2

2019 HCPCS LEVEL II, PROFESSIONAL EDITION ISBN: 978-1-62202-779-8

Copyright © 2019 by Elsevier Inc. All rights reserved.

Previous editions copyrighted 2018, 2017, 2016, 2015, 2014, 2013, 2012, 2011, 2010, 2009, 2008, 2007,
2006, 2005, 2004, 2003, 2002, 2001, 2000
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval
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www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information
or methods they should be mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.

International Standard Book Number: 978-1-62202-779-8

Our Commitment to Accuracy

The AMA is committed to producing accurate and reliable materials. To report corrections, please call the
AMA Unified Service Center at (800) 621-8335. AMA publication and product updates, errata, and addenda
can be found at amaproductupdates.org.

To purchase additional copies, contact the American Medical Association at 800-621-8335 or visit the AMA
store at amastore.com. Refer to item number OP231519.

3
Content Strategist: Brandi Graham
Senior Content Development Manager: Luke Held
Content Development Specialist: Anna Miller
Publishing Services Manager: Julie Eddy
Project Manager: Abigail Bradberry
Designer: Maggie Reid

Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1

4
 DEVELOPMENT OF THIS EDITION

Lead Technical Collaborator

Jackie Grass Koesterman, CPC
Coding and Reimbursement Specialist
Grand Forks, North Dakota

Technical Collaborators
Nancy Maguire, ACS, CRT, PCS, FCS, HCS-D, APC, AFC
Physician Consultant for Auditing and Education
Palm Bay, Florida

Patricia Cordy Henricksen, MS, CHCA, CPC-I, CPC, CCP-P, ACS-PM

AAPC/AHIMA Approved ICD-10-CM Trainer
Auditing, Coding, and Education Specialist
Soterion Medical Services/Merrick Management
Lexington, Kentucky

5
 CONTENTS

INTRODUCTION

GUIDE TO USING THE 2019 HCPCS LEVEL II CODES

SYMBOLS AND CONVENTIONS

2019 HCPCS UPDATES

NETTER’S ANATOMY ILLUSTRATIONS

2019 INDEX

2019 TABLE OF DRUGS

2019 HCPCS LEVEL II MODIFIERS

2019 HCPCS LEVEL II NATIONAL CODES

Appendix A—Jurisdiction List for DMEPOS HCPCS Codes

Appendix B—Chapter 1, General Correct Coding Policies for National

Correct Coding Initiative Policy Manual for Medicare Services

Figure Credits

Updates will be posted on codingupdates.com when available.

Check codingupdates.com for Practitioner and Facility Medically Unlikely Edits (MUEs) and
Column 1 and Column 2 Edits.

Check the Centers for Medicare and Medicaid Services (www.cms.gov/Manuals/IOM/list.asp)

website and codingupdates.com for full and select IOMs.

Notice: 2019 DMEPOS updates were unavailable at the time of printing. Check
codingupdates.com for updates and DMEPOS Modifiers in January.

6
7
 INTRODUCTION

2019 HCPCS quarterly updates available on the companion website at:

www.codingupdates.com
The Centers for Medicare and Medicaid Services (CMS) (formerly Health Care Financing
Administration [HCFA]) Healthcare Common Procedure Coding System (HCPCS) is a
collection of codes and descriptors that represent procedures, supplies, products, and services that
may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance
programs. The codes are divided as follows:
Level I: Codes and descriptors copyrighted by the American Medical Association’s (AMA’s)
Current Procedural Terminology, ed. 4 (CPT-4). These are five-position numeric codes
representing physician and non-physician services.
Level II: Includes codes and descriptors copyrighted by the American Dental Association’s
current dental terminology, seventh edition (CDT-7/8). These are five-position alphanumeric
codes comprising the D series. All other Level II codes and descriptors are approved and
maintained jointly by the alpha-numeric editorial panel (consisting of CMS, the Health
Insurance Association of America, and the Blue Cross and Blue Shield Association). These are
five-position alpha-numeric codes representing primarily items and non-physician services that
are not represented in the Level I codes.
Level III: The CMS eliminated Level III local codes. See Program Memorandum AB-02-113.
Headings are provided as a means of grouping similar or closely related items. The placement of
a code under a heading does not indicate additional means of classification, nor does it relate to
any health insurance coverage categories.
HCPCS also contains modifiers, which are two-position codes and descriptors used to indicate
that a service or procedure that has been performed has been altered by some specific circumstance
but not changed in its definition or code. Modifiers are grouped by the levels. Level I modifiers
and descriptors are copyrighted by the AMA. Level II modifiers are HCPCS modifiers. Modifiers
in the D series are copyrighted by the ADA.
HCPCS is designed to promote uniform reporting and statistical data collection of medical
procedures, supplies, products, and services.

HCPCS Disclaimer
Inclusion or exclusion of a procedure, supply, product, or service does not imply any health
insurance coverage or reimbursement policy.
HCPCS makes as much use as possible of generic descriptions, but the inclusion of brand
names to describe devices or drugs is intended only for indexing purposes; it is not meant to
convey endorsement of any particular product or drug.

Updating HCPCS

8
The primary updates are made annually. Quarterly updates are also issued by CMS.

9
 GUIDE TO USING THE
2019 HCPCS LEVEL II
CODES

Medical coding has long been a part of the health care profession. Through the years medical
coding systems have become more complex and extensive. Today, medical coding is an intricate
and immense process that is present in every health care setting. The increased use of electronic
submissions for health care services only increases the need for coders who understand the coding
process.
2019 HCPCS Level II was developed to help meet the needs of today’s coder.
All material adheres to the latest government versions available at the time of printing.

Annotated
Throughout this text, revisions and additions are indicated by the following symbols:
▶ New: Additions to the previous edition are indicated by the color triangle.
Revised: Revisions within the line or code from the previous edition are indicated by the
color arrow.
✔ Reinstated indicates a code that was previously deleted and has now been reactivated.
✖ deleted words have been removed from this year’s edition.

HCPCS Symbols

❂ Special coverage instructions apply to these codes. Usually these special coverage
instructions are included in the Internet Only Manuals (IOM). References to the IOM
locations are given in the form of Medicare Pub. 100 reference numbers listed below the
code. IOM select references are located at codingupdates.com.
H Not covered or valid by Medicare is indicated by the “No” symbol. Usually the reason for
the exclusion is included in the Internet Only Manuals (IOM) select references at
codingupdates.com.
✽ Carrier discretion is an indication that you must contact the individual third-party payers to
find out the coverage available for codes identified by this symbol.
Other Drugs approved for Medicare Part B and other FDA-approved drugs are listed as Other.
A2-Z3 ASC Payment Indicators identify the 2018 final payment for the code. A list of Payment

Indicators is listed in the front material of this text.

A-Y OPPS Status Indicators identify the 2018 final status assigned to the code. A list of Status

Indicators is listed in the front material of this text.

Bill Part B MAC.
Bill DME MAC.

10
Coding Indicates the American Hospital Association Coding Clinic® for HCPCS references by year,
Clinic
quarter, and page number.
DMEPOS identifies durable medical equipment, prosthetics, orthotics, and supplies that
may be eligible for payment from CMS.
♀ Indicates a code for female only.
♂ Indicates a code for male only.
Indicates a code with an indication of age.
Indicates a code included in the MIPS Quality Measure Specifications.
Indicates there is a maximum allowable number of units of service, per day, per patient for
physician/provider services (see codingupdates.com for Practitioner Medically Unlikely
Edits).
Indicates there is a maximum allowable number of units of service, per day, per patient in
the outpatient hospital setting (see codingupdates.com for Hospital Medically Unlikely
Edits).

Red, green, and blue typeface terms within the Table of Drugs and tabular section are terms
added by the publisher and do not appear in the official code set. Information
supplementing the official HCPCS Index produced by CMS is italicized.

11
SYMBOLS AND CONVENTIONS

12
13
Codes shown are for illustration purposes only and may not be current codes.

A2-Z3 ASC Payment Indicators

Final ASC Payment Indicators for CY 2019
Payment Payment Indicator Definition

14
 Indicator
A2 Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment
weight.
B5 Alternative code may be available; no payment made
D5 Deleted/discontinued code; no payment made.
F4 Corneal tissue acquisition, hepatitis B vaccine; paid at reasonable cost.
G2 Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS
relative payment weight.
H2 Brachytherapy source paid separately when provided integral to a surgical procedure on
ASC list; payment OPPS rate.
J7 OPPS pass-through device paid separately when provided integral to a surgical procedure
on ASC list; payment contractor-priced.
J8 Device-intensive procedure; paid at adjusted rate.
K2 Drugs and biologicals paid separately when provided integral to a surgical procedure on
ASC list; payment based on OPPS rate.
K7 Unclassified drugs and biologicals; payment contractor-priced.
L1 Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate payment
made.
L6 New Technology Intraocular Lens (NTIOL); special payment.
N1 Packaged service/item; no separate payment made.
P2 Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS
nonfacility PE RVUs; payment based on OPPS relative payment weight.
P3 Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS
nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs.
R2 Office-based surgical procedure added to ASC list in CY 2008 or later without MPFS
nonfacility PE RVUs; payment based on OPPS relative payment weight.
Z2 Radiology or diagnostic service paid separately when provided integral to a surgical
procedure on ASC list; payment based on OPPS relative payment weight.
Z3 Radiology or diagnostic service paid separately when provided integral to a surgical
procedure on ASC list; payment based on MPFS nonfacility PE RVUs.
CMS-1678-FC, Final Changes to the ASC Payment System and CY 2019 Payment Rates, http://www.cms.gov/Medicare/Medicare-Fee-
for-Service-Payment/ASCPayment/ASC-Regulations-and-Notices.

A-Y OPPS Status Indicators

Final OPPS Payment Status Indicators for CY 2019
Indicator Item/Code/Service OPPS Payment Status
A Services furnished to a hospital Not paid under OPPS. Paid by MACs
outpatient that are paid under a fee under a fee schedule or payment system
schedule or payment system other than other than OPPS. Services are subject to
OPPS,* for example: deductible or coinsurance unless
indicated otherwise.
• Ambulance Services
• Separately Payable Clinical Not subject to deductible or
Diagnostic Laboratory Services coinsurance.
• Separately Payable Non-Implantable

15
 Prosthetics and Orthotics
• Physical, Occupational, and Speech
Therapy
• Diagnostic Mammography
• Screening Mammography Not subject to deductible or
coinsurance.
B Codes that are not recognized by OPPS Not paid under OPPS.
when submitted on an outpatient
hospital Part B bill type (12x and 13x) • May be paid by MACs when
submitted on a different bill type, for
example, 75x (CORF), but not paid
under OPPS.
• An alternate code that is recognized
by OPPS when submitted on an
outpatient hospital Part B bill type
(12x and 13x) may be available.
C Inpatient Procedures Not paid under OPPS. Admit patient.
Bill as inpatient.
D Discontinued Codes Not paid under OPPS or any other
Medicare payment system.
E1 Items, Codes and Services: Not paid by Medicare when submitted
• Not covered by any Medicare on outpatient claims (any outpatient bill
outpatient benefit category type).
• Statutorily excluded by Medicare
• Not reasonable and necessary
E2 Items, Codes and Services: Not paid by Medicare when submitted
for which pricing information and on outpatient claims (any outpatient bill
claims data are not available type).
F Corneal Tissue Acquisition; Certain Not paid under OPPS. Paid at
CRNA Services and Hepatitis B reasonable cost.
Vaccines
G Pass-Through Drugs and Biologicals Paid under OPPS; separate APC
payment.
H Pass-Through Device Categories Separate cost-based pass-through
payment; not subject to copayment.
J1 Hospital Part B services paid through a Paid under OPPS; all covered Part B
comprehensive APC services on the claim are packaged with
the primary “J1” service for the claim,
except services with OPPS status
indicator of “F”, “G”, “H”, “L” and “U”;
ambulance services; diagnostic and
screening mammography; all preventive
services; and certain Part B inpatient
services.
J2 Hospital Part B Services That May Be Paid under OPPS; Addendum B
Paid Through a Comprehensive APC displays APC assignments when
services are separately payable.

(1) Comprehensive APC payment

based on OPPS comprehensive-
specific payment criteria. Payment
for all covered Part B services on

16
 the claim is packaged into a single
payment for specific combinations
of services, except services with
OPPS status indicator of “F”, “G”,
“H”, “L” and “U”; ambulance
services; diagnostic and screening
mammography; all preventive
services; and certain Part B
inpatient services.
(2) Packaged APC payment if billed on
the same claim as a HCPCS code
assigned status indicator “J1.”
(3) In other circumstances, payment is
made through a separate APC
payment or packaged into payment
for other services.
K Nonpass-Through Drugs and Paid under OPPS: separate APC
Nonimplantable Biologicals, including payment.
Therapeutic Radiopharmaceuticals
L Influenza Vaccine; Pneumococcal Not paid under OPPS. Paid at
Pneumonia Vaccine reasonable cost; not subject to
deductible or coinsurance.
M Items and Services Not Billable to the Not paid under OPPS.
MAC
N Items and Services Packaged into APC Paid under OPPS; payment is packaged
Rates into payment for other services.
Therefore, there is no separate APC
payment.
P Partial Hospitalization Paid under OPPS; per diem APC pay
ment.
Q1 STV-Packaged Codes Paid under OPPS; Addendum B
displays APC assignments when
services are separately payable.

(1) Packaged APC payment if billed on

the same claim as a HCPCS code
assigned status indicator “S,” “T,”
or “V.”
(2) Composite APC payment if billed
with specific combinations of
services based on OPPS composite-
specific payment criteria. Payment
is packaged into a single payment
for specific combinations of
services.
(3) In other circumstances, payment is
made through a separate APC
payment.
Q2 T-Packaged Codes Paid under OPPS; Addendum B
displays APC assignments when
services are separately payable.

(1) Packaged APC payment if billed on

the same claim as a HCPCS code
assigned status indicator “T.”

17
 (2) In other circumstances, payment is
made through a separate APC
payment.
Q3 Codes That May Be Paid Through a Paid under OPPS; Addendum B
Composite APC displays APC assignments when
services are separately payable.
Addendum M displays composite APC
assignments when codes are paid
through a composite APC.

(1) Composite APC payment based on

OPPS composite-specific payment
criteria. Payment is packaged into a
single payment for specific
combinations of service.
(2) In other circumstances, payment is
made through a separate APC
payment or packaged into payment
for other services.
Q4 Conditionally packaged laboratory tests Paid under OPPS or CLFS.

(1) Packaged APC payment if billed on

the same claim as a HCPCS code
assigned published status indicator
“J1,” “J2,” “S,” “T,” “V,” “Q1,”
“Q2,” or “Q3.”
(2) In other circumstances, laboratory
tests should have an SI=A and
payment is made under the CLFS.
R Blood and Blood Products Paid under OPPS; separate APC
payment.
S Procedure or Service, Not Discounted Paid under OPPS; separate APC
when Multiple payment.
T Procedure or Service, Multiple Paid under OPPS; separate APC
Procedure Reduction Applies payment.
U Brachytherapy Sources Paid under OPPS; separate APC
payment.
V Clinic or Emergency Department Visit Paid under OPPS; separate APC
payment.
Y Non-Implantable Durable Medical Not paid under OPPS. All institutional
Equipment providers other than home health
agencies bill to a DME MAC.
* Note — Payments “under a fee schedule or payment system other than OPPS” may be contractor priced.
CMS-1678-FC, Final Changes to the ASC Payment System and CY 2019 Payment Rates, http://www.cms.gov/Medicare/Medicare-Fee-
for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html.

18
 2019 HCPCS UPDATES

2019 HCPCS New/Revised/Deleted Codes and

Modifiers
HCPCS quarterly updates are posted on the companion website
(www.codingupdates.com) when available.

NEW CODES/MODIFIERS
CO
CQ
ER
G0
QA
QB
QQ
QR
VM
A4563
A5514
A6460
A6461
A9513
A9589
B4105
C1823
C8937
C9034
C9035
C9036
C9037
C9038
C9039
C9407
C9408
C9462
C9749
C9751
C9752
C9753
C9754
C9755
E0447
E0467
G0068
G0069
G0070
G0071
G0076
G0077
G0078
G0079
G0080
G0081
G0082
G0083
G0084

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G0085
G0086
G0087
G2000
G2010
G2011
G2012
G9873
G9874
G9875
G9876
G9877
G9878
G9879
G9880
G9881
G9882
G9883
G9884
G9885
G9890
G9891
G9978
G9979
G9980
G9981
G9982
G9983
G9984
G9985
G9986
G9987
J0185
J0517
J0567
J0584
J0599
J0841
J1301
J1454
J1628
J1746
J2062
J2797
J3245
J3304
J3316
J3397
J3398
J3591
J7170
J7177
J7203
J7318
J7329
J9044
J9057
J9153
J9173
J9229
J9311
J9312
L8608
L8698
L8701
L8702
M1000
M1001
M1002
M1003
M1004
M1005
M1006
M1007
M1008
M1009
M1010

20
M1011
M1012
M1013
M1014
M1015
M1016
M1017
M1018
M1019
M1020
M1021
M1022
M1023
M1024
M1025
M1026
M1027
M1028
M1029
M1030
M1031
M1032
M1033
M1034
M1035
M1036
M1037
M1038
M1039
M1040
M1041
M1042
M1043
M1044
M1045
M1046
M1047
M1048
M1049
M1050
M1051
M1052
M1053
M1054
M1055
M1056
M1057
M1058
M1059
M1060
M1061
M1062
M1063
M1064
M1065
M1066
M1067
M1068
M1069
M1070
M1071
Q2042
Q4183
Q4184
Q4185
Q4186
Q4187
Q4188
Q4189
Q4190
Q4191
Q4192
Q4193
Q4194
Q4195
Q4196
Q4197

21
Q4198
Q4200
Q4201
Q4202
Q4203
Q4204
Q5103
Q5104
Q5105
Q5106
Q5107
Q5108
Q5109
Q5110
Q9991
Q9992
T4545
V5171
V5172
V5181
V5211
V5212
V5213
V5214
V5215
V5221

REVISED CODES/MODIFIERS
Long Description Change
QE
QF
QG
A9273
C1889
E0218
E0483
G0499
G8647
G8648
G8649
G8650
G8651
G8652
G8653
G8654
G8655
G8656
G8657
G8658
G8659
G8660
G8661
G8662
G8663
G8664
G8665
G8666
G8667
G8668
G8669
G8670
G8671
G8672
G8673
G8674
G8709
G8749
G8806
G8880
G9428
G9429

22
G9431
G9454
G9457
G9509
G9511
G9530
G9531
G9532
G9537
G9573
G9574
G9594
G9596
G9612
G9614
G9625
G9627
G9628
G9630
G9631
G9633
G9649
G9651
G9683
G9685
G9727
G9729
G9731
G9733
G9735
G9737
G9739
G9755
G9764
G9765
G9772
G9773
G9803
G9804
J0834
J7178
J8655
J9041
K0037
Q2041
Q4133
Q4137
Q5101
V5190
V5200
V5230
V5240

Coverage Change
A5512

Coverage and Long Description Change

A5513

DELETED CODES/MODIFIERS
ZA
ZB
ZC
C8904
C8907
C9014
C9015
C9016
C9024
C9028
C9029

23
C9030
C9031
C9032
C9033
C9275
C9463
C9464
C9465
C9466
C9467
C9468
C9469
C9492
C9493
C9497
C9741
C9744
C9748
C9750
G9534
G9535
G9536
G9538
G9686
J0833
J9310
K0903
Q2040
Q4131
Q4172
Q5102
Q9993
Q9994
Q9995
V5170
V5180
V5210
V5220

NEW, REVISED, AND DELETED DENTAL CODES

New
D0412
D1516
D1517
D1526
D1527
D5282
D5283
D5876
D9130
D9613
D9944
D9945
D9946
D9961
D9990

Revised
D5211
D5212
D5630
D9219

Deleted
D1515
D1525
D5281
D9940

24
25
Plate 118 Cranial Nerves (Motor and Sensory Distribution): Schema. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

26
Plate 86 Nerves of Orbit. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

27
Plate 472 Cutaneous Innervation of Wrist and Hand. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

28
Plate 473 Arteries and Nerves of Upper Limb. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

29
Plate 544 Superficial Nerves and Veins of Lower Limb: Anterior View. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

30
Plate 545 Superficial Nerves and Veins of Lower Limb: Posterior View. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

31
Plate 500 Arteries and Nerves of Thigh: Anterior View. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

32
Plate 501 Arteries and Nerves of Thigh: Anterior View. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

33
Plate 502 Arteries and Nerves of Thigh: Posterior View. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

34
Plate 87 Eyeball. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

35
Plate 90 Intrinsic Arteries and Veins of Eye. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

36
Plate 81, Middle Eyelid. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

Plate 81, Upper Eyelid. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

37
Plate 82 Lacrimal Apparatus. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

38
Plate 92 Pathway of Sound Reception. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

39
Plate 94 Tympanic Cavity. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

Plate 93 Tympanic Cavity. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

40
Plate 95 Bony Membranous Labyrinth. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

41
Plate 57 Teeth. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

42
Plate 58 Tongue. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

43
Plate 49 Paranasal Sinuses. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

44
Plate 61 Salivary Glands. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

45
Plate 218 Coronary Arteries: Arteriographic Views. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

46
Plate 219 Coronary Arteries: Arteriographic Views. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

47
Plate 141 Arteries of Brain: Frontal View and Section. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

48
Plate 284 Mucosa and Musculature of Large Intestine. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

49
Plate 244 Cross Section of Thorax at T3-4 Disc Level. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

50
Plate 509 Knee: Cruciate and Collateral Ligaments. (Netter: Atlas of Human Anatomy, 4 ed, 2006, Saunders.)

51
INDEX

52
 A
Abatacept, J0129
Abciximab, J0130
Abdomen
dressing holder/binder, A4462
pad, low profile, L1270
Abduction control, each, L2624
Abduction restrainer, A4566
Abduction rotation bar, foot, L3140–L3170
adjustable shoe style positioning device, L3160
including shoes, L3140
plastic, heel-stabilizer, off-shelf, L3170
without shoes, L3150
AbobotulinumtoxintypeA, J0586
Absorption dressing, A6251–A6256
Access, site, occlusive, device, G0269
Access system, A4301
Accessories
ambulation devices, E0153–E0159
crutch attachment, walker, E0157
forearm crutch, platform attachment, E0153
leg extension, walker, E0158
replacement, brake attachment, walker, E0159
seat attachment, walker, E0156
walker, platform attachment, E0154
wheel attachment, walker, per pair, E0155
artificial kidney and machine; (see also ESRD), E1510–E1699
adjustable chair, ESRD patients, E1570
automatic peritoneal dialysis system, intermittent, E1592
bath conductivity meter, hemodialysis, E1550
blood leak detector, hemodialysis, replacement, E1560
blood pump, hemodialysis, replacement, E1620
cycler dialysis machine, peritoneal, E1594
deionizer water system, hemodialysis, E1615
delivery/instillation charges, hemodialysis equipment, E1600
hemodialysis machine, E1590
hemostats, E1637
heparin infusion pump, hemodialysis, E1520
kidney machine, dialysate delivery system, E1510
peritoneal dialysis clamps, E1634
portable travel hemodialyzer, E1635
reciprocating peritoneal dialysis system, E1630
replacement, air bubble detector, hemodialysis, E1530
replacement, pressure alarm, hemodialysis, E1540
reverse osmosis water system, hemodialysis, E1610
scale, E1639
sorbent cartridges, hemodialysis, E1636
transducer protectors, E1575
unipuncture control system, E1580
water softening system, hemodialysis, E1625

53
 wearable artificial kidney, E1632
beds, E0271–E0280, E0300–E0326
bed board, E0273
bed, board/table, E0315
bed cradle, E0280
bed pan, standard, E0275
bed side rails, E0305–E0310
bed-pan fracture, E0276
hospital bed, extra heavy duty, E0302, E0304
hospital bed, heavy duty, E0301–E0303
hospital bed, pediatric, electric, E0329
hospital bed, safety enclosure frame, E0316
mattress, foam rubber, E0272
mattress, innerspring, E0271
over-bed table, E0274
pediatric crib, E0300
powered pressure-reducing air mattress, E0277
wheelchairs, E0950–E1030, E1050–E1298, E2300–E2399, K0001–K0109
accessory tray, E0950
arm rest, E0994
back upholstery replacement, E0982
calf rest/pad, E0995
commode seat, E0968
detachable armrest, E0973
elevating leg rest, E0990
headrest cushion, E0955
lateral trunk/hip support, E0956
loop-holder, E0951–E0952
manual swingaway, E1028
manual wheelchair, adapter, amputee, E0959
manual wheelchair, anti-rollback device, E0974
manual wheelchair, anti-tipping device, E0971
manual wheelchair, hand rim with projections, E0967
manual wheelchair, headrest extension, E0966
manual wheelchair, lever-activated, wheel drive, E0988
manual wheelchair, one-arm drive attachment, E0958
manual wheelchair, power add-on, E0983–E0984
manual wheelchair, push activated power assist, E0986
manual wheelchair, solid seat insert, E0992
medial thigh support, E0957
modification, pediatric size, E1011
narrowing device, E0969
No. 2 footplates, E0970
oxygen related accessories, E1352–E1406
positioning belt/safety belt/pelvic strap, E0978
power-seating system, E1002–E1010
reclining back addition, pediatric size wheelchair, E1014
residual limb support system, E1020
safety vest, E0980
seat lift mechanism, E0985
seat upholstery replacement, E0981
shock absorber, E1015–E1018

54
 shoulder harness strap, E0960
ventilator tray, E1029–E1030
wheel lock brake extension, manual, E0961
wheelchair, amputee, accessories, E1170–E1200
wheelchair, fully inclining, accessories, E1050–E1093
wheelchair, heavy duty, accessories, E1280–E1298
wheelchair, lightweight, accessories, E1240–E1270
wheelchair, semi-reclining, accessories, E1100–E1110
wheelchair, special size, E1220–E1239
wheelchair, standard, accessories, E1130–E1161
whirlpool equipment, E1300–E1310
Ace type, elastic bandage, A6448–A6450
Acetaminophen, J0131
Acetazolamide sodium, J1120
Acetylcysteine
inhalation solution, J7604, J7608
injection, J0132
Activity, therapy, G0176
Acyclovir, J0133
Adalimumab, J0135
Additions to
fracture orthosis, L2180–L2192
abduction bar, L2300–L2310
adjustable motion knee joint, L2186
anterior swing band, L2335
BK socket, PTB and AFO, L2350
disk or dial lock, knee flexion, L2425
dorsiflexion and plantar flexion, L2220
dorsiflexion assist, L2210
drop lock, L2405
drop lock knee joint, L2182
extended steel shank, L2360
foot plate, stirrup attachment, L2250
hip joint, pelvic band, thigh flange, pelvic belt, L2192
integrated release mechanism, L2515
lacer custom-fabricated, L2320–L2330
lift loop, drop lock ring, L2492
limited ankle motion, L2200
limited motion knee joint, L2184
long tongue stirrup, L2265
lower extremity orthrosis, L2200–L2397
molded inner boot, L2280
offset knee joint, L2390
offset knee joint, heavy duty, L2395
Patten bottom, L2370
pelvic and thoracic control, L2570–L2680
plastic shoe insert with ankle joints, L2180
polycentric knee joint, L2387
pre-tibial shell, L2340
quadrilateral, L2188
ratchet lock knee extension, L2430
reinforced solid stirrup, L2260

55
 rocker bottom, custom fabricated, L2232
round caliper/plate attachment, L2240
split flat caliper stirrups, L2230
straight knee joint, heavy duty, L2385
straight knee, or offset knee joints, L2405–L2492
suspension sleeve, L2397
thigh/weight bearing, L2500–L2550
torsion control, ankle joint, L2375
torsion control, straight knee joint, L2380
varus/valgus correction, L2270–L2275
waist belt, L2190
general additions, orthosis, L2750–L2999
lower extremity, above knee section, soft interface, L2830
lower extremity, concentric adjustable torsion style mechanism, L2861
lower extremity, drop lock retainer, L2785
lower extremity, extension, per extension, per bar, L2760
lower extremity, femoral length sock, L2850
lower extremity, full kneecap, L2795
lower extremity, high strength, lightweight material, hybrid lamination, L2755
lower extremity, knee control, condylar pad, L2810
lower extremity, knee control, knee cap, medial or lateral, L2800
lower extremity orthrosis, non-corrosive finish, per bar, L2780
lower extremity orthrosis, NOS, L2999
lower extremity, plating chrome or nickel, per bar, L2750
lower extremity, soft interface, below knee, L2820
lower extremity, tibial length sock, L2840
orthotic side bar, disconnect device, L2768
Adenosine, J0151, J0153
Adhesive, A4364
bandage, A6413
disc or foam pad, A5126
remover, A4455, A4456
support, breast prosthesis, A4280
wound, closure, G0168
Adjunctive, dental, D9110–D9999
Administration, chemotherapy, Q0083–Q0085
both infusion and other technique, Q0085
infusion technique only, Q0084
other than infusion technique, Q0083
Administration, Part D
vaccine, hepatitis B, G0010
vaccine, influenza, G0008
vaccine, pneumococcal, G0009
Administrative, Miscellaneous and Investigational, A9000–A9999
alert or alarm device, A9280
artificial saliva, A9155
DME delivery set-up, A9901
exercise equipment, A9300
external ambulatory insulin delivery system, A9274
foot pressure off loading/supportive device, A9283
helmets, A8000–A8004
home glucose disposable monitor, A9275

56
 hot-water bottle, ice cap, heat wrap, A9273
miscellaneous DME, NOS, A9999
miscellaneous DME supply, A9900
monitoring feature/device, stand-alone or integrated, A9279
multiple vitamins, oral, per dose, A9153
non-covered item, A9270
non-prescription drugs, A9150
pediculosis treatment, topical, A9180
radiopharmaceuticals, A9500–A9700
reaching grabbing device, A9281
receiver, external, interstitial glucose monitoring system, A9278
sensor, invasive, interstitial continuous glucose monitoring, A9276
single vitamin/mineral trace element, A9152
spirometer, non-electronic, A9284
transmitter, interstitial continuous glucose monitoring system, A9277
wig, any type, A9282
wound suction, disposable, A9272
Admission, observation, G0379
Ado-trastuzumab, J9354
Adrenalin, J0171
Advanced life support, A0390, A0426, A0427, A0433
ALS2, A0433
ALS emergency transport, A0427
ALS mileage, A0390
ALS, non-emergency transport, A0426
Aerosol
compressor, E0571–E0572
compressor filter, A7013–A7014, K0178–K0179
mask, A7015, K0180
Aflibercept, J0178
AFO, E1815, E1830, L1900–L1990, L4392, L4396
Afstyla, J7210
Agalsidase beta, J0180
Aggrastat, J3245
A-hydroCort, J1710
Aid, hearing, V5030–V5263
Aide, home, health, G0156, S9122, T1021
home health aide/certified nurse assistant, in home, S9122
home health aide/certified nurse assistant, per visit, T1021
home health or hospital setting, G0156
Air bubble detector, dialysis, E1530
Air fluidized bed, E0194
Air pressure pad/mattress, E0186, E0197
Air travel and nonemergency transportation, A0140
Alarm
not otherwise classified, A9280
pressure, dialysis, E1540
Alatrofloxacin mesylate, J0200
Albumin, human, P9041, P9042
Albuterol
all formulations, inhalation solution, J7620
all formulations, inhalation solution, concentrated, J7610, J7611

57
 all formulations, inhalation solution, unit dose, J7609, J7613
Alcohol, A4244
Alcohol wipes, A4245
Alcohol/substance, assessment, G0396, G0397, H0001, H0003, H0049
alcohol abuse structured assessment, greater than 30 min., G0397
alcohol abuse structured assessment, 15–30 min., G0396
alcohol and/or drug assessment, Medicaid, H0001
alcohol and/or drug screening; laboratory analysis, Medicaid, H0003
alcohol and/or drug screening, Medicaid, H0049
Aldesleukin (IL2), J9015
Alefacept, J0215
Alemtuzumab, J0202
Alert device, A9280
Alginate dressing, A6196–A6199
alginate, pad more than 48 sq. cm, A6198
alginate, pad size 16 sq. cm, A6196
alginate, pad size more than 16 sq. cm, A6197
alginate, wound filler, sterile, A6199
Alglucerase, J0205
Alglucosidase, J0220
Alglucosidase alfa, J0221
Alphanate, J7186
Alpha-1–proteinase inhibitor, human, J0256, J0257
Alprostadil
injection, J0270
urethral supposity, J0275
ALS mileage, A0390
Alteplase recombinant, J2997
Alternating pressure mattress/pad, A4640, E0180, E0181, E0277
overlay/pad, alternating, pump, heavy duty, E0181
powered pressure-reducing air mattress, E0277
replacement pad, owned by patient, A4640
Alveoloplasty, D7310–D7321
in conjunction with extractions, four or more teeth, D7310
in conjunction with extractions, one to three teeth, D7311
not in conjunction with extractions, four or more teeth, D7320
not in conjunction with extractions, one to three teeth, D7321
Amalgam dental restoration, D2140–D2161
four or more surfaces, primary or permanent, D2161
one surface, primary or permanent, D2140
three surfaces, primary or permanent, D2160
two surfaces, primary or permanent, D2150
Ambulance, A0021–A0999
air, A0430, A0431, A0435, A0436
conventional, transport, one way, fixed wing, A0430
conventional, transport, one way, rotary wing, A0431
fixed wing air mileage, A0435
rotary wing air mileage, A0436
disposable supplies, A0382–A0398
ALS routine disposable supplies, A0398
ALS specialized service disposable supplies, A0394
ALS specialized service, esophageal intubation, A0396

58
 BLS routine disposable, A0832
BLS specialized service disposable supplies, defibrillation, A0384, A0392
non-emergency transport, fixed wing, S9960
non-emergency transport, rotary wing, S9961
oxygen, A0422
Ambulation device, E0100–E0159
brake attachment, wheeled walker replacement, E0159
cane, adjustable or fixed, with tip, E0100
cane, quad or three prong, adjustable or fixed, with tip, E0105
crutch attachment, walker, E0157
crutch forearm, each, with tips and handgrips, E0111
crutch substitute, lower leg platform, with or without wheels, each, E0118
crutch, underarm, articulating, spring assisted, each, E0117
crutches forearm, pair, tips and handgrips, E0110
crutches, underarm, other than wood, pair, with pads, tips and handgrips, E0114
crutches, underarm, other than wood, with pad, tip, handgrip, with or without shock absorber, each,
E0116
crutches, underarm, wood, each, with pad, tip and handgrip, E0113
leg extensions, walker, set (4), E0158
platform attachment, forearm crutch, each, E0153
platform attachment, walker, E0154
seat attachment, walker, E0156
walker, enclosed, four-sided frame, wheeled, posterior seat, E0144
walker, folding, adjustable or fixed height, E0135
walker, folding, wheeled, adjustable or fixed height, E0143
walker, heavy duty, multiple braking system, variable wheel resistance, E0147
walker, heavy duty, wheeled, rigid or folding, E0149
walker, heavy duty, without wheels, rigid or folding, E0148
walker, rigid, adjustable or fixed height, E0130
walker, rigid, wheeled, adjustable or fixed height, E0141
walker, with trunk support, adjystable or fixed height, any, E0140
wheel attachment, rigid, pick up walker, per pair, E0155
Amikacin Sulfate, J0278
Aminolevulinate, J7309
Aminolevulinic, J7345
Aminolevulinic acid HCl, J7308
Aminophylline, J0280
Amiodarone HCl, J0282
Amitriptyline HCl, J1320
Ammonia N-13, A9526
Ammonia test paper, A4774
Amniotic membrane, V2790
Aminolevulinic ◀
Ameluz, J7345 ◀
Amobarbital, J0300
Amphotericin B, J0285
Lipid Complex, J0287–J0289
Ampicillin
sodium, J0290
sodium/sulbactam sodium, J0295
Amputee
adapter, wheelchair, E0959

59
prosthesis, L5000–L7510, L7520, L7900, L8400–L8465
above knee, L5200–L5230
additions to exoskeletal knee-shin systems, L5710–L5782
additions to lower extremity, L5610–L5617
additions to socket insert and suspension, L5654–L5699
additions to socket variations, L5630–L5653
additions to test sockets, L5618–L5629
additions/replacements feet-ankle units, L5700–L5707
ankle, L5050–L5060
below knee, L5100–L5105
component modification, L5785–L5795
endoskeletal, L5810–L5999
endoskeleton, below knee, L5301–L5312
endoskeleton, hip disarticulation, L5331–L5341
fitting endoskeleton, above knee, L5321
fitting procedures, L5400–L5460
hemipelvectomy, L5280
hip disarticulation, L5250–L5270
initial prosthesis, L5500–L5505
knee disarticulation, L5150–L5160
male vacuum erection system, L7900
partial foot, L5000–L5020
preparatory prosthesis, L5510–L5600
prosthetic socks, L8400–L8485
repair, prosthetic device, L7520
tension ring, vacuum erection device, L7902
upper extremity, battery components, L7360–L7368
upper extremity, other/repair, L7400–L7510
upper extremity, preparatory, elbow, L6584–L6586
upper limb, above elbow, L6250
upper limb, additions, L6600–L6698
upper limb, below elbow, L6100–L6130
upper limb, elbow disarticulation, L6200–L6205
upper limb, endoskeletal, above elbow, L6500
upper limb, endoskeletal, below elbow, L6400
upper limb, endoskeletal, elbow disarticulation, L6450
upper limb, endoskeletal, interscapular thoracic, L6570
upper limb, endoskeletal, shoulder disarticulation, L6550
upper limb, external power, device, L6920–L6975
upper limb, interscapular thoracic, L6350–L6370
upper limb, partial hand, L6000–L6025
upper limb, postsurgical procedures, L6380–L6388
upper limb, preparatory, shoulder, interscapular, L6588–L6590
upper limb, preparatory, wrist, L6580–L6582
upper limb, shoulder disarticulation, L6300–L6320
upper limb, terminal devices, L6703–L6915, L7007–L7261
upper limb, wrist disarticulation, L6050–L6055
stump sock, L8470–L8485
single ply, fitting above knee, L8480
single ply, fitting, below knee, L8470
single ply, fitting, upper limb, L8485
wheelchair, E1170–E1190, E1200, K0100

60
 detachable arms, swing away detachable elevating footrests, E1190
detachable arms, swing away detachable footrests, E1180
detachable arms, without footrests or legrest, E1172
detachable elevating legrest, fixed full length arms, E1170
fixed full length arms, swing away detachable footrest, E1200
heavy duty wheelchair, swing away detachable elevating legrests, E1195
without footrests or legrest, fixed full length arms, E1171
Amygdalin, J3570
Anadulafungin, J0348
Analgesia, dental, D9230
Analysis
saliva, D0418
semen, G0027
Angiography, iliac, artery, G0278
Angiography, renal, non-selective, G0275
non-ophthalmic fluorescent vascular, C9733
reconstruction, G0288
Anistreplase, J0350
Ankle splint, recumbent, K0126–K0130
Ankle-foot orthosis (AFO), L1900–L1990, L2106–L2116, L4361, L4392, L4396
ankle gauntlet, custom fabricated, L1904
ankle gauntlet, prefabricated, off-shelf, L1902
double upright free plantar dorsiflexion, olid stirrup, calf-band/cuff, custom, L1990
fracture orthrosis, tibial fracture, thermoplastic cast material, custom, L2106
multiligamentus ankle support, prefabricated, off-shelf, L1906
plastic or other material, custom fabricated, L1940
plastic or other material, prefabricated, fitting and adjustment, L1932, L1951
plastic or other material, with ankle joint, prefabricated, fitting and adjustment, L1971
plastic, rigid anterior tibial section, custom fabricated, L1945
plastic, with ankle joint, custom, L1970
posterior, single bar, clasp attachment to shoe, L1910
posterior, solid ankle, plastic, custom, L1960
replacement, soft interface material, static AFO, L4392
single upright free plantar dorsiflection, solid stirrup, calf-band/cuff, custom, L1980
single upright with static or adjustable stop, custom, L1920
spiral, plastic, custom fabricated, L1950
spring wire, dorsiflexion assist calf band, L1900
static or dynamic AFO, adjustable for fit, minimal ambulation, L4396
supramalleolar with straps, custom fabricated, L1907
tibial fracture cast orthrosis, custom, L2108
tibial fracture orthrosis, rigid, prefabricated, fitting and adjustment, L2116
tibial fracture orthrosis, semi-rigid, prefabricated, fitting and adjustment, L2114
tibial fracture orthrosis, soft prefabricated, fitting and adjustment, L2112
walking boot, prefabricated, off-the-shelf, L4361
Anterior-posterior-lateral orthosis, L0700, L0710
Antibiotic, G8708–G8712
antibiotic not prescribed or dispensed, G8712
patient not prescribed or dispensed antibiotic, G8708
patient prescribed antibiotic, documented condition, G8709
patient prescribed or dispensed antibiotic, G8710
prescribed or dispensed antibiotic, G8711
Antidepressant, documentation, G8126–G8128

61
Anti-emetic, oral, J8498, J8597, Q0163–Q0181
antiemetic drug, oral NOS, J8597
antiemetic drug, rectal suppository, NOS, J8498
diphenhydramine hydrochloride, 50 mg, oral, Q0163
dolasetron mesylate, 100 mg, oral, Q0180
dronabinol, 2.5 mg, Q0167
granisetron hydrochloride, 1 mg, oral, Q0166
hydroxyzine pomoate, 25 mg, oral, Q0177
perphenazine, 4 mg, oral, Q0175
prochlorperazine maleate, 5 mg, oral, Q0164
promethazine hydrochloride, 12.5 mg, oral, Q0169
thiethylperazine maleate, 10 mg, oral, Q0174
trimethobenzamide hydrochloride, 250 mg, oral, Q0173
unspecified oral dose, Q0181
Anti-hemophilic factor (Factor VIII), J7190–J7192
Anti-inhibitors, per I.U., J7198
Antimicrobial, prophylaxis, documentation, D4281, G8201
Anti-neoplastic drug, NOC, J9999
Antithrombin III, J7197
Antithrombin recombinant, J7196
Antral fistula closure, oral, D7260
Apexification, dental, D3351–D3353
Apicoectomy, D3410–D3426
anterior, periradicular surgery, D3410
biscuspid (first root), D3421
(each additional root), D3426
molar (first root), D3425
Apomorphine, J0364
Appliance
cleaner, A5131
pneumatic, E0655–E0673
non-segmental pneumatic appliance, E0655, E0660, E0665, E0666
segmental gradient pressure, pneumatic appliance, E0671–E0673
segmental pneumatic appliance, E0656–E0657, E0667–E0670
Application, heat, cold, E0200–E0239
electric heat pad, moist, E0215
electric heat pad, standard, E0210
heat lamp with stand, E0205
heat lamp without stand, E0200
hydrocollator unit, pads, E0225
hydrocollator unit, portable, E0239
infrared heating pad system, E0221
non-contact wound warming device, E0231
paraffin bath unit, E0235
phototherapy (bilirubin), E0202
pump for water circulating pad, E0236
therapeutic lightbox, E0203
warming card, E0232
water circulating cold pad with pump, E0218
water circulating heat pad with pump, E0217
Aprotinin, J0365
Aqueous

62
 shunt, L8612
sterile, J7051
ARB/ACE therapy, G8473–G8475
Arbutamine HCl, J0395
Arch support, L3040–L3100
hallus-valgus night dynamic splint, off-shelf, L3100
intralesional, J3302
non-removable, attached to shoe, longitudinal, L3070
non-removable, attached to shoe, longitudinal/metatarsal, each, L3090
non-removable, attached to shoe, metatarsal, L3080
removable, premolded, longitudinal, L3040
removable, premolded, longitudinal/metatarsal, each, L3060
removable, premolded, metatarsal, L3050
Arformoterol, J7605
Argatroban, J0883–J0884
Aripiprazole, J0400, J0401, J1942
Arm, wheelchair, E0973
Arsenic trioxide, J9017
Arthrography, injection, sacroiliac, joint, G0259, G0260
Arthroscopy, knee, surgical, G0289, S2112
chondroplasty, different compartment, knee, G0289
harvesting of cartilage, knee, S2112
Artificial
Cornea, L8609
heart system, miscellaneous component, supply or accessory, L8698 ◀
kidney machines and accessories (see also Dialysis), E1510–E1699
larynx, L8500
saliva, A9155
Asparaginase, J9019–J9020
Aspirator, VABRA, A4480
Assessment
alcohol/substance (see also Alcohol/substance, assessment), G0396, G0397, H0001, H0003, H0049
assessment for hearing aid, V5010
audiologic, V5008–V5020
cardiac output, M0302
conformity evaluation, V5020
fitting/orientation, hearing aid, V5014
hearing screening, V5008
repair/modification hearing aid, V5014
speech, V5362–V5364
Assistive listening devices and accessories, V5281–V5290
FMlDM system, monaural, V5281
Astramorph, J2275
Atezolizumab, J9022
Atherectomy, PTCA, C9602, C9603
Atropine
inhalation solution, concentrated, J7635
inhalation solution, unit dose, J7636
Atropine sulfate, J0461
Attachment, walker, E0154–E0159
brake attachment, wheeled walker, replacement, E0159
crutch attachment, walker, E0157

63
 leg extension, walker, E0158
platform attachment, walker, E0154
seat attachment, walker, E0156
wheel attachment, rigid pick up walker, E0155
Audiologic assessment, V5008–V5020
Auditory osseointegrated device, L8690–L8694
Auricular prosthesis, D5914, D5927
Aurothioglucose, J2910
Avelumab, J9023
Azacitidine, J9025
Azathioprine, J7500, J7501
Azithromycin injection, J0456

B
Back supports, L0621–L0861, L0960
lumbar orthrosis, L0625–L0627
lumbar orthrosis, sagittal control, L0641–L0648
lumbar-sacral orthrosis, L0628–L0640
lumbar-sacral orthrosis, sagittal-coronal control, L0640, L0649–L0651
sacroiliac orthrosis, L0621–L0624
Baclofen, J0475, J0476
Bacterial sensitivity study, P7001
Bag
drainage, A4357
enema, A4458
irrigation supply, A4398
urinary, A4358, A5112
Bandage, conforming
elastic, >5″, A6450
elastic, >3″, <5″, A6449
elastic, load resistance 1.25 to 1.34 foot pounds, >3″, <5″, A6451
elastic, load resistance <1.35 foot pounds, >3″, <5″, A6452
elastic, <3″, A6448
non-elastic, non-sterile, >5″, A6444
non-elastic, non-sterile, width greater than or equal to 3″, <5″, A6443
non-elastic, non-sterile, width <3″, A6442
non-elastic, sterile, >5″, A6447
non-elastic, sterile, >3″ and <5″, A6446
Basiliximab, J0480
Bath, aid, E0160–E0162, E0235, E0240–E0249
bath tub rail, floor base, E0242
bath tub wall rail, E0241
bath/shower chair, with/without wheels, E0240
pad for water circulating heat unit, replacement, E0249
paraffin bath unit, portable, E0235
raised toilet seat, E0244
sitz bath chair, E0162
sitz type bath, portable, with faucet attachment, E0161
sitz type bath, portable, with/without commode, E0160
toilet rail, E0243
transfer bench, tub or toilet, E0248

64
 transfer tub rail attachment, E0246
tub stool or bench, E0245
Bathtub
chair, E0240
stool or bench, E0245, E0247–E0248
transfer rail, E0246
wall rail, E0241–E0242
Battery, L7360, L7364–L7368
charger, E1066, L7362, L7366
replacement for blood glucose monitor, A4233–A4236
replacement for cochlear implant device, L8618, L8623–L8625
replacement for TENS, A4630
ventilator, A4611–A4613
BCG live, intravesical, J9031
Beclomethasone inhalation solution, J7622
Bed
accessories, E0271–E0280, E0300–E0326
bed board, E0273
bed cradle, E0280
bed pan, fracture, metal, E0276
bed pan, standard, metal, E0275
mattress, foam rubber, E0272
mattress innerspring, E0271
over-bed table, E0274
power pressure-reducing air mattress, E0277
air fluidized, E0194
cradle, any type, E0280
drainage bag, bottle, A4357, A5102
hospital, E0250–E0270, E0300–E0329
pan, E0275, E0276
rail, E0305, E0310
safety enclosure frame/canopy, E0316
Behavioral, health, treatment services (Medicaid), H0002–H2037
activity therapy, H2032
alcohol/drug services, H0001, H0003, H0005–H0016, H0020–H0022, H0026–H0029,
H0049–H0050, H2034–H2036
assertive community treatment, H0040
community based wrap-around services, H2021–H2022
comprehensive community support, H2015–H2016
comprehensive medication services, H2010
comprehensive multidisciplinary evaluation, H2000
crisis intervention, H2011
day treatment, per diem, H2013
day treatment, per hour, H2012
developmental delay prevention activities, dependent child of client, H2037
family assessment, H1011
foster care, child, H0041–H0042
health screening, H0002
hotline service, H0030
medication training, H0034
mental health clubhouse services, H2030–H2031
multisystemic therapy, juveniles, H2033

65
 non-medical family planning, H1010
outreach service, H0023
partial hospitalization, H0035
plan development, non-physician, H0033
prenatal care, at risk, H1000–H1005
prevention, H0024–H0025
psychiatric supportive treatment, community, H0036–H0037
psychoeducational service, H2027
psychoscial rehabilitation, H2017–H2018
rehabilitation program, H2010
residential treatment program, H0017–H0019
respite care, not home, H0045
self-help/peer services, H0039
sexual offender treatment, H2028–H2029
skill training, H2014
supported employment, H2024–H2026
supported housing, H0043–H0044
therapeutic behavioral services, H2019–H2020
Behavioral therapy, cardiovascular disease, G0446
Belatacept, J0485
Belimumab, J0490
Belt
belt, strap, sleeve, garment, or covering, any type, A4467
extremity, E0945
ostomy, A4367
pelvic, E0944
safety, K0031
wheelchair, E0978, E0979
Bench, bathtub; (see also Bathtub), E0245
Bendamustine HCl
Bendeka, 1 mg, J9034
Treanda, 1 mg, J9033
Benesch boot, L3212–L3214
Bezlotoxuman, J0565 ◀
Benztropine, J0515
Beta-blocker therapy, G9188–G9192
Betadine, A4246, A4247
Betameth, J0704
Betamethasone
acetate and betamethasone sodium phosphate, J0702
inhalation solution, J7624
Bethanechol chloride, J0520
Bevacizumab, J9035, Q2024
Bezlotoxumab, J0565 ✖
Bicuspid (excluding final restoration), D3320
retreatment, by report, D3347
surgery, first root, D3421
Bifocal, glass or plastic, V2200–V2299
aniseikonic, bifocal, V2218
bifocal add-over 3.25 d, V2220
bifocal seg width over 28 mm, V2219
lenticular, bifocal, myodisc, V2215

66
 lenticular lens, V2221
specialty bifocal, by report, V2200
sphere, bifocal, V2200–V2202
spherocylinder, bifocal, V2203–V2214
Bilirubin (phototherapy) light, E0202
Binder, A4465
Biofeedback device, E0746
Bioimpedance, electrical, cardiac output, M0302
Biosimilar (infliximab), Q5102–Q5110
Biperiden lactate, J0190
Bitewing, D0270–D0277
four radiographic images, D0274
single radiographic image, D0270
three radiographic images, D0273
two radiographic images, D0272
vertical bitewings, 7–8 radiographic images, D0277
Bitolterol mesylate, inhalation solution
concentrated, J7628
unit dose, J7629
Bivalirudin, J0583
Bivigam, 500 mg, J1556
Bladder calculi irrigation solution, Q2004
Bleomycin sulfate, J9040
Blood
count, G0306, G0307, S3630
complete CBC, automated, without platelet count, G0307
complete CBC, automated without platelet count, automated WBC differential, G0306
eosinophil count, blood, direct, S3630
fresh frozen plasma, P9017
glucose monitor, E0607, E2100, E2101, S1030, S1031, S1034
blood glucose monitor, integrated voice synthesizer, E2100
blood glucose monitor with integrated lancing/blood sample, E2101
continuous noninvasive device, purchase, S1030
continuous noninvasive device, rental, S1031
home blood glucose monitor, E0607
glucose test, A4253
glucose, test strips, dialysis, A4772
granulocytes, pheresis, P9050
ketone test, A4252
leak detector, dialysis, E1560
leukocyte poor, P9016
mucoprotein, P2038
platelets, P9019
platelets, irradiated, P9032
platelets, leukocytes reduced, P9031
platelets, leukocytes reduced, irradiated, P9033
platelets, pheresis, P9034, P9072, P9073, P9100
platelets, pheresis, irradiated, P9036
platelets, pheresis, leukocytes reduced, P9035
platelets, pheresis, leukocytes reduced, irradiated, P9037
pressure monitor, A4660, A4663, A4670
pump, dialysis, E1620

67
 red blood cells, deglycerolized, P9039
red blood cells, irradiated, P9038
red blood cells, leukocytes reduced, P9016
red blood cells, leukocytes reduced, irradiated, P9040
red blood cells, washed, P9022
strips, A4253
supply, P9010–P9022
testing supplies, A4770
tubing, A4750, A4755
Blood collection devices accessory, A4257, E0620
BMI, G8417–G8422
Body jacket
scoliosis, L1300, L1310
Body mass index, G8417–G8422
Body sock, L0984
Bond or cement, ostomy skin, A4364
Bone
density, study, G0130
Boot
pelvic, E0944
surgical, ambulatory, L3260
Bortezomib, J9041
Brachytherapy radioelements, Q3001
brachytherapy, LDR, prostate, G0458
brachytherapy planar source, C2645
brachytherapy, source, hospital outpatient, C1716–C1717, C1719
Breast prosthesis, L8000–L8035, L8600
adhesive skin support, A4280
custom breast prosthesis, post mastectomy, L8035
garment with mastectomy form, post mastectomy, L8015
implantable, silicone or equal, L8600
mastectomy bra, with integrated breast prosthesis form, unilateral, L8001
mastectomy bra, with prosthesis form, bilateral, L8002
mastectomy bra, without integrated breast prosthesis form, L8000
mastectomy form, L8020
mastectomy sleeve, L8010
nipple prosthesis, L8032
silicone or equal, with integral adhesive, L8031
silicone or equal, without integral adhesive, L8030
Breast pump
accessories, A4281–A4286
adapter, replacement, A4282
cap, breast pump bottle, replacement, A4283
locking ring, replacement, A4286
polycarbonate bottle, replacement, A4285
shield and splash protector, replacement, A4284
tubing, replacement, A4281
electric, any type, E0603
heavy duty, hospital grade, E0604
manual, any type, E0602
Breathing circuit, A4618
Brentuximab Vedotin, J9042

68
Bridge
repair, by report, D6980
replacement, D6930
Brompheniramine maleate, J0945
Budesonide inhalation solution, J7626, J7627, J7633, J7634
Bulking agent, L8604, L8607
Buprenorphine hydrochlorides, J0592
Buprenorphine/Naloxone, J0571–J0575
Burn, compression garment, A6501–A6513
bodysuit, head-foot, A6501
burn mask, face and/or neck, A6513
chin strap, A6502
facial hood, A6503
foot to knee length, A6507
foot to thigh length, A6508
glove to axilla, A6506
glove to elbow, A6505
glove to wrist, A6504
lower trunk, including leg openings, A6511
trunk, including arms, down to leg openings, A6510
upper trunk to waist, including arm openings, A6509
Bus, nonemergency transportation, A0110
Busulfan, J0594, J8510
Butorphanol tartrate, J0595
Bypass, graft, coronary, artery
surgery, S2205–S2209

C
C-1 Esterase Inhibitor, J0596–J0598
Cabazitaxel, J9043
Cabergoline, oral, J8515
Cabinet/System, ultraviolet, E0691–E0694
multidirectional light system, 6 ft. cabinet, E0694
timer and eye protection, 4 foot, E0692
timer and eye protection, 6 foot, E0693
ultraviolet light therapy system, treatment area 2 sq ft., E0691
Caffeine citrate, J0706
Calcitonin-salmon, J0630
Calcitriol, J0636, S0169
Calcium
disodium edetate, J0600
gluconate, J0610
glycerophosphate and calcium lactate, J0620
lactate and calcium glycerophosphate, J0620
leucovorin, J0640
Calibrator solution, A4256
Canakinumab, J0638
Cancer, screening
cervical or vaginal, G0101
colorectal, G0104–G0106, G0120–G0122, G0328
alternative to screening colonoscopy, barium enema, G0120

69
 alternative to screening sigmoidoscopy, barium enema, G0106
barium enema, G0122
colonoscopy, high risk, G0105
colonoscopy, not at high-risk, G0121
fecal occult blood test-1–3 simultaneous, G0328
flexible sigmoidoscopy, G0104
prostate, G0102, G0103
Cane, E0100, E0105
accessory, A4636, A4637
Canister
disposable, used with suction pump, A7000
non-disposable, used with suction pump, A7001
Cannula, nasal, A4615
Capecitabine, oral, J8520, J8521
Capsaicin patch, J7336
Carbidopa 5 mg/levodopa 20 mg enteral suspension, J7340
Carbon filter, A4680
Carboplatin, J9045
Cardia Event, recorder, implantable, E0616
Cardiokymography, Q0035
Cardiovascular services, M0300–M0301
Fabric wrapping abdominal aneurysm, M0301
IV chelation therapy, M0300
Cardioverter-defibrillator, G0448
Care, coordinated, G9001–G9011, H1002
coordinated care fee, home monitoring, G9006
coordinated care fee, initial rate, G9001
coordinated care fee, maintenance rate, G9002
coordinated care fee, physician coordinated care oversight, G9008
coordinated care fee, risk adjusted high, initial, G9003
coordinated care fee, risk adjusted low, initial, G9004
coordinated care fee, risk adjusted maintenance, G9005
coordinated care fee, risk adjusted maintenance, level 3, G9009
coordinated care fee, risk adjusted maintenance, level 4, G9010
coordinated care fee, risk adjusted maintenance, level 5, G9011
coordinated care fee, scheduled team conference, G9007
prenatal care, at-risk, enhanced service, care coordination, H1002
Care plan, G0162
Carfilzomib, J9047
Caries susceptibility test, D0425
Carmustine, J9050
Case management, T1016, T1017
dental, D9991–D9994
Caspofungin acetate, J0637
Cast
diagnostic, dental, D0470
hand restoration, L6900–L6915
materials, special, A4590
supplies, A4580, A4590, Q4001–Q4051
body cast, adult, Q4001–Q4002
cast supplies (e.g. plaster), A4580
cast supplies, unlisted types, Q4050

70
 finger splint, static, Q4049
gauntlet cast, adult, Q4013–Q4014
gauntlet cast, pediatric, Q4015–Q4016
hip spica, adult, Q4025–Q4026
hip spica, pediatric, Q4027–Q4028
long arm cast, adult, Q4005–Q4006
long arm cast, pediatric, Q4007–Q4008
long arm splint, adult, Q4017–Q4018
long arm splint, pediatric, Q4019–Q4020
long leg cast, adult, Q4029–Q4030
long leg cast, pediatric, Q4031–Q4032
long leg cylinder cast, adult, Q4033–Q4034
long leg cylinder cast, pediatric, Q4035–Q4036
long leg splint, adult, Q4041–Q4042
long leg splint, pediatric, Q4043–Q4044
short arm cast, adult, Q4009–Q4010
short arm cast, pediatric, Q4011–Q4012
short arm splint, adult, Q4021–Q4022
short arm splint, pediatric, Q4023–Q4024
short leg cast, adult, Q4037–Q4038
short leg cast, pediatric, Q4039–Q4040
short leg splint, adult, Q4045–Q4046
short leg splint, pediatric, Q4047–Q4048
shoulder cast, adult, Q4003–Q4004
special casting material (fiberglass), A4590
splint supplies, miscellaneous, Q4051
thermoplastic, L2106, L2126
Caster
front, for power wheelchair, K0099
wheelchair, E0997, E0998
Catheter, A4300–A4355
anchoring device, A4333, A4334, A5200
cap, disposable (dialysis), A4860
external collection device, A4327–A4330, A4347–A7048
female external, A4327–A4328
indwelling, A4338–A4346
insertion tray, A4354
insulin infusion catheter, A4224
intermittent with insertion supplies, A4353
irrigation supplies, A4355
male external, A4324, A4325, A4326, A4348
oropharyngeal suction, A4628
starter set, A4329
trachea (suction), A4609, A4610, A4624
transluminal angioplasty, C2623
transtracheal oxygen, A4608
vascular, A4300–A4301
Catheterization, specimen collection, P9612, P9615
CBC, G0306, G0307
Cefazolin sodium, J0690
Cefepime HCl, J0692
Cefotaxime sodium, J0698

71
Ceftaroline fosamil, J0712
Ceftazidime, J0713, J0714
Ceftizoxime sodium, J0715
Ceftolozane 50 mg and tazobactam 25 mg, J0695
Ceftriaxone sodium, J0696
Cefuroxime sodium, J0697
CellCept, K0412
Cellular therapy, M0075
Cement, ostomy, A4364
Centrifuge, A4650
Centruroides Immune F(ab), J0716
Cephalin Floculation, blood, P2028
Cephalothin sodium, J1890
Cephapirin sodium, J0710
Certification, physician, home, health (per calendar month), G0179–G0182
Physician certification, home health, G0180
Physician recertification, home health, G0179
Physician supervision, home health, complex care, 30 min or more, G0181
Physician supervision, hospice 30 min or more, G0182
Certolizumab pegol, J0717
Cerumen, removal, G0268
Cervical
cancer, screening, G0101
cytopathology, G0123, G0124, G0141–G0148
screening, automated thin layer, manual rescreening, physician supervision, G0145
screening, automated thin layer preparation, cytotechnologist, physician interpretation, G0143
screening, automated thin layer preparation, physician supervision, G0144
screening, by cytotechnologist, physician supervision, G0123
screening, cytopathology smears, automated system, physician interpretation, G0141
screening, interpretation by physician, G0124
screening smears, automated system, manual rescreening, G0148
screening smears, automated system, physician supervision, G0147
halo, L0810–L0830
head harness/halter, E0942
orthosis, L0100–L0200
cervical collar molded to patient, L0170
cervical, flexible collar, L0120–L0130
cervical, multiple post collar, supports, L0180–L0200
cervical, semi-rigid collar, L0150–L0160, L0172, L0174
cranial cervical, L0112–L0113
traction, E0855, E0856
Cervical cap contraceptive, A4261
Cervical-thoracic-lumbar-sacral orthosis (CTLSO), L0700, L0710
Cetuximab, J9055
Chair
adjustable, dialysis, E1570
lift, E0627
rollabout, E1031
sitz bath, E0160–E0162
transport, E1035–E1039
chair, adult size, heavy duty, greater than 300 pounds, E1039
chair, adult size, up to 300 pounds, E1038

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 chair, pediatric, E1037
multi-positional patient transfer system, extra-wide, greater than 300 pounds, E1036
multi-positional patient transfer system, up to 300 pounds, E1035
Chelation therapy, M0300
Chemical endarterectomy, M0300
Chemistry and toxicology tests, P2028–P3001
Chemotherapy
administration (hospital reporting only), Q0083–Q0085
drug, oral, not otherwise classified, J8999
drugs; (see also drug by name), J9000–J9999
Chest shell (cuirass), E0457
Chest Wall Oscillation System, E0483
hose, replacement, A7026
vest, replacement, A7025
Chest wrap, E0459
Chin cup, cervical, L0150
Chloramphenicol sodium succinate, J0720
Chlordiazepoxide HCl, J1990
Chloromycetin sodium succinate, J0720
Chloroprocaine HCl, J2400
Chloroquine HCl, J0390
Chlorothiazide sodium, J1205
Chlorpromazine HCl, J3230
Chlorpromazine HCL, 5 mg, oral, Q0161
Chorionic gonadotropin, J0725
Choroid, lesion, destruction, G0186
Chromic phosphate P32 suspension, A9564
Chromium CR-51 sodium chromate, A9553
Cidofovir, J0740
Cilastatin sodium, imipenem, J0743
Cinacalcet, J0604
Ciprofloxacin
for intravenous infusion, J0744
octic suspension, J7342
Cisplatin, J9060
Cladribine, J9065
Clamp
dialysis, A4918
external urethral, A4356
Cleanser, wound, A6260
Cleansing agent, dialysis equipment, A4790
Clofarabine, J9027
Clonidine, J0735
Closure, wound, adhesive, tissue, G0168
Clotting time tube, A4771
Clubfoot wedge, L3380
Cochlear prosthetic implant, L8614
accessories, L8615–L8617, L8618
batteries, L8621–L8624
replacement, L8619, L8627–L8629
external controller component, L8628
external speech processor and controller, integrated system, L8619

73
 external speech processor, component, L8627
transmitting coil and cable, integrated, L8629
Codeine phosphate, J0745
Cold/Heat, application, E0200–E0239
bilirubin light, E0202
electric heat pad, moist, E0215
electric heat pad, standard, E0210
heat lamp with stand, E0205
heat lamp, without stand, E0200
hydrocollator unit, E0225
hydrocollator unit, portable, E0239
infrared heating pad system, E0221
non-contact wound warming device, E0231
paraffin bath unit, E0235
pump for water circulating pad, E0236
therapeutic lightbox, E0203
warming card, non-contact wound warming device, E0232
water circulating cold pad, with pump, E0218
water circulating heat pad, with pump, E0217
Colistimethate sodium, J0770
Collagen
meniscus implant procedure, G0428
skin test, G0025
urinary tract implant, L8603
wound dressing, A6020–A6024
Collagenase, Clostridium histolyticum, J0775
Collar, cervical
multiple post, L0180–L0200
nonadjust (foam), L0120
Collection and preparation, saliva, D0417
Colorectal, screening, cancer, G0104–G0106, G0120–G0122, G0328
Coly-Mycin M, J0770
Comfort items, A9190
Commode, E0160–E0175
chair, E0170–E0171
lift, E0172, E0625
pail, E0167
seat, wheelchair, E0968
Complete, blood, count, G0306, G0307
Composite dressing, A6200–A6205
Compressed gas system, E0424–E0446
oximeter device, E0445
portable gaseous oxygen system, purchase, E0430
portable gaseous oxygen system, rental, E0431
portable liquid oxygen, rental, container/supplies, E0434
portable liquid oxygen, rental, home liquefier, E0433
portable liquid oxygen system, purchase, container/refill adapter, E0435
portable oxygen contents, gaseous, 1 month, E0443
portable oxygen contents, liquid, 1 month, E0444
stationary liquid oxygen system, purchase, use of reservoir, E0440
stationary liquid oxygen system, rental, container/supplies, E0439
stationary oxygen contents, gaseous, 1 month, E0441

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 stationary oxygen contents, liquid, 1 month, E0442
stationary purchase, compressed gas system, E0425
stationary rental, compressed gaseous oxygen system, E0424
topical oxygen delivery system, NOS, E0446
Compression
bandage, A4460
burn garment, A6501–A6512
stockings, A6530–A6549
Compressor, E0565, E0650–E0652, E0670–E0672
aerosol, E0572, E0575
air, E0565
nebulizer, E0570–E0585
pneumatic, E0650–E0676
Conductive gel/paste, A4558
Conductivity meter, bath, dialysis, E1550
Conference, team, G0175, G9007, S0220, S0221
coordinate care fee, scheduled team conference, G9007
medical conference/physician/interdisciplinary team, patient present, 30 min, S0220
medical conference physician/interdisciplinary team, patient present, 60 min, S0221
scheduled interdisciplinary team conference, patient present, G0175
Congo red, blood, P2029
Consultation, S0285, S0311, T1040, T1041
dental, D9311
Telehealth, G0425–G0427
Contact layer, A6206–A6208
Contact lens, V2500–V2599
Continent device, A5081, A5082, A5083
Continuous glucose monitoring system
receiver, A9278, S1037
sensor, A9276, S1035
transmitter, A9277, S1036
Continuous passive motion exercise device, E0936
Continuous positive airway pressure device(CPAP), E0601
compressor, K0269
Contraceptive
cervical cap, A4261
condoms, A4267, A4268
diaphragm, A4266
intratubal occlusion device, A4264
intrauterine, copper, J7300
intrauterine, levonorgestrel releasing, J7296–J7298, J7301
patch, J7304
spermicide, A4269
supply, A4267–A4269
vaginal ring, J7303
Contracts, maintenance, ESRD, A4890
Contrast, Q9951–Q9969
HOCM, Q9958–Q9964
injection, iron based magnetic resonance, per ml, Q9953
Injection, non-radioactive, non-contrast, visualization adjunct, Q9968
injection, octafluoropropane microspheres, per ml, Q9956
injection, perflexane lipid microspheres, per ml, Q9955

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 injection, perflutren lipid microspheres, per ml, Q9957
LOCM, Q9965–Q9967
LOCM, 400 or greater mg/ml iodine, per ml, Q9951
oral magnetic resonance contrast, Q9954
Tc-99m per study dose, Q9969
Contrast material
injection during MRI, A4643
low osmolar, A4644–A4646
Coordinated, care, G9001–G9011
CORF, registered nurse- face-face, G0128
Corneal tissue processing, V2785
Corset, spinal orthosis, L0970–L0976
LSO, corset front, L0972
LSO, full corset, L0976
TLSO, corset front, L0970
TLSO, full corset, L0974
Corticorelin ovine triflutate, J0795
Corticotropin, J0800
Corvert, (see Ibutilide fumarate)
Cosyntropin, J0833, J0834
Cough stimulating device, A7020, E0482
Counseling
alcohol misuse, G0443
cardiovascular disease, G0448
control of dental disease, D1310, D1320
obesity, G0447
sexually transmitted infection, G0445
Count, blood, G0306, G0307
Counterpulsation, external, G0166
Cover, wound
alginate dressing, A6196–A6198
foam dressing, A6209–A6214
hydrogel dressing, A6242–A6248
non-contact wound warming cover, and accessory, A6000, E0231, E0232
specialty absorptive dressing, A6251–A6256
CPAP (continuous positive airway pressure) device, E0601
headgear, K0185
humidifier, A7046
intermittent assist, E0452
Cradle, bed, E0280
Crib, E0300
Cromolyn sodium, inhalation solution, unit dose, J7631, J7632
Crotalidae polyvalent immune fab, J0840
Crowns, D2710–D2983, D4249, D6720–D6794
clinical crown lengthening-hard tissue, D4249
fixed partial denture retainers, crowns, D6710–D6794
single restoration, D2710–D2983
Crutches, E0110–E0118
accessories, A4635–A4637, K0102
crutch substitute, lower leg, E0118
forearm, E0110–E0111
underarm, E0112–E0117

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Cryoprecipitate, each unit, P9012
CTLSO, L0700, L0710, L1000–L1120
addition, axilla sling, L1010
addition, cover for upright, each, L1120
addition, kyphosis pad, L1020
addition, kyphosis pad, floating, L1025
addition, lumbar bolster pad, L1030
addition, lumbar rib pad, L1040
addition, lumbar sling, L1090
addition, outrigger, L1080
addition, outrigger bilateral, vertical extensions, L1085
addition, ring flange, L1100
addition, ring flange, molded to patient model, L1110
addition, sternal pad, L1050
addition, thoracic pad, L1060
addition, trapezius sling, L1070
anterior-posterior-lateral control, molded to patient model (CTLSO), L0710
cervical, thoracic, lumbar, sacral orthrosis (CTLSO), L0700
furnishing initial orthrosis, L1000
immobilizer, infant size, L1001
tension based scoliosis orthosis, fitting, L1005
Cuirass, E0457
Culture sensitivity study, P7001
Cushion, wheelchair, E0977
Cyanocobalamin Cobalt C057, A9559
Cycler dialysis machine, E1594
Cyclophosphamide, J9070
oral, J8530
Cyclosporine, J7502, J7515, J7516
Cytarabine, J9100
liposome, J9098
Cytomegalovirus immune globulin (human), J0850
Cytopathology, cervical or vaginal, G0123, G0124,
G0141–G0148

77
 D
Dacarbazine, J9130
Daclizumab, J7513
Dactinomycin, J9120
Dalalone, J1100
Dalbavancin, 5mg, J0875
Dalteparin sodium, J1645
Daptomycin, J0878
Daratumumab, J9145
Darbepoetin Alfa, J0881–J0882
Daunorubicin
Citrate, J9151
HCl, J9150
DaunoXome, (see Daunorubicin citrate)
Decitabine, J0894
Decubitus care equipment, E0180–E0199
air fluidized bed, E0194
air pressure mattress, E0186
air pressure pad, standard mattress, E0197
dry pressure mattress, E0184
dry pressure pad, standard mattress, E0199
gel or gel-like pressure pad mattress, standard, E0185
gel pressure mattress, E0196
heel or elbow protector, E0191
positioning cushion, E0190
power pressure reducing mattress overlay, with pump, E0181
powered air flotation bed, E0193
pump, alternating pressure pad, replacement, E0182
synthetic sheepskin pad, E0189
water pressure mattress, E0187
water pressure pad, standard mattress, E0198
Deferoxamine mesylate, J0895
Defibrillator, external, E0617, K0606
battery, K0607
electrode, K0609
garment, K0608
Degarelix, J9155
Deionizer, water purification system, E1615
Delivery/set-up/dispensing, A9901
Denileukin diftitox, J9160
Denosumab, J0897
Density, bone, study, G0130
Dental procedures
adjunctive general services, D9110–D9999
alveoloplasty, D7310–D7321
analgesia, D9230
diagnostic, D0120–D0999
endodontics, D3000–D3999
evaluations, D0120–D0180
implant services, D6000–D6199

78
 implants, D3460, D5925, D6010–D6067, D6075–D6199
laboratory, D0415–D0999
maxillofacial, D5900–D5999
orthodontics, D8000–D8999
periodontics, D4000–D4999
preventive, D1000–D1999
prosthetics, D5911–D5960, D5999
prosthodontics, fixed, D6200–D6999
prosthodontics, removable, D5000–D5999
restorative, D2000–D2999
scaling, D4341–D4346, D6081
Dentures, D5110–D5899
Depo-estradiol cypionate, J1000
Dermal filler injection, G0429
Desmopressin acetate, J2597
Destruction, lesion, choroid, G0186
Detector, blood leak, dialysis, E1560
Developmental testing, G0451
Devices, other orthopedic, E1800–E1841
assistive listening device, V5267–V5290
Dexamethasone
acetate, J1094
inhalation solution, concentrated, J7637
inhalation solution, unit dose, J7638
intravitreal implant, J7312
oral, J8540
sodium phosphate, J1100
Dextran, J7100
Dextrose
saline (normal), J7042
water, J7060, J7070
Dextrose, 5% in lactated ringers infusion, J7121
Dextrostick, A4772
Diabetes
evaluation, G0245, G0246
shoes (fitting/modifications), A5500–A5508
deluxe feature, depth-inlay shoe, A5508
depth inlay shoe, A5500
molded from cast patient’s foot, A5501
shoe with metatarsal bar, A5505
shoe with off-set heel(s), A5506
shoe with rocker or rigid-bottom rocker, A5503
shoe with wedge(s), A5504
specified modification NOS, depth-inlay shoe, A5507
training, outpatient, G0108, G0109
Diagnostic
dental services, D0100–D0999
florbetaben, Q9983
flutemetamol F18, Q9982
mammography, digital image, G9899, G9900
radiology services, R0070–R0076
Dialysate

79
 concentrate additives, A4765
solution, A4720–A4728
testing solution, A4760
Dialysis
air bubble detector, E1530
bath conductivity, meter, E1550
chemicals/antiseptics solution, A4674
disposable cycler set, A4671
emergency, G0257
equipment, E1510–E1702
extension line, A4672–A4673
filter, A4680
fluid barrier, E1575
home, S9335, S9339
kit, A4820
pressure alarm, E1540
shunt, A4740
supplies, A4650–A4927
tourniquet, A4929
unipuncture control system, E1580
unscheduled, G0257
venous pressure clamp, A4918
Dialyzer, A4690
Diaper, T1500, T4521–T4540, T4543, T4544
adult incontinence garment, A4520, A4553
incontinence supply, rectal insert, any type, each, A4337
disposable penile wrap, T4545 ◀
Diazepam, J3360
Diazoxide, J1730
Diclofenac, J1130
Dicyclomine HCl, J0500
Diethylstilbestrol diphosphate, J9165
Digoxin, J1160
Digoxin immune fab (ovine), J1162
Dihydroergotamine mesylate, J1110
Dimenhydrinate, J1240
Dimercaprol, J0470
Dimethyl sulfoxide (DMSO), J1212
Diphenhydramine HCl, J1200
Dipyridamole, J1245
Disarticulation
lower extremities, prosthesis, L5000–L5999
above knee, L5200–L5230
additions exoskeletal-knee-shin system, L5710–L5782
additions to lower extremities, L5610–L5617
additions to socket insert, L5654–L5699
additions to socket variations, L5630–L5653
additions to test sockets, L5618–L5629
additions/replacements, feet-ankle units, L5700–L5707
ankle, L5050–L5060
below knee, L5100–L5105
component modification, L5785–L5795

80
 endoskeletal, L5810–L5999
endoskeletal, above knee, L5321
endoskeletal, hip disarticulation, L5331–L5341
endoskeleton, below knee, L5301–L5312
hemipelvectomy, L5280
hip disarticulation, L5250–L5270
immediate postsurgical fitting, L5400–L5460
initial prosthesis, L5500–L5505
knee disarticulation, L5150–L5160
partial foot, L5000–L5020
preparatory prosthesis, L5510–L5600
upper extremities, prosthesis, L6000–L6692
above elbow, L6250
additions to upper limb, L6600–L6698
below elbow, L6100–L6130
elbow disarticulation, L6200–L6205
endoskeletal, below elbow, L6400
endoskeletal, interscapular thoracic, L6570–L6590
endoskeletal, shoulder disarticulation, L6550
immediate postsurgical procedures, L6380–L6388
interscapular/thoracic, L6350–L6370
partial hand, L6000–L6026
shoulder disarticulation, L6300–L6320
wrist disarticulation, L6050–L6055
Disease
status, oncology, G9063–G9139
Dispensing, fee, pharmacy, G0333, Q0510–Q0514, S9430
dispensing fee inhalation drug(s), 30 days, Q0513
dispensing fee inhalation drug(s), 90 days, Q0514
inhalation drugs, 30 days, as a beneficiary, G0333
initial immunosuppressive drug(s), post transplanr, G0510
oral anti-cancer, oral anti-emetic, immunosuppressive, first prescription, Q0511
oral anti-cancer, oral anti-emetic, immunosuppressive, subsequent preparation, Q0512
Disposable supplies, ambulance, A0382, A0384, A0392–A0398
DME
miscellaneous, A9900–A9999
DME delivery, set up, A9901
DME supple, NOS, A9999
DME supplies, A9900
DMSO, J1212
Dobutamine HCl, J1250
Docetaxel, J9171
Documentation
antidepressant, G8126–G8128
blood pressure, G8476–G8478
bypass, graft, coronary, artery, documentation, G8160–G8163
CABG, G8160–G8163
dysphagia, G8232
dysphagia, screening, G8232, V5364
ECG, 12–lead, G8705, G8706
eye, functions, G8315–G8333
influenza, immunization, G8482–G8484

81
 pharmacologic therapy for osteoporosis, G8635
physician for DME, G0454
prophylactic antibiotic, G8702, G8703
prophylactic parenteral antibiotic, G8629–G8632
prophylaxis, DVT, G8218
prophylaxis, thrombosis, deep, vein, G8218
urinary, incontinence, G8063, G8267
Dolasetron mesylate, J1260
Dome and mouthpiece (for nebulizer), A7016
Dopamine HCl, J1265
Doripenem, J1267
Dornase alpha, inhalation solution, unit dose form, J7639
Doxercalciferol, J1270
Doxil, J9001
Doxorubicin HCl, J9000, J9002
Drainage
bag, A4357, A4358
board, postural, E0606
bottle, A5102
Dressing; (see also Bandage), A6020–A6406
alginate, A6196–A6199
collagen, A6020–A6024
composite, A6200–A6205
contact layer, A6206–A6208
foam, A6209–A6215
gauze, A6216–A6230, A6402–A6406
holder/binder, A4462
hydrocolloid, A6234–A6241
hydrogel, A6242–A6248
specialty absorptive, A6251–A6256
transparent film, A6257–A6259
tubular, A6457
wound, K0744–K0746
Droperidol, J1790
and fentanyl citrate, J1810
Dropper, A4649
Drugs; (see also Table of Drugs)
administered through a metered dose inhaler, J3535
antiemetic, J8498, J8597, Q0163–Q0181
chemotherapy, J8500–J9999
disposable delivery system, 50 ml or greater per hour, A4305
disposable delivery system, 5 ml or less per hour, A4306
immunosuppressive, J7500–J7599
infusion supplies, A4221, A4222, A4230–A4232
inhalation solutions, J7608–J7699
non-prescription, A9150
not otherwise classified, J3490, J7599, J7699, J7799, J7999, J8499, J8999, J9999
oral, NOS, J8499
prescription, oral, J8499, J8999
Dry pressure pad/mattress, E0179, E0184, E0199
Durable medical equipment (DME), E0100–E1830, K Codes
additional oxygen related equipment, E1352–E1406

82
 arm support, wheelchair, E2626–E2633
artificial kidney machines/accessories, E1500–E1699
attachments, E0156–E0159
bath and toilet aides, E0240–E0249
canes, E0100–E0105
commodes, E0160–E0175
crutches, E0110–E0118
decubitus care equipment, E0181–E0199
DME, respiratory, inexpensive, purchased, A7000–A7509
gait trainer, E8000–E8002
heat/cold application, E0200–E0239
hospital beds and accessories, E0250–E0373
humidifiers/nebulizers/compressors, oxygen IPPB, E0550–E0585
infusion supplies, E0776–E0791
IPPB machines, E0500
jaw motion rehabilitation system, E1700–E1702
miscellaneous, E1902–E2120
monitoring equipment, home glucose, E0607
negative pressure, E2402
other orthopedic devices, E1800–E1841
oxygen/respiratory equipment, E0424–E0487
pacemaker monitor, E0610–E0620
patient lifts, E0621–E0642
pneumatic compressor, E0650–E0676
rollout chair/transfer system, E1031–E1039
safety equipment, E0700–E0705
speech device, E2500–E2599
suction pump/room vaporizers, E0600–E0606
temporary DME codes, regional carriers, K0000–K9999
TENS/stimulation device(s), E0720–E0770
traction equipment, E0830–E0900
trapeze equipment, fracture frame, E0910–E0948
walkers, E0130–E0155
wheelchair accessories, E2201–E2397
wheelchair, accessories, E0950–E1030
wheelchair, amputee, E1170–E1200
wheelchair cusion/protection, E2601–E2621
wheelchair, fully reclining, E1050–E1093
wheelchair, heavy duty, E1280–E1298
wheelchair, lightweight, E1240–E1270
wheelchair, semi-reclining, E1100–E1110
wheelchair, skin protection, E2622–E2625
wheelchair, special size, E1220–E1239
wheelchair, standard, E1130–E1161
whirlpool equipment, E1300–E1310
Duraclon, (see Clonidine)
Dyphylline, J1180
Dysphagia, screening, documentation, G8232, V5364
Dystrophic, nails, trimming, G0127

83
Ear mold, V5264, V5265
Ecallantide, J1290
Echocardiography injectable contrast material, A9700
ECG, 12–lead, G8704
Eculizumab, J1300
ED, visit, G0380–G0384
Edetate
calcium disodium, J0600
disodium, J3520
Educational Services
chronic kidney disease, G0420, G0421
Eggcrate dry pressure pad/mattress, E0184, E0199
EKG, G0403–G0405
Elbow
disarticulation, endoskeletal, L6450
orthosis (EO), E1800, L3700–L3740, L3760, L3671
dynamic adjustable elbow flexion device, E1800
elbow arthrosis, L3702–L3766
protector, E0191
Electric hand, L7007–L7008
Electric, nerve, stimulator, transcutaneous, A4595, E0720–E0749
conductive garment, E0731
electric joint stimulation device, E0762
electrical stimulator supplies, A4595
electromagnetic wound treatment device, E0769
electronic salivary reflex stimulator, E0755
EMG, biofeedback device, E0746
functional electrical stimulator, nerve and/or muscle groups, E0770
functional stimulator sequential muscle groups, E0764
incontinence treatment system, E0740
nerve stimulator (FDA), treatment nausea and vomiting, E0765
osteogenesis stimulator, electrical, surgically implanted, E0749
osteogenesis stimulator, low-intensity ultrasound, E0760
osteogenesis stimulator, non-invasive, not spinal, E0747
osteogenesis stimulator, non-invasive, spinal, E0748
radiowaves, non-thermal, high frequency, E0761
stimulator, electrical shock unit, E0745
stimulator for scoliosis, E0744
TENS, four or more leads, E0730
TENS, two lead, E0720
Electrical stimulation device used for cancer treatment, E0766
Electrical work, dialysis equipment, A4870
Electrodes, per pair, A4555, A4556
Electromagnetic, therapy, G0295, G0329
Electronic medication compliance, T1505
Elevating leg rest, K0195
Elliotts b solution, J9175
Elotuzumab, J9176
Emergency department, visit, G0380–G0384
EMG, E0746
Eminase, J0350
Endarterectomy, chemical, M0300

84
Endodontic procedures, D3000–D3999
periapical services, D3410–D3470
pulp capping, D3110, D3120
root canal therapy, D3310–D3353
therapy, D3310–D3330
Endodontics, dental, D3000–D3999
Endoscope sheath, A4270
Endoskeletal system, addition, L5848, L5856–L5857, L5925, L5961, L5969
Enema, bag, A4458
Enfuvirtide, J1324
Enoxaparin sodium, J1650
Enteral
feeding supply kit (syringe) (pump) (gravity), B4034–B4036
formulae, B4149–B4156, B4157–B4162
nutrition infusion pump (with alarm) (without), B9000, B9002
therapy, supplies, B4000–B9999
enteral and parenteral pumps, B9002–B9999
enteral formula/medical supplies, B0434–B4162
parenteral solutions/supplies, B4164–B5200
Epinephrine, J0171
Epirubicin HCl, J9178
Epoetin alpha, J0885, Q4081
Epoetin beta, J0887–J0888
Epoprostenol, J1325
Equipment
decubitus, E0181–E0199
exercise, A9300, E0935, E0936
orthopedic, E0910–E0948, E1800–E8002
oxygen, E0424–E0486, E1353–E1406
pump, E0781, E0784, E0791
respiratory, E0424–E0601
safety, E0700, E0705
traction, E0830–E0900
transfer, E0705
trapeze, E0910–E0912, E0940
whirlpool, E1300, E1310
Erection device, tension ring, L7902
Ergonovine maleate, J1330
Eribulin mesylate, J9179
Ertapenem sodium, J1335
Erythromycin lactobionate, J1364
ESRD (End-Stage Renal Disease); (see also Dialysis)
machines and accessories, E1500–E1699
adjustable chair, ESRD, E1570
centrifuge, dialysis, E1500
dialysis equipment, NOS, E1699
hemodialysis, air bubble detector, replacement, E1530
hemodialysis, bath conductivity meter, E1550
hemodialysis, blood leak detector, replacement, E1560
hemodialysis, blood pump, replacement, E1620
hemodialysis equipment, delivery/instillation charges, E1600
hemodialysis, heparin infusion pump, E1520

85
 hemodialysis machine, E1590
hemodialysis, portable travel hemodialyzer system, E1635
hemodialysis, pressure alarm, E1540
hemodialysis, reverse osmosis water system, E1615
hemodialysis, sorbent cartridges, E1636
hemodialysis, transducer protectors, E1575
hemodialysis, unipuncture control system, E1580
hemodialysis, water softening system, E1625
hemostats, E1637
peritoneal dialysis, automatic intermittent system, E1592
peritoneal dialysis clamps, E1634
peritoneal dialysis, cycler dialysis machine, E1594
peritoneal dialysis, reciprocating system, E1630
scale, E1639
wearable artificial kidney, E1632
plumbing, A4870
supplies, A4651–A4929
acetate concentrate solution, hemodialysis, A4708
acid concentrate solution, hemodialysis, A4709
activated carbon filters, hemodialysis, A4680
ammonia test strip, dialysis, A4774
automatic blood pressure monitor, A4670
bicarbonate concentrate, powder, hemodialysis, A4707
bicarbonate concentrate, solution, A4706
blood collection tube, vaccum, dialysis, A4770
blood glucose test strip, dialysis, A4772
blood pressure cuff only, A4663
blood tubing, arterial and venous, hemodialysis, A4755
blood tubing, arterial or venous, hemodialysis, A4750
chemicals/antiseptics solution, clean dialysis equipment, A4674
dialysate solution, non-dextrose, A4728
dialysate solution, peritoneal dialysis, A4720–A4726, A4760–A4766
dialyzers, hemodialysis, A4690
disposable catheter tips, peritoneal dialysis, A4860
disposable cycler set, dialysis machine, A4671
drainage extension line, dialysis, sterile, A4672
extension line easy lock connectors, dialysis, A4673
fistula cannulation set, hemodialysis, A4730
injectable anesthetic, dialysis, A4737
occult blood test strips, dialysis, A4773
peritoneal dialysis, catheter anchoring device, A4653
protamine sulfate, hemodialysis, A4802
serum clotting timetube, dialysis, A4771
shunt accessory, hemodialysis, A4740
sphygmomanometer, cuff and stethoscope, A4660
syringes, A4657
topical anesthetic, dialysis, A4736
treated water, peritoneal dialysis, A4714
“Y set” tubing, peritoneal dialysis, A4719
Estrogen conjugated, J1410
Estrone (5, Aqueous), J1435
Etelcalcetide, J0606

