED201.011

Clinical Guidelines

Nutritional Support


Enteral Feeding Supply Kit; Pump Fed Per Day



MCG

MED201.011

Clinical Guidelines

Nutritional Support


Enteral Feeding Supply Kit; Gravity Fed Per Day



MCG

MED201.011

Clinical Guidelines

Nutritional Support

Home Infusion Therapy (HIT) B4102Enteral Formula For Adults Used To Replace Fluids

And Electrolytes (E.G. Clear Liquids) 500 Ml = 1 Unit

MCG

MED201.011

Clinical Guidelines

Nutritional Support


Enteral Formula For Pediatrics Used To Replace

Fluids And Electrolytes (E.G. Clear Liquids) 500 Ml = 1

Unit

MCG

MED201.011

Clinical Guidelines

Nutritional Support

Home Infusion Therapy (HIT) B4104 Additive For Enteral Formula (E.G. Fiber)MCG

MED201.011

Clinical Guidelines

Nutritional Support


Enteral Formula Manufactured Blenderized Natural

Foods With Intact Nutrients Includes Proteins Fats

Carbohydrates Vitamins And Minerals May Include

Fiber Administered Through An Enteral Feeding Tube

100 Calories = 1 Unit

MCG

MED201.011

Clinical Guidelines

Nutritional Support


Enteral Formula Nutritionally Complete With Intact

Nutrients Includes Proteins Fats Carbohydrates

Vitamins And Minerals May Include Fiber

Administered Through An Enteral Feeding Tube 100

Calories = 1 Unit

MCG

MED201.011

Clinical Guidelines

Nutritional Support


Enteral Formula Nutritionally Complete Calorically

Dense (Equal To Or Greater Than 1. 5 Kcal/Ml) With

Intact Nutrients Includes Proteins Fats

Carbohydrates Vitamins And Minerals May Include

Fiber Administered Through An Enteral Feeding Tube

100 Calories = 1 Unit

MCG

MED201.011

Clinical Guidelines

Nutritional Support

preauthorization requirements list effective … · 2020. 12. 22. · 70482 ct orbit/ear/fossa...

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