86
Eteplirsen, J1428
Ethanolamine oleate, J1430
Etidronate disodium, J1436
Etonogestrel implant system, J7307
Etoposide, J9181
oral, J8560
Euflexxa, J7323
Evaluation
conformity, V5020
contact lens, S0592
dental, D0120–D0180
diabetic, G0245, G0246
footwear, G8410–G8416
hearing, S0618, V5008, V5010
hospice, G0337
multidisciplinary, H2000
nursing, T1001
ocularist, S9150
performance measurement, S3005
resident, T2011
speech, S9152
team, T1024
Everolimus, J7527
Examination
gynecological, S0610–S0613
ophthalmological, S0620, S0621
oral, D0120–D0160
pinworm, Q0113
Exercise
class, S9451
equipment, A9300
External
ambulatory infusion pump, E0781, E0784
ambulatory insulin delivery system, A9274
power, battery components, L7360–L7368
power, elbow, L7160–L7191
urinary supplies, A4356–A4359
Extractions; (see also Dental procedures), D7111–D7140, D7251
Extremity
belt/harness, E0945
traction, E0870–E0880
Eye
case, V2756
functions, documentation, G8315–G8333
lens (contact) (spectacle), V2100–V2615
pad, patch, A6410–A6412
prosthetic, V2623, V2629
service (miscellaneous), V2700–V2799

F
Face tent, oxygen, A4619

87
Faceplate, ostomy, A4361
Factor IX, J7193, J7194, J7195, J7200–J7202
Factor VIIA coagulation factor, recombinant, J7189, J7205
Factor VIII, anti-hemophilic factor, J7182, J7185, J7190–J7192, J7207, J7209
Factor X, J7175
Factor XIII, anti-hemophilic factor, J7180, J7188
Factor XIII, A-subunit, J7181
Family Planning Education, H1010
Fee
coordinated care, G9001–G9011
dispensing, pharmacy, G0333, Q0510–Q0514, S9430
Fentanyl citrate, J3010
and droperidol, J1810
Fern test, Q0114
Ferumoxytol, Q0138, Q0139
Filgrastim (G-CSF &amp; TBO), J1442, J1447, Q5101
Filler, wound
alginate dressing, A6199
foam dressing, A6215
hydrocolloid dressing, A6240, A6241
hydrogel dressing, A6248
not elsewhere classified, A6261, A6262
Film, transparent (for dressing), A6257–A6259
Filter
aerosol compressor, A7014
dialysis carbon, A4680
ostomy, A4368
tracheostoma, A4481
ultrasonic generator, A7014
Fistula cannulation set, A4730
Flebogamma, J1572
Florbetapir F18, A9586
Flowmeter, E0440, E0555, E0580
Floxuridine, J9200
Fluconazole, injection, J1450
Fludarabine phosphate, J8562, J9185
Fluid barrier, dialysis, E1575
Flunisolide inhalation solution, J7641
Fluocinolone, J7311, J7313
Fluoride treatment, D1201–D1205
Fluorodeoxyglucose F-18 FDG, A9552
Fluorouracil, J9190
Fluphenazine decanoate, J2680
Foam
dressing, A6209–A6215
pad adhesive, A5126
Folding walker, E0135, E0143
Foley catheter, A4312–A4316, A4338–A4346
indwelling catheter, specialty type, A4340
indwelling catheter, three-way, continuous irrigation, A4346
indwelling catheter, two-way, all silicone, A4344
indwelling catheter, two-way latex, A4338

88
 insertion tray with drainage bag, A4312
insertion tray with drainage bag, three-way, continuous irrigation, A4316
insertion tray with drainage bag, two-way latex, A4314
insertion tray with drainage bag, two-way, silicone, A4315
insertion tray without drainage bag, A4313
Fomepizole, J1451
Fomivirsen sodium intraocular, J1452
Fondaparinux sodium, J1652
Foot care, G0247
Footdrop splint, L4398
Footplate, E0175, E0970, L3031
Footwear, orthopedic, L3201–L3265
additional charge for split size, L3257
Benesch boot, pair, child, L3213
Benesch boot, pair, infant, L3212
Benesch boot, pair, junior, L3214
custom molded shoe, prosthetic shoe, L3250
custom shoe, depth inlay, L3230
ladies shoe, hightop, L3217
ladies shoe, oxford, L3216
ladies shoe, oxford/brace, L3224
mens shoe, depth inlay, L3221
mens shoe, hightop, L3222
mens shoe, oxford, L3219
mens shoe, oxford/brace, L3225
molded shoe, custom fitted, Plastazote, L3253
non-standard size or length, L3255
non-standard size or width, L3254
Plastazote sandal, L3265
shoe, hightop, child, L3206
shoe, hightop, infant, L3204
shoe, hightop, junior, L3207
shoe molded/patient model, Plastazote, L3252
shoe, molded/patient model, silicone, L3251
shoe, oxford, child, L3202
shoe, oxford, infant, L3201
shoe, oxford, junior, L3203
surgical boot, child, L3209
surgical boot, infant, L3208
surgical boot, junior, L3211
surgical boot/shoe, L3260
Forearm crutches, E0110, E0111
Formoterol, J7640
fumarate, J7606
Fosaprepitant, J1453
Foscarnet sodium, J1455
Fosphenytoin, Q2009
Fracture
bedpan, E0276
frame, E0920, E0930, E0946–E0948
attached to bed/weights, E0920
attachments for complex cervical traction, E0948

89
 attachments for complex pelvic traction, E0947
dual, cross bars, attached to bed, E0946
free standing/weights, E0930
orthosis, L2106–L2136, L3980–L3984
ankle/foot orthosis, fracture, L2106–L2128
KAFO, fracture orthosis, L2132–L2136
upper extremity, fracture orthosis, L3980–L3984
orthotic additions, L2180–L2192, L3995
addition to upper extremity orthosis, sock, fracture, L3995
additions lower extremity fracture, L2180–L2192
Fragmin, (see Dalteparin sodium), J1645
Frames (spectacles), V2020, V2025
Deluxe frame, V2025
Purchases, V2020
Fulvestrant, J9395
Furosemide, J1940

G
Gadobutrol, A9585
Gadofosveset trisodium, A9583
Gadoxetate disodium, A9581
Gait trainer, E8000–E8002
Gallium Ga67, A9556
Gallium nitrate, J1457
Galsulfase, J1458
Gamma globulin, J1460, J1560
injection, gamma globulin (IM), 1cc, J1460
injection, gamma globulin (IM), over 10cc, J1560
Gammagard liquid, J1569
Gammaplex, J1557
Gamunex, J1561
Ganciclovir
implant, J7310
sodium, J1570
Garamycin, J1580
Gas system
compressed, E0424, E0425
gaseous, E0430, E0431, E0441, E0443
liquid, E0434–E0440, E0442, E0444
Gastric freezing, hypothermia, M0100
Gatifloxacin, J1590
Gauze; (see also Bandage)
impregnated, A6222–A6233, A6266
non-impregnated, A6402–A6404
Gefitinib, J8565
Gel
conductive, A4558
pressure pad, E0185, E0196
Gemcitabine HCl, J9201
Gemtuzumab ozogamicin, J9203
Generator

90
 neurostimulator (implantable), high frequency, C1822
ultrasonic with nebulizer, E0574–E0575
Gentamicin (Sulfate), J1580
Gingival procedures, D4210–D4240
gingival flap procedure, D4240–D4241
gingivectomy or gingivoplasty, D4210–D4212
Glasses
air conduction, V5070
binaural, V5120–V5150
behind the ear, V5140
body, V5120
glasses, V5150
in the ear, V5130
bone conduction, V5080
frames, V2020, V2025
hearing aid, V5230
Glaucoma
screening, G0117, G0118
Gloves, A4927
Glucagon HCl, J1610
Glucose
monitor includes all supplies, K0553
monitor with integrated lancing/blood sample collection, E2101
monitor with integrated voice synthesizer, E2100
receiver (monitor) dedicated, K0554
test strips, A4253, A4772
Gluteal pad, L2650
Glycopyrrolate, inhalation solution, concentrated, J7642
Glycopyrrolate, inhalation solution, unit dose, J7643
Gold
foil dental restoration, D2410–D2430
gold foil, one surface, D2410
gold foil, two surfaces, D2420
gold foli, three surfaces, D2430
sodium thiomalate, J1600
Golimumab, J1602
Gomco drain bottle, A4912
Gonadorelin HCl, J1620
Goserelin acetate implant; (see also Implant), J9202
Grab bar, trapeze, E0910, E0940
Grade-aid, wheelchair, E0974
Gradient, compression stockings, A6530–A6549
below knee, 18–30 mmHg, A6530
below knee, 30–40 mmHg, A6531
below knee, thigh length, 18–30 mmHg, A6533
full length/chap style, 18–30 mmHg, A6536
full length/chap style, 30–40 mmHg, A6537
full length/chap style, 40–50 mmHg, A6538
garter belt, A6544
non-elastic below knee, 30–50 mmhg, A6545
sleeve, NOS, A6549
thigh length, 30–40 mmHg, A6534

91
 thigh length, 40–50 mmHg, A6535
waist length, 18–30 mmHg, A6539
waist length, 30–40 mmHg, A6540
waist length, 40–50 mmHg, A6541
Granisetron HCl, J1626
XR, J1627
Gravity traction device, E0941
Gravlee jet washer, A4470
Guidelines, practice, oncology, G9056–G9062

H
Hair analysis (excluding arsenic), P2031
Halaven, Injection, eribulin mesylate, 0.1 mg, J9179
Hallus-Valgus dynamic splint, L3100
Hallux prosthetic implant, L8642
Halo procedures, L0810–L0860
addition HALO procedure, MRI compatible systems, L0859
addition HALO procedure, replacement liner, L0861
cervical halo/jacket vest, L0810
cervical halo/Milwaukee type orthosis, L0830
cervical halo/plaster body jacket, L0820
Haloperidol, J1630
decanoate, J1631
Halter, cervical head, E0942
Hand finger orthosis, prefabricated, L3923
Hand restoration, L6900–L6915
orthosis (WHFO), E1805, E1825, L3800–L3805, L3900–L3954
partial prosthesis, L6000–L6020
partial hand, little and/or ring finger remaining, L6010
partial hand, no finger, L6020
partial hand, thumb remaining, L6000
transcarpal/metacarpal or partial hand disarticulation prosthesis, L6025
rims, wheelchair, E0967
Handgrip (cane, crutch, walker), A4636
Harness, E0942, E0944, E0945
Headgear (for positive airway pressure device), K0185
Hearing
aid, V5030–V5267, V5298
aid-body worn, V5100
assistive listening device, V5268–V5274, V5281–V5290
battery, use in hearing device, V5266
contralateral routing, V5171–V5172, V5181, V5211–V5115, V5221 ◀
dispensing fee, binaural, V5160
dispensing fee, monaural hearing aid, any type, V5241
dispensing fee, unspecified hearing aid, V5090
ear impression, each, V5275
ear mold/insert, disposable, any type, V5265
ear mold/insert, not disposable, V5264
glasses, air conduction, V5070
glasses, bone conduction, V5080
hearing aid, analog, binaural, CIC, V5248

92
 hearing aid, analog, binaural, ITC, V5249
hearing aid, analog, monaural, CIC, V5242
hearing aid, analog, monaural, ITC, V5243
hearing aid, BICROS, V5210–V5240
hearing aid, binaural, V5120–V5150
hearing aid, CROS, V5170–V5200
hearing aid, digital, V5254–V5261
hearing aid, digitally programmable, V5244–V5247, V5250–V5253
hearing aid, disposable, any type, binaural, V5263
hearing aid, disposable, any type, monaural, V5262
hearing aid, monaural, V5030–V5060
hearing aid, NOC, V5298
hearing aid or assistive listening device/supplies/accessories, NOS, V5267
hearing service, miscellaneous, V5299
semi-implantable, middle ear, V5095
assessment, S0618, V5008, V5010
devices, L8614, V5000–V5299
services, V5000–V5999
Heat
application, E0200–E0239
infrared heating pad system, A4639, E0221
lamp, E0200, E0205
pad, A9273, E0210, E0215, E0237, E0249
Heater (nebulizer), E1372
Heavy duty, wheelchair, E1280–E1298, K0006, K0007, K0801–K0886
detachable arms, elevating legrests, E1280
detachable arms, swing away detachable footrest, E1290
extra heavy duty wheelchair, K0007
fixed full length arms, elevating legrest, E1295
fixed full length arms, swing away detachable footrest, E1285
heavy duty wheelchair, K0006
power mobility device, not coded by DME PDAC or no criteria, K0900
power operated vehicle, group 2, K0806–K0808
power operated vehicle, NOC, K0812
power wheelchair, group 1, K0813–K0816
power wheelchair, group 2, K0820–K0843
power wheelchair, group 3, K0848–K0864
power wheelchair, group 4, K0868–K0886
power wheelchair, group 5, pediatric, K0890–K0891
power wheelchair, NOC, K0898
power-operated vehicle, group 1, K0800–K0802
special wheelchair seat depth and/or width, by construction, E1298
special wheelchair seat depth, by upholstery, E1297
special wheelchair seat height from floor, E1296
Heel
elevator, air, E0370
protector, E0191
shoe, L3430–L3485
stabilizer, L3170
Helicopter, ambulance; (see also Ambulance)
Helmet
cervical, L0100, L0110

93
 head, A8000–A8004
Hemin, J1640
Hemipelvectomy prosthesis, L5280
Hemi-wheelchair, E1083–E1086
Hemodialysis machine, E1590
Hemodialysis, vessel mapping, G0365
Hemodialyzer, portable, E1635
Hemofil M, J7190
Hemophilia clotting factor, J7190–J7198
anti-inhibitor, per IU, J7198
anti-thrombin III, human, per IU, J7197
Factor IX, complex, per IU, J7194
Factor IX, purified, non-recombinant, per IU, J7193
Factor IX, recombinant, J7195
Factor VIII, human, per IU, J7190
Factor VIII, porcine, per IU, J7191
Factor VIII, recombinant, per IU, NOS, J7192
injection, antithrombin recombinant, 50 i.u., J7196
NOC, J7199
Hemostats, A4850, E1637
Hemostix, A4773
Hepagam B
IM, J1571
IV, J1573
Heparin
infusion pump, dialysis, E1520
lock flush, J1642
sodium, J1644
Hepatitis B, vaccine, administration, G0010
Hep-Lock (U/P), J1642
Hexalite, A4590
High osmolar contrast material, Q9958–Q9964
HOCM, 400 or greater mg/ml iodine, Q9964
HOCM, 150–199 mg/ml iodine, Q9959
HOCM, 200–249 mg/ml iodine, Q9960
HOCM, 250–299 mg/ml iodine, Q9961
HOCM, 300–349 mg/ml iodine, Q9962
HOCM, 350–399 mg/ml iodine, Q9963
HOCM, up to 149 mg/ml iodine, Q9958
Hip
disarticulation prosthesis, L5250, L5270
orthosis (HO), L1600–L1690
Hip-knee-ankle-foot orthosis (HKAFO), L2040–L2090
Histrelin
acetate, J1675
implant, J9225
HKAFO, L2040–L2090
Home
certification, home health, G0180
glucose, monitor, E0607, E2100, E2101, S1030, S1031
health, aide, G0156, S9122, T1021
health, aide, in home, per hour, S9122

94
 health, aide, per visit, T1021
health, clinical, social worker, G0155
health, hospice, each 15 min, G0156
health, occupational, therapist, G0152
health, physical therapist, G0151
health, physician, certification, G0179–G0182
health, respiratory therapy, S5180, S5181
recerticication, home health, G0179
supervision, home health, G0181
supervision, hospice, G0182
therapist, speech, S9128
Home Health Agency Services, T0221, T1022
care improvement home visit assessment, G9187
Home sleep study test, G0398–G0400
HOPPS, C1000–C9999
Hospice care
assisted living facility, Q5002
hospice facility, Q5010
inpatient hospice facility, Q5006
inpatient hospital, Q5005
inpatient psychiatric facility, Q5008
long term care facility, Q5007
nursing long-term facility, Q5003
patient’s home, Q5001
skilled nursing facility, Q5004
Hospice, evaluation, pre-election, G0337
Hospice physician supervision, G0182
Hospital
bed, E0250–E0304, E0328, E0329
observation, G0378, G0379
outpatient clinic visit, assessment, G0463
Hospital Outpatient Payment System, C1000–C9999
Hot water bottle, A9273
Human fibrinogen concentrate, J7178
Humidifier, A7046, E0550–E0563
durable, diring IPPB treatment, E0560
durable, extensive, IPPB, E0550
durable glass bottle type, for regulator, E0555
heated, used with positive airway pressure device, E0562
non-heated, used with positive airway pressure, E0561
water chamber, humidifier, replacement, positive airway device, A7046
Hyalgan, J7321
Hyalomatrix, Q4117
Hyaluronan, J7326, J7327
durolane, J7318 ◀
gel-Syn, J7328
genvisc, J7320
hymovis, J7322
Hyaluronate, sodium, J7317
Hyaluronidase, J3470
ovine, J3471–J3473
Hydralazine HCl, J0360

95
Hydraulic patient lift, E0630
Hydrocollator, E0225, E0239
Hydrocolloid dressing, A6234–A6241
Hydrocortisone
acetate, J1700
sodium phosphate, J1710
sodium succinate, J1720
Hydrogel dressing, A6231–A6233, A6242–A6248
Hydromorphone, J1170
Hydroxyprogesterone caproate, J1725–J1726, J1729
Hydroxyzine HCl, J3410
Hygienic item or device, disposable or non-disposable, any type, each, A9286
Hylan G-F 20, J7322
Hyoscyamine Sulfate, J1980
Hyperbaric oxygen chamber, topical, A4575
Hypertonic saline solution, J7130, J7131

I
Ibandronate sodium, J1740
Ibuprofen, J1741
Ibutilide Fumarate, J1742
Icatibant, J1744
Ice
cap, E0230
collar, E0230
Idarubicin HCl, J9211
Idursulfase, J1743
Ifosfamide, J9208
Iliac, artery, angiography, G0278
Iloprost, Q4074
Imaging, PET, G0219, G0235
any site, NOS, G0235
whole body, melanoma, non-covered indications, G0219
Imiglucerase, J1786
Immune globulin, J1575
Bivigam, 500 mg, J1556
Cuvitru, J1555
Flebogamma, J1572
Gammagard liquid, J1569
Gammaplex, J1557
Gamunex, J1561
HepaGam B, J1571
Hizentra, J1559
Intravenous services, supplies and accessories, Q2052
NOS, J1566
Octagam, J1568
Privigen, J1459
Rho(D), J2788, J2790, J2791
Rhophylac, J2791
Subcutaneous, J1562
Immunosuppressive drug, not otherwise classified, J7599

96
Implant
access system, A4301
aqueous shunt, L8612
breast, L8600
buprenorphine implant, J0570
cochlear, L8614, L8619
collagen, urinary tract, L8603
dental, D3460, D5925, D6010–D6067, D6075–D6199
crown, provisional, D6085
endodontic endosseous implant, D3460
facial augmentation implant prosthesis, D5925
implant supported prosthetics, D6055–D6067, D6075–D6077
other implant services, D6080–D6199
surgical placement, D6010–D6051
dextranomer/hyaluronic acid copolymer, L8604
ganciclovir, J7310
hallux, L8642
infusion pump, programmable, E0783, E0786
implantable, programmable, E0783
implantable, programmable, replacement, E0786
joint, L8630, L8641, L8658
interphalangeal joint spacer, silicone or equal, L8658
metacarpophalangeal joint implant, L8630
metatarsal joint implant, L8641
lacrimal duct, A4262, A4263
maintenance procedures, D6080
maxillofacial, D5913–D5937
auricular prosthesis, D5914
auricular prosthesis, replacement, D5927
cranial prosthesis, D5924
facial augmentation implant prosthesis, D5925
facial prosthesis, D5919
facial prosthesis, replacement, D5929
mandibular resection prosthesis, with guide flange, D5934
mandibular resection prosthesis, without guide flange, D5935
nasal prosthesis, D5913
nasal prosthesis, replacement, D5926
nasal septal prosthesis, D5922
obturator prosthesis, definitive, D5932
obturator prosthesis, modification, D5933
obturator prosthesis, surgical, D5931
obturator/prosthesis, interim, D5936
ocular prosthesis, D5916
ocular prosthesis, interim, D5923
orbital prosthesis, D5915
orbital prosthesis, replacement, D5928
trismus appliance, not for TM treatment, D5937
metacarpophalangeal joint, L8630
metatarsal joint, L8641
neurostimulator pulse generator, L8679, L8681–L8688
not otherwise specified, L8699
ocular, L8610

97
 ossicular, L8613
osteogenesis stimulator, E0749
percutaneous access system, A4301
removal, dental, D6100
repair, dental, D6090
replacement implantable intraspinal catheter, E0785
synthetic, urinary, L8606
urinary tract, L8603, L8606
vascular graft, L8670
Implantable radiation dosimeter, A4650
Impregnated gauze dressing, A6222–A6230, A6231–A6233
Incobotulinumtoxin a, J0588
Incontinence
appliances and supplies, A4310, A4331, A4332, A4360, A5071–A5075, A5081–A5093,
A5102–A5114
garment, A4520, T4521–T4543
adult sized disposable incontinence product, T4522–T4528
any type, e.g. brief, diaper, A4520
pediatric sized disposable incontinence product, T4529–T4532
youth sized disposable incontinence product, T4533–T4534
supply, A4335, A4356–A4360
bedside drainage bag, A4357
disposable external urethral clamp/compression device, A4360
external urethral clamp or compression device, A4356
incontinence supply, miscellaneous, A4335
urinary drainage bag, leg or abdomen, A4358
treatment system, E0740
Indium IN-111
carpromab pendetide, A9507
ibritumomab tiuxetan, A9542
labeled autologous platelets, A9571
labeled autologous white blood cells, A9570
oxyquinoline, A9547
pentetate, A9548
pentetreotide, A9572
satumomab, A4642
Infliximab injection, J1745
Influenza
afluria, Q2035
agriflu, Q2034
flulaval, Q2036
fluvirin, Q2037
fluzone, Q2038
immunization, documentation, G8482–G8484
not otherwise specified, Q2039
vaccine, administration, G0008
virus vaccine, Q2034–Q2039
Infusion
pump, ambulatory, with administrative equipment, E0781
pump, heparin, dialysis, E1520
pump, implantable, E0782, E0783
pump, implantable, refill kit, A4220

98
 pump, insulin, E0784
pump, mechanical, reusable, E0779, E0780
pump, uninterrupted infusion of Epiprostenol, K0455
replacement battery, A4602
saline, J7030–J7060
supplies, A4219, A4221, A4222, A4225, A4230–A4232, E0776–E0791
therapy, other than chemotherapeutic drugs, Q0081
Inhalation solution; (see also drug name), J7608–J7699, Q4074
Injection device, needle-free, A4210
Injections; (see also drug name), J0120–J7320, J7321–J7330, J9032, J9039, J9044, J9057, J9153,
J9173, J9229, J9271, J9299, J9308, Q9950, Q9991, Q9992 J9271, J9299, J9308, Q9950
ado-trastuzumab emtansine, 1 mg, J9354
aripiprazole, extended release, J0401
arthrography, sacroiliac, joint, G0259, G0260
carfilzomib, 1 mg, J9047
certolizumab pegol, J0717
dental service, D9610, D9630
other drugs/medicaments, by report, D9630
therapeutic parenteral drug, single administration, D9610
therapeutic parenteral drugs, two or more administrations, different medications, D9612
dermal filler (LDS), G0429
filgrastim, J1442
interferon beta-1a, IM, Q3027
interferon beta-1a, SC, Q3028
omacetaxtine mepesuccinate, 0.01 mg, J9262
pertuzumb, 1 mg, J9306
sculptra, 0.5 mg, Q2028
supplies for self-administered, A4211
vincristine, 1 mg, J9371
ziv-aflibercept, 1 mg, J9400
Inlay/onlay dental restoration, D2510–D2664
INR, monitoring, G0248–G0250
demonstration prior to initiation, home INR, G0248
physician review and interpretation, home INR, G0250
provision of test materials, home INR, G0249
Insertion tray, A4310–A4316
Instillation, hexaminolevulinate hydrochloride, A9589 ◀
Insulin, J1815, J1817, S5550–S5571
ambulatory, external, system, A9274
treatment, outpatient, G9147
Integra flowable wound matrix, Q4114
Interferon
Alpha, J9212–J9215
Beta-1a, J1826, Q3027, Q3028
Beta-1b, J1830
Gamma, J9216
Intermittent
assist device with continuous positive airway pressure device, E0470–E0472
limb compression device, E0676
peritoneal dialysis system, E1592
positive pressure breathing machine (IPPB), E0500
Interphalangeal joint, prosthetic implant, L8658, L8659

99
Interscapular thoracic prosthesis
endoskeletal, L6570
upper limb, L6350–L6370
Intervention, alcohol/substance (not tobacco), G0396–G0397
Intervention, tobacco, G9016
Intraconazole, J1835
Intraocular
lenses, V2630–V2632
Intraoral radiographs, dental, D0210–D0240
intraoral-complete series, D0210
intraoral-occlusal image, D0420
intraoral-periapical-each additional image, D0230
intraoral-periapical-first radiographic image, D0220
Intrapulmonary percussive ventilation system, E0481
Intrauterine copper contraceptive, J7300
Inversion/eversion correction device, A9285
Iodine I-123
iobenguane, A9582
ioflupane, A9584
sodium iodide, A9509, A9516
Iodine I-125
serum albumin, A9532
sodium iodide, A9527
sodium iothalamate, A9554
Iodine I-131
iodinated serum albumin, A9524
sodium iodide capsule, A9517, A9528
sodium iodide solution, A9529–A9531
Iodine Iobenguane sulfate I-131, A9508
Iodine swabs/wipes, A4247
IPD
system, E1592
Ipilimumab, J9228
IPPB machine, E0500
Ipratropium bromide, inhalation solution, unit dose, J7644, J7645
Irinotecan, J9205, J9206
Iron
Dextran, J1750
sucrose, J1756
Irrigation solution for bladder calculi, Q2004
Irrigation supplies, A4320–A4322, A4355, A4397–A4400
irrigation supply, sleeve, each, A4397
irrigation syringe, bulb, or piston, each, A4320
irrigation tubing set, bladder irrigation, A4355
ostomy irrigation set, A4400
ostomy irrigation supply, bag, A4398
ostomy irrigation supply, cone/catheter, A4399
Irrigation/evacuation system, bowel
control unit, E0350
disposable supplies for, E0352
manual pump enema, A4459
Isavuconazonium, J1833

100
Islet, transplant, G0341–G0343, S2102
Isoetharine HCl, inhalation solution
concentrated, J7647, J7648
unit dose, J7649, J7650
Isolates, B4150, B4152
Isoproterenol HCl, inhalation solution
concentrated, J7657, J7658
unit dose, J7659, J7660
Isosulfan blue, Q9968
Item, non-covered, A9270
IUD, J7300, S4989
IV pole, each, E0776, K0105
Ixabepilone, J9207

J
Jacket
scoliosis, L1300, L1310
Jaw, motion, rehabilitation system, E1700–E1702
Jenamicin, J1580
Jetria, (ocriplasmin), J7316

K
Kadcyla, ado-trastuzumab emtansine, 1 mg, J9354
Kanamycin sulfate, J1840, J1850
Kartop patient lift, toilet or bathroom; (see also Lift), E0625
Ketorolac thomethamine, J1885
Kidney
ESRD supply, A4650–A4927
machine, E1500–E1699
machine, accessories, E1500–E1699
system, E1510
wearable artificial, E1632
Kits
enteral feeding supply (syringe) (pump) (gravity), B4034–B4036
fistula cannulation (set), A4730
parenteral nutrition, B4220–B4224
administration kit, per day, B4224
supply kit, home mix, per day, B4222
supply kit, premix, per day, B4220
surgical dressing (tray), A4550
tracheostomy, A4625
Knee
arthroscopy, surgical, G0289, S2112, S2300
knee, surgical, harvesting cartilage, S2112
knee, surgical, removal loose body, chondroplasty, different compartment, G0289
shoulder, surgical, thermally-induced, capsulorraphy, S2300
disarticulation, prosthesis, L5150, L5160
joint, miniature, L5826
orthosis (KO), E1810, L1800–L1885
dynamic adjustable elbow entension/flexion device, E1800

101
 dynamic adjustable knee extension/flexion device, E1810
static-progressive devices, E1801, E1806, E1811, E1816–E1818, E1831, E1841
Knee-ankle-foot orthosis (KAFO), L2000–L2039, L2126–L2136
addition, high strength, lightweight material, L2755
base procedure, used with any knee joint, double upright, double bar, L2020
base procedure, used with any knee joint, full plastic double upright, L2036
base procedure, used with any knee joint, single upright, single bar, L2000
foot orthrosis, double upright, double bar, without knee joint, L2030
foot orthrosis, single upright, single bar, without knee joint, L2010
Kovaltry, J7211
Kyphosis pad, L1020, L1025

L
Laboratory
dental, D0415–D0999
adjunctive pre-diagnostic tests, mucosal abnormalities, D0431
analysis saliva sample, D0418
caries risk assessment, low, D0601
caries risk assessment, moderate, D0602
caries susceptibility tests, D0425
collection and preparation, saliva sample, D0417
collection of microorganisms for culture and sensitivity, D0415
diagnostic casts, D0470
oral pathology laboratory, D0472–D0502
processing, D0414
pulp vitality tests, D0460
services, P0000–P9999
viral culture, D0416
Laboratory tests
chemistry, P2028–P2038
cephalin flocculation, blood, P2028
congo red, blood, P2029
hair analysis, excluding arsenic, P2031
mucoprotein, blood, P2038
thymol turbidity, blood, P2033
microbiology, P7001
miscellaneous, P9010–P9615, Q0111–Q0115
blood, split unit, P9011
blood, whole, transfusion, unit, P9010
catheterization, collection specimen, multiple patients, P9615
catheterization, collection specimen, single patient, P9612
cryoprecipitate, each unit, P9012
fern test, Q0114
fresh frozen plasma, donor retested, each unit, P9060
fresh frozen plasma (single donor), frozen within 8 hours, P9017
fresh frozen plasma, within 8–24 hours of collection, each unit, P9059
granulocytes, pheresis, each unit, P9050
infusion, albumin (human), 25%, 20 ml, P9046
infusion, albumin (human), 25%, 50 ml, P9047
infusion, albumin (human), 5%, 250 ml, P9045
infusion, albumin (human), 5%, 50 ml, P9041

102
 infusion, plasma protein fraction, human, 5%, 250 ml, P9048
infusion, plasma protein fraction, human, 5%, 50 ml, P9043
KOH preparation, Q0112
pinworm examinations, Q0113
plasma, cryoprecipitate reduced, each unit, P9044
plasma, pooled, multiple donor, frozen, P9023
platelet rich plasma, each unit, P9020
platelets, each unit, P9019
platelets, HLA-matched leukocytes reduced, apheresis/pheresis, each unit, P9052
platelets, irradiated, each unit, P9032
platelets, leukocytes reduced, CMV-neg, aphresis/pheresis, each unit, P9055
platelets, leukocytes reduced, each unit, P9031
platelets, leukocytes reduced, irradiated, each unit, P9033
platelets, pheresis, each unit, P9034
platelets, pheresis, irradiated, each unit, P9036
platelets, pheresis, leukocytes reduced, CMV-neg, irradiated, each unit, P9053
platelets, pheresis, leukocytes reduced, each unit, P9035
platelets, pheresis, leukocytes reduced, irradiated, each unit, P9037
post-coital, direct qualitative, vaginal or cervical mucous, Q0115
red blood cells, deglycerolized, each unit, P9039
red blood cells, each unit, P9021
red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit, P9057
red blood cells, irradiated, each unit, P9038
red blood cells, leukocytes reduced, CMV-neg, irradiated, each unit, P9058
red blood cells, leukocytes reduced, each unit, P9016
red blood cells, leukocytes reduced, irradiated, each unit, P9040
red blood cells, washed, each unit, P9022
travel allowance, one way, specimen collection, home/nursing home, P9603, P9604
wet mounts, vaginal, cervical, or skin, Q0111
whole blood, leukocytes reduced, irradiated, each unit, P9056
whole blood or red blood cells, leukocytes reduced, CMV-neg, each unit, P9051
whole blood or red blood cells, leukocytes reduced, frozen, deglycerol, washed, each unit, P9054
toxicology, P3000–P3001, Q0091
Lacrimal duct, implant
permanent, A4263
temporary, A4262
Lactated Ringer’s infusion, J7120
Laetrile, J3570
Lancet, A4258, A4259
Language, screening, V5363
Lanreotide, J1930
Laronidase, J1931
Larynx, artificial, L8500
Laser blood collection device and accessory, A4257, E0620
LASIK, S0800
Lead investigation, T1029
Lead wires, per pair, A4557
Leg
bag, A4358, A5105, A5112
leg or abdomen, vinyl, with/without tubes, straps, each, A4358
urinary drainage bag, leg bag, leg/abdomen, latex, with/without tube, straps, A5112
urinary suspensory, leg bag, with/without tube, each, A5105

103
 extensions for walker, E0158
rest, elevating, K0195
rest, wheelchair, E0990
strap, replacement, A5113–A5114
Legg Perthes orthosis, L1700–L1755
Newington type, L1710
Patten bottom type, L1755
Scottish Rite type, L1730
Tachdjian type, L1720
Toronto type, L1700
Lens
aniseikonic, V2118, V2318
contact, V2500–V2599
gas permeable, V2510–V2513
hydrophilic, V2520–V2523
other type, V2599
PMMA, V2500–V2503
scleral, gas, V2530–V2531
eye, V2100–V2615, V2700–V2799
bifocal, glass or plastic, V2200–V2299
contact lenses, V2500–V2599
low vision aids, V2600–V2615
miscellaneous, V2700–V2799
single vision, glass or plastic, V2100–V2199
trifocal, glass or plastic, V2300–V2399
variable asphericity, V2410–V2499
intraocular, V2630–V2632
anterior chamber, V2630
iris supported, V2631
new technology, category 4, IOL, Q1004
new technology, category 5, IOL, Q1005
posterior chamber, V2632
telescopic lens, C1840
low vision, V2600–V2615
hand held vision aids, V2600
single lens spectacle mounted, V2610
telescopic and other compound lens system, V2615
progressive, V2781
Lepirudin, J1945
Lesion, destruction, choroid, G0186
Leucovorin calcium, J0640
Leukocyte poor blood, each unit, P9016
Leuprolide acetate, J1950, J9217, J9218, J9219
for depot suspension, 7.5 mg, J9217
implant, 65 mg, J9219
injection, for depot suspension, per 3.75 mg, J1950
per 1 mg, J9218
Levalbuterol, all formulations, inhalation solution
concentrated, J7607, J7612
unit dose, J7614, J7615
Levetiracetam, J1953
Levocarnitine, J1955

104
Levofloxacin, J1956
Levoleucovorin, J0641
Levonorgestrel, (contraceptive), implants and supplies, J7306
Levorphanol tartrate, J1960
Lexidronam, A9604
Lidocaine HCl, J2001
Lift
patient (includes seat lift), E0621–E0635
bathroom or toilet, E0625
mechanism incorporated into a combination liftchair, E0627
patient lift, electric, E0635
patient lift, hydraulic or mechanical, E0630
separate seat lift mechanism, patient owned furniture, non-electric, E0629
sling or seat, canvas or nylon, E0621
shoe, L3300–L3334
lift, elevation, heel, L3334
lift, elevation, heel and sole, cork, L3320
lift, elevation, heel and sole, Neoprene, L3310
lift, elevation, heel, tapered to metatarsals, L3300
lift, elevation, inside shoe, L3332
lift, elevation, metal extension, L3330
Lightweight, wheelchair, E1087–E1090, E1240–E1270
detachable arms, swing away detachable, elevating leg rests, E1240
detachable arms, swing away detachable footrest, E1260
fixed full length arms, swing away detachable elevating legrests, E1270
fixed full length arms, swing away detachable footrest, E1250
high strength, detachable arms desk, E1088
high strength, detachable arms desk or full length, E1090
high strength, fixed full length arms, E1087
high strength, fixed length arms swing away footrest, E1089
Lincomycin HCl, J2010
Linezolid, J2020
Liquid barrier, ostomy, A4363
Listening devices, assistive, V5281–V5290
personal blue tooth FM/DM, V5286
personal FM/DM adapter/boot coupling device for receiver, V5289
personal FM/DM binaural, 2 receivers, V5282
personal FM/DM, direct audio input, V5285
personal FM/DM, ear level receiver, V5284
personal FM/DM monaural, 1 receiver, V5281
personal FM/DM neck, loop induction receiver, V5283
personal FM/DM transmitter assistive listening device, V5288
transmitter microphone, V5290
Lodging, recipient, escort nonemergency transport, A0180, A0200
LOPS, G0245–G0247
follow-up evaluation and management, G0246
initial evaluation and management, G0245
routine foot care, G0247
Lorazepam, J2060
Loss of protective sensation, G0245–G0247
Low osmolar contrast material, Q9965–Q9967
Loxapine, for inhalation, J2062 ◀

105
LSO, L0621–L0640
Lubricant, A4332, A4402
Lumbar flexion, L0540
Lumbar-sacral orthosis (LSO), L0621–L0640
LVRS, services, G0302–G0305
Lymphocyte immune globulin, J7504, J7511

106
 M
Machine
IPPB, E0500
kidney, E1500–E1699
Magnesium sulphate, J3475
Maintenance contract, ESRD, A4890
Mammography, screening, G9899, G9900
Mannitol, J2150, J7665
Mapping, vessel, for hemodialysis access, G0365
Marker, tissue, A4648
Mask
aerosol, K0180
oxygen, A4620
Mastectomy
bra, L8000
form, L8020
prosthesis, L8030, L8600
sleeve, L8010
Matristem, Q4118
micromatrix, 1 mg, Q4118
Mattress
air pressure, E0186
alternating pressure, E0277
dry pressure, E0184
gel pressure, E0196
hospital bed, E0271, E0272
non-powered, pressure reducing, E0373
overlay, E0371–E0372
powered, pressure reducing, E0277
water pressure, E0187
Measurement period
left ventricular function testing, G8682
Mecasermin, J2170
Mechlorethamine HCl, J9230
Medicaid, codes, T1000–T9999
Medical and surgical supplies, A4206–A8999
Medical nutritional therapy, G0270, G0271
Medical services, other, M0000–M9999
Medroxyprogesterone acetate, J1050
Melphalan
HCl, J9245
oral, J8600
Mental, health, training services, G0177
Meperidine, J2175
and promethazine, J2180
Mepivacaine HCl, J0670
Mepolizumab, J2182
Meropenem, J2185
Mesna, J9209
Metacarpophalangeal joint, prosthetic implant, L8630, L8631

107
Metaproterenol sulfate, inhalation solution
concentrated, J7667, J7668
unit dose, J7669, J7670
Metaraminol bitartrate, J0380
Metatarsal joint, prosthetic implant, L8641
Meter, bath conductivity, dialysis, E1550
Methacholine chloride, J7674
Methadone HCl, J1230
Methergine, J2210
Methocarbamol, J2800
Methotrexate
oral, J8610
sodium, J9250, J9260
Methyldopate HCl, J0210
Methylene blue, Q9968
Methylnaltrexone, J2212
Methylprednisolone
acetate, J1020–J1040
injection, 20 mg, J1020
injection, 40 mg, J1030
injection, 80 mg, J1040
oral, J7509
sodium succinate, J2920, J2930
Metoclopramide HCl, J2765
Micafungin sodium, J2248
Microbiology test, P7001
Midazolam HCl, J2250
Mileage
ALS, A0390
ambulance, A0380, A0390
Milrinone lactate, J2260
Mini-bus, nonemergency transportation, A0120
Minocycline hydrochloride, J2265
Miscellaneous and investigational, A9000–A9999
Mitomycin, J7315, J9280
Mitoxantrone HCl, J9293
MNT, G0270, G0271
Mobility device, physician, service, G0372
Modalities, with office visit, M0005–M0008
Moisture exchanger for use with invasive mechanical ventilation, A4483
Moisturizer, skin, A6250
Molecular pathology procedure, G0452
Monitor
blood glucose, home, E0607
blood pressure, A4670
pacemaker, E0610, E0615
Monitoring feature/device, A9279
Monitoring, INR, G0248–G0250
demonstration prior to initiation, G0248
physician review and interpretation, G0250
provision of test materials, G0249
Monoclonal antibodies, J7505

108
Morphine sulfate, J2270
epidural or intrathecal use, J2274
Motion, jaw, rehabilitation system, E1700–E1702
motion rehabilitation system, E1700
replacement cushions, E1701
replacement measuring scales, E1702
Mouthpiece (for respiratory equipment), A4617
Moxifloxacin, J2280
Mucoprotein, blood, P2038
Multiaxial ankle, L5986
Multidisciplinary services, H2000–H2001, T1023–T1028
Multiple post collar, cervical, L0180–L0200
occipital/mandibular supports, adjustable, L0180
occipital/mandibular supports, adjustable cervical bars, L0200
SQMI, Guilford, Taylor types, L0190
Multi-Podus type AFO, L4396
Muromonab-CD3, J7505
Mycophenolate mofetil, J7517
Mycophenolic acid, J7518

N
Nabilone, J8650
Nails, trimming, dystrophic, G0127
Nalbuphine HCl, J2300
Naloxone HCl, J2310
Naltrexone, J2315
Nandrolone
decanoate, J2320
Narrowing device, wheelchair, E0969
Nasal
application device, K0183
pillows/seals (for nasal application device), K0184
vaccine inhalation, J3530
Nasogastric tubing, B4081, B4082
Natalizumab, J2323
Nebulizer, E0570–E0585
aerosol compressor, E0571, E0572
aerosol mask, A7015
corrugated tubing, disposable, A7010
filter, disposable, A7013
filter, non-disposable, A7014
heater, E1372
large volume, disposable, prefilled, A7008
large volume, disposable, unfilled, A7007
not used with oxygen, durable, glass, A7017
pneumatic, administration set, A7003, A7005, A7006
pneumatic, nonfiltered, A7004
portable, E0570
small volume, A7003–A7005
ultrasonic, E0575
ultrasonic, dome and mouthpiece, A7016

109
 ultrasonic, reservoir bottle, non-disposable, A7009
water collection device, large volume nebulizer, A7012
Necitumumab, J9295
Needle, A4215
bone marrow biopsy, C1830
non-coring, A4212
with syringe, A4206–A4209
Negative pressure wound therapy pump, E2402
accessories, A6550
Nelarabine, J9261
Neonatal transport, ambulance, base rate, A0225
Neostigmine methylsulfate, J2710
Nerve, conduction, sensory, test, G0255
Nerve stimulator with batteries, E0765
Nesiritide injection, J2324, J2325
Neupogen, injection, filgrastim, 1 mcg, J1442
Neuromuscular stimulator, E0745
Neurophysiology, intraoperative, monitoring, G0453
Neurostimulator
battery recharging system, L8695
external antenna, L8696
implantable pulse generator, L8679
pulse generator, L8681–L8688
dual array, non-rechargeable, with extension, L8688
dual array, rechargeable, with extension, L8687
patient programmer (external), replacement only, L8681
radiofrequency receiver, L8682
radiofrequency transmitter (external), sacral root receiver, bowel and bladder management, L8684
radiofrequency transmitter (external), with implantable receiver, L8683
single array, rechargeable, with extension, L8686
Nitrogen N-13 ammonia, A9526
NMES, E0720–E0749
Nonchemotherapy drug, oral, NOS, J8499
Noncovered services, A9270
Nonemergency transportation, A0080–A0210
Nonimpregnated gauze dressing, A6216–A6221, A6402–A6404
Nonprescription drug, A9150
Not otherwise classified drug, J3490, J7599, J7699, J7799, J8499, J8999, J9999, Q0181
NPH, J1820
NPWT, pump, E2402
NTIOL category 3, Q1003
NTIOL category 4, Q1004
NTIOL category 5, Q1005
Nursing care, T1030–T1031
Nursing service, direct, skilled, outpatient, G0128
Nusinersen, J2326
Nutrition
counseling, dental, D1310, D1320
enteral infusion pump, B9002
parenteral infusion pump, B9004, B9006
parenteral solution, B4164–B5200
therapy, medical, G0270, G0271

110
 O
O & P supply/accessory/service, L9900
Observation
admission, G0379
hospital, G0378
Obturator prosthesis
definitive, D5932
interim, D5936
surgical, D5931
Occipital/mandibular support, cervical, L0160
Occlusive device, placement, G0269
Occupational, therapy, G0129, S9129
Ocrelizumab, J2350
Ocriplasmin, J7316
Octafluoropropane, Q9956
Octagam, J1568
Octreotide acetate, J2353, J2354
Ocular prosthetic implant, L8610
Ofatumumab, J9302
Olanzapine, J2358
Olaratumab, J9285
Omacetaxine Mepesuccinate, J9262
Omalizumab, J2357
OnabotulinumtoxinA, J0585
Oncology
disease status, G9063–G9139
practice guidelines, G9056–G9062
visit, G9050–G9055
Ondansetron HCl, J2405
Ondansetron oral, Q0162
One arm, drive attachment, K0101
Ophthalmological examination, refraction, S0621
Oprelvekin, J2355
Oral and maxillofacial surgery, D7111–D7999
alveoloplasty, D7310–D7321
complicated suturing, D7911–D7912
excision of bone tissue, D7471–D7490
extractions, local, D7111–D7140
other repair procedures, D7920–D7999
other surgical procedures, D7260–D7295
reduction of dislocation/TMJ dysfunction, D7810–D7899
repair of traumatic wounds, D7910
surgical excision, intra-osseous lesions, D7440–D7465
surgical excision, soft tissue lesions, D7410–D7415
surgical extractions, D7210–D7251
surgical incision, D7510–D7560
treatment of fractures, compound, D7710–D7780
treatment of fractures, simple, D7610–D7680
vestibuloplasty, D7340–D7350
Oral device/appliance, E0485–E0486
Oral interface, A7047

111
Oral, NOS, drug, J8499
Oral/nasal mask, A7027
nasal pillows, A7029
oral cushion, A7028
Oritavancin, J2407
Oropharyngeal suction catheter, A4628
Orphenadrine, J2360
Orthodontics, D8000–D8999
Orthopedic shoes
arch support, L3040–L3100
footwear, L3000–L3649, L3201–L3265
insert, L3000–L3030
lift, L3300–L3334
miscellaneous additions, L3500–L3595
positioning device, L3140–L3170
transfer, L3600–L3649
wedge, L3340–L3420
Orthotic additions
carbon graphite lamination, L2755
fracture, L2180–L2192, L3995
halo, L0860
lower extremity, L2200–L2999, L4320
ratchet lock, L2430
scoliosis, L1010–L1120, L1210–L1290
shoe, L3300–L3595, L3649
spinal, L0970–L0984
upper limb, L3810–L3890, L3900, L3901, L3970–L3974, L3975–L3978, L3995
Orthotic devices
ankle-foot (AFO); (see also Orthopedic shoes), E1815, E1816, E1830, L1900–L1990,
L2102–L2116, L3160, L4361, L4397
anterior-posterior-lateral, L0700, L0710
cervical, L0100–L0200
cervical-thoracic-lumbar-sacral (CTLSO), L0700, L0710
elbow (EO), E1800, E1801, L3700–L3740, L3760–L3761, L3762
fracture, L2102–L2136, L3980–L3986
halo, L0810–L0830
hand, (WHFO), E1805, E1825, L3807, L3900–L3954, L3956
hand, finger, prefabricated, L3923
hip (HO), L1600–L1690
hip-knee-ankle-foot (HKAFO), L2040–L2090
interface material, E1820
knee (KO), E1810, E1811, L1800–L1885
knee-ankle-foot (KAFO); (see also Orthopedic shoes), L2000–L2038, L2126–L2136
Legg Perthes, L1700–L1755
lumbar, L0625–L0651
multiple post collar, L0180–L0200
not otherwise specified, L0999, L1499, L2999, L3999, L5999, L7499, L8039, L8239
pneumatic splint, L4350–L4380
pronation/supination, E1818
repair or replacement, L4000–L4210
replace soft interface material, L4390–L4394
sacroiliac, L0600–L0620, L0621–L0624

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 scoliosis, L1000–L1499
shoe, (see Orthopedic shoes)
shoulder (SO), L1840, L3650, L3674, L3678
shoulder-elbow-wrist-hand (SEWHO), L3960–L3978
side bar disconnect, L2768
spinal, cervical, L0100–L0200
spinal, DME, K0112–K0116
thoracic, L0210, L0220
thoracic-hip-knee-ankle (THKO), L1500–L1520
toe, E1830
wrist-hand-finger (WHFO), E1805, E1806, E1825, L3806–L3809, L3900–L3954, L3956
Orthovisc, J7324
Ossicula prosthetic implant, L8613
Osteogenesis stimulator, E0747–E0749, E0760
Osteotomy, segmented or subapical, D7944
Ostomy
accessories, A5093
belt, A4396
pouches, A4416–A4435, A5056, A5057
skin barrier, A4401–A4449, A4462
supplies, A4361–A4421, A5051–A5149, A5200
Otto Bock, prosthesis, L7007
Outpatient payment system, hospital, C1000–C9999
Overdoor, traction, E0860
Oxacillin sodium, J2700
Oxaliplatin, J9263
Oxygen
ambulance, A0422
battery charger, E1357
battery pack/cartridge, E1356
catheter, transtracheal, A7018
chamber, hyperbaric, topical, A4575
concentrator, E1390–E1391
DC power adapter, E1358
delivery system (topical), E0446
equipment, E0424–E0486, E1353–E1406
Liquid oxygen system, E0433
mask, A4620
medication supplies, A4611–A4627
rack/stand, E1355
regulator, E1352, E1353
respiratory equipment/supplies, E0424–E0480, A4611–A4627, E0481
supplies and equipment, E0425–E0444, E0455
tent, E0455
tubing, A4616
water vapor enriching system, E1405, E1406
wheeled cart, E1354
Oxymorphone HCl, J2410
Oxytetracycline HCl, J2460
Oxytocin, J2590

113
 P
Pacemaker monitor, E0610, E0615
Paclitaxel, J9267
Paclitaxel protein-bound particles, J9264
Pad
correction, CTLSO, L1020–L1060
gel pressure, E0185, E0196
heat, A9273, E0210, E0215, E0217, E0238, E0249
electric heat pad, moist, E0215
electric heat pad, standard, E0210
hot water bottle, ice cap or collar, heat and/or cold wrap, A9273
pad for water circulating heat unit, replacement only, E0249
water circulating heat pad with pump, E0217
orthotic device interface, E1820
sheepskin, E0188, E0189
water circulating cold with pump, E0218
water circulating heat unit, E0249
water circulating heat with pump, E0217
Pail, for use with commode chair, E0167
Pain assessment, G8730–G8732
Palate, prosthetic implant, L8618
Palifermin, J2425
Paliperidone palmitate, J2426
Palonosetron, J2469, J8655
Pamidronate disodium, J2430
Pan, for use with commode chair, E0167
Panitumumab, J9303
Papanicolaou screening smear (Pap), P3000, P3001, Q0091
cervical or vaginal, up to 3 smears, by technician, P3000
cervical or vaginal, up to 3 smears, physician interpretation, P3001
obtaining, preparing and conveyance, Q0091
Papaverine HCl, J2440
Paraffin, A4265
bath unit, E0235
Parenteral nutrition
administration kit, B4224
pump, B9004, B9006
solution, B4164–B5200
compounded amino acid and carbohydrates, with electrolytes, B4189–B4199, B5000–B5200
nutrition additives, homemix, B4216
nutrition administration kit, B4224
nutrition solution, amino acid, B4168–B4178
nutrition solution, carbohydrates, B4164, B4180
nutrition solution, per 10 grams, liquid, B4185
nutrition supply kit, homemix, B4222
supply kit, B4220, B4222
Paricalcitol, J2501
Parking fee, nonemergency transport, A0170
Partial Hospitalization, OT, G0129
Pasireotide long acting, J2502
Paste, conductive, A4558

114
Pathology and laboratory tests, miscellaneous, P9010–P9615
Pathology, surgical, G0416
Patient support system, E0636
Patient transfer system, E1035–E1036
Pediculosis (lice) treatment, A9180
PEFR, peak expiratory flow rate meter, A4614
Pegademase bovine, J2504
Pegaptanib, J2503
Pegaspargase, J9266
Pegfilgrastim, J2505
Peginesatide, J0890
Pegloticase, J2507
Pelvic
belt/harness/boot, E0944
traction, E0890, E0900, E0947
Pemetrexed, J9305
Penicillin
G benzathine/G benzathine and penicillin G procaine, J0558, J0561
G potassium, J2540
G procaine, aqueous, J2510
Pentamidine isethionate, J2545, J7676
Pentastarch, 10% solution, J2513
Pentazocine HCl, J3070
Pentobarbital sodium, J2515
Pentostatin, J9268
Peramivir, J2547
Percussor, E0480
Percutaneous access system, A4301
Perflexane lipid microspheres, Q9955
Perflutren lipid microspheres, Q9957
Periapical service, D3410–D3470
apicoectomy, bicuspid, first root, D3421
apicoectomy, each additional root, D3426
apicoectomy, molar, first root, D3425
apicoectomy/periradicular surgery-anterior, D3410
biological materials, aid soft and osseous tissue regeneration/periradicular surgery, D3431
bone graft, per tooth, periradicular surgery, D3429
endodonic endosseous implant, D3460
guided tissue regeneration/periradicular surgery, D3432
intentional replantation, D3470
periradicular surgery without apicoectomy, D3427
retrograde filling, per root, D3430
root amputation, D3450
Periodontal procedures, D4000–D4999
Periodontics, dental, D4000–D4999
Peroneal strap, L0980
Peroxide, A4244
Perphenazine, J3310
Personal care services, T1019–T1021
home health aide or CAN, per visit, T1021
per diem, T1020
provided by home health aide or CAN, per 15 minutes, T1019

115
Pertuzumab, J9306
Pessary, A4561, A4562
PET, G0219, G0235, G0252
Pharmacologic therapy, G8633
Pharmacy, fee, G0333
Phenobarbital sodium, J2560
Phentolamine mesylate, J2760
Phenylephrine HCl, J2370
Phenytoin sodium, J1165
Phisohex solution, A4246
Photofrin, (see Porfimer sodium)
Photorefraction keratectomy, (PRK), S0810
Phototherapeutic keratectomy, (PTK), S0812
Phototherapy light, E0202
Phytonadione, J3430
Pillow, cervical, E0943
Pin retention (per tooth), D2951
Pinworm examination, Q0113
Plasma
multiple donor, pooled, frozen, P9023, P9070
single donor, fresh frozen, P9017, P9071
Plastazote, L3002, L3252, L3253, L3265, L5654–L5658
addition to lower extremity socket insert, L5654
addition to lower extremity socket insert, above knee, L5658
addition to lower extremity socket insert, below knee, L5655
addition to lower extremity socket insert, knee disarticulation, L5656
foot insert, removable, plastazote, L3002
foot, molded shoe, custom fitted, plastazote, L3253
foot, shoe molded to patient model, plastazote, L3252
plastazote sandal, L3265
Platelet, P9073, P9100
concentrate, each unit, P9019
rich plasma, each unit, P9020
Platelets, P9031–P9037, P9052–P9053, P9055
Platform attachment
forearm crutch, E0153
walker, E0154
Plerixafor, J2562
Plicamycin, J9270
Plumbing, for home ESRD equipment, A4870
Pneumatic
appliance, E0655–E0673, L4350–L4380
compressor, E0650–E0652
splint, L4350–L4380
ventricular assist device, Q0477, Q0480–Q0505
Pneumatic nebulizer
administration set, small volume, filtered, A7006
administration set, small volume, nonfiltered, A7003
administration set, small volume, nonfiltered, nondisposable, A7005
small volume, disposable, A7004
Pneumococcal
vaccine, administration, G0009

116
Pontics, D6210–D6252
Porfimer, J9600
Portable
equipment transfer, R0070–R0076
gaseous oxygen, K0741, K0742
hemodialyzer system, E1635
liquid oxygen system, E0433
x-ray equipment, Q0092
Positioning seat, T5001
Positive airway pressure device, accessories, A7030–A7039, E0561–E0562
Positive expiratory pressure device, E0484
Post-coital examination, Q0115
Postural drainage board, E0606
Potassium
chloride, J3480
hydroxide preparation(KOH), Q0112
Pouch
fecal collection, A4330
ostomy, A4375–A4378, A5051–A5054, A5061–A5065
urinary, A4379–A4383, A5071–A5075
Practice, guidelines, oncology, G9056–G9062
Pralatrexate, J9307
Pralidoxime chloride, J2730
Prednisolone
acetate, J2650
oral, J7510
Prednisone, J7512
Prefabricated crown, D2930–D2933
Preparation kits, dialysis, A4914
Preparatory prosthesis, L5510–L5595
chemotherapy, J8999
nonchemotherapy, J8499
Pressure
alarm, dialysis, E1540
pad, A4640, E0180–E0199
Preventive dental procedures, D1000–D1999
Privigen, J1459
Procainamide HCl, J2690
Procedure
HALO, L0810–L0861
noncovered, G0293, G0294
scoliosis, L1000–L1499
Prochlorperazine, J0780
Prolotherapy, M0076
Promazine HCl, J2950
Promethazine
and meperdine, J2180
HCl, J2550
Propranolol HCl, J1800
Prostate, cancer, screening, G0102, G0103
Prosthesis
artificial larynx battery/accessory, L8505

117
 auricular, D5914
breast, L8000–L8035, L8600
dental, D5911–D5960, D5999
eye, L8610, L8611, V2623–V2629
fitting, L5400–L5460, L6380–L6388
foot/ankle one piece system, L5979
hand, L6000–L6020, L6026
implants, L8600–L8690
larynx, L8500
lower extremity, L5700–L5999, L8640–L8642
mandible, L8617
maxilla, L8616
maxillofacial, provided by a non-physician, L8040–L8048
miscellaneous service, L8499
obturator, D5931–D5933, D5936
ocular, V2623–V2629
repair of, L7520, L8049
socks (shrinker, sheath, stump sock), L8400–L8485
taxes, orthotic/prosthetic/other, L9999
tracheo-esophageal, L8507–L8509
upper extremity, L6000–L6999
vacuum erection system, L7900
Prosthetic additions
lower extremity, L5610–L5999
powered upper extremity range of motion assist device, L8701–L8702 ◀
upper extremity, L6600–L7405
Prosthetic, eye, V2623
Prosthodontic procedure
fixed, D6200–D6999
removable, D5000–D5899
Prosthodontics, removable, D5110–D5899
Protamine sulfate, J2720
Protectant, skin, A6250
Protector, heel or elbow, E0191
Protein C Concentrate, J2724
Protirelin, J2725
Psychotherapy, group, partial hospitalization, G0410–G0411
Pulp capping, D3110, D3120
Pulpotomy, D3220
partial, D3222
vitality test, D0460
Pulse generator, E2120
Pump
alternating pressure pad, E0182
ambulatory infusion, E0781
ambulatory insulin, E0784
blood, dialysis, E1620
breast, E0602–E0604
enteral infusion, B9000, B9002
external infusion, E0779
heparin infusion, E1520
implantable infusion, E0782, E0783

118
 implantable infusion, refill kit, A4220
infusion, supplies, A4230, A4232
negative pressure wound therapy, E2402
parenteral infusion, B9004, B9006
suction, portable, E0600
water circulating pad, E0236
wound, negative, pressure, E2402
Purification system, E1610, E1615
Pyridoxine HCl, J3415

Q
Quad cane, E0105
Quinupristin/dalfopristin, J2770

R
Rack/stand, oxygen, E1355
Radiesse, Q2026
Radioelements for brachytherapy, Q3001
Radiograph, dental, D0210–D0340
Radiological, supplies, A4641, A4642
Radiology service, R0070–R0076
Radiopharmaceutical diagnostic and therapeutic imaging agent, A4641, A4642, A9500–A9699
Radiosurgery, robotic, G0339–G0340
Radiosurgery, stereotactic, G0339, G0340
Rail
bathtub, E0241, E0242, E0246
bed, E0305, E0310
toilet, E0243
Ranibizumab, J2778
Rasburicase, J2783
Reaching/grabbing device, A9281
Reagent strip, A4252
Re-cement
crown, D2920
inlay, D2910
Reciprocating peritoneal dialysis system, E1630
Reclast, J3488, J3489
Reclining, wheelchair, E1014, E1050–E1070, E1100–E1110
Reconstruction, angiography, G0288
Rectal control system for vaginal insertion, A4563 ◀
Red blood cells, P9021, P9022
Regadenoson, J2785
Regular insulin, J1815, J1820
Regulator, oxygen, E1353
Rehabilitation
cardiac, S9472
program, H2001
psychosocial, H2017, H2018
pulmonary, S9473
system, jaw, motion, E1700–E1702

119
 vestibular, S9476
Removal, cerumen, G0268
Repair
contract, ESRD, A4890
durable medical equipment, E1340
maxillofacial prosthesis, L8049
orthosis, L4000–L4130
prosthetic, L7500, L7510
Replacement
battery, A4630
pad (alternating pressure), A4640
tanks, dialysis, A4880
tip for cane, crutches, walker, A4637
underarm pad for crutches, A4635
Resin dental restoration, D2330–D2394
Reslizumab, J2786
RespiGam, (see Respiratory syncytial virus immune globulin)
Respiratory
DME, A7000–A7527
equipment, E0424–E0601
function, therapeutic, procedure, G0237–G0239, S5180–S5181
supplies, A4604–A4629
Restorative dental procedure, D2000–D2999
Restraint, any type, E0710
Reteplase, J2993
Revascularization, C9603–C9608
Rho(D) immune globulin, human, J2788, J2790, J2791, J2792
Rib belt, thoracic, A4572, L0220
Rilanocept, J2793
RimabotulinumtoxinB, J0587
Ring, ostomy, A4404
Ringers lactate infusion, J7120
Risk-adjusted functional status
elbow, wrist or hand, G8667–G8670
hip, G8651–G8654
lower leg, foot or ankle, G8655–G8658
lumbar spine, G8659–G8662
neck, cranium, mandible, thoracic spine, ribs, or other, G8671–G8674
shoulder, G8663–G8666
Risperidone, J2794
Rituximab, J9310
Robin-Aids, L6000, L6010, L6020, L6855, L6860
Rocking bed, E0462
Rolapitant, J8670
Rollabout chair, E1031
Romidepsin, J9315
Romiplostim, J2796
Root canal therapy, D3310–D3353
Ropivacaine HCl, J2795
Rubidium Rb-82, A9555

120
 S
Sacral nerve stimulation test lead, A4290
Safety equipment, E0700
vest, wheelchair, E0980
Saline
hypertonic, J7130, J7131
infusion, J7030–J7060
solution, A4216–A4218, J7030–J7050
Saliva
artificial, A9155
collection and preparation, D0417
Samarium SM 153 Lexidronamm, A9605
Sargramostim (GM-CSF), J2820
Scale, E1639
Scoliosis, L1000–L1499
additions, L1010–L1120, L1210–L1290
Screening
alcohol misuse, G0442
cancer, cervical or vaginal, G0101
colorectal, cancer, G0104–G0106, G0120–G0122, G0328
cytopathology cervical or vaginal, G0123, G0124, G0141–G0148
depression, G0444
dysphagia, documentation, V5364
enzyme immunoassay, G0432
glaucoma, G0117, G0118
infectious agent antibody detection, G0433, G0435
language, V5363
mammography, digital image, G9899, G9900
prostate, cancer, G0102, G0103
speech, V5362
Sculptra, Q2028
Sealant
skin, A6250
tooth, D1351
Seat
attachment, walker, E0156
insert, wheelchair, E0992
lift (patient), E0621, E0627–E0629
upholstery, wheelchair, E0975, E0981
Sebelipase alfa, J2840
Secretin, J2850
Semen analysis, G0027
Semi-reclining, wheelchair, E1100, E1110
Sensitivity study, P7001
Sensory nerve conduction test, G0255
Sermorelin acetate, Q0515
Serum clotting time tube, A4771
Service
Allied Health, home health, hospice, G0151–G0161
behavioral health and/or substance abuse, H0001–H9999
hearing, V5000–V5999

121
 laboratory, P0000–P9999
mental, health, training, G0177
non-covered, A9270
physician, for mobility device, G0372
pulmonary, for LVRS, G0302–G0305
skilled, RN/LPN, home health, hospice, G0162
social, psychological, G0409–G0411
speech-language, V5336–V5364
vision, V2020–V2799
SEWHO, L3960–L3974, L3975–L3978
SEXA, G0130
Sheepskin pad, E0188, E0189
Shoes
arch support, L3040–L3100
for diabetics, A5500–A5514
insert, L3000–L3030, L3031
lift, L3300–L3334
miscellaneous additions, L3500–L3595
orthopedic, L3201–L3265
positioning device, L3140–L3170
transfer, L3600–L3649
wedge, L3340–L3485
Shoulder
disarticulation, prosthetic, L6300–L6320, L6550
orthosis (SO), L3650–L3674
spinal, cervical, L0100–L0200
Shoulder sling, A4566
Shoulder-elbow-wrist-hand orthosis (SEWHO), L3960–L3969, L3971–L3978
Shunt accessory for dialysis, A4740
aqueous, L8612
Sigmoidoscopy, cancer screening, G0104, G0106
Siltuximab, J2860
Sincalide, J2805
Sipuleucel-T, Q2043
Sirolimus, J7520
Sitz bath, E0160–E0162
Skin
barrier, ostomy, A4362, A4363, A4369–A4373, A4385, A5120
bond or cement, ostomy, A4364
sealant, protectant, moisturizer, A6250
substitute, Q4100–Q4204
Skyla, 13.5 mg, J7301
Sling, A4565
patient lift, E0621, E0630, E0635
Smear, Papanicolaou, screening, P3000, P3001, Q0091
SNCT, G0255
Social worker, clinical, home, health, G0155
Social worker, nonemergency transport, A0160
Social work/psychological services, CORF, G0409
Sock
body sock, L0984
prosthetic sock, L8417, L8420–L8435, L8470, L8480, L8485

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 stump sock, L8470–L8485
Sodium
chloride injection, J2912
ferric gluconate complex in sucrose, J2916
fluoride F-18, A9580
hyaluronate
Euflexxa, J7323
GELSYN-3, J7328
Hyalgan, J7321
Orthovisc, J7324
Supartz, J7321
Synvisc and Synvisc-One, J7325
Visco-3, J7321
phosphate P32, A9563
pyrophosphate, J1443
succinate, J1720
Solution
calibrator, A4256
dialysate, A4760
elliotts b, J9175
enteral formulae, B4149–B4156, B4157–B4162
parenteral nutrition, B4164–B5200
Solvent, adhesive remover, A4455
Somatrem, J2940
Somatropin, J2941
Sorbent cartridge, ESRD, E1636
Special size, wheelchair, E1220–E1239
Specialty absorptive dressing, A6251–A6256
Spectacle lenses, V2100–V2199
Spectinomycin HCl, J3320
Speech assessment, V5362–V5364
Speech generating device, E2500–E2599
Speech, pathologist, G0153
Speech-Language pathology, services, V5336–V5364
Spherocylinder, single vision, V2100–V2114
bifocal, V2203–V2214
trifocal, V2303–V2314
Spinal orthosis
cervical, L0100–L0200
cervical-thoracic-lumbar-sacral (CTLSO), L0700, L0710
DME, K0112–K0116
halo, L0810–L0830
multiple post collar, L0180–L0200
scoliosis, L1000–L1499
torso supports, L0960
Splint, A4570, L3100, L4350–L4380
ankle, L4390–L4398
dynamic, E1800, E1805, E1810, E1815, E1825, E1830, E1840
footdrop, L4398
supplies, miscellaneous, Q4051
Standard, wheelchair, E1130, K0001
Static progressive stretch, E1801, E1806, E1811, E1816, E1818, E1821

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Status
disease, oncology, G9063–G9139
STELARA, ustekinumab, 1 mg, J3357
Stent, transcatheter, placement, C9600, C9601
Stereotactic, radiosurgery, G0339, G0340
Sterile cefuroxime sodium, J0697
Sterile water, A4216–A4217
Stimulation, electrical, non-attended, G0281–G0283
Stimulators
neuromuscular, E0744, E0745
osteogenesis, electrical, E0747–E0749
salivary reflex, E0755
stoma absorptive cover, A5083
transcutaneous, electric, nerve, A4595, E0720–E0749
ultrasound, E0760
Stockings
gradient, compression, A6530–A6549
surgical, A4490–A4510
Stoma, plug or seal, A5081
Stomach tube, B4083
Streptokinase, J2995
Streptomycin, J3000
Streptozocin, J9320
Strip, blood glucose test, A4253–A4772
urine reagent, A4250
Strontium-89 chloride, supply of, A9600
Study, bone density, G0130
Stump sock, L8470–L8485
Stylet, A4212
Substance/Alcohol, assessment, G0396, G0397, H0001, H0003, H0049
Succinylcholine chloride, J0330
Suction pump
gastric, home model, E2000
portable, E0600
respiratory, home model, E0600
Sumatriptan succinate, J3030
Supartz, J7321
Supplies
battery, A4233–A4236, A4601, A4611–A4613, A4638
cast, A4580, A4590, Q4001–Q4051
catheters, A4300–A4306
contraceptive, A4267–A4269
diabetic shoes, A5500–A5513
dialysis, A4653–A4928
DME, other, A4630–A4640
dressings, A6000–A6513
enteral, therapy, B4000–B9999
incontinence, A4310–A4355, A5102–A5200
infusion, A4221, A4222, A4230–A4232, E0776–E0791
needle, A4212, A4215
needle-free device, A4210
ostomy, A4361–A4434, A5051–A5093, A5120–A5200

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 parenteral, therapy, B4000–B9999
radiological, A4641, A4642
refill kit, infusion pump, A4220
respiratory, A4604–A4629
self-administered injections, A4211
splint, Q4051
sterile water/saline and/or dextrose, A4216–A4218
surgical, miscellaneous, A4649
syringe, A4206–A4209, A4213, A4232
syringe with needle, A4206–A4209
urinary, external, A4356–A4360
Supply/accessory/service, A9900
Support
arch, L3040–L3090
cervical, L0100–L0200
spinal, L0960
stockings, L8100–L8239
Surgery, oral, D7000–D7999
Surgical
arthroscopy, knee, G0289, S2112
boot, L3208–L3211
dressing, A6196–A6406
procedure, noncovered, G0293, G0294
stocking, A4490–A4510
supplies, A4649
tray, A4550
Swabs, betadine or iodine, A4247
Synvisc and Synvisc-One, J7325
Syringe, A4213
with needle, A4206–A4209
System
external, ambulatory insulin, A9274
rehabilitation, jaw, motion, E1700–E1702
transport, E1035–E1039

T
Tables, bed, E0274, E0315
Tacrolimus
oral, J7503, J7507, J7508
parenteral, J7525
Taliglucerase, J3060
Talimogene laheroareovec, J9325
Tape, A4450–A4452
Taxi, non-emergency transportation, A0100
Team, conference, G0175, G9007, S0220, S0221
Technetium TC 99M
Arcitumomab, A9568
Bicisate, A9557
Depreotide, A9536
Disofenin, A9510
Exametazine, A9521

125
 Exametazine labeled autologous white blood cells, A9569
Fanolesomab, A9566
Glucepatate, A9550
Labeled red blood cells, A9560
Macroaggregated albumin, A9540
Mebrofenin, A9537
Mertiatide, A9562
Oxidronate, A9561
Pentetate, A9539, A9567
Pertechnetate, A9512
Pyrophosphate, A9538
Sestamibi, A9500
Succimer, A9551
Sulfur colloid, A9541
Teboroxime, A9501
Tetrofosmin, A9502
Tilmanocept, A9520
Tedizolid phosphate, J3090
TEEV, J0900
Telavancin, J3095
Telehealth, Q3014
Telehealth transmission, T1014
Temozolomide
injection, J9328
oral, J8700
Temporary codes, Q0000–Q9999, S0009–S9999
Temporomandibular joint, D0320, D0321
Temsirolimus, J9330
Tenecteplase, J3101
Teniposide, Q2017
TENS, A4595, E0720–E0749
Tent, oxygen, E0455
Terbutaline sulfate, J3105
inhalation solution, concentrated, J7680
inhalation solution, unit dose, J7681
Teriparatide, J3110
Terminal devices, L6700–L6895
Test
sensory, nerve, conduction, G0255
Testosterone
cypionate and estradiol cypionate, J1071
enanthate, J3121
undecanoate, J3145
Tetanus immune globulin, human, J1670
Tetracycline, J0120
Thallous Chloride TL 201, A9505
Theophylline, J2810
Therapeutic lightbox, A4634, E0203
Therapy
activity, G0176
electromagnetic, G0295, G0329
endodontic, D3222–D3330

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 enteral, supplies, B4000–B9999
medical, nutritional, G0270, G0271
occupational, G0129, H5300, S9129
occupational, health, G0152
parenteral, supplies, B4000–B9999
respiratory, function, procedure, G0237–S0239, S5180, S5181
speech, home, G0153, S9128
wound, negative, pressure, pump, E2402
Theraskin, Q4121
Thermometer, A4931–A4932
dialysis, A4910
Thiamine HCl, J3411
Thiethylperazine maleate, J3280
Thiotepa, J9340
Thoracic orthosis, L0210
Thoracic-hip-knee-ankle (THKAO), L1500–L1520
Thoracic-lumbar-sacral orthosis (TLSO)
scoliosis, L1200–L1290
spinal, L0450–L0492
Thymol turbidity, blood, P2033
Thyrotropin Alfa, J3240
Tigecycline, J3243
Tinzarparin sodium, J1655
Tip (cane, crutch, walker) replacement, A4637
Tire, wheelchair, E2211–E2225, E2381–E2395
Tirofiban, J3246
Tisagenlecleucel, Q2040
Tissue marker, A4648
TLSO, L0450–L0492, L1200–L1290
Tobacco
intervention, G9016
Tobramycin
inhalation solution, unit dose, J7682, J7685
sulfate, J3260
Tocilizumab, J2362
Toe device, E1831
Toilet accessories, E0167–E0179, E0243, E0244, E0625
Tolazoline HCl, J2670
Toll, non emergency transport, A0170
Tomographic radiograph, dental, D0322
Topical hyperbaric oxygen chamber, A4575
Topotecan, J8705, J9351
Torsemide, J3265
Trabectedin, J9352
Tracheostoma heat moisture exchange system, A7501–A7509
Tracheostomy
care kit, A4629
filter, A4481
speaking valve, L8501
supplies, A4623, A4629, A7523–A7524
tube, A7520–A7522
Tracheotomy mask or collar, A7525–A7526

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Traction
cervical, E0855, E0856
device, ambulatory, E0830
equipment, E0840–E0948
extremity, E0870–E0880
pelvic, E0890, E0900, E0947
Training
diabetes, outpatient, G0108, G0109
home health or hospice, G0162
services, mental, health, G0177
Transcutaneous electrical nerve stimulator (TENS), E0720–E0770
Transducer protector, dialysis, E1575
Transfer (shoe orthosis), L3600–L3640
Transfer system with seat, E1035
Transparent film (for dressing), A6257–A6259
Transplant
islet, G0341–G0343, S2102
Transport
chair, E1035–E1039
system, E1035–E1039
x-ray, R0070–R0076
Transportation
ambulance, A0021–A0999, Q3019, Q3020
corneal tissue, V2785
EKG (portable), R0076
handicapped, A0130
non-emergency, A0080–A0210, T2001–T2005
service, including ambulance, A0021, A0999, T2006
taxi, non-emergency, A0100
toll, non-emergency, A0170
volunteer, non-emergency, A0080, A0090
x-ray (portable), R0070, R0075, R0076
Transportation services
air services, A0430, A0431, A0435, A0436
ALS disposable supplies, A0398
ALS mileage, A0390
ALS specialized service, A0392, A0394, A0396
ambulance, ALS, A0426, A0427, A0433
ambulance, outside state, Medicaid, A0021
ambulance oxygen, A0422
ambulance, waiting time, A0420
ancillary, lodging, escort, A0200
ancillary, lodging, recipient, A0180
ancillary, meals, escort, A0210
ancillary, meals, recipient, A0190
ancillary, parking fees, tolls, A0170
BLS disposable supplies, A0382
BLS mileage, A0380
BLS specialized service, A0384
emergency, neonatal, one-way, A0225
extra ambulance attendant, A0424
ground mileage, A0425

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 non-emergency, air travel, A0140
non-emergency, bus, A0110
non-emergency, case worker, A0160
non-emergency, mini-bus, A0120
non-emergency, no vested interest, A0080
non-emergency, taxi, A0100
non-emergency, wheelchair van, A0130
non-emergency, with vested interest, A0090
paramedic intercept, A0432
response and treat, no transport, A0998
specialty transport, A0434
Transtracheal oxygen catheter, A7018
Trapeze bar, E0910–E0912, E0940
Trauma, response, team, G0390
Tray
insertion, A4310–A4316
irrigation, A4320
surgical; (see also kits), A4550
wheelchair, E0950
Treatment
bone, G0412–G0415
pediculosis (lice), A9180
services, behavioral health, H0002–H2037
Treprostinil, J3285
Triamcinolone, J3301–J3303
acetonide, J3300, J3301
diacetate, J3302
hexacetonide, J3303
inhalation solution, concentrated, J7683
inhalation solution, unit dose, J7684
Triflupromazine HCl, J3400
Trifocal, glass or plastic, V2300–V2399
aniseikonic, V2318
lenticular, V2315, V2321
specialty trifocal, by report, V2399
sphere, plus or minus, V2300–V2302
spherocylinder, V2303–V2314
trifocal add-over 3.25d, V2320
trifocal, seg width over 28 mm, V2319
Trigeminal division block anesthesia, D9212
Trimethobenzamide HCl, J3250
Trimetrexate glucuoronate, J3305
Trimming, nails, dystrophic, G0127
Triptorelin pamoate, J3315
Trismus appliance, D5937
Truss, L8300–L8330
addition to standard pad, scrotal pad, L8330
addition to standard pad, water pad, L8320
double, standard pads, L8310
single, standard pad, L8300
Tube/Tubing
anchoring device, A5200

129
 blood, A4750, A4755
corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet, A4337
drainage extension, A4331
gastrostomy, B4087, B4088
irrigation, A4355
larynectomy, A4622
nasogastric, B4081, B4082
oxygen, A4616
serum clotting time, A4771
stomach, B4083
suction pump, each, A7002
tire, K0091, K0093, K0095, K0097
tracheostomy, A4622
urinary drainage, K0280

U
Ultrasonic nebulizer, E0575
Ultrasound, S8055, S9024
paranasal sinus ultrasound, S9024
ultrasound guidance, multifetal pregnancy reduction, technical component, S8055
Ultraviolet, cabinet/system, E0691, E0694
Ultraviolet light therapy system, A4633, E0691–E0694
light therapy system in 6 foot cabinet, E0694
replacement bulb/lamp, A4633
therapy system panel, 4 foot, E0692
therapy system panel, 6 foot, E0693
treatment area 2 sq feet or less, E0691
Unclassified drug, J3490
Underpads, disposable, A4554
Unipuncture control system, dialysis, E1580
Upper extremity addition, locking elbow, L6693
Upper extremity fracture orthosis, L3980–L3999
Upper limb prosthesis, L6000–L7499
Urea, J3350
Ureterostomy supplies, A4454–A4590
Urethral suppository, Alprostadil, J0275
Urinal, E0325, E0326
Urinary
catheter, A4338–A4346, A4351–A4353
indwelling catheter, A4338–A4346
intermittent urinary catheter, A4351–A4353
male external catheter, A4349
collection and retention (supplies), A4310–A4360
bedside drainage bag, A4357
disposable external urethral clamp, A4360
external urethral clamp, A4356
female external urinary collection device, A4328
insertion trays, A4310–A4316, A4354–A4355
irrigation syringe, A4322
irrigation tray, A4320
male external catheter/integral collection chamber, A4326

130
 perianal fecal collection pouch, A4330
therapeutic agent urinary catheter irrigation, A4321
urinary drainage bag, leg/abdomen, A4358
supplies, external, A4335, A4356–A4358
bedside drainage bag, A4357
external urethral clamp/compression device, A4356
incontinence supply, A4335
urinary drainage bag, leg or abdomen, A4358
tract implant, collagen, L8603
tract implant, synthetic, L8606
Urine
sensitivity study, P7001
tests, A4250
Urofollitropin, J3355
Urokinase, J3364, J3365
Ustekinumab, J3357, J3758
U-V lens, V2755

V
Vabra aspirator, A4480
Vaccination, administration
flublok, Q2033
hepatitis B, G0010
influenza virus, G0008
pneumococcal, G0009
Vaccine
administration, influenza, G0008
administration, pneumococcal, G0009
hepatitis B, administration, G0010
Vaginal
cancer, screening, G0101
cytopathologist, G0123
cytopathology, G0123, G0124, G0141–G0148
screening, cervical/vaginal, thin-layer, cytopathologist, G0123
screening, cervical/vaginal, thin-layer, physician interpretation, G0124
screening cytopathology smears, automated, G0141–G0148
Vancomycin HCl, J3370
Vaporizer, E0605
Vascular
catheter (appliances and supplies), A4300–A4306
disposable drug delivery system, >50 ml/hr, A4305
disposable drug delivery system, <50 ml/hr, A4306
implantable access catheter, external, A4300
implantable access total, catheter, A4301
graft material, synthetic, L8670
Vasoxyl, J3390
Vedolizumab, J3380
Vehicle, power-operated, K0800–K0899
Velaglucerase alfa, J3385
Venous pressure clamp, dialysis, A4918
Ventilator

131
 battery, A4611–A4613
home ventilator, any type, E0465, E0466
used with invasive interface (e.g., tracheostomy tube), E0465
used with non-invasive interface (e.g., mask, chest shell), E0466
moisture exchanger, disposable, A4483
Ventricular assist device, Q0478–Q0504, Q0506–Q0509
battery clips, electric or electric/pneumatic, replacement, Q0497
battery, lithium-ion, electric or electric/pneumatic, replacement, Q0506
battery, other than lithium-ion, electric or electric/pneumatic, replacement, Q0496
battery, pneumatic, replacement, Q0503
battery/power-pack charger, electric or electric/pneumatic, replacement, Q0495
belt/vest/bag, carry external components, replacement, Q0499
driver, replacement, Q0480
emergency hand pump, electric or electric/pneumatic, replacement, Q0494
emergency power source, electric, replacement, Q0490
emergency power source, electric/pneumatic, replacement, Q0491
emergency power supply cable, electric, replacement, Q0492
emergency power supply cable, electric/pneumatic, replacement, Q0493
filters, electric or electric/pneumatic, replacement, Q0500
holster, electric or electric/pneumatic, replacement, Q0498
leads (pneumatic/electrical), replacement, Q0487
microprocessor control unit, electric/pneumatic combination, replacement, Q0482
microprocessor control unit, pneumatic, replacement, Q0481
miscellaneous supply, external VAD, Q0507
miscellaneous supply, implanted device, Q0508
miscellaneous supply, implanted device, payment not made under Medicare Part A, Q0509
mobility cart, replacement, Q0502
monitor control cable, electric, replacement, Q0485
monitor control cable, electric/pneumatic, Q0486
monitor/display module, electric, replacement, Q0483
monitor/display module, electric/electric pneumatic, replacement, Q0484
power adapter, pneumatic, replacement, vehicle type, Q0504
power adapter, vehicle type, Q0478
power module, replacement, Q0479
power-pack base, electric, replacement, Q0488
power-pack base, electric/pneumatic, replacement, Q0489
shower cover, electric or electric/pneumatic, replacement, Q0501
Verteporfin, J3396
Vest, safety, wheelchair, E0980
Vinblastine sulfate, J9360
Vincristine sulfate, J9370, J9371
Vinorelbine tartrate, J9390
Vision service, V2020–V2799
bifocal, glass or plastic, V2200–V2299
contact lenses, V2500–V2599
frames, V2020–V2025
intraocular lenses, V2630–V2632
low-vision aids, V2600–V2615
miscellaneous, V2700–V2799
prosthetic eye, V2623–V2629
spectacle lenses, V2100–V2199
trifocal, glass or plastic, V2300–V2399

132
 variable asphericity, V2410–V2499
Visit, emergency department, G0380–G0384
Visual, function, postoperative cataract surgery, G0915–G0918
Vitamin B-12 cyanocobalamin, J3420
Vitamin K, J3430
Voice
amplifier, L8510
prosthesis, L8511–L8514
Von Willebrand Factor Complex, human, J7179, J7183, J7187
Voriconazole, J3465

W
Waiver, T2012–T2050
assessment/plan of care development, T2024
case management, per month, T2022
day habilitation, per 15 minutes, T2021
day habilitation, per diem, T2020
habilitation, educational, per diem, T2012
habilitation, educational, per hour, T2013
habilitation, prevocational, per diem, T2014
habilitation, prevocational, per hour, T2015
habilitation, residential, 15 minutes, T2017
habilitation, residential, per diem, T2016
habilitation, supported employment, 15 minutes, T2019
habilitation, supported employment, per diem, T2018
targeted case management, per month, T2023
waiver services NOS, T2025
Walker, E0130–E0149
accessories, A4636, A4637
attachments, E0153–E0159
enclosed, four-sided frame, E0144
folding (pickup), E0135
folding, wheeled, E0143
heavy duty, multiple braking system, E0147
heavy duty, wheeled, rigid or folding, E0149
heavy duty, without wheels, E0148
rigid (pickup), E0130
rigid, wheeled, E0141
with trunk support, E0140
Walking splint, L4386
Washer, Gravlee jet, A4470
Water
dextrose, J7042, J7060, J7070
distilled (for nebulizer), A7018
pressure pad/mattress, E0187, E0198
purification system (ESRD), E1610, E1615
softening system (ESRD), E1625
sterile, A4714
WBC/CBC, G0306
Wedges, shoe, L3340–L3420
Wellness visit; annual, G0438, G0439

133
Wet mount, Q0111
Wheel attachment, rigid pickup walker, E0155
Wheelchair, E0950–E1298, K0001–K0108, K0801–K0899
accessories, E0192, E0950–E1030, E1065–E1069, E2211–E2230, E2300–E2399,
E2626–E2633
amputee, E1170–E1200
back, fully reclining, manual, E1226
component or accessory, not otherwise specified, K0108
cushions, E2601–E2625
custom manual wheelchair base, K0008
custom motorized/power base, K0013
foot box, E0954
heavy duty, E1280–E1298, K0006, K0007, K0801–K0886
lateral thigh or knee support, E0953
lightweight, E1087–E1090, E1240–E1270
narrowing device, E0969
power add-on, E0983–E0984
reclining, fully, E1014, E1050–E1070, E1100–E1110
semi-reclining, E1100–E1110
shock absorber, E1015–E1018
specially sized, E1220, E1230
standard, E1130, K0001
stump support system, K0551
tire, E0999
transfer board or device, E0705
tray, K0107
van, non-emergency, A0130
youth, E1091
WHFO with inflatable air chamber, L3807
Whirlpool equipment, E1300–E1310
WHO, wrist extension, L3914
Wig, A9282
Wipes, A4245, A4247
Wound
cleanser, A6260
closure, adhesive, G0168
cover
alginate dressing, A6196–A6198
collagen dressing, A6020–A6024
foam dressing, A6209–A6214
hydrocolloid dressing, A6234–A6239
hydrogel dressing, A6242–A6247
non-contact wound warming cover, and accessory, E0231–E0232
specialty absorptive dressing, A6251–A6256
filler
alginate dressing, A6199
collagen based, A6010
foam dressing, A6215
hydrocolloid dressing, A6240–A6241
hydrogel dressing, A6248
not elsewhere classified, A6261–A6262
matrix, Q4114

134
 pouch, A6154
therapy, negative, pressure, pump, E2402
wound suction, A9272, K0743
Wrapping, fabric, abdominal aneurysm, M0301
Wrist
disarticulation prosthesis, L6050, L6055
electronic wrist rotator, L7259
hand/finger orthosis (WHFO), E1805, E1825, L3800–L3954

X
Xenon Xe 133, A9558
X-ray
equipment, portable, Q0092, R0070, R0075
single, energy, absorptiometry (SEXA), G0130
transport, R0070–R0076
Xylocaine HCl, J2000

Y
Yttrium Y-90 ibritumomab, A9543

Z
Ziconotide, J2278
Zidovudine, J3485
Ziprasidone mesylate, J3486
Zoledronic acid, J3489

◀ New Revised ✔ Reinstated deleted Deleted

135
TABLE OF DRUGS

136
IA Intra-arterial administration
IU International unit
IV Intravenous administration
IM Intramuscular administration
IT Intrathecal
SC Subcutaneous administration
INH Administration by inhaled solution
VAR Various routes of administration
OTH Other routes of administration
ORAL Administered orally

Intravenous administration includes all methods, such as gravity infusion, injections, and timed pushes. The
“VAR” posting denotes various routes of administration and is used for drugs that are commonly administered
into joints, cavities, tissues, or topical applications, in addition to other parenteral administrations. Listings
posted with “OTH” indicate other administration methods, such as suppositories or catheter injections.

Blue typeface terms are added by publisher.

METHOD OF
DRUG NAME DOSAGE ADMINISTRATION HCPCS CODE

A
Abatacept 10 mg IV J0129
Abbokinase 5,000 IU vial IV J3364
250,000 IU IV J3365
vial
Abbokinase, Open Cath 5,000 IU vial IV J3364
Abciximab 10 mg IV J0130
Abelcet 10 mg IV J0287-J0289
Abilify Maintena 1 mg J0401
ABLC 50 mg IV J0285
AbobotulinumtoxintypeA 5 units IM J0586
Abraxane 1 mg J9264
Accuneb 1 mg J7613
Acetadote 100 mg J0132
Acetaminophen 10 mg IV J0131
Acetazolamide sodium up to 500 IM, IV J1120
mg
Acetylcysteine
injection 100 mg IV J0132
unit dose form per gram INH J7604, J7608
Achromycin up to 250 IM, IV J0120
mg

Actemra 1 mg J3262

137
ACTH up to 40 IV, IM, SC J0800
units
Acthar up to 40 IV, IM, SC J0800
units
Acthib J3490
Acthrel 1 mcg J0795
Actimmune 3 million SC J9216
units
Activase 1 mg IV J2997
Acyclovir 5 mg J0133
J8499
Adagen 25 IU J2504
Adalimumab 20 mg SC J0135
Adcetris 1 mg IV J9042
Adenocard 1 mg IV J0153
Adenoscan 1 mg IV J0153
Adenosine 1 mg IV J0153
Ado-trastuzumab Emtansine 1 mg IV J9354
Adrenalin Chloride up to 1 ml SC, IM J0171
ampule
Adrenalin, epinephrine 0.1 mg SC, IM J0171
Adriamycin, PFS, RDF 10 mg IV J9000
Adrucil 500 mg IV J9190
Advate per IU J7192
Aflibercept 1 mg OTH J0178
Agalsidase beta 1 mg IV J0180
Aggrastat 0.25 mg IM, IV J3246
A-hydrocort up to 50 mg IV, IM, SC J1710
up to 100 J1720
mg
Akineton per 5 mg IM, IV J0190
Akynzeo 300 mg and J8655
0.5 mg
Alatrofloxacin mesylate, injection 100 mg IV J0200
Albumin P9041, P9045,
P9046, P9047
Albuterol 0.5 mg INH J7620
concentrated form 1 mg INH J7610, J7611
unit dose form 1 mg INH J7609, J7613
Aldesleukin per single IM, IV J9015
use vial
Aldomet up to 250 IV J0210
mg
Aldurazyme 0.1 mg J1931

138
Alefacept 0.5 mg IM, IV J0215
Alemtuzumab 1 mg J0202
Alferon N 250,000 IU IM J9215
Alglucerase per 10 units IV J0205
Alglucosidase alfa 10 mg IV J0220, J0221
Alimta 10 mg J9305
Alkaban-AQ 1 mg IV J9360
Alkeran 2 mg ORAL J8600
50 mg IV J9245
AlloDerm per square Q4116
centimeter
AlloSkin per square Q4115
centimeter
Aloxi 25 mcg J2469
Alpha 1-proteinase inhibitor, human 10 mg IV J0256, J0257
Alphanate J7186
AlphaNine SD per IU J7193
Alprolix per IU J7201
Alprostadil
injection 1.25 mcg OTH J0270
urethral suppository each OTH J0275
Alteplase recombinant 1 mg IV J2997
Alupent per 10 mg INH J7667, J7668
noncompounded, unit dose 10 mg INH J7669
unit does 10 mg INH J7670
AmBisome 10 mg IV J0289
Amcort per 5 mg IM J3302
A-methaPred up to 40 mg IM, IV J2920
up to 125 IM, IV J2930
mg
Amgen 1 mcg SC J9212
Amifostine 500 mg IV J0207
Amikacin sulfate 100 mg IM, IV J0278
Aminocaproic Acid J3490
Aminolevalinic acid HCl unit dose OTH J7308
(354 mg)
Aminolevulinic acid Hcl 10% Gel 10 mg OTH J7345
Aminolevulinate 1g OTH J7309
Aminophylline/Aminophyllin up to 250 IV J0280
mg
Amiodarone HCl 30 mg IV J0282
Amitriptyline HCl up to 20 mg IM J1320

139
Amobarbital up to 125 IM, IV J0300
mg
Amphadase 1 ml J3470
Amphocin 50 mg IV J0285
Amphotericin B 50 mg IV J0285
Amphotericin B, lipid complex 10 mg IV J0287-J0289
Ampicillin
sodium up to 500 IM, IV J0290
mg
sodium/sulbactam sodium per 1.5 g IM, IV J0295
Amygdalin J3570
Amytal up to 125 IM, IV J0300
mg
Anabolin LA 100 up to 50 mg IM J2320
Anadulafungin 1 mg IV J0348
Anascorp up to 120 IV J0716
mg
Anastrozole 1 mg J8999
Ancef 500 mg IV, IM J0690
Andrest 90-4 1 mg IM J3121
Andro-Cyp 1 mg J1071
Andro-Cyp 200 1 mg J1071
Andro L.A. 200 1 mg IM J3121
Andro-Estro 90-4 1 mg IM J3121
Andro/Fem 1 mg J1071
Androgyn L.A. 1 mg IM J3121
Androlone-50 up to 50 mg J2320
Androlone-D 100 up to 50 mg IM J2320
Andronaq-50 up to 50 mg IM J3140
Andronaq-LA 1 mg J1071
Andronate-100 1 mg J1071
Andronate-200 1 mg J1071
Andropository 100 1 mg IM J3121
Andryl 200 1 mg IM J3121
Anectine up to 20 mg IM, IV J0330
Anergan 25 up to 50 mg IM, IV J2550
12.5 mg ORAL Q0169
Anergan 50 up to 50 mg IM, IV J2550
12.5 mg ORAL Q0169
Angiomax 1 mg J0583
Anidulafungin 1 mg IV J0348
Anistreplase 30 units IV J0350

140
Antiflex up to 60 mg IM, IV J2360
Anti-Inhibitor per IU IV J7198
Antispas up to 20 mg IM J0500
Antithrombin III (human) per IU IV J7197
Antithrombin recombinant 50 IU IV J7196
Anzemet 10 mg IV J1260
50 mg ORAL S0174
100 mg ORAL Q0180
Apidra Solostar per 50 units J1817
A.P.L. per 1,000 IM J0725
USP units
Apligraf per square Q4101
centimeter
Apomorphine Hydrochloride 1 mg SC J0364
Aprepitant 1 mg IV J0185 ◀
Aprepitant 5 mg ORAL J8501
Apresoline up to 20 mg IV, IM J0360
Aprotinin 10,000 kiu J0365
AquaMEPHYTON per 1 mg IM, SC, IV J3430
Aralast 10 mg IV J0256
Aralen up to 250 IM J0390
mg
Aramine per 10 mg IV, IM, SC J0380
Aranesp
ESRD use 1 mcg J0882
Non-ESRD use 1 mcg J0881
Arbutamine 1 mg IV J0395
Arcalyst 1 mg J2793
Aredia per 30 mg IV J2430
Arfonad, see Trimethaphan camsylate
Arformoterol tartrate 15 mcg INH J7605
Argatroban
(for ESRD use) 1 mg IV J0884
(for non-ESRD use) 1 mg IV J0883
Aridol 25% in 50 IV J2150
ml
5 mg INH J7665
Arimidex J8999
Aripiprazole 0.25 mg IM J0400
Aripiprazole, extended release 1 mg IV J0401
Aripiprazole lauroxil 1 mg IV J1942
Aristada 3.9 ml J1942

141
Aristocort Forte per 5 mg IM J3302
Aristocort Intralesional per 5 mg IM J3302
Aristospan Intra-Articular per 5 mg VAR J3303
Aristospan Intralesional per 5 mg VAR J3303
Arixtra per 0.5 m J1652
Aromasin J8999
Arranon 50 mg J9261
Arrestin up to 200 IM J3250
mg
250 mg ORAL Q0173
Arsenic trioxide 1 mg IV J9017
Arzerra 10 mg J9302
Asparaginase 1,000 units IV, IM J9019
10,000 units IV, IM J9020
Astagraf XL 0.1 mg J7508
Astramorph PF up to 10 mg IM, IV, SC J2270
Atezolizumab 10 mg IV J9022
Atgam 250 mg IV J7504
Ativan 2 mg IM, IV J2060
Atropine
concentrated form per mg INH J7635
unit dose form per mg INH J7636
sulfate 0.01 mg IV, IM, SC J0461, J7636
Atrovent per mg INH J7644, J7645
ATryn 50 IU IV J7196
Aurothioglucose up to 50 mg IM J2910
Autologous cultured chondrocytes OTH J7330
implant
Autoplex T per IU IV J7198, J7199
AUVI-Q 0.15 mg J0171
Avastin 10 mg J9035
Avelox 100 mg J2280
Avelumab 10 mg IV J9023
Avonex 30 mcg IM J1826
1 mcg IM Q3027
1 mcg SC Q3028
Azacitidine 1 mg SC J9025
Azasan 50 mg J7500
Azathioprine 50 mg ORAL J7500
Azathioprine, parenteral 100 mg IV J7501
Azithromycin, dihydrate 1 gram ORAL Q0144
Azithromycin, injection 500 mg IV J0456

142
B
Baciim J3490
Bacitracin J3490
Baclofen 10 mg IT J0475
Baclofen for intrathecal trial 50 mcg OTH J0476
Bactocill up to 250 IM, IV J2700
mg
BAL in oil per 100 mg IM J0470
Banflex up to 60 mg IV, IM J2360
Basiliximab 20 mg IV J0480
BCG (Bacillus Calmette and Guerin), per vial IV J9031
live
Bebulin per IU J7194
Beclomethasone inhalation solution, per mg INH J7622
unit dose form
Belatacept 1 mg IV J0485
Beleodaq 10 mg J9032
Belimumab 10 mg IV J0490
Belinostat 10 mg IV J9032
Bena-D 10 up to 50 mg IV, IM J1200
Bena-D 50 up to 50 mg IV, IM J1200
Benadryl up to 50 mg IV, IM J1200
Benahist 10 up to 50 mg IV, IM J1200
Benahist 50 up to 50 mg IV, IM J1200
Ben-Allergin-50 up to 50 mg IV, IM J1200
50 mg ORAL Q0163
Bendamustine HCl
Bendeka 1 mg IV J9034
Treanda 1 mg IV J9033
Benefix per IU IV J7195
Benlysta 10 mg J0490
Benoject-10 up to 50 mg IV, IM J1200
Benoject-50 up to 50 mg IV, IM J1200
Benralizumab 1 mg IV J0517 ◀
Bentyl up to 20 mg IM J0500
Benzocaine J3490
Benztropine mesylate per 1 mg IM, IV J0515
Berinert 10 units J0597
Berubigen up to 1,000 IM, SC J3420
mcg
Beta amyloid per study OTH A9599
dose

143
Betalin 12 up to 1,000 IM, SC J3420
mcg
Betameth per 3 mg IM, IV J0702
Betamethasone Acetate J3490
Betamethasone Acetate & per 3 mg IM J0702
Betamethasone Sodium Phosphate
Betamethasone inhalation solution, per mg INH J7624
unit dose form
Betaseron 0.25 mg SC J1830
Bethanechol chloride up to 5 mg SC J0520
Bethkis 300 mg J7682
Bevacizumab 10 mg IV J9035
Bevacizumab-awwb 10 mg IV Q5107 ◀
Bezlotoxumab 10 mg IV J0565
Bicillin C-R 100,000 J0558
units
Bicillin C-R 900/300 100,000 IM J0558, J0561
units
Bicillin L-A 100,000 IM J0561
units
BiCNU 100 mg IV J9050
Biperiden lactate per 5 mg IM, IV J0190
Bitolterol mesylate
concentrated form per mg INH J7628
unit dose form per mg INH J7629
Bivalirudin 1 mg IV J0583
Blenoxane 15 units IM, IV, SC J9040
Bleomycin sulfate 15 units IM, IV, SC J9040
Blinatumomab 1 microgram IV J9039
Blincyto 1 mcg J9039
Boniva 1 mg J1740
Bortezomib 0.1 mg IV J9041
Bortezomib, not otherwise specified 0.1 mg J9044 ◀
Botox 1 unit J0585
Bravelle 75 IU J3355
Brentuximab Vedotin 1 mg IV J9042
Brethine
concentrated form per 1 mg INH J7680
unit dose per 1 mg INH J7681
up to 1 mg SC, IV J3105
Bricanyl Subcutaneous up to 1 mg SC, IV J3105
Brompheniramine maleate per 10 mg IM, SC, IV J0945
Bronkephrine, see Ethylnorepinephrine

144
HCl
Bronkosol
concentrated form per mg INH J7647, J7648
unit dose form per mg INH J7649, J7650
Brovana J7605
Budesonide inhalation solution
concentrated form 0.25 mg INH J7633, J7634
unit dose form 0.5 mg INH J7626, J7627
Bumetanide J3490
Bupivacaine J3490
Buprenex 0.3 mg J0592
Buprenorphine Hydrochloride 0.1 mg IM J0592
Buprenorphine/Naloxone 1 mg ORAL J0571
< = 3 mg ORAL J0572
> 3 mg but < ORAL J0573
= 6 mg
> 6 mg but < ORAL J0574
= 10 mg
> 10 mg ORAL J0575
Buprenorphine extended release < = 100 mg ORAL Q9991 ◀
> 100 mg ORAL Q9992 ◀
Burosumab-twza 1 mg IV J05894 ◀
Busulfan 1 mg IV J0594
2 mg ORAL J8510
Butorphanol tartrate 1 mg J0595
C
C1 Esterase Inhibitor 10 units IV J0596-J0599
Cabazitaxel 1 mg IV J9043
Cabergoline 0.25 mg ORAL J8515
Cafcit 5 mg IV J0706
Caffeine citrate 5 mg IV J0706
Caine-1 10 mg IV J2001
Caine-2 10 mg IV J2001
Calcijex 0.1 mcg IM J0636
Calcimar up to 400 SC, IM J0630
units
Calcitonin-salmon up to 400 SC, IM J0630
units
Calcitriol 0.1 mcg IM J0636
Calcitrol J8499
Calcium Disodium Versenate up to 1,000 IV, SC, IM J0600
mg

145
Calcium gluconate per 10 ml IV J0610
Calcium glycerophosphate and calcium per 10 ml IM, SC J0620
lactate
Caldolor 100 mg IV J1741
Calphosan per 10 ml IM, SC J0620
Camptosar 20 mg IV J9206
Canakinumab 1 mg SC J0638
Cancidas 5 mg J0637
Capecitabine 150 mg ORAL J8520
500 mg ORAL J8521
Capsaicin patch per sq cm OTH J7336
Carbidopa 5 mg/levodopa 20 mg IV J7340
enteral suspension
Carbocaine per 10 ml VAR J0670
Carbocaine with Neo-Cobefrin per 10 ml VAR J0670
Carboplatin 50 mg IV J9045
Carfilzomib 1 mg IV J9047
Carimune 500 mg J1566
Carmustine 100 mg IV J9050
Carnitor per 1 g IV J1955
Carticel J7330
Caspofungin acetate 5 mg IV J0637
Cathflo Activase 1 mg J2997
Caverject per 1.25 mcg J0270
Cayston 500 mg S0073
Cefadyl up to 1 g IV, IM J0710
Cefazolin sodium 500 mg IV, IM J0690
Cefepime hydrochloride 500 mg IV J0692
Cefizox per 500 mg IM, IV J0715
Cefotaxime sodium per 1 g IV, IM J0698
Cefotetan J3490
Cefoxitin sodium 1g IV, IM J0694
Ceftaroline fosamil 1 mg J0712
Ceftazidime per 500 mg IM, IV J0713
Ceftazidime and avibactam 0.5 g/0.125 IV J0714
g
Ceftizoxime sodium per 500 mg IV, IM J0715
Ceftolozane 50 mg and Tazobactam IV J0695
25 mg
Ceftriaxone sodium per 250 mg IV, IM J0696
Cefuroxime sodium, sterile per 750 mg IM, IV J0697
Celestone Soluspan per 3 mg IM J0702

146
CellCept 250 mg ORAL J7517
Cel-U-Jec per 4 mg IM, IV Q0511
Cenacort A-40 1 mg J3300
per 10 mg IM J3301
Cenacort Forte per 5 mg IM J3302
Centruroides Immune F(ab) up to 120 IV J0716
mg
Cephalothin sodium up to 1 g IM, IV J1890
Cephapirin sodium up to 1 g IV, IM J0710
Ceprotin 10 IU J2724
Ceredase per 10 units IV J0205
Cerezyme 10 units J1786
Cerliponase alfa 1 mg IV J0567 ◀
Certolizumab pegol 1 mg SC J0717
Cerubidine 10 mg IV J9150
Cetuximab 10 mg IV J9055
Chealamide per 150 mg IV J3520
Chirhostim 1 mcg IV J2850
Chloramphenicol Sodium Succinate up to 1 g IV J0720
Chlordiazepoxide HCl up to 100 IM, IV J1990
mg
Chloromycetin Sodium Succinate up to 1 g IV J0720
Chloroprocaine HCl per 30 ml VAR J2400
Chloroquine HCl up to 250 IM J0390
mg
Chlorothiazide sodium per 500 mg IV J1205
Chlorpromazine 5 mg ORAL Q0161
Chlorpromazine HCl up to 50 mg IM, IV J3230
Cholografin Meglumine per ml Q9961
Chorex-5 per 1,000 IM J0725
USP units
Chorex-10 per 1,000 IM J0725
USP units
Chorignon per 1,000 IM J0725
USP units
Chorionic Gonadotropin per 1,000 IM J0725
USP units
Choron 10 per 1,000 IM J0725
USP units
Cidofovir 375 mg IV J0740
Cilastatin sodium, imipenem per 250 mg IV, IM J0743
Cimzia 1 mg SC J0717
Cinacalcet ORAL J0604

147
Cinryze 10 units J0598
Cipro IV 200 mg IV J0706
Ciprofloxacin 200 mg IV J0706
octic suspension 6 mg OTH J7342
J3490
Cisplatin, powder or solution per 10 mg IV J9060
Cladribine per mg IV J9065
Claforan per 1 gm IM, IV J0698
Cleocin Phosphate J3490
Clindamycin J3490
Clofarabine 1 mg IV J9027
Clolar 1 mg J9027
Clonidine Hydrochloride 1 mg Epidural J0735
Cobex up to 1,000 IM, SC J3420
mcg
Codeine phosphate per 30 mg IM, IV, SC J0745
Codimal-A per 10 mg IM, SC, IV J0945
Cogentin per 1 mg IM, IV J0515
Colistimethate sodium up to 150 IM, IV J0770
mg
Collagenase, Clostridium Histolyticum 0.01 mg OTH J0775
Coly-Mycin M up to 150 IM, IV J0770
mg
Compa-Z up to 10 mg IM, IV J0780
Copanlisib 1 mg IV J9057 ◀
Compazine up to 10 mg IM, IV J0780
5 mg ORAL Q0164
J8498
Compounded drug, not otherwise J7999
classified
Compro J8498
Conray per ml Q9961
Conray 30 per ml Q9958
Conray 43 per ml Q9960
Copaxone 20 mg J1595
Cophene-B per 10 mg IM, SC, IV J0945
Copper contraceptive, intrauterine OTH J7300
Cordarone 30 mg IV J0282
Corgonject-5 per 1,000 IM J0725
USP units
Corifact 1 IU J7180
Corticorelin ovine triflutate 1 mcg J0795
Corticotropin up to 40 IV, IM, SC J0800

148
Corticotropin up to 40 IV, IM, SC J0800
units

Cortisone Acetate Micronized J3490

Cortrosyn per 0.25 mg IM, IV J0835
Corvert 1 mg J1742
Cosmegen 0.5 mg IV J9120
Cosyntropin per 0.25 mg IM, IV J0833, J0834
Cotranzine up to 10 mg IM, IV J0780
Crofab up to 1 gram J0840
Cromolyn Sodium J8499
Cromolyn sodium, unit dose form per 10 mg INH J7631, J7632
Crotalidae immune f(ab’)2 (equine) 120 mg IV J0841 ◀
Crotalidae Polyvalent Immune Fab up to 1 gram IV J0840
Crysticillin 300 A.S. up to IM, IV J2510 ✖
600,000
units
Crysticillin 600 A.S. up to IM, IV J2510
600,000
units
Cubicin 1 mg J0878
Cuvitru J7799
Cyclophosphamide 100 mg IV J9070
oral 25 mg ORAL J8530
Cyclosporine 25 mg ORAL J7515
100 mg ORAL J7502
parenteral 250 mg IV J7516
Cymetra 1 cc Q4112
Cyramza 5 mg J9308
Cysto-Cornray II per ml Q9958
Cystografin per ml Q9958
Cytarabine 100 mg SC, IV J9100
Cytarabine liposome 10 mg IT J9098
CytoGam per vial J0850
Cytomegalovirus immune globulin per vial IV J0850
intravenous (human)
Cytosar-U 100 mg SC, IV J9100
Cytovene 500 mg IV J1570
Cytoxan 100 mg IV J8530, J9070
D
D-5-W, infusion 1000 cc IV J7070
Dacarbazine 100 mg IV J9130
Daclizumab 25 mg IV J7513

149
Dactinomycin 0.5 mg IV J9120
Dalalone 1 mg IM, IV, OTH J1100
Dalalone L.A. 1 mg IM J1094
Dalbavancin 5 mg IV J0875
Dalteparin sodium per 2500 IU SC J1645
Daptomycin 1 mg IV J0878
Daratumumab 10 mg IV J9145
Darbepoetin Alfa 1 mcg IV, SC J0881, J0882
Darzalex 10 mg J9145
Daunorubicin citrate, liposomal 10 mg IV J9151
formulation
Daunorubicin HCl 10 mg IV J9150
Daunoxome 10 mg IV J9151
DDAVP 1 mcg IV, SC J2597
Decadron 1 mg IM, IV, OTH J1100
0.25 mg J8540
Decadron Phosphate 1 mg IM, IV, OTH J1100
Decadron-LA 1 mg IM J1094
Deca-Durabolin up to 50 mg IM J2320
Decaject 1 mg IM, IV, OTH J1100
Decaject-L.A. 1 mg IM J1094
Decitabine 1 mg IV J0894
Decolone-50 up to 50 mg IM J2320
Decolone-100 up to 50 mg IM J2320
De-Comberol 1 mg J1071
Deferoxamine mesylate 500 mg IM, SC, IV J0895
Definity per ml J3490, Q9957
Degarelix 1 mg SC J9155
Dehist per 10 mg IM, SC, IV J0945
Deladumone 1 mg IM J3121
Deladumone OB 1 mg IM J3121
Delatest 1 mg IM J3121
Delatestadiol 1 mg IM J3121
Delatestryl 1 mg IM J3121
Delestrogen up to 10 mg IM J1380
Delta-Cortef 5 mg ORAL J7510
Demadex 10 mg/ml IV J3265
Demerol HCl per 100 mg IM, IV, SC J2175
Denileukin diftitox 300 mcg IV J9160
Denosumab 1 mg SC J0897
DepAndro 100 1 mg J1071

150
DepAndro 200 1 mg J1071
DepAndrogyn 1 mg J1071
DepGynogen up to 5 mg IM J1000
DepMedalone 40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
DepMedalone 80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
DepoCyt 10 mg J9098
Depo-estradiol cypionate up to 5 mg IM J1000
Depogen up to 5 mg IM J1000
Depoject 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depo-Medrol 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depopred-40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depopred-80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Depo-Provera Contraceptive 1 mg J1050
Depotest 1 mg J1071
Depo-Testadiol 1 mg J1071
Depo-Testosterone 1 mg J1071
Depotestrogen 1 mg J1071
Dermagraft per square Q4106
centimeter
Desferal Mesylate 500 mg IM, SC, IV J0895
Desmopressin acetate 1 mcg IV, SC J2597
Dexacen-4 1 mg IM, IV, OTH J1100
Dexacen LA-8 1 mg IM J1094
Dexamethasone
concentrated form per mg INH J7637
intravitreal implant 0.1 mg OTH J7312
unit form per mg INH J7638
oral 0.25 mg ORAL J8540
acetate 1 mg IM J1094

151
 sodium phosphate 1 mg IM, IV, OTH J1100
Dexasone 1 mg IM, IV, OTH J1100
Dexasone L.A. 1 mg IM J1094
Dexferrum 50 mg J1750
Dexone 0.25 mg ORAL J8540
1 mg IM, IV, OTH J1100
Dexone LA 1 mg IM J1094
Dexpak 0.25 mg ORAL J8540
Dexrazoxane hydrochloride 250 mg IV J1190
Dextran 40 500 ml IV J7100
Dextran 75 500 ml IV J7110
Dextrose 5%/normal saline solution 500 ml = 1 IV J7042
unit
Dextrose/water (5%) 500 ml = 1 IV J7060
unit
D.H.E. 45 per 1 mg J1110
Diamox up to 500 IM, IV J1120
mg
Diazepam up to 5 mg IM, IV J3360
Diazoxide up to 300 IV J1730
mg
Dibent up to 20 mg IM J0500
Diclofenac sodium 37.5 IV J1130
Dicyclomine HCl up to 20 mg IM J0500
Didronel per 300 mg IV J1436
Diethylstilbestrol diphosphate 250 mg IV J9165
Diflucan 200 mg IV J1450
DigiFab per vial J1162
Digoxin up to 0.5 mg IM, IV J1160
Digoxin immune fab (ovine) per vial J1162
Dihydrex up to 50 mg IV, IM J1200
50 mg ORAL Q0163
Dihydroergotamine mesylate per 1 mg IM, IV J1110
Dilantin per 50 mg IM, IV J1165
Dilaudid up to 4 mg SC, IM, IV J1170
250 mg OTH S0092
Dilocaine 10 mg IV J2001
Dilomine up to 20 mg IM J0500
Dilor up to 500 IM J1180
mg
Dimenhydrinate up to 50 mg IM, IV J1240
Dimercaprol per 100 mg IM J0470

152
Dimethyl sulfoxide 50%, 50 ml OTH J1212
Dinate up to 50 mg IM, IV J1240
Dioval up to 10 mg IM J1380
Dioval 40 up to 10 mg IM J1380
Dioval XX up to 10 mg IM J1380
Diphenacen-50 up to 50 mg IV, IM J1200
50 mg ORAL Q0163
Diphenhydramine HCl
injection up to 50 mg IV, IM J1200
oral 50 mg ORAL Q0163
Diprivan 10 mg J2704
J3490
Dipyridamole per 10 mg IV J1245
Disotate per 150 mg IV J3520
Di-Spaz up to 20 mg IM J0500
Ditate-DS 1 mg IM J3121
Diuril Sodium per 500 mg IV J1205
D-Med 80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
DMSO, Dimethyl sulfoxide 50% 50 ml OTH J1212
Dobutamine HCl per 250 mg IV J1250
Dobutrex per 250 mg IV J1250
Docefrez 1 mg J9171
Docetaxel 20 mg IV J9170
Dolasetron mesylate
injection 10 mg IV J1260
tablets 100 mg ORAL Q0180
Dolophine HCl up to 10 mg IM, SC J1230
Dommanate up to 50 mg IM, IV J1240
Donbax 10 mg J1267
Dopamine 40 mg J1265
Dopamine HCl 40 mg J1265
Doribax 10 mg J1267
Doripenem 10 mg IV J1267
Dornase alpha, unit dose form per mg INH J7639
Dotarem 0.1 ml A9575
Doxercalciferol 1 mcg IV J1270
Doxil 10 mg IV J9000, Q2050
Doxorubicin HCL 10 mg IV J9000
Doxy 100 mg J3490

153
Dramamine up to 50 mg IM, IV J1240
Dramanate up to 50 mg IM, IV J1240
Dramilin up to 50 mg IM, IV J1240
Dramocen up to 50 mg IM, IV J1240
Dramoject up to 50 mg IM, IV J1240
Dronabinol 2.5 mg ORAL Q0167
Droperidol up to 5 mg IM, IV J1790
Droperidol and fentanyl citrate up to 2 ml IM, IV J1810
ampule
Droxia ORAL J8999
Drug administered through a metered INH J3535
dose inhaler
DTIC-Dome 100 mg IV J9130
Dua-Gen L.A. 1 mg IM J3121
DuoNeb up to 2.5 mg J7620
Duopa 20 ml J7340
Duoval P.A. 1 mg IM J3121
Durabolin up to 50 mg IM J2320
Duracillin A.S. up to IM, IV J2510
600,000
units
Duraclon 1 mg Epidural J0735
Dura-Estrin up to 5 mg IM J1000
Duragen-10 up to 10 mg IM J1380
Duragen-20 up to 10 mg IM J1380
Duragen-40 up to 10 mg IM J1380
Duralone-40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Duralone-80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Duralutin, see Hydroxyprogesterone
Caproate
Duramorph up to 10 mg IM, IV, SC J2270, J2274
Duratest-100 1 mg J1071
Duratest-200 1 mg J1071
Duratestrin 1 mg J1071
Durathate-200 1 mg IM J3121
Durvalumab 10 mg IV J9173 ◀
Dymenate up to 50 mg IM, IV J1240
Dyphylline up to 500 IM J1180
mg

154
Dysport 5 units J0586
Dalvance 5 mg J0875
E
Ecallantide 1 mg SC J1290
Eculizumab 10 mg IV J1300
Edaravone 1 mg IV J1301 ◀
Edetate calcium disodium up to 1,000 IV, SC, IM J0600
mg
Edetate disodium per 150 mg IV J3520
Elaprase 1 mg J1743
Elavil up to 20 mg IM J1320
Elelyso 10 units J3060
Eligard 7.5 mg J9217
Elitek 0.5 mg J2783
Ellence 2 mg J9178
Elliotts B solution 1 ml OTH J9175
Eloctate per IU J7205
Elosulfase alfa 1 mg IV J1322

155
Elotuzumab 1 mg IV J9176
Eloxatin 0.5 mg J9263
Elspar 10,000 units IV, IM J9020
Emend J1453, J8501
Emete-Con, see Benzquinamide
Eminase 30 units IV J0350
Empliciti 1 mg J9176
Enbrel 25 mg IM, IV J1438
Endrate ethylenediamine-tetra-acetic per 150 mg IV J3520
acid
Enfuvirtide 1 mg SC J1324
Engerix-B J3490
Enovil up to 20 mg IM J1320
Enoxaparin sodium 10 mg SC J1650
Entyvio J3380
Eovist 1 ml A9581
Epinephrine J7799
Epinephrine, adrenalin 0.1 mg SC, IM J0171
Epirubicin hydrochloride 2 mg J9178
Epoetin alfa 100 units IV, SC Q4081
Epoetin alfa, non-ESRD use 1000 units IV J0885
Epoetin alfa, ESRD use 100 mg IV, SC Q5105 ◀
Epoetin alfa, non-ESRD use 1000 units IV Q5106 ◀
Epoetin beta, ESRD use 1 mcg IV J0887
Epoetin beta, non-ESRD use 1 mcg IV J0888
Epogen 1,000 units J0885
Q4081
Epoprostenol 0.5 mg IV J1325
Eptifibatide, injection 5 mg IM, IV J1327
Eraxis 1 mg IV J0348
Erbitux 10 mg J9055
Ergonovine maleate up to 0.2 mg IM, IV J1330
Eribulin mesylate 0.1 mg IV J9179
Erivedge 150 mg J8999
Ertapenem sodium 500 mg IM, IV J1335
Erwinase 1,000 units IV, IM J9019
10,000 units IV, IM J9020
Erythromycin lactobionate 500 mg IV J1364
Estra-D up to 5 mg IM J1000
Estradiol
L.A. up to 10 mg IM J1380

156
 L.A. 20 up to 10 mg IM J1380
L.A. 40 up to 10 mg IM J1380
Estradiol Cypionate up to 5 mg IM J1000
Estradiol valerate up to 10 mg IM J1380
Estra-L 20 up to 10 mg IM J1380
Estra-L 40 up to 10 mg IM J1380
Estra-Testrin 1 mg IM J3121
Estro-Cyp up to 5 mg IM J1000
Estrogen, conjugated per 25 mg IV, IM J1410
Estroject L.A. up to 5 mg IM J1000
Estrone per 1 mg IM J1435
Estrone 5 per 1 mg IM J1435
Estrone Aqueous per 1 mg IM J1435
Estronol per 1 mg IM J1435
Estronol-L.A. up to 5 mg IM J1000
Etanercept, injection 25 mg IM, IV J1438
Etelcalcetide 0.1 mg IV Q4078
Eteplirsen 10 mg IV J1428
Ethamolin 100 mg J1430
Ethanolamine 100 mg J1430, J3490
Ethyol 500 mg IV J0207
Etidronate disodium per 300 mg IV J1436
Etonogestrel implant J7307
Etopophos 10 mg IV J9181
Etoposide 10 mg IV J9181
oral 50 mg ORAL J8560
Euflexxa per dose OTH J7323
Everolimus 0.25 mg ORAL J7527
Everone 1 mg IM J3121
Evomela 50 mg J9245
Eylea 1 mg OTH J0178
F
Fabrazyme 1 mg IV J0180
Factor IX
anti-hemophilic factor, purified, non- per IU IV J7193
recombinant
anti-hemophilic factor, recombinant per IU IV J7195, J7200-
J7202
complex per IU IV J7194
Factor VIIa (coagulation factor, 1 mcg IV J7189
recombinant)
Factor VIII (anti-hemophilic factor)

157
 human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7182, J7185,
J7192, J7188
Factor VIII (anti-hemophilic factor
recombinant)
(Afstyla) per IU IV J7210
(Kovaltry) per IU IV J7211
Factor VIII Fc fusion (recombinant) per IU IV J7205, J7207,
J7209
Factor X (human) per IU IV J7175
Factor XIII A-subunit (recombinant) per IU IV J7181
Factors, other hemophilia clotting per IU IV J7196
Factrel per 100 mcg SC, IV J1620
Famotidine J3490
Faslodex 25 mg J9395
Feiba NF J7198
Feiba VH Immuno per IU IV J7196
Fentanyl citrate 0.1 mg IM, IV J3010
Feraheme 1 mg Q0138,
Q0139
Ferric carboxymaltose 1 mg IV J1439
Ferric pyrophosphate citrate solution 0.1 mg of iron IV J1443
Ferrlecit 12.5 mg J2916
Ferumoxytol 1 mg Q0138,
Q0139
Filgrastim-aafi 1 mcg IV Q5110 ◀
Filgrastim
(G-CSF) 1 mcg SC, IV J1442, Q5101
(TBO) 1 mcg IV J1447
Firazyr 1 mg SC J1744
Firmagon 1 mg J9155
Flebogamma 500 mg IV J1572
1 cc J1460
Flexoject up to 60 mg IV, IM J2360
Flexon up to 60 mg IV, IM J2360
Flolan 0.5 mg IV J1325
Flo-Pred 5 mg J7510
Florbetaben f18, diagnostic per study dose IV Q9983
Floxuridine 500 mg IV J9200
Fluconazole 200 mg IV J1450
Fludara 1 mg ORAL J8562
50 mg IV J9185

158
Fludarabine phosphate 1 mg ORAL J8562
50 mg IV J9185
Flunisolide inhalation solution, unit per mg INH J7641
dose form
Fluocinolone OTH J7311, J7313
Fluorouracil 500 mg IV J9190
Fluphenazine decanoate up to 25 mg J2680
Flutamide J8999
Flutemetamol f18, diagnostic per study dose IV Q9982
Folex 5 mg IA, IM, IT, J9250
IV
50 mg IA, IM, IT, J9260
IV
Folex PFS 5 mg IA, IM, IT, J9250
IV
50 mg IA, IM, IT, J9260
IV
Follutein per 1,000 USP units IM J0725
Folotyn 1 mg J9307
Fomepizole 15 mg J1451
Fomivirsen sodium 1.65 mg Intraocular J1452
Fondaparinux sodium 0.5 mg SC J1652
Formoterol 12 mcg INH J7640
Formoterol fumarate 20 mcg INH J7606
Fortaz per 500 mg IM, IV J0713
Fosaprepitant 1 mg IV J1453
Foscarnet sodium per 1,000 mg IV J1455
Foscavir per 1,000 mg IV J1455
Fosnetupitant 235 mg and palonosetron IV J1454 ◀
0.25 mg
Fosphenytoin 50 mg IV Q2009
Fragmin per 2,500 IU J1645
FUDR 500 mg IV J9200
Fulvestrant 25 mg IM J9395
Fungizone intravenous 50 mg IV J0285
Furomide M.D. up to 20 mg IM, IV J1940
Furosemide up to 20 mg IM, IV J1940
G
Gablofen 10 mg J0475
50 mcg J0476
Gadavist 0.1 ml A9585
Gadoxetate disodium 1 ml IV A9581
Gallium nitrate 1 mg IV J1457

159
Galsulfase 1 mg IV J1458
Gamastan 1 cc IM J1460
over 10 cc IM J1560
Gamma globulin 1 cc IM J1460
over 10 cc IM J1560
Gammagard Liquid 500 mg IV J1569
Gammagard S/D J1566
GammaGraft per square centimeter Q4111
Gammaplex 500 mg IV J1557
Gammar 1 cc IM J1460
over 10 cc IM J1560
Gammar-IV, see Immune globin
intravenous (human)
Gamulin RH
immune globulin, human 100 IU J2791
1 dose package, 300 IM J2790
mcg
immune globulin, human, solvent 100 IU IV J2792
detergent
Gamunex 500 mg IV J1561
Ganciclovir, implant 4.5 mg OTH J7310
Ganciclovir sodium 500 mg IV J1570
Ganirelix J3490
Garamycin, gentamicin up to 80 mg IM, IV J1580
Gastrografin per ml Q9963
Gatifloxacin 10 mg IV J1590
Gazyva 10 mg J9301
Gefitinib 250 mg ORAL J8565
Gel-One per dose OTH J7326
Gemcitabine HCl 200 mg IV J9201
Gemsar 200 mg IV J9201
Gemtuzumab ozogamicin 5 mg IV J9300
Gengraf 100 mg J7502
25 mg ORAL J7515
Genotropin 1 mg J2941
Gentamicin Sulfate up to 80 mg IM, IV J1580, J7699
Gentran 500 ml IV J7100
Gentran 75 500 ml IV J7110
Geodon 10 mg J3486
Gesterol 50 per 50 mg J2675
Glassia 10 mg IV J0257
Glatiramer Acetate 20 mg SC J1595

160
Gleevec (Film-Coated) 400 mg J8999
GlucaGen per 1 mg J1610
Glucagon HCl per 1 mg SC, IM, IV J1610
Glukor per 1,000 USP units IM J0725
Glycopyrrolate
concentrated form per 1 mg INH J7642
unit dose form per 1 mg INH J7643
Gold sodium thiomalate up to 50 mg IM J1600
Golimumab 1 mg IV J1602
Gonadorelin HCl per 100 mcg SC, IV J1620
Gonal-F J3490
Gonic per 1,000 USP units IM J0725
Goserelin acetate implant per 3.6 mg SC J9202
Graftjacket per square centimeter Q4107
Graftjacket Xpress 1 cc Q4113
Granisetron HCl
extended release 0.1 mg IV J1627
injection 100 mcg IV J1626
oral 1 mg ORAL Q0166
Guselkumab 1 mg IV J1628 ◀
Gynogen L.A. A10 up to 10 mg IM J1380
Gynogen L.A. A20 up to 10 mg IM J1380
Gynogen L.A. A40 up to 10 mg IM J1380
H
Halaven 0.1 mg J9179
Haldol up to 5 mg IM, IV J1630
Haloperidol up to 5 mg IM, IV J1630
Haloperidol decanoate per 50 mg IM J1631
Haloperidol Lactate up to 5 mg J1630
Hectoral 1 mcg IV J1270
Helixate FS per IU J7192
Hemin 1 mg J1640
Hemofil M per IU IV J7190
Hemophilia clotting factors (e.g., anti- per IU IV J7198
inhibitors)
NOC per IU IV J7199
Hepagam B 0.5 ml IM J1571
0.5 ml IV J1573
Heparin sodium 1,000 units IV, SC J1644
Heparin sodium (heparin lock flush) 10 units IV J1642
Heparin Sodium (Procine) per 1,000 units J1644

161
Hep-Lock 10 units IV J1642
Hep-Lock U/P 10 units IV J1642
Herceptin 10 mg IV J9355
Hexabrix 320 per ml Q9967
Hexadrol Phosphate 1 mg IM, IV, J1100
OTH
Hexaminolevulinate hydrochloride 100 mg IV A9589 ◀
Histaject per 10 mg IM, SC, IV J0945
Histerone 50 up to 50 mg IM J3140
Histerone 100 up to 50 mg IM J3140
Histrelin
acetate 10 mcg J1675
implant 50 mg OTH J9225, J9226
Hizentra, see Immune globulin
Humalog per 5 units J1815
per 50 units J1817
Human fibrinogen concentrate 100 mg IV J7178
Human fibrinogen concentrate (fibryga) 1 mg IV J7177 ◀
Humate-P per IU J7187
Humatrope 1 mg J2941
Humira 20 mg J0135
Humulin per 5 units J1815
per 50 units J1817
Hyalgan, Spurtaz or VISCO-3 IA J7321
Hyaluronan or derivative per dose IV J7327
Durolane 1 mg IA J7318 ◀
Gel-Syn 0.1 mg IA J7328
Gelsyn-3 0.1 mg IV J7328
Gen Visc 850 1 mg IA J7320
Hymovis 1 mg IA J7322
Trivisc 1 mg IV J7329 ◀
Hyaluronic Acid J3490
Hyaluronidase up to 150 units SC, IV J3470
Hyaluronidase
ovine up to 999 units VAR J3471
ovine per 1000 units VAR J3472
recombinant 1 usp SC J3473
Hyate:C per IU IV J7191
Hybolin Decanoate up to 50 mg IM J2320
Hybolin Improved, see Nandrolone
phenpropionate
Hycamtin 0.25 mg ORAL J8705

162
 4 mg IV J9351
Hydralazine HCl up to 20 mg IV, IM J0360
Hydrate up to 50 mg IM, IV J1240
Hydrea J8999
Hydrocortisone acetate up to 25 mg IV, IM, SC J1700
Hydrocortisone sodium phosphate up to 50 mg IV, IM, SC J1710
Hydrocortisone succinate sodium up to 100 mg IV, IM, SC J1720
Hydrocortone Acetate up to 25 mg IV, IM, SC J1700
Hydrocortone Phosphate up to 50 mg IM, IV, SC J1710
Hydromorphone HCl up to 4 mg SC, IM, IV J1170
Hydroxyprogesterone Caproate 1 mg IM J1725
(Makena) 10 mg IV J1726
NOS 10 mg IV J1729
Hydroxyurea J8999
Hydroxyzine HCl up to 25 mg IM J3410
Hydroxyzine Pamoate 25 mg ORAL Q0177
Hylan G-F 20 OTH J7322
Hylenex 1 USP unit J3473
Hyoscyamine sulfate up to 0.25 mg SC, IM, IV J1980
Hyperrho S/D 300 mcg J2790
100 IU J2792
Hyperstat IV up to 300 mg IV J1730
Hyper-Tet up to 250 units IM J1670
HypRho-D 300 mcg IM J2790
J2791
50 mcg J2788
Hyrexin-50 up to 50 mg IV, IM J1200
Hyzine-50 up to 25 mg IM J3410
I
Ibalizumab-uiyk 10 mg IV J1746 ◀
Ibandronate sodium 1 mg IV J1740
Ibuprofen 100 mg IV J1741
Ibutilide fumarate 1 mg IV J1742
Icatibant 1 mg SC J1744
Idamycin 5 mg IV J9211
Idarubicin HCl 5 mg IV J9211
Idursulfase 1 mg IV J1743
Ifex 1g IV J9208
Ifosfamide 1g IV J9208
Ilaris 1 mg J0638
Iloprost 20 mcg INH Q4074

163
Ilotycin, see Erythromycin gluceptate
Iluvien 0.01 mg J7313
Imferon 50 mg J1750
Imiglucerase 10 units IV J1786
Imitrex 6 mg SC J3030
Imlygic per 1 million plaque J9325, J9999
forming units
Immune globulin
Bivigam 500 mg IV J1556
Cuvitru 100 mg IV J1555
Flebogamma 500 mg IV J1572
Gammagard Liquid 500 mg IV J1569
Gammaplex 500 mg IV J1557
Gamunex 500 mg IV J1561
HepaGam B 0.5 ml IM J1571
0.5 ml IV J1573
Hizentra 100 mg SC J1559
Hyaluronidase, (HYQVIA) 100 mg IV J1575
NOS 500 mg IV J1566, J1599
Octagam 500 mg IV J1568
Privigen 500 mg IV J1459
Rhophylac 100 IU IM J2791
Subcutaneous 100 mg SC J1562
Immunosuppressive drug, not otherwise J7599
classified
Imuran 50 mg ORAL J7500
100 mg IV J7501
Inapsine up to 5 mg IM, IV J1790
Incobotulinumtoxin type A 1 unit IM J0588
Increlex 1 mg J2170
Inderal up to 1 mg IV J1800
Infed 50 mg J1750
Infergen 1 mcg SC J9212
Inflectra Q5102
Infliximab ◀
dyyb 10 mg IM, IV Q5103 ◀
abda 10 mg IM, IV Q5104 ◀
qbtx 10 mg IM, IV Q5109 ◀
Infliximab, injection 10 mg IM, IV J1745, Q5102 ✖
Infumorph 10 mg J2274
Injectafer 1 mg J1439
Injection factor ix, glycopegylated 1 iu IV J7203 ◀

164
Injection sulfur hexafluoride lipid per ml IV Q9950
microspheres
Innohep 1,000 iu SC J1655
Innovar up to 2 ml ampule IM, IV J1810
Inotuzumab orogamicin 0.1 mg IV J9229 ◀
Insulin 5 units SC J1815
Insulin-Humalog per 50 units J1817
Insulin lispro 50 units SC J1817
Intal per 10 mg INH J7631, J7632
Integra
Bilayer Matrix Wound Dressing per square centimeter Q4104
(BMWD)
Dermal Regeneration Template per square centimeter Q4105
(DRT)
Flowable Wound Matrix 1 cc Q4114
Matrix per square centimeter Q4108
Integrilin 5 mg IM, IV J1327
Interferon alfa-2a, recombinant 3 million units SC, IM J9213
Interferon alfa-2b, recombinant 1 million units SC, IM J9214
Interferon alfa-n3 (human leukocyte 250,000 IU IM J9215
derived)
Interferon alphacon-1, recombinant 1 mcg SC J9212
Interferon beta-1a 30 mcg IM J1826
1 mcg IM Q3027
1 mcg SC Q3028
Interferon beta-1b 0.25 mg SC J1830
Interferon gamma-1b 3 million units SC J9216
Intrauterine copper contraceptive OTH J7300
Intron-A 1 million units J9214
Invanz 500 mg J1335
Invega Sustenna 1 mg J2426
Ipilimumab 1 mg IV J9228
Ipratropium bromide, unit dose form per mg INH J3535, J7620,
J7644, J7645
Iressa 250 mg J8565
Irinotecan 20 mg IV J9206, J9205
Iron dextran 50 mg IV, IM J1750
Iron sucrose 1 mg IV J1756
Irrigation solution for Tx of bladder per 50 ml OTH Q2004
calculi
Isavuconazonium 1 mg IV J1833
Isocaine HCl per 10 ml VAR J0670
Isoetharine HCl

165
 concentrated form per mg INH J7647, J7648
unit dose form per mg INH J7649, J7650
Isoproterenol HCl
concentrated form per mg INH J7657, J7658
unit dose form per mg INH J7659, J7660
Isovue per ml Q9966,
Q9967
Istodax 1 mg J9315
Isuprel
concentrated form per mg INH J7657, J7658
unit dose form per mg INH J7659, J7660
Itraconazole 50 mg IV J1835
Ixabepilone 1 mg IV J9207
Ixempra 1 mg J9207
J
Jenamicin up to 80 mg IM, IV J1580
Jetrea 0.125 mg J7316
Jevtana 1 mg J9043
K
Kabikinase per 250,000 IU IV J2995
Kadcyla 1 mg J9354
Kalbitor 1 mg J1290
Kaleinate per 10 ml IV J0610
Kanamycin sulfate up to 75 mg IM, IV J1850
up to 500 mg IM, IV J1840
Kantrex up to 75 mg IM, IV J1850
up to 500 mg IM, IV J1840
Keflin up to 1 g IM, IV J1890
Kefurox per 750 mg J0697
Kefzol 500 mg IV, IM J0690
Kenaject-40 1 mg J3300
per 10 mg IM J3301
Kenalog-10 1 mg J3300
per 10 mg IM J3301
Kenalog-40 1 mg J3300
per 10 mg IM J3301
Kepivance 50 mcg J2425
Keppra 10 mg J1953
Keroxx 1 cc IV Q4202 ◀
Kestrone 5 per 1 mg IM J1435
Ketorolac tromethamine per 15 mg IM, IV J1885

166
Key-Pred 25 up to 1 ml IM J2650
Key-Pred 50 up to 1 ml IM J2650
Key-Pred-SP, see Prednisolone sodium
phosphate
Keytruda 1 mg J9271
K-Flex up to 60 mg IV, IM J2360
Kinevac 5 mcg IV J2805
Kitabis PAK per 300 mg J7682
Klebcil up to 75 mg IM, IV J1850
up to 500 mg IM, IV J1840
Koate-HP (anti-hemophilic factor)
human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7192
Kogenate
human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7192
Konakion per 1 mg IM, SC, IV J3430
Konyne-80 per IU IV J7194
Krystexxa 1 mg J2507
Kyleena 19.5 mg OTH J7296
Kyprolis 1 mg J9047
Kytril 1 mg ORAL Q0166
1 mg IV S0091
100 mcg IV J1626
L
L.A.E. 20 up to 10 mg IM J1380
Laetrile, Amygdalin, vitamin B-17 J3570
Lanoxin up to 0.5 mg IM, IV J1160
Lanreotide 1 mg SC J1930
Lantus per 5 units J1815
Largon, see Propiomazine HCl
Laronidase 0.1 mg IV J1931
Lasix up to 20 mg IM, IV J1940
L-Caine 10 mg IV J2001
Lemtrada 1 mg J0202
Lepirudin 50 mg J1945
Leucovorin calcium per 50 mg IM, IV J0640
Leukeran J8999
Leukine 50mcg IV J2820

167
Leuprolide acetate per 1 mg IM J9218
Leuprolide acetate (for depot per 3.75 mg IM J1950
suspension)
7.5 mg IM J9217
Leuprolide acetate implant 65 mg OTH J9219
Leustatin per mg IV J9065
Levalbuterol HCl
concentrated form 0.5 mg INH J7607, J7612
unit dose form 0.5 mg INH J7614, J7615
Levaquin I.U. 250 mg IV J1956
Levetiracetam 10 mg IV J1953
Levocarnitine per 1 gm IV J1955
Levo-Dromoran up to 2 mg SC, IV J1960
Levofloxacin 250 mg IV J1956
Levoleucovorin calcium 0.5 mg IV J0641
Levonorgestrel implant OTH J7306
Levonorgestrel-releasing intrauterine 52 mg OTH J7297, J7298
contraceptive system
Kyleena 19.5 mg OTH J7296
Levorphanol tartrate up to 2 mg SC, IV J1960
Levsin up to 0.25 mg SC, IM, IV J1980
Levulan Kerastick unit dose (354 mg) OTH J7308
Lexiscan 0.1 mg J2785
Librium up to 100 mg IM, IV J1990
Lidocaine HCl 10 mg IV J2001
Lidoject-1 10 mg IV J2001
Lidoject-2 10 mg IV J2001
Liletta 52 mg OTH J7297
Lincocin up to 300 mg IV J2010
Lincomycin HCl up to 300 mg IV J2010
Linezolid 200 mg IV J2020
Lioresal 10 mg IT J0475
J0476
Liposomal ◀
Cytarabine 2.27 mg IV J9153 ◀
Daunorubicin 1 mg IV J9153 ◀
Liquaemin Sodium 1,000 units IV, SC J1644
LMD (10%) 500 ml IV J7100
Locort 1.5 mg J8540
Lorazepam 2 mg IM, IV J2060
Lovenox 10 mg SC J1650
Loxapine 1 mg OTH J2062 ◀

168
Lucentis 0.1 mg J2778
Lufyllin up to 500 mg IM J1180
Lumason per ml Q9950
Luminal Sodium up to 120 mg IM, IV J2560
Lumizyme 10 mg J0221
Lupon Depot 7.5 mg J9217
3.75 mg J1950
Lupron per 1 mg IM J9218
per 3.75 mg IM J1950
7.5 mg IM J9217
Lyophilized, see Cyclophosphamide,
lyophilized
M
Macugen 0.3 mg J2503
Magnesium sulfate 500 mg J3475
Magnevist per ml A9579
Makena 1 mg J1725
Mannitol 25% in 50 ml IV J2150
5 mg INH J7665
Marcaine J3490
Marinol 2.5 mg ORAL Q0167
Marmine up to 50 mg IM, IV J1240
Matulane 50 mg J8999
Maxipime 500 mg IV J0692
MD-76R per ml Q9963
MD Gastroview per ml Q9963
Mecasermin 1 mg SC J2170
Mechlorethamine HCl (nitrogen 10 mg IV J9230
mustard), HN2
Medralone 40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Medralone 80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Medrol per 4 mg ORAL J7509
Medroxyprogesterone acetate 1 mg IM J1050
Mefoxin 1g IV, IM J0694
Megestrol Acetate J8999
Melphalan HCl 50 mg IV J9245
Melphalan, oral 2 mg ORAL J8600
Menoject LA 1 mg J1071

169
Mepergan injection up to 50 mg IM, IV J2180
Meperidine and promethazine HCl up to 50 mg IM, IV J2180
Meperidine HCl per 100 mg IM, IV, SC J2175
Mepivacaine HCl per 10 ml VAR J0670
Mepolizumab 1 mg IV J2182
Mercaptopurine J8999
Meropenem 100 mg IV J2185
Merrem 100 mg J2185
Mesna 200 mg IV J9209
Mesnex 200 mg IV J9209
Metaprel
concentrated form per 10 mg INH J7667, J7668
unit dose form per 10 mg INH J7669, J7670
Metaproterenol sulfate
concentrated form per 10 mg INH J7667, J7668
unit dose form per 10 mg INH J7669, J7670
Metaraminol bitartrate per 10 mg IV, IM, SC J0380
Metastron per millicurie A9600
Methacholine chloride 1 mg INH J7674
Methadone HCl up to 10 mg IM, SC J1230
Methergine up to 0.2 mg J2210
Methocarbamol up to 10 ml IV, IM J2800
Methotrexate LPF 5mg IV, IM, IT, J9250
IA
50 mg IV, IM, IT, J9260
IA
Methotrexate, oral 2.5 mg ORAL J8610
Methotrexate sodium 5 mg IV, IM, IT, J9250
IA
50 mg IV, IM, IT, J9260
IA
Methyldopate HCl up to 250 mg IV J0210
Methylergonovine maleate up to 0.2 mg J2210
Methylnaltrexone 0.1 mg SC J2212
Methylprednisolone acetate 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Methylprednisolone, oral per 4 mg ORAL J7509
Methylprednisolone sodium succinate up to 40 mg IM, IV J2920
up to 125 mg IM, IV J2930
Metoclopramide HCl up to 10 mg IV J2765
Metrodin 75 IU J3355

170
Metronidazole J3490
Metvixia 1g OTH J7309
Miacalcin up to 400 units SC, IM J0630
Micafungin sodium 1 mg J2248
MicRhoGAM 50 mcg J2788
Midazolam HCl per 1 mg IM, IV J2250
Milrinone lactate 5 mg IV J2260
Minocine 1 mg J2265
Minocycline Hydrochloride 1 mg IV J2265
Mircera 1 mcg J0887, J0888
Mirena 52 mg OTH J7297, J7298
Mithracin 2,500 mcg IV J9270
Mitomycin 0.2 mg Ophthalmic J7315
5 mg IV J9280
Mitosol 0.2 mg Ophthalmic J7315
5 mg IV J9280
Mitoxantrone HCl per 5 mg IV J9293
Monocid, see Cefonicic sodium
Monoclate-P
human per IU IV J7190
porcine per IU IV J7191
Monoclonal antibodies, parenteral 5 mg IV J7505
Mononine per IU IV J7193
Monovisc J7327
Morphine sulfate up to 10 mg IM, IV, SC J2270
preservative-free 10 mg SC, IM, IV J2274
Moxifloxacin 100 mg IV J2280
Mozobil 1 mg J2562
M-Prednisol-40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
M-Prednisol-80 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Mucomyst
unit dose form per gram INH J7604, J7608
Mucosol
injection 100 mg IV J0132
unit dose per gram INH J7604, J7608
MultiHance per ml A9577
MultiHance Multipack per ml A9578

171
Muromonab-CD3 5 mg IV J7505
Muse OTH J0275
1.25 mcg OTH J0270
Mustargen 10 mg IV J9230
Mutamycin
0.2 mg Ophthalmic J7315
5 mg IV J9280
Mycamine 1 mg J2248
Mycophenolate Mofetil 250 mg ORAL J7517
Mycophenolic acid 180 mg ORAL J7518
Myfortic 180 mg J7518
Myleran 1 mg J0594
2 mg ORAL J8510
Mylotarg 5mg IV J9300
Myobloc per 100 units IM J0587
Myochrysine up to 50 mg IM J1600
Myolin up to 60 mg IV, IM J2360
N
Nabilone 1 mg ORAL J8650
Nafcillin J3490
Naglazyme 1 mg J1458
Nalbuphine HCl per 10 mg IM, IV, SC J2300
Naloxone HCl per 1 mg IM, IV, SC J2310, J3490
Naltrexone J3490
Naltrexone, depot form 1 mg IM J2315
Nandrobolic L.A. up to 50 mg IM J2320
Nandrolone decanoate up to 50 mg IM J2320
Narcan 1 mg IM, IV, SC J2310
Naropin 1 mg J2795
Nasahist B per 10mg IM, SC, IV J0945
Nasal vaccine inhalation INH J3530
Natalizumab 1 mg IV J2323
Natrecor 0.1 mg J2325
Navane, see Thiothixene
Navelbine per 10 mg IV J9390
ND Stat per 10 mg IM, SC, IV J0945
Nebcin up to 80 mg IM, IV J3260
NebuPent per 300 mg INH J2545, J7676
Necitumumab 1 mg IV J9295
Nelarabine 50 mg IV J9261
Nembutal Sodium Solution per 50 mg IM, IV, J2515

172
 OTH
Neocyten up to 60 mg IV, IM J2360
Neo-Durabolic up to 50 mg IM J2320
Neoquess up to 20 mg IM J0500
Neoral 100 mg J7502
25 mg J7515
Neosar 100 mg IV J9070
Neostigmine methylsulfate up to 0.5 mg IM, IV, SC J2710
Neo-Synephrine up to 1 ml SC, IM, IV J2370
Nervocaine 1% 10 mg IV J2001
Nervocaine 2% 10 mg IV J2001
Nesacaine per 30 ml VAR J2400
Nesacaine-MPF per 30 ml VAR J2400
Nesiritide 0.1 mg IV J2325
Netupitant 300 mg and palonosetron ORAL J8655
0.5 mg
Neulasta 6 mg J2505
Neumega 5 mg SC J2355
Neupogen
(G-CSF) 1 mcg SC, IV J1442
Neutrexin per 25 mg IV J3305
Nipent per 10 mg IV J9268
Nivolumab 1 mg IV J9299
Nolvadex J8999
Nordryl up to 50mg IV, IM J1200
50mg ORAL Q0163
Norflex up to 60 mg IV, IM J2360
Norzine up to 10 mg IM J3280
Not otherwise classified drugs J3490
other than inhalation solution J7799
administered through DME
inhalation solution administered J7699
through DME
anti-neoplastic J9999
chemotherapeutic ORAL J8999
immunosuppressive J7599
nonchemotherapeutic ORAL J8499
Novantrone per 5 mg IV J9293
Novarel per 1,000 USP Units J0725
Novolin per 5 units J1815
per 50 units J1817
Novolog per 5 units J1815

173
 per 50 units J1817
Novo Seven 1 mcg IV J7189
Novoeight J7182
NPH 5 units SC J1815
Nplate 100 units J0587
10 mcg J2796
Nubain per 10 mg IM, IV, SC J2300
Nulecit 12.5 mg J2916
Nulicaine 10 mg IV J2001
Nulojix 1 mg IV J0485
Numorphan up to 1 mg IV, SC, IM J2410
Numorphan H.P. up to 1 mg IV, SC, IM J2410

174
Nusinersen 0.1 mg IV J2326
Nutropin 1 mg J2941
O
Oasis Burn Matrix per square Q4103
centimeter
Oasis Wound Matrix per square Q4102
centimeter
Obinutuzumab 10 mg J9301
Ocriplasmin 0.125 mg IV J7316
Ocrelizumab 1 mg IV J2350
Octagam 500 mg IV J1568
Octreotide Acetate, injection 1 mg IM J2353
25 mcg IV, SQ J2354
Oculinum per unit IM J0585
Ofatumumab 10 mg IV J9302
Ofev J8499
Ofirmev 10 mg IV J0131
O-Flex up to 60 mg IV, IM J2360
Oforta 10 mg J8562
Olanzapine 1 mg IM J2358
Olaratumab 10 mg IV J9285
Omacetaxine Mepesuccinate 0.01 mg IV J9262
Omalizumab 5 mg SC J2357
Omnipaque per ml Q9965, Q9966,
Q9967
Omnipen-N up to 500 mg IM, IV J0290
per 1.5 gm IM, IV J0295
Omniscan per ml A9579
Omnitrope 1 mg J2941
Omontys 0.1 mg IV, SC J0890
OnabotulinumtoxinA 1 unit IM J0585
Oncaspar per single dose vial IM, IV J9266
Oncovin 1 mg IV J9370
Ondansetron HCI 1 mg IV J2405
1 mg ORAL Q0162
Onivyde 1 mg J9205
Opana up to 1 mg J2410
Opdivo 1 mg J9299
Oprelvekin 5 mg SC J2355
Optimark per ml A9579
Optiray per ml Q9966, Q9967

Optison per ml Q9956

175
Oraminic II per10mg IM, SC, J0945
IV
Orapred per 5 mg ORAL J7510
Orbactiv 10 mg J2407
Orencia 10 mg J0129
Oritavancin 10 mg IV J2407
Ormazine up to 50 mg IM, IV J3230
Orphenadrine citrate up to 60 mg IV, IM J2360
Orphenate up to 60 mg IV, IM J2360
Orthovisc OTH J7324
Or-Tyl up to 20 mg IM J0500
Osmitrol J7799
Ovidrel J3490
Oxacillin sodium up to 250 mg IM, IV J2700
Oxaliplatin 0.5 mg IV J9263
Oxilan per ml Q9967
Oxymorphone HCl up to 1 mg IV, SC, J2410
IM
Oxytetracycline HCl up to 50 mg IM J2460
Oxytocin up to 10 units IV, IM J2590
Ozurdex 0.1 mg J7312
P
Paclitaxel 1 mg IV J9267
Paclitaxel protein-bound particles 1 mg IV J9264
Palifermin 50 mcg IV J2425
Paliperidone Palmitate 1 mg IM J2426
Palonosetron HCl 25 mcg IV J2469
Netupitant 300 mg and palonosetron 0.5 ORAL J8655
mg
Pamidronate disodium per 30 mg IV J2430
Panhematin 1 mg J1640
Panitumumab 10 mg IV J9303
Papaverine HCl up to 60 mg IV, IM J2440
Paragard T 380 A OTH J7300
Paraplatin 50 mg IV J9045
Paricalcitol, injection 1 mcg IV, IM J2501
Pasireotide, long acting 1 mg IV J2502
Pathogen(s) test for platelets OTH P9100
Peforomist 20 mcg J7606
Pegademase bovine 25 IU J2504
Pegaptinib 0.3 mg OTH J2503
Pegaspargase per single dose vial IM, IV J9266

176
Pegasys J3490
Pegfilgrastim 0.5 mg SC J2505
Pegfilgrastim-jmdb 0.5 mg SC Q5108 ◀
Peginesatide 0.1 mg IV, SC J0890
Peg-Intron J3490
Pegloticase 1 mg IV J2507
Pembrolizumab 1 mg IV J9271
Pemetrexed 10 mg IV J9305
Penicillin G Benzathine 100,000 units IM J0561
Penicillin G Benzathine and Penicillin G 100,000 units IM J0558
Procaine
Penicillin G potassium up to 600,000 units IM, IV J2540
Penicillin G procaine, aqueous up to 600,000 units IM, IV J2510
Penicillin G Sodium J3490
Pentam per 300 mg J7676
Pentamidine isethionate per 300 mg INH, J2545, J7676
IM
Pentastarch, 10% 100 ml J2513
Pentazocine HCl 30 mg IM, SC, J3070
IV
Pentobarbital sodium per 50 mg IM, IV, J2515
OTH
Pentostatin per 10 mg IV J9268
Peramivir 1 mg IV J2547
Perjeta 1 mg J9306
Permapen up to 600,000 IM J0561
Perphenazine
Injection up to 5 mg IM, IV J3310
tablets 4 mg ORAL Q0175
Persantine IV per 10 mg IV J1245
Pertuzumab 1 mg IV J9306
Pet Imaging
Fluciclovine F-18, diagnostic 1 millcurie IV A9588
Gallium Ga-68, dotatate, diagnostic 0.1 millicurie IV A9587
Pfizerpen up to 600,000 units IM, IV J2540
Pfizerpen A.S. up to 600,000 units IM, IV J2510
Phenadoz J8498
Phenazine 25 up to 50 mg IM, IV J2550
12.5 mg ORAL Q0169
Phenazine 50 up to 50 mg IM, IV J2550
12.5 mg ORAL Q0169
Phenergan 12.5 mg ORAL Q0169

177
 up to 50 mg IM, IV J2550
J8498
Phenobarbital sodium up to 120 mg IM, IV J2560
Phentolamine mesylate up to 5 mg IM, IV J2760
Phenylephrine HCl up to 1 ml SC, IM, J2370, J7799
IV
Phenytoin sodium per 50 mg IM, IV J1165
Photofrin 75 mg IV J9600
Phytonadione (Vitamin K) per 1 mg IM, SC, J3430
IV
Piperacillin/Tazobactam Sodium, injection 1.125 g IV J2543
Pitocin up to 10 units IV, IM J2590
Plantinol AQ 10 mg IV J9060
Plasma
cryoprecipitate reduced each unit IV P9044
pooled multiple donor, frozen each unit IV P9023, P9070
(single donor), pathogen reduced, frozen each unit IV P9071
Plas+SD each unit IV P9023
Platelets, pheresis, pathogen reduced each unit IV P9073
Pathogen(s) test for platelets OTH P9100
Platinol 10 mg IV, IM J9060
Plerixafor 1 mg SC J2562
Plicamycin 2,500 mcg IV J9270
Polocaine per 10 ml VAR J0670
Polycillin-N up to 500 mg IM, IV J0290
per 1.5 gm IM, IV J0295
Polygam 500 mg J1566
Porfimer Sodium 75 mg IV J9600
Portrazza 1 mg J9295
Positron emission tomography
radiopharmaceutical, diagnostic
for non-tumor identification, NOC IV A9598
for tumor identification, NOC IV A9597
Potassium chloride per 2 mEq IV J3480
Potassium Chloride up to 1,000 cc J7120
Pralatrexate 1 mg IV J9307
Pralidoxime chloride up to 1 g IV, IM, J2730
SC
Predalone-50 up to 1 ml IM J2650
Predcor-25 up to 1 ml IM J2650
Predcor-50 up to 1 ml IM J2650
Predicort-50 up to 1 ml IM J2650

178
Prednisolone acetate up to 1 ml IM J2650
Prednisolone, oral 5 mg ORAL J7510
Prednisone, immediate release or delayed 1 mg ORAL J7512
release
Predoject-50 up to 1 ml IM J2650
Pregnyl per 1,000 USP units IM J0725
Premarin Intravenous per 25 mg IV, IM J1410
Prescription, chemotherapeutic, not ORAL J8999
otherwise specified
Prescription, nonchemotherapeutic, not ORAL J8499
otherwise specified
Prialt 1 mcg J2278
Primacor 5 mg IV J2260
Primatrix per square Q4110
centimeter
Primaxin per 250 mg IV, IM J0743
Priscoline HCl up to 25 mg IV J2670
Privigen 500 mg IV J1459
Probuphine System Kit J0570
Procainamide HCl up to 1 g IM, IV J2690
Prochlorperazine up to 10 mg IM, IV J0780
J8498
Prochlorperazine maleate 5 mg ORAL Q0164
5 mg S0183
Procrit J0885
Q4081
Pro-Depo, see Hydroxyprogesterone
Caproate
Profasi HP per 1,000 USP units IM J0725
Profilnine Heat-Treated
non-recombinant per IU IV J7193
recombinant per IU IU J7195, J7200-
J7202
complex per IU IV J7194
Profonol 10 mg/ml J3490
Progestaject per 50 mg J2675
Progesterone per 50 mg IM J2675
Prograf
oral 1 mg ORAL J7507
parenteral 5mg J7525
Prohance Multipack per ml A9576
Prokine 50 mcg IV J2820
Prolastin 10 mg IV J0256

179
Proleukin per single use vial IM, IV J9015
Prolia 1 mg J0897
Prolixin Decanoate up to 25 mg IM, SC J2680
Promazine HCl up to 25 mg IM J2950
Promethazine J8498
Promethazine HCl
injection up to 50 mg IM, IV J2550
oral 12.5 mg ORAL Q0169
Promethegan J8498
Pronestyl up to 1 g IM, IV J2690
Proplex SX-T
non-recombinant per IU IV J7193
recombinant per IU J7195, J7200-
J7202
complex per IU IV J7194
Proplex T
non-recombinant per IU IV J7193
recombinant per IU J7195, J7200-
J7202
complex per IU IV J7194
Propofol 10 mg IV J2704
Propranolol HCl up to 1 mg IV J1800
Prorex-25
up to 50 mg IM, IV J2550
12.5 mg ORAL Q0169
Prorex-50 up to 50 mg IM, IV J2550
12.5 mg ORAL Q0169
Prostaglandin E1 per 1.25 mcg J0270
Prostaphlin up to 1 g IM, IV J2690
Prostigmin up to 0.5 mg IM, IV, J2710
SC
Prostin VR Pediatric 0.5 mg J0270
Protamine sulfate per 10 mg IV J2720
Protein C Concentrate 10 IU IV J2724
Prothazine up to 50 mg IM, IV J2550
12.5 mg ORAL Q0169
Protirelin per 250 mcg IV J2725
Protonix J3490
Protopam Chloride up to 1 g IV, IM, J2730
SC
Provenge Q2043
Proventil

180
 concentrated form 1 mg INH J7610, J7611
unit dose form 1 mg INH J7609, J7613
Provocholine per 1 mg J7674
Prozine-50 up to 25 mg IM J2950
Pulmicort Respules
concentrated form 0.25 mg INH J7633, J7634
unit does 0.5 mg INH J7626, J7627
Pulmozyme per mg J7639
Pyridoxine HCl 100 mg J3415
Q
Quelicin up to 20 mg IV, IM J0330
Quinupristin/dalfopristin 500 mg (150/350) IV J2770
Qutenza per square cm J7336
R
Ramucirumab 5 mg IV J9308
Ranibizumab 0.1 mg OTH J2778
Ranitidine HCl, injection 25 mg IV, IM J2780
Rapamune 1 mg ORAL J7520
Rasburicase 0.5 mg IV J2783
Rebif 11 mcg Q3026
Reclast 1 mg J3489
Recombinate
human per IU IV J7190
porcine per IU IV J7191
recombinant per IU IV J7192
Recombivax J3490
Redisol up to 1,000 mcg IM, SC J3420
Regadenoson 0.1 mg IV J2785
Regitine up to 5 mg IM, IV J2760
Reglan up to 10 mg IV J2765
Regular 5 units SC J1815
Relefact TRH per 250 mcg IV J2725
Relistor 0.1 mg SC J2212
Remicade 10 mg IM, IV J1745
Remodulin 1 mg J3285
Renflexis Q5102
ReoPro 10 mg IV J0130
Rep-Pred 40 20 mg IM J1020
40 mg IM J1030
80 mg IM J1040
Rep-Pred 80 20 mg IM J1020

181
 40 mg IM J1030
80 mg IM J1040
Resectisol J7799
Reslizumab 1 mg IV J2786
Retavase 18.1 mg IV J2993
Reteplase 18.8 mg IV J2993
Retisert J7311
Retrovir 10 mg IV J3485
Rheomacrodex 500 ml IV J7100
Rhesonativ 300 mcg IM J2790
50 mg J2788
Rheumatrex Dose Pack 2.5 mg ORAL J8610
Rho(D)
immune globulin IM, IV J2791
immune globulin, human 1 dose package/300 IM J2790
mcg
50 mg IM J2788
immune globulin, human, solvent 100 IV, IU J2792
detergent
RhoGAM 300 mcg IM J2790
50 mg J2788
Rhophylac 100 IU IM, IV J2791
Riastap 100 mg J7178
Rifadin J3490
Rifampin J3490
Rilonacept 1 mg SC J2793
RimabotulinumtoxinB 100 units IM J0587
Rimso-50 50 ml J1212
Ringers lactate infusion up to 1,000 cc IV J7120, J7121
Risperdal Costa 0.5 mg J2794
Risperidone 0.5 mg IM J2794
Rituxan 100 mg IV J9310
Rituximab 100 mg IV J9310
Rixubis J7200
Robaxin up to 10 ml IV, IM J2800
Rocephin per 250 mg IV, IM J0696
Roferon-A 3 million units SC, IM J9213
Rolapitant 0.5 mg IV J2797 ◀
Rolapitant, oral, 1 mg 1 mg ORAL J8670
Romidepsin 1 mg IV J9315
Romiplostim 10 mcg SC J2796
Ropivacaine Hydrochloride 1 mg OTH J2795

182
Rubex 10 mg IV J9000
Rubramin PC up to 1,000 mcg IM, SC J3420
S
Saizen 1 mg J2941
Saline solution 10 ml A4216
5% dextrose 500 ml IV J7042
infusion 250 cc IV J7050
1,000 cc IV J7030
sterile 500 ml = 1 unit IV, J7040
OTH
Sandimmune 25 mg ORAL J7515
100 mg ORAL J7502
250 mg OTH J7516
Sandoglobulin, see Immune globin
intravenous (human)
Sandostatin, Lar Depot 25 mcg J2354
1 mg IM J2353
Sargramostim (GM-CSF) 50 mcg IV J2820
Sculptra 0.5 mg IV Q2028
Sebelelipase alfa 1 mg IV J2840
Selestoject per 4 mg IM, IV J0702
Sermorelin acetate 1 mcg SC Q0515
Serostim 1 mg J2941
Signifor LAR 20 ml J2502
Siltuximab 10 mg IV J2860
Simponi Aria 1 mg J1602
Simulect 20 mg J0480
Sincalide 5 mcg IV J2805
Sinografin per ml Q9963
Sinusol-B per 10 mg IM, SC, J0945
IV
Sirolimus 1 mg ORAL J7520
Sivextro 1 mg J3090
Skyla 13.5 mg OTH J7301
Smz-TMP J3490
Sodium Chloride 1,000 cc J7030
500 ml = 1 unit J7040
500 ml A4217
250 cc J7050
Bacteriostatic 10 ml A4216
Sodium Chloride Concentrate J7799
Sodium ferricgluconate in sucrose 12.5 mg J2916

183
Sodium Hyaluronate J3490
Euflexxa J7323
Hyalgan, Spurtaz, Visco-3 J7321 ✖
Orthovisc J7324
Solganal up to 50 mg IM J2910
Soliris 10 mg J1300
Solu-Cortef up to 50 mg IV, IM, J1710
SC
100 mg J1720
Solu-Medrol up to 40 mg IM, IV J2920
up to 125 mg IM, IV J2930
Solurex 1 mg IM, IV, J1100
OTH
Solurex LA 1 mg IM J1094
Somatrem 1 mg SC J2940
Somatropin 1 mg SC J2941
Somatulin Depot 1 mg J1930
Sparine up to 25 mg IM J2950
Spasmoject up to 20 mg IM J0500
Spectinomycin HCl up to 2 g IM J3320
Sporanox 50 mg IV J1835
Staphcillin, see Methicillin sodium
Stelara 1 mg J3357
Stilphostrol 250 mg IV J9165
Streptase 250,000 IU IV J2995
Streptokinase per 250,000 IU, IV J2995
Streptomycin up to 1 g IM J3000
Streptomycin Sulfate up to 1 g IM J3000
Streptozocin 1 gm IV J9320
Strontium-89 chloride per millicurie A9600
Sublimaze 0.1 mg IM, IV J3010
Succinylcholine chloride up to 20 mg IV, IM J0330
Sufentanil Citrate J3490
Sumarel Dosepro 6 mg J3030
Sumatriptan succinate 6 mg SC J3030
Supartz OTH J7321
Supprelin LA 50 mg J9226
Surostrin up to 20 mg IV, IM J0330
Sus-Phrine up to 1 ml ampule SC, IM J0171
Synercid 500 mg (150/350) IV J2770
Synkavite per 1 mg IM, SC, J3430
IV

184
Synribo 0.01 mg J9262
Syntocinon up to 10 units IV, IM J2590
Synvisc and Synvisc-One 1 mg OTH J7325
Syrex 10 ml A4216
Sytobex 1,000 mcg IM, SC J3420
T
Tacrolimus
(Envarsus XR) 0.25 mg ORAL J7503
oral, extended release 0.1 mg ORAL J7508
oral, immediate release 1 mg ORAL J7507
parenteral 5 mg IV J7525
Taliglucerase Alfa 10 units IV J3060
Talimogene laherparepvec per 1 million plaque IV J9325
forming units
Talwin 30 mg IM, SC, J3070
IV
Tamoxifen Citrate J8999
Taractan, see Chlorprothixene
Taxol 1 mg IV J9267
Taxotere 20mg IV J9171
Tazicef per 500 mg J0713
Tazidime, see Ceftazidime Technetium TC per dose A9500
Sestambi
J0713
Tedizolid phosphate 1 mg IV J3090
TEEV 1 mg IM J3121
Teflaro 1 mg J0712
Telavancin 10 mg IV J3095
Temodar 5 mg ORAL J8700, J9328
Temozolomide 1 mg IV J9328
5 mg ORAL J8700
Temsirolimus 1 mg IV J9330
Tenecteplase 1 mg IV J3101
Teniposide 50 mg Q2017
Tepadina 15 mg J9340
Tequin 10 mg IV J1590
Terbutaline sulfate up to 1 mg SC, IV J3105
concentrated form per 1 mg INH J7680
unit dose form per 1 mg INH J7681
Teriparatide 10 mcg SC J3110
Terramycin IM up to 50 mg IM J2460
Testa-C 1 mg J1071

185
Testadiate 1 mg IM J3121
Testadiate-Depo 1 mg J1071
Testaject-LA 1 mg J1071
Testaqua up to 50 mg IM J3140
Test-Estro Cypionates 1 mg J1071
Test-Estro-C 1 mg J1071
Testex up to 100 mg IM J3150
Testo AQ up to 50 mg J3140
Testoject-50 up to 50 mg IM J3140
Testoject-LA 1 mg J1071
Testone
LA 100 1 mg IM J3121
LA 200 1 mg IM J3121
Testopel Pellets J3490
Testosterone Aqueous up to 50 mg IM J3140
Testosterone cypionate 1 mg IM J1071
Testosterone enanthate 1 mg IM J3121
Testosterone undecanoate 1 mg IM J3145
Testradiol 90/4 1 mg IM J3121
Testrin PA 1 mg IM J3121
Testro AQ up to 50 mg J3140
Tetanus immune globulin, human up to 250 units IM J1670
Tetracycline up to 250 mg IM, IV J0120
Thallous Chloride TI-201 per MCI A9505
Theelin Aqueous per 1 mg IM J1435
Theophylline per 40 mg IV J2810
TheraCys per vial IV J9031
Thiamine HCl 100 mg J3411
Thiethylperazine maleate
injection up to 10 mg IM J3280
oral 10 mg ORAL Q0174
Thiotepa 15 mg IV J9340
Thorazine up to 50 mg IM, IV J3230
Thrombate III per IU J7197
Thymoglobulin (see also Immune globin)
anti-thymocyte globulin, equine 250 mg IV J7504
anti-thymocyte globulin, rabbit 25 mg IV J7511
Thypinone per 250 mcg IV J2725
Thyrogen 0.9 mg IM, SC J3240
Thyrotropin Alfa, injection 0.9 mg IM, SC J3240
Tice BCG per vial IV J9031

186
Ticon
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Tigan
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Tigecycline 1 mg IV J3243
Tiject-20
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Tinzaparin 1,000 IU SC J1655
Tirofiban Hydrochloride, injection 0.25 mg IM, IV J3246
TNKase 1 mg IV J3101
Tobi 300 mg INH J7682, J7685
Tobramycin, inhalation solution 300 mg INH J7682, J7685
Tobramycin sulfate up to 80 mg IM, IV J3260
Tocilizumab 1 mg IV J3262
Tofranil, see Imipramine HCl
Tolazoline HCl up to 25 mg IV J2670
Toposar 10 mg J9181
Topotecan 0.25 mg ORAL J8705
0.1 mg IV J9351
Toradol per 15 mg IM, IV J1885
Torecan
injection up to 10 mg IM J3280
oral 10 mg ORAL Q0174
Torisel 1 mg J9330
Tornalate
concentrated form per mg INH J7628
unit dose per mg INH J7629
Torsemide 10 mg/ml IV J3265
Totacillin-N up to 500 mg IM, IV J0290
per 1.5 gm IM, IV J0295
Trabectedin 0.1 mg IV J9352
Trastuzumab 10 mg IV J9355
Treanda 1 mg IV J3490, J9033
Trelstar 3.75 mg J3315
Treprostinil 1 mg J3285, J7686
Trexall 2.5 mg ORAL J8610
Triam-A 1 mg J3300
per 10 mg IM J3301

187
Triamcinolone
concentrated form per 1 mg INH J7683
unit dose per 1 mg INH J7684
Triamcinolone acetonide 1 mg J3300
per 10 mg IM J3301
Triamcinolone acetonide XR 1 mg IM J3304 ◀
Triamcinolone diacetate per 5 mg IM J3302
Triamcinolone hexacetonide per 5 mg VAR J3303
Triesence 1 mg J3300
per 10 mg IM J3301
Triethylene thio-Phosphoramide/T 15 mg J9340
Triflupromazine HCl up to 20 mg IM, IV J3400
Tri-Kort 1 mg J3300
per 10 mg IM J3301
Trilafon 4 mg ORAL Q0175
up to 5 mg IM, IV J3310
Trilog 1 mg J3300
per 10 mg IM J3301
Trilone per 5 mg J3302
Trimethobenzamide HCl
injection up to 200 mg IM J3250
oral 250 mg ORAL Q0173
Trimetrexate glucuronate per 25 mg IV J3305
Triptorelin Pamoate 3.75 mg SC J3315
Triptorelin XR 3.75 mg SC J3316 ◀
Trisenox 1 mg IV J9017
Trobicin up to 2 g IM J3320
Trovan 100 mg IV J0200
Tysabri 1 mg J2323
Tyvaso 1.74 mg J7686
U
Ultravist 240 per ml Q9966
Ultravist 300 per ml Q9967
Ultravist 370 per ml Q9967
Ultrazine-10 up to 10 mg IM, IV J0780
Unasyn per 1.5 gm IM, IV J0295
Unclassified drugs (see also Not elsewhere J3490
classified)
Unclassified drugs or biological used for IV J3591 ◀
ESRD on dialysis
Unspecified oral antiemetic Q0181
Urea up to 40 g IV J3350

188
Ureaphil up to 40 g IV J3350
Urecholine up to 5 mg SC J0520
Urofollitropin 75 IU J3355
Urokinase 5,000 IU vial IV J3364
250,000 IU vial IV J3365
Ustekinumab 1 mg SC J3357
1 mg IV J3358
V
Valcyte J3490
Valergen 10 10 mg IM J1380
Valergen 20 10 mg IM J1380
Valergen 40 up to 10 mg IM J1380
Valertest No. 1 1 mg IM J3121
Valertest No. 2 1 mg IM J3121
Valganciclovir HCL J8499
Valium up to 5 mg IM, IV J3360
Valrubicin, intravesical 200 mg OTH J9357
Valstar 200 mg OTH J9357
Vancocin 500 mg IV, IM J3370
Vancoled 500 mg IV, IM J3370
Vancomycin HCl 500 mg IV, IM J3370
Vantas 50 mg J9226, J9225
Varubi 90 mg J8670
Vasceze per 10 mg J1642
Vasoxyl, see Methoxamine HCl
Vectibix 10 mg J9303
Vedolizumab 1 mg IV J3380
Velaglucerase alfa 100 units IV J3385
Velban 1 mg IV J9360
Velcade 0.1 mg J9041
Veletri 0.5 mg J1325
Velsar 1 mg IV J9360
Venofer 1 mg IV J1756
Ventavis 20 mcg Q4074
Ventolin 0.5 mg INH J7620
concentrated form 1 mg INH J7610, J7611
unit dose form 1 mg INH J7609, J7613
VePesid 50 mg ORAL J8560
Veritas Collagen Matrix J3490
Versed per 1 mg IM, IV J2250
Verteporfin 0.1 mg IV J3396

189
Vesprin up to 20 mg IM, IV J3400
Vestronidase alfa-vjbk 1 mg IV J3397 ◀
VFEND IV 10 mg IV J3465
V-Gan 25 up to 50 mg IM, IV J2550
12.5 mg ORAL Q0169
V-Gan 50 up to 50 mg IM, IV J2550
12.5 mg ORAL Q0169
Viadur 65 mg OTH J9219
Vibativ 10 mg J3095
Vinblastine sulfate 1 mg IV J9360
Vincasar PFS 1 mg IV J9370
Vincristine sulfate 1 mg IV J9370
Vincristine sulfate Liposome 1 mg IV J9371
Vinorelbine tartrate per 10 mg IV J9390
Vispaque per ml Q9966, Q9967
Vistaject-25 up to 25 mg IM J3410
Vistaril up to 25 mg IM J3410
25mg ORAL Q0177
Vistide 375 mg IV J0740
Visudyne 0.1 mg IV J3396
Vitamin B-12 cyanocobalamin up to 1,000 mcg IM, SC J3420
Vitamin K, phytonadione, menadione, per 1 mg IM, SC, J3430
menadiol sodium diphosphate IV
Vitrase per 1 USP unit J3471
Vivaglobin 100 mg J1562
Vivitrol 1 mg J2315
Von Willebrand Factor Complex, human per IU VWF:RCo IV J7187
Wilate per IU VWF IV J7183
Vonvendi per IU VWF IV J7179
Voretigene neparvovec-rzyl 1 billion vector IV J3398 ◀
genomes
Voriconazole 10 mg IV J3465
Vpriv 100 units J3385
W
Wehamine up to 50 mg IM, IV J1240
Wehdryl up to 50 mg IM, IV J1200
50 mg ORAL Q0163
Wellcovorin per 50 mg IM, IV J0640
Wilate per IU IV J7183
Win Rho SD 100 IU IV J2792
Wyamine Sulfate, see Mephentermine
sulfate

190
Wycillin up to 600,000 units IM, IV J2510
Wydase up to 150 units SC, IV J3470
X
Xeloda 150 mg ORAL J8520
500 mg ORAL J8521
Xeomin 1 unit J0588
Xgera 1 mg J0987
Xgeva 1 mg J0897
Xiaflex 0.01 mg J0775
Xolair 5 mg J2357
Xopenex 0.5 mg INH J7620
concentrated form 1 mg INH J7610, J7611,
J7612
unit dose form 1 mg INH J7609, J7613,
J7614
Xylocaine HCl 10 mg IV J2001
Xyntha per IU IV J7185, J7192,
J7182, J7188
Y
Yervoy see Ipilimumab
Yondelis 0.1 mg J9352, J9999
Z
Zaltrap 1 mg J9400
Zanosar 1g IV J9320
Zantac 25 mg IV, IM J2780
Zarxio 1 mcg Q5101
Zemaira 10 mg IV J0256
Zemplar 1 mcg IM, IV J2501
Zenapax 25 mg IV J7513
Zerbaxa 1 gm J0695
Zetran up to 5 mg IM, IV J3360
Ziconotide 1 mcg OTH J2278
Zidovudine 10 mg IV J3485
Zinacef per 750 mg IM, IV J0697
Zinecard per 250 mg J1190
Ziprasidone Mesylate 10 mg IM J3486
Zithromax 1 gm ORAL Q0144
Injection 500 mg IV J0456
Ziv-Aflibercept 1 mg IV J9400
Zmax 1g Q0144
Zofran 1 mg IV J2405
1 mg ORAL Q0162

191
Zoladex per 3.6 mg SC J9202
Zoledronic Acid 1 mg IV J3489
Zolicef 500 mg IV, IM J0690
Zometra 1 mg J3489
Zorbtive 1 mg J2941
Zortress 0.25 mg ORAL J7527
Zosyn 1.125 g IV J2543
Zovirax 5 mg J8499
Zyprexa Relprevv 1 mg J2358
Zyvox 200 mg IV J2020

◀ New Revised ✔ Reinstated deleted Deleted

192
LEVEL II NATIONAL CODES

2019 HCPCS quarterly updates available on the companion website at:

http://www.codingupdates.com

DISCLAIMER
Every effort has been made to make this text complete and accurate, but no guarantee, warranty,
or representation is made for its accuracy or completeness. This text is based on the Centers for
Medicare and Medicaid Services Healthcare Common Procedure Coding System (HCPCS).

193
Do not report HCPCS modifiers with MIPS CPT Category II codes, rather, use Performance
Measurement Modifiers 1P, 2P, 3P, and 8P, as instructed in the CPT guidelines for Category II
codes under “Modifiers.”

LEVEL II NATIONAL MODIFIERS

✽ A1 Dressing for one wound
✽ A2 Dressing for two wounds
✽ A3 Dressing for three wounds
✽ A4 Dressing for four wounds
✽ A5 Dressing for five wounds
✽ A6 Dressing for six wounds
✽ A7 Dressing for seven wounds
✽ A8 Dressing for eight wounds
✽ A9 Dressing for nine or more wounds
❂ AA Anesthesia services performed personally by anesthesiologist
IOM: 100-04, 12, 90.4
❂ AD Medical supervision by a physician: more than four concurrent anesthesia procedures
IOM: 100-04, 12, 90.4
✽ AE Registered dietician
✽ AF Specialty physician
✽ AG Primary physician
❂ AH Clinical psychologist
IOM: 100-04, 12, 170
✽ AI Principal physician of record
❂ AJ Clinical social worker
IOM: 100-04, 12, 170; 100-04, 12, 150
✽ AK Nonparticipating physician
❂ AM Physician, team member service
Not assigned for Medicare
Cross Reference QM
✽ AO Alternate payment method declined by provider of service
✽ AP Determination of refractive state was not performed in the course of diagnostic
ophthalmological examination
✽ AQ Physician providing a service in an unlisted health professional shortage area (HPSA)
✽ AR Physician provider services in a physician scarcity area
✽ AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at
surgery
✽ AT Acute treatment (this modifier should be used when reporting service 98940, 98941,
98942)
✽ AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply
✽ AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic
✽ AW Item furnished in conjunction with a surgical dressing
✽ AX Item furnished in conjunction with dialysis services

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 ✽ AY Item or service furnished to an ESRD patient that is not for the treatment of ESRD
H AZ Physician providing a service in a dental health professional shortage area for the purpose
of an electronic health record incentive payment
✽ BA Item furnished in conjunction with parenteral enteral nutrition (PEN) services
✽ BL Special acquisition of blood and blood products
✽ BO Orally administered nutrition, not by feeding tube
✽ BP The beneficiary has been informed of the purchase and rental options and has elected to
purchase the item
✽ BR The beneficiary has been informed of the purchase and rental options and has elected to
rent the item
✽ BU The beneficiary has been informed of the purchase and rental options and after 30 days
has not informed the supplier of his/her decision
✽ CA Procedure payable only in the inpatient setting when performed emergently on an
outpatient who expires prior to admission
✽ CB Service ordered by a renal dialysis facility (RDF) physician as part of the ESRD
beneficiary’s dialysis benefit, is not part of the composite rate, and is separately
reimbursable
✽ CC Procedure code change (Use CC when the procedure code submitted was changed either
for administrative reasons or because an incorrect code was filed)
❂ CD AMCC test has been ordered by an ESRD facility or MCP physician that is part of the
composite rate and is not separately billable
❂ CE AMCC test has been ordered by an ESRD facility or MCP physician that is a composite
rate test but is beyond the normal frequency covered under the rate and is separately
reimbursable based on medical necessity
❂ CF AMCC test has been ordered by an ESRD facility or MCP physician that is not part of
the composite rate and is separately billable
✽ CG Policy criteria applied
❂ CH 0 percent impaired, limited or restricted
❂ CI At least 1 percent but less than 20 percent impaired, limited or restricted
❂ CJ At least 20 percent but less than 40 percent impaired, limited or restricted
❂ CK At least 40 percent but less than 60 percent impaired, limited or restricted
❂ CL At least 60 percent but less than 80 percent impaired, limited or restricted
❂ CM At least 80 percent but less than 100 percent impaired, limited or restricted
❂ CN 100 percent impaired, limited or restricted
▶ ✽ CO Outpatient occupational therapy services furnished in whole or in part by an occupational
therapy assistant
✽ CR Catastrophe/Disaster related
✽ CS Item or service related, in whole or in part, to an illness, injury, or condition that was
caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf
of Mexico, including but not limited to subsequent clean-up activities
✽ CT Computed tomography services furnished using equipment that does not meet each of
the attributes of the national electrical manufacturers association (NEMA) XR-29-2013
standard
Coding Clinic: 2017, Q1, P6
▶ ✽ CQ Outpatient physical therapy services furnished in whole or in part by a physical therapist
assistant
✽ DA Oral health assessment by a licensed health professional other than a dentist
✽ E1 Upper left, eyelid
Coding Clinic: 2016, Q3, P3

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 ✽ E2 Lower left, eyelid
Coding Clinic: 2016, Q3, P3
✽ E3 Upper right, eyelid
Coding Clinic: 2011, Q3, P6

✽ E4 Lower right, eyelid

❂ EA Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer
chemotherapy
CMS requires claims for non-ESRD ESAs (J0881 and J0885) to include one of three
modifiers: EA, EB, EC.
❂ EB Erythropoetic stimulating agent (ESA) administered to treat anemia due to anti-cancer
radiotherapy
CMS requires claims for non-ESRD ESAs (J0881 and J0885) to include one of three
modifiers: EA, EB, EC.
❂ EC Erythropoetic stimulating agent (ESA) administered to treat anemia not due to anti-
cancer radiotherapy or anti-cancer chemotherapy
CMS requires claims for non-ESRD ESAs (J0881 and J0885) to include one of three
modifiers: EA, EB, EC.
❂ ED Hematocrit level has exceeded 39% (or hemoglobin level has exceeded 13.0 g/dl) for 3 or
more consecutive billing cycles immediately prior to and including the current cycle
❂ EE Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded 13.0 g/dl)
for 3 or more consecutive billing cycles immediately prior to and including the current
cycle
❂ EJ Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate,
infliximab
❂ EM Emergency reserve supply (for ESRD benefit only)
✽ EP Service provided as part of Medicaid early periodic screening diagnosis and treatment
(EPSDT) program
▶ ✽ ER Items and services furnished by a provider-based, off-campus emergency department
✽ ET Emergency services
✽ EX Expatriate beneficiary
✽ EY No physician or other licensed health care provider order for this item or service
Items billed before a signed and dated order has been received by the supplier must be
submitted with an EY modifier added to each related HCPCS code.
✽ F1 Left hand, second digit
✽ F2 Left hand, third digit
✽ F3 Left hand, fourth digit
✽ F4 Left hand, fifth digit
✽ F5 Right hand, thumb
✽ F6 Right hand, second digit
✽ F7 Right hand, third digit
✽ F8 Right hand, fourth digit
✽ F9 Right hand, fifth digit
✽ FA Left hand, thumb
H FB Item provided without cost to provider, supplier or practitioner, or full credit received for
replaced device (examples, but not limited to, covered under warranty, replaced due to
defect, free samples)
❂ FC Partial credit received for replaced device
✽ FP Service provided as part of family planning program

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 ✽ FX X-ray taken using film
Coding Clinic: 2017, Q1, P6
✽ FY X-ray taken using computed radiography technology/cassette-based imaging
▶ ✽ G0 Telehealth services for diagnosis, evaluation, or treatment, of symptoms of an acute stroke
✽ G1 Most recent URR reading of less than 60
IOM: 100-04, 8, 50.9
✽ G2 Most recent URR reading of 60 to 64.9
IOM: 100-04, 8, 50.9
✽ G3 Most recent URR reading of 65 to 69.9
IOM: 100-04, 8, 50.9
✽ G4 Most recent URR reading of 70 to 74.9
IOM: 100-04, 8, 50.9
✽ G5 Most recent URR reading of 75 or greater
IOM: 100-04, 8, 50.9
✽ G6 ESRD patient for whom less than six dialysis sessions have been provided in a month
IOM: 100-04, 8, 50.9
❂ G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life
threatening
IOM: 100-02, 15, 20.1; 100-03, 3, 170.3
✽ G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive
surgical procedure
✽ G9 Monitored anesthesia care for patient who has history of severe cardiopulmonary
condition
✽ GA Waiver of liability statement issued as required by payer policy, individual case
An item/service is expected to be denied as not reasonable and necessary and an ABN is
on file. Modifier GA can be used on either a specific or a miscellaneous HCPCS code.
Modifiers GA and GY should never be reported together on the same line for the same
HCPCS code.
✽ GB Claim being resubmitted for payment because it is no longer covered under a global
payment demonstration
❂ GC This service has been performed in part by a resident under the direction of a teaching
physician
IOM: 100-04, 12, 90.4, 100
✽ GD Units of service exceeds medically unlikely edit value and represents reasonable and
necessary services
❂ GE This service has been performed by a resident without the presence of a teaching
physician under the primary care exception
✽ GF Non-physician (e.g., nurse practitioner (NP), certified registered nurse anesthetist
(CRNA), certified registered nurse (CRN), clinical nurse specialist (CNS), physician
assistant (PA)) services in a critical access hospital
✽ GG Performance and payment of a screening mammogram and diagnostic mammogram on
the same patient, same day
✽ GH Diagnostic mammogram converted from screening mammogram on same day
✽ GJ “Opt out” physician or practitioner emergency or urgent service
✽ GK Reasonable and necessary item/service associated with a GA or GZ modifier
An upgrade is defined as an item that goes beyond what is medically necessary under
Medicare’s coverage requirements. An item can be considered an upgrade even if the
physician has signed an order for it. When suppliers know that an item will not be paid in
full because it does not meet the coverage criteria stated in the LCD, the supplier can still
obtain partial payment at the time of initial determination if the claim is billed using one
of the upgrade modifiers (GK or GL).

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 (https://www.cms.gov/manuals/downloads/clm104c01.pdf)
✽ GL Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no
Advance Beneficiary Notice (ABN)
✽ GM Multiple patients on one ambulance trip
✽ GN Services delivered under an outpatient speech language pathology plan of care
✽ GO Services delivered under an outpatient occupational therapy plan of care
✽ GP Services delivered under an outpatient physical therapy plan of care
✽ GQ Via asynchronous telecommunications system
✽ GR This service was performed in whole or in part by a resident in a department of Veterans
Affairs medical center or clinic, supervised in accordance with VA policy
❂ GS Dosage of erythropoietin-stimulating agent has been reduced and maintained in response
to hematocrit or hemoglobin level
❂ GT Via interactive audio and video telecommunication systems
✽ GU Waiver of liability statement issued as required by payer policy, routine notice
❂ GV Attending physician not employed or paid under arrangement by the patient’s hospice
provider
❂ GW Service not related to the hospice patient’s terminal condition
✽ GX Notice of liability issued, voluntary under payer policy
GX modifier must be submitted with non-covered charges only. This modifier
differentiates from the required uses in conjunction with ABN.
(https://www.cms.gov/manuals/downloads/clm104c01.pdf)
H GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit
or, for non-Medicare insurers, is not a contract benefit
Examples of “statutorily excluded” include: Infusion drug not administered using a
durable infusion pump, a wheelchair that is for use for mobility outside the home or
hearing aids. GA and GY should never be coded together on the same line for the same
HCPCS code. (https://www.cms.gov/manuals/downloads/clm104c01.pdf)
H GZ Item or service expected to be denied as not reasonable or necessary
Used when an ABN is not on file and can be used on either a specific or a miscellaneous
HCPCS code. It would never be correct to place any combination of GY, GZ or GA
modifiers on the same claim line and will result in rejected or denied claim for invalid
coding. (https://www.cms.gov/manuals/downloads/clm104c01.pdf)
H H9 Court-ordered
H HA Child/adolescent program
H HB Adult program, nongeriatric
H HC Adult program, geriatric
H HD Pregnant/parenting women’s program
H HE Mental health program
H HF Substance abuse program
H HG Opioid addiction treatment program
H HH Integrated mental health/substance abuse program
H HI Integrated mental health and intellectual disability/developmental disabilities program
H HJ Employee assistance program
H HK Specialized mental health programs for high-risk populations
H HL Intern
H HM Less than bachelor degree level

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H HN Bachelors degree level
H HO Masters degree level
H HP Doctoral level
H HQ Group setting
H HR Family/couple with client present
H HS Family/couple without client present
H HT Multi-disciplinary team
H HU Funded by child welfare agency
H HV Funded by state addictions agency
H HW Funded by state mental health agency
H HX Funded by county/local agency
H HY Funded by juvenile justice agency
H HZ Funded by criminal justice agency
✽ J1 Competitive acquisition program nopay submission for a prescription number
✽ J2 Competitive acquisition program, restocking of emergency drugs after emergency
administration
✽ J3 Competitive acquisition program (CAP), drug not available through CAP as written,
reimbursed under average sales price methodology
✽ J4 DMEPOS item subject to DMEPOS competitive bidding program that is furnished by a
hospital upon discharge
✽ JA Administered intravenously
This modifier is informational only (not a payment modifier) and may be submitted with
all injection codes. According to Medicare, reporting this modifier is voluntary. (CMS
Pub. 100-04, chapter 8, section 60.2.3.1 and Pub. 100-04, chapter 17, section 80.11)
✽ JB Administered subcutaneously
✽ JC Skin substitute used as a graft
✽ JD Skin substitute not used as a graft
✽ JE Administered via dialysate
✽ JG Drug or biological acquired with 340B drug pricing program discount
✽ JW Drug amount discarded/not administered to any patient
Use JW to identify unused drugs or biologicals from single use vial/package that are
appropriately discarded. Bill on separate line for payment of discarded drug/biological.
IOM: 100-4, 17, 40
Coding Clinic: 2016, Q4, P4-7; 2010, Q3, P10
✽ K0 Lower extremity prosthesis functional Level 0 - does not have the ability or potential to
ambulate or transfer safely with or without assistance and a prosthesis does not enhance
their quality of life or mobility.
✽ K1 Lower extremity prosthesis functional Level 1 - has the ability or potential to use a
prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the
limited and unlimited household ambulator.
✽ K2 Lower extremity prosthesis functional Level 2 - has the ability or potential for ambulation
with the ability to traverse low level environmental barriers such as curbs, stairs or uneven
surfaces. Typical of the limited community ambulator.
✽ K3 Lower extremity prosthesis functional Level 3 - has the ability or potential for ambulation
with variable cadence. Typical of the community ambulator who has the ability to traverse
most environmental barriers and may have vocational, therapeutic, or exercise activity that
demands prosthetic utilization beyond simple locomotion.
✽ K4 Lower extremity prosthesis functional Level 4 - has the ability or potential for prosthetic

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 ambulation that exceeds the basic ambulation skills, exhibiting high impact, stress, or
energy levels, typical of the prosthetic demands of the child, active adult, or athlete.
✽ KA Add on option/accessory for wheelchair
✽ KB Beneficiary requested upgrade for ABN, more than 4 modifiers identified on claim
✽ KC Replacement of special power wheelchair interface
✽ KD Drug or biological infused through DME
✽ KE Bid under round one of the DMEPOS competitive bidding program for use with non-
competitive bid base equipment
✽ KF Item designated by FDA as Class III device
✽ KG DMEPOS item subject to DMEPOS competitive bidding program number 1
✽ KH DMEPOS item, initial claim, purchase or first month rental
✽ KI DMEPOS item, second or third month rental
✽ KJ DMEPOS item, parenteral enteral nutrition (PEN) pump or capped rental, months four
to fifteen
✽ KK DMEPOS item subject to DMEPOS competitive bidding program number 2
✽ KL DMEPOS item delivered via mail
✽ KM Replacement of facial prosthesis including new impression/moulage
✽ KN Replacement of facial prosthesis using previous master model
✽ KO Single drug unit dose formulation
✽ KP First drug of a multiple drug unit dose formulation
✽ KQ Second or subsequent drug of a multiple drug unit dose formulation
✽ KR Rental item, billing for partial month
❂ KS Glucose monitor supply for diabetic beneficiary not treated with insulin
✽ KT Beneficiary resides in a competitive bidding area and travels outside that competitive
bidding area and receives a competitive bid item
✽ KU DMEPOS item subject to DMEPOS competitive bidding program number 3
✽ KV DMEPOS item subject to DMEPOS competitive bidding program that is furnished as
part of a professional service
✽ KW DMEPOS item subject to DMEPOS competitive bidding program number 4
✽ KX Requirements specified in the medical policy have been met
Used for physical, occupational, or speech-language therapy to request an exception to
therapy payment caps and indicate the services are reasonable and necessary and that
there is documentation of medical necessity in the patient’s medical record. (Pub 100-04
Attachment - Business Requirements Centers for Medicare and Medicaid Services,
Transmittal 2457, April 27, 2012)
Medicare requires modifier KX for implanted permanent cardiac pacemakers, single
chamber or duel chamber, for one of the following CPT codes: 33206, 33207, 33208.
✽ KY DMEPOS item subject to DMEPOS competitive bidding program number 5
✽ KZ New coverage not implemented by managed care
✽ LC Left circumflex coronary artery
✽ LD Left anterior descending coronary artery
✽ LL Lease/rental (use the LL modifier when DME equipment rental is to be applied against
the purchase price)
✽ LM Left main coronary artery
✽ LR Laboratory round trip
FDA-monitored intraocular lens implant

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❂ LS
✽ LT Left side (used to identify procedures performed on the left side of the body)
Modifiers LT and RT identify procedures which can be performed on paired organs.
Used for procedures performed on one side only. Should also be used when the
procedures are similar but not identical and are performed on paired body parts.
Coding Clinic: 2016, Q3, P5
✽ M2 Medicare secondary payer (MSP)
✽ MS Six month maintenance and servicing fee for reasonable and necessary parts and labor
which are not covered under any manufacturer or supplier warranty
✽ NB Nebulizer system, any type, FDA-cleared for use with specific drug
✽ NR New when rented (use the NR modifier when DME which was new at the time of rental
is subsequently purchased)
✽ NU New equipment
✽ P1 A normal healthy patient
✽ P2 A patient with mild systemic disease
✽ P3 A patient with severe systemic disease
✽ P4 A patient with severe systemic disease that is a constant threat to life
✽ P5 A moribund patient who is not expected to survive without the operation
✽ P6 A declared brain-dead patient whose organs are being removed for donor purposes
H PA Surgical or other invasive procedure on wrong body part
H PB Surgical or other invasive procedure on wrong patient
H PC Wrong surgery or other invasive procedure on patient
✽ PD Diagnostic or related non diagnostic item or service provided in a wholly owned or
operated entity to a patient who is admitted as an inpatient within 3 days
✽ PI Positron emission tomography (PET) or PET/computed tomography (CT) to inform the
initial treatment strategy of tumors that are biopsy proven or strongly suspected of being
cancerous based on other diagnostic testing
✽ PL Progressive addition lenses
✽ PM Post mortem
✽ PN Non-excepted service provided at an off-campus, outpatient, provider-based department
of a hospital
✽ PO Expected services provided at off-campus, outpatient, provider-based department of a
hospital
✽ PS Positron emission tomography (PET) or PET/computed tomography (CT) to inform the
subsequent treatment strategy of cancerous tumors when the beneficiary’s treating
physician determines that the PET study is needed to inform subsequent antitumor
strategy
✽ PT Colorectal cancer screening test; converted to diagnostic text or other procedure
Assign this modifier with the appropriate CPT procedure code for colonoscopy, flexible
sigmoidoscopy, or barium enema when the service is initiated as a colorectal cancer
screening service but then becomes a diagnostic service. (MLN Matters article MM7012
(PDF, 75 KB) Reference Medicare Transmittal 3232 April 3, 2015.
Coding Clinic: 2011, Q1, P10
❂ Q0 Investigational clinical service provided in a clinical research study that is in an approved
clinical research study
❂ Q1 Routine clinical service provided in a clinical research study that is in an approved clinical
research study
✽ Q2 Demonstration procedure/service
✽ Q3 Live kidney donor surgery and related services

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 ✽ Q4 Service for ordering/referring physician qualifies as a service exemption
❂ Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a
substitute physical therapist furnishing outpatient physical therapy services in a health
professional shortage area, a medically underserved area, or a rural area
IOM: 100-04, 1, 30.2.10
❂ Q6 Service furnished under a fee-for-time compensation arrangement by a substitute
physician or by a substitute physical therapist furnishing outpatient physical therapy
services in a health professional shortage area, a medically underserved area, or a rural area
IOM: 100-04, 1, 30.2.11
✽ Q7 One Class A finding
✽ Q8 Two Class B findings
✽ Q9 One Class B and two Class C findings
▶ ✽ QA Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use
differ and the average of the two amounts is less than 1 liter per minute (lpm)
▶ ✽ QB Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use
differ and the average of the two amounts exceeds 4 liters per minute (lpm) and portable
oxygen is prescribed
✽ QC Single channel monitoring
✽ QD Recording and storage in solid state memory by a digital recorder
✽ QE Prescribed amount of stationary oxygen while at rest is less than 1 liter per minute (LPM)
✽ QF Prescribed amount of stationary oxygen while at rest exceeds 4 liters per minute (LPM)
and portable oxygen is prescribed
✽ QG Prescribed amount of stationary oxygen while at rest is greater than 4 liters per minute
(LPM)
✽ QH Oxygen conserving device is being used with an oxygen delivery system
❂ QJ Services/items provided to a prisoner or patient in state or local custody, however, the
state or local government, as applicable, meets the requirements in 42 CFR 411.4 (B)
❂ QK Medical direction of two, three, or four concurrent anesthesia procedures involving
qualified individuals
IOM: 100-04, 12, 50K, 90
✽ QL Patient pronounced dead after ambulance called
✽ QM Ambulance service provided under arrangement by a provider of services
✽ QN Ambulance service furnished directly by a provider of services
❂ QP Documentation is on file showing that the laboratory test(s) was ordered individually or
ordered as a CPT-recognized panel other than automated profile codes 80002-80019,
G0058, G0059, and G0060.
✽ QQ Ordering professional consulted a qualified clinical decision support mechanism for this
service and the related data was provided to the furnishing professional
▶ ✽ QR Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use
differ and the average of the two amounts is greater than 4 liters per minute (lpm)
❂ QS Monitored anesthesia care service
IOM: 100-04, 12, 30.6, 501
✽ QT Recording and storage on tape by an analog tape recorder
✽ QW CLIA-waived test
✽ QX CRNA service: with medical direction by a physician
❂ QY Medical direction of one certified registered nurse anesthetist (CRNA) by an
anesthesiologist
IOM: 100-04, 12, 50K, 90
CRNA service: without medical direction by a physician

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✽ QZ
✽ RA Replacement of a DME, orthotic or prosthetic item
Contractors will deny claims for replacement parts when furnished in conjunction with
the repair of a capped rental item and billed with modifier RB, including claims for parts
submitted using code E1399, that are billed during the capped rental period (i.e., the last
day of the 13th month of continuous use or before). Repair includes all maintenance,
servicing, and repair of capped rental DME because it is included in the allowed rental
payment amounts. (Pub 100-20 One-Time Notification Centers for Medicare &amp;
Medicaid Services, Transmittal: 901, May 13, 2011)
✽ RB Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair
✽ RC Right coronary artery
✽ RD Drug provided to beneficiary, but not administered “incident-to”
✽ RE Furnished in full compliance with FDA-mandated risk evaluation and mitigation strategy
(REMS)
✽ RI Ramus intermedius coronary artery
✽ RR Rental (use the ‘RR’ modifier when DME is to be rented)
✽ RT Right side (used to identify procedures performed on the right side of the body)
Modifiers LT and RT identify procedures which can be performed on paired organs.
Used for procedures performed on one side only. Should also be used when the
procedures are similar but not identical and are performed on paired body parts.
Coding Clinic: 2016, Q3, P5
H SA Nurse practitioner rendering service in collaboration with a physician
H SB Nurse midwife
✽ SC Medically necessary service or supply
H SD Services provided by registered nurse with specialized, highly technical home infusion
training
H SE State and/or federally funded programs/services
✽ SF Second opinion ordered by a professional review organization (PRO) per Section 9401,
P.L. 99-272 (100% reimbursement – no Medicare deductible or coinsurance)
✽ SG Ambulatory surgical center (ASC) facility service
Only valid for surgical codes. After 1/1/08 not required for ASC facility charges.
H SH Second concurrently administered infusion therapy
H SJ Third or more concurrently administered infusion therapy
H SK Member of high risk population (use only with codes for immunization)
H SL State supplied vaccine
H SM Second surgical opinion
H SN Third surgical opinion
H SQ Item ordered by home health
H SS Home infusion services provided in the infusion suite of the IV therapy provider
H ST Related to trauma or injury
H SU Procedure performed in physician’s office (to denote use of facility and equipment)
H SV Pharmaceuticals delivered to patient’s home but not utilized
✽ SW Services provided by a certified diabetic educator
H SY Persons who are in close contact with member of high-risk population (use only with
codes for immunization)
✽ T1 Left foot, second digit
Left foot, third digit

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✽ T2
✽ T3 Left foot, fourth digit
✽ T4 Left foot, fifth digit
✽ T5 Right foot, great toe
✽ T6 Right foot, second digit
✽ T7 Right foot, third digit
✽ T8 Right foot, fourth digit
✽ T9 Right foot, fifth digit
✽ TA Left foot, great toe
✽ TB Drug or biological acquired with 340B drug pricing program discount, reported for
informational purposes
✽ TC Technical component; under certain circumstances, a charge may be made for the
technical component alone; under those circumstances the technical component charge is
identified by adding modifier TC to the usual procedure number; technical component
charges are institutional charges and not billed separately by physicians; however, portable
x-ray suppliers only bill for technical component and should utilize modifier TC; the
charge data from portable x-ray suppliers will then be used to build customary and
prevailing profiles.
H TD RN
H TE LPN/LVN
H TF Intermediate level of care
H TG Complex/high tech level of care
H TH Obstetrical treatment/services, prenatal or postpartum
H TJ Program group, child and/or adolescent
H TK Extra patient or passenger, nonambulance
H TL Early intervention/individualized family service plan (IFSP)
H TM Individualized education program (IEP)
H TN Rural/outside providers’ customary service area
H TP Medical transport, unloaded vehicle
H TQ Basic life support transport by a volunteer ambulance provider
H TR School-based individual education program (IEP) services provided outside the public
school district responsible for the student
✽ TS Follow-up service
H TT Individualized service provided to more than one patient in same setting
H TU Special payment rate, overtime
H TV Special payment rates, holidays/weekends
H TW Back-up equipment
H U1 Medicaid Level of Care 1, as defined by each State
H U2 Medicaid Level of Care 2, as defined by each State
H U3 Medicaid Level of Care 3, as defined by each State
H U4 Medicaid Level of Care 4, as defined by each State
H U5 Medicaid Level of Care 5, as defined by each State
H U6 Medicaid Level of Care 6, as defined by each State
H U7 Medicaid Level of Care 7, as defined by each State

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H U8 Medicaid Level of Care 8, as defined by each State
H U9 Medicaid Level of Care 9, as defined by each State
H UA Medicaid Level of Care 10, as defined by each State
H UB Medicaid Level of Care 11, as defined by each State
H UC Medicaid Level of Care 12, as defined by each State
H UD Medicaid Level of Care 13, as defined by each State
✽ UE Used durable medical equipment
H UF Services provided in the morning
H UG Services provided in the afternoon
H UH Services provided in the evening
✽ UJ Services provided at night
H UK Services provided on behalf of the client to someone other than the client (collateral
relationship)
✽ UN Two patients served
✽ UP Three patients served
✽ UQ Four patients served
✽ UR Five patients served
✽ US Six or more patients served
✽ V1 Demonstration Modifier 1
✽ V2 Demonstration Modifier 2
✽ V3 Demonstration Modifier 3
✽ V5 Vascular catheter (alone or with any other vascular access)
✽ V6 Arteriovenous graft (or other vascular access not including a vascular catheter)
✽ V7 Arteriovenous fistula only (in use with two needles)
✽ VM Medicare diabetes prevention program (MDPP) virtual make-up session
✽ VP Aphakic patient
✽ X1 Continuous/broad services: for reporting services by clinicians, who provide the principal
care for a patient, with no planned endpoint of the relationship; services in this category
represent comprehensive care, dealing with the entire scope of patient problems, either
directly or in a care coordination role; reporting clinician service examples include, but are
not limited to: primary care, and clinicians providing comprehensive care to patients in
addition to specialty care
✽ X2 Continuous/focused services: for reporting services by clinicians whose expertise is needed
for the ongoing management of a chronic disease or a condition that needs to be managed
and followed with no planned endpoint to the relationship; reporting clinician service
examples include but are not limited to: a rheumatologist taking care of the patient’s
rheumatoid arthritis longitudinally but not providing general primary care services
✽ X3 Episodic/broad services: for reporting services by clinicians who have broad responsibility
for the comprehensive needs of the patient that is limited to a defined period and
circumstance such as a hospitalization; reporting clinician service examples include but are
not limited to the hospitalist’s services rendered providing comprehensive and general
care to a patient while admitted to the hospital
✽ X4 Episodic/focused services: for reporting services by clinicians who provide focused care on
particular types of treatment limited to a defined period and circumstance; the patient has
a problem, acute or chronic, that will be treated with surgery, radiation, or some other
type of generally time-limited intervention; reporting clinician service examples include
but are not limited to, the orthopedic surgeon performing a knee replacement and seeing

205
 the patient through the postoperative period
✽ X5 Diagnostic services requested by another clinician: for reporting services by a clinician
who furnishes care to the patient only as requested by another clinician or subsequent and
related services requested by another clinician; this modifier is reported for patient
relationships that may not be adequately captured by the above alternative categories;
reporting clinician service examples include but are not limited to, the radiologist’s
interpretation of an imaging study requested by another clinician
✽ XE Separate encounter, a service that is distinct because it occurred during a separate
encounter
✽ XP Separate practitioner, a service that is distinct because it was performed by a different
practitioner
✽ XS Separate structure, a service that is distinct because it was performed on a separate
organ/structure
✽ XU Unusual non-overlapping service, the use of a service that is distinct because it does not
overlap usual components of the main service
ZA Novartis/Sandoz ✖
ZB Pfizer/Hospira ✖
ZC Merck/Samsung Bioepis ✖

Ambulance Modifiers
Modifiers that are used on claims for ambulance services are created by combining two alpha
characters. Each alpha character, with the exception of X, represents an origin (source) code or a
destination code. The pair of alpha codes creates one modifier. The first position alpha-code =
origin; the second position alpha-code = destination. On form CMS-1491, used to report
ambulance services, Item 12 should contain the origin code and Item 13 should contain the
destination code. Origin and destination codes and their descriptions are as follows:
D Diagnostic or therapeutic site other than P or H when these are used as origin codes
E Residential, domiciliary, custodial facility (other than an 1819 facility)
G Hospital-based ESRD facility
H Hospital
I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport
J Freestanding ESRD facility
N Skilled nursing facility
P Physician’s office
R Residence
S Scene of accident or acute event
X Intermediate stop at physician’s office on way to hospital (destination code only)

◀ New Revised ✔ Reinstated deleted Deleted H Not covered or valid by Medicare ❂ Special coverage
instructions ✽ Carrier discretion Bill Part B MAC Bill DME MAC MIPS Quantity Physician
Quantity Hospital ♀ Female only ♂ Male only Age DMEPOS A2-Z3 ASC Payment Indicator A-Y
ASC Status Indicator Coding Clinic

206
TRANSPORT SERVICES INCLUDING AMBULANCE (A0000-A0999)
H A0021 Ambulance service, outside state per mile, transport (Medicaid only)
Cross Reference A0030
H A0080 Non-emergency transportation, per mile - vehicle provided by volunteer (individual or organization), with
no vested interest
H A0090 Non-emergency transportation, per mile - vehicle provided by individual (family member, self, neighbor)
with vested interest
H A0100 Non-emergency transportation; taxi
H A0110 Non-emergency transportation and bus, intra- or interstate carrier
H A0120 Non-emergency transportation: mini-bus, mountain area transports, or other transportation systems

H A0130 Non-emergency transportation: wheelchair van

H A0140 Non-emergency transportation and air travel (private or commercial), intra- or interstate
H A0160 Non-emergency transportation: per mile - caseworker or social worker
H A0170 Transportation: ancillary: parking fees, tolls, other
H A0180 Non-emergency transportation: ancillary: lodging - recipient
H A0190 Non-emergency transportation: ancillary: meals - recipient
H A0200 Non-emergency transportation: ancillary: lodging - escort
H A0210 Non-emergency transportation: ancillary: meals - escort
H A0225 Ambulance service, neonatal transport, base rate, emergency transport, one way
H A0380 BLS mileage (per mile)
Cross Reference A0425
H A0382 BLS routine disposable supplies
H A0384 BLS specialized service disposable supplies; defibrillation (used by ALS ambulances and BLS ambulances in
jurisdictions where defibrillation is permitted in BLS ambulances)
H A0390 ALS mileage (per mile)
Cross Reference A0425
H A0392 ALS specialized service disposable supplies; defibrillation (to be used only in jurisdictions where
defibrillation cannot be performed in BLS ambulances)
H A0394 ALS specialized service disposable supplies; IV drug therapy
H A0396 ALS specialized service disposable supplies; esophageal intubation
H A0398 ALS routine disposable supplies
H A0420 Ambulance waiting time (ALS or BLS), one half (½) hour increments

Waiting Time Table

UNITS TIME
1 ½ to 1 hr.
2 1 to 1½ hrs.
3 1½ to 2 hrs.
4 2 to 2½ hrs.
5 2½ to 3 hrs.
6 3 to 3½ hrs.
7 3½ to 4 hrs.
8 4 to 4½ hrs.
9 4½ to 5 hrs.

207
 10 5 to 5½ hrs.

H A0422 Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation
H A0424 Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); (requires medical review)

✽ A0425 Ground mileage, per statute mile

✽ A0426 Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS 1)
✽ A0427 Ambulance service, advanced life support, emergency transport, Level 1 (ALS 1-Emergency)
✽ A0428 Ambulance service, basic life support, non-emergency transport (BLS)
✽ A0429 Ambulance service, basic life support, emergency transport (BLS-Emergency)
✽ A0430 Ambulance service, conventional air services, transport, one way (fixed wing)
✽ A0431 Ambulance service, conventional air services, transport, one way (rotary wing)
✽ A0432 Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company, which is
prohibited by state law from billing third party payers
✽ A0433 Advanced life support, Level 2 (ALS2)
✽ A0434 Specialty care transport (SCT)
✽ A0435 Fixed wing air mileage, per statute mile
✽ A0436 Rotary wing air mileage, per statute mile
H A0888 Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)

MCM: 2125
H A0998 Ambulance response and treatment, no transport
IOM: 100-02, 10, 20
❂ A0999 Unlisted ambulance service
IOM: 100-02, 10, 20

MEDICAL AND SURGICAL SUPPLIES (A4000-A8004)

Injection and Infusion

✽ A4206 Syringe with needle, sterile 1 cc or less, each
✽ A4207 Syringe with needle, sterile 2 cc, each
✽ A4208 Syringe with needle, sterile 3 cc, each
✽ A4209 Syringe with needle, sterile 5 cc or greater, each
H A4210 Needle-free injection device, each
IOM: 100-03, 4, 280.1
❂ A4211 Supplies for self-administered injections
IOM: 100-02, 15, 50
✽ A4212 Non-coring needle or stylet with or without catheter
✽ A4213 Syringe, sterile, 20 cc or greater, each
✽ A4215 Needle, sterile, any size, each
❂ A4216 Sterile water, saline and/or dextrose diluent/flush, 10 ml
Other: Sodium Chloride, Bacteriostatic, Syrex
IOM: 100-02, 15, 50
❂ A4217 Sterile water/saline, 500 ml
Other: Sodium Chloride

208
 IOM: 100-02, 15, 50
❂ A4218 Sterile saline or water, metered dose dispenser, 10 ml
Other: Sodium Chloride
❂ A4220 Refill kit for implantable infusion pump
Do not report with 95990 or 95991 since Medicare payment for these codes includes the refill kit.
IOM: 100-03, 4, 280.1
✽ A4221 Supplies for maintenance of noninsulin drug infusion catheter, per week (list drugs separately)
Includes dressings for catheter site and flush solutions not directly related to drug infusion.
✽ A4222 Infusion supplies for external drug infusion pump, per cassette or bag (list drug separately)
Includes cassette or bag, diluting solutions, tubing and/or administration supplies, port cap changes,
compounding charges, and preparation charges.
✽ A4223 Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately)
IOM: 100-03, 4, 280.1
✽ A4224 Supplies for maintenance of insulin infusion catheter, per week
❂ A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each
IOM: 100-03, 1, 50.3
❂ A4230 Infusion set for external insulin pump, non-needle cannula type
Requires prior authorization and copy of invoice.
IOM: 100-03, 4, 280.1

Figure 1 Insulin pump.

❂ A4231 Infusion set for external insulin pump, needle type

Requires prior authorization and copy of invoice.
IOM: 100-03, 4, 280.1
H A4232 Syringe with needle for external insulin pump, sterile, 3 cc
Reports insulin reservoir for use with external insulin infusion pump (E0784); may be glass or plastic;
includes needle for drawing up insulin. Does not include insulin for use in reservoir.
IOM: 100-03, 4, 280.1

Replacement Batteries
✽ A4233 Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose
monitor owned by patient, each
✽ A4234 Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by
patient, each
✽ A4235 Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by
patient, each

209
 ✽ A4236 Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by
patient, each

Miscellaneous Supplies
✽ A4244 Alcohol or peroxide, per pint
✽ A4245 Alcohol wipes, per box
✽ A4246 Betadine or pHisoHex solution, per pint
✽ A4247 Betadine or iodine swabs/wipes, per box
✽ A4248 Chlorhexidine containing antiseptic, 1 ml
H A4250 Urine test or reagent strips or tablets (100 tablets or strips)
IOM: 100-02, 15, 110
H A4252 Blood ketone test or reagent strip, each
Medicare Statute 1861(n)
❂ A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips
Test strips (1 unit = 50 strips); noninsulin treated (every 3 months) 100 test strips (1×/day testing), 100
lancets (1×/day testing); modifier KS
IOM: 100-03, 1, 40.2
❂ A4255 Platforms for home blood glucose monitor, 50 per box
IOM: 100-03, 1, 40.2
❂ A4256 Normal, low and high calibrator solution/chips
IOM: 100-03, 1, 40.2
✽ A4257 Replacement lens shield cartridge for use with laser skin piercing device, each
❂ A4258 Spring-powered device for lancet, each
IOM: 100-03, 1, 40.2
❂ A4259 Lancets, per box of 100
IOM: 100-03, 1, 40.2
H A4261 Cervical cap for contraceptive use ♀
Medicare Statute 1862A1
❂ A4262 Temporary, absorbable lacrimal duct implant, each
IOM: 100-04, 12, 20.3, 30.4
❂ A4263 Permanent, long term, non-dissolvable lacrimal duct implant, each
Bundled with insertion if performed in physician office.
IOM: 100-04, 12, 30.4
H A4264 Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
Reports the Essure device.
❂ A4265 Paraffin, per pound
IOM: 100-03, 4, 280.1
H A4266 Diaphragm for contraceptive use ♀
H A4267 Contraceptive supply, condom, male, each ♂
H A4268 Contraceptive supply, condom, female, each ♀
H A4269 Contraceptive supply, spermicide (e.g., foam, gel), each
✽ A4270 Disposable endoscope sheath, each
✽ A4280 Adhesive skin support attachment for use with external breast prosthesis, each ♀
✽ A4281 Tubing for breast pump, replacement ♀
✽ A4282 Adapter for breast pump, replacement ♀
✽ A4283 Cap for breast pump bottle, replacement ♀

210
 ✽ A4284 Breast shield and splash protector for use with breast pump, replacement ♀
✽ A4285 Polycarbonate bottle for use with breast pump, replacement ♀
✽ A4286 Locking ring for breast pump, replacement ♀
✽ A4290 Sacral nerve stimulation test lead, each
Service not separately priced by Part B (e.g., services not covered, bundled, used by Part A only)

Implantable Catheters
❂ A4300 Implantable access catheter, (e.g., venous, arterial, epidural subarachnoid, or peritoneal, etc.) external access

IOM: 100-02, 15, 120

✽ A4301 Implantable access total; catheter, port/reservoir (e.g., venous, arterial, epidural, subarachnoid, peritoneal,
etc.)

Disposable Drug Delivery System

✽ A4305 Disposable drug delivery system, flow rate of 50 ml or greater per hour
✽ A4306 Disposable drug delivery system, flow rate of less than 50 ml per hour

Incontinence Appliances and Care Supplies

❂ A4310 Insertion tray without drainage bag and without catheter (accessories only)
IOM: 100-02, 15, 120
❂ A4311 Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating
(Teflon, silicone, silicone elastomer, or hydrophilic, etc.)
IOM: 100-02, 15, 120
❂ A4312 Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone
Must meet criteria for indwelling catheter and medical record must justify need for:
• Recurrent encrustation
• Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120

211
Figure 2 Foley catheter.

❂ A4313 Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous
irrigation
Must meet criteria for indwelling catheter and medical record must justify need for:
• Recurrent encrustation
• Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120
❂ A4314 Insertion tray with drainage bag with indwelling catheter, Foley type, twoway latex with coating (Teflon,
silicone, silicone elastomer or hydrophilic, etc.)
IOM: 100-02, 15, 120
❂ A4315 Insertion tray with drainage bag with indwelling catheter, Foley type, twoway, all silicone
IOM: 100-02, 15, 120
❂ A4316 Insertion tray with drainage bag with indwelling catheter, Foley type, threeway, for continuous irrigation

IOM: 100-02, 15, 120

❂ A4320 Irrigation tray with bulb or piston syringe, any purpose
IOM: 100-02, 15, 120
❂ A4321 Therapeutic agent for urinary catheter irrigation
IOM: 100-02, 15, 120
❂ A4322 Irrigation syringe, bulb, or piston, each
IOM: 100-02, 15, 120
❂ A4326 Male external catheter with integral collection chamber, any type, each ♂
IOM: 100-02, 15, 120
❂ A4327 Female external urinary collection device; meatal cup, each ♀

212
 IOM: 100-02, 15, 120
❂ A4328 Female external urinary collection device; pouch, each ♀
IOM: 100-02, 15, 120
❂ A4330 Perianal fecal collection pouch with adhesive, each
IOM: 100-02, 15, 120
❂ A4331 Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or
urostomy pouch, each
IOM: 100-02, 15, 120
❂ A4332 Lubricant, individual sterile packet, each
IOM: 100-02, 15, 120
❂ A4333 Urinary catheter anchoring device, adhesive skin attachment, each
IOM: 100-02, 15, 120
❂ A4334 Urinary catheter anchoring device, leg strap, each
IOM: 100-02, 15, 120
❂ A4335 Incontinence supply; miscellaneous
IOM: 100-02, 15, 120
❂ A4336 Incontinence supply, urethral insert, any type, each
IOM: 100-02, 15, 120
❂ A4337 Incontinence supply, rectal insert, any type, each
IOM: 100-02, 15, 120
❂ A4338 Indwelling catheter; Foley type, twoway latex with coating (Teflon, silicone, silicone elastomer, or
hydrophilic, etc.), each
IOM: 100-02, 15, 120
❂ A4340 Indwelling catheter; specialty type (e.g., coude, mushroom, wing, etc.), each
Must meet criteria for indwelling catheter and medical record must justify need for:
• Recurrent encrustation
• Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120
❂ A4344 Indwelling catheter, Foley type, twoway, all silicone, each
Must meet criteria for indwelling catheter and medical record must justify need for:
• Recurrent encrustation
• Inability to pass a straight catheter
• Sensitivity to latex
Must be medically necessary.
IOM: 100-02, 15, 120
❂ A4346 Indwelling catheter; Foley type, three way for continuous irrigation, each
IOM: 100-02, 15, 120
❂ A4349 Male external catheter, with or without adhesive, disposable, each ♂
IOM: 100-02, 15, 120
❂ A4351 Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, or
hydrophilic, etc.), each
IOM: 100-02, 15, 120
❂ A4352 Intermittent urinary catheter; coude (curved) tip, with or without coating (Teflon, silicone, silicone
elastomeric, or hydrophilic, etc.), each
IOM: 100-02, 15, 120
❂ A4353 Intermittent urinary catheter, with insertion supplies
IOM: 100-02, 15, 120

213
 ❂ A4354 Insertion tray with drainage bag but without catheter
IOM: 100-02, 15, 120
❂ A4355 Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foley catheter, each

IOM: 100-02, 15, 120

External Urinary Supplies

❂ A4356 External urethral clamp or compression device (not to be used for catheter clamp), each
IOM: 100-02, 15, 120
❂ A4357 Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each

IOM: 100-02, 15, 120

❂ A4358 Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each
IOM: 100-02, 15, 120
❂ A4360 Disposable external urethral clamp or compression device, with pad and/or pouch, each

Figure 3 Ostomy pouch.

Ostomy Supplies
❂ A4361 Ostomy faceplate, each
IOM: 100-02, 15, 120
❂ A4362 Skin barrier; solid, 4 × 4 or equivalent; each
IOM: 100-02, 15, 120
❂ A4363 Ostomy clamp, any type, replacement only, each
❂ A4364 Adhesive, liquid or equal, any type, per oz
Fee schedule category: Ostomy, tracheostomy, and urologicals items.
IOM: 100-02, 15, 120
✽ A4366 Ostomy vent, any type, each
❂ A4367 Ostomy belt, each
IOM: 100-02, 15, 120
✽ A4368 Ostomy filter, any type, each
❂ A4369 Ostomy skin barrier, liquid (spray, brush, etc.), per oz
IOM: 100-02, 15, 120
❂ A4371 Ostomy skin barrier, powder, per oz
IOM: 100-02, 15, 120

214
❂ A4372 Ostomy skin barrier, solid 4 × 4 or equivalent, standard wear, with built-in convexity, each
IOM: 100-02, 15, 120
❂ A4373 Ostomy skin barrier, with flange (solid, flexible, or accordion), with built-in convexity, any size, each

IOM: 100-02, 15, 120

❂ A4375 Ostomy pouch, drainable, with faceplate attached, plastic, each
IOM: 100-02, 15, 120
❂ A4376 Ostomy pouch, drainable, with faceplate attached, rubber, each
IOM: 100-02, 15, 120
❂ A4377 Ostomy pouch, drainable, for use on faceplate, plastic, each
IOM: 100-02, 15, 120
❂ A4378 Ostomy pouch, drainable, for use on faceplate, rubber, each
IOM: 100-02, 15, 120
❂ A4379 Ostomy pouch, urinary, with faceplate attached, plastic, each
IOM: 100-02, 15, 120
❂ A4380 Ostomy pouch, urinary, with faceplate attached, rubber, each
IOM: 100-02, 15, 120
❂ A4381 Ostomy pouch, urinary, for use on faceplate, plastic, each
IOM: 100-02, 15, 120
❂ A4382 Ostomy pouch, urinary, for use on faceplate, heavy plastic, each
IOM: 100-02, 15, 120
❂ A4383 Ostomy pouch, urinary, for use on faceplate, rubber, each
IOM: 100-02, 15, 120
❂ A4384 Ostomy faceplate equivalent, silicone ring, each
IOM: 100-02, 15, 120
❂ A4385 Ostomy skin barrier, solid 4 × 4 or equivalent, extended wear, without built-in convexity, each

IOM: 100-02, 15, 120

❂ A4387 Ostomy pouch closed, with barrier attached, with built-in convexity (1 piece), each
IOM: 100-02, 15, 120
❂ A4388 Ostomy pouch, drainable, with extended wear barrier attached (1 piece), each
IOM: 100-02, 15, 120
❂ A4389 Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each
IOM: 100-02, 15, 120
❂ A4390 Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each

IOM: 100-02, 15, 120

❂ A4391 Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each
IOM: 100-02, 15, 120
❂ A4392 Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each

IOM: 100-02, 15, 120

❂ A4393 Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each

IOM: 100-02, 15, 120

❂ A4394 Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce
IOM: 100-02, 15, 20
❂ A4395 Ostomy deodorant for use in ostomy pouch, solid, per tablet
IOM: 100-02, 15, 20

215
❂ A4396 Ostomy belt with peristomal hernia support
IOM: 100-02, 15, 120
❂ A4397 Irrigation supply; sleeve, each
IOM: 100-02, 15, 120
❂ A4398 Ostomy irrigation supply; bag, each
IOM: 100-02, 15, 120
❂ A4399 Ostomy irrigation supply; cone/catheter, with or without brush
IOM: 100-02, 15, 120
❂ A4400 Ostomy irrigation set
IOM: 100-02, 15, 120
❂ A4402 Lubricant, per ounce
IOM: 100-02, 15, 120
❂ A4404 Ostomy ring, each
IOM: 100-02, 15, 120
❂ A4405 Ostomy skin barrier, non-pectin based, paste, per ounce
IOM: 100-02, 15, 120
❂ A4406 Ostomy skin barrier, pectin-based, paste, per ounce
IOM: 100-02, 15, 120
❂ A4407 Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 × 4
inches or smaller, each
IOM: 100-02, 15, 120
❂ A4408 Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, larger
than 4 × 4 inches, each
IOM: 100-02, 15, 120
❂ A4409 Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, without built-in convexity, 4
× 4 inches or smaller, each
IOM: 100-02, 15, 120
❂ A4410 Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, without built-in convexity,
larger than 4 × 4 inches, each
IOM: 100-02, 15, 120
❂ A4411 Ostomy skin barrier, solid 4 × 4 or equivalent, extended wear, with built-in convexity, each
❂ A4412 Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), without filter, each

IOM: 100-02, 15, 120

❂ A4413 Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), with filter, each

IOM: 100-02, 15, 120

❂ A4414 Ostomy skin barrier, with flange (solid, flexible, or accordion), without built-in convexity, 4 × 4 inches or
smaller, each
IOM: 100-02, 15, 120
❂ A4415 Ostomy skin barrier, with flange (solid, flexible, or accordion), without built-in convexity, larger than 4 × 4
inches, each
IOM: 100-02, 15, 120
✽ A4416 Ostomy pouch, closed, with barrier attached, with filter (1 piece), each
✽ A4417 Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each

✽ A4418 Ostomy pouch, closed; without barrier attached, with filter (1 piece), each
✽ A4419 Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each

✽ A4420 Ostomy pouch, closed; for use on barrier with locking flange (2 piece), each

216
 ✽ A4421 Ostomy supply; miscellaneous
❂ A4422 Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thicken liquid stomal
output, each
IOM: 100-02, 15, 120
✽ A4423 Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each
✽ A4424 Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each
✽ A4425 Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each

✽ A4426 Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each
✽ A4427 Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each

✽ A4428 Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each

✽ A4429 Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1
piece), each
✽ A4430 Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap
with valve (1 piece), each
✽ A4431 Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each
✽ A4432 Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece),
each
✽ A4433 Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each
✽ A4434 Ostomy pouch, urinary; for use on barrier with locking flange, with faucettype tap with valve (2 piece), each

✽ A4435 Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without
filter, each

Miscellaneous Supplies
❂ A4450 Tape, non-waterproof, per 18 square inches
If used with surgical dressings, billed with AW modifier (in addition to appropriate A1-A9 modifier).
IOM: 100-02, 15, 120
❂ A4452 Tape, waterproof, per 18 square inches
If used with surgical dressings, billed with AW modifier (in addition to appropriate A1-A9 modifier).
IOM: 100-02, 15, 120
❂ A4455 Adhesive remover or solvent (for tape, cement or other adhesive), per ounce
IOM: 100-02, 15, 120
❂ A4456 Adhesive remover, wipes, any type, each
May be reimbursed for male or female clients to home health DME providers and DME medical suppliers
in the home setting.
IOM: 100-02, 15, 120
✽ A4458 Enema bag with tubing, reusable
✽ A4459 Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type

✽ A4461 Surgical dressing holder, non-reusable, each

✽ A4463 Surgical dressing holder, reusable, each
✽ A4465 Non-elastic binder for extremity
H A4467 Belt, strap, sleeve, garment, or covering, any type
❂ A4470 Gravlee jet washer
Symptoms suggestive of endometrial disease must be present for this disposable diagnostic tool to be

217
 covered.
IOM: 100-02, 16, 90; 100-03, 4, 230.5
❂ A4480 VABRA aspirator
Symptoms suggestive of endometrial disease must be present for this disposable diagnostic tool to be
covered.
IOM: 100-02, 16, 90; 100-03, 4, 230.6
❂ A4481 Tracheostoma filter, any type, any size, each
IOM: 100-02, 15, 120
❂ A4483 Moisture exchanger, disposable, for use with invasive mechanical ventilation
IOM: 100-02, 15, 120
H A4490 Surgical stockings above knee length, each
IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1
H A4495 Surgical stockings thigh length, each
IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1
H A4500 Surgical stockings below knee length, each
IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1
H A4510 Surgical stockings full length, each
IOM: 100-02, 15, 100; 100-02, 15, 110; 100-03, 4, 280.1
H A4520 Incontinence garment, any type (e.g., brief, diaper), each
IOM: 100-03, 4, 280.1
❂ A4550 Surgical trays
No longer payable by Medicare; included in practice expense for procedures. Some private payers may pay,
most private payers follow Medicare guidelines.
IOM: 100-04, 12, 20.3, 30.4
H A4553 Non-disposable underpads, all sizes
IOM: 100-03, 4, 280.1
H A4554 Disposable underpads, all sizes
IOM: 100-03, 4, 280.1
H A4555 Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only

✽ A4556 Electrodes (e.g., apnea monitor), per pair

✽ A4557 Lead wires (e.g., apnea monitor), per pair
✽ A4558 Conductive gel or paste, for use with electrical device (e.g., TENS, NMES), per oz
✽ A4559 Coupling gel or paste, for use with ultrasound device, per oz
✽ A4561 Pessary, rubber, any type ♀
✽ A4562 Pessary, non-rubber, any type ♀
▶ ✽ A4563 Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories,
any type each
✽ A4565 Slings
H A4566 Shoulder sling or vest design, abduction restrainer, with or without swathe control, prefabricated, includes
fitting and adjustment
H A4570 Splint
IOM: 100-02, 6, 10; 100-02, 15, 100; 100-04, 4, 240
✽ A4575 Topical hyperbaric oxygen chamber, disposable
H A4580 Cast supplies (e.g., plaster)
IOM: 100-02, 6, 10; 100-02, 15, 100; 100-04, 4, 240
H A4590 Special casting material (e.g., fiberglass)
IOM: 100-02, 6, 10; 100-02, 15, 100; 100-04, 4, 240

218
 ❂ A4595 Electrical stimulator supplies, 2 lead, per month (e.g., TENS, NMES)
IOM: 100-03, 2, 160.13
✽ A4600 Sleeve for intermittent limb compression device, replacement only, each

Figure 4 Arm sling.

✽ A4601 Lithium ion battery, rechargeable, for non-prosthetic use, replacement

✽ A4602 Replacement battery for external infusion pump owned by patient, lithium, 1.5 volt, each
✽ A4604 Tubing with integrated heating element for use with positive airway pressure device
✽ A4605 Tracheal suction catheter, closed system, each
✽ A4606 Oxygen probe for use with oximeter device, replacement
✽ A4608 Transtracheal oxygen catheter, each

Supplies for Respiratory and Oxygen Equipment

H A4611 Battery, heavy duty; replacement for patient owned ventilator
Medicare Statute 1834(a)(3)(a)
H A4612 Battery cables; replacement for patientowned ventilator
Medicare Statute 1834(a)(3)(a)
H A4613 Battery charger; replacement for patient-owned ventilator
Medicare Statute 1834(a)(3)(a)
✽ A4614 Peak expiratory flow rate meter, hand held
❂ A4615 Cannula, nasal
IOM: 100-03, 2, 160.6; 100-04, 20, 100.2
❂ A4616 Tubing (oxygen), per foot
IOM: 100-03, 2, 160.6; 100-04, 20, 100.2

219
Figure 5 Nasal cannula.

❂ A4617 Mouth piece

IOM: 100-03, 2, 160.6; 100-04, 20, 100.2
❂ A4618 Breathing circuits
IOM: 100-03, 2, 160.6; 100-04, 20, 100.2
❂ A4619 Face tent
IOM: 100-03, 2, 160.6; 100-04, 20, 100.2
❂ A4620 Variable concentration mask
IOM: 100-03, 2, 160.6; 100-04, 20, 100.2
❂ A4623 Tracheostomy, inner cannula
IOM: 100-02, 15, 120; 100-03, 1, 20.9
✽ A4624 Tracheal suction catheter, any type, other than closed system, each
Sterile suction catheters are medically necessary only for tracheostomy suctioning. Limitations include three
suction catheters per day when covered for medically necessary tracheostomy suctioning. Assign DX V44.0
or V55.0 on the claim form. (CMS Manual System, Pub. 100-3, NCD manual, Chapter 1, Section 280-1)
❂ A4625 Tracheostomy care kit for new tracheostomy
Dressings used with tracheostomies are included in the allowance for the code. This starter kit is covered
after a surgical tracheostomy.
(https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/tracheostomy_care_supplies.htm
IOM: 100-02, 15, 120
❂ A4626 Tracheostomy cleaning brush, each
IOM: 100-02, 15, 120
H A4627 Spacer, bag, or reservoir, with or without mask, for use with metered dose inhaler
IOM: 100-02, 15, 110

220
Figure 6 Tracheostomy cannula.

✽ A4628 Oropharyngeal suction catheter, each

No more than three catheters per week are covered for medically necessary oropharyngeal suctioning because
the catheters can be reused if cleansed and disinfected. (MS Manual System, Pub. 100-3, NCD manual,
Chapter 1, Section 280-1)
❂ A4629 Tracheostomy care kit for established tracheostomy
IOM: 100-02, 15, 120

Replacement Parts
❂ A4630 Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient
IOM: 100-03, 3, 160.7
✽ A4633 Replacement bulb/lamp for ultraviolet light therapy system, each
✽ A4634 Replacement bulb for therapeutic light box, tabletop model
❂ A4635 Underarm pad, crutch, replacement, each
IOM: 100-03, 4, 280.1
❂ A4636 Replacement, handgrip, cane, crutch, or walker, each
IOM: 100-03, 4, 280.1
❂ A4637 Replacement, tip, cane, crutch, walker, each
IOM: 100-03, 4, 280.1
✽ A4638 Replacement battery for patientowned ear pulse generator, each
✽ A4639 Replacement pad for infrared heating pad system, each
❂ A4640 Replacement pad for use with medically necessary alternating pressure pad owned by patient
IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3

Supplies for Radiological Procedures

✽ A4641 Radiopharmaceutical, diagnostic, not otherwise classified
Is not an applicable tracer for PET scans
✽ A4642 Indium In-111 satumomab pendetide, diagnostic, per study dose, up to 6 millicuries

Miscellaneous Supplies
✽ A4648 Tissue marker, implantable, any type, each
Coding Clinic: 2018, Q2, P4,5; 2013, Q3, P9

✽ A4649 Surgical supply miscellaneous

221
 ✽ A4650 Implantable radiation dosimeter, each
❂ A4651 Calibrated microcapillary tube, each
IOM: 100-04, 3, 40.3
❂ A4652 Microcapillary tube sealant
IOM: 100-04, 3, 40.3

Supplies for Dialysis

✽ A4653 Peritoneal dialysis catheter anchoring device, belt, each
❂ A4657 Syringe, with or without needle, each
IOM: 100-04, 8, 90.3.2
❂ A4660 Sphygmomanometer/blood pressure apparatus with cuff and stethoscope
IOM: 100-04, 8, 90.3.2
❂ A4663 Blood pressure cuff only
IOM: 100-04, 8, 90.3.2
H A4670 Automatic blood pressure monitor
IOM: 100-04, 8, 90.3.2
❂ A4671 Disposable cycler set used with cycler dialysis machine, each
IOM: 100-04, 8, 90.3.2
❂ A4672 Drainage extension line, sterile, for dialysis, each
IOM: 100-04, 8, 90.3.2
❂ A4673 Extension line with easy lock connectors, used with dialysis
IOM: 100-04, 8, 90.3.2
❂ A4674 Chemicals/antiseptics solution used to clean/sterilize dialysis equipment, per 8 oz
IOM: 100-04, 8, 90.3.2
❂ A4680 Activated carbon filters for hemodialysis, each
IOM: 100-04, 8, 90.3.2
❂ A4690 Dialyzers (artificial kidneys), all types, all sizes, for hemodialysis, each
IOM: 100-04, 8, 90.3.2
❂ A4706 Bicarbonate concentrate, solution, for hemodialysis, per gallon
IOM: 100-04, 8, 90.3.2
❂ A4707 Bicarbonate concentrate, powder, for hemodialysis, per packet
IOM: 100-04, 8, 90.3.2
❂ A4708 Acetate concentrate solution, for hemodialysis, per gallon
IOM: 100-04, 8, 90.3.2
❂ A4709 Acid concentrate, solution, for hemodialysis, per gallon
IOM: 100-04, 8, 90.3.2
❂ A4714 Treated water (deionized, distilled, or reverse osmosis) for peritoneal dialysis, per gallon
IOM: 100-03, 4, 230.7; 100-04, 3, 40.3
❂ A4719 “Y set” tubing for peritoneal dialysis
IOM: 100-04, 8, 90.3.2
❂ A4720 Dialysate solution, any concentration of dextrose, fluid volume greater than 249 cc, but less than or equal to
999 cc, for peritoneal dialysis
Do not use AX modifier.
IOM: 100-04, 8, 90.3.2
❂ A4721 Dialysate solution, any concentration of dextrose, fluid volume greater than 999 cc but less than or equal to
1999 cc, for peritoneal dialysis
IOM: 100-04, 8, 90.3.2
❂ A4722 Dialysate solution, any concentration of dextrose, fluid volume greater than 1999 cc but less than or equal to

222
 2999 cc, for peritoneal dialysis
IOM: 100-04, 8, 90.3.2
❂ A4723 Dialysate solution, any concentration of dextrose, fluid volume greater than 2999 cc but less than or equal to
3999 cc, for peritoneal dialysis
IOM: 100-04, 8, 90.3.2
❂ A4724 Dialysate solution, any concentration of dextrose, fluid volume greater than 3999 cc but less than or equal to
4999 cc for peritoneal dialysis
IOM: 100-04, 8, 90.3.2
❂ A4725 Dialysate solution, any concentration of dextrose, fluid volume greater than 4999 cc but less than or equal to
5999 cc, for peritoneal dialysis
IOM: 100-04, 8, 90.3.2
❂ A4726 Dialysate solution, any concentration of dextrose, fluid volume greater than 5999 cc, for peritoneal dialysis

IOM: 100-04, 8, 90.3.2

✽ A4728 Dialysate solution, non-dextrose containing, 500 ml
❂ A4730 Fistula cannulation set for hemodialysis, each
IOM: 100-04, 8, 90.3.2
❂ A4736 Topical anesthetic, for dialysis, per gram
IOM: 100-04, 8, 90.3.2
❂ A4737 Injectable anesthetic, for dialysis, per 10 ml
IOM: 100-04, 8, 90.3.2
❂ A4740 Shunt accessory, for hemodialysis, any type, each
IOM: 100-04, 8, 90.3.2
❂ A4750 Blood tubing, arterial or venous, for hemodialysis, each
IOM: 100-04, 8, 90.3.2
❂ A4755 Blood tubing, arterial and venous combined, for hemodialysis, each
IOM: 100-04, 8, 90.3.2
❂ A4760 Dialysate solution test kit, for peritoneal dialysis, any type, each
IOM: 100-04, 8, 90.3.2
❂ A4765 Dialysate concentrate, powder, additive for peritoneal dialysis, per packet
IOM: 100-04, 8, 90.3.2
❂ A4766 Dialysate concentrate, solution, additive for peritoneal dialysis, per 10 ml
IOM: 100-04, 8, 90.3.2
❂ A4770 Blood collection tube, vacuum, for dialysis, per 50
IOM: 100-04, 8, 90.3.2
❂ A4771 Serum clotting time tube, for dialysis, per 50
IOM: 100-04, 8, 90.3.2
❂ A4772 Blood glucose test strips, for dialysis, per 50
IOM: 100-04, 8, 90.3.2
❂ A4773 Occult blood test strips, for dialysis, per 50
IOM: 100-04, 8, 90.3.2
❂ A4774 Ammonia test strips, for dialysis, per 50
IOM: 100-04, 8, 90.3.2
❂ A4802 Protamine sulfate, for hemodialysis, per 50 mg
IOM: 100-04, 8, 90.3.2
❂ A4860 Disposable catheter tips for peritoneal dialysis, per 10
IOM: 100-04, 8, 90.3.2
❂ A4870 Plumbing and/or electrical work for home hemodialysis equipment

223
 IOM: 100-04, 8, 90.3.2
❂ A4890 Contracts, repair and maintenance, for hemodialysis equipment
IOM: 100-02, 15, 110.2
❂ A4911 Drain bag/bottle, for dialysis, each
❂ A4913 Miscellaneous dialysis supplies, not otherwise specified
Items not related to dialysis must not be billed with the miscellaneous codes A4913 or E1699.
❂ A4918 Venous pressure clamp, for hemodialysis, each
❂ A4927 Gloves, non-sterile, per 100
❂ A4928 Surgical mask, per 20
❂ A4929 Tourniquet for dialysis, each
❂ A4930 Gloves, sterile, per pair
✽ A4931 Oral thermometer, reusable, any type, each
✽ A4932 Rectal thermometer, reusable, any type, each

Additional Ostomy Supplies

❂ A5051 Ostomy pouch, closed; with barrier attached (1 piece), each
IOM: 100-02, 15, 120
❂ A5052 Ostomy pouch, closed; without barrier attached (1 piece), each
IOM: 100-02, 15, 120
❂ A5053 Ostomy pouch, closed; for use on faceplate, each
IOM: 100-02, 15, 120
❂ A5054 Ostomy pouch, closed; for use on barrier with flange (2 piece), each
IOM: 100-02, 15, 120
❂ A5055 Stoma cap
IOM: 100-02, 15, 120
❂ A5056 Ostomy pouch, drainable, with extended wear barrier attached, with filter (1 piece), each
IOM: 100-02, 15, 120
❂ A5057 Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter (1 piece),
each
IOM: 100-02, 15, 120
✽ A5061 Ostomy pouch, drainable; with barrier attached (1 piece), each
IOM: 100-02, 15, 120
❂ A5062 Ostomy pouch, drainable; without barrier attached (1 piece), each
IOM: 100-02, 15, 120
❂ A5063 Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each
IOM: 100-02, 15, 120
❂ A5071 Ostomy pouch, urinary; with barrier attached (1 piece), each
IOM: 100-02, 15, 120
❂ A5072 Ostomy pouch, urinary; without barrier attached (1 piece), each
IOM: 100-02, 15, 120
❂ A5073 Ostomy pouch, urinary; for use on barrier with flange (2 piece), each
IOM: 100-02, 15, 120
❂ A5081 Stoma plug or seal, any type
IOM: 100-02, 15, 120
❂ A5082 Continent device; catheter for continent stoma
IOM: 100-02, 15, 120
✽ A5083 Continent device, stoma absorptive cover for continent stoma

224
 ❂ A5093 Ostomy accessory; convex insert
IOM: 100-02, 15, 120

Additional Incontinence and Ostomy Supplies

❂ A5102 Bedside drainage bottle with or without tubing, rigid or expandable, each
IOM: 100-02, 15, 120
❂ A5105 Urinary suspensory, with leg bag, with or without tube, each
IOM: 100-02, 15, 120
❂ A5112 Urinary drainage bag, leg bag, leg or abdomen, latex, with or without tube, with straps, each
IOM: 100-02, 15, 120
❂ A5113 Leg strap; latex, replacement only, per set
IOM: 100-02, 15, 120
❂ A5114 Leg strap; foam or fabric, replacement only, per set
IOM: 100-02, 15, 120
❂ A5120 Skin barrier, wipes or swabs, each
IOM: 100-02, 15, 120
❂ A5121 Skin barrier; solid, 6 × 6 or equivalent, each
IOM: 100-02, 15, 120
❂ A5122 Skin barrier; solid, 8 × 8 or equivalent, each
IOM: 100-02, 15, 120
❂ A5126 Adhesive or non-adhesive; disk or foam pad
IOM: 100-02, 15, 120
❂ A5131 Appliance cleaner, incontinence and ostomy appliances, per 16 oz
IOM: 100-02, 15, 120
❂ A5200 Percutaneous catheter/tube anchoring device, adhesive skin attachment
IOM: 100-02, 15, 120

Diabetic Shoes, Fitting, and Modifications

❂ A5500 For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay
shoe manufactured to accommodate multi-density insert(s), per shoe
IOM: 100-02, 15, 140
❂ A5501 For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s)
of patient’s foot (custom-molded shoe), per shoe
The diabetic patient must have at least one of the following conditions: peripheral neuropathy with evidence
of callus formation, pre-ulcerative calluses, previous ulceration, foot deformity, previous amputation or poor
circulation.
IOM: 100-02, 15, 140
❂ A5503 For diabetics only, modification (including fitting) of off-the-shelf depthinlay shoe or custom-molded shoe
with roller or rigid rocker bottom, per shoe
IOM: 100-02, 15, 140
❂ A5504 For diabetics only, modification (including fitting) of off-the-shelf depthinlay shoe or custom-molded shoe
with wedge(s), per shoe
IOM: 100-02, 15, 140
❂ A5505 For diabetics only, modification (including fitting) of off-the-shelf depthinlay shoe or custom-molded shoe
with metatarsal bar, per shoe
IOM: 100-02, 15, 140
❂ A5506 For diabetics only, modification (including fitting) of off-the-shelf depthinlay shoe or custom-molded shoe
with off-set heel(s), per shoe
IOM: 100-02, 15, 140

225
 ❂ A5507 For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe
or custom-molded shoe, per shoe
Only used for not otherwise specified therapeutic modifications to shoe or for repairs to a diabetic shoe(s)
IOM: 100-02, 15, 140
❂ A5508 For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custommolded shoe, per shoe

IOM: 100-02, 15, 40

❂ A5510 For diabetics only, direct formed, compression molded to patient’s foot without external heat source,
multipledensity insert(s) prefabricated, per shoe
IOM: 100-02, 15, 140
✽ A5512 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230
degrees Fahrenheit or higher, total contact with patient’s foot, including arch, base layer minimum of 1/4
inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher),
prefabricated, each
✽ A5513 For diabetics only, multiple density insert, custom molded from model of patient’s foot, total contact with
patient’s foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher),
includes arch filler and other shaping material, custom fabricated, each
▶ ❂ A5514 For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified
CAD model created from a digitized scan of the patient, total contact with patient’s foot, including arch,
base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other
shaping material, custom fabricated, each

Dressings
H A6000 Non-contact wound warming wound cover for use with the non-contact wound warming device and
warming card
IOM: 100-02, 16, 20
❂ A6010 Collagen based wound filler, dry form, sterile, per gram of collagen
IOM: 100-02, 15, 100
❂ A6011 Collagen based wound filler, gel/paste, per gram of collagen
IOM: 100-02, 15, 100
❂ A6021 Collagen dressing, sterile, size 16 sq. in. or less, each
IOM: 100-02, 15, 100
❂ A6022 Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each
IOM: 100-02, 15, 100
❂ A6023 Collagen dressing, sterile, size more than 48 sq. in., each
IOM: 100-02, 15, 100
❂ A6024 Collagen dressing wound filler, sterile, per 6 inches
IOM: 100-02, 15, 100
✽ A6025 Gel sheet for dermal or epidermal application (e.g., silicone, hydrogel, other), each
If used for the treatment of keloids or other scars, a silicone gel sheet will not meet the definition of the
surgical dressing benefit and will be denied as noncovered.
❂ A6154 Wound pouch, each
Waterproof collection device with drainable port that adheres to skin around wound. Usual dressing change
is up to 3 times per week.
IOM: 100-02, 15, 100
❂ A6196 Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing

IOM: 100-02, 15, 100

❂ A6197 Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in., but less than or
equal to 48 sq. in., each dressing
IOM: 100-02, 15, 100

226
❂ A6198 Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. in., each dressing

IOM: 100-02, 15, 100

❂ A6199 Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches
IOM: 100-02, 15, 100
❂ A6203 Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Usual composite dressing change is up to 3 times per week, one wound cover per dressing change.
IOM: 100-02, 15, 100
❂ A6204 Composite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size
adhesive border, each dressing
Usual composite dressing change is up to 3 times per week, one wound cover per dressing change.
IOM: 100-02, 15, 100
❂ A6205 Composite dressing, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

Usual composite dressing change is up to 3 times per week, one wound cover per dressing change.
IOM: 100-02, 15, 100
❂ A6206 Contact layer, sterile, 16 sq. in. or less, each dressing
Contact layers are porous to allow wound fluid to pass through for absorption by separate overlying dressing
and are not intended to be changed with each dressing change. Usual dressing change is up to once per
week.
IOM: 100-02, 15, 100
❂ A6207 Contact layer, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing
Contact layer dressings are used to line the entire wound; they are not intended to be changed with each
dressing change. Usual dressing change is up to once per week.
IOM: 100-02, 15, 100
❂ A6208 Contact layer, sterile, more than 48 sq. in., each dressing
Contact layer dressings are used to line the entire wound; they are not intended to be changed with each
dressing change. Usual dressing change is up to once per week.
IOM: 100-02, 15, 100
❂ A6209 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Made of open cell, medical grade expanded polymer; with nonadherent property over wound site.
IOM: 100-02, 15, 100
❂ A6210 Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in.,
without adhesive border, each dressing
Foam dressings are covered items when used on full thickness wounds (e.g., stage III or IV ulcers) with
moderate to heavy exudates. Usual dressing change for a foam wound cover when used as primary dressing is
up to 3 times per week. When foam wound cover is used as a secondary dressing for wounds with very heavy
exudates, dressing change may be up to 3 times per week. Usual dressing change for foam wound fillers is up
to once per day (A6209-A6215).
IOM: 100-02, 15, 100
❂ A6211 Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

IOM: 100-02, 15, 100

❂ A6212 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

IOM: 100-02, 15, 100

❂ A6213 Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with
any size adhesive border, each dressing
IOM: 100-02, 15, 100

227
❂ A6214 Foam dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each
dressing
IOM: 100-02, 15, 100
❂ A6215 Foam dressing, wound filler, sterile, per gram
IOM: 100-02, 15, 100
❂ A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

IOM: 100-02, 15, 100

❂ A6217 Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in.,
without adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6218 Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing

IOM: 100-02, 15, 100

❂ A6219 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

IOM: 100-02, 15, 100

❂ A6220 Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any
size adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6221 Gauze, non-impregnated, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

IOM: 100-02, 15, 100

❂ A6222 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less,
without adhesive border, each dressing
Substances may have been incorporated into dressing material (i.e., iodinated agents, petrolatum, zinc paste,
crystalline sodium chloride, chlorhexadine gluconate [CHG], bismuth tribromophenate [BTP], water,
aqueous saline, hydrogel, or agents).
IOM: 100-02, 15, 100
❂ A6223 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in.
but less than or equal to 48 sq. in., without adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6224 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 48 sq. in.,
without adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6228 Gauze, impregnated, water or normal saline, sterile, pad size 16 sq. in. or less, without adhesive border, each
dressing
IOM: 100-02, 15, 100
❂ A6229 Gauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. in. but less than or equal to
48 sq. in., without adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6230 Gauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. in., without adhesive border,
each dressing
IOM: 100-02, 15, 100
❂ A6231 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq. in. or less, each dressing

IOM: 100-02, 15, 100

❂ A6232 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq. in., but less
than or equal to 48 sq. in., each dressing
IOM: 100-02, 15, 100
❂ A6233 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size more than 48 sq. in., each dressing

228
 IOM: 100-02, 15, 100
❂ A6234 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each
dressing
This type of dressing is usually used on wounds with light to moderate exudate with an average of three
dressing changes per week.
IOM: 100-02, 15, 100
❂ A6235 Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in.,
without adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6236 Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each
dressing
IOM: 100-02, 15, 100
❂ A6237 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each
dressing
IOM: 100-02, 15, 100
❂ A6238 Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in.,
with any size adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6239 Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border,
each dressing
IOM: 100-02, 15, 100
❂ A6240 Hydrocolloid dressing, wound filler, paste, sterile, per ounce
IOM: 100-02, 15, 100
❂ A6241 Hydrocolloid dressing, wound filler, dry form, sterile, per gram
IOM: 100-02, 15, 100
❂ A6242 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Considered medically necessary when used on full thickness wounds with minimal or no exudate (e.g., stage
III or IV ulcers).
Usually up to one dressing change per day is considered medically necessary, but if well documented and
medically necessary, the payer may allow more frequent dressing changes.
IOM: 100-02, 15, 100
❂ A6243 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in.,
without adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6244 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each
dressing
IOM: 100-02, 15, 100
❂ A6245 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each
dressing
Coverage of a non-elastic gradient compression wrap is limited to one per 6 months per leg.
IOM: 100-02, 15, 100
❂ A6246 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in.,
with any size adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6247 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each
dressing
IOM: 100-02, 15, 100
❂ A6248 Hydrogel dressing, wound filler, gel, per fluid ounce
IOM: 100-02, 15, 100

229
❂ A6250 Skin sealants, protectants, moisturizers, ointments, any type, any size
IOM: 100-02, 15, 100
❂ A6251 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each
dressing
IOM: 100-02, 15, 100
❂ A6252 Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48
sq. in., without adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6253 Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border,
each dressing
IOM: 100-02, 15, 100
❂ A6254 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border,
each dressing
IOM: 100-02, 15, 100
❂ A6255 Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48
sq. in., with any size adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6256 Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive
border, each dressing
Considered medically necessary when used for moderately or highly exudative wounds (e.g., stage III or IV
ulcers).
IOM: 100-02, 15, 100
❂ A6257 Transparent film, sterile, 16 sq. in. or less, each dressing
Considered medically necessary when used on open partial thickness wounds with minimal exudate or closed
wounds.
IOM: 100-02, 15, 100
❂ A6258 Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing
IOM: 100-02, 15, 100
❂ A6259 Transparent film, sterile, more than 48 sq. in., each dressing
IOM: 100-02, 15, 100
❂ A6260 Wound cleansers, any type, any size
IOM: 100-02, 15, 100
❂ A6261 Wound filler, gel/paste, per fluid ounce, not otherwise specified
Units of service for wound fillers are 1 gram, 1 fluid ounce, 6 inch length, or 1 yard depending on product.
IOM: 100-02, 15, 100
❂ A6262 Wound filler, dry form, per gram, not otherwise specified
Dry forms (e.g., powder, granules, beads) are used to eliminate dead space in an open wound.
IOM: 100-02, 15, 100
❂ A6266 Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any width, per linear yard

IOM: 100-02, 15, 100

❂ A6402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

IOM: 100-02, 15, 100

❂ A6403 Gauze, non-impregnated, sterile, pad size more than 16 sq. in., less than or equal to 48 sq. in., without
adhesive border, each dressing
IOM: 100-02, 15, 100
❂ A6404 Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

IOM: 100-02, 15, 100

230
✽ A6407 Packing strips, non-impregnated, sterile, up to 2 inches in width, per linear yard
IOM: 100-02, 15, 100
❂ A6410 Eye pad, sterile, each
IOM: 100-02, 15, 100

231
 Eye pad, non-sterile, each N
❂ A6411
IOM: 100-02, 15, 100
Eye patch, occlusive, each N
✽ A6412

Bandages
Adhesive bandage, first-aid type, any size, each E1
H A6413
First aid type bandage is a wound cover with a pad size of less than 4 sq. in. Does not meet
the definition of the surgical dressing benefit and will be denied as non-covered.
Medicare Statute 1861(s)(5)
✽ A6441 Padding bandage, non-elastic, nonwoven/non-knitted, width greater than or equal to three
inches and less than five inches, per yard N

✽ A6442 Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches,
per yard N
Non-elastic, moderate or high compression that is typically sustained for one week
✽ A6443 Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to
three inches and less than five inches, per yard N

✽ A6444 Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to
five inches, per yard N

✽ A6445 Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per
yard N

✽ A6446 Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three
inches and less than five inches, per yard N

✽ A6447 Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five
inches, per yard N

✽ A6448 Light compression bandage, elastic, knitted/woven, width less than three inches, per yard
N
Used to hold wound cover dressings in place over a wound. Example is an ACE type elastic
bandage.
✽ A6449 Light compression bandage, elastic, knitted/woven, width greater than or equal to three
inches and less than five inches, per yard N

✽ A6450 Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches,
per yard N

✽ A6451 Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot
pounds at 50% maximum stretch, width greater than or equal to three inches and less than
five inches, per yard N

Elastic bandages that produce moderate compression that is typically sustained for one week
Medicare considers coverage if part of a multi-layer compression bandage system for the
treatment of a venous stasis ulcer. Do not assign for strains or sprains.
✽ A6452 High compression bandage, elastic, knitted/woven, load resistance greater than or equal to
1.35 foot pounds at 50% maximum stretch, width greater than or equal to three inches and
less than five inches, per yard N

Elastic bandages that produce high compression that is typically sustained for one week
✽ A6453 Self-adherent bandage, elastic, non-knitted/non-woven, width less than three inches, per yard
N

✽ A6454 Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three
inches and less than five inches, per yard N

✽ A6455 Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to five
inches, per yard N

✽ A6456 Zinc paste impregnated bandage, nonelastic, knitted/woven, width greater than or equal to
three inches and less than five inches, per yard N

Tubular dressing with or without elastic, any width, per linear yard N
✽ A6457
Synthetic resorbable wound dressing, sterile, pad size 16 sq. in. or less, without adhesive

232
▶ ✽ A6460 border, each dressing N

▶ ✽ A6461 Synthetic resorbable wound dressing, sterile, pad size more than 16 sq. in. but less than or
equal to 48 sq. in., without adhesive border, each dressing N

Compression Garments
Compression burn garment, bodysuit (head to foot), custom fabricated N
❂ A6501
Garments used to reduce hypertrophic scarring and joint contractures following burn injury
IOM: 100-02, 15, 100
Compression burn garment, chin strap, custom fabricated N
❂ A6502
IOM: 100-02, 15, 100
Compression burn garment, facial hood, custom fabricated N
❂ A6503
IOM: 100-02, 15, 100
Compression burn garment, glove to wrist, custom fabricated N
❂ A6504
IOM: 100-02, 15, 100
Compression burn garment, glove to elbow, custom fabricated N
❂ A6505
IOM: 100-02, 15, 100
Compression burn garment, glove to axilla, custom fabricated N
❂ A6506
IOM: 100-02, 15, 100
Compression burn garment, foot to knee length, custom fabricated N
❂ A6507
IOM: 100-02, 15, 100
Compression burn garment, foot to thigh length, custom fabricated N
❂ A6508
IOM: 100-02, 15, 100
❂ A6509 Compression burn garment, upper trunk to waist including arm openings (vest), custom
fabricated N

IOM: 100-02, 15, 100

❂ A6510 Compression burn garment, trunk, including arms down to leg openings (leotard), custom
fabricated N

IOM: 100-02, 15, 100

❂ A6511 Compression burn garment, lower trunk including leg openings (panty), custom fabricated
N

IOM: 100-02, 15, 100

Compression burn garment, not otherwise classified N
❂ A6512
IOM: 100-02, 15, 100
Compression burn mask, face and/or neck, plastic or equal, custom fabricated B
✽ A6513
Gradient compression stocking, below knee, 18-30 mmHg, each E1
H A6530
IOM: 100-03, 4, 280.1
Gradient compression stocking, below knee, 30-40 mmHg, each N
❂ A6531
Covered when used in treatment of open venous stasis ulcer. Modifiers A1-A9 are not
assigned. Must be billed with AW, RT, or LT.
IOM: 100-02, 15, 100
Gradient compression stocking, below knee, 40-50 mmHg, each N
❂ A6532
Covered when used in treatment of open venous stasis ulcer. Modifiers A1-A9 are not
assigned. Must be billed with AW, RT, or LT.
IOM: 100-02, 15, 100
Gradient compression stocking, thigh length, 18-30 mmHg, each E1
H A6533
IOM: 100-02, 15, 130; 100-03, 4, 280.1
Gradient compression stocking, thigh length, 30-40 mmHg, each E1
H A6534
IOM: 100-02, 15, 130; 100-03, 4, 280.1
Gradient compression stocking, thigh length, 40-50 mmHg, each E1
H A6535

233
 IOM: 100-02, 15, 130; 100-03, 4, 280.1
Gradient compression stocking, full length/chap style, 18-30 mmHg, each E1
H A6536
IOM: 100-02, 15, 130; 100-03, 4, 280.1
Gradient compression stocking, full length/chap style, 30-40 mmHg, each E1
H A6537
IOM: 100-02, 15, 130; 100-03, 4, 280.1
Gradient compression stocking, full length/chap style, 40-50 mmHg, each E1
H A6538
IOM: 100-02, 15, 130; 100-03, 4, 280.1
Gradient compression stocking, waist length, 18-30 mmHg, each E1
H A6539
IOM: 100-02, 15, 130; 100-03, 4, 280.1
Gradient compression stocking, waist length, 30-40 mmHg, each E1
H A6540
IOM: 100-02, 15, 130; 100-03, 4, 280.1
Gradient compression stocking, waist length, 40-50 mmHg, each E1
H A6541
IOM: 100-02, 15, 130; 100-03, 4, 280.1
Gradient compression stocking, garter belt E1
H A6544
IOM: 100-02, 15, 130; 100-03, 4, 280.1
Gradient compression wrap, nonelastic, below knee, 30-50 mm hg, each N
❂ A6545
Modifiers RT and/or LT must be appended. When assigned for bilateral items (left/right) on
the same date of service, bill both items on the same claim line using RT/LT modifiers and 2
units of service.
IOM: 10-02, 15, 100
Gradient compression stocking/sleeve, not otherwise specified E1
H A6549
IOM: 100-02, 15, 130; 100-03, 4, 280.1

Wound Care
✽ A6550 Wound care set, for negative pressure wound therapy electrical pump, includes all supplies
and accessories N

Respiratory Supplies
Canister, disposable, used with suction pump, each Y
✽ A7000
Canister, non-disposable, used with suction pump, each Y
✽ A7001
Tubing, used with suction pump, each Y
✽ A7002
✽ A7003 Administration set, with small volume nonfiltered pneumatic nebulizer, disposable
Y
Small volume nonfiltered pneumatic nebulizer, disposable Y
✽ A7004
✽ A7005 Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable
Y
Administration set, with small volume filtered pneumatic nebulizer Y
✽ A7006
Large volume nebulizer, disposable, unfilled, used with aerosol compressor Y
✽ A7007
Large volume nebulizer, disposable, prefilled, used with aerosol compressor Y
✽ A7008
Reservoir bottle, nondisposable, used with large volume ultrasonic nebulizer Y
✽ A7009
Corrugated tubing, disposable, used with large volume nebulizer, 100 feet Y
✽ A7010
Water collection device, used with large volume nebulizer Y
✽ A7012
Filter, disposable, used with aerosol compressor or ultrasonic generator Y
✽ A7013
Filter, non-disposable, used with aerosol compressor or ultrasonic generator Y
✽ A7014
Aerosol mask, used with DME nebulizer Y
✽ A7015
Dome and mouthpiece, used with small volume ultrasonic nebulizer Y
✽ A7016
❂ A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen

234
 IOM: 100-03, 4, 280.1 Y

Water, distilled, used with large volume nebulizer, 1000 ml Y

✽ A7018
✽ A7020 Interface for cough stimulating device, includes all components, replacement only
Y
✽ A7025 High frequency chest wall oscillation system vest, replacement for use with patient owned
equipment, each N

✽ A7026 High frequency chest wall oscillation system hose, replacement for use with patient owned
equipment, each Y

✽ A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each
Y

Oral cushion for combination oral/nasal mask, replacement only, each Y

✽ A7028
Nasal pillows for combination oral/nasal mask, replacement only, pair Y
✽ A7029
Full face mask used with positive airway pressure device, each Y
✽ A7030
Face mask interface, replacement for full face mask, each Y
✽ A7031
Cushion for use on nasal mask interface, replacement only, each Y
✽ A7032
Pillow for use on nasal cannula type interface, replacement only, pair Y
✽ A7033
✽ A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or
without head strap Y

Headgear used with positive airway pressure device Y

✽ A7035
Chinstrap used with positive airway pressure device Y
✽ A7036
Tubing used with positive airway pressure device Y
✽ A7037
Filter, disposable, used with positive airway pressure device Y
✽ A7038
Filter, non disposable, used with positive airway pressure device Y
✽ A7039
One way chest drain valve N
✽ A7040
Water seal drainage container and tubing for use with implanted chest tube N
✽ A7041
Oral interface used with positive airway pressure device, each Y
✽ A7044
❂ A7045 Exhalation port with or without swivel used with accessories for positive airway devices,
replacement only Y

IOM: 100-03, 4, 230.17

❂ A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each
Y

IOM: 100-03, 4, 230.17

Oral interface used with respiratory suction pump, each N
✽ A7047
✽ A7048 Vacuum drainage collection unit and tubing kit, including all supplies needed for collection
unit change, for use with implanted catheter, each N

Tracheostomy Supplies
Tracheostoma valve, including diaphragm, each N
❂ A7501
IOM: 100-02, 15, 120
Replacement diaphragm/faceplate for tracheostoma valve, each N
❂ A7502
IOM: 100-02, 15, 120
❂ A7503 Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange
system, each N

IOM: 100-02, 15, 120

Filter for use in a tracheostoma heat and moisture exchange system, each N
❂ A7504
IOM: 100-02, 15, 120
❂ A7505 Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or

235
 with a tracheostoma valve, each N

IOM: 100-02, 15, 120

❂ A7506 Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve,
any type, each N

IOM: 100-02, 15, 120

❂ A7507 Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and
moisture exchange system, each N

IOM: 100-02, 15, 120

❂ A7508 Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange
system and/or with a tracheostoma valve, each N

IOM: 100-02, 15, 120

❂ A7509 Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and
moisture exchange system, each N

IOM: 100-02, 15, 120

✽ A7520 Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone or equal, each
N

✽ A7521 Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each

N

✽ A7522 Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each
N
Tracheostomy shower protector, each N
✽ A7523
Tracheostoma stent/stud/button, each N
✽ A7524
Tracheostomy mask, each N
✽ A7525
Tracheostomy tube collar/holder, each N
✽ A7526
Tracheostomy/laryngectomy tube plug/stop, each N
✽ A7527

Figure 7 Helmet.

Helmets
Helmet, protective, soft, prefabricated, includes all components and accessories Y
✽ A8000
Helmet, protective, hard, prefabricated, includes all components and accessories Y
✽ A8001
Helmet, protective, soft, custom fabricated, includes all components and accessories Y
✽ A8002
Helmet, protective, hard, custom fabricated, includes all components and accessories Y
✽ A8003
Soft interface for helmet, replacement only Y
✽ A8004

ADMINISTRATIVE, MISCELLANEOUS, AND

236
INVESTIGATIONAL (A9000-A9999)
NOTE: The following codes do not imply that codes in other sections are necessarily covered.

Miscellaneous Supplies
Non-prescription drugs B
❂ A9150
IOM: 100-02, 15, 50
Single vitamin/mineral/trace element, oral, per dose, not otherwise specified E1
H A9152
H A9153 Multiple vitamins, with or without minerals and trace elements, oral, per dose, not otherwise
specified E1

Artificial saliva, 30 ml B
✽ A9155
H A9180 Pediculosis (lice infestation) treatment, topical, for administration by patient/caretaker
E1
Non-covered item or service E1
H A9270
IOM: 100-02, 16, 20
H A9272 Wound suction, disposable, includes dressing, all accessories and components, any type, each
E1

Medicare Statute 1861(n)

Cold or hot water bottle, ice cap or collar, heat and/or cold wrap, any type E1
H A9273
H A9274 External ambulatory insulin delivery system, disposable, each, includes all supplies and
accessories E1

Medicare Statute 1861(n)

Home glucose disposable monitor, includes test strips E1
H A9275
H A9276 Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose
monitoring system, one unit = 1 day supply E1

Medicare Statute 1861(n)

H A9277 Transmitter; external, for use with interstitial continuous glucose monitoring system
Medicare Statute 1861(n) E1

H A9278 Receiver (monitor); external, for use with interstitial continuous glucose monitoring system
E1
Medicare Statute 1861(n)
H A9279 Monitoring feature/device, stand-alone or integrated, any type, includes all accessories,
components and electronics, not otherwise classified E1

Medicare Statute 1861(n)

Alert or alarm device, not otherwise classified E1
H A9280
Medicare Statute 1861
Reaching/grabbing device, any type, any length, each E1
H A9281
Medicare Statute 1862 SSA
Wig, any type, each E1
H A9282
Medicare Statute 1862 SSA
Foot pressure off loading/supportive device, any type, each E1
H A9283
Medicare Statute 1862A(i)13
Spirometer, non-electronic, includes all accessories N
❂ A9284
Inversion/eversion correction device A
✽ A9285
Hygienic item or device, disposable or non-disposable, any type, each E1
H A9286
Medicare Statute 1834
Exercise equipment E1
H A9300
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

237
Supplies for Radiology Procedures (Radiopharmaceuticals)
Technetium Tc-99m sestamibi, diagnostic, per study dose N1 N
✽ A9500
Should be filed on same claim as procedure code reporting radiopharmaceutical. Verify with
payer definition of a “study.”
Coding Clinic: 2006, Q2, P5
Technetium Tc-99m teboroxime, diagnostic, per study dose N1 N
✽ A9501
Technetium Tc-99m tetrofosmin, diagnostic, per study dose N1 N
✽ A9502
Coding Clinic: 2006, Q2, P5
✽ A9503 Technetium Tc-99m medronate, diagnostic, per study dose, up to 30 millicuries
N1 N
✽ A9504 Technetium Tc-99m apcitide, diagnostic, per study dose, up to 20 millicuries
N1 N
Thallium Tl-201 thallous chloride, diagnostic, per millicurie N1 N
✽ A9505
✽ A9507 Indium In-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries
N1 N
Iodine I-131 iobenguane sulfate, diagnostic, per 0.5 millicurie N1 N
✽ A9508
Iodine I-123 sodium iodide, diagnostic, per millicurie N1 N
✽ A9509
✽ A9510 Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 millicuries
N1 N
Technetium Tc-99m pertechnetate, diagnostic, per millicurie N1 N
✽ A9512
Lutetium lu 177, dotatate, therapeutic, 1 millicurie G
▶ ❂ A9513
Choline C-11, diagnostic, per study dose up to 20 millicuries K2 G
✽ A9515
✽ A9516 Iodine I-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries
N1 N
Iodine I-131 sodium iodide capsule(s), therapeutic, per millicurie K
✽ A9517
Technetium Tc-99m tilmanocept, diagnostic, up to 0.5 millicuries N1 N
✽ A9520
✽ A9521 Technetium Tc-99m exametazime, diagnostic, per study dose, up to 25 millicuries
N1 N
Iodine I-131 iodinated serum albumin, diagnostic, per 5 microcuries N1 N
✽ A9524
Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries N1 N
✽ A9526
Iodine I-125, sodium iodide solution, therapeutic, per millicurie H2 U
✽ A9527
Iodine I-131 sodium iodide capsule(s), diagnostic, per millicurie N1 N
✽ A9528
Iodine I-131 sodium iodide solution, diagnostic, per millicurie N1 N
✽ A9529
Iodine I-131 sodium iodide solution, therapeutic, per millicurie K
✽ A9530
✽ A9531 Iodine I-131 sodium iodide, diagnostic, per microcurie (up to 100 microcuries)
N1 N
Iodine I-125 serum albumin, diagnostic, per 5 microcuries N1 N
✽ A9532
✽ A9536 Technetium Tc-99m depreotide, diagnostic, per study dose, up to 35 millicuries
N1 N
✽ A9537 Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries
N1 N
✽ A9538 Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries
N1 N
✽ A9539 Technetium Tc-99m pentetate, diagnostic, per study dose, up to 25 millicuries
N1 N
✽ A9540 Technetium Tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10
millicuries N1 N

✽ A9541 Technetium Tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries
N1 N
✽ A9542 Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries
Specifically for diagnostic use. N1 N

✽ A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries
K

238
 Specifically for therapeutic use.
✽ A9546 Cobalt Co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 microcurie
N1 N
Indium In-111 oxyquinoline, diagnostic, per 0.5 millicurie N1 N
✽ A9547
Indium In-111 pentetate, diagnostic, per 0.5 millicurie N1 N
✽ A9548
✽ A9550 Technetium Tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 millicuries
N1 N

✽ A9551 Technetium Tc-99m succimer, diagnostic, per study dose, up to 10 millicuries

N1 N
✽ A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries
Coding Clinic: 2008, Q3, P7 N1 N

✽ A9553 Chromium Cr-51 sodium chromate, diagnostic, per study dose, up to 250 microcuries
N1 N
✽ A9554 Iodine I-125 sodium Iothalamate, diagnostic, per study dose, up to 10 microcuries
N1 N
Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries N1 N
✽ A9555
Gallium Ga-67 citrate, diagnostic, per millicurie N1 N
✽ A9556
✽ A9557 Technetium Tc-99m bicisate, diagnostic, per study dose, up to 25 millicuries
N1 N
Xenon Xe-133 gas, diagnostic, per 10 millicuries N1 N
✽ A9558
✽ A9559 Cobalt Co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 microcurie
N1 N
✽ A9560 Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries
N1 N
Coding Clinic: 2008, Q3, P7
✽ A9561 Technetium Tc-99m oxidronate, diagnostic, per study dose, up to 30 millicuries
N1 N
✽ A9562 Technetium Tc-99m mertiatide, diagnostic, per study dose, up to 15 millicuries
N1 N
Sodium phosphate P-32, therapeutic, per millicurie K
✽ A9563
Chromic phosphate P-32 suspension, therapeutic, per millicurie E1
✽ A9564
✽ A9566 Technetium Tc-99m fanolesomab, diagnostic, per study dose, up to 25 millicuries
N1 N
✽ A9567 Technetium Tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 millicuries
N1 N
✽ A9568 Technetium TC-99m arcitumomab, diagnostic, per study dose, up to 45 millicuries
N1 N
✽ A9569 Technetium Tc-99m exametazime labeled autologous white blood cells, diagnostic, per study
dose N1 N

✽ A9570 Indium In-111 labeled autologous white blood cells, diagnostic, per study dose
N1 N
Indium In-111 labeled autologous platelets, diagnostic, per study dose N1 N
✽ A9571
Indium In-111 pentetreotide, diagnostic, per study dose, up to 6 millicuries N1 N
✽ A9572
Injection, gadoterate meglumine, 0.1 ml N1 N
✽ A9575
Other: Dotarem
Injection, gadoteridol, (ProHance Multipack), per ml N1 N
✽ A9576
Injection, gadobenate dimeglumine (MultiHance), per ml N1 N
✽ A9577
Injection, gadobenate dimeglumine (MultiHance Multipack), per ml N1 N
✽ A9578
✽ A9579 Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified
(NOS), per ml N1 N

Other: Magnevist, Omniscan, Optimark, Prohance

Sodium fluoride F-18, diagnostic, per study dose, up to 30 millicuries N1 N
✽ A9580
Injection, gadoxetate disodium, 1 ml N1 N
✽ A9581
Local Medicare contractors may require the use of modifier JW to identify unused product

239
 from singledose vials that are appropriately discarded.
Other: Eovist
Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries N1 N
✽ A9582
Molecular imaging agent that assists in the identification of rare neuroendocrine tumors.
Injection, gadofosveset trisodium, 1 ml N1 N
✽ A9583
Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 millicuries N1 N
✽ A9584
Coding Clinic: 2012, Q1, P9
Injection, gadobutrol, 0.1 ml N1 N
✽ A9585
Other: Gadavist
Coding Clinic: 2012, Q1, P8
Florbetapir F18, diagnostic, per study dose, up to 10 millicuries N1 N
❂ A9586
Gallium Ga-68, dotatate, diagnostic, 0.1 millicurie K2 G
✽ A9587
Coding Clinic: 2017, Q1, P9
Instillation, hexaminolevulinate hydrochloride, 100 mg N1 N
▶ ✽ A9589
Fluciclovine F-18, diagnostic, 1 millicurie K2 G
✽ A9588
Coding Clinic: 2017, Q1, P9
✽ A9597 Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not
otherwise classified N1 N
Coding Clinic: 2017, Q1, P8-9

✽ A9598 Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification,

not otherwise classified N1 N
Coding Clinic: 2017, Q1, P8-9
Strontium Sr-89 chloride, therapeutic, per millicurie K
✽ A9600
✽ A9604 Samarium SM-153 lexidronam, therapeutic, per treatment dose, up to 150 millicuries
K
Radium Ra-223 dichloride, therapeutic, per microcurie K
✽ A9606
Non-radioactive contrast imaging material, not otherwise classified, per study N1 N
❂ A9698
IOM: 100-04, 12, 70; 100-04, 13, 20
Coding Clinic: 2017, Q1, P8
Radiopharmaceutical, therapeutic, not otherwise classified N
✽ A9699
Supply of injectable contrast material for use in echocardiography, per study N1 N
❂ A9700
IOM: 100-04, 12, 30.4
Coding Clinic: 2017, Q1, P8

Miscellaneous Service Component

✽ A9900 Miscellaneous DME supply, accessory, and/or service component of another HCPCS code
On DMEPOS fee schedule as a payable replacement for miscellaneous implanted or non- Y

implanted items.
DME delivery, set up, and/or dispensing service component of another HCPCS code A
✽ A9901
Miscellaneous DME supply or accessory, not otherwise specified Y
✽ A9999
On DMEPOS fee schedule as a payable replacement for miscellaneous implanted or non-
implanted items.

ENTERAL AND PARENTERAL THERAPY (B4000-B9999)

Enteral Feeding Supplies
❂ B4034 Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing
syringe, administration set tubing, dressings, tape Y

Dressings used with gastrostomy tubes for enteral nutrition (covered under the prosthetic
device benefit) are included in the payment.

240
 IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4035 Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/flushing
syringe, administration set tubing, dressings, tape Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4036 Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/flushing
syringe, administration set tubing, dressings, tape Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
Nasogastric tubing with stylet Y
❂ B4081
More than 3 nasogastric tubes (B4081-B4083), or 1 gastrostomy/jejunostomy tube (B4087-
B4088) every three months is rarely medically necessary.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
Nasogastric tubing without stylet Y
❂ B4082
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
Stomach tube - Levine type Y
❂ B4083
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
Gastrostomy/jejunostomy tube, standard, any material, any type, each A
✽ B4087
PEN: On Fee Schedule
Gastrostomy/jejunostomy tube, lowprofile, any material, any type, each A
✽ B4088
PEN: On Fee Schedule

Enteral Formulas and Additives

Food thickener, administered orally, per ounce E1
H B4100
❂ B4102 Enteral formula, for adults, used to replace fluids and electrolytes (e.g., clear liquids), 500 ml =
1 unit Y

IOM: 100-03, 3, 180.2

❂ B4103 Enteral formula, for pediatrics, used to replace fluids and electrolytes (e.g., clear liquids), 500
ml = 1 unit Y

IOM: 100-03, 3, 180.2

Additive for enteral formula (e.g., fiber) E1
❂ B4104
IOM: 100-03, 3, 180.2
In-line cartridge containing digestive enzyme(s) for enteral feeding, each Y
▶ ❂ B4105
Cross Reference Q9994
❂ B4149 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 Y

Produced to meet unique nutrient needs for specific disease conditions; medical record must
document specific condition and need for special nutrient.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4150 Enteral formulae, 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 Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule

241
❂ B4152 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 Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4153 Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain),
includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through
an enteral feeding tube, 100 calories = 1 unit Y

If 2 enteral nutrition products described by same HCPCS code and provided at same time
billed on single claim line with units of service reflecting total calories of both nutrients
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4154 Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease
of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or
minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1
unit Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4155 Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients,
carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arginine), fat
(e.g., medium chain triglycerides) or combination, administered through an enteral feeding
tube, 100 calories = 1 unit Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4157 Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of
metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber,
administered through an enteral feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4158 Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins,
fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered
through an enteral feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4159 Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes
proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron,
administered through an enteral feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4160 Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater
than 0.7 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 Y

IOM: 100-03, 3, 180.2

❂ B4161 Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes
fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral
feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

❂ B4162 Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism,
includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered
through an enteral feeding tube, 100 calories = 1 unit Y

IOM: 100-03, 3, 180.2

242
Figure 8 Total Parenteral Nutrition (TPN) involves percutaneous placement of central venous catheter into vena cava or right atrium.

Parenteral Nutritional Solutions and Supplies

❂ B4164 Parenteral nutrition solution: carbohydrates (dextrose), 50% or less (500 ml = 1 unit) - home
mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
Parenteral nutrition solution; amino acid, 3.5%, (500 ml = 1 unit) - home mix Y
❂ B4168
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4172 Parenteral nutrition solution; amino acid, 5.5% through 7%, (500 ml = 1 unit) - home mix
Y
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
❂ B4176 Parenteral nutrition solution; amino acid, 7% through 8.5%, (500 ml = 1 unit) - home mix
Y
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4178 Parenteral nutrition solution: amino acid, greater than 8.5% (500 ml = 1 unit) - home mix
Y
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4180 Parenteral nutrition solution; carbohydrates (dextrose), greater than 50% (500 ml = 1 unit) -
home mix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
Parenteral nutrition solution, per 10 grams lipids B
❂ B4185
PEN: On Fee Schedule
❂ B4189 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes,
trace elements, and vitamins, including preparation, any strength, 10 to 51 grams of protein -
premix Y

243
 IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B4193 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes,
trace elements, and vitamins, including preparation, any strength, 52 to 73 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4197 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes,
trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4199 Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes,
trace elements and vitamins, including preparation, any strength, over 100 grams of protein -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B4216 Parenteral nutrition; additives (vitamins, trace elements, heparin, electrolytes) home mix per
day Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
Parenteral nutrition supply kit; premix, per day Y
❂ B4220
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
Parenteral nutrition supply kit; home mix, per day Y
❂ B4222
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
Parenteral nutrition administration kit, per day Y
❂ B4224
Dressings used with parenteral nutrition (covered under the prosthetic device benefit) are
included in the payment. (www.cms.gov/medicarecoverage-database/)
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
❂ B5000 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes,
trace elements, and vitamins, including preparation, any strength, renal - Aminosyn-RF,
NephrAmine, RenAmine - premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B5100 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes,
trace elements, and vitamins, including preparation, any strength, hepatic, HepatAmine -
premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
❂ B5200 Parenteral nutrition solution compounded amino acid and carbohydrates with electrolytes,
trace elements, and vitamins, including preparation, any strength, stress-branch chain amino
acids-FreAmine-HBC - premix Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

Enteral and Parenteral Pumps

Enteral nutrition infusion pump, any type Y
❂ B9002
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule

244
 ❂ B9004 Parenteral nutrition infusion pump, portable Y

IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

PEN: On Fee Schedule
Parenteral nutrition infusion pump, stationary Y
❂ B9006
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
PEN: On Fee Schedule
NOC for enteral supplies Y
❂ B9998
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2
NOC for parenteral supplies Y
❂ B9999
Determine if an alternative HCPCS Level II or a CPT code better describes the service being
reported. This code should be reported only if a more specific code is unavailable.
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

CMS HOSPITAL OUTPATIENT PAYMENT SYSTEM (C1000-

C9999)
NOTE: C-codes are used on Medicare Ambulatory Surgical Center (ASC) and Hospital
Outpatient Prospective Payment System (OPPS) claims, but may also be recognized on claims
from other providers or by other payment systems. As of 10/01/2006, the following non-OPPS
providers have been able to bill Medicare using the C-codes, or an appropriate CPT code on
Types of Bill (TOBs) 12X, 13X, or 85X:
• Critical Access Hospitals (CAHs);
• Indian Health Service Hospitals (IHS);
• Hospitals located in American Samoa, Guam, Saipan or the Virgin Islands; and
• Maryland waiver hospitals.

The billing of C-codes by Method I and Method II Critical Access Hospitals (CAHs) is limited
to the billing for facility (technical) services. The C-codes shall not be billed by Method II CAHs
for professional services with revenue codes (RCs) 96X, 97X, or 98X.

C codes are updated quarterly by the Centers for Medicare and Medicaid Services (CMS).

Devices and Supplies

Anchor/Screw for opposing bone-tobone or soft tissue-to-bone (implantable) N1 N
❂ C1713
Medicare Statute 1833(t)
Coding Clinic: 2018, Q2, P5; Q1, P4; 2016, Q3, P16; 2015, Q3, P2; 2010, Q2, P3
Catheter, transluminal atherectomy, directional N1 N
❂ C1714
Medicare Statute 1833(t)

Figure 9 (A) Brachytherapy device, (B) Brachytherapy device inserted.

245
 Brachytherapy needle N1 N
❂ C1715
Medicare Statute 1833(t)

Brachytherapy Sources
Brachytherapy source, non-stranded, gold-198, per source H2 U
❂ C1716
Medicare Statute 1833(t)
Brachytherapy source, non-stranded, high dose rate iridium 192, per source H2 U
❂ C1717
Medicare Statute 1833(t)
❂ C1719 Brachytherapy source, non-stranded, non-high dose rate iridium-192, per source
Medicare Statute 1833(t) H2 U

Cardioverter-Defibrilators
Cardioverter-defibrillator, dual chamber (implantable) N1 N
❂ C1721
Related CPT codes: 33224, 33240, 33249.
Medicare Statute 1833(t)
Cardioverter-defibrillator, single chamber (implantable) N1 N
❂ C1722
Related CPT codes: 33240, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2017, Q2, P5; 2006, Q2, P9

Catheters
Catheter, transluminal atherectomy, rotational N1 N
❂ C1724
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P9
❂ C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, infusion/perfusion
capability) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q3, P16, P19
Catheter, balloon dilatation, nonvascular N1 N
❂ C1726
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16, P19
Catheter, balloon tissue dissector, non-vascular (insertable) N1 N
❂ C1727
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16
Catheter, brachytherapy seed administration N1 N
❂ C1728
Medicare Statute 1833(t)
Catheter, drainage N1 N
❂ C1729
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P17
❂ C1730 Catheter, electrophysiology, diagnostic, other than 3D mapping (19 or fewer electrodes)
Medicare Statute 1833(t) N1 N
Coding Clinic: 2016, Q3, P17

❂ C1731 Catheter, electrophysiology, diagnostic, other than 3D mapping (20 or more electrodes)
Medicare Statute 1833(t) N1 N
Coding Clinic: 2016, Q3, P17
Catheter, electrophysiology, diagnostic/ablation, 3D or vector mapping N1 N
❂ C1732
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P15, P17, P19

❂ C1733 Catheter, electrophysiology, diagnostic/ablation, other than 3D or vector mapping, other than
cooltip N1 N

Medicare Statute 1833(t)

246
 Coding Clinic: 2016, Q3, P17
Endoscope, retrograde imaging/illumination colonoscope device (implantable) N1 N
❂ C1749
Medicare Statute 1833(t)
Catheter, hemodialysis/peritoneal, long-term N1 N
❂ C1750
Medicare Statute 1833(t)
Coding Clinic: 2015, Q4, P6
❂ C1751 Catheter, infusion, inserted peripherally, centrally, or midline (other than hemodialysis)
Medicare Statute 1833(t) N1 N

Catheter, hemodialysis/peritoneal, short-term N1 N

❂ C1752
Medicare Statute 1833(t)
Catheter, intravascular ultrasound N1 N
❂ C1753
Medicare Statute 1833(t)
Catheter, intradiscal N1 N
❂ C1754
Medicare Statute 1833(t)
Catheter, instraspinal N1 N
❂ C1755
Medicare Statute 1833(t)
Catheter, pacing, transesophageal N1 N
❂ C1756
Medicare Statute 1833(t)
Catheter, thrombectomy/embolectomy N1 N
❂ C1757
Medicare Statute 1833(t)
Catheter, ureteral N1 N
❂ C1758
Medicare Statute 1833(t)
Catheter, intracardiac echocardiography N1 N
❂ C1759
Medicare Statute 1833(t)

Devices
Closure device, vascular (implantable/insertable) N1 N
❂ C1760
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19
Connective tissue, human (includes fascia lata) N1 N
❂ C1762
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P9, P16, P19; 2015, Q3, P2; 2003, Q3, P12
Connective tissue, non-human (includes synthetic) N1 N
❂ C1763
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P9, P17, P19; 2010, Q4, P3; Q2, P3; 2003, Q3, P12
Event recorder, cardiac (implantable) N1 N
❂ C1764
Medicare Statute 1833(t)
Coding Clinic: 2015, Q2, P8
Adhesion barrier N1 N
❂ C1765
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16

❂ C1766 Introducer/sheath, guiding, intracardiac electrophysiological, steerable, other than peel-away

Medicare Statute 1833(t) N1 N

Generator, neurostimulator (implantable), nonrechargeable N1 N

❂ C1767
Related CPT codes: 61885, 61886, 63685, 64590.
Medicare Statute 1833(t)
Coding Clinic: 2007, Q1, P8
Graft, vascular N1 N
❂ C1768
Medicare Statute 1833(t)
Guide wire N1 N
❂ C1769

247
 Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P3; 2007, Q2, P7-8
Imaging coil, magnetic reasonance (insertable) N1 N
❂ C1770
Medicare Statute 1833(t)
Repair device, urinary, incontinence, with sling graft N1 N
❂ C1771
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19; 2008, Q3, P7
Infusion pump, programmable (implantable) N1 N
❂ C1772
Medicare Statute 1833(t)
Retrieval device, insertable (used to retrieve fractured medical devices) N1 N
❂ C1773
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19
Joint device (implantable) N1 N
❂ C1776
Medicare Statute 1833(t)
Coding Clinic: 2018, Q3, P6; 2016, Q3, P3, P18; 2010, Q3, P6; 2008, Q4, P10
Lead, cardioverter-defibrillator, endocardial single coil (implantable) N1 N
❂ C1777
Related CPT codes: 33216, 33217, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2017, Q2, P5; 2006, Q2, P9
Lead, neurostimulator (implantable) N1 N
❂ C1778
Related CPT codes: 43647, 63650, 63655, 63663, 63664, 64553, 64555, 64560, 64561,
64565, 64573, 64575, 64577, 64580, 64581.
Medicare Statute 1833(t)
Coding Clinic: 2007, Q1, P8
Lead, pacemaker, trasvenous VDD single pass N1 N
❂ C1779
Related CPT codes: 33206, 33207, 33208, 33210, 33211, 33214, 33216, 33217, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19
Lens, intraocular (new technology) N1 N
❂ C1780
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
Mesh (implantable) N1 N
❂ C1781
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18-19; 2012, Q2, P3; 2010, Q2, P2-3
Morcellator N1 N
❂ C1782
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
Ocular implant, aqueous drainage assist device N1 N
❂ C1783
Medicare Statute 1833(t)
Coding Clinic: 2017, Q1, P5
Ocular device, intraoperative, detached retina N1 N
❂ C1784
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
Pacemaker, dual chamber, rateresponsive (implantable) N1 N
❂ C1785
Related CPT codes: 33206, 33207, 33208, 33213, 33214, 33224.
Medicare Statute 1833(t)
Pacemaker, single chamber, rateresponsive (implantable) N1 N
❂ C1786
Related CPT codes: 33206, 33207, 33212.
Medicare Statute 1833(t)

248
Figure 10 (A) Single pacemaker, (B) Dual pacemaker, (C) Biventricular pacemaker.

Patient programmer, neurostimulator N1 N

❂ C1787
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19
Port, indwelling (implantable) N1 N
❂ C1788
Medicare Statute 1833(t)
Prosthesis, breast (implantable) N1 N
❂ C1789
Medicare Statute 1833(t)
N1 N
❂ C1813 Prosthesis, penile, inflatable ♂
Medicare Statute 1833(t)
Retinal tamponade device, silicone oil N1 N
❂ C1814
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19; 2006, Q2, P9
Prosthesis, urinary sphincter (implantable) N1 N
❂ C1815
Medicare Statute 1833(t)
Receiver and/or transmitter, neurostimulator (implantable) N1 N
❂ C1816
Medicare Statute 1833(t)
Septal defect implant system, intracardiac N1 N
❂ C1817
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19
Integrated keratoprosthesic N1 N
❂ C1818
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
Surgical tissue localization and excision device (implantable) N1 N
❂ C1819
Medicare Statute 1833(t)
❂ C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system
Related CPT codes: 61885, 61886, 63685, 64590. N1 N

Medicare Statute 1833(t)

Coding Clinic: 2016, Q2, P7
Interspinous process distraction device (implantable) N1 N
❂ C1821
Medicare Statute 1833(t)
❂ C1822 Generator, neurostimulator (implantable), high frequency, with rechargeable battery and
charging system N1 N

Medicare Statute 1833(T)

Coding Clinic: 2016, Q2, P7

▶ ❂ C1823 Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and

stimulation leads H

Medicare Statute 1833(t)

Powered bone marrow biopsy needle N1 N
❂ C1830
Medicare Statute 1833(t)

249
❂ C1840 Lens, intraocular (telescopic) N1 N

Medicare Statute 1833(t)

Coding Clinic: 2012, Q3, P10
Retinal prosthesis, includes all internal and external components J7 N
❂ C1841
Medicare Statute 1833(t)
❂ C1842 Retinal prosthesis, includes all internal and external components; add-on to C1841
Medicare Statute 1833(t) J7 E1
Coding Clinic: 2017, Q1, P6
Stent, coated/covered, with delivery system N1 N
❂ C1874
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16-17, P19
Stent, coated/covered, without delivery system N1 N
❂ C1875
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16-17
Stent, non-coated/non-covered, with delivery system N1 N
❂ C1876
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19
Stent, non-coated/non-covered, without delivery system N1 N
❂ C1877
Medicare Statute 1833(t)
Material for vocal cord medialization, synthetic (implantable) N1 N
❂ C1878
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
Vena cava filter N1 N
❂ C1880
Medicare Statute 1833(t)
Dialysis access system (implantable) N1 N
❂ C1881
Medicare Statute 1833(t)
Cardioverter-defibrillator, other than single or dual chamber (implantable) N1 N
❂ C1882
Related CPT codes: 33224, 33240, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16; 2012, Q2, P9; 2006, Q2, P9
Adapter/Extension, pacing lead or neurostimulator lead (implantable) N1 N
❂ C1883
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P15, P17; 2007, Q1, P8
Embolization protective system N1 N
❂ C1884
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P17
Catheter, transluminal angioplasty, laser N1 N
❂ C1885
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, p16, Q1, P5
Catheter, extravascular tissue ablation, any modality (insertable) N1 N
❂ C1886
Medicare Statute 1833(t)
Catheter, guiding (may include infusion/perfusion capability) N1 N
❂ C1887
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P17
Catheter, ablation, non-cardiac, endovascular (implantable) N1 N
❂ C1888
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P16
Implantable/insertable device, not otherwise classified N1 N
❂ C1889
Medicare Statute 1833(T)
Infusion pump, non-programmable, permanent (implantable) N1 N
❂ C1891
Medicare Statute 1833(t)

250
 ❂ C1892 Introducer/sheath, guiding, intracardiac electrophysiological, fixed-curve, peel-away
Medicare Statute 1833(t) N1 N
Coding Clinic: 2016, Q3, P19
❂ C1893 Introducer/sheath, guiding, intracardiac electrophysiological, fixed-curve, other than peel-
away N1 N

Medicare Statute 1833(t)

❂ C1894 Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser
Medicare Statute 1833(t) N1 N

Lead, cardioverter-defibrillator, endocardial dual coil (implantable) N1 N

❂ C1895
Related CPT codes: 33216, 33217, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2006, Q2, P9
❂ C1896 Lead, cardioverter-defibrillator, other than endocardial single or dual coil (implantable)
Related CPT codes: 33216, 33217, 33249. N1 N

Medicare Statute 1833(t)

Lead, neurostimulator test kit (implantable) N1 N
❂ C1897
Related CPT codes: 43647, 63650, 63655, 63663, 63664, 64553, 64555, 64560, 64561,
64565, 64575, 64577, 64580, 64581.
Medicare Statute 1833(t)
Coding Clinic: 2007, Q1, P8
Lead, pacemaker, other than transvenous VDD single pass N1 N
❂ C1898
Related CPT codes: 33206, 33207, 33208, 33210, 33211, 33214, 33216, 33217, 33249.
Medicare Statute 1833(t)
Coding Clinic: 2002, Q3, P8
Lead, pacemaker/cardioverter-defibrillator combination (implantable) N1 N
❂ C1899
Related CPT codes: 33216, 33217, 33249.
Medicare Statute 1833(t)
Lead, left ventricular coronary venous system N1 N
❂ C1900
Related CPT codes: 33224, 33225.
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
Lung biopsy plug with delivery system N1 N
❂ C2613
Medicare Statute 1833(t)
Coding Clinic: 2015, Q2, P11
Probe, percutaneous lumbar discectomy N1 N
❂ C2614
Medicare Statute 1833(t)
Sealant, pulmonary, liquid N1 N
❂ C2615
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18

Brachytherapy Source
Brachytherapy source, non-stranded, yttrium-90, per source H2 U
❂ C2616
Medicare Statute 1833(t)

Cardiovascular and Genitourinary Devices

Stent, non-coronary, temporary, without delivery system N1 N
❂ C2617
Medicare Statute 1833(t)
Coding Clinic: 2018, Q1, P4; 2016, Q3, P3, P19
Probe/needle, cryoablation N1 N
❂ C2618
Medicare Statute 1833(t)
Pacemaker, dual chamber, non rateresponsive (implantable) N1 N
❂ C2619

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 Related CPT codes: 33206, 33207, 33208, 33213, 33214, 33224.
Medicare Statute 1833(t)
Pacemaker, single chamber, non rateresponsive (implantable) N1 N
❂ C2620
Related CPT codes: 33206, 33207, 33212, 33224.
Medicare Statute 1833(t)
Pacemaker, other than single or dual chamber (implantable) N1 N
❂ C2621
Related CPT codes: 33206, 33207, 33208, 33212, 33213, 33214, 33224.
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18; 2002, Q3, P8
N1 N
❂ C2622 Prosthesis, penile, noninflatable ♂
Medicare Statute 1833(t)
Catheter, transluminal angioplasty, drug-coated, non-laser N1 N
❂ C2623
Medicare Statute 1833(t)
❂ C2624 Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all
system components N1 N

Medicare Statute 1833(t)

Coding Clinic: 2015, Q3, P2
Stent, non-coronary, temporary, with delivery system N1 N
❂ C2625
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P19; 2015, Q2, P9
Infusion pump, non-programmable, temporary (implantable) N1 N
❂ C2626
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P18
Catheter, suprapubic/cystoscopic N1 N
❂ C2627
Medicare Statute 1833(t)
Catheter, occlusion N1 N
❂ C2628
Medicare Statute 1833(t)
❂ C2629 Introducer/Sheath, other than guiding, other than intracardiac electrophysiological, laser
Medicare Statute 1833(t) N1 N

❂ C2630 Catheter, electrophysiology, diagnostic/ablation, other than 3D or vector mapping, cool-tip

N1 N
Medicare Statute 1833(t)
Coding Clinic: 2016, Q3, P17
Repair device, urinary, incontinence, without sling graft N1 N
❂ C2631
Medicare Statute 1833(t)

Brachytherapy Sources
❂ C2634 Brachytherapy source, non-stranded, high activity, iodine-125, greater than 1.01 mci (NIST),
per source H2 U

Medicare Statute 1833(t)

❂ C2635 Brachytherapy source, non-stranded, high activity, palladium-103, greater than 2.2 mci
(NIST), per source H2 U

Medicare Statute 1833(t)

Brachytherapy linear source, nonstranded, palladium-103, per 1 mm H2 U
❂ C2636
Brachytherapy source, non-stranded, Ytterbium-169, per source B
❂ C2637
Medicare Statute 1833(t)
Brachytherapy source, stranded, iodine-125, per source H2 U
❂ C2638
Medicare Statute 1833(t)(2)
Brachytherapy source, non-stranded, iodine-125, per source H2 U
❂ C2639
Medicare Statute 1833(t)(2)

252
 ❂ C2640 Brachytherapy source, stranded, palladium-103, per source H2 U

Medicare Statute 1833(t)(2)

Brachytherapy source, non-stranded, palladium-103, per source H2 U
❂ C2641
Medicare Statute 1833(t)(2)
Brachytherapy source, stranded, cesium-131, per source H2 U
❂ C2642
Medicare Statute 1833(t)(2)
Brachytherapy source, non-stranded, cesium-131, per source H2 U
❂ C2643
Medicare Statute 1833(t)(2)
Brachytherapy source, Cesium-131 chloride solution, per millicurie H2 U
❂ C2644
Medicare Statute 1833(t)
Brachytherapy planar source, palladium-103, per square millimeter H2 U
❂ C2645
Medicare Statute 1833(T)
Brachytherapy source, stranded, not otherwise specified, per source H2 U
❂ C2698
Medicare Statute 1833(t)(2)
Brachytherapy source, non-stranded, not otherwise specified, per source H2 U
❂ C2699
Medicare Statute 1833(t)(2)

Skin Substitute Graft Application

❂ C5271 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up
to 100 sq cm; first 25 sq cm or less wound surface area T

Medicare Statute 1833(t)

❂ C5272 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up
to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in
addition to code for primary procedure) N

Medicare Statute 1833(t)

❂ C5273 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area
greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of
infants and children T

Medicare Statute 1833(t)

❂ C5274 Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area
greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part
thereof, or each additional 1% of body area of infants and children, or part thereof (list
separately in addition to code for primary procedure) N

Medicare Statute 1833(t)

❂ C5275 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25
sq cm or less wound surface area T

Medicare Statute 1833(t)

❂ C5276 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each
additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for
primary procedure) N

Medicare Statute 1833(t)

❂ C5277 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to
100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
T

Medicare Statute 1833(t)

❂ C5278 Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,
genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to
100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional

253
 1% of body area of infants and children, or part thereof (list separately in addition to code for
primary procedure) N

Medicare Statute 1833(t)

Magnetic Resonance Angiography: Trunk and Lower Extremities

Magnetic resonance angiography with contrast, abdomen Z2 Q3
❂ C8900
Medicare Statute 1833(t)(2)
Magnetic resonance angiography without contrast, abdomen Z2 Q3
❂ C8901
Medicare Statute 1833(t)(2)
❂ C8902 Magnetic resonance angiography without contrast followed by with contrast, abdomen
Medicare Statute 1833(t)(2) Z2 Q3

Magnetic resonance imaging with contrast, breast; unilateral Z2 Q3

❂ C8903
Medicare Statute 1833(t)(2)
C8904 Magnetic resonance imaging without contrast, breast; unilateral ✖
❂ C8905 Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral
Medicare Statute 1833(t)(2) Z2 Q3

Magnetic resonance imaging with contrast, breast; bilateral Z2 Q3

❂ C8906
Medicare Statute 1833(t)(2)
C8907 Magnetic resonance imaging without contrast, breast; bilateral ✖
❂ C8908 Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral
Medicare Statute 1833(t)(2) Z2 Q3

Magnetic resonance angiography with contrast, chest (excluding myocardium) Z2 Q3

❂ C8909
Medicare Statute 1833(t)(2)
❂ C8910 Magnetic resonance angiography without contrast, chest (excluding myocardium)
Medicare Statute 1833(t)(2) Z2 Q3

❂ C8911 Magnetic resonance angiography without contrast followed by with contrast, chest (excluding
myocardium) Z2 Q3

Medicare Statute 1833(t)(2)

Magnetic resonance angiography with contrast, lower extremity Z2 Q3
❂ C8912
Medicare Statute 1833(t)(2)
Magnetic resonance angiography without contrast, lower extremity Z2 Q3
❂ C8913
Medicare Statute 1833(t)(2)
❂ C8914 Magnetic resonance angiography without contrast followed by with contrast, lower extremity
Z2 Q3
Medicare Statute 1833(t)(2)
Magnetic resonance angiography with contrast, pelvis Z2 Q3
❂ C8918
Medicare Statute 1833(t)(2)
Magnetic resonance angiography without contrast, pelvis Z2 Q3
❂ C8919
Medicare Statute 1833(t)(2)
❂ C8920 Magnetic resonance angiography without contrast followed by with contrast, pelvis
Medicare Statute 1833(t)(2) Z2 Q3

Transthoracic and Transesophageal Echocardiography

❂ C8921 Transthoracic echocardiography with contrast, or without contrast followed by with contrast,
for congenital cardiac anomalies; complete S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8922 Transthoracic echocardiography with contrast, or without contrast followed by with contrast,
for congenital cardiac anomalies; follow-up or limited study S

254
 Medicare Statute 1833(t)(2)
Coding Clinic: 2012, Q3, P8
❂ C8923 Transthoracic echocardiography with contrast, or without contrast followed by with contrast,
real-time with image documentation (2D), includes M-mode recording, when performed,
complete, without spectral or color Doppler echocardiography S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8924 Transthoracic echocardiography with contrast, or without contrast followed by with contrast,
real-time with image documentation (2D), includes M-mode recording, when performed,
follow-up or limited study S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8925 Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with
contrast, real time with image documentation (2D) (with or without M-mode recording);
including probe placement, image acquisition, interpretation and report S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8926 Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with
contrast, for congenital cardiac anomalies; including probe placement, image acquisition,
interpretation and report S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8

❂ C8927 Transesophageal echocardiography (TEE) with contrast, or without contrast followed by with
contrast, for monitoring purposes, including probe placement, real time 2-dimensional image
acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically
changing) cardiac pumping function and to therapeutic measures on an immediate time basis
S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8928 Transthoracic echocardiography with contrast, or without contrast followed by with contrast,
real-time with image documentation (2D), includes M-mode recording, when performed,
during rest and cardiovascular stress test using treadmill, bicycle exercise and/or
pharmacologically induced stress, with interpretation and report S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8
❂ C8929 Transthoracic echocardiography with contrast, or without contrast followed by with contrast,
real-time with image documentation (2D), includes M-mode recording, when performed,
complete, with spectral Doppler echocardiography, and with color flow Doppler
echocardiography S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8

❂ C8930 Transthoracic echocardiography, with contrast, or without contrast followed by with contrast,
real-time with image documentation (2D), includes M-mode recording, when performed,
during rest and cardiovascular stress test using treadmill, bicycle exercise and/or
pharmacologically induced stress, with interpretation and report; including performance of
continuous electrocardiographic monitoring, with physician supervision S

Medicare Statute 1833(t)(2)

Coding Clinic: 2012, Q3, P8

Magnetic Resonance Angiography: Spine and Upper Extremities

Magnetic resonance angiography with contrast, spinal canal and contents Z2 Q3
❂ C8931
Medicare Statute 1833(t)
Magnetic resonance angiography without contrast, spinal canal and contents Z2 Q3
❂ C8932
Medicare Statute 1833(t)

255
 ❂ C8933 Magnetic resonance angiography without contrast followed by with contrast, spinal canal and
contents Z2 Q3

Medicare Statute 1833(t)

Magnetic resonance angiography with contrast, upper extremity Z2 Q3
❂ C8934
Medicare Statute 1833(t)
Magnetic resonance angiography without contrast, upper extremity Z2 Q3
❂ C8935
Medicare Statute 1833(t)
❂ C8936 Magnetic resonance angiography without contrast followed by with contrast, upper extremity
Medicare Statute 1833(t) Z2 Q3

▶ ❂ C8937 Computer-aided detection, including computer algorithm analysis of breast MRI image data
for lesion detection/characterization, pharmacokinetic analysis, with further physician review
for interpretation (list separately in addition to code for primary procedure) N

Medicare Statute 1833(t)

Drugs and Biologicals

❂ C8957 Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8
hours), requiring use of portable or implantable pump S

Medicare Statute 1833(t)

Coding Clinic: 2008, Q3, P8
C9014 Injection, cerliponase alfa, 1 mg ✖
C9015 Injection, C-1 esterase inhibitor (human), haegarda, 10 units ✖
C9016 Injection, triptorelin extended release, 3.75 mg ✖
C9024 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine ✖
C9028 Injection, inotuzumab ozogamicin, 0.1 mg ✖
C9029 Injection, guselkumab, 1 mg ✖
Injection, dexamethasone 9%, intraocular, 1 mcg G
▶ ❂ C9034
Medicare Statute 1833(t)
Injection, aripiprazole lauroxil (aristada initio), 1 mg G
▶ ❂ C9035
Medicare Statute 1833(t)
Injection, patisiran, 0.1 mg G
▶ ❂ C9036
Medicare Statute 1833(t)
Injection, risperidone (perseris), 0.5 mg G
▶ ❂ C9037
Medicare Statute 1833(t)
Injection, mogamulizumab-kpkc, 1 mg G
▶ ❂ C9038
Medicare Statute 1833(t)
Injection, plazomicin, 5 mg G
▶ ❂ C9039
Medicare Statute 1833(t)
Injection, pantoprazole sodium, per vial N1 N
❂ C9113
Medicare Statute 1833(t)

256
❂ C9132 Prothrombin complex concentrate (human), Kcentra, per i.u. of Factor IX activity
Medicare Statute 1833(t) K2 K

Injection, clevidipine butyrate, 1 mg N1 N

❂ C9248
Medicare Statute 1833(t)
Human plasma fibrin sealant, vaporheated, solvent-detergent (ARTISS), 2 ml K2 K
❂ C9250
Example of diagnosis codes to be reported with C9250: T20.00-T25.799.
Medicare Statute 621MMA
Injection, lacosamide, 1 mg N1 N
❂ C9254
Medicare Statute 621MMA
injection, bevacizumab, 0.25 mg K2 K
❂ C9257
Medicare Statute 1833(t)
C9275 Injection, hexaminolevulinate hydrochloride, 100 mg, per study dose ✖
Lidocaine 70 mg/tetracaine 70 mg, per patch N1 N
❂ C9285
Medicare Statute 1833(t)
Coding Clinic: 2011, Q3, P9
Injection, bupivacine liposome, 1 mg N1 N
❂ C9290
Medicare Statute 1833(t)
Injection, glucarpidase, 10 units K2 K
❂ C9293
Medicare Statute 1833(t)
❂ C9352 Microporous collagen implantable tube (NeuraGen Nerve Guide), per centimeter length
N1 N
Medicare Statute 621MMA
❂ C9353 Microporous collagen implantable slit tube (NeuraWrap Nerve Protector), per centimeter
length N1 N

Medicare Statute 621MMA

❂ C9354 Acellular pericardial tissue matrix of non-human origin (Veritas), per square centimeter
N1 N
Medicare Statute 621MMA
Collagen nerve cuff (NeuroMatrix), per 0.5 centimeter length N1 N
❂ C9355
Medicare Statute 621MMA
❂ C9356 Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide
Tendon Protector Sheet), per square centimeter N1 N

Medicare Statute 621MMA

❂ C9358 Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen
Matrix), per 0.5 square centimeters N1 N

Medicare Statute 621MMA

Coding Clinic: 2013, Q3, P9; 2012, Q2, P7

❂ C9359 Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold
Putty, Integra OS Osteoconductive Scaffold Putty), per 0.5 cc N1 N

Medicare Statute 1833(t)

Coding Clinic: 2015, Q3, P2

❂ C9360 Dermal substitute, native, nondenatured collagen, neonatal bovine origin (SurgiMend
Collagen Matrix), per 0.5 square centimeters N1 N

Medicare Statute 621MMA

Coding Clinic: 2012, Q2, P7
❂ C9361 Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 centimeter length
N1 N

Medicare Statute 621MMA

❂ C9362 Porous purified collagen matrix bone void filler (Integra Mozaik Osteoconductive Scaffold
Strip), per 0.5 cc N1 N

Medicare Statute 621MMA

257
 Coding Clinic: 2010, Q2, P8
Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter N1 N
❂ C9363
Medicare Statute 621MMA
Coding Clinic: 2012, Q2, P7; 2010, Q2, P8
Porcine implant, Permacol, per square centimeter N1 N
❂ C9364
Medicare Statute 621MMA
Unclassified drugs or biologicals K7 A
❂ C9399
Medicare Statute 621MMA
Coding Clinic: 2017, Q1, P1-3, P8; 2016, Q4, P10; 2014, Q2, P8; 2013, Q2, P3; 2010, Q3, P8
Iodine i-131 iobenguane, diagnostic, 1 millicurie G
▶ ❂ C9407
Medicare Statute 1833(t)
Iodine i-131 iobenguane, therapeutic, 1 millicurie G
▶ ❂ C9408
Medicare Statute 1833(t)
Injection, phenylephrine and ketorolac, 4 ml vial N1 N
❂ C9447
Medicare Statute 1833(t)
Injection, cangrelor, 1 mg K2 G
❂ C9460
Medicare Statute 1833(t)
Injection, delafloxacin, 1 mg K2 G
▶ ❂ C9462
Medicare Statute 1833(t)
Injection, sotalol hydrochloride, 1 mg K2 G
❂ C9482
Medicare Statute 1833(t)
Coding Clinic: 2016, Q4, P9
Injection, conivaptan hydrochloride, 1 mg K2 G
❂ C9488
Medicare Statute 1833(t)
C9492 Injection, durvalumab, 10 mg ✖
C9493 Injection, edaravone, 1 mg ✖
C9497 Loxapine, inhalation powder, 10 mg ✖

Percutaneous Transcatheter and Transluminal Coronary Procedures

❂ C9600 Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary
angioplasty when performed; a single major coronary artery or branch J1

Medicare Statute 1833(t)

❂ C9601 Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary
angioplasty when performed; each additional branch of a major coronary artery (list separately
in addition to code for primary procedure) N

Medicare Statute 1833(t)

❂ C9602 Percutaneous transluminal coronary atherectomy, with drug eluting intracoronary stent, with
coronary angioplasty when performed; a single major coronary artery or branch J1

Medicare Statute 1833(t)

❂ C9603 Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with
coronary angioplasty when performed; each additional branch of a major coronary artery (list
separately in addition to code for primary procedure) N

Medicare Statute 1833(t)

❂ C9604 Percutaneous transluminal revascularization of or through coronary artery bypass graft
(internal mammary, free arterial, venous), any combination of drug-eluting intracoronary
stent, atherectomy and angioplasty, including distal protection when performed; a single
vessel J1

❂ C9605 Percutaneous transluminal revascularization of or through coronary artery bypass graft

(internal mammary, free arterial, venous), any combination of drug-eluting intracoronary
stent, atherectomy and angioplasty, including distal protection when performed; each
additional branch subtended by the bypass graft (list separately in addition to code for primary

258
 procedure) N

Medicare Statute 1833(t)

❂ C9606 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute
myocardial infarction, coronary artery or coronary artery bypass graft, any combination of
drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration
thrombectomy when performed, single vessel J1

Medicare Statute 1833(t)

❂ C9607 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery,
coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting
intracoronary stent, atherectomy and angioplasty; single vessel J1

Medicare Statute 1833(t)

❂ C9608 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery,
coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting
intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary
artery branch, or bypass graft (list separately in addition to code for primary procedure)
N
Medicare Statute 1833(t)

Therapeutic Services and Supplies

Placement of endorectal intracavitary applicator for high intensity brachytherapy T
❂ C9725
Medicare Statute 1833(t)
❂ C9726 Placement and removal (if performed) of applicator into breast for intraoperative radiation
therapy, add-on to primary breast procedure N

Medicare Statute 1833(t)

Insertion of implants into the soft palate; minimum of three implants T
❂ C9727
Medicare Statute 1833(t)
❂ C9728 Placement of interstitial device(s) for radiation therapy/surgery guidance (e.g., fiducial
markers, dosimeter), for other than the following sites (any approach): abdomen, pelvis,
prostate, retroperitoneum, thorax, single or multiple S

Medicare Statute 1833(t)

Coding Clinic: 2018, Q2, P4
Non-ophthalmic fluorescent vascular angiography Q2
❂ C9733
Medicare Statute 1833(t)
Coding Clinic: 2012, Q1, P7

❂ C9734 Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with
magnetic resonance (MR) guidance J1

Medicare Statute 1833(t)

❂ C9738 Adjunctive blue light cystoscopy with fluorescent imaging agent (list separately in addition to
code for primary procedure) N1 N

Medicare Statute 1833(t)

Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants J1
❂ C9739
Medicare Statute 1833(t)
Coding Clinic: 2014, Q2, P6
Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants J1
❂ C9740
Medicare Statute 1833(t)
Coding Clinic: 2014, Q2, P6
C9741 Right heart catheterization with implantation of wireless pressure sensor in the ✖
pulmonary artery, including any type of measurement, angiography, imaging supervision,
interpretation, and report
C9744 Ultrasound, abdominal, with contrast ✖
Nasal endoscopy, surgical; balloon dilation of eustachian tube J1
❂ C9745
Medicare Statute 1833(t)

259
 ❂ C9746 Transperineal implantation of permanent adjustable balloon continence device, with
cystourethroscopy, when performed and/or fluoroscopy, when performed J1
Medicare Statute 1833(t)
❂ C9747 Ablation of prostate, transrectal, high intensity focused ultrasound (HIFU), including
imaging guidance J1
Medicare Statute 1833(t)
C9748 Transurethral destruction of prostate tissue; by radiofrequency water vapor (steam) ✖
thermal therapy
Repair of nasal vestibular lateral wall stenosis with implant(s) J1
▶ ❂ C9749
Medicare Statute 1833(t)
▶ ❂ C9751 Bronchoscopy, rigid or flexible, transbronchial ablation of lesion(s) by microwave energy,
including fluoroscopic guidance, when performed, with computed tomography acquisition(s)
and 3-D rendering, computer-assisted, imageguided navigation, and endobronchial
ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (e.g.,
aspiration[s]/biopsy[ies]) and all mediastinal and/or hilar lymph node stations or structures
and therapeutic intervention(s) T

Medicare Statute 1833(t)

▶ ❂ C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging
guidance (e.g., fluoroscopy), lumbar/sacrum J1
Medicare Statute 1833(t)
▶ ❂ C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including
imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for
primary procedure) N

Medicare Statute 1833(t)

▶ ❂ C9754 Creation of arteriovenous fistula, percutaneous; direct, any site, including all imaging and
radiologic supervision and interpretation, when performed and secondary procedures to
redirect blood flow (e.g., transluminal balloon angioplasty, coil embolization, when
performed) J1
Medicare Statute 1833(t)
▶ ❂ C9755 Creation of arteriovenous fistula, percutaneous using magnetic-guided arterial and venous
catheters and radiofrequency energy, including flowdirecting procedures (e.g., vascular coil
embolization with radiologic supervision and interpretation, when performed) and
fistulogram(s), angiography, venography, and/or ultrasound, with radiologic supervision and
interpretation, when performed J1
Medicare Statute 1833(t)
Radiolabeled product provided during a hospital inpatient stay N
❂ C9898
❂ C9899 Implanted prosthetic device, payable only for inpatients who do not have inpatient coverage
Medicare Statute 1833(t) A

DENTAL PROCEDURES (D0000-D9999)

Diagnostic (D0120-D0999)
Clinical Oral Evaluations
D0120 Periodic oral evaluation - established patient E1

An evaluation performed on a patient of record to determine any changes in the patient’s

dental and medical health status since a previous comprehensive or periodic evaluation. This
includes an oral cancer evaluation and periodontal screening where indicated, and may require
interpretation of information acquired through additional diagnostic procedures. Report
additional diagnostic procedures separately.
D0140 Limited oral evaluation - problem focused E1
An evaluation limited to a specific oral health problem or complaint. This may require
interpretation of information acquired through additional diagnostic procedures. Report

260
 additional diagnostic procedures separately. Definitive procedures may be required on the
same date as the evaluation. Typically, patients receiving this type of evaluation present with a
specific problem and/or dental emergencies, trauma, acute infections, etc.
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver
E1
Diagnostic services performed for a child under the age of three, preferably within the first six
months of the eruption of the first primary tooth, including recording the oral and physical
health history, evaluation of caries susceptibility, development of an appropriate preventive
oral health regimen and communication with and counseling of the child’s parent, legal
guardian and/or primary caregiver.
D0150 Comprehensive oral evaluation - new or established patient S
Used by a general dentist and/or a specialist when evaluating a patient comprehensively. This
applies to new patients; established patients who have had a significant change in health
conditions or other unusual circumstances, by report, or established patients who have been
absent from active treatment for three or more years. It is a thorough evaluation and recording
of the extraoral and intraoral hard and soft tissues. It may require interpretation of
information acquired through additional diagnostic procedures. Additional diagnostic
procedures should be reported separately. This includes an evaluation for oral cancer where
indicated, the evaluation and recording of the patient’s dental and medical history and a
general health assessment. It may include the evaluation and recording of dental caries,
missing or unerupted teeth, restorations, existing prostheses, occlusal relationships,
periodontal conditions (including periodontal screening and/or charting), hard and soft tissue
anomalies, etc.
D0160 Detailed and extensive oral evaluation - problem focused, by report E1
A detailed and extensive problem focused evaluation entails extensive diagnostic and cognitive
modalities based on the findings of a comprehensive oral evaluation. Integration of more
extensive diagnostic modalities to develop a treatment plan for a specific problem is required.
The condition requiring this type of evaluation should be described and documented.
Examples of conditions requiring this type of evaluation may include dentofacial anomalies,
complicated perioprosthetic conditions, complex temporomandibular dysfunction, facial pain
of unknown origin, conditions requiring multi-disciplinary consultation, etc.
D0170 Re-evaluation - limited, problem focused (established patient; not postoperative visit) E1
Assessing the status of a previously existing condition. For example: - a traumatic injury where
no treatment was rendered but patient needs follow-up monitoring; - evaluation for
undiagnosed continuing pain; - soft tissue lesion requiring follow-up evaluation.
D0171 Re-evaluation - post-operative office visit E1

D0180 Comprehensive periodontal evaluation - new or established patient E1

This procedure is indicated for patients showing signs or symptoms of periodontal disease and
for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal
conditions, probing and charting, evaluation and recording of the patient’s dental and medical
history and general health assessment. It may include the evaluation and recording of dental
caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer
evaluation.

Pre-Diagnostic Services
D0190 Screening of a patient E1

A screening, including state or federally mandated screenings, to determine an individual’s

need to be seen by a dentist for diagnosis.
D0191 Assessment of a patient E1

A limited clinical inspection that is performed to identify possible signs of oral or systemic
disease, malformation, or injury, and the potential need for referral for diagnosis and
treatment.

Diagnostic Imaging

261
D0210 Intraoral - complete series of radiographic image E1
A radiographic survey of the whole mouth, usually consisting of 14-22 periapical and
posterior bitewing images intended to display the crowns and roots of all teeth, periapical
areas and alveolar bone.
Cross Reference 70320
D0220 Intraoral - periapical first radiographic image E1
Cross Reference 70300
D0230 Intraoral - periapical each additional radiographic image E1
Cross Reference 70310
D0240 Intraoral - occlusal radiographic image S

D0250 Extra-oral — 2D projection radiographic image created using a stationary radiation source,
detector S
These images include, but are not limited to: Lateral Skull; Posterior-Anterior Skull;
Submentovertex; Waters; Reverse Tomes; Oblique Mandibular Body; Lateral Ramus.
D0251 Extra-oral posterior dental radiographic image Q1

Image limited to exposure of complete posterior teeth in both dental arches. This is a unique
image that is not derived from another image.
D0270 Bitewing - single radiographic image S

D0272 Bitewings - two radiographic images S

D0273 Bitewings - three radiographic images E1

D0274 Bitewings - four radiographic images S

D0277 Vertical bitewings - 7 to 8 radiographic images S

This does not constitute a full mouth intraoral radiographic series.

D0310 Sialography E1

Cross Reference 70390

D0320 Temporomandibular joint arthrogram, including injection E1

Cross Reference 70332

D0321 Other temporomandibular joint radiographic image, by report E1
Cross Reference 76499
D0322 Tomographic survey E1

D0330 Panoramic radiographic image E1

Cross Reference 70320

D0340 2D cephalometric radiographic image - acquisition, measurement and analysis E1
Image of the head made using a cephalostat to standardize anatomic positioning, and with
reproducible x-ray beam geometry.
Cross Reference 70350
D0350 2D oral/facial photographic image obtained intra-orally or extraorally E1

D0351 3D photographic image E1

This procedure is for dental or maxillofacial diagnostic purposes. Not applicable for a CAD-
CAM procedure.
D0364 Cone beam CT capture and interpretation with limited field of view - less than one whole jaw
E1
D0365 Cone beam CT capture and interpretation with field of view of one full dental arch -
mandible E1

D0366 Cone beam CT capture and interpretation with field of view of one full dental arch - maxilla,
with or without cranium E1

D0367 Cone beam CT capture and interpretation with field of view of both jaws, with or without
cranium E1

D0368 Cone beam CT capture and interpretation for TMJ series including two or more exposures
E1
D0369 Maxillofacial MRI capture and interpretation E1

262
 D0370 Maxillofacial ultrasound capture and interpretation E1

D0371 Sialoendoscopy capture and interpretation E1

D0380 Cone beam CT image capture with limited field of view - less than one whole jaw E1

D0381 Cone beam CT image capture with field of view of one full dental arch - mandible E1

D0382 Cone beam CT image capture with field of view of one full dental arch - maxilla, with or
without cranium E1

D0383 Cone beam CT image capture with field of view of both jaws, with or without cranium E1

D0384 Cone beam CT image capture for TMJ series including two or more exposures E1

D0385 Maxillofacial MRI image capture E1

D0386 Maxillofacial ultrasound image capture E1

D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image,
including report E1

D0393 Treatment simulation using 3D image volume E1

The use of 3D image volumes for simulation of treatment including, but not limited to, dental
implant placement, orthognathic surgery and orthodontic tooth movement.
D0394 Digital subtraction of two or more images or image volumes of the same modality E1
To demonstrate changes that have occurred over time.
D0395 Fusion of two or more 3D image volumes of one or more modalities E1

Tests and Examinations

D0411 HbA1c in-office point of service testing E1

Blood gucose level test - in-office using a glucose meter E1

▶ D0412
D0414 Laboratory processing of microbial specimen to include culture and sensitivity studies,
preparation and transmission of written report E1

D0415 Collection of microorganisms for culture and sensitivity E1

Cross Reference D0410

D0416 Viral culture B

A diagnostic test to identify viral organisms, most often herpes virus.

D0417 Collection and preparation of saliva sample for laboratory diagnostic testing E1

D0418 Analysis of saliva sample E1

Chemical or biological analysis of saliva sample for diagnostic purposes.
D0422 Collection and preparation of genetic sample material for laboratory analysis and report E1

D0423 Genetic test for susceptibility to diseases - specimen analysis E1

Certified laboratory analysis to detect specific genetic variations associated with increased
susceptibility for diseases.
D0425 Caries susceptibility tests E1

Not to be used for carious dentin staining.

D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including
premalignant and malignant lesions, not to include cytology or biopsy procedures B

D0460 Pulp vitality tests S

Includes multiple teeth and contra lateral comparison(s), as indicated.
D0470 Diagnostic casts E1

Also known as diagnostic models or study models.

Oral Pathology Laboratory (Use Codes D0472 – D0502)

D0472 Accession of tissue, gross examination, preparation and transmission of written report B
To be used in reporting architecturally intact tissue obtained by invasive means.
D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of
written report B

263
 To be used in reporting architecturally intact tissue obtained by invasive means.
D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical
margins for presence of disease, preparation and transmission of written report B
To be used in reporting architecturally intact tissue obtained by invasive means.
D0475 Decalcification procedure B
Procedure in which hard tissue is processed in order to allow sectioning and subsequent
microscopic examination.
D0476 Special stains for microorganisms B
Procedure in which additional stains are applied to biopsy or surgical specimen in order to
identify microorganisms.
D0477 Special stains, not for microorganisms B
Procedure in which additional stains are applied to a biopsy or surgical specimen in order to
identify such things as melanin, mucin, iron, glycogen, etc.
D0478 Immunohistochemical stains B
A procedure in which specific antibody based reagents are applied to tissue samples in order to
facilitate diagnosis.
D0479 Tissue in-situ hybridization, including interpretation B

A procedure which allows for the identification of nucleic acids, DNA and RNA, in the tissue
sample in order to aid in the diagnosis of microorganisms and tumors.
D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and
transmission of written report B
To be used in reporting disaggregated, non-transepithelial cell cytology sample via mild
scraping of the oral mucosa.
D0481 Electron microscopy B

D0482 Direct immunofluorescence B

A technique used to identify immunoreactants which are localized to the patient’s skin or
mucous membranes.
D0483 Indirect immunofluorescence B
A technique used to identify circulating immunoreactants.
D0484 Consultation on slides prepared elsewhere B
A service provided in which microscopic slides of a biopsy specimen prepared at another
laboratory are evaluated to aid in the diagnosis of a difficult case or to offer a consultative
opinion at the patient’s request. The findings are delivered by written report.
D0485 Consultation, including preparation of slides from biopsy material supplied by referring source
B
A service that requires the consulting pathologist to prepare the slides as well as render a
written report. The slides are evaluated to aid in the diagnosis of a difficult case or to offer a
consultative opinion at the patient’s request.
D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination,
preparation and transmission of written report E1

Analysis, and written report of findings, of cytologic sample of disaggregated transepithelial

cells.
D0502 Other oral pathology procedures, by report B

Tests and Examinations

D0600 Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes
in structure of enamel, dentin, and cementum S

D0601 Caries risk assessment and documentation, with a finding of low risk E1

Using recognized assessment tools.

D0602 Caries risk assessment and documentation, with a finding of moderate risk E1

Using recognized assessment tools.

264
 D0603 Caries risk assessment and documentation, with a finding of high risk E1
Using recognized assessment tools.

None
D0999 Unspecified diagnostic procedure, by report B
Used for procedure that is not adequately described by a code. Describe procedure.

Preventative (D1110-D1999)
Dental Prophylaxis
D1110 Prophylaxis - adult E1
Removal of plaque, calculus and stains from the tooth structures in the permanent and
transitional dentition. It is intended to control local irritational factors.
D1120 Prophylaxis - child E1
Removal of plaque, calculus and stains from the tooth structures in the primary and
transitional dentition. It is intended to control local irritational factors.

Topical Fluoride Treatment (Office Procedure)

D1206 Topical application of fluoride varnish E1

D1208 Topical application of fluoride — excluding varnish E1

Other Preventative Services

D1310 Nutritional counseling for the control of dental disease E1
Counseling on food selection and dietary habits as a part of treatment and control of
periodontal disease and caries.
D1320 Tobacco counseling for the control and prevention of oral disease E1

Tobacco prevention and cessation services reduce patient risks of developing tobacco-related
oral diseases and conditions and improves prognosis for certain dental therapies.
D1330 Oral hygiene instruction E1

This may include instructions for home care. Examples include tooth brushing technique,
flossing, use of special oral hygiene aids.
D1351 Sealant - per tooth E1
Mechanically and/or chemically prepared enamel surface sealed to prevent decay.
D1352 Preventive resin restoration in a moderate to high caries risk patient — permanent tooth
Conservative restoration of an active cavitated lesion in a pit or fissure that does not E1

extend into dentin; includes placement of a sealant in any radiating non-carious fissures or
pits.
D1353 Sealant repair — per tooth E1

D1354 Interim caries arresting medicament application — per tooth E1

Conservative treatment of an active, non-symptomatic carious lesion by topical application of

a caries arresting or inhibiting medicament and without mechanical removal of sound tooth
structure.

Space Maintenance (Passive Appliances)

D1510 Space maintainer - fixed - unilateral S

Excludes a distal shoe space maintainer.

Space Maintainer - fixed - bilateral, maxillary S
▶ D1516
Space Maintainer - fixed - bilateral, mandibular S
▶ D1517
D1520 Space maintainer - removable - unilateral S

Space maintainer - removable - bilateral, maxillary S

▶ D1526
Space maintainer - removable - bilateral, mandibular S
▶ D1527

265
 D1550 Re-cement or re-bond space maintainer S

D1555 Removal of fixed space maintainer E1

Procedure performed by dentist or practice that did not originally place the appliance.

Space Maintainers
D1575 Distal shoe space maintainer - fixed - unilateral S
Fabrication and delivery of fixed appliance extending subgingivally and distally to guide the
eruption of the first permanent molar. Does not include ongoing follow-up or adjustments, or
replacement appliances, once the tooth has erupted.

None
D1999 Unspecified preventive procedure, by report E1
Used for procedure that is not adequately described by another CDT Code. Describe
procedure.

Restorative (D2140-D2999)
Amalgam Restorations (Including Polishing)
D2140 Amalgam - one surface, primary or permanent E1

D2150 Amalgam - two surfaces, primary or permanent E1

D2160 Amalgam - three surfaces, primary or permanent E1

D2161 Amalgam - four or more surfaces, primary or permanent E1

Resin-Based Composite Restorations – Direct

D2330 Resin-based composite - one surface, anterior E1

D2331 Resin-based composite - two surfaces, anterior E1

D2332 Resin-based composite - three surfaces, anterior E1

D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) E1
Incisal angle to be defined as one of the angles formed by the junction of the incisal and the
mesial or distal surface of an anterior tooth.
D2390 Resin-based composite crown, anterior E1

Full resin-based composite coverage of tooth.

D2391 Resin-based composite - one surface, posterior E1
Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not a
preventive procedure.
D2392 Resin-based composite - two surfaces, posterior E1

D2393 Resin-based composite - three surfaces, posterior E1

D2394 Resin-based composite - four or more surfaces, posterior E1

Gold Foil Restorations

D2410 Gold foil - one surface E1

D2420 Gold foil - two surfaces E1

D2430 Gold foil - three surfaces E1

Inlay/Onlay Restorations
D2510 Inlay - metallic - one surface E1

D2520 Inlay - metallic - two surfaces E1

D2530 Inlay - metallic - three or more surfaces E1

D2542 Onlay - metallic - two surfaces E1

D2543 Onlay - metallic - three surfaces E1

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 D2544 Onlay - metallic - four or more surfaces E1

D2610 Inlay - porcelain/ceramic - one surface E1

D2620 Inlay - porcelain/ceramic - two surfaces E1

D2630 Inlay - porcelain/ceramic - three or more surfaces E1

D2642 Onlay - porcelain/ceramic - two surfaces E1

D2643 Onlay - porcelain/ceramic - three surfaces E1

D2644 Onlay - porcelain/ceramic - four or more surfaces E1

D2650 Inlay - resin-based composite - one surface E1

D2651 Inlay - resin-based composite - two surfaces E1

D2652 Inlay - resin-based composite - three or more surfaces E1

D2662 Onlay - resin-based composite - two surfaces E1

D2663 Onlay - resin-based composite - three surfaces E1

D2664 Onlay - resin-based composite - four or more surfaces E1

Crowns – Single Restoration Only

D2710 Crown - resin-based composite (indirect) E1

D2712 Crown - 3/4 resin-based composite (indirect) E1

This procedure does not include facial veneers.

D2720 Crown - resin with high noble metal E1

D2721 Crown - resin with predominantly base metal E1

D2722 Crown - resin with noble metal E1

D2740 Crown - porcelain/ceramic E1

D2750 Crown - porcelain fused to high noble metal E1

D2751 Crown - porcelain fused to predominantly base metal E1

D2752 Crown - porcelain fused to noble metal E1

D2780 Crown - 3/4 cast high noble metal E1

D2781 Crown - 3/4 cast predominantly base metal E1

D2782 Crown - 3/4 cast noble metal E1

D2783 Crown - 3/4 porcelain/ceramic E1

This procedure does not include facial veneers.
D2790 Crown - full cast high noble metal E1

D2791 Crown - full cast predominantly base metal E1

D2792 Crown - full cast noble metal E1

D2794 Crown - titanium E1

D2799 Provisional crown - further treatment or completion of diagnosis necessary prior to final
impression E1

Not to be used as a temporary crown for a routine prosthetic restoration.

Other Restorative Services

D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration E1

D2915 Re-cement or re-bond indirectly fabricated cast or prefabricated post and core E1

D2920 Re-cement or re-bond crown E1

D2921 Reattachment of tooth fragment, incisal edge or cusp E1

D2929 Prefabricated porcelain/ceramic crown - primary tooth E1

D2930 Prefabricated stainless steel crown - primary tooth E1

D2931 Prefabricated stainless steel crown - permanent tooth E1

D2932 Prefabricated resin crown E1

D2933 Prefabricated stainless steel crown with resin window E1

267
 Open-face stainless steel crown with aesthetic resin facing or veneer.
D2934 Prefabricated esthetic coated stainless steel crown - primary tooth E1

Stainless steel primary crown with exterior esthetic coating.

D2940 Protective restoration E1
Direct placement of a restorative material to protect tooth and/or tissue form. This procedure
may be used to relieve pain, promote healing, or prevent further deterioration. Not to be used
for endodontic access closure, or as a base or liner under a restoration.
D2941 Interim therapeutic restoration - primary dentition E1
Placement of an adhesive restorative material following caries debridement by hand or other
method for the management of early childhood caries. Not considered a definitive restoration.
D2949 Restorative foundation for an indirect restoration E1
Placement of restorative material to yield a more ideal form, including elimination of
undercuts.
D2950 Core build-up, including any pins when required E1
Refers to building up of coronal structure when there is insufficient retention for a separate
extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box
form, or concave irregularity in a preparation.
D2951 Pin retention - per tooth, in addition to restoration E1

D2952 Post and core in addition to crown, indirectly fabricated E1

Post and core are custom fabricated as a single unit.
D2953 Each additional indirectly fabricated post - same tooth E1

To be used with D2952.

D2954 Prefabricated post and core in addition to crown E1

Core is built around a prefabricated post. This procedure includes the core material.
D2955 Post removal E1

D2957 Each additional prefabricated post - same tooth E1

To be used with D2954.
D2960 Labial veneer (laminate) - chairside E1
Refers to labial/facial direct resin bonded veneers.
D2961 Labial veneer (resin laminate) - laboratory E1

Refers to labial/facial indirect resin bonded veneers.

D2962 Labial veneer (porcelain laminate) - laboratory E1
Refers also to facial veneers that extend interproximally and/or cover the incisal edge.
Porcelain/ceramic veneers presently include all ceramic and porcelain veneers.
D2971 Additional procedures to construct new crown under existing partial denture framework E1
To be reported in addition to a crown code.
D2975 Coping E1

A thin covering of the coronal portion of a tooth, usually devoid of anatomic contour, that can
be used as a definitive restoration.
D2980 Crown repair, necessitated by restorative material failure E1

D2981 Inlay repair necessitated by restorative material failure E1

D2982 Onlay repair necessitated by restorative material failure E1

D2983 Veneer repair necessitated by restorative material failure E1

D2990 Resin infiltration of incipient smooth surface lesions E1

Placement of an infiltrating resin restoration for strengthening, stabilizing and/or limiting the
progression of the lesion.

None
D2999 Unspecified restorative procedure, by report S

Use for procedure that is not adequately described by a code. Describe procedure.

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Endodontics (D3110-D3999)
Pulp Capping
D3110 Pulp cap - direct (excluding final restoration) E1
Procedure in which the exposed pulp is covered with a dressing or cement that protects the
pulp and promotes healing and repair.
D3120 Pulp cap - indirect (excluding final restoration) E1
Procedure in which the nearly exposed pulp is covered with a protective dressing to protect
the pulp from additional injury and to promote healing and repair via formation of secondary
dentin. This code is not to be used for bases and liners when all caries has been removed.

Pulpotomy
D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the
dentinocemental junction and application of medicament E1

Pulpotomy is the surgical removal of a portion of the pulp with the aim of maintaining the
vitality of the remaining portion by means of an adequate dressing.
– To be performed on primary or permanent teeth.
– This is not to be construed as the first stage of root canal therapy.
– Not to be used for apexogenesis.
D3221 Pulpal debridement, primary and permanent teeth E1

Pulpal debridement for the relief of acute pain prior to conventional root canal therapy. This
procedure is not to be used when endodontic treatment is completed on the same day.
D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development
Removal of a portion of the pulp and application of a medicament with the aim of E1

maintaining the vitality of the remaining portion to encourage continued physiological

development and formation of the root. This procedure is not to be construed as the first
stage of root canal therapy.

Endodontic Therapy on Primary Teeth

D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) E1
Primary incisors and cuspids.
D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
Primary first and second molars. E1

Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care)
D3310 Endodontic therapy, anterior tooth (excluding final restoration) E1

D3320 Endodontic therapy, premolar tooth (excluding final restoration) E1

D3330 Endodontic therapy, molar (excluding final restoration) E1

D3331 Treatment of root canal obstruction; non-surgical access E1

In lieu of surgery, the formation of a pathway to achieve an apical seal without surgical
intervention because of a non-negotiable root canal blocked by foreign bodies, including but
not limited to separated instruments, broken posts or calcification of 50% or more of the
length of the tooth root.
D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth E1

Considerable time is necessary to determine diagnosis and/or provide initial treatment before
the fracture makes the tooth unretainable.
D3333 Internal root repair of perforation defects E1

Non-surgical seal of perforation caused by resorption and/or decay but not iatrogenic by
provider filing claim.

Endodontic Retreatment
D3346 Retreatment of previous root canal therapy - anterior E1

269
 D3347 Retreatment of previous root canal therapy - premolar E1

D3348 Retreatment of previous root canal therapy - molar E1

Apexification/Recalcification
D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root
resorption, etc.) E1
Includes opening tooth, preparation of canal spaces, first placement of medication and
necessary radiographs. (This procedure may include first phase of complete root canal
therapy.)
D3352 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of
perforations, root resorption, pulp space disinfection, etc.) E1
For visits in which the intra-canal medication is replaced with new medication. Includes any
necessary radiographs.
D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical
closure/calcific repair of perforations, root resorption, etc.) E1
Includes removal of intra-canal medication and procedures necessary to place final root canal
filling material including necessary radiographs. (This procedure includes last phase of
complete root canal therapy.)

Pulpal Regeneration
D3355 Pulpal regeneration - initial visit E1

Includes opening tooth, preparation of canal spaces, placement of medication.

D3356 Pulpal regeneration - interim medication replacement E1

D3357 Pulpal regeneration - completion of treatment E1

Does not include final restoration.

Apicoectomy/Periradicular Services
D3410 Apicoectomy - anterior E1

For surgery on root of anterior tooth. Does not include placement of retrograde filling
material.
D3421 Apicoectomy - premolar (first root) E1
For surgery on one root of a premolar. Does not include placement of retrograde filling
material. If more than one root is treated, see D3426.
D3425 Apicoectomy - molar (first root) E1

For surgery on one root of a molar tooth. Does not include placement of retrograde filling
material. If more than one root is treated, see D3426.
D3426 Apicoectomy (each additional root) E1

Typically used for premolar and molar surgeries when more than one root is treated during
the same procedure. This does not include retrograde filling material placement.
D3427 Periradicular surgery without apicoectomy E1

D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site E1

Includes non-autogenous graft material.

D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the
same surgical site E1

Includes non-autogenous graft material.

D3430 Retrograde filling - per root E1
For placement of retrograde filling material during periradicular surgery procedures. If more
than one filling is placed in one root - report as D3999 and describe.
D3431 Bologic materials to aid in soft and osseous tissue regeneration in conjunction with
periradicular surgery E1

D3432 Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular

270
 surgery E1

D3450 Root amputation - per root E1

Root resection of a multi-rooted tooth while leaving the crown. If the crown is sectioned, see
D3920.
D3460 Endodontic endosseous implant S
Placement of implant material, which extends from a pulpal space into the bone beyond the
end of the root.
D3470 Intentional replantation (including necessary splinting) E1
For the intentional removal, inspection and treatment of the root and replacement of a tooth
into its own socket. This does not include necessary retrograde filling material placement.

Other Endodontic Procedures

D3910 Surgical procedure for isolation of tooth with rubber dam E1

D3920 Hemisection (including any root removal), not including root canal therapy E1
Includes separation of a multi-rooted tooth into separate sections containing the root and the
overlying portion of the crown. It may also include the removal of one or more of those
sections.
D3950 Canal preparation and fitting of preformed dowel or post E1

Should not be reported in conjunction with D2952, D2953, D2954 or D2957 by the same
practitioner.

None
D3999 Unspecified endodontic procedure, by report S

Used for procedure that is not adequately described by a code. Describe procedure.

Periodontics (D4210-D4999)
Surgical Services (Including Usual Postoperative Care)
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per
quadrant E1

It is performed to eliminate suprabony pockets or to restore normal architecture when gingival

enlargements or asymmetrical or unaesthetic topography is evident with normal bony
configuration.
Cross Reference 41820
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per
quadrant E1

It is performed to eliminate suprabony pockets or to restore normal architecture when gingival

enlargements or asymmetrical or unaesthetic topography is evident with normal bony
configuration.
D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth E1

D4230 Anatomical crown exposure - four or more contiguous teeth or bounded tooth spaces per
quadrant E1

This procedure is utilized in an otherwise periodontally healthy area to remove enlarged

gingival tissue and supporting bone (ostectomy) to provide an anatomically correct gingival
relationship.
D4231 Anatomical crown exposure - one to three teeth or bounded tooth spaces per quadrant E1

This procedure is utilized in an otherwise periodontally healthy area to remove enlarged

gingival tissue and supporting bone (ostectomy) to provide an anatomically correct gingival
relationship.
D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth
bounded spaces per quadrant E1

A soft tissue flap is reflected or resected to allow debridement of the root surface and the
removal of granulation tissue. Osseous recontouring is not accomplished in conjunction with

271
 this procedure. May include open flap curettage, reverse bevel flap surgery, modified Kirkland
flap procedure, and modified Widman surgery. This procedure is performed in the presence
of moderate to deep probing depths, loss of attachment, need to maintain esthetics, need for
increased access to the root surface and alveolar bone, or to determine the presence of a
cracked tooth, fractured root, or external root resorption. Other procedures may be required
concurrent to D4240 and should be reported separately using their own unique codes.
D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth
bounded spaces per quadrant E1
A soft tissue flap is reflected or resected to allow debridement of the root surface and the
removal of granulation tissue. Osseous recontouring is not accomplished in conjunction with
this procedure. May include open flap curettage, reverse bevel flap surgery, modified Kirkland
flap procedure, and modified Widman surgery. This procedure is performed in the presence
of moderate to deep probing depths, loss of attachment, need to maintain esthetics, need for
increased access to the root surface and alveolar bone, or to determine the presence of a
cracked tooth, fractured root, or external root resorption. Other procedures may be required
concurrent to D4241 and should be reported separately using their own unique codes.
D4245 Apically positioned flap E1
Procedure is used to preserve keratinized gingiva in conjunction with osseous resection and
second stage implant procedure. Procedure may also be used to preserve keratinized/attached
gingiva during surgical exposure of labially impacted teeth, and may be used during treatment
of periimplantitis.
D4249 Clinical crown lengthening - hard tissue E1

This procedure is employed to allow a restorative procedure on a tooth with little or no tooth
structure exposed to the oral cavity. Crown lengthening requires reflection of a full thickness
flap and removal of bone, altering the crown to root ratio. It is performed in a healthy
periodontal environment, as opposed to osseous surgery, which is performed in the presence
of periodontal disease.
D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more
contiguous teeth or tooth bounded spaces per quadrant S

This procedure modifies the bony support of the teeth by reshaping the alveolar process to
achieve a more physiologic form during the surgical procedure. This must include the removal
of supporting bone (ostectomy) and/or non-supporting bone (osteoplasty). Other procedures
may be required concurrent to D4260 and should be reported using their own unique codes.
D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three
contiguous teeth or tooth bounded spaces per quadrant E1
This procedure modifies the bony support of the teeth by reshaping the alveolar process to
achieve a more physiologic form during the surgical procedure. This must include the removal
of supporting bone (ostectomy) and/or non-supporting bone (osteoplasty). Other procedures
may be required concurrent to D4261 and should be reported using their own unique codes.
D4263 Bone replacement graft - retained natural tooth - first site in quadrant S

This procedure involves the use of grafts to stimulate periodontal regeneration when the
disease process has led to a deformity of the bone. This procedure does not include flap entry
and closure, wound debridement, osseous contouring, or the placement of biologic materials
to aid in osseous tissue regeneration or barrier membranes. Other separate procedures
delivered concurrently are documented with their own codes. Not to be reported for an
edentulous space or an extraction site.
D4264 Bone replacement graft - retained natural tooth - each additional site in quadrant S
This procedure involves the use of grafts to stimulate periodontal regeneration when the
disease process has led to a deformity of the bone. This procedure does not include flap entry
and closure, wound debridement, osseous contouring, or the placement of biologic materials
to aid in osseous tissue regeneration or barrier membranes. This procedure is performed
concurrently with one or more bone replacement grafts to document the number of sites
involved. Not to be reported for an edentulous space or an extraction site.
D4265 Biologic materials to aid in soft and osseous tissue regeneration E1

Biologic materials may be used alone or with other regenerative substrates such as bone and

272
 barrier membranes, depending upon their formulation and the presentation of the periodontal
defect. This procedure does not include surgical entry and closure, wound debridement,
osseous contouring, or the placement of graft materials and/or barrier membranes. Other
separate procedures may be required concurrent to D4265 and should be reported using their
own unique codes.
D4266 Guided tissue regeneration - resorbable barrier, per site E1
This procedure does not include flap entry and closure, or, when indicated, wound
debridement, osseous contouring, bone replacement grafts, and placement of biologic
materials to aid in osseous regeneration. This procedure can be used for periodontal and peri-
implant defects.
D4267 Guided tissue regeneration - nonresorbable barrier, per site, (includes membrane removal)
This procedure does not include flap entry and closure, or, when indicated, wound E1
debridement, osseous contouring, bone replacement grafts, and placement of biologic
materials to aid in osseous regeneration. This procedure can be used for periodontal and peri-
implant defects.
D4268 Surgical revision procedure, per tooth S
This procedure is to refine the results of a previously provided surgical procedure. This may
require a surgical procedure to modify the irregular contours of hard or soft tissue. A
mucoperiosteal flap may be elevated to allow access to reshape alveolar bone. The flaps are
replaced or repositioned and sutured.
D4270 Pedicle soft tissue graft procedure S

A pedicle flap of gingiva can be raised from an edentulous ridge, adjacent teeth, or from the
existing gingiva on the tooth and moved laterally or coronally to replace alveolar mucosa as
marginal tissue. The procedure can be used to cover an exposed root or to eliminate a gingival
defect if the root is not too prominent in the arch.
D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites)
first tooth, implant, or edentulous tooth position in graft S
There are two surgical sites. The recipient site utilizes a split thickness incision, retaining the
overlapping flap of gingiva and/or mucosa. The connective tissue is dissected from a separate
donor site leaving an epithelialized flap for closure.
D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjuction with surgical
procedures in the same anatomical area) E1

This procedure is performed in an edentulous area adjacent to a tooth, allowing removal of a

tissue wedge to gain access for debridement, permit close flap adaptation, and reduce pocket
depths.
D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first
tooth, implant, or edentulous tooth position in graft E1

There is only a recipient surgical site utilizing split thickness incision, retaining the overlaying
flap of gingiva and/or mucosa. A donor surgical site is not present.
D4276 Combined connective tissue and double pedicle graft, per tooth E1

Advanced gingival recession often cannot be corrected with a single procedure. Combined
tissue grafting procedures are needed to achieve the desired outcome.
D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth,
implant or edentulous tooth position in graft E1

D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional
contiguous tooth, implant or edentulous tooth position in same graft site E1

Used in conjunction with D4277.

D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) -
each additional contiguous tooth, implant or edentulous tooth position in same graft site
Used in conjunction with D4273. E1

D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor
material) - each additional contiguous tooth, implant or edentulous tooth position in same
graft site E1

273
 Used in conjunction with D4275.

Non-Surgical Periodontal Services

D4320 Provisional splinting - intracoronal E1
This is an interim stabilization of mobile teeth. A variety of methods and appliances may be
employed for this purpose. Identify the teeth involved.
D4321 Provisional splinting - extracoronal E1
This is an interim stabilization of mobile teeth. A variety of methods and appliances may be
employed for this purpose. Identify the teeth involved.
D4341 Periodontal scaling and root planing - four or more teeth per quadrant E1
This procedure involves instrumentation of the crown and root surfaces of the teeth to remove
plaque and calculus from these surfaces. It is indicated for patients with periodontal disease
and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure
designed for the removal of cementum and dentin that is rough, and/or permeated by calculus
or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This
procedure may be used as a definitive treatment in some stages of periodontal disease and/or
as a part of pre-surgical procedures in others.
D4342 Periodontal scaling and root planing - one to three teeth, per quadrant E1

This procedure involves instrumentation of the crown and root surfaces of the teeth to remove
plaque and calculus from these surfaces. It is indicated for patients with periodontal disease
and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure
designed for the removal of cementum and dentin that is rough, and/or permeated by calculus
or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This
procedure may be used as a definitive treatment in some stages of periodontal disease and/or
as a part of pre-surgical procedures in others.
D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth,
after oral evaluation E1

The removal of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when
there is generalized moderate or severe gingival inflammation in the absence of periodontitis.
It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets,
and moderate to severe bleeding on probing. Should not be reported in conjunction with
prophylaxis, scaling and root planing, or debridement procedures.
D4355 Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a
subsequent visit S

Full mouth debridement involves the preliminary removal of plaque and calculus that
interferes with the ability of the dentist to perform a comprehensive oral evaluation. Not to be
completed on the same day as D0150, D0160, or D0180.
D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased
crevicular tissue, per tooth S

FDA approved subgingival delivery devices containing antimicrobial medication(s) are

inserted into periodontal pockets to suppress the pathogenic microbiota. These devices slowly
release the pharmacological agents so they can remain at the intended site of action in a
therapeutic concentration for a sufficient length of time.

Other Periodontal Services

D4910 Periodontal maintenance E1

This procedure is instituted following periodontal therapy and continues at varying intervals,
determined by the clinical evaluation of the dentist, for the life of the dentition or any implant
replacements. It includes removal of the bacterial plaque and calculus from supragingival and
subgingival regions, site specific scaling and root planing where indicated, and polishing the
teeth. If new or recurring periodontal disease appears, additional diagnostic and treatment
procedures must be considered.
D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) E1

274
 D4921 Gingival irrigation - per quadrant E1
Irrigation of gingival pockets with medicinal agent. Not to be used to report use of mouth
rinses or noninvasive chemical debridement.

None
D4999 Unspecified periodontal procedure, by report E1
Use for procedure that is not adequately described by a code. Describe procedure.

Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care)
D5110 Complete denture - maxillary E1

D5120 Complete denture - mandibular E1

D5130 Immediate denture - maxillary E1

Includes limited follow-up care only; does not include required future rebasing/relining
procedure(s).
D5140 Immediate denture - mandibular E1

Includes limited follow-up care only; does not include required future rebasing/relining
procedure(s).

Partial Dentures (Including Routine Post-Delivery Care)

D5211 Maxillary partial denture-resin base (including retentive/clasping materials, rests and teeth)
Includes acrylic resin base denture with resin or wrought wire clasps. E1

D5212 Mandibular partial denture-resin base (including, retentive/clasping materials, rests and teeth)
E1
Includes acrylic resin base denture with resin or wrought wire clasps.
D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any
conventional clasps, rests and teeth) E1

D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any
conventional clasps, rests and teeth) E1

D5221 Immediate maxillary partial denture - resin base (including any conventional clasps, rests and
teeth) E1
Includes limited follow-up care only; does not include future rebasing/relining procedure(s).
D5222 Immediate mandibular partial denture - resin base (including any conventional clasps, rests
and teeth) E1

Includes limited follow-up care only; does not include future rebasing/relining procedure(s).
D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases
(including any conventional clasps, rests and teeth) E1
Includes limited follow-up care only; does not include future rebasing/relining procedure(s).
D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases
(including any conventional clasps, rests and teeth) E1

Includes limited follow-up care only; does not include future rebasing/relining procedure(s).
D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) E1

D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) E1

▶ D5282 Removable unilateral partial denture - one piece cast metal (including clasps and teeth),
maxillary E1

▶ D5283 Removable unilateral partial denture - one piece cast metal (including clasps and teeth),
mandibular E1

Adjustment to Dentures
D5410 Adjust complete denture - maxillary E1

D5411 Adjust complete denture - mandibular E1

275
 D5421 Adjust partial denture - maxillary E1

D5422 Adjust partial denture - mandibular E1

Repairs to Complete Dentures

D5511 Repair broken complete denture base, mandibular E1

D5512 Repair broken complete denture base, maxillary E1

D5520 Replace missing or broken teethcomplete denture (each tooth) E1

Repairs to Partial Dentures

D5611 Repair resin partial denture base, mandibular E1

D5612 Repair resin partial denture base, maxillary E1

D5621 Repair cast partial framework, mandibular E1

D5622 Repair cast partial framework, maxillary E1

D5630 Repair or replace broken, retentive clasping materials - per tooth E1

D5640 Replace broken teeth - per tooth E1

D5650 Add tooth to existing partial denture E1

D5660 Add clasp to existing partial denture - per tooth E1

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) E1

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) E1

Denture Rebase Procedures

D5710 Rebase complete maxillary denture E1

D5711 Rebase complete mandibular denture E1

D5720 Rebase maxillary partial denture E1

D5721 Rebase mandibular partial denture E1

Denture Reline Procedures

D5730 Reline complete maxillary denture (chairside) E1

D5731 Reline lower complete mandibular denture (chairside) E1

D5740 Reline maxillary partial denture (chairside) E1

D5741 Reline mandibular partial denture (chairside) E1

D5750 Reline complete maxillary denture (laboratory) E1

D5751 Reline complete mandibular denture (laboratory) E1

D5760 Reline maxillary partial denture (laboratory) E1

D5761 Reline mandibular partial denture (laboratory) E1

Interim Prosthesis
D5810 Interim complete denture (maxillary) E1

D5811 Interim complete denture (mandibular) E1

D5820 Interim partial denture (maxillary) E1

Includes any necessary clasps and rests.

D5821 Interim partial denture (mandibular) E1

Includes any necessary clasps and rests.

Other Removable Prosthetic Services

D5850 Tissue conditioning, maxillary E1

Treatment reline using materials designed to heal unhealthy ridges prior to more definitive
final restoration.
D5851 Tissue conditioning, mandibular E1

276
 Treatment reline using materials designed to heal unhealthy ridges prior to more definitive
final restoration.
D5862 Precision attachment, by report E1
Each set of male and female components should be reported as one precision attachment.
Describe the type of attachment used.
D5863 Overdenture - complete maxillary E1

D5864 Overdenture - partial maxillary E1

D5865 Overdenture - complete mandibular E1

D5866 Overdenture - partial mandibular E1

D5867 Replacement of replaceable part of semi-precision or precision attachment (male or female

component) E1

D5875 Modification of removable prosthesis following implant surgery E1

Attachment assemblies are reported using separate codes.

Add metal substructure to acrylic full denture (per arch) E1
▶ D5876

None
D5899 Unspecified removable prosthodontic procedure, by report E1
Use for a procedure that is not adequately described by a code. Describe procedure.

Maxillofacial Prosthetics
D5911 Facial moulage (sectional) S

A sectional facial moulage impression is a procedure used to record the soft tissue contours of
a portion of the face. Occasionally several separate sectional impressions are made, then
reassembled to provide a full facial contour cast. The impression is utilized to create a partial
facial moulage and generally is not reusable.
D5912 Facial moulage (complete) S
Synonymous terminology: facial impression, face mask impression. A complete facial moulage
impression is a procedure used to record the soft tissue contours of the whole face. The
impression is utilized to create a facial moulage and generally is not reusable.
D5913 Nasal prosthesis E1

Synonymous terminology: artificial nose. A removable prosthesis attached to the skin, which
artificially restores part or all of the nose. Fabrication of a nasal prosthesis requires creation of
an original mold. Additional prostheses usually can be made from the same mold, and
assuming no further tissue changes occur, the same mold can be utilized for extended periods
of time. When a new prosthesis is made from the existing mold, this procedure is termed a
nasal prosthesis replacement.
Cross Reference 21087
D5914 Auricular prosthesis E1

Synonymous terminology: artificial ear, ear prosthesis. A removable prosthesis, which

artificially restores part or all of the natural ear. Usually, replacement prostheses can be made
from the original mold if tissue bed changes have not occurred. Creation of an auricular
prosthesis requires fabrication of a mold, from which additional prostheses usually can be
made, as needed later (auricular prosthesis, replacement).
Cross Reference 21086
D5915 Orbital prosthesis E1

A prosthesis, which artificially restores the eye, eyelids, and adjacent hard and soft tissue, lost
as a result of trauma or surgery. Fabrication of an orbital prosthesis requires creation of an
original mold. Additional prostheses usually can be made from the same mold, and assuming
no further tissue changes occur, the same mold can be utilized for extended periods of time.
When a new prosthesis is made from the existing mold, this procedure is termed an orbital
prosthesis replacement.
Cross Reference L8611

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D5916 Ocular prosthesis E1
Synonymous terminology: artificial eye, glass eye. A prosthesis, which artificially replaces an
eye missing as a result of trauma, surgery or congenital absence. The prosthesis does not
replace missing eyelids or adjacent skin, mucosa or muscle. Ocular prostheses require
semiannual or annual cleaning and polishing. Also, occasional revisions to re-adapt the
prosthesis to the tissue bed may be necessary. Glass eyes are rarely made and cannot be re-
adapted.
Cross Reference V2623, V2629
D5919 Facial prosthesis E1
Synonymous terminology: prosthetic dressing. A removable prosthesis, which artificially
replaces a portion of the face, lost due to surgery, trauma or congenital absence. Flexion of
natural tissues may preclude adaptation and movement of the prosthesis to match the adjacent
skin. Salivary leakage, when communicating with the oral cavity, adversely affects retention.
Cross Reference 21088
D5922 Nasal septal prosthesis E1

Synonymous terminology: septal plug, septal button. Removable prosthesis to occlude

(obturate) a hole within the nasal septal wall. Adverse chemical degradation in this moist
environment may require frequent replacement. Silicone prostheses are occasionally subject to
fungal invasion.
Cross Reference 30220
D5923 Ocular prosthesis, interim E1

Synonymous terminology: eye shell, shell, ocular conformer, conformer. A temporary

replacement generally made of clear acrylic resin for an eye lost due to surgery or trauma. No
attempt is made to re-establish esthetics. Fabrication of an interim ocular prosthesis generally
implies subsequent fabrication of an aesthetic ocular prosthesis.
Cross Reference 92330
D5924 Cranial prosthesis E1

Synonymous terminology: skull plate, cranioplasty prosthesis, cranial implant. A

biocompatible, permanently implanted replacement of a portion of the skull bones; an
artificial replacement for a portion of the skull bone.
Cross Reference 62143
D5925 Facial augmentation implant prosthesis E1
Synonymous terminology: facial implant. An implantable biocompatible material generally
onlayed upon an existing bony area beneath the skin tissue to fill in or collectively raise
portions of the overlaying facial skin tissues to create acceptable contours. Although some
forms of pre-made surgical implants are commercially available, the facial augmentation is
usually custom made for surgical implantation for each individual patient due to the irregular
or extensive nature of the facial deficit.
Cross Reference 21208
D5926 Nasal prosthesis, replacement E1

Synonymous terminology: replacement nose. An artificial nose produced from a previously

made mold. A replacement prosthesis does not require fabrication of a new mold. Generally,
several prostheses can be made from the same mold assuming no changes occur in the tissue
bed due to surgery or age related topographical variations.
Cross Reference 21087
D5927 Auricular prosthesis, replacement E1

Synonymous terminology: replacement ear. An artificial ear produced from a previously made
mold. A replacement prosthesis does not require fabrication of a new mold. Generally, several
prostheses can be made from the same mold assuming no changes occur in the tissue bed due
to surgery or age related topographical variations.
Cross Reference 21086
D5928 Orbital prosthesis, replacement E1
A replacement for a previously made orbital prosthesis. A replacement prosthesis does not
require fabrication of a new mold. Generally, several prostheses can be made from the same

278
 mold assuming no changes occur in the tissue bed due to surgery or age related topographical
variations.
Cross Reference 67550
D5929 Facial prosthesis, replacement E1
A replacement facial prosthesis made from the original mold. A replacement prosthesis does
not require fabrication of a new mold. Generally, several prostheses can be made from the
same mold assuming no changes occur in the tissue bed due to further surgery or age related
topographical variations.
Cross Reference 21088
D5931 Obturator prosthesis, surgical E1
Synonymous terminology: obturator, surgical stayplate, immediate temporary obturator. A
temporary prosthesis inserted during or immediately following surgical or traumatic loss of a
portion or all of one or both maxillary bones and contiguous alveolar structures (e.g., gingival
tissue, teeth). Frequent revisions of surgical obturators are necessary during the ensuing
healing phase (approximately six months). Some dentists prefer to replace many or all teeth
removed by the surgical procedure in the surgical obturator, while others do not replace any
teeth. Further surgical revisions may require fabrication of another surgical obturator (e.g., an
initially planned small defect may be revised and greatly enlarged after the final pathology
report indicates margins are not free of tumor).
Cross Reference 21079
D5932 Obturator prosthesis, definitive E1

Synonymous terminology: obturator. A prosthesis, which artificially replaces part or all of the
maxilla and associated teeth, lost due to surgery, trauma or congenital defects. A definitive
obturator is made when it is deemed that further tissue changes or recurrence of tumor are
unlikely and a more permanent prosthetic rehabilitation can be achieved; it is intended for
long-term use.
Cross Reference 21080
D5933 Obturator prosthesis, modification E1

Synonymous terminology: adjustment, denture adjustment, temporary or office reline.

Revision or alteration of an existing obturator (surgical, interim, or definitive); possible
modifications include relief of the denture base due to tissue compression, augmentation of
the seal or peripheral areas to affect adequate sealing or separation between the nasal and oral
cavities.
Cross Reference 21080
D5934 Mandibular resection prosthesis with guide flange E1

Synonymous terminology: resection device, resection appliance. A prosthesis which guides the
remaining portion of the mandible, left after a partial resection, into a more normal
relationship with the maxilla. This allows for some tooth-to-tooth or an improved tooth
contact. It may also artificially replace missing teeth and thereby increase masticatory
efficiency.
Cross Reference 21081
D5935 Mandibular resection prosthesis without guide flange E1

A prosthesis which helps guide the partially resected mandible to a more normal relation with
the maxilla allowing for increased tooth contact. It does not have a flange or ramp, however,
to assist in directional closure. It may replace missing teeth and thereby increase masticatory
efficiency. Dentists who treat mandibulectomy patients may prefer to replace some, all or
none of the teeth in the defect area. Frequently, the defect’s margins preclude even partial
replacement. Use of a guide (a mandibular resection prosthesis with a guide flange) may not
be possible due to anatomical limitations or poor patient tolerance. Ramps, extended occlusal
arrangements and irregular occlusal positioning relative to the denture foundation frequently
preclude stability of the prostheses, and thus some prostheses are poorly tolerated under such
adverse circumstances.
Cross Reference 21081
D5936 Obturator/prosthesis, interim E1

279
 Synonymous terminology: immediate postoperative obturator. A prosthesis which is made
following completion of the initial healing after a surgical resection of a portion or all of one
or both the maxillae; frequently many or all teeth in the defect area are replaced by this
prosthesis. This prosthesis replaces the surgical obturator, which is usually inserted at, or
immediately following the resection.
Generally, an interim obturator is made to facilitate closure of the resultant defect after initial
healing has been completed. Unlike the surgical obturator, which usually is made prior to
surgery and frequently revised in the operating room during surgery, the interim obturator is
made when the defect margins are clearly defined and further surgical revisions are not
planned. It is a provisional prosthesis, which may replace some or all lost teeth, and other lost
bone and soft tissue structures. Also, it frequently must be revised (termed an obturator
prosthesis modification) during subsequent dental procedures (e.g., restorations, gingival
surgery) as well as to compensate for further tissue shrinkage before a definitive obturator
prosthesis is made.
Cross Reference 21079
D5937 Trismus appliance (not for tm treatment) E1
Synonymous terminology: occlusal device for mandibular trismus, dynamic bite opener. A
prosthesis, which assists the patient in increasing their oral aperture width in order to eat as
well as maintain oral hygiene. Several versions and designs are possible, all intending to ease
the severe lack of oral opening experienced by many patients immediately following extensive
intraoral surgical procedures.
D5951 Feeding aid E1

Synonymous terminology: feeding prosthesis. A prosthesis, which maintains the right and left
maxillary segments of an infant cleft palate patient in their proper orientation until surgery is
performed to repair the cleft. It closes the oral-nasal cavity defect, thus enhancing sucking and
swallowing. Used on an interim basis, this prosthesis achieves separation of the oral and nasal
cavities in infants born with wide clefts necessitating delayed closure. It is eliminated if
surgical closure can be affected or, alternatively, with eruption of the deciduous dentition a
pediatric speech aid may be made to facilitate closure of the defect.
D5952 Speech aid prosthesis, pediatric E1

Synonymous terminology: nasopharyngeal obturator, speech appliance, obturator, cleft palate

appliance, prosthetic speech aid, speech bulb. A temporary or interim prosthesis used to close
a defect in the hard and/or soft palate. It may replace tissue lost due to developmental or
surgical alterations. It is necessary for the production of intelligible speech. Normal lateral
growth of the palatal bones necessitates occasional replacement of this prosthesis. Intermittent
revisions of the obturator section can assist in maintenance of palatalpharyngeal closure
(termed a speech aid prosthesis modification). Frequently, such prostheses are not fabricated
before the deciduous dentition is fully erupted since clasp retention is often essential.
Cross Reference 21084
D5953 Speech aid prosthesis, adult E1

Synonymous terminology: prosthetic speech appliance, speech aid, speech bulb. A definitive
prosthesis, which can improve speech in adult cleft palate patients either by obturating
(sealing off) a palatal cleft or fistula, or occasionally by assisting an incompetent soft palate.
Both mechanisms are necessary to achieve velopharyngeal competency. Generally, this
prosthesis is fabricated when no further growth is anticipated and the objective is to achieve
long-term use. Hence, more precise materials and techniques are utilized. Occasionally such
procedures are accomplished in conjunction with precision attachments in crown work
undertaken on some or all maxillary teeth to achieve improved aesthetics.
Cross Reference 21084
D5954 Palatal augmentation prosthesis E1

Synonymous terminology: superimposed prosthesis, maxillary glossectomy prosthesis,

maxillary speech prosthesis, palatal drop prosthesis. A removable prosthesis which alters the
hard and/or soft palate’s topographical form adjacent to the tongue.
Cross Reference 21082
D5955 Palatal lift prosthesis, definitive E1

280
 A prosthesis which elevates the soft palate superiorly and aids in restoration of soft palate
functions which may be lost due to an acquired, congenital or developmental defect. A
definitive palatal lift is usually made for patients whose experience with an interim palatal lift
has been successful, especially if surgical alterations are deemed unwarranted.
Cross Reference 21083
D5958 Palatal lift prosthesis, interim E1
Synonymous terminology: diagnostic palatal lift. A prosthesis which elevates and assists in
restoring soft palate function which may be lost due to clefting, surgery, trauma or unknown
paralysis. It is intended for interim use to determine its usefulness in achieving
palatalpharyngeal competency or enhance swallowing reflexes. This prosthesis is intended for
interim use as a diagnostic aid to assess the level of possible improvement in speech
intelligibility. Some clinicians believe use of a palatal lift on an interim basis may stimulate an
otherwise flaccid soft palate to increase functional activity, subsequently lessening its need.
Cross Reference 21083
D5959 Palatal lift prosthesis, modification E1

Synonymous terminology: revision of lift, adjustment. Alterations in the adaptation, contour,

form or function of an existing palatal lift necessitated due to tissue impingement, lack of
function, poor clasp adaptation or the like.
Cross Reference 21083
D5960 Speech aid prosthesis, modification E1
Synonymous terminology: adjustment, repair, revision. Any revision of a pediatric or adult
speech aid not necessitating its replacement. Frequently, revisions of the obturating section of
any speech aid is required to facilitate enhanced speech intelligibility. Such revisions or repairs
do not require complete remaking of the prosthesis, thus extending its longevity.
Cross Reference 21084
D5982 Surgical stent E1
Synonymous terminology: periodontal stent, skin graft stent, columellar stent. Stents are
utilized to apply pressure to soft tissues to facilitate healing and prevent cicatrization or
collapse. A surgical stent may be required in surgical and post-surgical revisions to achieve
close approximation of tissues. Usually such materials as temporary or interim soft denture
liners, gutta percha, or dental modeling impression compound may be used.
Cross Reference 21085
D5983 Radiation carrier S
Synonymous terminology: radiotherapy prosthesis, carrier prosthesis, radiation applicator,
radium carrier, intracavity carrier, intracavity applicator. A device used to administer radiation
to confined areas by means of capsules, beads or needles of radiation emitting materials such
as radium or cesium. Its function is to hold the radiation source securely in the same location
during the entire period of treatment. Radiation oncologists occasionally request these devices
to achieve close approximation and controlled application of radiation to a tumor deemed
amiable to eradication.
D5984 Radiation shield S

Synonymous terminology: radiation stent, tongue protector, lead shield. An intraoral

prosthesis designed to shield adjacent tissues from radiation during orthovoltage treatment of
malignant lesions of the head and neck region.
D5985 Radiation cone locator S

Synonymous terminology: docking device, cone locator. A prosthesis utilized to direct and
reduplicate the path of radiation to an oral tumor during a split course of irradiation.
D5986 Fluoride gel carrier E1

Synonymous terminology: fluoride applicator. A prosthesis, which covers the teeth in either
dental arch and is used to apply topical fluoride in close proximity to tooth enamel and dentin
for several minutes daily.
D5987 Commissure splint S

Synonymous terminology: lip splint. A device placed between the lips, which assists in
achieving increased opening between the lips. Use of such devices enhances opening where

281
 surgical, chemical or electrical alterations of the lips has resulted in severe restriction or
contractures.
D5988 Surgical splint E1
Synonymous terminology: Gunning splint, modified Gunning splint, labiolingual splint,
fenestrated splint, Kingsley splint, cast metal splint. Splints are designed to utilize existing
teeth and/or alveolar processes as points of anchorage to assist in stabilization and
immobilization of broken bones during healing. They are used to re-establish, as much as
possible, normal occlusal relationships during the process of immobilization. Frequently,
existing prostheses (e.g., a patient’s complete dentures) can be modified to serve as surgical
splints. Frequently, surgical splints have arch bars added to facilitate intermaxillary fixation.
Rubber elastics may be used to assist in this process. Circummandibular eyelet hooks can be
utilized for enhanced stabilization with wiring to adjacent bone.
D5991 Vesicobullous disease medicament carrier E1

A custom fabricated carrier that covers the teeth and alveolar mucosa, or alveolar mucosa
alone, and is used to deliver prescription medicaments for treatment of immunologically
mediated vesiculobullous disease.
D5992 Adjust maxillofacial prosthetic appliance, by report E1

D5993 Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required
adjustments, by report E1

D5994 Periodontal medicament carrier with peripheral seal - laboratory processed E1

A custom fabricated, laboratory processed carrier that covers the teeth and alveolar mucosa.
Used as a vehicle to deliver prescribed medicaments for sustained contact with the gingiva,
alveolar mucosa, and into the periodontal sulcus or pocket.
D5999 Unspecified maxillofacial prosthesis, by report E1
Used for procedure that is not adequately described by a code. Describe procedure.

Implant Services (D6010-D6199)

D6010-D6199: FPD = fixed partial denture

Surgical Services
D6010 Surgical placement of implant body: endosteal implant E1

Cross Reference 21248

D6011 Second stage implant surgery E1
Surgical access to an implant body for placement of a healing cap or to enable placement of an
abutment.
D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant
Includes removal during later therapy to accommodate the definitive restoration, which E1
may include placement of other implants.
D6013 Surgical placement of mini implant E1

D6040 Surgical placement: eposteal implant E1

An eposteal (subperiosteal) framework of a biocompatible material designed and fabricated to

fit on the surface of the bone of the mandible or maxilla with permucosal extensions which
provide support and attachment of a prosthesis. This may be a complete arch or unilateral
appliance. Eposteal implants rest upon the bone and under the periosteum.
Cross Reference 21245
D6050 Surgical placement: transosteal implant E1

A transosteal (transosseous) biocompatible device with threaded posts penetrating both the
superior and inferior cortical bone plates of the mandibular symphysis and exiting through the
permucosa providing support and attachment for a dental prosthesis. Transosteal implants are
placed completely through the bone and into the oral cavity from extraoral or intraoral.
Cross Reference 21244

Implant Supported Prosthetics

282
D6051 Interim abutment - includes placement and removal E1
Includes placement and removal. A healing cap is not an interim abutment.
D6052 Semi-precision attachment abutment E1
Includes placement of keeper assembly.
D6055 Connecting bar — implant supported or abutment supported E1
Utilized to stabilize and anchor a prosthesis.
D6056 Prefabricated abutment - includes modification and placement E1
Modification of a prefabricated abutment may be necessary.
D6057 Custom fabricated abutment - includes placement E1
Created by a laboratory process, specific for an individual application.
D6058 Abutment supported porcelain/ceramic crown E1
A single crown restoration that is retained, supported and stabilized by an abutment on an
implant.
D6059 Abutment supported porcelain fused to metal crown (high noble metal) E1
A single metal-ceramic crown restoration that is retained, supported and stabilized by an
abutment on an implant.
D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) E1
A single metal-ceramic crown restoration that is retained, supported and stabilized by an
abutment on an implant.
D6061 Abutment supported porcelain fused to metal crown (noble metal) E1

A single metal-ceramic crown restoration that is retained, supported and stabilized by an

abutment on an implant.
D6062 Abutment supported cast metal crown (high noble metal) E1

A single cast metal crown restoration that is retained, supported and stabilized by an
abutment on an implant.
D6063 Abutment supported cast metal crown (predominantly base metal) E1
A single cast metal crown restoration that is retained, supported and stabilized by an
abutment on an implant.
D6064 Abutment supported cast metal crown (noble metal) E1

A single cast metal crown restoration that is retained, supported and stabilized by an
abutment on an implant.
D6065 Implant supported porcelain/ceramic crown E1
A single crown restoration that is retained, supported and stabilized by an implant.
D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
E1
A single metal-ceramic crown restoration that is retained, supported and stabilized by an
implant.
D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) E1

A single cast metal or milled crown restoration that is retained, supported and stabilized by an
implant.
D6068 Abutment supported retainer for porcelain/ceramic FPD E1

A ceramic retainer for a fixed partial denture that gains retention, support and stability from
an abutment on an implant.
D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) E1

A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability
from an abutment on an implant.
D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
A metal-ceramic retainer for a fixed partial denture that gains retention, support and E1

stability from an abutment on an implant.

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) E1

A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability

283
 from an abutment on an implant.
D6072 Abutment supported retainer for cast metal FPD (high noble metal) E1

A cast metal retainer for a fixed partial denture that gains retention, support and stability from
an abutment on an implant.
D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) E1
A cast metal retainer for a fixed partial denture that gains retention, support and stability from
an abutment on an implant.
D6074 Abutment supported retainer for cast metal FPD (noble metal) E1
A cast metal retainer for a fixed partial denture that gains retention, support and stability from
an abutment on an implant.
D6075 Implant supported retainer for ceramic FPD E1
A ceramic retainer for a fixed partial denture that gains retention, support and stability from
an implant.
D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or
high noble metal) E1

A metal-ceramic retainer for a fixed partial denture that gains retention, support and stability
from an implant.
D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)
E1
A cast metal retainer for a fixed partial denture that gains retention, support and stability from
an implant.

Other Implant Services

D6080 Implant maintenance procedures when prostheses are removed and reinserted, including
cleansing of prostheses and abutments E1

This procedure includes active debriding of the implant(s) and examination of all aspects of
the implant system(s), including the occlusion and stability of the superstructure. The patient
is also instructed in thorough daily cleansing of the implant(s). This is not a per implant code,
and is indicated for implant supported fixed prostheses.
D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant,
including cleaning of the implant surfaces, without flap entry and closure E1

This procedure is not performed in conjunction with D1110, D4910, or D4346.

D6085 Provisional implant crown E1

Used when a period of healing is necessary prior to fabrication and placement of permanent
prosthetic.
D6090 Repair implant supported prosthesis by report E1

This procedure involves the repair or replacement of any part of the implant supported
prosthesis.
Cross Reference 21299
D6091 Replacement of semi-precision or precision attachment (male or female component) of
implant/abutment supported prosthesis, per attachment E1

This procedure applies to the replaceable male or female component of the attachment.
D6092 Re-cement or re-bond implant/abutment supported crown E1

D6093 Re-cement or re-bond implant/abutment supported fixed partial denture E1

D6094 Abutment supported crown - (titanium) E1

A single crown restoration that is retained, supported and stabilized by an abutment on an

implant. May be cast or milled.
D6095 Repair implant abutment, by report E1

This procedure involves the repair or replacement of any part of the implant abutment.
Cross Reference 21299
D6096 Remove broken implant retaining screw E1

284
Surgical Services
D6100 Implant removal, by report E1
This procedure involves the surgical removal of an implant. Describe procedure.
Cross Reference 21299
D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface
cleaning of exposed implant surfaces, including flap entry and closure E1

D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single
implant and includes surface cleaning of the exposed implant surfaces and flap entry and
closure E1

D6103 Bone graft for repair of peri-implant defect - does not include flap entry and closure E1
Placement of a barrier membrane or biologic materials to aid in osseous regeneration, are
reported separately.
D6104 Bone graft at time of implant placement E1
Placement of a barrier membrane, or biologic materials to aid in osseous regeneration are
reported separately.

Implant Supported Prosthetics

D6110 Implant/abutment supported removable denture for edentulous arch - maxillary E1

D6111 Implant/abutment supported removable denture for edentulous arch - mandibular E1

D6112 Implant/abutment supported removable denture for partially edentulous arch - maxillary
E1
D6113 Implant/abutment supported removable denture for partially edentulous arch - mandibular
E1
D6114 Implant/abutment supported fixed denture for edentulous arch - maxillary E1

D6115 Implant/abutment supported fixed denture for edentulous arch - mandibular E1

D6116 Implant/abutment supported fixed denture for partially edentulous arch - maxillary E1

D6117 Implant/abutment supported fixed denture for partially edentulous arch - mandibular E1

D6118 Implant/abutment supported interim fixed denture for edentulous arch mandibular E1

Used when a period of healing is necessary prior to fabrication and placement of a permanent
prosthetic.
D6119 Implant/abutment supported interim fixed denture for edentulous arch maxillary E1
Used when a period of healing is necessary prior to fabrication and placement of a permanent
prosthetic.
D6190 Radiographic/surgical implant index, by report E1

An appliance, designed to relate osteotomy or fixture position to existing anatomic structures,

to be utilized during radiographic exposure for treatment planning and/or during osteotomy
creation for fixture installation.
D6194 Abutment supported retainer crown for FPD (titanium) E1

A retainer for a fixed partial denture that gains retention, support and stability from an
abutment on an implant. May be cast or milled.

None
D6199 Unspecified implant procedure, by report E1

Use for procedure that is not adequately described by a code. Describe procedure.
Cross Reference 21299

Prosthodontics, fixed (D6205-D6999)

Fixed Partial Denture Pontics
D6205 Pontic - indirect resin based composite E1

Not to be used as a temporary or provisional prosthesis.

D6210 Pontic - cast high noble metal E1

285
 D6211 Pontic - cast predominantly base metal E1

D6212 Pontic - cast noble metal E1

D6214 Pontic - titanium E1

D6240 Pontic - porcelain fused to high noble metal E1

D6241 Pontic - porcelain fused to predominantly base metal E1

D6242 Pontic - porcelain fused to noble metal E1

IOM: 100-02, 15, 150
D6245 Pontic - porcelain/ceramic E1

D6250 Pontic - resin with high noble metal E1

D6251 Pontic - resin with predominantly base metal E1

D6252 Pontic - resin with noble metal E1

D6253 Provisional pontic - further treatment or completion of diagnosis necessary prior to final
impression E1
Not to be used as a temporary pontic for routine prosthetic fixed partial dentures.

Fixed Partial Denture Retainers – Inlays/Onlays

D6545 Retainer - cast metal for resin bonded fixed prosthesis E1

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis E1

D6549 Retainer - for resin bonded fixed prosthesis E1

D6600 Retainer inlay - porcelain/ceramic, two surfaces E1

D6601 Retainer inlay - porcelain/ceramic, three or more surfaces E1

D6602 Retainer inlay - cast high noble metal, two surfaces E1

D6603 Retainer inlay - cast high noble metal, three or more surfaces E1

D6604 Retainer inlay - cast predominantly base metal, two surfaces E1

D6605 Retainer inlay - cast predominantly base metal, three or more surfaces E1

D6606 Retainer inlay - cast noble metal, two surfaces E1

D6607 Retainer inlay - cast noble metal, three or more surfaces E1

D6608 Retainer onlay - porcelain/ceramic, two surfaces E1

D6609 Retainer onlay - porcelain/ceramic, three or more surfaces E1

D6610 Retainer onlay - cast high noble metal, two surfaces E1

D6611 Retainer onlay - cast high noble metal, three or more surfaces E1

D6612 Retainer onlay - cast predominantly base metal, two surfaces E1

D6613 Retainer onlay - cast predominantly base metal, three or more surfaces E1

D6614 Retainer onlay - cast noble metal, two surfaces E1

D6615 Retainer onlay - cast noble metal, three or more surfaces E1

D6624 Retainer inlay - titanium E1

D6634 Retainer onlay - titanium E1

Fixed Partial Denture Retainers – Crowns

D6710 Retainer crown - indirect resin based composite E1

Not to be used as a temporary or provisional prosthesis.

D6720 Retainer crown - resin with high noble metal E1

D6721 Retainer crown - resin with predominantly base metal E1

D6722 Retainer crown - resin with noble metal E1

D6740 Retainer crown - porcelain/ceramic E1

D6750 Retainer crown - porcelain fused to high noble metal E1

D6751 Retainer crown - porcelain fused to predominantly base metal E1

D6752 Retainer crown - porcelain fused to noble metal E1

286
D6780 Retainer crown - 3/4 cast high noble metal E1

D6781 Retainer crown - 3/4 cast predominantly based metal E1

D6782 Retainer crown - 3/4 cast noble metal E1

D6783 Retainer crown - 3/4 porcelain/ceramic E1

287
 D6790 Retainer crown - full cast high noble metal E1

D6791 Retainer crown - full cast predominantly base metal E1

D6792 Retainer crown - full cast noble metal E1

D6793 Provisional retainer crown - further treatment or completion of diagnosis necessary prior to
final impression E1
Not to be used as a temporary retainer crown for routine prosthetic fixed partial dentures.
D6794 Retainer crown - titanium E1

Other Fixed Partial Denture Services

D6920 Connector bar S
A device attached to fixed partial denture retainer or coping which serves to stabilize and
anchor a removable overdenture prosthesis.
D6930 Re-cement or re-bond fixed partial denture E1

D6940 Stress breaker E1

A non-rigid connector.
D6950 Precision attachment E1

A male and female pair constitutes one precision attachment, and is separate from the
prosthesis.
D6980 Bridge repair necessitated by restorative material failure E1

D6985 Pediatric partial denture, fixed E1

This prosthesis is used primarily for aesthetic purposes.

None
D6999 Unspecified fixed prosthodontic procedure, by report E1
Used for procedure that is not adequately described by a code. Describe procedure.

Oral and Maxillofacial Surgery (D7111-D7999)

Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Postoperative Care)
D7111 Extraction, coronal remnants - primary tooth S
Removal of soft tissue-retained coronal remnants.
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) S
Includes removal of tooth structure, minor smoothing of socket bone, and closure, as
necessary.
D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including
elevation of mucoperiosteal flap if indicated S

Includes related cutting of gingiva and bone, removal of tooth structure, minor smoothing of
socket bone and closure.
D7220 Removal of impacted tooth - soft tissue S

Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation.
D7230 Removal of impacted tooth - partially bony S

Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal.
D7240 Removal of impacted tooth - completely bony S

Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone
removal.
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications S
Most or all of crown covered by bone; unusually difficult or complicated due to factors such as
nerve dissection required, separate closure of maxillary sinus required or aberrant tooth
position.
D7250 Removal of residual tooth roots (cutting procedure) S

Includes cutting of soft tissue and bone, removal of tooth structure, and closure.

288
 D7251 Coronectomy — intentional partial tooth removal E1
Intentional partial tooth removal is performed when a neurovascular complication is likely if
the entire impacted tooth is removed.

Other Surgical Procedures

D7260 Oral antral fistula closure S
Excision of fistulous tract between maxillary sinus and oral cavity and closure by advancement
flap.
D7261 Primary closure of a sinus perforation S
Subsequent to surgical removal of tooth, exposure of sinus requiring repair, or immediate
closure of oroantral or oralnasal communication in absence of fistulous tract.
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth E1
Includes splinting and/or stabilization.
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or
stabilization) E1

D7280 Exposure of an unerupted tooth E1

An incision is made and the tissue is reflected and bone removed as necessary to expose the
crown of an impacted tooth not intended to be extracted.
D7282 Mobilization of erupted or malpositioned tooth to aid eruption E1
To move/luxate teeth to eliminate ankylosis; not in conjunction with an extraction.
D7283 Placement of device to facilitate eruption of impacted tooth B

Placement of an orthodontic bracket, band or other device on an unerupted tooth, after its
exposure, to aid in its eruption. Report the surgical exposure separately using D7280.
D7285 Incisional biopsy of oral tissue - hard (bone, tooth) E1

For partial removal of specimen only. This procedure involves biopsy of osseous lesions and is
not used for apicoectomy/periradicular surgery. This procedure does not entail an excision.
Cross Reference 20220, 20225, 20240, 20245
D7286 Incisional biopsy of oral tissue - soft E1
For partial removal of an architecturally intact specimen only. This procedure is not used at
the same time as codes for apicoectomy/periradicular curettage. This procedure does not entail
an excision.
Cross Reference 40808
D7287 Exfoliative cytological sample collection E1
For collection of non-transepithelial cytology sample via mild scraping of the oral mucosa.
D7288 Brush biopsy - transepithelial sample collection B

For collection of oral disaggregated transepithelial cells via rotational brushing of the oral
mucosa.
D7290 Surgical repositioning of teeth E1
Grafting procedure(s) is/are additional.
D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report S

The supraosseous connective tissue attachment is surgically severed around the involved teeth.
Where there are adjacent teeth, the transseptal fiberotomy of a single tooth will involve a
minimum of three teeth. Since the incisions are within the gingival sulcus and tissue and the
root surface is not instrumented, this procedure heals by the reunion of connective tissue with
the root surface on which viable periodontal tissue is present (reattachment).
D7292 Placement of temporary anchorage device [screw retained plate] requiring flap; includes device
removal E1

D7293 Placement of temporary anchorage device requiring flap; includes device removal E1

D7294 Placement of temporary anchorage device without flap; includes device removal E1

D7295 Harvest of bone for use in autogenous grafting procedure E1

Reported in addition to those autogenous graft placement procedures that do not include

289
 harvesting of bone.
D7296 Corticotomy one to three teeth or tooth spaces, per quadrant E1

This procedure involves creating multiple cuts, perforations, or removal of cortical, alveolar or
basal bone of the jaw for the purpose of facilitating orthodontic repositioning of the dentition.
This procedure includes flap entry and closure. Graft material and membrane, if used, should
be reported separately.
D7297 Corticotomy four or more teeth or tooth spaces, per quadrant E1
This procedure involves creating multiple cuts, perforations, or removal of cortical, alveolar or
basal bone of the jaw for the purpose of facilitating orthodontic repositioning of the dentition.
This procedure includes flap entry and closure. Graft material and membrane, if used, should
be reported separately.

Alveoloplasty – Preparation of Ridge

D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per
quadrant E1
The alveoloplasty is distinct (separate procedure) from extractions. Usually in preparation for a
prosthesis or other treatments such as radiation therapy and transplant surgery.
Cross Reference 41874
D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per
quadrant E1

The alveoloplasty is distinct (separate procedure) from extractions. Usually in preparation for a
prosthesis or other treatments such as radiation therapy and transplant surgery.
D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per
quadrant E1
No extractions performed in an edentulous area. See D7310 if teeth are being extracted
concurrently with the alveoloplasty. Usually in preparation for a prosthesis or other treatments
such as radiation therapy and transplant surgery.
Cross Reference 41870
D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per
quadrant B
No extractions performed in an edentulous area. See D7311 if teeth are being extracted
concurrently with the alveoloplasty. Usually in preparation for a prosthesis or other treatments
such as radiation therapy and transplant surgery.

Vestibuloplasty
D7340 Vestibuloplasty - ridge extension (second epithelialization) E1

Cross Reference 40840, 40842, 40843, 40844

D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachments, revision
of soft tissue attachment, and management of hypertrophied and hyperplastic tissue) E1

Cross Reference 40845

Excision of Soft Tissue Lesions

D7410 Excision of benign lesion up to 1.25 cm E1

D7411 Excision of benign lesion greater than 1.25 cm E1

D7412 Excision of benign lesion, complicated E1

Requires extensive undermining with advancement or rotational flap closure.
D7413 Excision of malignant lesion up to 1.25 cm E1

D7414 Excision of malignant lesion greater than 1.25 cm E1

D7415 Excision of malignant lesion, complicated E1

Requires extensive undermining with advancement or rotational flap closure.

Excision of Intra-Osseous Lesions

290
 D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm E1

D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm E1

D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm E1

D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm E1

D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm E1

D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm
E1

Excision of Soft Tissue Lesions

D7465 Destruction of lesion(s) by physical or chemical methods, by report E1
Examples include using cryo, laser or electro surgery.
Cross Reference 41850

Excision of Bone Tissue

D7471 Removal of lateral exostosis (maxilla or mandible) E1

Cross Reference 21031, 21032

D7472 Removal of torus palatinus E1

D7473 Removal of torus mandibularis E1

D7485 Reduction of osseous tuberosity E1

D7490 Radical resection of maxilla or mandible E1

Partial resection of maxilla or mandible; removal of lesion and defect with margin of normal
appearing bone. Reconstruction and bone grafts should be reported separately.
Cross Reference 21095

Surgical Incision
D7510 Incision and drainage of abscess - intraoral soft tissue E1
Involves incision through mucosa, including periodontal origins.
Cross Reference 41800
D7511 Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of
multiple fascial spaces) B

Incision is made intraorally and dissection is extended into adjacent fascial space(s) to provide
adequate drainage of abscess/cellulitis.
D7520 Incision and drainage of abscess - extraoral soft tissue E1

Involves incision through skin.

Cross Reference 41800
D7521 Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of
multiple fascial spaces) B
Incision is made extraorally and dissection is extended into adjacent fascial space(s) to provide
adequate drainage of abscess/cellulitis.
D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue E1
Cross Reference 41805, 41828
D7540 Removal of reaction-producing foreign bodies, musculoskeletal system E1

May include, but is not limited to, removal of splinters, pieces of wire, etc., from muscle
and/or bone.
Cross Reference 20520, 41800, 41806
D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone E1
Removal of loose or sloughed-off dead bone caused by infection or reduced blood supply.
Cross Reference 20999
D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body E1

Cross Reference 31020

291
Treatment of Closed Fractures
D7610 Maxilla - open reduction (teeth immobilized, if present) E1
Teeth may be wired, banded or splinted together to prevent movement. Incision required for
interosseous fixation.
D7620 Maxilla - closed reduction (teeth immobilized if present) E1
No incision required to reduce fracture. See D7610 if interosseous fixation is applied.
D7630 Mandible - open reduction (teeth immobilized, if present) E1
Teeth may be wired, banded or splinted together to prevent movement. Incision required to
reduce fracture.
D7640 Mandible - closed reduction (teeth immobilized if present) E1
No incision required to reduce fracture. See D7630 if interosseous fixation is applied.
D7650 Malar and/or zygomatic arch - open reduction E1

D7660 Malar and/or zygomatic arch - closed reduction E1

D7670 Alveolus - closed reduction, may include stabilization of teeth E1

Teeth may be wired, banded or splinted together to prevent movement.

D7671 Alveolus - open reduction, may include stabilization of teeth E1
Teeth may be wired, banded or splinted together to prevent movement.
D7680 Facial bones - complicated reduction with fixation and multiple surgical approaches E1
Facial bones include upper and lower jaw, cheek, and bones around eyes, nose, and ears.

Treatment of Open Fractures

D7710 Maxilla - open reduction E1

Incision required to reduce fracture.

Cross Reference 21346
D7720 Maxilla - closed reduction E1
Cross Reference 21345
D7730 Mandible - open reduction E1

Incision required to reduce fracture.

Cross Reference 21461, 21462
D7740 Mandible - closed reduction E1

Cross Reference 21455

D7750 Malar and/or zygomatic arch - open reduction E1

Incision required to reduce fracture.

Cross Reference 21360, 21365
D7760 Malar and/or zygomatic arch - closed reduction E1
Cross Reference 21355
D7770 Alveolus - open reduction stabilization of teeth E1

Fractured bone(s) are exposed to mouth or outside the face. Incision required to reduce
fracture.
Cross Reference 21422
D7771 Alveolus, closed reduction stabilization of teeth E1

Fractured bone(s) are exposed to mouth or outside the face.

D7780 Facial bones - complicated reduction with fixation and multiple approaches E1

Incision required to reduce fracture. Facial bones include upper and lower jaw, cheek, and
bones around eyes, nose, and ears.
Cross Reference 21433, 21435

Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunction

D7810 Open reduction of dislocation E1

Access to TMJ via surgical opening.

292
 Cross Reference 21490
D7820 Closed reduction of dislocation E1

Joint manipulated into place; no surgical exposure.

Cross Reference 21480
D7830 Manipulation under anesthesia E1
Usually done under general anesthesia or intravenous sedation.
Cross Reference 00190
D7840 Condylectomy E1
Removal of all or portion of the mandibular condyle (separate procedure).
Cross Reference 21050
D7850 Surgical discectomy, with/without implant E1
Excision of the intra-articular disc of a joint.
Cross Reference 21060
D7852 Disc repair E1

Repositioning and/or sculpting of disc; repair of perforated posterior attachment.

Cross Reference 21299
D7854 Synovectomy E1
Excision of a portion or all of the synovial membrane of a joint.
Cross Reference 21299
D7856 Myotomy E1

Cutting of muscle for therapeutic purposes (separate procedure).

Cross Reference 21299
D7858 Joint reconstruction E1
Reconstruction of osseous components including or excluding soft tissues of the joint with
autogenous, homologous, or alloplastic materials.
Cross Reference 21242, 21243
D7860 Arthrotomy E1

Cutting into joint (separate procedure).

D7865 Arthroplasty E1

Reduction of osseous components of the joint to create a pseudoarthrosis or eliminate an

irregular remodeling pattern (osteophytes).
Cross Reference 21240
D7870 Arthrocentesis E1

Withdrawal of fluid from a joint space by aspiration.

Cross Reference 21060
D7871 Non-arthroscopic lysis and lavage E1

Inflow and outflow catheters are placed into the joint space. The joint is lavaged and
manipulated as indicated in an effort to release minor adhesions and synovial vacuum
phenomenon as well as to remove inflammation products from the joint space.
D7872 Arthroscopy - diagnosis, with or without biopsy E1

Cross Reference 29800

D7873 Arthroscopy: lavage and lysis of adhesions E1

Removal of adhesions using the arthroscope and lavage of the joint cavities.
Cross Reference 29804
D7874 Arthroscopy: disc repositioning and stabilization E1

Repositioning and stabilization of disc using arthroscopic techniques.

Cross Reference 29804
D7875 Arthroscopy: synovectomy E1

Removal of inflamed and hyperplastic synovium (partial/complete) via an arthroscopic

technique.

293
 Cross Reference 29804
D7876 Arthroscopy: discectomy E1

Removal of disc and remodeled posterior attachment via the arthroscope.

Cross Reference 29804
D7877 Arthroscopy: debridement E1
Removal of pathologic hard and/or soft tissue using the arthroscope.
Cross Reference 29804
D7880 Occlusal orthotic device, by report E1
Presently includes splints provided for treatment of temporomandibular joint dysfunction.
Cross Reference 21499
D7881 Occlusal orthotic device adjustment E1

D7899 Unspecified TMD therapy, by report E1

Used for procedure that is not adequately described by a code. Describe procedure.
Cross Reference 21499

Repair of Traumatic Wounds

D7910 Suture of recent small wounds up to 5 cm E1

Cross Reference 12011, 12013

Complicated Suturing (Reconstruction Requiring Delicate Handling of Tissue and Wide Undermining
for Meticulous Closure)
D7911 Complicated suture - up to 5 cm E1

Cross Reference 12051, 12052

D7912 Complicated suture - greater than 5 cm E1
Cross Reference 13132

Other Repair Procedures

D7920 Skin graft (identify defect covered, location, and type of graft) E1

D7921 Collection and application of autologous blood concentrate product E1

D7940 Osteoplasty - for orthognathic deformities S

Reconstruction of jaws for correction of congenital, developmental or acquired traumatic or

surgical deformity.
D7941 Osteotomy - mandibular rami E1
Cross Reference 21193, 21195, 21196
D7943 Osteotomy - mandibular rami with bone graft; includes obtaining the graft E1

Cross Reference 21194

D7944 Osteotomy - segmented or subapical E1

Report by range of tooth numbers within segment.

Cross Reference 21198, 21206
D7945 Osteotomy - body of mandible E1
Sectioning of lower jaw. This includes exposure, bone cut, fixation, routine wound closure and
normal postoperative follow-up care.
Cross Reference 21193, 21194, 21195, 21196
D7946 LeFort I (maxilla - total) E1

Sectioning of the upper jaw. This includes exposure, bone cuts, downfracture, repositioning,
fixation, routine wound closure and normal post-operative follow-up care.
Cross Reference 21147
D7947 LeFort I (maxilla - segmented) E1

When reporting a surgically assisted palatal expansion without downfracture, this code would
entail a reduced service and should be “by report.”

294
 Cross Reference 21145, 21146
D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) -
without bone graft E1
Sectioning of upper jaw. This includes exposure, bone cuts, downfracture, segmentation of
maxilla, repositioning, fixation, routine wound closure and normal post-operative follow-up
care.
Cross Reference 21150
D7949 LeFort II or LeFort III - with bone graft E1
Includes obtaining autografts.
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or
nonautogenous, by report E1
This procedure is for ridge augmentation or reconstruction to increase height, width and/or
volume of residual alveolar ridge. It includes obtaining graft material. Placement of a barrier
membrane, if used, should be reported separately.
Cross Reference 21247
D7951 Sinus augmentation with bone or bone substitutes E1
The augmentation of the sinus cavity to increase alveolar height for reconstruction of
edentulous portions of the maxilla. This procedure is performed via a lateral open approach.
This includes obtaining the bone or bone substitutes. Placement of a barrier membrane if used
should be reported separately.
D7952 Sinus augmentation via a vertical approach E1

The augmentation of the sinus to increase alveolar height by vertical access through the ridge
crest by raising the floor of the sinus and grafting as necessary. This includes obtaining the
bone or bone substitutes.
D7953 Bone replacement graft for ridge preservation - per site E1
Graft is placed in an extraction or implant removal site at the time of the extraction or removal
to preserve ridge integrity (e.g., clinically indicated in preparation for implant reconstruction
or where alveolar contour is critical to planned prosthetic reconstruction). Does not include
obtaining graft material. Membrane, if used should be reported separately.
D7955 Repair of maxillofacial soft and/or hard tissue defect E1

Reconstruction of surgical, traumatic, or congenital defects of the facial bones, including the
mandible, may utilize graft materials in conjunction with soft tissue procedures to repair and
restore the facial bones to form and function. This does not include obtaining the graft and
these procedures may require multiple surgical approaches. This procedure does not include
edentulous maxilla and mandibular reconstruction for prosthetic considerations.
Cross Reference 21299
D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to
another procedure E1
Removal or release of mucosal and muscle elements of a buccal, labial or lingual frenum that is
associated with a pathological condition, or interferes with proper oral development or
treatment.
Cross Reference 40819, 41010, 41115
D7963 Frenuloplasty E1

Excision of frenum with accompanying excision or repositioning of aberrant muscle and z-

plasty or other local flap closure.
D7970 Excision of hyperplastic tissue - per arch E1

D7971 Excision of pericoronal gingival E1

Removal of inflammatory or hypertrophied tissues surrounding partially erupted/impacted

teeth.
Cross Reference 41821
D7972 Surgical reduction of fibrous tuberosity E1

D7979 Non surgical sialolithotomy E1

A sialolith is removed from the gland or ductal portion of the gland without surgical incision

295
 into the gland or the duct of the gland; for example via manual manipulation, ductal dilation,
or any other non-surgical method.
D7980 Surgical sialolithotomy E1
Procedure by which a stone within a salivary gland or its duct is removed, either intraorally or
extraorally.
Cross Reference 42330, 42335, 42340
D7981 Excision of salivary gland, by report E1
Cross Reference 42408
D7982 Sialodochoplasty E1
Procedure for the repair of a defect and/or restoration of a portion of a salivary gland duct.
Cross Reference 42500
D7983 Closure of salivary fistula E1
Closure of an opening between a salivary duct and/or gland and the cutaneous surface, or an
opening into the oral cavity through other than the normal anatomic pathway.
Cross Reference 42600
D7990 Emergency tracheotomy E1
Formation of a tracheal opening usually below the cricoid cartilage to allow for respiratory
exchange.
Cross Reference 21070
D7991 Coronoidectomy E1

Removal of the coronoid process of the mandible.

Cross Reference 21070
D7995 Synthetic graft - mandible or facial bones, by report E1
Includes allogenic material.
Cross Reference 21299
D7996 Implant-mandible for augmentation purposes (excluding alveolar ridge), by report E1

Cross Reference 21299

D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar E1

D7998 Intraoral placement of a fixation device not in conjunction with a fracture E1

The placement of intermaxillary fixation appliance for documented medically accepted
treatments not in association with fractures.

None
D7999 Unspecified oral surgery procedure, by report E1
Used for procedure that is not adequately described by a code. Describe procedure.
Cross Reference 21299

Orthodontics (D8010-D8999)
Limited Orthodontic Treatment
D8010 Limited orthodontic treatment of the primary dentition E1

D8020 Limited orthodontic treatment of the transitional dentition E1

D8030 Limited orthodontic treatment of the adolescent dentition E1

D8040 Limited orthodontic treatment of the adult dentition E1

Interceptive Orthodontic Treatment

D8050 Interceptive orthodontic treatment of the primary dentition E1

D8060 Interceptive orthodontic treatment of the transitional dentition E1

Comprehensive Orthodontic Treatment

D8070 Comprehensive orthodontic treatment of the transitional dentition E1

296
 D8080 Comprehensive orthodontic treatment of the adolescent dentition E1

D8090 Comprehensive orthodontic treatment of the adult dentition E1

Minor Treatment to Control Harmful Habits

D8210 Removable appliance therapy E1
Removable indicates patient can remove; includes appliances for thumb sucking and tongue
thrusting.
D8220 Fixed appliance therapy E1
Fixed indicates patient cannot remove appliance; includes appliances for thumb sucking and
tongue thrusting.

Other Orthodontic Services

D8660 Pre-orthodontic treatment examination to monitor growth and development E1
Periodic observation of patient dentition, at intervals established by the dentist, to determine
when orthodontic treatment should begin. Diagnostic procedures are documented separately.
D8670 Periodic orthodontic treatment visit E1

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s))

E1
D8681 Removable orthodontic retainer adjustment E1

D8690 Orthodontic treatment (alternative billing to a contract fee) E1

Services provided by dentist other than original treating dentist. A method of payment
between the provider and responsible party for services that reflect an open-ended fee
arrangement.
D8691 Repair of orthodontic appliance E1
Does not include bracket and standard fixed ortho appliances. It does include functional
appliances and palatal expanders.
D8692 Replacement of lost or broken retainer E1

D8693 Re-cement or re-bond of fixed retainer E1

D8694 Repair of fixed retainers, includes reattachment E1

D8695 Removal of fixed orthodontic appliances for reasons other than completion of treatment E1

None
D8999 Unspecified orthodontic procedure, by report E1
Used for procedure that is not adequately described by a code. Describe procedure.

Adjunctive General Services (D9110-D9999)

Unclassified Treatment
D9110 Palliative (emergency) treatment of dental pain - minor procedures N

This is typically reported on a “per visit” basis for emergency treatment of dental pain.
D9120 Fixed partial denture sectioning E1
Separation of one or more connections between abutments and/or pontics when some portion
of a fixed prosthesis is to remain intact and serviceable following sectioning and extraction or
other treatment. Includes all recontouring and polishing of retained portions.
Temporomandibular joint dysfunction - non-invasive physical therapies E1
▶ D9130

Anesthesia
D9210 Local anesthesia not in conjunction with operative or surgical procedures E1

Cross Reference 90784

D9211 Regional block anesthesia E1
Cross Reference 01995
D9212 Trigeminal division block anesthesia E1

297
 Cross Reference 64400
D9215 Local anesthesia in conjunction with operative or surgical procedures E1

Cross Reference 90784

D9219 Evaluation for moderate sedation or general anesthesia E1

D9222 Deep sedation/general anesthesia first 15 minutes E1

Anesthesia time begins when the doctor administering the anesthetic agent initiates the
appropriate anesthesia and non-invasive monitoring protocol and remains in continuous
attendance of the patient. Anesthesia services are considered completed when the patient may
be safely left under the observation of trained personnel and the doctor may safely leave the
room to attend to other patients or duties.
The level of anesthesia is determined by the anesthesia provider’s documentation of the
anesthetic effects upon the central nervous system and not dependent upon the route of
administration.
D9223 Deep sedation/general anesthesia - each subsequent 15 minute increment E1

D9230 Inhalation of nitrous oxide/analgesia, anxiolysis N

D9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutes E1

Anesthesia time begins when the doctor administering the anesthetic agent initiates the
appropriate anesthesia and non-invasive monitoring protocol and remains in continuous
attendance of the patient. Anesthesia services are considered completed when the patient may
be safely left under the observation of trained personnel and the doctor may safely leave the
room to attend to other patients or duties.
The level of anesthesia is determined by the anesthesia provider’s documentation of the
anesthetic effects upon the central nervous system and not dependent upon the route of
administration.
D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment
E1
D9248 Non-intravenous conscious sedation N
This includes non-IV minimal and moderate sedation. A medically controlled state of
depressed consciousness while maintaining the patient’s airway, protective reflexes and the
ability to respond to stimulation or verbal commands. It includes nonintravenous
administration of sedative and/or analgesic agent(s) and appropriate monitoring.
The level of anesthesia is determined by the anesthesia provider’s documentation of the
anesthetic’s effects upon the central nervous system and not dependent upon the route of
administration.

Professional Consultation
D9310 Consultation - diagnostic service provided by dentist or physician other than requesting
dentist or physician E1

A patient encounter with a practitioner whose opinion or advice regarding evaluation and/or
management of a specific problem; may be requested by another practitioner or appropriate
source. The consultation includes an oral evaluation. The consulted practitioner may initiate
diagnostic and/or therapeutic services.
D9311 Consultation with a medical health care professional E1
Treating dentist consults with a medical health care professional concerning medical issues
that may affect patient’s planned dental treatment.

Professional Visits
D9410 House/extended care facility call E1
Includes visits to nursing homes, longterm care facilities, hospice sites, institutions, etc.
Report in addition to reporting appropriate code numbers for actual services performed.
D9420 Hospital or ambulatory surgical center call E1
Care provided outside the dentist’s office to a patient who is in a hospital or ambulatory
surgical center. Services delivered to the patient on the date of service are documented

298
 separately using the applicable procedure codes.
D9430 Office visit for observation (during regularly scheduled hours) - no other services performed
E1
D9440 Office visit-after regularly scheduled hours E1

Cross Reference 99050

D9450 Case presentation, detailed and extensive treatment planning E1
Established patient. Not performed on same day as evaluation.

Drugs
D9610 Therapeutic parenteral drug, single administration E1
Includes single administration of antibiotics, steroids, anti-inflammatory drugs, or other
therapeutic medications. This code should not be used to report administration of sedative,
anesthetic or reversal agents.
D9612 Therapeutic parenteral drugs, two or more administrations, different medications E1
Includes multiple administrations of antibiotics, steroids, anti-inflammatory drugs or other
therapeutic medications. This code should not be used to report administration of sedatives,
anesthetic or reversal agents. This code should be reported when two or more different
medications are necessary and should not be reported in addition to code D9610 on the same
date.
Infiltration of sustained release therapeutic drug - single or multiple sites E1
▶ D9613
D9630 Drugs or medicaments dispensed in the office for home use B
Includes, but is not limited to oral antibiotics, oral analgesics, and topical fluoride; does not
include writing prescriptions.

Miscellaneous Services
D9910 Application of desensitizing medicament E1
Includes in-office treatment for root sensitivity. Typically reported on a “per visit” basis for
application of topical fluoride. This code is not to be used for bases, liners or adhesives used
under restorations.
D9911 Application of desensitizing resin for cervical and/or root surface, per tooth E1

Typically reported on a “per tooth” basis for application of adhesive resins. This code is not to
be used for bases, liners, or adhesives used under restorations.
D9920 Behavior management, by report E1

May be reported in addition to treatment provided. Should be reported in 15-minute

increments.
D9930 Treatment of complications (postsurgical) - unusual circumstances, by report S

For example, treatment of a dry socket following extraction or removal of bony sequestrum.
D9932 Cleaning and inspection of removable complete denture, maxillary E1

This procedure does not include any adjustments.

D9933 Cleaning and inspection of removable complete denture, mandibular E1
This procedure does not include any adjustments.
D9934 Cleaning and inspection of removable partial denture, maxillary E1

This procedure does not include any adjustments.

D9935 Cleaning and inspection of removable partial denture, mandibular E1
This procedure does not include any adjustments.
D9941 Fabrication of athletic mouthguard E1

Cross Reference 21089

D9942 Repair and/or reline of occlusal guard E1

D9943 Occlusal guard adjustment E1

Occlusal guard - hard appliance, full arch E1

▶ D9944
Occlusal guard - soft appliance, full arch E1
▶ D9945

299
 ▶ D9946 Occlusal guard - hard appliance, partial arch E1

D9950 Occlusion analysis - mounted case S

Includes, but is not limited to, facebow, interocclusal records tracings, and diagnostic wax-up;
for diagnostic casts, see D0470.
D9951 Occlusal adjustment - limited S
May also be known as equilibration; reshaping the occlusal surfaces of teeth to create
harmonious contact relationships between the maxillary and mandibular teeth. Presently
includes discing/odontoplasty/enamoplasty. Typically reported on a “per visit” basis. This
should not be reported when the procedure only involves bite adjustment in the routine post-
delivery care for a direct/indirect restoration or fixed/removable prosthodontics.
D9952 Occlusal adjustment - complete S
Occlusal adjustment may require several appointments of varying length, and sedation may be
necessary to attain adequate relaxation of the musculature. Study casts mounted on an
articulating instrument may be utilized for analysis of occlusal disharmony. It is designed to
achieve functional relationships and masticatory efficiency in conjunction with restorative
treatment, orthodontics, orthognathic surgery, or jaw trauma when indicated. Occlusal
adjustment enhances the healing potential of tissues affected by the lesions of occlusal trauma.
Duplicate/copy of patient’s records E1
▶ D9961
D9970 Enamel microabrasion E1

The removal of discolored surface enamel defects resulting from altered mineralization or
decalcification of the superficial enamel layer. Submit per treatment visit.
D9971 Odontoplasty 1 - 2 teeth; includes removal of enamel projections E1

D9972 External bleaching - per arch - performed in office E1

D9973 External bleaching - per tooth E1

D9974 Internal bleaching - per tooth E1

D9975 External bleaching for home application, per arch; includes materials and fabrication of
custom trays E1

Non-Clinical Procedures
D9985 Sales tax E1

D9986 Missed appointment E1

D9987 Cancelled appointment E1

Certified translation or sign-language services - per visit E1

▶ D9990
D9991 Dental case management - addressing appointment compliance barriers E1

Individualized efforts to assist a patient to maintain scheduled appointments by solving

transportation challenges or other barriers.
D9992 Dental case management - care coordination E1
Assisting in a patient’s decisions regarding the coordination of oral health care services across
multiple providers, provider types, specialty areas of treatment, health care settings, health care
organizations and payment systems. This is the additional time and resources expended to
provide experience or expertise beyond that possessed by the patient.
D9993 Dental case management - motivational interviewing E1

Patient-centered, personalized counseling using methods such as Motivational Interviewing

(MI) to identify and modify behaviors interfering with positive oral health outcomes. This is a
separate service from traditional nutritional or tobacco counseling.
D9994 Dental case management - patient education to improve oral health literacy E1
Individual, customized communication of information to assist the patient in making
appropriate health decisions designed to improve oral health literacy, explained in a manner
acknowledging economic circumstances and different cultural beliefs, values, attitudes,
traditions and language preferences, and adopting information and services to these
differences, which requires the expenditure of time and resources beyond that of an oral
evaluation or case presentation.

300
 D9995 Teledentistry synchronous; real-time encounter E1
Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date
of service.
D9996 Teledentistry asynchronous; information stored and forwarded to dentist for subsequent
review E1
Reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date
of service.

None
D9999 Unspecified adjunctive procedure, by report E1
Used for procedure that is not adequately described by a code. Describe procedure.
Cross Reference 21499

DURABLE MEDICAL EQUIPMENT (E0100-E8002)

Canes
Cane, includes canes of all materials, adjustable or fixed, with tip Y
❂ E0100
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1; 100-03, 4, 280.2
❂ E0105 Cane, quad or three prong, includes canes of all materials, adjustable or fixed, with tips
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1; 100-03, 4, 280.2

Coding Clinic: 2016, Q3, P3

Crutches
❂ E0110 Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete
with tips and handgrips Y

Crutches are covered when prescribed for a patient who is normally ambulatory but suffers
from a condition that impairs ambulation. Provides minimal to moderate weight support
while ambulating.
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
❂ E0111 Crutch forearm, includes crutches of various materials, adjustable or fixed, each, with tips and
handgrips Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0112 Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips, and handgrips
Y
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
❂ E0113 Crutch underarm, wood, adjustable or fixed, each, with pad, tip, and handgrip
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1 Y

❂ E0114 Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

❂ E0116 Crutch, underarm, other than wood, adjustable or fixed, with pad, tip, handgrip, with or
without shock absorber, each Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

Crutch, underarm, articulating, spring assisted, each Y
❂ E0117
IOM: 100-02, 15, 110.1
Crutch substitute, lower leg platform, with or without wheels, each E1
✽ E0118

Walkers
Walker, rigid (pickup), adjustable or fixed height Y
❂ E0130

301
 Standard walker criteria for payment: Individual has a mobility limitation that significantly
impairs ability to participate in mobility-related activities of daily living that cannot be
adequately or safely addressed by a cane. The patient is able to use the walker safely; the
functional mobility deficit can be resolved with use of a standard walker.
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Walker, folding (pickup), adjustable or fixed height Y
❂ E0135
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Walker, with trunk support, adjustable or fixed height, any type Y
❂ E0140
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Walker, rigid, wheeled, adjustable or fixed height Y
❂ E0141
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Walker, folding, wheeled, adjustable or fixed height Y
❂ E0143
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
❂ E0144 Walker, enclosed, four sided framed, rigid or folding, wheeled, with posterior seat
Y
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Walker, heavy duty, multiple braking system, variable wheel resistance Y
❂ E0147
Heavy-duty walker is labeled as capable of supporting more than 300 pounds
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1

Figure 11 Walkers.

Walker, heavy duty, without wheels, rigid or folding, any type, each Y
✽ E0148
Heavy-duty walker is labeled as capable of supporting more than 300 pounds
Walker, heavy duty, wheeled, rigid or folding, any type Y
✽ E0149
Heavy-duty walker is labeled as capable of supporting more than 300 pounds
Platform attachment, forearm crutch, each Y
✽ E0153
Platform attachment, walker, each Y
✽ E0154
Wheel attachment, rigid pick-up walker, per pair Y
✽ E0155

Attachments
Seat attachment, walker Y
✽ E0156
Crutch attachment, walker, each Y
✽ E0157
Leg extensions for walker, per set of four (4) Y
✽ E0158
Leg extensions are considered medically necessary DME for patients 6 feet tall or more.
Brake attachment for wheeled walker, replacement, each Y
✽ E0159

Sitz Bath/Equipment
Sitz type bath or equipment, portable, used with or without commode Y
❂ E0160
IOM: 100-03, 4, 280.1
❂ E0161 Sitz type bath or equipment, portable, used with or without commode, with faucet
attachment/s Y

IOM: 100-03, 4, 280.1

302
 ❂ E0162 Sitz bath chair Y

IOM: 100-03, 4, 280.1

Commodes
Commode chair, mobile or stationary, with fixed arms Y
❂ E0163
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Commode chair, mobile or stationary, with detachable arms Y
❂ E0165
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Pail or pan for use with commode chair, replacement only Y
❂ E0167
IOM: 100-03, 4, 280.1
✽ E0168 Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms,
any type, each Y

Extra-wide or heavy duty commode chair is labeled as capable of supporting more than 300
pounds
Commode chair with integrated seat lift mechanism, electric, any type Y
✽ E0170
Commode chair with integrated seat lift mechanism, non-electric, any type Y
✽ E0171
Seat lift mechanism placed over or on top of toilet, any type E1
H E0172
Medicare Statute 1861 SSA
Foot rest, for use with commode chair, each Y
✽ E0175

Decubitus Care Equipment

❂ E0181 Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty
Y

Requires the provider to determine medical necessity compliance. To demonstrate the

requirements in the medical policy were met, attach KX.
IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3
Pump for alternating pressure pad, for replacement only Y
❂ E0182
IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3
Dry pressure mattress Y
❂ E0184
IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3
Gel or gel-like pressure pad for mattress, standard mattress length and width Y
❂ E0185
IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3
Air pressure mattress Y
❂ E0186
IOM: 100-03, 4, 280.1
Water pressure mattress Y
❂ E0187
IOM: 100-03, 4, 280.1
Synthetic sheepskin pad Y
❂ E0188
IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3
Lambswool sheepskin pad, any size Y
❂ E0189
IOM: 100-03, 4, 280.1; 100-08, 5, 5.2.3
❂ E0190 Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories
E1

IOM: 100-02, 15, 110.1

Heel or elbow protector, each Y
✽ E0191
Powered air flotation bed (low air loss therapy) Y
✽ E0193
Air fluidized bed Y
❂ E0194
IOM: 100-03, 4, 280.1
Gel pressure mattress Y
❂ E0196

303
 IOM: 100-03, 4, 280.1
Air pressure pad for mattress, standard mattress length and width Y
❂ E0197
IOM: 100-03, 4, 280.1
Water pressure pad for mattress, standard mattress length and width Y
❂ E0198
IOM: 100-03, 4, 280.1
Dry pressure pad for mattress, standard mattress length and width Y
❂ E0199
IOM: 100-03, 4, 280.1

Heat/Cold Application
Heat lamp, without stand (table model), includes bulb, or infrared element Y
❂ E0200
Covered when medical review determines patient’s medical condition is one for which
application of heat by heat lamp is therapeutically effective
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Phototherapy (bilirubin) light with photometer Y
✽ E0202
Therapeutic lightbox, minimum 10,000 lux, table top model E1
H E0203
IOM: 100-03, 4, 280.1
Heat lamp, with stand, includes bulb, or infrared element Y
❂ E0205
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Electric heat pad, standard Y
❂ E0210
Flexible device containing electric resistive elements producing heat; has fabric cover to
prevent burns; with or without timing devices for automatic shut-off
IOM: 100-03, 4, 280.1
Electric heat pad, moist Y
❂ E0215
Flexible device containing electric resistive elements producing heat. Must have component
that will absorb and retain liquid (water).
IOM: 100-03, 4, 280.1
Water circulating heat pad with pump Y
❂ E0217
Consists of flexible pad containing series of channels through which water is circulated by
means of electrical pumping mechanism and heated in external reservoir
IOM: 100-03, 4, 280.1
Fluid circulating cold pad with pump, any type Y
❂ E0218
IOM: 100-03, 4, 280.1
Infrared heating pad system Y
✽ E0221
Hydrocollator unit, includes pads Y
❂ E0225
IOM: 100-02, 15, 230; 100-03, 4, 280.1
H E0231 Non-contact wound warming device (temperature control unit, AC adapter and power cord)
for use with warming card and wound cover E1

IOM: 100-02, 16, 20

H E0232 Warming card for use with the noncontact wound warming device and non-contact wound
warming wound cover E1

IOM: 100-02, 16, 20

Paraffin bath unit, portable, (see medical supply code A4265 for paraffin) Y
❂ E0235
Ordered by physician and patient’s condition expected to be relieved by long-term use of
modality
IOM: 100-02, 15, 230; 100-03, 4, 280.1
Pump for water circulating pad Y
❂ E0236
IOM: 100-03, 4, 280.1
Hydrocollator unit, portable Y
❂ E0239
IOM: 100-02, 15, 230; 100-03, 4, 280.1

304
Bath and Toilet Aids
Bath/shower chair, with or without wheels, any size E1
H E0240
IOM: 100-03, 4, 280.1
Bath tub wall rail, each E1
H E0241
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Bath tub rail, floor base E1
H E0242
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Toilet rail, each E1
H E0243
IOM: 100-02, 15, 110.1; 100-03, 4, 280.1
Raised toilet seat E1
H E0244
IOM: 100-03, 4, 280.1
Tub stool or bench E1
H E0245
IOM: 100-03, 4, 280.1
Transfer tub rail attachment E1
✽ E0246
Transfer bench for tub or toilet with or without commode opening E1
❂ E0247
IOM: 100-03, 4, 280.1
Transfer bench, heavy duty, for tub or toilet with or without commode opening E1
❂ E0248
Heavy duty transfer bench is labeled as capable of supporting more than 300 pounds
IOM: 100-03, 4, 280.1

Pad for Heating Unit

Pad for water circulating heat unit, for replacement only Y
❂ E0249
Describes durable replacement pad used with water circulating heat pump system
IOM: 100-03, 4, 280.1

Hospital Beds and Accessories

Hospital bed, fixed height, with any type side rails, with mattress Y
❂ E0250
IOM: 100-02, 15, 110.1; 100-03, 4, 280.7
Hospital bed, fixed height, with any type side rails, without mattress Y
❂ E0251
IOM: 100-02, 15, 110.1; 100-03, 4, 280.7
Hospital bed, variable height, hi-lo, with any type side rails, with mattress Y
❂ E0255
IOM: 100-02, 15, 110.1; 100-03, 4, 280.7
Hospital bed, variable height, hi-lo, with any type side rails, without mattress Y
❂ E0256
IOM: 100-02, 15, 110.1; 100-03, 4, 280.7
❂ E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without
mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0265 Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with
mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0266 Hospital bed, total electric (head, foot and height adjustments), with any type side rails,
without mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

H E0270 Hospital bed, institutional type includes: oscillating, circulating and Stryker frame, with
mattress E1

IOM: 100-03, 4, 280.1

305
❂ E0271 Mattress, innerspring Y

IOM: 100-03, 4, 280.1; 100-03, 4, 280.7

Mattress, foam rubber Y
❂ E0272
IOM: 100-03, 4, 280.1; 100-03, 4, 280.7
Bed board E1
H E0273
IOM: 100-03, 4, 280.1
Over-bed table E1
H E0274
IOM: 100-03, 4, 280.1
Bed pan, standard, metal or plastic Y
❂ E0275
IOM: 100-03, 4, 280.1
Bed pan, fracture, metal or plastic Y
❂ E0276
IOM: 100-03, 4, 280.1
Powered pressure-reducing air mattress Y
❂ E0277
IOM: 100-03, 4, 280.1
Bed cradle, any type Y
✽ E0280
Hospital bed, fixed height, without side rails, with mattress Y
❂ E0290
IOM: 100-02, 15, 110.1; 100-03, 4, 280.7
Hospital bed, fixed height, without side rails, without mattress Y
❂ E0291
IOM: 100-02, 15, 110.1; 100-03, 4, 280.7
Hospital bed, variable height, hi-lo, without side rails, with mattress Y
❂ E0292
IOM: 100-02, 15, 110.1; 100-03, 4, 280.7
Hospital bed, variable height, hi-lo, without side rails, without mattress Y
❂ E0293
IOM: 100-02, 15, 110.1; 100-03, 4, 280.7
❂ E0294 Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress
Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0296 Hospital bed, total electric (head, foot and height adjustments), without side rails, with
mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

❂ E0297 Hospital bed, total electric (head, foot and height adjustments), without side rails, without
mattress Y

IOM: 100-02, 15, 110.1; 100-03, 4, 280.7

Pediatric crib, hospital grade, fully enclosed, with or without top enclosure Y
✽ E0300
❂ E0301 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less
than or equal to 600 pounds, with any type side rails, without mattress Y

IOM: 100-03, 4, 280.7

❂ E0302 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds,
with any type side rails, without mattress Y

IOM: 100-03, 4, 280.7

❂ E0303 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less
than or equal to 600 pounds, with any type side rails, with mattress Y

IOM: 100-03, 4, 280.7

❂ E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds,
with any type side rails, with mattress Y

IOM: 100-03, 4, 280.7

Bed side rails, half length Y
❂ E0305

306
 IOM: 100-03, 4, 280.7
Bed side rails, full length Y
❂ E0310
IOM: 100-03, 4, 280.7
Bed accessory: board, table, or support device, any type E1
H E0315
IOM: 100-03, 4, 280.1
Safety enclosure frame/canopy for use with hospital bed, any type Y
✽ E0316
Y
❂ E0325 Urinal; male, jug-type, any material ♂
IOM: 100-03, 4, 280.1
Y
❂ E0326 Urinal; female, jug-type, any material ♀
IOM: 100-03, 4, 280.1
✽ E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and
side rails up to 24 inches above the spring, includes mattress Y

✽ E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard,
footboard and side rails up to 24 inches above the spring, includes mattress Y

Control unit for electronic bowel irrigation/evacuation system E1

✽ E0350
Pulsed Irrigation Enhanced Evacuation (PIEE) is pulsed irrigation of severely impacted fecal
material and may be necessary for patients who have not responded to traditional bowel
program.
✽ E0352 Disposable pack (water reservoir bag, speculum, valving mechanism and collection bag/box)
for use with the electronic bowel irrigation/evacuation system E1

Therapy kit includes 1 B-Valve circuit, 2 containment bags, 1 lubricating jelly, 1 bed pad, 1
tray liner-waste disposable bag, and 2 hose clamps
Air pressure elevator for heel E1
✽ E0370
✽ E0371 Non powered advanced pressure reducing overlay for mattress, standard mattress length and
width Y

Patient has at least one large Stage III or Stage IV pressure sore (greater than 2 × 2 cm.) on
trunk, with only two turning surfaces on which to lie
Powered air overlay for mattress, standard mattress length and width Y
✽ E0372
Non powered advanced pressure reducing mattress Y
✽ E0373

Oxygen and Related Respiratory Equipment

❂ E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator,
flowmeter, humidifier, nebulizer, cannula or mask, and tubing Y

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0425 Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier,
nebulizer, cannula or mask, and tubing E1

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0430 Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula
or mask, and tubing E1

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter,
humidifier, cannula or mask, and tubing Y

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

✽ E0433 Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen
containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask
and tubing, with or without supply reservoir and contents gauge Y

❂ E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier,
flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing Y

Fee schedule payments for stationary oxygen system rentals are all-inclusive and represent
monthly allowance for beneficiary. Non-Medicare payers may rent device to beneficiaries, or

307
 arrange for purchase of device.
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6
❂ E0435 Portable liquid oxygen system, purchase; includes portable container, supply reservoir,
flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6 E1

❂ E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter,
humidifier, nebulizer, cannula or mask, and tubing Y

This allowance includes payment for equipment, contents, and accessories furnished during
rental month
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6
❂ E0440 Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator,
regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing E1

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

Stationary oxygen contents, gaseous, 1 month’s supply = 1 unit Y
❂ E0441
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6
Stationary oxygen contents, liquid, 1 month’s supply = 1 unit Y
❂ E0442
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6
Portable oxygen contents, gaseous, 1 month’s supply = 1 unit Y
❂ E0443
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6
Portable oxygen contents, liquid, 1 month’s supply = 1 unit Y
❂ E0444
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

Figure 12 Oximeter device.

Oximeter device for measuring blood oxygen levels noninvasively N

✽ E0445
✽ E0446 Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories
A

▶ ❂ E0447 Portable oxygen contents, liquid, 1 month’s supply = 1 unit, prescribed amount at rest or
nighttime exceeds 4 liters per minute (lpm) Y

Oxygen tent, excluding croup or pediatric tents Y

❂ E0455
IOM: 100-03, 4, 280.1; 100-04, 20, 30.6
Chest shell (cuirass) E1
H E0457
Chest wrap E1
H E0459
Rocking bed with or without side rails Y
✽ E0462
❂ E0465 Home ventilator, any type, used with invasive interface (e.g., tracheostomy tube)
IOM: 100-03, 4, 280.1 Y

❂ E0466 Home ventilator, any type, used with non-invasive interface (e.g., mask, chest shell)
Y
IOM: 100-03, 4, 280.1
▶ ❂ E0467 Home ventilator, multi-function respiratory device, also performs any or all of the additional
functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation,
includes all accessories, components and supplies for all functions Y

Respiratory assist device, bi-level pressure capability, without backup rate feature, used with

308
 ❂ E0470 noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous
positive airway pressure device) Y

IOM: 100-03, 4, 240.2

❂ E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with
noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous
positive airway pressure device) Y

IOM: 100-03, 4, 240.2

❂ E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with
invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive
airway pressure device) Y

IOM: 100-03, 4, 240.2

Percussor, electric or pneumatic, home model Y
❂ E0480
IOM: 100-03, 4, 240.2
Intrapulmonary percussive ventilation system and related accessories E1
H E0481
IOM: 100-03, 4, 240.2
Cough stimulating device, alternating positive and negative airway pressure Y
✽ E0482
✽ E0483 High frequency chest wall oscillation system, includes all accessories and supplies, each
Y

Oscillatory positive expiratory pressure device, non-electric, any type, each Y

✽ E0484
✽ E0485 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable,
prefabricated, includes fitting and adjustment Y

✽ E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable,
custom fabricated, includes fitting and adjustment Y

Spirometer, electronic, includes all accessories N

❂ E0487

IPPB Machines
❂ E0500 IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or
external power source Y

IOM: 100-03, 4, 240.2

Humidifiers/Nebulizers/Compressors for Use with Oxygen IPPB Equipment

❂ E0550 Humidifier, durable for extensive supplemental humidification during IPPB treatments or
oxygen delivery Y

IOM: 100-03, 4, 240.2

❂ E0555 Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or
flowmeter Y

IOM: 100-03, 4, 280.1; 100-04, 20, 30.6

❂ E0560 Humidifier, durable for supplemental humidification during IPPB treatment or oxygen
delivery Y

IOM: 100-03, 4, 280.1

309
Figure 13 Nebulizer

Humidifier, non-heated, used with positive airway pressure device Y

✽ E0561
Humidifier, heated, used with positive airway pressure device Y
✽ E0562
✽ E0565 Compressor, air power source for equipment which is not self-contained or cylinder driven
Y

Nebulizer, with compressor Y

❂ E0570
IOM: 100-03, 4, 240.2; 100-03, 4, 280.1
Aerosol compressor, adjustable pressure, light duty for intermittent use Y
✽ E0572
Ultrasonic/electronic aerosol generator with small volume nebulizer Y
✽ E0574
Nebulizer, ultrasonic, large volume Y
❂ E0575
IOM: 100-03, 4, 240.2
❂ E0580 Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or
flowmeter Y

IOM: 100-03, 4, 240.2; 100-03, 4, 280.1

Nebulizer, with compressor and heater Y
❂ E0585
IOM: 100-03, 4, 240.2; 100-03, 4, 280.1

Suction Pump/CPAP
Respiratory suction pump, home model, portable or stationary, electric Y
❂ E0600
IOM: 100-03, 4, 240.2
Continuous positive airway pressure (CPAP) device Y
❂ E0601
IOM: 100-03, 4, 240.4

Breast Pump
Y
✽ E0602 Breast pump, manual, any type ♀
Bill either manual breast pump or breast pump kit
N
✽ E0603 Breast pump, electric (AC and/or DC), any type ♀
A
✽ E0604 Breast pump, hospital grade, electric (AC and/or DC), any type ♀

Other Breathing Aids

Vaporizer, room type Y
❂ E0605
IOM: 100-03, 4, 240.2
Postural drainage board Y
❂ E0606

310
 IOM: 100-03, 4, 240.2

Monitoring Equipment
Home blood glucose monitor Y
❂ E0607
Document recipient or caregiver is competent to monitor equipment and that device is
designed for home rather than clinical use
IOM: 100-03, 4, 280.1; 100-03, 1, 40.2
❂ E0610 Pacemaker monitor, self-contained, (checks battery depletion, includes audible and visible
check systems) Y

IOM: 100-03, 1, 20.8

❂ E0615 Pacemaker monitor, self-contained, checks battery depletion and other pacemaker
components, includes digital/visible check systems Y

IOM: 100-03, 1, 20.8

Implantable cardiac event recorder with memory, activator and programmer N
✽ E0616
Assign when two 30-day pre-symptom external loop recordings fail to establish a definitive
diagnosis.

Figure 14 Glucose monitor.

External defibrillator with integrated electrocardiogram analysis Y

✽ E0617
Apnea monitor, without recording feature Y
✽ E0618
Apnea monitor, with recording feature Y
✽ E0619
Skin piercing device for collection of capillary blood, laser, each Y
✽ E0620

Patient Lifts
Sling or seat, patient lift, canvas or nylon Y
❂ E0621
IOM: 100-03, 4, 240.2, 280.4
Patient lift, bathroom or toilet, not otherwise classified E1
H E0625
IOM: 100-03, 4, 240.2
Seat lift mechanism, electric, any type Y
❂ E0627
IOM: 100-03, 4, 280.4; 100-04, 4, 20
Seat lift mechanism, non-electric, any type Y
❂ E0629
IOM: 100-04, 4, 20
❂ E0630 Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s)
IOM: 100-03, 4, 240.2 Y

Patient lift, electric, with seat or sling Y

❂ E0635
IOM: 100-03, 4, 240.2
✽ E0636 Multipositional patient support system, with integrated lift, patient accessible controls
Y

H E0637 Combination sit to stand frame/table system, any size including pediatric, with seat lift
feature, with or without wheels E1

IOM: 100-03, 4, 240.2

311
 H E0638 Standing frame/table system, one position (e.g., upright, supine or prone stander), any size
including pediatric, with or without wheels E1

IOM: 100-03, 4, 240.2

✽ E0639 Patient lift, moveable from room to room with disassembly and reassembly, includes all
components/accessories E1

Patient lift, fixed system, includes all components/accessories E1

✽ E0640
H E0641 Standing frame/table system, multiposition (e.g., three-way stander), any size including
pediatric, with or without wheels E1

IOM: 100-03, 4, 240.2

H E0642 Standing frame/table system, mobile (dynamic stander), any size including pediatric
IOM: 100-03, 4, 240.2 E1

Pneumatic Compressor and Appliances

Pneumatic compressor, non-segmental home model Y
❂ E0650
Lymphedema pumps are classified as segmented or nonsegmented, depending on whether
distinct segments of devices can be inflated sequentially.
IOM: 100-03, 4, 280.6
❂ E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure
Y
IOM: 100-03, 4, 280.6
❂ E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure
IOM: 100-03, 4, 280.6 Y

❂ E0655 Non-segmental pneumatic appliance for use with pneumatic compressor, half arm
Y
IOM: 100-03, 4, 280.6
Segmental pneumatic appliance for use with pneumatic compressor, trunk Y
❂ E0656
Segmental pneumatic appliance for use with pneumatic compressor, chest Y
❂ E0657
❂ E0660 Non-segmental pneumatic appliance for use with pneumatic compressor, full leg
IOM: 100-03, 4, 280.6 Y

❂ E0665 Non-segmental pneumatic appliance for use with pneumatic compressor, full arm
Y
IOM: 100-03, 4, 280.6
❂ E0666 Non-segmental pneumatic appliance for use with pneumatic compressor, half leg
IOM: 100-03, 4, 280.6 Y

Segmental pneumatic appliance for use with pneumatic compressor, full leg Y
❂ E0667
IOM: 100-03, 4, 280.6
Segmental pneumatic appliance for use with pneumatic compressor, full arm Y
❂ E0668
IOM: 100-03, 4, 280.6
Segmental pneumatic appliance for use with pneumatic compressor, half leg Y
❂ E0669
IOM: 100-03, 4, 280.6
❂ E0670 Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and
trunk Y

IOM: 100-03, 4, 280.6

Segmental gradient pressure pneumatic appliance, full leg Y
❂ E0671
IOM: 100-03, 4, 280.6
Segmental gradient pressure pneumatic appliance, full arm Y
❂ E0672
IOM: 100-03, 4, 280.6
Segmental gradient pressure pneumatic appliance, half leg Y
❂ E0673
IOM: 100-03, 4, 280.6

312
 ✽ E0675 Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial
insufficiency (unilateral or bilateral system) Y

✽ E0676 Intermittent limb compression device (includes all accessories), not otherwise specified
Y

Ultraviolet Light Therapy Systems

✽ E0691 Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment
area 2 square feet or less Y

✽ E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 foot
panel Y

✽ E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 foot
panel Y

✽ E0694 Ultraviolet multidirectional light therapy system in 6 foot cabinet, includes bulbs/lamps, timer
and eye protection Y

Safety Equipment
Safety equipment, device or accessory, any type E1
✽ E0700
Transfer device, any type, each B
❂ E0705

Restraints
Restraints, any type (body, chest, wrist or ankle) E1
✽ E0710

Transcutaneous and/or Neuromuscular Electrical Nerve Stimulators (TENS)

❂ E0720 Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation
Y

A Certificate of Medical Necessity (CMN) is not needed for a TENS rental, but is needed
purchase.
IOM: 100-03, 2, 160.2; 100-03, 4, 280.1
❂ E0730 Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple
nerve stimulation Y

IOM: 100-03, 2, 160.2; 100-03, 4, 280.1

❂ E0731 Form fitting conductive garment for delivery of TENS or NMES (with conductive fibers
separated from the patient’s skin by layers of fabric) Y

IOM: 100-03, 2, 160.13

Non-implanted pelvic floor electrical stimulator, complete system Y
❂ E0740
IOM: 100-03, 4, 230.8
Neuromuscular stimulator for scoliosis Y
✽ E0744
Neuromuscular stimulator, electronic shock unit Y
❂ E0745
IOM: 100-03, 2, 160.12
Electromyography (EMG), biofeedback device N
❂ E0746
IOM: 100-03, 1, 30.1

313
 ❂ E0747 Osteogenesis stimulator, electrical, non-invasive, other than spinal applications
Y
Devices are composed of two basic parts: Coils that wrap around cast and pulse generator
that produces electric current
Osteogenesis stimulator, electrical, non-invasive, spinal applications Y
❂ E0748
Device should be applied within 30 days as adjunct to spinal fusion surgery
Osteogenesis stimulator, electrical, surgically implanted N
❂ E0749
Electronic salivary reflex stimulator (intra-oral/non-invasive) E1
✽ E0755
Osteogenesis stimulator, low intensity ultrasound, noninvasive Y
✽ E0760
Ultrasonic osteogenesis stimulator may not be used concurrently with other noninvasive
stimulators
❂ E0761 Non-thermal pulsed high frequency radiowaves, high peak power electromagnetic energy
treatment device E1

✽ E0762 Transcutaneous electrical joint stimulation device system, includes all accessories
B

❂ E0764 Functional neuromuscular stimulator, transcutaneous stimulation of sequential muscle

groups of ambulation with computer control, used for walking by spinal cord injured,
entire system, after completion of training program Y

IOM: 100-03, 2, 160.12

✽ E0765 FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and
vomiting Y

✽ E0766 Electrical stimulation device used for cancer treatment, includes all accessories, any type
Y

❂ E0769 Electrical stimulation or electromagnetic wound treatment device, not otherwise classified
B

IOM: 100-04, 32, 11.1

❂ E0770 Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle
groups, any type, complete system, not otherwise specified Y

Infusion Supplies
IV pole Y
✽ E0776
PEN: On Fee Schedule
✽ E0779 Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater
Y

Requires prior authorization and copy of invoice

This is a capped rental infusion pump modifier. The correct monthly modifier (KH, KI,
KJ) is used to indicate which month the rental is for (i.e., KH, month 1; KI, months 2 and
3; KJ, months 4 through 13).
✽ E0780 Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours
Y
Requires prior authorization and copy of invoice
❂ E0781 Ambulatory infusion pump, single or multiple channels, electric or battery operated with
administrative equipment, worn by patient Y

IOM: 100-03, 1, 50.3

❂ E0782 Infusion pump, implantable, non-programmable (includes all components, e.g., pump,
cathether, connectors, etc.) N

IOM: 100-03, 1, 50.3

❂ E0783 Infusion pump system, implantable, programmable (includes all components, e.g., pump,
catheter, connectors, etc.) N

IOM: 100-03, 1, 50.3

External ambulatory infusion pump, insulin Y
❂ E0784

314
 IOM: 100-03, 4, 280.14
❂ E0785 Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion
pump, replacement N

IOM: 100-03, 1, 50.3

❂ E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal
catheter) N

IOM: 100-03, 1, 50.3

Parenteral infusion pump, stationary, single or multi-channel Y
❂ E0791
IOM: 100-02, 15, 120; 100-03, 3, 180.2; 100-04, 20, 100.2.2

Traction Equipment and Orthopedic Devices

Ambulatory traction device, all types, each N
❂ E0830
IOM: 100-03, 4, 280.1
Traction frame, attached to headboard, cervical traction Y
❂ E0840
IOM: 100-03, 4, 280.1
✽ E0849 Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction
force to other than mandible Y

Traction stand, free standing, cervical traction Y

❂ E0850
IOM: 100-03, 4, 280.1
Cervical traction equipment not requiring additional stand or frame Y
✽ E0855
Cervical traction device, with inflatable air bladder(s) Y
✽ E0856
Traction equipment, overdoor, cervical Y
❂ E0860
IOM: 100-03, 4, 280.1
Traction frame, attached to footboard, extremity traction, (e.g., Buck’s) Y
❂ E0870
IOM: 100-03, 4, 280.1
Traction stand, free standing, extremity traction (e.g., Buck’s) Y
❂ E0880
IOM: 100-03, 4, 280.1
Traction frame, attached to footboard, pelvic traction Y
❂ E0890
IOM: 100-03, 4, 280.1
Traction stand, free standing, pelvic traction (e.g., Buck’s) Y
❂ E0900
IOM: 100-03, 4, 280.1
Trapeze bars, A/K/A patient helper, attached to bed, with grab bar Y
❂ E0910
IOM: 100-03, 4, 280.1
❂ E0911 Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to
bed, with grab bar Y

IOM: 100-03, 4, 280.1

❂ E0912 Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free
standing, complete with grab bar Y

IOM: 100-03, 4, 280.1

Fracture frame, attached to bed, includes weights Y
❂ E0920
IOM: 100-03, 4, 280.1
Fracture frame, free standing, includes weights Y
❂ E0930
IOM: 100-03, 4, 280.1
Continuous passive motion exercise device for use on knee only Y
❂ E0935
To qualify for coverage, use of device must commence within two days following surgery
IOM: 100-03, 4, 280.1
Continuous passive motion exercise device for use other than knee E1
H E0936
Trapeze bar, free standing, complete with grab bar Y
❂ E0940

315
 IOM: 100-03, 4, 280.1
Gravity assisted traction device, any type Y
❂ E0941
IOM: 100-03, 4, 280.1
Cervical head harness/halter Y
✽ E0942
Pelvic belt/harness/boot Y
✽ E0944
Extremity belt/harness Y
✽ E0945
❂ E0946 Fracture, frame, dual with cross bars, attached to bed (e.g., Balken, 4 poster)
IOM: 100-03, 4, 280.1 Y

Fracture frame, attachments for complex pelvic traction Y

❂ E0947
IOM: 100-03, 4, 280.1
Fracture frame, attachments for complex cervical traction Y
❂ E0948
IOM: 100-03, 4, 280.1

Wheelchair Accessories
Wheelchair accessory, tray, each Y
❂ E0950
IOM: 100-03, 4, 280.1
Heel loop/holder, any type, with or without ankle strap, each Y
✽ E0951
Toe loop/holder, any type, each Y
❂ E0952
IOM: 100-03, 4, 280.1
✽ E0953 Wheelchair accessory, lateral thigh or knee support, any type, including fixed mounting
hardware, each Y

✽ E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting hardware,
each foot Y

✽ E0955 Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware,
each Y

✽ E0956 Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting
hardware, each Y

✽ E0957 Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware,
each Y

Manual wheelchair accessory, one-arm drive attachment, each Y

❂ E0958
IOM: 100-03, 4, 280.1
Manual wheelchair accessory, adapter for amputee, each B
✽ E0959
IOM: 100-03, 4, 280.1
✽ E0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting
hardware Y

Manual wheelchair accessory, wheel lock brake extension (handle), each B

✽ E0961
IOM: 100-03, 4, 280.1
Manual wheelchair accessory, headrest extension, each B
✽ E0966
IOM: 100-03, 4, 280.1
❂ E0967 Manual wheelchair accessory, hand rim with projections, any type, replacement only, each
Y

IOM: 100-03, 4, 280.1

Commode seat, wheelchair Y
❂ E0968
IOM: 100-03, 4, 280.1
Narrowing device, wheelchair Y
❂ E0969
IOM: 100-03, 4, 280.1
No. 2 footplates, except for elevating leg rest E1
H E0970
IOM: 100-03, 4, 280.1

316
 Cross Reference K0037, K0042
Manual wheelchair accessory, antitipping device, each B
✽ E0971
IOM: 100-03, 4, 280.1
Cross Reference K0021
❂ E0973 Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each
B

IOM: 100-03, 4, 280.1

Manual wheelchair accessory, antirollback device, each B
❂ E0974
IOM: 100-03, 4, 280.1
Wheelchair accessory, positioning belt/safety belt/pelvic strap, each B
✽ E0978
Safety vest, wheelchair Y
✽ E0980
Wheelchair accessory, seat upholstery, replacement only, each Y
✽ E0981
Wheelchair accessory, back upholstery, replacement only, each Y
✽ E0982
✽ E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized
wheelchair, joystick control Y

✽ E0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized
wheelchair, tiller control Y

Wheelchair accessory, seat lift mechanism Y

✽ E0985
Manual wheelchair accessory, push-rim activated power assist system Y
✽ E0986
Manual wheelchair accessory, leveractivated, wheel drive, pair Y
✽ E0988
Wheelchair accessory, elevating leg rest, complete assembly, each B
✽ E0990
IOM: 100-03, 4, 280.1
Manual wheelchair accessory, solid seat insert B
✽ E0992
Arm rest, each Y
❂ E0994
IOM: 100-03, 4, 280.1
Wheelchair accessory, calf rest/pad, replacement only, each B
✽ E0995
IOM: 100-03, 4, 280.1
Wheelchair accessory, power seating system, tilt only Y
✽ E1002
✽ E1003 Wheelchair accessory, power seating system, recline only, without shear reduction
Y

✽ E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear reduction
Y

✽ E1005 Wheelchair accessory, power seating system, recline only, with power shear reduction
Y

✽ E1006 Wheelchair accessory, power seating system, combination tilt and recline, without shear
reduction Y

✽ E1007 Wheelchair accessory, power seating system, combination tilt and recline, with mechanical
shear reduction Y

✽ E1008 Wheelchair accessory, power seating system, combination tilt and recline, with power
shear reduction Y

✽ E1009 Wheelchair accessory, addition to power seating system, mechanically linked leg elevation
system, including pushrod and leg rest, each Y

✽ E1010 Wheelchair accessory, addition to power seating system, power leg elevation system,
including leg rest, pair Y

❂ E1011 Modification to pediatric size wheelchair, width adjustment package (not to be dispensed
with initial chair) Y

IOM: 100-03, 4, 280.1

✽ E1012 Wheelchair accessory, addition to power seating system, center mount power elevating leg

317
 rest/platform, complete system, any type, each Y

Reclining back, addition to pediatric size wheelchair Y

❂ E1014
IOM: 100-03, 4, 280.1
Shock absorber for manual wheelchair, each Y
❂ E1015
IOM: 100-03, 4, 280.1
Shock absorber for power wheelchair, each Y
❂ E1016
IOM: 100-03, 4, 280.1
❂ E1017 Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each
Y

IOM: 100-03, 4, 280.1

❂ E1018 Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each
Y

IOM: 100-03, 4, 280.1

Residual limb support system for wheelchair, any type Y
❂ E1020
IOM: 100-03, 3, 280.3
✽ E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware
for joystick, other control interface or positioning accessory Y

Wheelchair accessory, ventilator tray, fixed Y

✽ E1029
Wheelchair accessory, ventilator tray, gimbaled Y
✽ E1030

Rollabout Chair, Transfer System, Transport Chair

Rollabout chair, any and all types with casters 5” or greater Y
❂ E1031
IOM: 100- 03, 4, 280.1
❂ E1035 Multi-positional patient transfer system, with integrated seat, operated by care giver,
patient weight capacity up to and including 300 lbs Y

IOM: 100-02, 15, 110

✽ E1036 Multi-positional patient transfer system, extra-wide, with integrated seat, operated by
caregiver, patient weight capacity greater than 300 lbs Y

Transport chair, pediatric size Y

❂ E1037
IOM: 100-03, 4, 280.1
❂ E1038 Transport chair, adult size, patient weight capacity up to and including 300 pounds
Y

IOM: 100-03, 4, 280.1

✽ E1039 Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds
Y

Wheelchair: Fully Reclining

❂ E1050 Fully-reclining wheelchair, fixed full length arms, swing away detachable elevating leg
rests Y

IOM: 100-03, 4, 280.1

❂ E1060 Fully-reclining wheelchair, detachable arms, desk or full length, swing away detachable
elevating legrests Y

IOM: 100-03, 4, 280.1

❂ E1070 Fully-reclining wheelchair, detachable arms (desk or full length) swing away detachable
footrests Y

IOM: 100-03, 4, 280.1

Wheelchair: Hemi
❂ E1083 Hemi-wheelchair, fixed full length arms, swing away detachable elevating leg rest

318
 Y

IOM: 100-03, 4, 280.1

❂ E1084 Hemi-wheelchair, detachable arms desk or full length arms, swing away detachable
elevating leg rests Y

IOM: 100-03, 4, 280.1

Hemi-wheelchair, fixed full length arms, swing away detachable foot rests E1
H E1085
IOM: 100-03, 4, 280.1
Cross Reference K0002
H E1086 Hemi-wheelchair, detachable arms desk or full length, swing away detachable footrests
E1

IOM: 100-03, 4, 280.1

Cross Reference K0002

Wheelchair: High-strength Lightweight

❂ E1087 High strength lightweight wheelchair, fixed full length arms, swing away detachable
elevating leg rests Y

IOM: 100-03, 4, 280.1

❂ E1088 High strength lightweight wheelchair, detachable arms desk or full length, swing away
detachable elevating leg rests Y

IOM: 100-03, 4, 280.1

H E1089 High strength lightweight wheelchair, fixed length arms, swing away detachable footrest
E1

IOM: 100-03, 4, 280.1

Cross Reference K0004
H E1090 High strength lightweight wheelchair, detachable arms desk or full length, swing away
detachable foot rests E1

IOM: 100-03, 4, 280.1

Cross Reference K0004

Wheelchair: Wide Heavy Duty

❂ E1092 Wide heavy duty wheelchair, detachable arms (desk or full length) swing away detachable
elevating leg rests Y

IOM: 100-03, 4, 280.1

❂ E1093 Wide heavy duty wheelchair, detachable arms (desk or full length arms), swing away
detachable foot rests Y

IOM: 100-03, 4, 280.1

Wheelchair: Semi-reclining
❂ E1100 Semi-reclining wheelchair, fixed full length arms, swing away detachable elevating leg
rests Y

IOM: 100-03, 4, 280.1

❂ E1110 Semi-reclining wheelchair, detachable arms (desk or full length), elevating leg rest
Y

IOM: 100-03, 4, 280.1

Wheelchair: Standard
H E1130 Standard wheelchair, fixed full length arms, fixed or swing away detachable footrests
E1

IOM: 100-03, 4, 280.1

Cross Reference K0001

319
 H E1140 Wheelchair, detachable arms, desk or full length, swing away detachable footrests
E1
IOM: 100-03, 4, 280.1
Cross Reference K0001
❂ E1150 Wheelchair, detachable arms, desk or full length, swing away detachable elevating legrests
Y

IOM: 100-03, 4, 280.1

❂ E1160 Wheelchair, fixed full length arms, swing away detachable elevating legrests
IOM: 100-03, 4, 280.1 Y

Manual adult size wheelchair, includes tilt in space Y

✽ E1161

Wheelchair: Amputee
❂ E1170 Amputee wheelchair, fixed full length arms, swing away detachable elevating legrests
Y

IOM: 100-03, 4, 280.1

Amputee wheelchair, fixed full length arms, without footrests or legrest Y
❂ E1171
IOM: 100-03, 4, 280.1
❂ E1172 Amputee wheelchair, detachable arms (desk or full length) without footrests or legrest
Y

IOM: 100-03, 4, 280.1

❂ E1180 Amputee wheelchair, detachable arms (desk or full length) swing away detachable
footrests Y

IOM: 100-03, 4, 280.1

❂ E1190 Amputee wheelchair, detachable arms (desk or full length), swing away detachable
elevating legrests Y

IOM: 100-03, 4, 280.1

❂ E1195 Heavy duty wheelchair, fixed full length arms, swing away detachable elevating legrests
Y

IOM: 100-03, 4, 280.1

❂ E1200 Amputee wheelchair, fixed full length arms, swing away detachable footrest
IOM: 100-03, 4, 280.1 Y

Wheelchair: Other and Accessories

❂ E1220 Wheelchair; specially sized or constructed (indicate brand name, model number, if any)
and justification Y

IOM: 100-03, 4, 280.3

Wheelchair with fixed arm, footrests Y
❂ E1221
IOM: 100-03, 4, 280.3
Wheelchair with fixed arm, elevating legrests Y
❂ E1222
IOM: 100-03, 4, 280.3
Wheelchair with detachable arms, footrests Y
❂ E1223
IOM: 100-03, 4, 280.3
Wheelchair with detachable arms, elevating legrests Y
❂ E1224
IOM: 100-03, 4, 280.3
❂ E1225 Wheelchair accessory, manual semireclining back, (recline greater than 15 degrees, but
less than 80 degrees), each Y

IOM: 100-03, 4, 280.3

❂ E1226 Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each
B

IOM: 100-03, 4, 280.1

320
 ❂ E1227 Special height arms for wheelchair Y
IOM: 100-03, 4, 280.3
Special back height for wheelchair Y
❂ E1228
IOM: 100-03, 4, 280.3

Wheelchair: Pediatric
Wheelchair, pediatric size, not otherwise specified Y
✽ E1229
❂ E1230 Power operated vehicle (three or four wheel non-highway), specify brand name and model
number Y

Patient is unable to operate manual wheelchair; patient capable of safely operating

controls for scooter; patient can transfer safely in and out of scooter
IOM: 100-08, 5, 5.2.3
❂ E1231 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system
Y

IOM: 100-03, 4, 280.1

❂ E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system
Y

IOM: 100-03, 4, 280.1

❂ E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system
Y

IOM: 100-03, 4, 280.1

❂ E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system
Y

IOM: 100-03, 4, 280.1

Wheelchair, pediatric size, rigid, adjustable, with seating system Y
❂ E1235
IOM: 100-03, 4, 280.1
Wheelchair, pediatric size, folding, adjustable, with seating system Y
❂ E1236
IOM: 100-03, 4, 280.1
Wheelchair, pediatric size, rigid, adjustable, without seating system Y
❂ E1237
IOM: 100-03, 4, 280.1
Wheelchair, pediatric size, folding, adjustable, without seating system Y
❂ E1238
IOM: 100-03, 4, 280.1
Power wheelchair, pediatric size, not otherwise specified Y
✽ E1239

Wheelchair: Lightweight
❂ E1240 Lightweight wheelchair, detachable arms, (desk or full length) swing away detachable,
elevating leg rests Y

IOM: 100-03, 4, 280.1

H E1250 Lightweight wheelchair, fixed full length arms, swing away detachable footrest
IOM: 100-03, 4, 280.1 E1

Cross Reference K0003

H E1260 Lightweight wheelchair, detachable arms (desk or full length) swing away detachable
footrest E1

IOM: 100-03, 4, 280.1

Cross Reference K0003
❂ E1270 Lightweight wheelchair, fixed full length arms, swing away detachable elevating legrests
Y

IOM: 100-03, 4, 280.1

Wheelchair: Heavy Duty

321
 ❂ E1280 Heavy duty wheelchair, detachable arms (desk or full length), elevating legrests
Y
IOM: 100-03, 4, 280.1
H E1285 Heavy duty wheelchair, fixed full length arms, swing away detachable footrest
IOM: 100-03, 4, 280.1 E1

Cross Reference K0006

H E1290 Heavy duty wheelchair, detachable arms (desk or full length) swing away detachable
footrest E1

IOM: 100-03, 4, 280.1

Cross Reference K0006
Heavy duty wheelchair, fixed full length arms, elevating legrest Y
❂ E1295
IOM: 100-03, 4, 280.1
Special wheelchair seat height from floor Y
❂ E1296
IOM: 100-03, 4, 280.3
Special wheelchair seat depth, by upholstery Y
❂ E1297
IOM: 100-03, 4, 280.3
Special wheelchair seat depth and/or width, by construction Y
❂ E1298
IOM: 100-03, 4, 280.3

Whirlpool Equipment
Whirlpool, portable (overtub type) E1
H E1300
IOM: 100-03, 4, 280.1
Whirlpool, non-portable (built-in type) Y
❂ E1310
IOM: 100-03, 4, 280.1

Additional Oxygen Related Equipment

Oxygen accessory, flow regulator capable of positive inspiratory pressure Y
✽ E1352
Regulator Y
❂ E1353
IOM: 100-03, 4, 240.2
✽ E1354 Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type,
replacement only, each Y

Stand/rack Y
❂ E1355
IOM: 100-03, 4, 240.2
✽ E1356 Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement
only, each Y

✽ E1357 Oxygen accessory, battery charger for portable concentrator, any type, replacement only,
each Y

❂ E1358 Oxygen accessory, DC power adapter for portable concentrator, any type, replacement
only, each Y

Immersion external heater for nebulizer Y

❂ E1372
IOM: 100-03, 4, 240.2
❂ E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater
oxygen concentration at the prescribed flow rate Y

IOM: 100-03, 4, 240.2

❂ E1391 Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater
oxygen concentration at the prescribed flow rate, each Y

IOM: 100-03, 4, 240.2

Portable oxygen concentrator, rental Y
❂ E1392
IOM: 100-03, 4, 240.2

322
 ✽ E1399 Durable medical equipment, miscellaneous Y
Example: Therapeutic exercise putty; rubber exercise tubing; anti-vibration gloves.
On DMEPOS fee schedule as a payable replacement for miscellaneous implanted or non-
implanted items.
Oxygen and water vapor enriching system with heated delivery Y
❂ E1405
IOM: 100-03, 4, 240.2
Oxygen and water vapor enriching system without heated delivery Y
❂ E1406
IOM: 100-03, 4, 240.2

Artificial Kidney Machines and Accessories

Centrifuge, for dialysis A
❂ E1500
❂ E1510 Kidney, dialysate delivery syst kidney machine, pump recirculating, air removal syst.
flowrate meter, power off, heater and temperature control with alarm, I.V. poles, pressure
gauge, concentrate container A

Heparin infusion pump for hemodialysis A

❂ E1520
Air bubble detector for hemodialysis, each, replacement A
❂ E1530
Pressure alarm for hemodialysis, each, replacement A
❂ E1540
Bath conductivity meter for hemodialysis, each A
❂ E1550
Blood leak detector for hemodialysis, each, replacement A
❂ E1560
Adjustable chair, for ESRD patients A
❂ E1570
Transducer protectors/fluid barriers for hemodialysis, any size, per 10 A
❂ E1575
Unipuncture control system for hemodialysis A
❂ E1580
Hemodialysis machine A
❂ E1590
Automatic intermittent peritoneal dialysis system A
❂ E1592
Cycler dialysis machine for peritoneal dialysis A
❂ E1594
Delivery and/or installation charges for hemodialysis equipment A
❂ E1600
Reverse osmosis water purification system, for hemodialysis A
❂ E1610
IOM: 100-03, 4, 230.7
Deionizer water purification system, for hemodialysis A
❂ E1615
IOM: 100-03, 4, 230.7
Blood pump for hemodialysis replacement A
❂ E1620
Water softening system, for hemodialysis A
❂ E1625
IOM: 100-03, 4, 230.7
Reciprocating peritoneal dialysis system A
✽ E1630
Wearable artificial kidney, each A
❂ E1632
Peritoneal dialysis clamps, each B
❂ E1634
IOM: 100-04, 8, 60.4.2; 100-04, 8, 90.1; 100-04, 18, 80; 100-04, 18, 90
Compact (portable) travel hemodialyzer system A
❂ E1635
Sorbent cartridges, for hemodialysis, per 10 A
❂ E1636
Hemostats, each A
❂ E1637
Scale, each A
❂ E1639
Dialysis equipment, not otherwise specified A
❂ E1699

Jaw Motion Rehabilitation System

Jaw motion rehabilitation system Y
✽ E1700

323
 Must be prescribed by physician
Replacement cushions for jaw motion rehabilitation system, pkg. of 6 Y
✽ E1701
✽ E1702 Replacement measuring scales for jaw motion rehabilitation system, pkg. of 200
Y

Other Orthopedic Devices

✽ E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface material
Y

✽ E1801 Static progressive stretch elbow device, extension and/or flexion, with or without range of
motion adjustment, includes all components and accessories Y

✽ E1802 Dynamic adjustable forearm pronation/supination device, includes soft interface material
Y

✽ E1805 Dynamic adjustable wrist extension/flexion device, includes soft interface material
Y

✽ E1806 Static progressive stretch wrist device, flexion and/or extension, with or without range of
motion adjustment, includes all components and accessories Y

✽ E1810 Dynamic adjustable knee extension/flexion device, includes soft interface material
Y

✽ E1811 Static progressive stretch knee device, extension and/or flexion, with or without range of
motion adjustment, includes all components and accessories Y

Dynamic knee, extension/flexion device with active resistance control Y

✽ E1812
✽ E1815 Dynamic adjustable ankle extension/flexion device, includes soft interface material
Y

✽ E1816 Static progressive stretch ankle device, flexion and/or extension, with or without range of
motion adjustment, includes all components and accessories Y

✽ E1818 Static progressive stretch forearm pronation/supination device with or without range of
motion adjustment, includes all components and accessories Y

✽ E1820 Replacement soft interface material, dynamic adjustable extension/flexion device

Y

✽ E1821 Replacement soft interface material/cuffs for bi-directional static progressive stretch device
Y

✽ E1825 Dynamic adjustable finger extension/flexion device, includes soft interface material
Y

✽ E1830 Dynamic adjustable toe extension/flexion device, includes soft interface material
Y

✽ E1831 Static progressive stretch toe device, extension and/or flexion, with or without range of
motion adjustment, includes all components and accessories Y

✽ E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface

material Y

✽ E1841 Static progressive stretch shoulder device, with or without range of motion adjustment,
includes all components and accessories Y

Miscellaneous
✽ E1902 Communication board, non-electronic augmentative or alternative communication device
Y

Gastric suction pump, home model, portable or stationary, electric Y

✽ E2000
Blood glucose monitor with integrated voice synthesizer Y
❂ E2100
IOM: 100-03, 4, 230.16
Blood glucose monitor with integrated lancing/blood sample Y
❂ E2101
IOM: 100-03, 4, 230.16

324
 ✽ E2120 Pulse generator system for tympanic treatment of inner ear endolymphatic fluid
Y

Wheelchair Assessories: Manual and Power

✽ E2201 Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20
inches and less than 24 inches Y

✽ E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches
Y
✽ E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches
Y

✽ E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches

Y
✽ E2205 Manual wheelchair accessory, handrim without projections (includes ergonomic or
contoured), any type, replacement only, each Y

✽ E2206 Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each
Y

Wheelchair accessory, crutch and cane holder, each Y

✽ E2207
Wheelchair accessory, cylinder tank carrier, each Y
✽ E2208
Accessory arm trough, with or without hand support, each Y
✽ E2209
Wheelchair accessory, bearings, any type, replacement only, each Y
✽ E2210
Manual wheelchair accessory, pneumatic propulsion tire, any size, each Y
✽ E2211
✽ E2212 Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each
Y

✽ E2213 Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type,
any size, each Y

Manual wheelchair accessory, pneumatic caster tire, any size, each Y

✽ E2214
✽ E2215 Manual wheelchair accessory, tube for pneumatic caster tire, any size, each
Y
Manual wheelchair accessory, foam filled propulsion tire, any size, each Y
✽ E2216
Manual wheelchair accessory, foam filled caster tire, any size, each Y
✽ E2217
Manual wheelchair accessory, foam propulsion tire, any size, each Y
✽ E2218
Manual wheelchair accessory, foam caster tire, any size, each Y
✽ E2219
✽ E2220 Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement
only, each Y

✽ E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size,
replacement only, each Y

✽ E2222 Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any
size, replacement only, each Y

✽ E2224 Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only,
each Y

✽ E2225 Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each
Y

Manual wheelchair accessory, caster fork, any size, replacement only, each Y
✽ E2226
Manual wheelchair accessory, gear reduction drive wheel, each Y
✽ E2227
✽ E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each
Y
Manual wheelchair accessory, manual standing system Y
✽ E2230
✽ E2231 Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any
type mounting hardware Y

✽ E2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware

325
 Y
✽ E2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardware
Y
✽ E2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardware
Y

✽ E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardware
Y

✽ E2295 Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows
coordinated movement of multiple positioning features Y

Wheelchair accessory, power seat elevation system, any type Y

✽ E2300
Wheelchair accessory, power standing system, any type Y
✽ E2301
✽ E2310 Power wheelchair accessory, electronic connection between wheelchair controller and one
power seating system motor, including all related electronics, indicator feature, mechanical
function selection switch, and fixed mounting hardware Y

✽ E2311 Power wheelchair accessory, electronic connection between wheelchair controller and two
or more power seating system motors, including all related electronics, indicator feature,
mechanical function selection switch, and fixed mounting hardware Y

✽ E2312 Power wheelchair accessory, hand or chin control interface, miniproportional remote
joystick, proportional, including fixed mounting hardware Y

✽ E2313 Power wheelchair accessory, harness for upgrade to expandable controller, including all
fasteners, connectors and mounting hardware, each Y

✽ E2321 Power wheelchair accessory, hand control interface, remote joystick, nonproportional,
including all related electronics, mechanical stop switch, and fixed mounting hardware
Y

✽ E2322 Power wheelchair accessory, hand control interface, multiple mechanical switches,
nonproportional, including all related electronics, mechanical stop switch, and fixed
mounting hardware Y

✽ E2323 Power wheelchair accessory, specialty joystick handle for hand control interface,
prefabricated Y

Power wheelchair accessory, chin cup for chin control interface Y

✽ E2324
✽ E2325 Power wheelchair accessory, sip and puff interface, nonproportional, including all related
electronics, mechanical stop switch, and manual swingaway mounting hardware
Y
Power wheelchair accessory, breath tube kit for sip and puff interface Y
✽ E2326
✽ E2327 Power wheelchair accessory, head control interface, mechanical, proportional, including all
related electronics, mechanical direction change switch, and fixed mounting hardware
Y

✽ E2328 Power wheelchair accessory, head control or extremity control interface, electronic,
proportional, including all related electronics and fixed mounting hardware
Y
✽ E2329 Power wheelchair accessory, head control interface, contact switch mechanism,
nonproportional, including all related electronics, mechanical stop switch, mechanical
direction change switch, head array, and fixed mounting hardware Y

✽ E2330 Power wheelchair accessory, head control interface, proximity switch mechanism,
nonproportional, including all related electronics, mechanical stop switch, mechanical
direction change switch, head array, and fixed mounting hardware Y

✽ E2331 Power wheelchair accessory, attendant control, proportional, including all related
electronics and fixed mounting hardware Y

Power wheelchair accessory, nonstandard seat frame width, 20-23 inches Y

✽ E2340
Power wheelchair accessory, nonstandard seat frame width, 24-27 inches Y
✽ E2341
✽ E2342 Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 inches
Y

326
✽ E2343 Power wheelchair accessory, nonstandard seat frame depth, 22-25 inches Y

✽ E2351 Power wheelchair accessory, electronic interface to operate speech generating device using
power wheelchair control interface Y

Power wheelchair accessory, Group 34 non-sealed lead acid battery, each Y

✽ E2358
✽ E2359 Power wheelchair accessory, Group 34 sealed lead acid battery, each (e.g., gel cell,
absorbed glassmat) Y

Power wheelchair accessory, 22 NF non-sealed lead acid battery, each Y

✽ E2360
✽ E2361 Power wheelchair accessory, 22NF sealed lead acid battery, each (e.g., gel cell, absorbed
glassmat) Y

Power wheelchair accessory, group 24 non-sealed lead acid battery, each Y

✽ E2362
✽ E2363 Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed
glassmat) Y

Power wheelchair accessory, U-1 non-sealed lead acid battery, each Y

✽ E2364
✽ E2365 Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g., gel cell, absorbed
glassmat) Y

✽ E2366 Power wheelchair accessory, battery charger, single mode, for use with only one battery
type, sealed or non-sealed, each Y

✽ E2367 Power wheelchair accessory, battery charger, dual mode, for use with either battery type,
sealed or non-sealed, each Y

Power wheelchair component, drive wheel motor, replacement only Y

✽ E2368
Power wheelchair component, drive wheel gear box, replacement only Y
✽ E2369
✽ E2370 Power wheelchair component, integrated drive wheel motor and gear box combination,
replacement only Y

✽ E2371 Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed
glass mat), each Y

Power wheelchair accessory, group 27 non-sealed lead acid battery, each Y

✽ E2372
✽ E2373 Power wheelchair accessory, hand or chin control interface, compact remote joystick,
proportional, including fixed mounting hardware Y

❂ E2374 Power wheelchair accessory, hand or chin control interface, standard remote joystick (not
including controller), proportional, including all related electronics and fixed mounting
hardware, replacement only Y

❂ E2375 Power wheelchair accessory, nonexpandable controller, including all related electronics
and mounting hardware, replacement only Y

❂ E2376 Power wheelchair accessory, expandable controller, including all related electronics and
mounting hardware, replacement only Y

❂ E2377 Power wheelchair accessory, expandable controller, including all related electronics and
mounting hardware, upgrade provided at initial issue Y

Power wheelchair component, actuator, replacement only Y

✽ E2378
❂ E2381 Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each
Y

❂ E2382 Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement
only, each Y

❂ E2383 Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type,
any size, replacement only, each Y

❂ E2384 Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each
Y

❂ E2385 Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only,
each Y

❂ E2386 Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each

327
 Y

❂ E2387 Power wheelchair accessory, foam filled caster tire, any size, replacement only, each
Y

❂ E2388 Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each
Y

❂ E2389 Power wheelchair accessory, foam caster tire, any size, replacement only, each
Y

❂ E2390 Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement
only, each Y

❂ E2391 Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size,
replacement only, each Y

❂ E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any
size, replacement only, each Y

❂ E2394 Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each
Y

❂ E2395 Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each
Y

Power wheelchair accessory, caster fork, any size, replacement only, each Y
❂ E2396
Power wheelchair accessory, lithiumbased battery, each Y
✽ E2397

Negative Pressure
Negative pressure wound therapy electrical pump, stationary or portable Y
✽ E2402
Document at least every 30 calendar days the quantitative wound characteristics, including
wound surface area (length, width and depth).
Medicare coverage up to a maximum of 15 dressing kits (A6550) per wound per month
unless documentation states that the wound size requires more than one dressing kit for
each dressing change.

Speech Device
❂ E2500 Speech generating device, digitized speech, using pre-recorded messages, less than or
equal to 8 minutes recording time Y

IOM: 100-03, 1, 50.1

❂ E2502 Speech generating device, digitized speech, using pre-recorded messages, greater than 8
minutes but less than or equal to 20 minutes recording time Y

IOM: 100-03, 1, 50.1

❂ E2504 Speech generating device, digitized speech, using pre-recorded messages, greater than 20
minutes but less than or equal to 40 minutes recording time Y

IOM: 100-03, 1, 50.1

❂ E2506 Speech generating device, digitized speech, using pre-recorded messages, greater than 40
minutes recording time Y

IOM: 100-03, 1, 50.1

❂ E2508 Speech generating device, synthesized speech, requiring message formulation by spelling
and access by physical contact with the device Y

IOM: 100-03, 1, 50.1

❂ E2510 Speech generating device, synthesized speech, permitting multiple methods of message
formulation and multiple methods of device access Y

IOM: 100-03, 1, 50.1

❂ E2511 Speech generating software program, for personal computer or personal digital assistant
Y

IOM: 100-03, 1, 50.1

328
 ❂ E2512 Accessory for speech generating device, mounting system Y

IOM: 100-03, 1, 50.1

Accessory for speech generating device, not otherwise classified Y
❂ E2599
IOM: 100-03, 1, 50.1

Wheelchair: Cushion
General use wheelchair seat cushion, width less than 22 inches, any depth Y
✽ E2601
✽ E2602 General use wheelchair seat cushion, width 22 inches or greater, any depth
Y
✽ E2603 Skin protection wheelchair seat cushion, width less than 22 inches, any depth
Y

✽ E2604 Skin protection wheelchair seat cushion, width 22 inches or greater, any depth
Y
Positioning wheelchair seat cushion, width less than 22 inches, any depth Y
✽ E2605
✽ E2606 Positioning wheelchair seat cushion, width 22 inches or greater, any depth
Y
✽ E2607 Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any
depth Y

✽ E2608 Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any
depth Y

Custom fabricated wheelchair seat cushion, any size Y

✽ E2609
Wheelchair seat cushion, powered B
✽ E2610
✽ E2611 General use wheelchair back cushion, width less than 22 inches, any height, including any
type mounting hardware Y

✽ E2612 General use wheelchair back cushion, width 22 inches or greater, any height, including
any type mounting hardware Y

✽ E2613 Positioning wheelchair back cushion, posterior, width less than 22 inches, any height,
including any type mounting hardware Y

✽ E2614 Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height,
including any type mounting hardware Y

✽ E2615 Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any
height, including any type mounting hardware Y

✽ E2616 Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any
height, including any type mounting hardware Y

✽ E2617 Custom fabricated wheelchair back cushion, any size, including any type mounting
hardware Y

Replacement cover for wheelchair seat cushion or back cushion, each Y

✽ E2619
✽ E2620 Positioning wheelchair back cushion, planar back with lateral supports, width less than 22
inches, any height, including any type mounting hardware Y

✽ E2621 Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches or
greater, any height, including any type mounting hardware Y

Wheelchair: Skin Protection

✽ E2622 Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth
Y

✽ E2623 Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
Y

✽ E2624 Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22
inches, any depth Y

✽ E2625 Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or
greater, any depth Y

329
Wheelchair: Arm Support
✽ E2626 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair,
balanced, adjustable Y

✽ E2627 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair,
balanced, adjustable rancho type Y

✽ E2628 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair,
balanced, reclining Y

✽ E2629 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair,
balanced, friction arm support (friction dampening to proximal and distal joints)
Y

✽ E2630 Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and
hand support, overhead elbow forearm hand sling support, yoke type suspension support
Y

✽ E2631 Wheelchair accessory, addition to mobile arm support, elevating proximal arm
Y

✽ E2632 Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with
elastic balance control Y

Wheelchair accessory, addition to mobile arm support, supinator Y

✽ E2633

Pediatric Gait Trainer

H E8000 Gait trainer, pediatric size, posterior support, includes all accessories and components
E1

H E8001 Gait trainer, pediatric size, upright support, includes all accessories and components
E1
H E8002 Gait trainer, pediatric size, anterior support, includes all accessories and components
E1

TEMPORARY PROCEDURES/PROFESSIONAL SERVICES

(G0000-G9999)
NOTE: Series “G”, “K”, and “Q” in the Level II coding are reserved for CMS assignment. “G”,
“K”, and “Q” codes are temporary national codes for items or services requiring uniform national
coding between one year’s update and the next. Sometimes “temporary” codes remain for more
than one update. If “G”, “K”, and “Q” codes are not converted to permanent codes in Level I or
Level II series in the following update, they will remain active until converted in following years or
until CMS notifies contractors to delete them. All active “G”, “K”, and “Q” codes at the time of
update will be included on the update file for contractors. In addition, deleted codes are retained
on the file for informational purposes, with a deleted indicator, for four years.

Vaccine Administration
Administration of influenza virus vaccine S
✽ G0008
Coinsurance and deductible do not apply. If provided, report significant, separately
identifiable E/M for medically necessary services (Z23).
Coding Clinic: 2016, Q4, P3
Administration of pneumococcal vaccine S
✽ G0009
Reported once in a lifetime based on risk; Medicare covers cost of vaccine and
administration (Z23)
Copayment, coinsurance, and deductible waived.
(https://www.cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf)
Coding Clinic: 2016, Q4, P3
Administration of hepatitis B vaccine S
✽ G0010
Report for other than OPPs. Coinsurance and deductible apply; Medicare covers both
cost of vaccine and administration (Z23)

330
 Copayment/coinsurance and deductible are waived.
(https://www.cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf)
Coding Clinic: 2016, Q4, P3

Semen Analysis
Q4
✽ G0027 Semen analysis; presence and/or motility of sperm excluding Huhner ♂
Laboratory Certification: Hematology

Administration, Payment and Care Management Services

▶ ✽ G0068 Professional services for the administration of anti-infective, pain management, chelation,
pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug
administration calendar day in the individual’s home, each 15 minutes A

▶ ✽ G0069 Professional services for the administration of subcutaneous immunotherapy for each
infusion drug administration calendar day in the individual’s home, each 15 minutes A

▶ ✽ G0070 Professional services for the administration of chemotherapy for each infusion drug
administration calendar day in the individual’s home, each 15 minutes A

▶ ✽ G0071 Payment for communication technologybased services for 5 minutes or more of a virtual
(non-face-to-face) communication between an rural health clinic (RHC) or federally
qualified health center (FQHC) practitioner and RHC or FQHC patient, or 5 minutes or
more of remote evaluation of recorded video and/or images by an RHC or FQHC
practitioner, occurring in lieu of an office visit; RHC or FQHC only A

▶ ✽ G0076 Brief (20 minutes) care management home visit for a new patient. For use only in a
Medicare-approved CMMI model. (Services must be furnished within a beneficiary’s
home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0077 Limited (30 minutes) care management home visit for a new patient. For use only in a
Medicare-approved CMMI model. (Services must be furnished within a beneficiary’s
home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0078 Moderate (45 minutes) care management home visit for a new patient. For use only in a
Medicareapproved CMMI model. (Services must be furnished within a beneficiary’s
home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0079 Comprehensive (60 minutes) care management home visit for a new patient. For use only
in a Medicareapproved CMMI model. (Services must be furnished within a beneficiary’s
home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0080 Extensive (75 minutes) care management home visit for a new patient. For use only in a
Medicareapproved CMMI model. (Services must be furnished within a beneficiary’s
home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0081 Brief (20 minutes) care management home visit for an existing patient. For use only in a
Medicare-approved CMMI model. (Services must be furnished within a beneficiary’s
home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0082 Limited (30 minutes) care management home visit for an existing patient. For use only in
a Medicare-approved CMMI model. (Services must be furnished within a beneficiary’s
home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0083 Moderate (45 minutes) care management home visit for an existing patient. For use only
in a Medicare-approved CMMI model. (Services must be furnished within a beneficiary’s
home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0084 Comprehensive (60 minutes) care management home visit for an existing patient. For use
only in a Medicareapproved CMMI model. (Services must be furnished within a
beneficiary’s home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0085 Extensive (75 minutes) care management home visit for an existing patient. For use only
in a Medicareapproved CMMI model. (Services must be furnished within a beneficiary’s
home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0086 Limited (30 minutes) care management home care plan oversight. For use only in a
Medicare-approved CMMI model. (Services must be furnished within a beneficiary’s

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 home, domiciliary, rest home, assisted living and/or nursing facility.) B

▶ ✽ G0087 Comprehensive (60 minutes) care management home care plan oversight. For use only in
a Medicare-approved CMMI model. (Services must be furnished within a beneficiary’s
home, domiciliary, rest home, assisted living and/or nursing facility.) B

Screening Services
Cervical or vaginal cancer screening; pelvic and clinical breast examination S
❂ G0101
Covered once every two years and annually if high risk for cervical/vaginal cancer, or if
childbearing age patient has had an abnormal Pap smear in preceding three years. High
risk diagnosis, Z77.9
Coding Clinic: 2002, Q4, P8
Prostate cancer screening; digital rectal examination N
❂ G0102
Covered annually by Medicare (Z12.5). Not separately payable with an E/M code
(99201-99499).
IOM: 100-02, 6, 10; 100-04, 4, 240; 100-04, 18, 50.1
Prostate cancer screening; prostate specific antigen test (PSA) A
❂ G0103
Covered annually by Medicare (Z12.5)
IOM: 100-02, 6, 10; 100-04, 4, 240; 100-04, 18, 50
Laboratory Certification: Routine chemistry
Colorectal cancer screening; flexible sigmoidoscopy T
❂ G0104
Covered once every 48 months for beneficiaries age 50+
Co-insurance waived under Section 4104.
Coding Clinic: 2011, Q2, P4
Colorectal cancer screening; colonoscopy on individual at high risk T
❂ G0105
Screening colonoscopy covered once every 24 months for high risk for developing
colorectal cancer. May use modifier 53 if appropriate (physician fee schedule).
Co-insurance waived under Section 4104.
Coding Clinic: 2018, Q2, P4; 2011, Q2, P4
❂ G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium
enema S

Barium enema (not high risk) (alternative to G0104). Covered once every 4 years for
beneficiaries age 50+. Use modifier 26 for professional component only.
Coding Clinic: 2011, Q2, P4

Diabetes Management Training Services

✽ G0108 Diabetes outpatient self-management training services, individual, per 30 minutes
A
Report for beneficiaries diagnosed with diabetes.
Effective January 2011, DSMT will be included in the list of reimbursable Medicare
telehealth services.
✽ G0109 Diabetes outpatient self-management training services, group session (2 or more) per 30
minutes A

Report for beneficiaries diagnosed with diabetes.

Effective January 2011, DSMT will be included in the list of reimbursable Medicare
telehealth services.

Screening Services
✽ G0117 Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist
S

Covered once per year (full 11 months between screenings). Bundled with all other
ophthalmic services provided on same day. Diagnosis code Z13.5.
✽ G0118 Glaucoma screening for high risk patient furnished under the direct supervision of an

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 optometrist or ophthalmologist S

Covered once per year (full 11 months between screenings). Diagnosis code Z13.5.
❂ G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema.
S

Barium enema for patients with a high risk of developing colorectal. Covered once every 2
years. Used as an alternative to G0105. Use modifier 26 for professional component only.
❂ G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
T

Screening colonoscopy for patients that are not high risk. Covered once every 10 years,
but not within 48 months of a G0104. For non-Medicare patients report 45378.
Co-insurance waived under Section 4104.
Coding Clinic: 2018, Q2, P4
Colorectal cancer screening; barium enema E1
H G0122
Medicare: this service is denied as noncovered, because it fails to meet the requirements of
the benefit. The beneficiary is liable for payment.
❂ G0123 Screening cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation, screening by cytotechnologist under
A
physician supervision ♀
Use G0123 or G0143 or G0144 or G0145 or G0147 or G0148 or P3000 for Pap smears
NOT requiring physician interpretation (technical component).
IOM: 100-03, 3, 190.2; 100-04, 18, 30
Laboratory Certification: Cytology
❂ G0124 Screening cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation, requiring interpretation by physician
B
♀
Report professional component for Pap smears requiring physician interpretation.
IOM: 100-03, 3, 190.2; 100-04, 18, 30
Laboratory Certification: Cytology

Miscellaneous Services, Diagnostic and Therapeutic

Trimming of dystrophic nails, any number Q1
❂ G0127
Must be used with a modifier (Q7, Q8, or Q9) to show that the foot care service is needed
because the beneficiary has a systemic disease. Limit 1 unit of service.
IOM: 100-02, 15, 290
❂ G0128 Direct (face-to-face with patient) skilled nursing services of a registered nurse provided in
a comprehensive outpatient rehabilitation facility, each 10 minutes beyond the first 5
minutes B

A separate nursing service that is clearly identifiable in the Plan of Treatment and not part
of other services. Documentation must support this service. Examples include: Insertion of
a urinary catheter, intramuscular injections, bowel disimpaction, nursing assessment, and
education. Restricted coverage by Medicare.
Medicare Statute 1833(a)
✽ G0129 Occupational therapy services requiring the skills of a qualified occupational therapist,
furnished as a component of a partial hospitalization treatment program, per session (45
minutes or more) P

❂ G0130 Single energy x-ray absorptiometry (SEXA) bone density study, one or more sites;
appendicular skeleton (peripheral) (e.g., radius, wrist, heel) Z3 S

Covered every 24 months (more frequently if medically necessary). Use modifier 26 for
professional component only.
Preventive service; no deductible
IOM: 100-03, 2, 150.3; 100-04, 13, 140.1
✽ G0141 Screening cytopathology smears, cervical or vaginal, performed by automated system, with

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 manual rescreening, requiring interpretation by physician ♀ B

Co-insurance, copay, and deductible waived

Report professional component for Pap smears requiring physician interpretation. Refer to
diagnosis of Z92.89, Z12.4, Z12.72, or Z12.89 to report appropriate risk level.
Laboratory Certification: Cytology
✽ G0143 Screening cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation, with manual screening and
A
rescreening by cytotechnologist under physician supervision ♀
Co-insurance, copay, and deductible waived
Laboratory Certification: Cytology
✽ G0144 Screening cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation, with screening by automated system,
A
under physician supervision ♀
Co-insurance, copay, and deductible waived
Laboratory Certification: Cytology
✽ G0145 Screening cytopathology, cervical or vaginal (any reporting system), collected in
preservative fluid, automated thin layer preparation, with screening by automated system
A
and manual rescreening under physician supervision ♀
Co-insurance, copay, and deductible waived
Laboratory Certification: Cytology
✽ G0147 Screening cytopathology smears, cervical or vaginal; performed by automated system
A
under physician supervision ♀
Co-insurance, copay, and deductible waived
Laboratory Certification: Cytology
✽ G0148 Screening cytopathology smears, cervical or vaginal; performed by automated system with
A
manual rescreening ♀
Co-insurance, copay, and deductible waived
Laboratory Certification: Cytology
✽ G0151 Services performed by a qualified physical therapist in the home health or hospice setting,
each 15 minutes B

✽ G0152 Services performed by a qualified occupational therapist in the home health or hospice
setting, each 15 minutes B

✽ G0153 Services performed by a qualified speech-language pathologist in the home health or

hospice setting, each 15 minutes B

Services of clinical social worker in home health or hospice settings, each 15 minutes B
✽ G0155
✽ G0156 Services of home health/health aide in home health or hospice settings, each 15 minutes
B
✽ G0157 Services performed by a qualified physical therapist assistant in the home health or
hospice setting, each 15 minutes B

✽ G0158 Services performed by a qualified occupational therapist assistant in the home health or
hospice setting, each 15 minutes B

✽ G0159 Services performed by a qualified physical therapist, in the home health setting, in the
establishment or delivery of a safe and effective physical therapy maintenance program,
each 15 minutes B

✽ G0160 Services performed by a qualified occupational therapist, in the home health setting, in the
establishment or delivery of a safe and effective occupational therapy maintenance
program, each 15 minutes B

✽ G0161 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 B

✽ G0162 Skilled services by a registered nurse (RN) for management and evaluation of the plan of
care; each 15 minutes (the patient’s underlying condition or complication requires an RN

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 to ensure that essential non-skilled care achieves its purpose in the home health or hospice
setting) B
Transmittal No. 824 (CR7182)
External counterpulsation, per treatment session Q1
❂ G0166
IOM: 100-03, 1, 20.20
Wound closure utilizing tissue adhesive(s) only B
✽ G0168
Report for wound closure with only tissue adhesive. If a practitioner utilizes tissue
adhesive in addition to staples or sutures to close a wound, HCPCS code G0168 is not
separately reportable, but is included in the tissue repair.
The only closure material used for a simple repair, coverage based on payer.
Coding Clinic: 2005, Q1, P5; 2001, Q4, P12; Q3, P13

Figure 15 Tissue adhesive.

✽ G0175 Scheduled interdisciplinary team conference (minimum of three exclusive of patient care
nursing staff) with patient present V

❂ G0176 Activity therapy, such as music, dance, art or play therapies not for recreation, related to
the care and treatment of patient’s disabling mental health problems, per session (45
minutes or more) P

Paid in partial hospitalization

❂ G0177 Training and educational services related to the care and treatment of patient’s disabling
mental health problems per session (45 minutes or more) N

Paid in partial hospitalization

✽ G0179 Physician recertification for Medicarecovered home health services under a home health
plan of care (patient not present), including contacts with home health agency and review
of reports of patient status required by physicians to affirm the initial implementation of
the plan of care that meets patient’s needs, per recertification period M

The recertification code is used after a patient has received services for at least 60 days (or
one certification period) when the physician signs the certification after the initial
certification period.
✽ G0180 Physician certification for Medicarecovered home health services under a home health
plan of care (patient not present), including contacts with home health agency and review
of reports of patient status required by physicians to affirm the initial implementation of
the plan of care that meets patient’s needs, per certification period M

This code can be billed only when the patient has not received Medicare covered home
health services for at least 60 days.

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 ✽ G0181 Physician supervision of a patient receiving Medicare-covered services provided by a
participating home health agency (patient not present) requiring complex and
multidisciplinary care modalities involving regular physician development and/or revision
of care plans, review of subsequent reports of patient status, review of laboratory and other
studies, communication (including telephone calls) with other health care professionals
involved in the patient’s care, integration of new information into the medical treatment
plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more
M
Coding Clinic: 2015, Q2, P10

✽ G0182 Physician supervision of a patient under a Medicare-approved hospice (patient not

present) requiring complex and multidisciplinary care modalities involving regular
physician development and/or revision of care plans, review of subsequent reports of
patient status, review of laboratory and other studies, communication (including telephone
calls) with other health care professionals involved in the patient’s care, integration of new
information into the medical treatment plan and/or adjustment of medical therapy, within
a calendar month, 30 minutes or more M
Coding Clinic: 2015, Q2, P10
✽ G0186 Destruction of localized lesion of choroid (for example, choroidal neovascularization);
photocoagulation, feeder vessel technique (one or more sessions) T

Figure 16 PET scan.

PET imaging whole body; melanoma for non-covered indications E1

H G0219
Example: Assessing regional lymph nodes in melanoma.
IOM: 100-03, 4, 220.6
Coding Clinic: 2007, Q1, P6
PET imaging, any site, not otherwise specified E1
H G0235
Example: Prostate cancer diagnosis and initial staging.
IOM: 100-03, 4, 220.6
Coding Clinic: 2007, Q1, P6

✽ G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, face to

face, one on one, each 15 minutes (includes monitoring) S

✽ G0238 Therapeutic procedures to improve respiratory function, other than described by G0237,
one on one, face to face, per 15 minutes (includes monitoring) S

✽ G0239 Therapeutic procedures to improve respiratory function or increase strength or endurance

of respiratory muscles, two or more individuals (includes monitoring) S

❂ G0245 Initial physician evaluation and management of a diabetic patient with diabetic sensory
neuropathy resulting in a loss of protective sensation (LOPS) which must include (1) the
diagnosis of LOPS, (2) a patient history, (3) a physical examination that consist of at least
the following elements: (A) visual inspection of the forefoot, hindfoot and toe web spaces,
(B) evaluation of a protective sensation, (C) evaluation of foot structure and biomechanics,
(D) evaluation of vascular status and skin integrity, and (E) evaluation and
recommendation of footwear, and (4) patient education V

IOM: 100-03, 1, 70.2.1

❂ G0246 Follow-up physician evaluation and management of a diabetic patient with diabetic
sensory neuropathy resulting in a loss of protective sensation (LOPS) to include at least

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 the following: (1) a patient history, (2) a physical examination that includes: (A) visual
inspection of the forefoot, hindfoot and toe web spaces, (B) evaluation of protective
sensation, (C) evaluation of foot structure and biomechanics, (D) evaluation of vascular
status and skin integrity, and (E) evaluation and recommendation of footwear, and (3)
patient education V

IOM: 100-03, 1, 70.2.1; 100-02, 15, 290

❂ G0247 Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy
resulting in a loss of protective sensation (LOPS) to include, the local care of superficial
wounds (i.e., superficial to muscle and fascia) and at least the following if present: (1) local
care of superficial wounds, (2) debridement of corns and calluses, and (3) trimming and
debridement of nails Q1

IOM: 100-03, 1, 70.2.1

❂ G0248 Demonstration, prior to initiation, of home INR monitoring for patient with either
mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who
meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face
demonstration of use and care of the INR monitor, obtaining at least one blood sample,
provision of instructions for reporting home INR test results, and documentation of
patient’s ability to perform testing and report results V

❂ G0249 Provision of test materials and equipment for home INR monitoring of patient with either
mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who
meets Medicare coverage criteria; includes provision of materials for use in the home and
reporting of test results to physician; testing not occurring more frequently than once a
week; testing materials, billing units of service include 4 tests V

❂ G0250 Physician review, interpretation, and patient management of home INR testing for
patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous
thromboembolism who meets Medicare coverage criteria; testing not occurring more
frequently than once a week; billing units of service include 4 tests M

H 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) E1
IOM: 100-03, 4, 220.6
Coding Clinic: 2007, Q1, P6
H G0255 Current perception threshold/sensory nerve conduction test (SNCT), per limb, any nerve
E1
IOM: 100-03, 2, 160.23
❂ G0257 Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital
outpatient department that is not certified as an ESRD facility S
Coding Clinic: 2003, Q1, P9
Injection procedure for sacroiliac joint; arthrography N
❂ G0259
Replaces 27096 for reporting injections for Medicare beneficiaries
Used by Part A only (facility), not priced by Part B Medicare.
❂ G0260 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other
therapeutic agent, with or without arthrography T

ASCs report when a therapeutic sacroiliac joint injection is administered in ASC

✽ G0268 Removal of impacted cerumen (one or both ears) by physician on same date of service as
audiologic function testing N

Report only when a physician, not an audiologist, performs the procedure.

Use with DX H61.2- when performed by physician.
Coding Clinic: 2016, Q2, P2-3; 2003, Q1, P12

❂ G0269 Placement of occlusive device into either a venous or arterial access site, post surgical or
interventional procedure (e.g., angioseal plug, vascular plug) N

Report for replacement of vasoseal. Hospitals may report the closure device as a supply
with C1760. Bundled status on Physician Fee Schedule.
Coding Clinic: 2011, Q3, P4; 2010, Q4, P6

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✽ G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second
referral in same year for change in diagnosis, medical condition or treatment regimen
(including additional hours needed for renal disease), individual, face to face with the
patient, each 15 minutes A

Requires physician referral for beneficiaries with diabetes or renal disease. Services must
be provided by dietitian/nutritionist. Co-insurance and deductible waived.
✽ G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second
referral in same year for change in diagnosis, medical condition, or treatment regimen
(including additional hours needed for renal disease), group (2 or more individuals), each
30 minutes A

Requires physician referral for beneficiaries with diabetes or renal disease. Services must
be provided by dietitian/nutritionist. Co-insurance and deductible waived.
❂ G0276 Blinded procedure for lumbar stenosis, percutaneous image-guided lumbar decompression
(PILD) or placebocontrol, performed in an approved coverage with evidence development
(CED) clinical trial J1

Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval S
❂ G0277
IOM: 100-03, 1, 20.29
Coding Clinic: 2015, Q3, P7
✽ G0278 Iliac and/or femoral artery angiography, non-selective, bilateral or ipsilateral to catheter
insertion, performed at the same time as cardiac catheterization and/or coronary
angiography, includes positioning or placement of the catheter in the distal aorta or
ipsilateral femoral or iliac artery, injection of dye, production of permanent images, and
radiologic supervision and interpretation (list separately in addition to primary procedure)
N

Medicare specific code not reported for iliac injection used as a guiding shot for a closure
device
Coding Clinic: 2011, Q3, P4; 2006, Q4, P7
✽ G0279 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to
G0204 or G0206) A

✽ G0281 Electrical stimulation, (unattended), to one or more areas, for chronic stage III and stage
IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not
demonstrating measurable signs of healing after 30 days of conventional care, as part of a
therapy plan of care A

Reported by encounter/areas and not by site. Therapists report G0281 and G0283 rather
than 97014.
H G0282 Electrical stimulation, (unattended), to one or more areas, for wound care other than
described in G0281 E1
IOM: 100-03, 4, 270.1
✽ G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than
wound care, as part of a therapy plan of care A

Reported by encounter/areas and not by site. Therapists report G0281 and G0283 rather
than 97014.
✽ G0288 Reconstruction, computed tomographic angiography of aorta for surgical planning for
vascular surgery N

✽ G0289 Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving
of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a
different compartment of the same knee N

Add-on code reported with knee arthroscopy code for major procedure performed-
reported once per extra compartment
“The code may be reported twice (or with a unit of two) if the physician performs these
procedures in two compartments, in addition to the compartment where the main
procedure was performed.” (http://www.ama-
assn.org/resources/doc/cpt/orthopaedics.pdf)
Noncovered surgical procedure(s) using conscious sedation, regional, general or spinal

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❂ G0293 anesthesia in a Medicare qualifying clinical trial, per day Q1

❂ G0294 Noncovered procedure(s) using either no anesthesia or local anesthesia only, in a Medicare
qualifying clinical trial, per day Q1

H G0295 Electromagnetic therapy, to one or more areas, for wound care other than described in
G0329 or for other uses E1
IOM: 100-03, 4, 270.1
✽ G0296 Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT
scan (service is for eligibility determination and shared decision making) S

Low dose CT scan (LDCT) for lung cancer screening S

✽ G0297
✽ G0299 Direct skilled nursing services of a registered nurse (RN) in the home health or hospice
setting, each 15 minutes B

✽ G0300 Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or
hospice setting, each 15 minutes B

✽ G0302 Pre-operative pulmonary surgery services for preparation for LVRS, complete course of
services, to include a minimum of 16 days of services S

✽ G0303 Pre-operative pulmonary surgery services for preparation for LVRS, 10 to 15 days of
services S

✽ G0304 Pre-operative pulmonary surgery services for preparation for LVRS, 1 to 9 days of services
S

✽ G0305 Post-discharge pulmonary surgery services after LVRS, minimum of 6 days of services
S

✽ G0306 Complete CBC, automated (HgB, HCT, RBC, WBC, without platelet count) and
automated WBC differential count Q4

Laboratory Certification: Hematology

✽ G0307 Complete CBC, automated (HgB, HCT, RBC, WBC; without platelet count)
Laboratory Certification: Hematology Q4

❂ G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous
A
Co-insurance and deductible waived
Reported for Medicare patients 501; one FOBT per year, with either G0107 (guaiac-
based) or G0328 (immunoassay-based)
Laboratory Certification: Routine chemistry, Hematology
Coding Clinic: 2012, Q2, P9
✽ G0329 Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure
ulcers, arterial ulcers, and diabetic ulcers and venous stasis ulcers not demonstrating
measurable signs of healing after 30 days of conventional care as part of a therapy plan of
care A

❂ G0333 Pharmacy dispensing fee for inhalation drug(s); initial 30-day supply as a beneficiary
M

Medicare will reimburse an initial dispensing fee to a pharmacy for initial 30-day period of
inhalation drugs furnished through DME.

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Figure 17 Electromagnetic device.

Hospice evaluation and counseling services, pre-election B

✽ G0337
✽ G0339 Image-guided robotic linear acceleratorbased stereotactic radiosurgery, complete course of
therapy in one session or first session of fractionated treatment B

✽ G0340 Image-guided robotic linear acceleratorbased stereotactic radiosurgery, delivery including

collimator changes and custom plugging, fractionated treatment, all lesions, per session,
second through fifth sessions, maximum five sessions per course of treatment B

❂ G0341 Percutaneous islet cell transplant, includes portal vein catheterization and infusion
C
IOM: 100-03, 4, 260.3; 100-04, 32, 70
❂ G0342 Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion
C

IOM: 100-03, 4, 260.3

❂ G0343 Laparotomy for islet cell transplant, includes portal vein catheterization and infusion
C

IOM: 100-03, 4, 260.3

✽ G0365 Vessel mapping of vessels for hemodialysis access (services for preoperative vessel mapping
prior to creation of hemodialysis access using an autogenous hemodialysis conduit,
including arterial inflow and venous outflow) S

Includes evaluation of the relevant arterial and venous vessels. Use modifier 26 for
professional component only.
❂ G0372 Physician service required to establish and document the need for a power mobility device
M

Providers should bill the E/M code and G0372 on the same claim.

Hospital Services: Observation and Emergency Department

Hospital observation service, per hour N
❂ G0378
Report all related services in addition to G0378. Report units of hours spent in
observation (rounded to the nearest hour). Hospitals report the ED or clinic visit with a
CPT code or, if applicable, G0379 (direct admit to observation) and G0378 (hospital
observation services, per hour).
Coding Clinic: 2007, Q1, P10; 2006, Q3, P7-8
Direct admission of patient for hospital observation care J2
❂ G0379
Report all related services in addition to G0379. Report units of hours spent in
observation (rounded to the nearest hour). Hospitals report the ED or clinic visit with a
CPT code or, if applicable, G0379 (direct admit to observation) and G0378 (hospital
observation services, per hour).
Coding Clinic: 2007, Q1, P7

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✽ G0380 Level 1 hospital emergency department visit provided in a type B emergency department;
(the ED must meet at least one of the following requirements: (1) it is licensed by the
state in which it is located under applicable state law as an emergency room or emergency
department; (2) it is held out to the public (by name, posted signs, advertising, or other
means) as a place that provides care for emergency medical conditions on an urgent basis
without requiring a previously scheduled appointment; or (3) during the calendar year
immediately preceding the calendar year in which a determination under 42 CFR 489.24
is being made, based on a representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient visits for the treatment
of emergency medical conditions on an urgent basis without requiring a previously
scheduled appointment) J2
Coding Clinic: 2009, Q1, P4; 2007, Q2, P1
✽ G0381 Level 2 hospital emergency department visit provided in a type B emergency department;
(the ED must meet at least one of the following requirements: (1) it is licensed by the
state in which it is located under applicable state law as an emergency room or emergency
department; (2) it is held out to the public (by name, posted signs, advertising, or other
means) as a place that provides care for emergency medical conditions on an urgent basis
without requiring a previously scheduled appointment; or (3) during the calendar year
immediately preceding the calendar year in which a determination under 42 CFR 489.24
is being made, based on a representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient visits for the treatment
of emergency medical conditions on an urgent basis without requiring a previously
scheduled appointment) J2
Coding Clinic: 2009, Q1, P4; 2007, Q2, P1

✽ G0382 Level 3 hospital emergency department visit provided in a type B emergency department;
(the ED must meet at least one of the following requirements: (1) it is licensed by the
state in which it is located under applicable state law as an emergency room or emergency
department; (2) it is held out to the public (by name, posted signs, advertising, or other
means) as a place that provides care for emergency medical conditions on an urgent basis
without requiring a previously scheduled appointment; or (3) during the calendar year
immediately preceding the calendar year in which a determination under 42 CFR 489.24
is being made, based on a representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient visits for the treatment
of emergency medical conditions on an urgent basis without requiring a previously
scheduled appointment) J2
Coding Clinic: 2009, Q1, P4; 2007, Q2, P1

✽ G0383 Level 4 hospital emergency department visit provided in a type B emergency department;
(the ED must meet at least one of the following requirements: (1) it is licensed by the
state in which it is located under applicable state law as an emergency room or emergency
department; (2) it is held out to the public (by name, posted signs, advertising, or other
means) as a place that provides care for emergency medical conditions on an urgent basis
without requiring a previously scheduled appointment; or (3) during the calendar year
immediately preceding the calendar year in which a determination under 42 CFR 489.24
is being made, based on a representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient visits for the treatment
of emergency medical conditions on an urgent basis without requiring a previously
scheduled appointment) J2
Coding Clinic: 2009, Q1, P4; 2007, Q2, P1

✽ G0384 Level 5 hospital emergency department visit provided in a type B emergency department;
(the ED must meet at least one of the following requirements: (1) it is licensed by the
state in which it is located under applicable state law as an emergency room or emergency
department; (2) it is held out to the public (by name, posted signs, advertising, or other
means) as a place that provides care for emergency medical conditions on an urgent basis
without requiring a previously scheduled appointment; or (3) during the calendar year
immediately preceding the calendar year in which a determination under 42 CFR 489.24
is being made, based on a representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient visits for the treatment

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 of emergency medical conditions on an urgent basis without requiring a previously
scheduled appointment) J2
Coding Clinic: 2009, Q1, P4; 2007, Q2, P1

Trauma Response Team

Trauma response team associated with hospital critical care service S
❂ G0390
Coding Clinic: 2007, Q2, P5

Alcohol Substance Abuse Assessment and Intervention

✽ G0396 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit,
DAST), and brief intervention 15 to 30 minutes S

Bill instead of 99408 and 99409

✽ G0397 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit,
DAST), and intervention, greater than 30 minutes S

Bill instead of 99408 and 99409

Home Sleep Study Test

✽ G0398 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7
channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen
saturation S

✽ G0399 Home sleep test (HST) with type III portable monitor, unattended; minimum of 4
channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation
S

✽ G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3
channels S

Initial Examination for Medicare Enrollment

✽ G0402 Initial preventive physical examination; face-to-face visit, services limited to new
beneficiary during the first 12 months of Medicare enrollment V

Depending on circumstances, 99201-99215 may be assigned with modifier 25 to report an

E/M service as a significant, separately identifiable service in addition to the Initial
Preventive Physical Examination (IPPE), G0402.
Copayment and coinsurance waived, deductible waived.
Coding Clinic: 2009, Q4, P8

Electrocardiogram
✽ G0403 Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial
preventive physical examination with interpretation and report M

Optional service may be ordered or performed at discretion of physician. Once in a life-

time screening, stemming from a referral from Initial Preventive Physical Examination
(IPPE). Both deductible and co-payment apply.
✽ G0404 Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and
report, performed as a screening for the initial preventive physical examination
S
✽ G0405 Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed
as a screening for the initial preventive physical examination B

Follow-up Telehealth Consultation

✽ G0406 Follow-up inpatient consultation, limited, physicians typically spend 15 minutes
communicating with the patient via telehealth B

These telehealth modifers are required when billing for telehealth services with codes
G0406-G0408 and G0425-G0427:
• GT, via interactive audio and video telecommunications system

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 • GQ, via asynchronous telecommunications system
✽ G0407 Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes
communicating with the patient via telehealth B

✽ G0408 Follow-up inpatient consultation, complex, physicians typically spend 35 minutes

communicating with the patient via telehealth B

Psychological Services
✽ G0409 Social work and psychological services, directly relating to and/or furthering the patient’s
rehabilitation goals, each 15 minutes, face-to-face; individual (services provided by a
CORF-qualified social worker or psychologist in a CORF) B

✽ G0410 Group psychotherapy other than of a multiple-family group, in a partial hospitalization

setting, approximately 45 to 50 minutes P
Coding Clinic: 2009, Q4, P9, 10
✽ G0411 Interactive group psychotherapy, in a partial hospitalization setting, approximately 45 to
50 minutes P
Coding Clinic: 2009, Q4, P9, 10

Fracture Treatment
✽ G0412 Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral or
bilateral for pelvic bone fracture patterns which do not disrupt the pelvic ring includes
internal fixation, when performed C

✽ G0413 Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for
fracture patterns which disrupt the pelvic ring, unilateral or bilateral, (includes ilium,
sacroiliac joint and/or sacrum) J1

✽ G0414 Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns
which disrupt the pelvic ring, unilateral or bilateral, includes internal fixation when
performed (includes pubic symphysis and/or superior/inferior rami) C

✽ G0415 Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns
which disrupt the pelvic ring, unilateral or bilateral, includes internal fixation, when
performed (includes ilium, sacroiliac joint and/or sacrum) C

Surgical Pathology: Prostate Biopsy

✽ G0416 Surgical pathology, gross and microscopic examinations for prostate needle biopsy, any
Q2
method ♂
This testing requires a facility to have either a CLIA certificate of registration (certificate
type code 9), a CLIA certificate of compliance (certificate type code 1), or a CLIA
certificate of accreditation (certificate type code 3). A facility without a valid, current,
CLIA certificate, with a current CLIA certificate of waiver (certificate type code 2) or
with a current CLIA certificate for provider-performed microscopy procedures (certificate
type code 4), must not be permitted to be paid for these tests. This code has a TC, 26
(physician), or gobal component.
Laboratory Certification: Histopathology
Coding Clinic: 2013, Q2, P6

Educational Services
✽ G0420 Face-to-face educational services related to the care of chronic kidney disease; individual,
per session, per one hour A

CKD is kidney damage of 3 months or longer, regardless of the cause of kidney damage.
Sessions billed in increments of one hour (if session is less than one hour, it must last at
least 31 minutes to be billable. Sessions less than one hour and longer than 31 minutes is
billable as one session. No more than 6 sessions of KDE services in a beneficiary’s lifetime.
✽ G0421 Face-to-face educational services related to the care of chronic kidney disease; group, per
session, per one hour A

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 Group setting: 2 to 20, report codes G0420 and G0421 with diagnosis code N18.4.

Cardiac and Pulmonary Rehabilitation

✽ G0422 Intensive cardiac rehabilitation; with or without continuous ECG monitoring with
exercise, per session S

Includes the same service as 93798 but at a greater frequency; may be reported with as
many as six hourly sessions on a single date of service. Includes medical nutrition services
to reduce cardiac disease risk factors.
✽ G0423 Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without
exercise, per session S

Includes the same service as 93797 but at a greater frequency; may be reported with as
many as six hourly sessions on a single date of service. Includes medical nutrition services
to reduce cardiac disease risk factors.
✽ G0424 Pulmonary rehabilitation, including exercise (includes monitoring), one hour, per session,
up to two sessions per day S

Includes therapeutic services and all related monitoring services to inprove respiratory
function. Do not report with G0237, G0238, or G0239.

Initial Telehealth Consultation

✽ G0425 Telehealth consultation, emergency department or initial inpatient, typically 30 minutes
communicating with the patient via telehealth B

Problem Focused: Problem focused history and examination, with straightforward medical
decision making complexity. Typically 30 minutes communicating with patient via
telehealth.
✽ G0426 Initial inpatient telehealth consultation, emergency department or initial inpatient,
typically 50 minutes communicating with the patient via telehealth B

Detailed: Detailed history and examination, with moderate medical decision making
complexity. Typically 50 minutes communicating with patient via telehealth.
✽ G0427 Initial inpatient telehealth consultation, emergency department or initial inpatient,
typically 70 minutes or more communicating with the patient via telehealth B

Comprehensive: Comprehensive history and examination, with high medical decision

making complexity. Typically 70 minutes or more communicating with patient via
telehealth.

Fillers
H G0428 Collagen meniscus implant procedure for filling meniscal defects (e.g., cmi, collagen
scaffold, menaflex) E1

✽ G0429 Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g.,
as a result of highly active antiretroviral therapy) T

Designated for dermal fillers Sculptra&reg; and Radiesse (Medicare).

(https://www.cms.gov/ContractorLearningResources/downloads/JA6953.pdf)
Coding Clinic: 2010, Q3, P8

Laboratory Screening
✽ G0432 Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1
and/or HIV-2, screening A

Laboratory Certification: Virology, General immunology

Coding Clinic: 2010, Q2, P10

✽ G0433 Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA)

technique, HIV-1 and/or HIV-2, screening A

Laboratory Certification: Virology, General immunology

Coding Clinic: 2010, Q2, P10
Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2,

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 ✽ G0435 screening A
Coding Clinic: 2010, Q2, P10

Counselling, Wellness, and Screening Services

✽ G0438 Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
A

✽ G0439 Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent
visit A

Annual alcohol misuse screening, 15 minutes S

✽ G0442
Coding Clinic: 2012, Q1, P7
Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes S
✽ G0443
Coding Clinic: 2012, Q1, P7
Annual depression screening, 15 minutes S
✽ G0444
✽ G0445 High intensity behavioral counseling to prevent sexually transmitted infection; face-to-
face, individual, includes: education, skills training and guidance on how to change sexual
behavior; performed semi-annually, 30 minutes S

✽ G0446 Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15
minutes S
Coding Clinic: 2012, Q2, P8
Face-to-face behavioral counseling for obesity, 15 minutes S
✽ G0447
Coding Clinic: 2012, Q1, P8
✽ G0448 Insertion or replacement of a permanent pacing cardioverterdefibrillator system with
transvenous lead(s), single or dual chamber with insertion of pacing electrode, cardiac
venous system, for left ventricular pacing B

✽ G0451 Development testing, with interpretation and report, per standardized instrument form
Q3

Miscellaneous Services
Molecular pathology procedure; physician interpretation and report B
✽ G0452
✽ G0453 Continuous intraoperative neurophysiology monitoring, from outside the operating room
(remote or nearby), per patient, (attention directed exclusively to one patient) each 15
minutes (list in addition to primary procedure) N

✽ G0454 Physician documentation of face-to-face visit for durable medical equipment

determination performed by nurse practitioner, physician assistant or clinical nurse
specialist B

✽ G0455 Preparation with instillation of fecal microbiota by any method, including assessment of
donor specimen Q1
Coding Clinic: 2013, Q3, P8
Low dose rate (LDR) prostate brachytherapy services, composite rate B
✽ G0458
✽ G0459 Inpatient telehealth pharmacologic management, including prescription, use, and review
of medication with no more than minimal medical psychotherapy B

✽ G0460 Autologous platelet rich plasma for chronic wounds/ulcers, including phlebotomy,
centrifugation, and all other preparatory procedures, administration and dressings, per
treatment T

Hospital outpatient clinic visit for assessment and management of a patient J2

✽ G0463
✽ G0464 Colorectal cancer screening; stoolbased DNA and fecal occult hemoglobin (e.g., KRAS,
NDRG4 and BMP3)
Cross Reference 81528
Laboratory Certification: General immunology, Routine chemistry, Clinical cytogenetics

Federally Qualified Health Center Visits

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 ✽ G0466 Federally qualified health center (FQHC) visit, new patient; a medicallynecessary, face-
to-face encounter (one-on-one) between a new patient and a FQHC practitioner during
which time one or more FQHC services are rendered and includes a typical bundle of
Medicare-covered services that would be furnished per diem to a patient receiving a
FQHC visit A

✽ G0467 Federally qualified health center (FQHC) visit, established patient; a medically-necessary,
face-to-face encounter (one-on-one) between an established patient and a FQHC
practitioner during which time one or more FQHC services are rendered and includes a
typical bundle of Medicarecovered services that would be furnished per diem to a patient
receiving a FQHC visit A

✽ G0468 Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that
includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV)
and includes a typical bundle of Medicare-covered services that would be furnished per
diem to a patient receiving an IPPE or AWV A

✽ G0469 Federally qualified health center (FQHC) visit, mental health, new patient; a medically-
necessary, face-to-face mental health encounter (one-on-one) between a new patient and a
FQHC practitioner during which time one or more FQHC services are rendered and
includes a typical bundle of Medicare-covered services that would be furnished per diem
to a patient receiving a mental health visit A

✽ G0470 Federally qualified health center (FQHC) visit, mental health, established patient; a
medically-necessary, face-to-face mental health encounter (one-on-one) between an
established patient and a FQHC practitioner during which time one or more FQHC
services are rendered and includes a typical bundle of Medicare-covered services that
would be furnished per diem to a patient receiving a mental health visit A

Other Miscellaneous Services

✽ G0471 Collection of venous blood by venipuncture or urine sample by catheterization from an
individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health
agency (HHA) A

❂ G0472 Hepatitis C antibody screening, for individual at high risk and other covered indication(s)
A

Medicare Statute 1861SSA

Laboratory Certification: General immunology
Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes S
✽ G0473
HIV antigen/antibody, combination assay, screening A
✽ G0475
Laboratory Certification: Virology, General immunology
✽ G0476 Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV),
high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer
screening, must be performed in addition to pap test A

Laboratory Certification: Virology

Drug Tests
✽ G0480 Drug test(s), definitive, utilizing drug identification methods able to identify individual
drugs and distinguish between structural isomers (but not necessarily stereoisomers),
including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type,
single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and
enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all
sources(s), includes specimen validity testing, per day, 1-7 drug class(es), including
metabolite(s) if performed Q4
Coding Clinic: 2018, Q1, P5

✽ G0481 Drug test(s), definitive, utilizing drug identification methods able to identify individual
drugs and distinguish between structural isomers (but not necessarily stereoisomers),
including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type,

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 single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and
enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all
sources(s), includes specimen validity testing, per day, 8-14 drug class(es), including
metabolite(s) if performed Q4
Coding Clinic: 2018, Q1, P5
✽ G0482 Drug test(s), definitive, utilizing drug identification methods able to identify individual
drugs and distinguish between structural isomers (but not necessarily stereoisomers),
including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type,
single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and
enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all
sources(s), includes specimen validity testing, per day, 15-21 drug class(es), including
metabolite(s) if performed Q4
Coding Clinic: 2018, Q1, P5
✽ G0483 Drug test(s), definitive, utilizing drug identification methods able to identify individual
drugs and distinguish between structural isomers (but not necessarily stereoisomers),
including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type,
single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and
enzymatic methods (e.g., alcohol dehydrogenase)); qualitative or quantitative, all
sources(s), includes specimen validity testing, per day, 22 or more drug class(es), including
metabolite(s) if performed Q4
Coding Clinic: 2018, Q1, P5

Home Health Nursing Visit: Area of Shortage

✽ G0490 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) A

Dialysis Procedure
✽ G0491 Dialysis procedure at a Medicare certified esrd facility for acute kidney injury without
ESRD B

✽ G0492 Dialysis procedure with single evaluation by a physician or other qualified health care
professional for acute kidney injury without ESRD B

Home Health or Hospice: Skilled Services

✽ G0493 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) B

✽ G0494 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) B

✽ G0495 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 B

✽ G0496 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 B

Chemotherapy Administration
✽ G0498 Chemotherapy administration, intravenous infusion technique; initiation of infusion in
the office/clinic setting using office/clinic pump/supplies, with continuation of the
infusion in the community setting (e.g., home, domiciliary, rest home or assisted living)
using a portable pump provided by the office/clinic, includes follow up office/clinic visit at
the conclusion of the infusion S

347
Hepatitis B Screening
✽ G0499 Hepatitis B screening in non-pregnant, high risk individual includes hepatitis B surface
antigen (HBsAG), antibodies to HBsAG (anti-HBs) and antibodies to hepatitis B core
antigen (anti-hbc), and is followed by a neutralizing confirmatory test, when performed,
only for an initially reactive HBsAG result A

Laboratory Certification: Virology

Moderate Sedation Services

✽ G0500 Moderate sedation services provided by the same physician or other qualified health care
professional performing a gastrointestinal endoscopic service that sedation supports,
requiring the presence of an independent trained observer to assist in the monitoring of
the patient’s level of consciousness and physiological status; initial 15 minutes of intra-
service time; patient age 5 years or older (additional time may be reported with 99153, as
appropriate) N

Resource-Intensive Service
✽ G0501 Resource-intensive services for patients for whom the use of specialized mobility-assistive
technology (such as adjustable height chairs or tables, patient lift, and adjustable padded
leg supports) is medically necessary and used during the provision of an office/outpatient,
evaluation and management visit (list separately in addition to primary service) N

Psychiatric Care Management

✽ G0506 Comprehensive assessment of and care planning for patients requiring chronic care
management services (list separately in addition to primary monthly care management
service) N

Critical Care Telehealth Consultation

✽ G0508 Telehealth consultation, critical care, initial, physicians typically spend 60 minutes
communicating with the patient and providers via telehealth B

✽ G0509 Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes
communicating with the patient and providers via telehealth B

Rural Health Clinic: Management and Care

❂ G0511 Rural health clinic or federally qualified health center (RHC or FQHC) only, general care
management, 20 minutes or more of clinical staff time for chronic care management
services or behavioral health integration services directed by an RHC or FQHC
practitioner (physician, NP, PA, or CNM), per calendar month A

❂ G0512 Rural health clinic or federally qualified health center (RHC/FQHC) only, psychiatric
collaborative care model (psychiatric CoCM), 60 minutes or more of clinical staff time for
psychiatric CoCM services directed by an RHC or FQHC practitioner (physician, NP,
PA, or CNM) and including services furnished by a behavioral health care manager and
consultation with a psychiatric consultant, per calendar month A

Prolonged Preventive Services

✽ G0513 Prolonged preventive service(s) (beyond the typical service time of the primary procedure),
in the office or other outpatient setting requiring direct patient contact beyond the usual
service; first 30 minutes (list separately in addition to code for preventive service) N

✽ G0514 Prolonged preventive service(s) (beyond the typical service time of the primary procedure),
in the office or other outpatient setting requiring direct patient contact beyond the usual
service; each additional 30 minutes (list separately in addition to code G0513 for
additional 30 minutes of preventive service) N

Cognitive Development

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 ✽ G0515 Development of cognitive skills to improve attention, memory, problem solving (includes
compensatory training), direct (one-on-one) patient contact, each 15 minutes A

Non-biodegradable Drug Delivery Implants: Removal and Insertion

✽ G0516 Insertion of non-biodegradable drug delivery implants, 4 or more (services for subdermal
rod implant) Q1

✽ G0517 Removal of non-biodegradable drug delivery implants, 4 or more (services for subdermal
implants) Q1

✽ G0518 Removal with reinsertion, nonbiodegradable drug delivery implants, 4 or more (services
for subdermal implants) Q1

Drug Test
✽ G0659 Drug test(s), definitive, utilizing drug identification methods able to identify individual
drugs and distinguish between structural isomers (but not necessarily stereoisomers),
including but not limited to GC/MS (any type, single or tandem) and LC/MS (any type,
single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and
enzymatic methods (e.g., alcohol dehydrogenase), performed without method or
drugspecific calibration, without matrixmatched quality control material, or without use of
stable isotope or other universally recognized internal standard(s) for each drug, drug
metabolite or drug class per specimen; qualitative or quantitative, all sources, includes
specimen validity testing, per day, any number of drug classes Q4

Quality Care Measures: Cataract Surgery

Improvement in visual function achieved within 90 days following cataract surgery M
✽ G0913
Patient care survey was not completed by patient M
✽ G0914
✽ G0915 Improvement in visual function not achieved within 90 days following cataract surgery
M
Satisfaction with care achieved within 90 days following cataract surgery M
✽ G0916
Patient satisfaction survey was not completed by patient M
✽ G0917
Satisfaction with care not achieved within 90 days following cataract surgery M
✽ G0918

Therapy, Evaluation and Assessment

▶ ✽ G2000 Blinded administration of convulsive therapy procedure, either electroconvulsive therapy
(ECT, current covered gold standard) or magnetic seizure therapy (MST, non-covered
experimental therapy), performed in an approved IDE-based clinical trial, per treatment
session S

▶ ✽ G2010 Remote evaluation of recorded video and/or images submitted by an established patient
(e.g., store and forward), including interpretation with follow-up with the patient within
24 business hours, not originating from a related E/M service provided within the
previous 7 days nor leading to an E/M service or procedure within the next 24 hours or
soonest available appointment M

▶ ✽ G2011 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT,
DAST), and brief intervention, 5-14 minutes S

▶ ✽ G2012 Brief communication technology-based service, e.g., virtual check-in, by a physician or

other qualified health care professional who can report evaluation and management
services, provided to an established patient, not originating from a related E/M service
provided within the previous 7 days nor leading to an E/M service or procedure within the
next 24 hours or soonest available appointment; 5-10 minutes of medical discussion M

Guidance
Ultrasonic guidance for placement of radiation therapy fields B
❂ G6001
✽ G6002 Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation

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 therapy B

Radiation Treatment
✽ G6003 Radiation treatment delivery, single treatment area, single port or parallel opposed ports,
simple blocks or no blocks: up to 5 mev B

✽ G6004 Radiation treatment delivery, single treatment area, single port or parallel opposed ports,
simple blocks or no blocks: 6-10 mev B

✽ G6005 Radiation treatment delivery, single treatment area, single port or parallel opposed ports,
simple blocks or no blocks: 11-19 mev B

✽ G6006 Radiation treatment delivery, single treatment area, single port or parallel opposed ports,
simple blocks or no blocks: 20 mev or greater B

✽ G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: up to 5 mev B

✽ G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: 6-10 mev B

✽ G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: 11-19 mev B

✽ G6010 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single
treatment area, use of multiple blocks: 20 mev or greater B

✽ G6011 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 mev
B

✽ G6012 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 mev
B

✽ G6013 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 mev
B

✽ G6014 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking,
tangential ports, wedges, rotational beam, compensators, electron beam; 20 mev or greater
B

✽ G6015 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially
and temporally modulated beams, binary, dynamic MLC, per treatment session
B
✽ G6016 Compensator-based beam modulation treatment delivery of inverse planned treatment
using 3 or more high resolution (milled or cast) compensator, convergent beam modulated
fields, per treatment session B

✽ G6017 Intra-fraction localization and tracking of target or patient motion during delivery of
radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction
of treatment B

Quality Measures
✽ G8395 Left ventricular ejection fraction (LVEF)>=40% or documentation as normal or mildly
depressed left ventricular systolic function M

Left ventricular ejection fraction (LVEF) not performed or documented M

✽ G8396
✽ G8397 Dilated macular or fundus exam performed, including documentation of the presence or
absence of macular edema and level of severity of retinopathy M

Dilated macular or fundus exam not performed M

✽ G8398
✽ G8399 Patient with documented results of a central dual-energy x-ray absorptiometry (DXA)
ever being performed M

✽ G8400 Patient with central dual-energy x-ray absorptiometry (DXA) results not documented
M

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✽ G8404 Lower extremity neurological exam performed and documented M

Lower extremity neurological exam not performed M

✽ G8405
Footwear evaluation performed and documented M
✽ G8410
Footwear evaluation was not performed M
✽ G8415
✽ G8416 Clinician documented that patient was not an eligible candidate for footwear evaluation
measure M

BMI is documented above normal parameters and a follow-up plan is documented M

✽ G8417
BMI is documented below normal parameters and a follow-up plan is documented M
✽ G8418
✽ G8419 BMI is documented outside normal parameters, no follow-up plan documented, no reason
given M

BMI is documented within normal parameters and no follow-up plan is required M

✽ G8420
BMI not documented and no reason is given M
✽ G8421
✽ G8422 BMI not documented, documentation the patient is not eligible for BMI calculation
M
✽ G8427 Eligible clinician attests to documenting in the medical record they obtained, updated, or
reviewed the patient’s current medications M

✽ G8428 Current list of medications not documented as obtained, updated, or reviewed by the
eligible clinician, reason not given M

✽ G8430 Eligible clinician attests to documenting in the medical record the patient is not eligible
for a current list of medications being obtained, updated, or reviewed by the eligible
clinician M

✽ G8431 Screening for depression is documented as being positive and a follow-up plan is
documented M

Depression screening not documented, reason not given M

✽ G8432
Screening for depression not completed, documented reason M
✽ G8433
✽ G8442 Pain assessment not documented as being performed, documentation the patient is not
eligible for a pain assessment using a standardized tool at the time of the encounter M

Beta-blocker therapy prescribed M

✽ G8450
✽ G8451 beta therapy for LVEF < 40% not prescribed for reasons documented by the clinician
(e.g., low blood pressure, fluid overload, asthma, patients recently treated with an
intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient
declined, other patient reasons or other reasons attributable to the healthcare system)
M
Beta-blocker therapy not prescribed M
✽ G8452
M
✽ G8465 High or very high risk of recurrence of prostate cancer ♂
✽ G8473 Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy prescribed M

✽ G8474 Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy not prescribed for reasons documented by the clinician (e.g., allergy, intolerance,
pregnancy, renal failure due to ACE inhibitor, diseases of the aortic or mitral valve, other
medical reasons) or (e.g., patient declined, other patient reasons) or (e.g., lack of drug
availability, other reasons attributable to the health care system) M

✽ G8475 Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy not prescribed, reason not given M

✽ G8476 Most recent blood pressure has a systolic measurement of < 140 mmHg and a diastolic
measurement of <90 mmHg M

✽ G8477 Most recent blood pressure has a systolic measurement of > = 140 mmHg and/or a
diastolic measurement of >=90 mmHg M

Blood pressure measurement not performed or documented, reason not given M

✽ G8478
Influenza immunization administered or previously received M
✽ G8482

351
✽ G8483 Influenza immunization was not administered for reasons documented by clinician (e.g.,
patient allergy or other medical reasons, patient declined or other patient reasons, vacine
not available or other system reasons) M

Influenza immunization was not administered, reason not given M

✽ G8484
✽ G8506 Patient receiving angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor
blocker (ARB) therapy M

✽ G8509 Pain assessment documented as positive using a standardized tool, follow-up plan not
documented, reason not given M

Screening for depression is documented as negative, a follow-up plan is not required M

✽ G8510
✽ G8511 Screening for depression documented as positive, follow up plan not documented, reason
not given M

✽ G8535 Elder maltreatment screen not documented; documentation that patient is not eligible for
the elder maltreatment screen at the time of the encounter M

No documentation of an elder maltreatment screen, reason not given M

✽ G8536
✽ G8539 Functional outcome assessment documented as positive using a standardized tool and a
care plan based on identified deficiencies on the date of functional outcome assessment is
documented M

✽ G8540 Functional outcome assessment not documented as being performed, documentation the
patient is not eligible for a functional outcome assessment using a standardized tool at the
time of the encounter M

✽ G8541 Functional outcome assessment using a standardized tool not documented, reason not
given M

✽ G8542 Functional outcome assessment using a standardized tool is documented; no functional

deficiencies identified, care plan not required M

✽ G8543 Documentation of a positive functional outcome assessment using a standardized tool;

care plan not documented, reason not given M

✽ G8559 Patient referred to a physician (preferably a physician with training in disorders of the ear)
for an otologic evaluation M

Patient has a history of active drainage from the ear within the previous 90 days M
✽ G8560
✽ G8561 Patient is not eligible for the referral for otologic evaluation for patients with a history of
active drainage measure M

✽ G8562 Patient does not have a history of active drainage from the ear within the previous 90 days
M

✽ G8563 Patient not referred to a physician (preferably a physician with training in disorders of the
ear) for an otologic evaluation, reason not given M

✽ G8564 Patient was referred to a physician (preferably a physician with training in disorders of the
ear) for an otologic evaluation, reason not specified M

Verification and documentation of sudden or rapidly progressive hearing loss M

✽ G8565
✽ G8566 Patient is not eligible for the “referral for otologic evaluation for sudden or rapidly
progressive hearing loss” measure M

✽ G8567 Patient does not have verification and documentation of sudden or rapidly progressive
hearing loss M

✽ G8568 Patient was not referred to a physician (preferably a physician with training in disorders of
the ear) for an otologic evaluation, reason not given M

Prolonged postoperative intubation (>24 hrs) required M

✽ G8569
Prolonged postoperative intubation (>24 hrs) not required M
✽ G8570
✽ G8571 Development of deep sternal wound infection/mediastinitis within 30 days postoperatively
M
No deep sternal wound infection/mediastinitis M
✽ G8572
Stroke following isolated CABG surgery M
✽ G8573

352
✽ G8574 No stroke following isolated CABG surgery M

Developed postoperative renal failure or required dialysis M

✽ G8575
No postoperative renal failure/dialysis not required M
✽ G8576
✽ G8577 Re-exploration required due to mediastinal bleeding with or without tamponade, graft
occlusion, valve disfunction, or other cardiac reason M

✽ G8578 Re-exploration not required due to mediastinal bleeding with or without tamponade, graft
occlusion, valve dysfunction, or other cardiac reason M

Aspirin or another antiplatelet therapy used M

✽ G8598
Aspirin or another antiplatelet therapy not used, reason not given M
✽ G8599
IV T-PA initiated within three hours (<=180 minutes) of time last known well M
✽ G8600
✽ G8601 IV T-PA not initiated within three hours (<=180 minutes) of time last known well for
reasons documented by clinician M

✽ G8602 IV T-PA not initiated within three hours (<=180 minutes) of time last known well, reason
not given M

✽ G8627 Surgical procedure performed within 30 days following cataract surgery for major
complications (e.g., retained nuclear fragments, endophthalmitis, dislocated or wrong
power IOL, retinal detachment, or wound dehiscence) M

✽ G8628 Surgical procedure not performed within 30 days following cataract surgery for major
complications (e.g., retained nuclear fragments, endophthalmitis, dislocated or wrong
power IOL, retinal detachment, or wound dehiscence) M

Pharmacologic therapy (other than minierals/vitamins) for osteoporosis prescribed M

✽ G8633
Pharmacologic therapy for osteoporosis was not prescribed, reason not given M
✽ G8635
✽ G8647 Risk-adjusted functional status change residual score for the knee impairment successfully
calculated and the score was equal to zero (0) or greater than zero (>0) M

✽ G8648 Risk-adjusted functional status change residual score for the knee impairment successfully
calculated and the score was less than zero (<0) M

✽ G8649 Risk-adjusted functional status change residual scores for the knee impairment not
measured because the patient did not complete FOTO’S status survey near discharge, not
appropriate M

✽ G8650 Risk-adjusted functional status change residual scores for the knee impairment not
measured because the patient did not complete FOTO’S functional intake on admission
and/or follow up status survey near discharge, reason not given M

✽ G8651 Risk-adjusted functional status change residual score for the hip impairment successfully
calculated and the score was equal to zero (0) or greater than zero (>0) M

✽ G8652 Risk-adjusted functional status change residual score for the hip impairment successfully
calculated and the score was less than zero (<0) M

✽ G8653 Risk-adjusted functional status change residual scores for the hip impairment not
measured because the patient did not complete follow up status survey near discharge,
patient not appropriate M

✽ G8654 Risk-adjusted functional status change residual scores for the hip impairment not
measured because the patient did not complete FOTO’S functional intake on admission
and/or follow up status survey near discharge, reason not given M

✽ G8655 Risk-adjusted functional status change residual score for the foot or ankle impairment
successfully calculated and the score was equal to zero (0) or greater than zero (>0) M

✽ G8656 Risk-adjusted functional status change residual score for the foot or ankle impairment
successfully calculated and the score was less than zero (<0) M

✽ G8657 Risk-adjusted functional status change residual scores for the foot or ankle impairment
not measured because the patient did not complete FOTO’S status survey near discharge,
patient not appropriate M

✽ G8658 Risk-adjusted functional status change residual scores for the foot or ankle impairment
not measured because the patient did not complete FOTO’S functional intake on

353
 admission and/or follow up status survey near discharge, reason not given M

✽ G8659 Risk-adjusted functional status change residual score for the low back impairment
successfully calculated and the score was equal to zero (0) or greater than zero (>0) M

✽ G8660 Risk-adjusted functional status change residual score for the low back impairment
successfully calculated and the score was less than zero (<0) M

✽ G8661 Risk-adjusted functional status change residual scores for the low back impairment not
measured because the patient did not complete FOTO’S status survey near discharge,
patient not appropriate M

✽ G8662 Risk-adjusted functional status change residual scores for the low back impairment not
measured because the patient did not complete FOTO’S functional intake on admission
and/or follow up status survey near discharge, reason not given M

✽ G8663 Risk-adjusted functional status change residual score for the shoulder impairment
successfully calculated and the score was equal to zero (0) or greater than zero (>0) M

✽ G8664 Risk-adjusted functional status change residual score for the shoulder impairment
successfully calculated and the score was less than zero (<0) M

✽ G8665 Risk-adjusted functional status change residual scores for the shoulder impairment not
measured because the patient did not complete FOTO’S functional status survey near
discharge, patient not appropriate M

✽ G8666 Risk-adjusted functional status change residual scores for the shoulder impairment not
measured because the patient did not complete FOTO’S functional intake on admission
and/or follow up status survey near discharge, reason not given M

✽ G8667 Risk-adjusted functional status change residual score for the elbow, wrist or hand
impairment successfully calculated and the score was equal to zero (0) or greater than zero
(>0) M

✽ G8668 Risk-adjusted functional status change residual score for the elbow, wrist or hand
impairment successfully calculated and the score was less than zero (<0) M

✽ G8669 Risk-adjusted functional status change residual scores for the elbow, wrist or hand
impairment not measured because the patient did not complete the FS status survey near
discharge, patient not appropriate M

✽ G8670 Risk-adjusted functional status change residual scores for the elbow, wrist or hand
impairment not measured because the patient did not complete the FS intake on
admission and/or follow up status survey near discharge, reason not given M

✽ G8671 Risk-adjusted functional status change residual score for the neck, cranium, mandible,
thoracic spine, ribs, or other general orthopaedic impairment successfully calculated and
the score was equal to zero (0) or greater than zero (>0) M

✽ G8672 Risk-adjusted functional status change residual score for the neck, cranium, mandible,
thoracic spine, ribs, or other general orthopaedic impairment successfully calculated and
the score was less than zero (<0) M

✽ G8673 Risk-adjusted functional status change residual scores for the neck, cranium, mandible,
thoracic spine, ribs, or other general orthopaedic impairment not measured because the
patient did not complete the FS status survey near discharge, patient not appropriate
M
✽ G8674 Risk-adjusted functional status change residual scores for the neck, cranium, mandible,
thoracic spine, ribs, or other general orthopaedic impairment not measured because the
patient did not complete the FS intake on admission and/or follow up status survey near
discharge, reason not given M

Left ventriucular ejection fraction (LVEF) <40% M

✽ G8694
Patient not prescribed or dispensed antibiotic M
✽ G8708
✽ G8709 Patient prescribed or dispensed antibiotic for documented medical reason(s) within three
days after the initial diagnosis of URI (e.g., intestinal infection, pertussis, bacterial
infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis,
chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis,
mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections,
pneumonia/gonococcal infections, venereal disease [syphilis, chlamydia, inflammatory

354
 diseases (female reproductive organs)], infections of the kidney, cystitis or UTI, and acne)
M
Patient prescribed or dispensed antibiotic M
✽ G8710
Prescribed or dispensed antibiotic M
✽ G8711
Antibiotic not prescribed or dispensed M
✽ G8712
✽ G8721 PT category (primary tumor), PN category (regional lymph nodes), and histologic grade
were documented in pathology report M

✽ G8722 Documentation of medical reason(s) for not including the PT category, the PN category
or the histologic grade in the pathology report (e.g., re-excision without residual tumor;
noncarcinomasanal canal) M

Specimen site is other than anatomic location of primary tumor M

✽ G8723
✽ G8724 PT category, PN category and histologic grade were not documented in the pathology
report, reason not given M

✽ G8730 Pain assessment documented as positive using a standardized tool and a follow-up plan is
documented M

✽ G8731 Pain assessment using a standardized tool is documented as negative, no follow-up plan
required M

No documentation of pain assessment, reason not given M

✽ G8732
✽ G8733 Elder maltreatment screen documented as positive and a follow-up plan is documented
M
Elder maltreatment screen documented as negative, no follow-up required M
✽ G8734
✽ G8735 Elder maltreatment screen documented as positive, follow-up plan not documented,
reason not given M

✽ G8749 Absence of signs of melanoma (tenderness, jaundice, localized neurologic signs such as
weakness, or any other sign suggesting systemic spread) or absence of symptoms of
melanoma (cough, dyspnea, pain, paresthesia, or any other symptom suggesting the
possibility of systemic spread of melanoma) M

Most recent systolic blood pressure <140 mmhg M

✽ G8752
Most recent systolic blood pressure >=140 mmhg M
✽ G8753
Most recent diastolic blood pressure <90 mmhg M
✽ G8754
Most recent diastolic blood pressure >=90 mmhg M
✽ G8755
No documentation of blood pressure measurement, reason not given M
✽ G8756
Normal blood pressure reading documented, follow-up not required M
✽ G8783
Blood pressure reading not documented, reason not given M
✽ G8785
Specimen site other than anatomic location of esophagus M
✽ G8797
Specimen site other than anatomic location of prostate M
✽ G8798
✽ G8806 Performance of trans-abdominal or trans-vaginal ultrasound and pregnancy location
documented M

✽ G8807 Trans-abdominal or trans-vaginal ultrasound not performed for reasons documented by

clinician (e.g., patient has visited the ED multiple times within 72 hours, patient has a
documented intrauterine pregnancy [IUP]) M

Trans-abdominal or trans-vaginal ultrasound not performed, reason not given M

✽ G8808
Rh-immunoglobulin (RhoGAM) ordered M
✽ G8809
✽ G8810 Rh-immunoglobulin (RhoGAM) not ordered for reasons documented by clinician (e.g.,
patient had prior documented report of RhoGAM within 12 weeks, patient refusal) M

✽ G8811 Documentation RH-immunoglobulin (RhoGAM) was not ordered, reason not given
M
✽ G8815 Documented reason in the medical records for why the statin therapy was not prescribed
(i.e., lower extremity bypass was for a patient with nonartherosclerotic disease) M

355
✽ G8816 Statin medication prescribed at discharge M

Statin therapy not prescribed at discharge, reason not given M

✽ G8817
Patient discharge to home no later than post-operative day #7 M
✽ G8818
Patient not discharged to home by post-operative day #7 M
✽ G8825
Patient discharge to home no later than post-operative day #2 following EVAR M
✽ G8826
Patient not discharged to home by post-operative day #2 following EVAR M
✽ G8833
Patient discharged to home no later than post-operative day #2 following CEA M
✽ G8834
Patient not discharged to home by post-operative day #2 following CEA M
✽ G8838
✽ G8839 Sleep apnea symptoms assessed, including presence or absence of snoring and daytime
sleepiness M

✽ G8840 Documentation of reason(s) for not documenting an assessment of sleep symptoms (e.g.,
patient didn’t have initial daytime sleepiness, patient visited between initial testing and
initiation of therapy) M

Sleep apnea symptoms not assessed, reason not given M

✽ G8841
✽ G8842 Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) measured at the
time of initial diagnosis M

✽ G8843 Documentation of reason(s) for not measuring an Apnea Hypopnea Index (AHI) or a
Respiratory Disturbance Index (RDI) at the time of initial diagnosis (e.g., psychiatric
disease, dementia, patient declined, financial, insurance coverage, test ordered but not yet
completed) M

✽ G8844 Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) not measured at
the time of initial diagnosis, reason not given M

Positive airway pressure therapy prescribed M

✽ G8845
✽ G8846 Moderate or severe obstructive sleep apnea (Apnea Hypopnea Index (AHI) or Respiratory
Disturbance Index (RDI) of 15 or greater) M

✽ G8849 Documentation of reason(s) for not prescribing positive airway pressure therapy (e.g.,
patient unable to tolerate, alternative therapies use, patient declined, financial, insurance
coverage) M

Positive airway pressure therapy not prescribed, reason not given M

✽ G8850
✽ G8851 Objective measurement of adherence to positive airway pressure therapy, documented
M
Positive airway pressure therapy prescribed M
✽ G8852
✽ G8854 Documentation of reason(s) for not objectively measuring adherence to positive airway
pressure therapy (e.g., patient didn’t bring data from continuous positive airway pressure
[CPAP], therapy was not yet initiated, not available on machine) M

✽ G8855 Objective measurement of adherence to positive airway pressure therapy not performed,
reason not given M

Referral to a physician for an otologic evaluation performed M

✽ G8856
✽ G8857 Patient is not eligible for the referral for otologic evaluation measure (e.g., patients who
are already under the care of a physician for acute or chronic dizziness) M

Referral to a physician for an otologic evaluation not performed, reason not given M
✽ G8858
✽ G8861 Within the past 2 years, central dualenergy x-ray absorptiometry (DXA) ordered and
documented, review of systems and medication history or pharmacologic therapy (other
than minerals/vitamins) for osteoporosis prescribed M

Patients not assessed for risk of bone loss, reason not given M
✽ G8863
Pneumococcal vaccine administered or previously received M
✽ G8864
✽ G8865 Documentation of medical reason(s) for not administering or previously receiving
pneumococcal vaccine (e.g., patient allergic reaction, potential adverse drug reaction)
M
Documentation of patient reason(s) for not administering or previously receiving

356
✽ G8866 pneumococcal vaccine (e.g., patient refusal) M

Pneumococcal vaccine not administered or previously received, reason not given M

✽ G8867
Patient has documented immunity to hepatitis B and initiating anti-TNF therapy M
✽ G8869
✽ G8872 Excised tissue evaluated by imaging intraoperatively to confirm successful inclusion of
targeted lesion M

✽ G8873 Patients with needle localization specimens which are not amenable to intraoperative
imaging such as MRI needle wire localization, or targets which are tentatively identified
on mammogram or ultrasound which do not contain a biopsy marker but which can be
verified on intraoperative inspection or pathology (e.g., needle biopsy site where the
biopsy marker is remote from the actual biopsy site) M

✽ G8874 Excised tissue not evaluated by imaging intraoperatively to confirm successful inclusion of
targeted lesion M

✽ G8875 Clinician diagnosed breast cancer preoperatively by a minimally invasive biopsy method
M
✽ G8876 Documentation of reason(s) for not performing minimally invasive biopsy to diagnose
breast cancer preoperatively (e.g., lesion too close to skin, implant, chest wall, etc., lesion
could not be adequately visualized for needle biopsy, patient condition prevents needle
biopsy [weight, breast thickness, etc.], duct excision without imaging abnormality,
prophylactic mastectomy, reduction mammoplasty, excisional biopsy performed by
another physician) M

✽ G8877 Clinician did not attempt to achieve the diagnosis of breast cancer preoperatively by a
minimally invasive biopsy method, reason not given M

Sentinel lymph node biopsy procedure performed M

✽ G8878
✽ G8880 Documentation of reason(s) sentinel lymph node biopsy not performed (e.g., reasons
could include but not limited to; non-invasive cancer, incidental discovery of breast cancer
on prophylactic mastectomy, incidental discovery of breast cancer on reduction
mammoplasty, pre-operative biopsy proven lymph node (LN) metastases, inflammatory
carcinoma, stage 3 locally advanced cancer, recurrent invasive breast cancer, clinically node
positive after neoadjuvant systemic therapy, patient refusal after informed consent; patient
with significant age, comorbidities, or limited life expectancy and favorable tumor;
adjuvant systemic therapy unlikely to change) M

Stage of breast cancer is greater than T1N0M0 or T2N0M0 M

✽ G8881
Sentinel lymph node biopsy procedure not performed, reason not given M
✽ G8882
Biopsy results reviewed, communicated, tracked and documented M
✽ G8883
Clinician documented reason that patient’s biopsy results were not reviewed M
✽ G8884
Biopsy results not reviewed, communicated, tracked or documented M
✽ G8885
✽ G8907 Patient documented not to have experienced any of the following events: a burn prior to
discharge; a fall within the facility; wrong site/side/patient/procedure/implant event; or a
hospital transfer or hospital admission upon discharge from the facility M

Patient documented to have received a burn prior to discharge M

✽ G8908
Patient documented not to have received a burn prior to discharge M
✽ G8909
Patient documented to have experienced a fall within ASC M
✽ G8910
Patient documented not to have experienced a fall within ambulatory surgical center M
✽ G8911
✽ G8912 Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong
procedure or wrong implant event M

✽ G8913 Patient documented not to have experienced a wrong site, wrong side, wrong patient,
wrong procedure or wrong implant event M

✽ G8914 Patient documented to have experienced a hospital transfer or hospital admission upon
discharge from ASC M

✽ G8915 Patient documented not to have experienced a hospital transfer or hospital admission
upon discharge from ASC M

357
✽ G8916 Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis,
antibiotic initiated on time M

✽ G8917 Patient with preoperative order for IV antibiotic surgical site infection (SSI) prophylaxis,
antibiotic not initiated on time M

✽ G8918 Patient without preoperative order for IV antibiotic surgical site infection(SSI)
prophylaxis M

✽ G8923 Left ventricular ejection fraction (LVEF) <40% or documentation of moderately or

severely depressed left ventricular systolic function M

✽ G8924 Spirometry test results demonstrate FEV1/FVC <70%, FEV <60% predicted and patient
has COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) M

✽ G8925 Spirometry test results demonstrate FEV1>=60% FEV1/FVC>=70%, predicted or patient

does not have COPD symptoms M

Spirometry test not performed or documented, reason not given M

✽ G8926
✽ G8934 Left ventricular ejection fraction (LVEF) <40% or documentation of moderately or
severely depressed left ventricular systolic function M

✽ G8935 Clinician prescribed angiotensin converting enzyme (ACE) inhibitor or angiotensin

receptor blocker (ARB) therapy M

✽ G8936 Clinician documented that patient was not an eligible candidate for angiotensin
converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (e.g.,
allergy, intolerance, pregnancy, renal failure due to ace inhibitor, diseases of the aortic or
mitral valve, other medical reasons) or (e.g., patient declined, other patient reasons) or
(e.g., lack of drug availability, other reasons attributable to the health care system) M

✽ G8937 Clinician did not prescribe angiotensin converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB) therapy, reason not given M

✽ G8938 BMI is documented as being outside of normal limits, follow-up plan is not documented,
documentation the patient is not eligible M

✽ G8939 Pain assessment documented as positive, follow-up plan not documented, documentation
the patient is not eligible at the time of the encounter at the time of the encounter M

✽ G8941 Elder maltreatment screen documented as positive, follow-up plan not documented,
documentation the patient is not eligible for follow-up plan at the time of the encounter
M

✽ G8942 Functional outcomes assessment using a standardized tool is documented within the
previous 30 days and care plan, based on identified deficiencies on the date of the
functional outcome assessment, is documented M

AJCC melanoma cancer stage 0 through IIC melanoma M

✽ G8944
✽ G8946 Minimally invasive biopsy method attempted but not diagnostic of breast cancer (e.g.,
high risk lesion of breast such as atypical ductal hyperplasia, lobular neoplasia, atypical
lobular hyperplasia, lobular carcinoma in situ, atypical columnar hyperplasia, flat epithelial
atypia, radial scar, complex sclerosing lesion, papillary lesion, or any lesion with spindle
cells) M

✽ G8950 Pre-hypertensive or hypertensive blood pressure reading documented, and the indicated
follow-up documented M

✽ G8952 Pre-hypertensive or hypertensive blood pressure reading documented, indicated follow-up

not documented, reason not given M

Most recent assessment of adequacy of volume management documented M

✽ G8955
Patient receiving maintenance hemodialysis in an outpatient dialysis facility M
✽ G8956
Assessment of adequacy of volume management not documented, reason not given M
✽ G8958
✽ G8959 Clinician treating major depressive disorder communicates to clinician treating comorbid
condition M

✽ G8960 Clinician treating major depressive disorder did not communicate to clinician treating
comorbid condition, reason not given M

Cardiac stress imaging test primarily performed on low-risk surgery patient for

358
✽ G8961 preoperative evaluation within 30 days preceding this surgery M

✽ G8962 Cardiac stress imaging test performed on patient for any reason including those who did
not have low risk surgery or test that was performed more than 30 days preceding low risk
surgery M

✽ G8963 Cardiac stress imaging performed primarily for monitoring of asymptomatic patient who
had PCI within 2 years M

✽ G8964 Cardiac stress imaging test performed primarily for any other reason than monitoring of
asymptomatic patient who had PCI within 2 years (e.g., symptomatic patient, patient
greater than 2 years since PCI, initial evaluation, etc.) M

✽ G8965 Cardiac stress imaging test primarily performed on low CHD risk patient for initial
detection and risk assessment M

✽ G8966 Cardiac stress imaging test performed on symptomatic or higher than low CHD risk
patient or for any reason other than initial detection and risk assessment M

Warfarin or another FDA-approved oral anticoagulant is prescribed M

✽ G8967
✽ G8968 Documentation of medical reason(s) for not prescribing warfarin or another FDA-
approved anticoagulant (e.g., atrial appendage device in place) M

✽ G8969 Documentation of patient reason(s) for not prescribing warfarin or another FDA-
approved oral anticoagulant that is FDA approved for the prevention of
thromboembolism (e.g., patient choice of having atrial appendage device placed) M

No risk factors or one moderate risk factor for thromboembolism M

✽ G8970
Most recent hemoglobin (Hgb) level <10 g/dl M
✽ G8973

359
 Hemoglobin level measurement not documented, reason not given M
✽ G8974
✽ G8975 Documentation of medical reason(s) for patient having a hemoglobin level <10g/dl (e.g.,
patients who have non-renal etiologies of anemia [e.g., sickle cell anemia or other
hemoglobinopathies, hypersplenism, primary bone marrow disease, anemia related to
chemotherapy for diagnosis of malignancy, postoperative bleeding, active bloodstream or
peritoneal infection], other medical reasons) M

Most recent hemoglobin (Hgb) level >= 10 g/dl M

✽ G8976

Functional Limitation
✽ G8978 Mobility: walking & moving around functional limitation, current status, at therapy
episode outset and at reporting intervals E1

✽ G8979 Mobility: walking & moving around functional limitation, projected goal status, at
therapy episode outset, at reporting intervals, and at discharge or to end reporting E1

✽ G8980 Mobility: walking & moving around functional limitation, discharge status, at discharge
from therapy or to end reporting E1

✽ G8981 Changing and maintaining body position functional limitation, current status, at therapy
episode outset and at reporting intervals E1

✽ G8982 Changing and maintaining body position functional limitation, projected goal status, at
therapy episode outset, at reporting intervals, and at discharge or to end reporting E1

✽ G8983 Changing and maintaining body position functional limitation, discharge status, at
discharge from therapy or to end reporting E1

✽ G8984 Carrying, moving and handling objects functional limitation, current status, at therapy
episode outset and at reporting intervals E1

✽ G8985 Carrying, moving and handling objects, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting E1

✽ G8986 Carrying, moving & handling objects functional limitation, discharge status, at discharge
from therapy or to end reporting E1

✽ G8987 Self-care functional limitation, current status, at therapy episode outset and at reporting
intervals E1

✽ G8988 Self-care functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting E1

✽ G8989 Self-care functional limitation, discharge status, at discharge from therapy or to end
reporting E1

✽ G8990 Other physical or occupational therapy primary functional limitation, current status, at
therapy episode outset and at reporting intervals E1

✽ G8991 Other physical or occupational therapy primary functional limitation, projected goal
status, at therapy episode outset, at reporting intervals, and at discharge or to end
reporting E1

✽ G8992 Other physical or occupational therapy primary functional limitation, discharge status, at
discharge from therapy or to end reporting E1

✽ G8993 Other physical or occupational therapy subsequent functional limitation, current status, at
therapy episode outset and at reporting intervals E1

✽ G8994 Other physical or occupational therapy subsequent functional limitation, projected goal
status, at therapy episode outset, at reporting intervals, and at discharge or to end
reporting E1

✽ G8995 Other physical or occupational therapy subsequent functional limitation, discharge status,
at discharge from therapy or to end reporting E1

✽ G8996 Swallowing functional limitation, current status at therapy episode outset and at reporting
intervals E1

✽ G8997 Swallowing functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting E1

✽ G8998 Swallowing functional limitation, discharge status, at discharge from therapy or to end

360
 reporting E1

✽ G8999 Motor speech functional limitation, current status at therapy episode outset and at
reporting intervals E1

Coordinated Care
Coordinated care fee, initial rate B
❂ G9001
Coordinated care fee, maintenance rate B
❂ G9002
Coordinated care fee, risk adjusted high, initial B
❂ G9003
Coordinated care fee, risk adjusted low, initial B
❂ G9004
Coordinated care fee, risk adjusted maintenance B
❂ G9005
Coordinated care fee, home monitoring B
❂ G9006
Coordinated care fee, scheduled team conference B
❂ G9007
Coordinated care fee, physician coordinated care oversight services B
❂ G9008
Coordinated care fee, risk adjusted maintenance, level 3 B
❂ G9009
Coordinated care fee, risk adjusted maintenance, level 4 B
❂ G9010
Coordinated care fee, risk adjusted maintenance, level 5 B
❂ G9011
Other specified case management services not elsewhere classified B
❂ G9012

Demonstration Project
ESRD demo basic bundle Level I E1
H G9013
ESRD demo expanded bundle including venous access and related services E1
H G9014
H G9016 Smoking cessation counseling, individual, in the absence of or in addition to any other
evaluation and management service, per session (6-10 minutes) [demo project code only]
E1

✽ G9017 Amantadine hydrochloride, oral, per 100 mg (for use in a Medicare-approved

demonstration project) A

✽ G9018 Zanamivir, inhalation powder, administered through inhaler, per 10 mg (for use in a
Medicare-approved demonstration project) A

✽ G9019 Oseltamivir phosphate, oral, per 75 mg (for use in a Medicare-approved demonstration

project) A

✽ G9020 Rimantadine hydrochloride, oral, per 100 mg (for use in a Medicare-approved

demonstration project) A

✽ G9033 Amantadine hydrochloride, oral brand, per 100 mg (for use in a Medicareapproved
demonstration project) A

✽ G9034 Zanamivir, inhalation powder, administered through inhaler, brand, per 10 mg (for use in
a Medicareapproved demonstration project) A

✽ G9035 Oseltamivir phosphate, oral, brand, per 75 mg (for use in a Medicare-approved

demonstration project) A

✽ G9036 Rimantadine hydrochloride, oral, brand, per 100 mg (for use in a Medicare-approved
demonstration project) A

H G9050 Oncology; primary focus of visit; work-up, evaluation, or staging at the time of cancer
diagnosis or recurrence (for use in a Medicare-approved demonstration project) E1

H G9051 Oncology; primary focus of visit; treatment decision-making after disease is staged or
restaged, discussion of treatment options, supervising/coordinating active cancer directed
therapy or managing consequences of cancer directed therapy (for use in a Medicare-
approved demonstration project) E1

H G9052 Oncology; primary focus of visit; surveillance for disease recurrence for patient who has
completed definitive cancer-directed therapy and currently lacks evidence of recurrent
disease; cancer directed therapy might be considered in the future (for use in a Medicare-

361
 approved demonstration project) E1

H G9053 Oncology; primary focus of visit; expectant management of patient with evidence of
cancer for whom no cancer directed therapy is being administered or arranged at present;
cancer directed therapy might be considered in the future (for use in a Medicare-approved
demonstration project) E1

H G9054 Oncology; primary focus of visit; supervising, coordinating or managing care of patient
with terminal cancer or for whom other medical illness prevents further cancer treatment;
includes symptom management, end-of-life care planning, management of palliative
therapies (for use in a Medicare-approved demonstration project) E1

H G9055 Oncology; primary focus of visit; other, unspecified service not otherwise listed (for use in
a Medicare-approved demonstration project) E1

H G9056 Oncology; practice guidelines; management adheres to guidelines (for use in a Medicare-
approved demonstration project) E1

H G9057 Oncology; practice guidelines; management differs from guidelines as a result of patient
enrollment in an institutional review board approved clinical trial (for use in a
Medicareapproved demonstration project) E1

H G9058 Oncology; practice guidelines; management differs from guidelines because the treating
physician disagrees with guideline recommendations (for use in a Medicare-approved
demonstration project) E1

H G9059 Oncology; practice guidelines; management differs from guidelines because the patient,
after being offered treatment consistent with guidelines, has opted for alternative
treatment or management, including no treatment (for use in a Medicare-approved
demonstration project) E1

H G9060 Oncology; practice guidelines; management differs from guidelines for reason(s)
associated with patient comorbid illness or performance status not factored into guidelines
(for use in a Medicare-approved demonstration project) E1

H G9061 Oncology; practice guidelines; patient’s condition not addressed by available guidelines
(for use in a Medicareapproved demonstration project) E1

H G9062 Oncology; practice guidelines; management differs from guidelines for other reason(s) not
listed (for use in a Medicare-approved demonstration project) E1

✽ G9063 Oncology; disease status; limited to non-small cell lung cancer; extent of disease initially
established as stage I (prior to neo-adjuvant therapy, if any) with no evidence of disease
progression, recurrence, or metastases (for use in a Medicare-approved demonstration
project) M

✽ G9064 Oncology; disease status; limited to non-small cell lung cancer; extent of disease initially
established as stage II (prior to neo-adjuvant therapy, if any) with no evidence of disease
progression, recurrence, or metastases (for use in a Medicare-approved demonstration
project) M

✽ G9065 Oncology; disease status; limited to non-small cell lung cancer; extent of disease initially
established as stage IIIA (prior to neo-adjuvant therapy, if any) with no evidence of
disease progression, recurrence, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9066 Oncology; disease status; limited to non-small cell lung cancer; stage IIIB-IV at diagnosis,
metastatic, locally recurrent, or progressive (for use in a Medicare-approved demonstration
project) M

✽ G9067 Oncology; disease status; limited to non-small cell lung cancer; extent of disease unknown,
staging in progress, or not listed (for use in a Medicareapproved demonstration project)
M
✽ G9068 Oncology; disease status; limited to small cell and combined small cell/nonsmall cell;
extent of disease initially established as limited with no evidence of disease progression,
recurrence, or metastases (for use in a Medicareapproved demonstration project) M

✽ G9069 Oncology; disease status; small cell lung cancer, limited to small cell and combined small
cell/non-small cell; extensive stage at diagnosis, metastatic, locally recurrent, or progressive
(for use in a Medicare-approved demonstration project) M

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✽ G9070 Oncology; disease status; small cell lung cancer, limited to small cell and combined small
cell/non-small cell; extent of disease unknown, staging in progress, or not listed (for use in
a Medicare-approved demonstration project) M

✽ G9071 Oncology; disease status; invasive female breast cancer (does not include ductal carcinoma
in situ); adenocarcinoma as predominant cell type; stage I or stage IIA-IIB; or T3, N1,
M0; and ER and/or PR positive; with no evidence of disease progression, recurrence, or
M
metastases (for use in a Medicare-approved demonstration project) ♀
✽ G9072 Oncology; disease status; invasive female breast cancer (does not include ductal carcinoma
in situ); adenocarcinoma as predominant cell type; stage I, or stage IIA-IIB; or T3, N1,
M0; and ER and PR negative; with no evidence of disease progression, recurrence, or
M
metastases (for use in a Medicare-approved demonstration project) ♀
✽ G9073 Oncology; disease status; invasive female breast cancer (does not include ductal carcinoma
in situ); adenocarcinoma as predominant cell type; stage IIIA-IIIB; and not T3, N1, M0;
and ER and/or PR positive; with no evidence of disease progression, recurrence, or
M
metastases (for use in a Medicare-approved demonstration project) ♀
✽ G9074 Oncology; disease status; invasive female breast cancer (does not include ductal carcinoma
in situ); adenocarcinoma as predominant cell type; stage IIIA-IIIB; and not T3, N1, M0;
and ER and PR negative; with no evidence of disease progression, recurrence, or
M
metastases (for use in a Medicare-approved demonstration project) ♀
✽ G9075 Oncology; disease status; invasive female breast cancer (does not include ductal carcinoma
in situ); adenocarcinoma as predominant cell type; M1 at diagnosis, metastatic, locally
recurrent, or progressive (for use in a Medicare-approved demonstration project) ♀ M
✽ G9077 Oncology; disease status; prostate cancer, limited to adenocarcinoma as predominant cell
type; T1-T2c and Gleason 2-7 and PSA < or equal to 20 at diagnosis with no evidence of
disease progression, recurrence, or metastases (for use in a Medicare-approved
M
demonstration project) ♂
✽ G9078 Oncology; disease status; prostate cancer, limited to adenocarcinoma as predominant cell
type; T2 or T3a Gleason 8-10 or PSA >20 at diagnosis with no evidence of disease
progression, recurrence, or metastases (for use in a Medicare-approved demonstration
M
project) ♂
✽ G9079 Oncology; disease status; prostate cancer, limited to adenocarcinoma as predominant cell
type; T3b-T4, any N; any T, N1 at diagnosis with no evidence of disease progression,
recurrence, or metastases (for use in a Medicareapproved demonstration project) ♂ M
✽ G9080 Oncology; disease status; prostate cancer, limited to adenocarcinoma; after initial
treatment with rising PSA or failure of PSA decline (for use in a Medicare-approved
M
demonstration project) ♂
✽ G9083 Oncology; disease status; prostate cancer, limited to adenocarcinoma; extent of disease
unknown, staging in progress, or not listed (for use in a Medicare-approved
M
demonstration project) ♂
✽ G9084 Oncology; disease status; colon cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; extent of disease initially established as T1-3, N0, M0 with no
evidence of disease progression, recurrence, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9085 Oncology; disease status; colon cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; extent of disease initially established as T4, N0, M0 with no
evidence of disease progression, recurrence, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9086 Oncology; disease status; colon cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; extent of disease initially established as T1-4, N1-2, M0 with no
evidence of disease progression, recurrence, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9087 Oncology; disease status; colon cancer, limited to invasive cancer, adenocarcinoma as

363
 predominant cell type; M1 at diagnosis, metastatic, locally recurrent, or progressive with
current clinical, radiologic, or biochemical evidence of disease (for use in a Medicare-
approved demonstration project) M

✽ G9088 Oncology; disease status; colon cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; M1 at diagnosis, metastatic, locally recurrent, or progressive
without current clinical, radiologic, or biochemical evidence of disease (for use in a
Medicare-approved demonstration project) M

✽ G9089 Oncology; disease status; colon cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; extent of disease unknown, staging in progress, or not listed (for
use in a Medicare-approved demonstration project) M

✽ G9090 Oncology; disease status; rectal cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; extent of disease initially established as T1-2, N0, M0 (prior to
neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or
metastases (for use in a Medicare-approved demonstration project) M

✽ G9091 Oncology; disease status; rectal cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; extent of disease initially established as T3, N0, M0 (prior to
neoadjuvant therapy, if any) with no evidence of disease progression, recurrence, or
metastases (for use in a Medicare-approved demonstration project) M

✽ G9092 Oncology; disease status; rectal cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; extent of disease initially established as T1-3, N1-2, M0 (prior to
neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence or
metastases (for use in a Medicare-approved demonstration project) M

✽ G9093 Oncology; disease status; rectal cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; extent of disease initially established as T4, any N, M0 (prior to
neo-adjuvant therapy, if any) with no evidence of disease progression, recurrence, or
metastases (for use in a Medicare-approved demonstration project) M

✽ G9094 Oncology; disease status; rectal cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; M1 at diagnosis, metastatic, locally recurrent, or progressive (for
use in a Medicare-approved demonstration project) M

✽ G9095 Oncology; disease status; rectal cancer, limited to invasive cancer, adenocarcinoma as
predominant cell type; extent of disease unknown, staging in progress, or not listed (for
use in a Medicare-approved demonstration project) M

✽ G9096 Oncology; disease status; esophageal cancer, limited to adenocarcinoma or squamous cell
carcinoma as predominant cell type; extent of disease initially established as T1-T3, N0-
N1 or NX (prior to neo-adjuvant therapy, if any) with no evidence of disease progression,
recurrence, or metastases (for use in a Medicare-approved demonstration project) M

✽ G9097 Oncology; disease status; esophageal cancer, limited to adenocarcinoma or squamous cell
carcinoma as predominant cell type; extent of disease initially established as T4, any N,
M0 (prior to neo-adjuvant therapy, if any) with no evidence of disease progression,
recurrence, or metastases (for use in a Medicare-approved demonstration project) M

✽ G9098 Oncology; disease status; esophageal cancer, limited to adenocarcinoma or squamous cell
carcinoma as predominant cell type; M1 at diagnosis, meta-static, locally recurrent, or
progressive (for use in a Medicareapproved demonstration project) M

✽ G9099 Oncology; disease status; esophageal cancer, limited to adenocarcinoma or squamous cell
carcinoma as predominant cell type; extent of disease unknown, staging in progress, or not
listed (for use in a Medicare-approved demonstration project) M

✽ G9100 Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell
type; post R0 resection (with or without neoadjuvant therapy) with no evidence of disease
recurrence, progression, or metastases (for use in a Medicare-approved demonstration
project) M

✽ G9101 Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell
type; post R1 or R2 resection (with or without neoadjuvant therapy) with no evidence of
disease progression, or metastases (for use in a Medicare-approved demonstration project)
M

364
✽ G9102 Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell
type; clinical or pathologic M0, unresectable with no evidence of disease progression, or
metastases (for use in a Medicareapproved demonstration project M

✽ G9103 Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell
type; clinical or pathologic M1 at diagnosis, metastatic, locally recurrent, or progressive
(for use in a Medicare-approved demonstration project) M

✽ G9104 Oncology; disease status; gastric cancer, limited to adenocarcinoma as predominant cell
type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-
approved demonstration project M

✽ G9105 Oncology; disease status; pancreatic cancer, limited to adenocarcinoma as predominant

cell type; post R0 resection without evidence of disease progression, recurrence, or
metastases (for use in a Medicare-approved demonstration project) M

✽ G9106 Oncology; disease status; pancreatic cancer, limited to adenocarcinoma; post R1 or R2

resection with no evidence of disease progression or metastases (for use in a Medicare-
approved demonstration project) M

✽ G9107 Oncology; disease status; pancreatic cancer, limited to adenocarcinoma; unresectable at

diagnosis, M1 at diagnosis, metastatic, locally recurrent, or progressive (for use in a
Medicareapproved demonstration project) M

✽ G9108 Oncology; disease status; pancreatic cancer, limited to adenocarcinoma; extent of disease
unknown, staging in progress, or not listed (for use in a Medicare-approved
demonstration project) M

✽ G9109 Oncology; disease status; head and neck cancer, limited to cancers of oral cavity, pharynx
and larynx with squamous cell as predominant cell type; extent of disease initially
established as T1-T2 and N0, M0 (prior to neo-adjuvant therapy, if any) with no evidence
of disease progression, recurrence, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9110 Oncology; disease status; head and neck cancer, limited to cancers of oral cavity, pharynx,
and larynx with squamous cell as predominant cell type; extent of disease initially
established as T3-4 and/or N1-3, M0 (prior to neo-adjuvant therapy, if any) with no
evidence of disease progression, recurrence, or metastases (for use in a Medicare-approved
demonstration project) M

✽ G9111 Oncology; disease status; head and neck cancer, limited to cancers of oral cavity, pharynx
and larynx with squamous cell as predominant cell type; M1 at diagnosis, metastatic,
locally recurrent, or progressive (for use in a Medicare-approved demonstration project)
M
✽ G9112 Oncology; disease status; head and neck cancer, limited to cancers of oral cavity, pharynx
and larynx with squamous cell as predominant cell type; extent of disease unknown,
staging in progress, or not listed (for use in a Medicare-approved demonstration project)
M

✽ G9113 Oncology; disease status; ovarian cancer, limited to epithelial cancer; pathologic stage IA-
B (grade 1) without evidence of disease progression, recurrence, or metastases (for use in a
M
Medicare-approved demonstration project) ♀
✽ G9114 Oncology; disease status; ovarian cancer, limited to epithelial cancer; pathologic stage IA-
B (grade 2-3); or stage IC (all grades); or stage II; without evidence of disease progression,
recurrence, or metastases (for use in a Medicare-approved demonstration project) ♀ M
✽ G9115 Oncology; disease status; ovarian cancer, limited to epithelial cancer; pathologic stage III-
IV; without evidence of progression, recurrence, or metastases (for use in a
M
Medicareapproved demonstration project) ♀
✽ G9116 Oncology; disease status; ovarian cancer, limited to epithelial cancer; evidence of disease
progression, or recurrence and/or platinum resistance (for use in a Medicare-approved
M
demonstration project) ♀
✽ G9117 Oncology; disease status; ovarian cancer, limited to epithelial cancer; extent of disease
unknown, staging in progress, or not listed (for use in a Medicare-approved
M
demonstration project) ♀

365
✽ G9123 Oncology; disease status; chronic myelogenous leukemia, limited to Philadelphia
chromosome positive and/or BCR-ABL positive; chronic phase not in hematologic,
cytogenetic, or molecular remission (for use in a Medicare-approved demonstration
project) M

✽ G9124 Oncology; disease status; chronic myelogenous leukemia, limited to Philadelphia

chromosome positive and/or BCR-ABL positive; accelerated phase not in hematologic
cytogenetic, or molecular remission (for use in a Medicare-approved demonstration
project) M

✽ G9125 Oncology; disease status; chronic myelogenous leukemia, limited to Philadelphia

chromosome positive and/or BCR-ABL positive; blast phase not in hematologic,
cytogenetic, or molecular remission (for use in a Medicareapproved demonstration
project) M

✽ G9126 Oncology; disease status; chronic myelogenous leukemia, limited to Philadelphia

chromosome positive and/or BCR-ABL positive; in hematologic, cytogenetic, or
molecular remission (for use in a Medicare-approved demonstration project) M

✽ G9128 Oncology: disease status; limited to multiple myeloma, systemic disease; smouldering,
stage I (for use in a Medicare-approved demonstration project) M

✽ G9129 Oncology; disease status; limited to multiple myeloma, systemic disease; stage II or higher
(for use in a Medicare-approved demonstration project) M

✽ G9130 Oncology; disease status; limited to multiple myeloma, systemic disease; extent of disease
unknown, staging in progress, or not listed (for use in a Medicare-approved
demonstration project) M

✽ G9131 Oncology; disease status; invasive female breast cancer (does not include ductal carcinoma
in situ); adenocarcinoma as predominant cell type; extent of disease unknown, staging in
M
progress, or not listed (for use in a Medicare-approved demonstration project) ♀
✽ G9132 Oncology; disease status; prostate cancer, limited to adenocarcinoma; hormone-
refractory/androgenindependent (e.g., rising PSA on antiandrogen therapy or post-
orchiectomy); clinical metastases (for use in a Medicare-approved demonstration project)
M
♂
✽ G9133 Oncology; disease status; prostate cancer, limited to adenocarcinoma; hormone-
responsive; clinical metastases or M1 at diagnosis (for use in a Medicare-approved
M
demonstration project) ♂
✽ G9134 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular classification; stage I, II
at diagnosis, not relapsed, not refractory (for use in a Medicareapproved demonstration
project) M

✽ G9135 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular classification; stage III,
IV, not relapsed, not refractory (for use in a Medicareapproved demonstration project)
M
✽ G9136 Oncology; disease status; non-Hodgkin’s lymphoma, transformed from original cellular
diagnosis to a second cellular classification (for use in a Medicare-approved demonstration
project) M

✽ G9137 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular classification;

relapsed/refractory (for use in a Medicare-approved demonstration project) M

✽ G9138 Oncology; disease status; non-Hodgkin’s lymphoma, any cellular classification; diagnostic
evaluation, stage not determined, evaluation of possible relapse or non-response to
therapy, or not listed (for use in a Medicareapproved demonstration project) M

✽ G9139 Oncology; disease status; chronic myelogenous leukemia, limited to Philadelphia

chromosome positive and/or BCR-ABL positive; extent of disease unknown, staging in
progress, not listed (for use in a Medicare-approved demonstration project) M

✽ G9140 Frontier extended stay clinic demonstration; for a patient stay in a clinic approved for the
CMS demonstration project; the following measures should be present: the stay must be
equal to or greater than 4 hours; weather or other conditions must prevent transfer or the
case falls into a category of monitoring and observation cases that are permitted by the
rules of the demonstration; there is a maximum frontier extended stay clinic (FESC) visit

366
 of 48 hours, except in the case when weather or other conditions prevent transfer;
payment is made on each period up to 4 hours, after the first 4 hours A

Warfarin Responsiveness Testing

✽ G9143 Warfarin responsiveness testing by genetic technique using any method, any number of
specimen(s) N

This would be a once-in-a-lifetime test unless there is a reason to believe that the patient’s
personal genetic characteristics would change over time.
(https://www.cms.gov/ContractorLearningResources/downloads/JA6715.pdf)
Laboratory Certification: General immunology, Hematology
Coding Clinic: 2010, Q2, P10

Outpatient IV Insulin Treatment

H G9147 Outpatient intravenous insulin treatment (OIVIT) either pulsatile or continuous, by any
means, guided by the results of measurements for: respiratory quotient; and/or, urine urea
nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium
concentration E1

On December 23, 2009, CMS issued a national non-coverage decision on the use of
OIVIT. CR 6775.
Not covered on Physician Fee Schedule
Coding Clinic: 2010, Q2, P10

Quality Assurance
National committee for quality assurance - level 1 medical home M
✽ G9148
National committee for quality assurance - level 2 medical home M
✽ G9149
National committee for quality assurance - level 3 medical home M
✽ G9150
MAPCP demonstration - state provided services M
✽ G9151
MAPCP demonstration - community health teams M
✽ G9152
MAPCP demonstration - physician incentive pool M
✽ G9153

Wheelchair Evaluation
Evaluation for wheelchair requiring face to face visit with physician M
✽ G9156

Cardiac Monitoring
✽ G9157 Transesophageal doppler measurement of cardiac output (including probe placement,
image acquisition, and interpretation per course of treatment) for monitoring purposes
B

Functional Limitation
✽ G9158 Motor speech functional limitation, discharge status, at discharge from therapy or to end
reporting E1

✽ G9159 Spoken language comprehension functional limitation, current status at therapy episode
outset and at reporting intervals E1

✽ G9160 Spoken language comprehension functional limitation, projected goal status at therapy
episode outset, at reporting intervals, and at discharge or to end reporting E1

✽ G9161 Spoken language comprehension functional limitation, discharge status at discharge from
therapy or to end reporting E1

✽ G9162 Spoken language expression functional limitation, current status at therapy episode outset
and at reporting intervals E1

✽ G9163 Spoken language expression functional limitation, projected goal status at therapy episode

367
 outset, at reporting intervals, and at discharge or to end reporting E1

✽ G9164 Spoken language expression functional limitation, discharge status at discharge from
therapy or to end reporting E1

✽ G9165 Attention functional limitation, current status at therapy episode outset and at reporting
intervals E1

✽ G9166 Attention functional limitation, projected goal status at therapy episode outset, at
reporting intervals, and at discharge or to end reporting E1

✽ G9167 Attention functional limitation, discharge status at discharge from therapy or to end
reporting E1

✽ G9168 Memory functional limitation, current status at therapy episode outset and at reporting
intervals E1

✽ G9169 Memory functional limitation, projected goal status at therapy episode outset, at reporting
intervals, and at discharge or to end reporting E1

✽ G9170 Memory functional limitation, discharge status at discharge from therapy or to end
reporting E1

✽ G9171 Voice functional limitation, current status at therapy episode outset and at reporting
intervals E1

✽ G9172 Voice functional limitation, projected goal status at therapy episode outset, at reporting
intervals, and at discharge or to end reporting E1

✽ G9173 Voice functional limitation, discharge status at discharge from therapy or to end reporting
E1

✽ G9174 Other speech language pathology functional limitation, current status at therapy episode
outset and at reporting intervals E1

✽ G9175 Other speech language pathology functional limitation, projected goal status at therapy
episode outset, at reporting intervals, and at discharge or to end reporting E1

✽ G9176 Other speech language pathology functional limitation, discharge status at discharge from
therapy or to end reporting E1

✽ G9186 Motor speech functional limitation, projected goal status at therapy episode outset, at
reporting intervals, and at discharge or to end reporting E1

Bundled Payment Care Improvement

✽ G9187 Bundled payments for care improvement initiative home visit for patient assessment
performed by a qualified health care professional for individuals not considered
homebound including, but not limited to, assessment of safety, falls, clinical status, fluid
status, medication reconciliation/management, patient compliance with orders/plan of
care, performance of activities of daily living, appropriateness of care setting; (for use only
in the Medicare-approved bundled payments for care improvement initiative); may not be
billed for a 30-day period covered by a transitional care management code E1

Quality Measures: Miscellaneous

Beta-blocker therapy not prescribed, reason not given M
✽ G9188
Beta-blocker therapy prescribed or currently being taken M
✽ G9189
✽ G9190 Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., allergy,
intolerance, other medical reasons) M

✽ G9191 Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient
declined, other patient reasons) M

✽ G9192 Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other
reasons attributable to the health care system) M

✽ G9196 Documentation of medical reason(s) for not ordering a first or second generation
cephalosporin for antimicrobial prophylaxis (e.g., patients enrolled in clinical trials,
patients with documented infection prior to surgical procedure of interest, patients who
were receiving antibiotics more than 24 hours prior to surgery [except colon surgery

368
 patients taking oral prophylactic antibiotics], patients who were receiving antibiotics
within 24 hours prior to arrival [except colon surgery patients taking oral prophylactic
antibiotics], other medical reason(s)) M

✽ G9197 Documentation of order for first or second generation cephalosporin for antimicrobial
prophylaxis M

✽ G9198 Order for first or second generation cephalosporin for antimicrobial prophylaxis was not
documented, reason not given M

✽ G9212 DSM-IVTM criteria for major depressive disorder documented at the initial evaluation
M
✽ G9213 DSM-IV-TR criteria for major depressive disorder not documented at the initial
evaluation, reason not otherwise specified M

✽ G9223 Pneumocystis jiroveci pneumonia prophylaxis prescribed within 3 months of low CD4+
cell count below 500 cells/mm3 or a CD4 percentage below 15% M

Foot exam was not performed, reason not given M

✽ G9225
✽ G9226 Foot examination performed (includes examination through visual inspection, sensory
exam with 10-g monofilament plus testing any one of the following: vibration using 128-
hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold, and
pulse exam; report when all of the 3 components are completed) M

✽ G9227 Functional outcome assessment documented, care plan not documented, documentation
the patient is not eligible for a care plan at the time of the encounter M

✽ G9228 Chlamydia, gonorrhea and syphilis screening results documented (report when results are
present for all of the 3 screenings) M

✽ G9229 Chlamydia, gonorrhea, and syphilis screening results not documented (patient refusal is
the only allowed exception) M

Chlamydia, gonorrhea, and syphilis not screened, reason not given M

✽ G9230
✽ G9231 Documentation of end stage renal disease (ESRD), dialysis, renal transplant before or
during the measurement period or pregnancy during the measurement period M

✽ G9232 Clinician treating major depressive disorder did not communicate to clinician treating
comorbid condition for specified patient reason (e.g., patient is unable to communicate
the diagnosis of a comorbid condition; the patient is unwilling to communicate the
diagnosis of a comorbid condition; or the patient is unaware of the comorbid condition, or
any other specified patient reason) M

✽ G9239 Documentation of reasons for patient initiating maintenance hemodialysis with a catheter
as the mode of vascular access (e.g., patient has a maturing AVF/AVG, time-limited trial
of hemodialysis, other medical reasons, patient declined AVF/AVG, other patient
reasons, patient followed by reporting nephrologist for fewer than 90 days, other system
reasons) M

✽ G9240 Patient whose mode of vascular access is a catheter at the time maintenance hemodialysis
is initiated M

✽ G9241 Patient whose mode of vascular access is not a catheter at the time maintenance
hemodialysis is initiated M

✽ G9242 Documentation of viral load equal to or greater than 200 copies/ml or viral load not
performed M

Documentation of viral load less than 200 copies/ml M

✽ G9243
✽ G9246 Patient did not have at least one medical visit in each 6 month period of the 24 month
measurement period, with a minimum of 60 days between medical visits M

✽ G9247 Patient had at least one medical visit in each 6 month period of the 24 month
measurement period, with a minimum of 60 days between medical visits M

✽ G9250 Documentation of patient pain brought to a comfortable level within 48 hours from initial
assessment M

✽ G9251 Documentation of patient with pain not brought to a comfortable level within 48 hours
from initial assessment M

Documentation of patient discharged to home later than post-operative day 2 following

369
✽ G9254 CAS M

✽ G9255 Documentation of patient discharged to home no later than post operative day 2 following
CAS M

Documentation of patient death following CAS M

✽ G9256
Documentation of patient stroke following CAS M
✽ G9257
Documentation of patient stroke following CEA M
✽ G9258
Documentation of patient survival and absence of stroke following CAS M
✽ G9259
Documentation of patient death following CEA M
✽ G9260
Documentation of patient survival and absence of stroke following CEA M
✽ G9261
Documentation of patient death in the hospital following endovascular AAA repair M
✽ G9262
Documentation of patient discharged alive following endovascular AAA repair M
✽ G9263
✽ G9264 Documentation of patient receiving maintenance hemodialysis for greater than or equal to
90 days with a catheter for documented reasons (e.g., other medical reasons, patient
declined AVF/AVG, other patient reasons) M

✽ G9265 Patient receiving maintenance hemodialysis for greater than or equal to 90 days with a
catheter as the mode of vascular access M

✽ G9266 Patient receiving maintenance hemodialysis for greater than or equal to 90 days without a
catheter as the mode of vascular access M

✽ G9267 Documentation of patient with one or more complications or mortality within 30 days
M
Documentation of patient with one or more complications within 90 days M
✽ G9268
✽ G9269 Documentation of patient without one or more complications and without mortality
within 30 days M

Documentation of patient without one or more complications within 90 days M

✽ G9270
Blood pressure has a systolic value of <140 and a diastolic value of <90 M
✽ G9273
✽ G9274 Blood pressure has a systolic value of = 140 and a diastolic value of = 90 or systolic value
<140 and diastolic value = 90 or systolic value = 140 and diastolic value <90 M

Documentation that patient is a current non-tobacco user M

✽ G9275
Documentation that patient is a current tobacco user M
✽ G9276
✽ G9277 Documentation that the patient is on daily aspirin or anti-platelet or has documentation
of a valid contraindication or exception to aspirin/anti-platelet;
contraindications/exceptions include anti-coagulant use, allergy to aspirin or anti-platelets,
history of gastrointestinal bleed and bleeding disorder; additionally, the following
exceptions documented by the physician as a reason for not taking daily aspirin or anti-
platelet are acceptable (use of non-steroidal antiinflammatory agents, documented risk for
drug interaction, uncontrolled hypertension defined as >180 systolic or >110 diastolic or
gastroesophageal reflux) M

Documentation that the patient is not on daily aspirin or anti-platelet regimen M

✽ G9278
✽ G9279 Pneumococcal screening performed and documentation of vaccination received prior to
discharge M

Pneumococcal vaccination not administered prior to discharge, reason not specified M

✽ G9280
✽ G9281 Screening performed and documentation that vaccination not indicated/patient refusal
M
✽ G9282 Documentation of medical reason(s) for not reporting the histological type or NSCLC-
NOS classification with an explanation (e.g., biopsy taken for other purposes in a patient
with a history of non-small cell lung cancer or other documented medical reasons) M

✽ G9283 Non small cell lung cancer biopsy and cytology specimen report documents classification
into specific histologic type or classified as NSCLC-NOS with an explanation M

✽ G9284 Non small cell lung cancer biopsy and cytology specimen report does not document
classification into specific histologic type or classified as NSCLCNOS with an

370
 explanation M

✽ G9285 Specimen site other than anatomic location of lung or is not classified as non small cell
lung cancer M

Antibiotic regimen prescribed within 10 days after onset of symptoms M

✽ G9286
Antibiotic regimen not prescribed within 10 days after onset of symptoms M
✽ G9287
✽ G9288 Documentation of medical reason(s) for not reporting the histological type or NSCLC-
NOS classification with an explanation (e.g., a solitary fibrous tumor in a person with a
history of non-small cell carcinoma or other documented medical reasons) M

✽ G9289 Non-small cell lung cancer biopsy and cytology specimen report documents classification
into specific histologic type or classified as NSCLC-NOS with an explanation M

✽ G9290 Non-small cell lung cancer biopsy and cytology specimen report does not document
classification into specific histologic type or classified as NSCLCNOS with an
explanation M

✽ G9291 Specimen site other than anatomic location of lung, is not classified as non small cell lung
cancer or classified as NSCLC-NOS M

✽ G9292 Documentation of medical reason(s) for not reporting PT category and a statement on
thickness and ulceration and for PT1, mitotic rate (e.g., negative skin biopsies in a patient
with a history of melanoma or other documented medical reasons) M

✽ G9293 Pathology report does not include the PT category and a statement on thickness and
ulceration and for PT1, mitotic rate M

✽ G9294 Pathology report includes the PT category and a statement on thickness and ulceration
and for PT1, mitotic rate M

Specimen site other than anatomic cutaneous location M

✽ G9295
✽ G9296 Patients with documented shared decision-making including discussion of conservative
(non-surgical) therapy (e.g., NSAIDs, analgesics, weight loss, exercise, injections) prior to
the procedure M

✽ G9297 Shared decision-making including discussion of conservative (nonsurgical) therapy (e.g.,

NSAIDs, analgesics, weight loss, exercise, injections) prior to the procedure not
documented, reason not given M

✽ G9298 Patients who are evaluated for venous thromboembolic and cardiovascular risk factors
within 30 days prior to the procedure (e.g., history of DVT, PE, MI, arrhythmia and
stroke) M

✽ G9299 Patients who are not evaluated for venous thromboembolic and cardiovascular risk factors
within 30 days prior to the procedure (e.g., history of DVT, PE, MI, arrhythmia and
stroke, reason not given) M

✽ G9300 Documentation of medical reason(s) for not completely infusing the prophylactic
antibiotic prior to the inflation of the proximal tourniquet (e.g., a tourniquet was not used)
M

✽ G9301 Patients who had the prophylactic antibiotic completely infused prior to the inflation of
the proximal tourniquet M

✽ G9302 Prophylactic antibiotic not completely infused prior to the inflation of the proximal
tourniquet, reason not given M

✽ G9303 Operative report does not identify the prosthetic implant specifications including the
prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of
each prosthetic implant, reason not given M

✽ G9304 Operative report identifies the prosthetic implant specifications including the prosthetic
implant manufacturer, the brand name of the prosthetic implant and the size of each
prosthetic implant M

✽ G9305 Intervention for presence of leak of endoluminal contents through an anastomosis not
required M

✽ G9306 Intervention for presence of leak of endoluminal contents through an anastomosis

required M

371
✽ G9307 No return to the operating room for a surgical procedure, for complications of the
principal operative procedure, within 30 days of the principal operative procedure M

✽ G9308 Unplanned return to the operating room for a surgical procedure, for complications of the
principal operative procedure, within 30 days of the principal operative procedure M

No unplanned hospital readmission within 30 days of principal procedure M

✽ G9309
Unplanned hospital readmission within 30 days of principal procedure M
✽ G9310
No surgical site infection M
✽ G9311
Surgical site infection M
✽ G9312
✽ G9313 Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time
of diagnosis for documented reason M

✽ G9314 Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time
of diagnosis, reason not given M

✽ G9315 Documentation amoxicillin, with or without clavulanate, prescribed as a first line

antibiotic at the time of diagnosis M

✽ G9316 Documentation of patient-specific risk assessment with a risk calculator based on multi-
institutional clinical data, the specific risk calculator used, and communication of risk
assessment from risk calculator with the patient or family M

✽ G9317 Documentation of patient-specific risk assessment with a risk calculator based on multi-
institutional clinical data, the specific risk calculator used, and communication of risk
assessment from risk calculator with the patient or family not completed M

Imaging study named according to standardized nomenclature M

✽ G9318
Imaging study not named according to standardized nomenclature, reason not given M
✽ G9319
✽ G9321 Count of previous CT (any type of CT) and cardiac nuclear medicine (myocardial
perfusion) studies documented in the 12-month period prior to the current study M

✽ G9322 Count of previous CT and cardiac nuclear medicine (myocardial perfusion) studies not
documented in the 12-month period prior to the current study, reason not given M

✽ G9326 CT studies performed not reported to a radiation dose index registry that is capable of
collecting at a minimum all necessary data elements, reason not given M

✽ G9327 CT studies performed reported to a radiation dose index registry that is capable of
collecting at a minimum all necessary data elements M

✽ G9329 DICOM format image data available to non-affiliated external healthcare facilities or
entities on a secure, media free, reciprocally searchable basis with patient authorization for
at least a 12-month period after the study not documented in final report, reason not
given M

✽ G9340 Final report documented that DICOM format image data available to nonaffiliated
external healthcare facilities or entities on a secure, media free, reciprocally searchable
basis with patient authorization for at least a 12-month period after the study M

✽ G9341 Search conducted for prior patient CT studies completed at non-affiliated external
healthcare facilities or entities within the past 12-months and are available through a
secure, authorized, media-free, shared archive prior to an imaging study being performed
M

✽ G9342 Search not conducted prior to an imaging study being performed for prior patient CT
studies completed at non-affiliated external healthcare facilities or entities within the past
12-months and are available through a secure, authorized, media-free, shared archive,
reason not given M

✽ G9344 Due to system reasons search not conducted for DICOM format images for prior patient
CT imaging studies completed at non-affiliated external healthcare facilities or entities
within the past 12 months that are available through a secure, authorized, mediafree,
shared archive (e.g., non-affiliated external healthcare facilities or entities does not have
archival abilities through a shared archival system) M

✽ G9345 Follow-up recommendations documented according to recommended guidelines for

incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or

372
 that no follow-up is needed) based at a minimum on nodule size and patient risk factors
M
✽ G9347 Follow-up recommendations not documented according to recommended guidelines for
incidentally detected pulmonary nodules, reason not given M

✽ G9348 CT scan of the paranasal sinuses ordered at the time of diagnosis for documented reasons
M

✽ G9349 Documentation of a CT scan of the paranasal sinuses ordered at the time of diagnosis or
received within 28 days after date of diagnosis M

✽ G9350 CT scan of the paranasal sinuses not ordered at the time of diagnosis or received within
28 days after date of diagnosis M

✽ G9351 More than one CT scan of the paranasal sinuses ordered or received within 90 days after
diagnosis M

✽ G9352 More than one CT scan of the paranasal sinuses ordered or received within 90 days after
the date of diagnosis, reason not given M

✽ G9353 More than one CT scan of the paranasal sinuses ordered or received within 90 days after
the date of diagnosis for documented reasons (e.g., patients with complications, second
CT obtained prior to surgery, other medical reasons) M

✽ G9354 One CT scan or no CT scan of the paranasal sinuses ordered within 90 days after the date
of diagnosis M

Elective delivery or early induction not performed M

✽ G9355
Elective delivery or early induction performed M
✽ G9356
Post-partum screenings, evaluations and education performed M
✽ G9357
Post-partum screenings, evaluations and education not performed M
✽ G9358
✽ G9359 Documentation of negative or managed positive TB screen with further evidence that TB
is not active within one year of patient visit M

No documentation of negative or managed positive TB screen M

✽ G9360
✽ G9361 Medical indication for induction [documentation of reason(s) for elective delivery (c-
section) or early induction (e.g., hemorrhage and placental complications, hypertension,
preeclampsia and eclampsia, rupture of membranes-premature or prolonged, maternal
conditions complicating pregnancy/delivery, fetal conditions complicating
pregnancy/delivery, late pregnancy, prior uterine surgery, or participation in clinical trial)]
M
Sinusitis caused by, or presumed to be caused by, bacterial infection M
✽ G9364
One high-risk medication ordered M
✽ G9365
One high-risk medication not ordered M
✽ G9366
At least two different high-risk medications ordered M
✽ G9367
At least two different high-risk medications not ordered M
✽ G9368
Patient offered assistance with end of life issues during the measurement period M
✽ G9380
Patient not offered assistance with end of life issues during the measurement period M
✽ G9382
Patient received screening for HCV infection within the 12 month reporting period M
✽ G9383
✽ G9384 Documentation of medical reason(s) for not receiving annual screening for HCV infection
(e.g., decompensated cirrhosis indicating advanced disease [i.e., ascites, esophageal
variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ
transplant, limited life expectancy, other medical reasons) M

✽ G9385 Documentation of patient reason(s) for not receiving annual screening for HCV infection
(e.g., patient declined, other patient reasons) M

✽ G9386 Screening for HCV infection not received within the 12 month reporting period, reason
not given M

✽ G9389 Unplanned rupture of the posterior capsule requiring vitrectomy during cataract surgery
M
No unplanned rupture of the posterior capsule requiring vitrectomy during cataract

373
✽ G9390 surgery M

✽ G9393 Patient with an initial PHQ-9 score greater than nine who achieves remission at 12
months as demonstrated by a 12 month (+/- 30 days) phq-9 score of less than five M

✽ G9394 Patient who had a diagnosis of bipolar disorder or personality disorder, death, permanent
nursing home resident or receiving hospice or palliative care any time during the
measurement or assessment period M

✽ G9395 Patient with an initial PHQ-9 score greater than nine who did not achieve remission at 12
months as demonstrated by a 12 month (+/- 30 days) PHQ-9 score greater than or equal
to five M

✽ G9396 Patient with an initial PHQ-9 score greater than nine who was not assessed for remission
at 12 months (+/- 30 days) M

✽ G9399 Documentation in the patient record of a discussion between the physician/clinician and
the patient that includes all of the following: treatment choices appropriate to genotype,
risks and benefits, evidence of effectiveness, and patient preferences toward the outcome
of the treatment M

✽ G9400 Documentation of medical or patient reason(s) for not discussing treatment options;
medical reasons: patient is not a candidate for treatment due to advanced physical or
mental health comorbidity (including active substance use); currently receiving antiviral
treatment; successful antiviral treatment (with sustained virologic response) prior to
reporting period; other documented medical reasons; patient reasons: patient unable or
unwilling to participate in the discussion or other patient reasons M

✽ G9401 No documentation of a discussion in the patient record of a discussion between the

physician or other qualified health care professional and the patient that includes all of the
following: treatment choices appropriate to genotype, risks and benefits, evidence of
effectiveness, and patient preferences toward treatment M

Patient received follow-up on the date of discharge or within 30 days after discharge M
✽ G9402
✽ G9403 Clinician documented reason patient was not able to complete 30 day follow-up from
acute inpatient setting discharge (e.g., patient death prior to follow-up visit, patient non-
compliant for visit follow-up) M

✽ G9404 Patient did not receive follow-up on the date of discharge or within 30 days after
discharge M

Patient received follow-up within 7 days from discharge M

✽ G9405
✽ G9406 Clinician documented reason patient was not able to complete 7 day follow-up from acute
inpatient setting discharge (i.e patient death prior to follow-up visit, patient non-
compliance for visit follow-up) M

Patient did not receive follow-up on or within 7 days after discharge M

✽ G9407
Patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days M
✽ G9408
✽ G9409 Patients without cardiac tamponade and/or pericardiocentesis occurring within 30 days
M
✽ G9410 Patient admitted within 180 days, status post CIED implantation, replacement, or
revision with an infection requiring device removal or surgical revision M

✽ G9411 Patient not admitted within 180 days, status post CIED implantation, replacement, or
revision with an infection requiring device removal or surgical revision M

✽ G9412 Patient admitted within 180 days, status post CIED implantation, replacement, or
revision with an infection requiring device removal or surgical revision M

✽ G9413 Patient not admitted within 180 days, status post CIED implantation, replacement, or
revision with an infection requiring device removal or surgical revision M

✽ G9414 Patient had one dose of meningococcal vaccine on or between the patient’s 11th and 13th
birthdays M

✽ G9415 Patient did not have one dose of meningococcal vaccine on or between the patient’s 11th
and 13th birthdays M

✽ G9416 Patient had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one
tetanus, diphtheria toxoids vaccine (Td) on or between the patient’s 10th and 13th

374
 birthdays M

✽ G9417 Patient did not have one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap)
on or between the patient’s 10th and 13th birthdays M

✽ G9418 Primary non-small cell lung cancer biopsy and cytology specimen report documents
classification into specific histologic type or classified as NSCLCNOS with an
explanation M

✽ G9419 Documentation of medical reason(s) for not including the histological type or NSCLC-
NOS classification with an explanation (e.g., biopsy taken for other purposes in a patient
with a history of primary non-small cell lung cancer or other documented medical reasons)
M

✽ G9420 Specimen site other than anatomic location of lung or is not classified as primary non-
small cell lung cancer M

✽ G9421 Primary non-small cell lung cancer biopsy and cytology specimen report does not
document classification into specific histologic type or classified as NSCLC-NOS with an
explanation M

✽ G9422 Primary lung carcinoma resection report documents pT category, pN category and for
non-small cell lung cancer, histologic type (squamous cell carcinoma, adenocarcinoma and
not nsclc-nos) M

✽ G9423 Documentation of medical reason for not including pT category, pN category and
histologic type [for patient with appropriate exclusion criteria (e.g., metastatic disease,
benign tumors, malignant tumors other than carcinomas, inadequate surgical specimens)]
M
Specimen site other than anatomic location of lung, or classified as NSCLC-NOS M
✽ G9424
✽ G9425 Primary lung carcinoma resection report does not document pT category, pN category and
for non-small cell lung cancer, histologic type (squamous cell carcinoma, adenocarcinoma)
M

✽ G9426 Improvement in median time from ED arrival to initial ED oral or parenteral pain
medication administration performed for ED admitted patients M

✽ G9427 Improvement in median time from ED arrival to initial ED oral or parenteral pain
medication administration not performed for ED admitted patients M

✽ G9428 Pathology report includes the pT category and a statement on thickness, ulceration and
mitotic rate M

✽ G9429 Documentation of medical reason(s) for not including pT category and a statement on
thickness, ulceration and mitotic rate (e.g., negative skin biopsies in a patient with a
history of melanoma or other documented medical reasons) M

Specimen site other than anatomic cutaneous location M

✽ G9430
✽ G9431 Pathology report does not include the pT category and a statement on thickness,
ulceration and mitotic rate M

✽ G9432 Asthma well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score and results
documented M

✽ G9434 Asthma not well-controlled based on the ACT, C-ACT, ACQ, or ATAQ score, or
specified asthma control tool not used, reason not given M

Patients who were born in the years 1945-1965 M

✽ G9448
History of receiving blood transfusions prior to 1992 M
✽ G9449
History of injection drug use M
✽ G9450
Patient received one-time screening for HCV infection M
✽ G9451
✽ G9452 Documentation of medical reason(s) for not receiving one-time screening for HCV
infection (e.g., decompensated cirrhosis indicating advanced disease [i.e., ascites,
esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist
for organ transplant, limited life expectancy, other medical reasons) M

✽ G9453 Documentation of patient reason(s) for not receiving one-time screening for HCV
infection (e.g., patient declined, other patient reasons) M

375
✽ G9454 One-time screening for HCV infection not received within 12 month reporting period
and no documentation of prior screening for HCV infection, reason not given M

✽ G9455 Patient underwent abdominal imaging with ultrasound, contrast enhanced CT or contrast
MRI for HCC M

✽ G9456 Documentation of medical or patient reason(s) for not ordering or performing screening
for HCC. medical reason: comorbid medical conditions with expected survival <5 years,
hepatic decompensation and not a candidate for liver transplantation, or other medical
reasons; patient reasons: patient declined or other patient reasons (e.g., cost of tests, time
related to accessing testing equipment) M

✽ G9457 Patient did not undergo abdominal imaging and did not have a documented reason for
not undergoing abdominal imaging in the submission period M

✽ G9458 Patient documented as tobacco user and received tobacco cessation intervention (must
include at least one of the following: advice given to quit smoking or tobacco use,
counseling on the benefits of quitting smoking or tobacco use, assistance with or referral
to external smoking or tobacco cessation support programs, or current enrollment in
smoking or tobacco use cessation program) if identified as a tobacco user M

Currently a tobacco non-user M

✽ G9459
✽ G9460 Tobacco assessment or tobacco cessation intervention not performed, reason not given
M
✽ G9468 Patient not receiving corticosteroids greater than or equal to 10 mg/day of prednisone
equivalents for 60 or greater consecutive days or a single prescription equating to 600 mg
prednisone or greater for all fills M

✽ G9469 Patients who have received or are receiving corticosteroids greater than or equal to 10
mg/day of prednisone equivalents for 60 or greater consecutive days or a single
prescription equating to 600 mg prednisone or greater for all fills M

✽ G9470 Patients not receiving corticosteroids greater than or equal to 10 mg/day of prednisone
equivalents for 60 or greater consecutive days or a single prescription equating to 600 mg
prednisone or greater for all fills M

✽ G9471 Within the past 2 years, central dualenergy x-ray absorptiometry (DXA) not ordered or
documented M

✽ G9472 Within the past 2 years, central dualenergy x-ray absorptiometry (DXA) not ordered and
documented, no review of systems and no medication history or pharmacologic therapy
(other than minerals/vitamins) for osteoporosis prescribed M

Services performed by chaplain in the hospice setting, each 15 minutes B

✽ G9473
Services performed by dietary counselor in the hospice setting, each 15 minutes B
✽ G9474
Services performed by other counselor in the hospice setting, each 15 minutes B
✽ G9475
Services performed by volunteer in the hospice setting, each 15 minutes B
✽ G9476
Services performed by care coordinator in the hospice setting, each 15 minutes B
✽ G9477
✽ G9478 Services performed by other qualified therapist in the hospice setting, each 15 minutes
B
Services performed by qualified pharmacist in the hospice setting, each 15 minutes B
✽ G9479
Admission to Medicare Care Choice Model program (MCCM) B
✽ G9480
✽ G9481 Remote in-home visit for the evaluation and management of a new patient for use only in
the Medicare-approved comprehensive care for joint replacement model, which requires
these 3 key components: a problem focused history; a problem focused examination; and
straightforward medical decision making, furnished in real time using interactive audio
and video technology. Counseling and coordination of care with other physicians, other
qualified health care professionals or agencies are provided consistent with the nature of
the problem(s) and the needs of the patient or the family or both. Usually, the presenting
problem(s) are self limited or minor. Typically, 10 minutes are spent with the patient or
family or both via real time, audio and video intercommunications technology B

✽ G9482 Remote in-home visit for the evaluation and management of a new patient for use only in
the Medicare-approved comprehensive care for joint replacement model, which requires

376
 these 3 key components: an expanded problem focused history; an expanded problem
focused examination; straightforward medical decision making, furnished in real time
using interactive audio and video technology. Counseling and coordination of care with
other physicians, other qualified health care professionals or agencies are provided
consistent with the nature of the problem(s) and the needs of the patient or the family or
both. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20
minutes are spent with the patient or family or both via real time, audio and video
intercommunications technology B

✽ G9483 Remote in-home visit for the evaluation and management of a new patient for use only in
the Medicare-approved comprehensive care for joint replacement model, which requires
these 3 key components: a detailed history; a detailed examination; medical decision
making of low complexity, furnished in real time using interactive audio and video
technology. Counseling and coordination of care with other physicians, other qualified
health care professionals or agencies are provided consistent with the nature of the
problem(s) and the needs of the patient or the family or both. Usually, the presenting
problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient or
family or both via real time, audio and video intercommunications technology B

✽ G9484 Remote in-home visit for the evaluation and management of a new patient for use only in
the Medicare-approved comprehensive care for joint replacement model, which requires
these 3 key components: a comprehensive history; a comprehensive examination; medical
decision making of moderate complexity, furnished in real time using interactive audio
and video technology. Counseling and coordination of care with other physicians, other
qualified health care professionals or agencies are provided consistent with the nature of
the problem(s) and the needs of the patient or the family or both. Usually, the presenting
problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the
patient or family or both via real time, audio and video intercommunications technology
B
✽ G9485 Remote in-home visit for the evaluation and management of a new patient for use only in
the Medicare-approved comprehensive care for joint replacement model, which requires
these 3 key components: a comprehensive history; a comprehensive examination; medical
decision making of high complexity, furnished in real time using interactive audio and
video technology. Counseling and coordination of care with other physicians, other
qualified health care professionals or agencies are provided consistent with the nature of
the problem(s) and the needs of the patient or the family or both. Usually, the presenting
problem(s) are of moderate to high severity. Typically, 60 minutes are spent with the
patient or family or both via real time, audio and video intercommunications technology
B
✽ G9486 Remote in-home visit for the evaluation and management of an established patient for use
only in the Medicareapproved comprehensive care for joint replacement model, which
requires at least 2 of the following 3 key components: a problem focused history; a
problem focused examination; straightforward medical decision making, furnished in real
time using interactive audio and video technology. Counseling and coordination of care
with other physicians, other qualified health care professionals or agencies are provided
consistent with the nature of the problem(s) and the needs of the patient or the family or
both. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes
are spent with the patient or family or both via real time, audio and video
intercommunications technology B

✽ G9487 Remote in-home visit for the evaluation and management of an established patient for use
only in the Medicareapproved comprehensive care for joint replacement model, which
requires at least 2 of the following 3 key components: an expanded problem focused
history; an expanded problem focused examination; medical decision making of low
complexity, furnished in real time using interactive audio and video technology.
Counseling and coordination of care with other physicians, other qualified health care
professionals or agencies are provided consistent with the nature of the problem(s) and the
needs of the patient or the family or both. Usually, the presenting problem(s) are of low to
moderate severity. Typically, 15 minutes are spent with the patient or family or both via
real time, audio and video intercommunications technology B

377
✽ G9488 Remote in-home visit for the evaluation and management of an established patient for use
only in the Medicareapproved comprehensive care for joint replacement model, which
requires at least 2 of the following 3 key components: a detailed history; a detailed
examination; medical decision making of moderate complexity, furnished in real time
using interactive audio and video technology. Counseling and coordination of care with
other physicians, other qualified health care professionals or agencies are provided
consistent with the nature of the problem(s) and the needs of the patient or the family or
both. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25
minutes are spent with the patient or family or both via real time, audio and video
intercommunications technology B

✽ G9489 Remote in-home visit for the evaluation and management of an established patient for use
only in the Medicareapproved comprehensive care for joint replacement model, which
requires at least 2 of the following 3 key components: a comprehensive history; a
comprehensive examination; medical decision making of high complexity, furnished in
real time using interactive audio and video technology. Counseling and coordination of
care with other physicians, other qualified health care professionals or agencies are
provided consistent with the nature of the problem(s) and the needs of the patient or the
family or both. Usually, the presenting problem(s) are of moderate to high severity.
Typically, 40 minutes are spent with the patient or family or both via real time, audio and
video intercommunications technology B

✽ G9490 Comprehensive care for joint replacement model, home visit for patient assessment
performed by clinical staff for an individual not considered homebound, including, but not
necessarily limited to patient assessment of clinical status, safety/fall prevention, functional
status/ambulation, medication reconciliation/management, compliance with orders/plan
of care, performance of activities of daily living, and ensuring beneficiary connections to
community and other services. (for use only in the Medicareapproved CJR model); may
not be billed for a 30 day period covered by a transitional care management code B

✽ G9497 Received instruction from the anesthesiologist or proxy prior to the day of surgery to
abstain from smoking on the day of surgery M

Antibiotic regimen prescribed M

✽ G9498
✽ G9500 Radiation exposure indices, or exposure time and number of fluorographic images in final
report for procedures using fluoroscopy, documented M

✽ G9501 Radiation exposure indices, or exposure time and number of fluorographic images not
documented in final report for procedure using fluoroscopy, reason not given M

✽ G9502 Documentation of medical reason for not performing foot exam (i.e., patients who have
had either a bilateral amputation above or below the knee, or both a left and right
amputation above or below the knee before or during the measurement period) M

Patient taking tamsulosin hydrochloride M

✽ G9503
✽ G9504 Documented reason for not assessing Hepatitis B virus (HBV) status (e.g. patient not
initiating anti-TNF therapy, patient declined) prior to initiating anti-TNF therapy M

✽ G9505 Antibiotic regimen prescribed within 10 days after onset of symptoms for documented
medical reason M

Biologic immune response modifier prescribed M

✽ G9506
✽ G9507 Documentation that the patient is on a statin medication or has documentation of a valid
contraindication or exception to statin medications; contraindications/exceptions that can
be defined by diagnosis codes include pregnancy during the measurement period, active
liver disease, rhabdomyolysis, end stage renal disease on dialysis and heart failure; provider
documented contraindications/exceptions include breastfeeding during the measurement
period, woman of child-bearing age not actively taking birth control, allergy to statin, drug
interaction (HIV protease inhibitors, nefazodone, cyclosporine, gemfibrozil, and danazol)
and intolerance (with supporting documentation of trying a statin at least once within the
last 5 years or diagnosis codes for myostitis or toxic myopathy related to drugs) M

Documentation that the patient is not on a statin medication M

✽ G9508
Adult patients 18 years of age or older with major depression or dysthymia who reached

378
✽ G9509 remission at 12 months as demonstrated by a 12 month (+/-60 days) PHQ-9 or PHQ-9m
score of less than 5 M

✽ G9510 Remission at 12 months not demonstrated by a 12 month (+/-30 days) PHQ-9 score of
less than five; either PHQ-9 score was not assessed or is greater than or equal to 5 M

✽ G9511 Index event date PHQ-9 score greater than 9 documented during the 12 month
denominator identification period M

Individual had a PDC of 0.8 or greater M

✽ G9512
Individual did not have a PDC of 0.8 or greater M
✽ G9513
Patient required a return to the operating room within 90 days of surgery M
✽ G9514
Patient did not require a return to the operating room within 90 days of surgery M
✽ G9515
✽ G9516 Patient achieved an improvement in visual acuity, from their preoperative level, within 90
days of surgery M

✽ G9517 Patient did not achieve an improvement in visual acuity, from their preoperative level,
within 90 days of surgery, reason not given M

Documentation of active injection drug use M

✽ G9518
✽ G9519 Patient achieves final refraction (spherical equivalent) +/-0.5 diopters of their planned
refraction within 90 days of surgery M

✽ G9520 Patient does not achieve final refraction (spherical equivalent) +/-0.5 diopters of their
planned refraction within 90 days of surgery M

✽ G9521 Total number of emergency department visits and inpatient hospitalizations less than two
in the past 12 months M

✽ G9522 Total number of emergency department visits and inpatient hospitalizations equal to or
greater than two in the past 12 months or patient not screened, reason not given M

Patient discontinued from hemodialysis or peritoneal dialysis M

✽ G9523
Patient was referred to hospice care M
✽ G9524
✽ G9525 Documentation of patient reason(s) for not referring to hospice care (e.g., patient
declined, other patient reasons) M

Patient was not referred to hospice care, reason not given M

✽ G9526
✽ G9529 Patient with minor blunt head trauma had an appropriate indication(s) for a head CT
M
✽ G9530 Patient presented within a minor blunt head trauma and had a head CT ordered for
trauma by an emergency care provider M

✽ G9531 Patient has documentation of ventricular shunt, brain tumor, multisystem trauma,
pregnancy, or is currently taking an antiplatelet medication including: abciximab,
cangrelor, cilostazol, clopidogrel, eptifibatide, prasugrel, ticlopidine, ticagrelor, tirofiban,
or vorapaxar M

✽ G9532 Patient had a head CT for trauma ordered by someone other than an emergency care
provider, or was ordered for a reason other than trauma M

✽ G9533 Patient with minor blunt head trauma did not have an appropriate indication(s) for a head
CT M

G9534 Advanced brain imaging (CTA, CT, MRA or MRI) was not ordered ✖
G9535 Patients with a normal neurological examination ✖
G9536 Documentation of medical reason(s) for ordering an advanced brain imaging study ✖
(i.e., patient has an abnormal neurological examination; patient has the coexistence of
seizures, or both; recent onset of severe headache; change in the type of headache; signs of
increased intracranial pressure (e.g., papilledema, absent venous pulsations on funduscopic
examination, altered mental status, focal neurologic deficits, signs of meningeal irritation);
HIVpositive patients with a new type of headache; immunocompromised patient with
unexplained headache symptoms; patient on coagulopathy/anti-coagulation or anti-
platelet therapy; very young patients with unexplained headache symptoms)
✽ G9537 Documentation of system reason(s) for obtaining imaging of the head (CT or MRI) (i.e.,

379
 needed as part of a clinical trial; other clinician ordered the study) M

G9538 Advanced brain imaging (CTA, CT, MRA or MRI) was ordered ✖
Intent for potential removal at time of placement M
✽ G9539
Patient alive 3 months post procedure M
✽ G9540
Filter removed within 3 months of placement M
✽ G9541
✽ G9542 Documented re-assessment for the appropriateness of filter removal within 3 months of
placement M

✽ G9543 Documentation of at least two attempts to reach the patient to arrange a clinical re-
assessment for the appropriateness of filter removal within 3 months of placement M

✽ G9544 Patients that do not have the filter removed, documented re-assessment for the
appropriateness of filter removal, or documentation of at least two attempts to reach the
patient to arrange a clinical re-assessment for the appropriateness of filter removal within
3 months of placement M

✽ G9547 Incidental finding: liver lesion <=0.5 cm, cystic kidney lesion <1.0 cm or adrenal lesion
<=1.0 cm M

Final reports for abdominal imaging studies with follow-up imaging recommended M
✽ G9548
✽ G9549 Documentation of medical reason(s) that follow-up imaging is indicated (e.g., patient has
a known malignancy that can metastasize, other medical reason(s) such as fever in an
immunocompromised patient) M

✽ G9550 Final reports for abdominal imaging studies with follow-up imaging not recommended
M
✽ G9551 Final reports for abdominal imaging studies without an incidentally found lesion noted:
liver lesion <=0.5 cm, cystic kidney lesion <1.0 cm or adrenal lesion <=1.0 cm noted or no
lesion found M

Incidental thyroid nodule <1.0 cm noted in report M

✽ G9552
Prior thyroid disease diagnosis M
✽ G9553
✽ G9554 Final reports for CT, CTA, MRI or MRA of the chest or neck or ultrasound of the neck
with follow-up imaging recommended M

✽ G9555 Documentation of medical reason(s) for recommending follow up imaging (e.g., patient
has multiple endocrine neoplasia, patient has cervical lymphadenopathy, other medical
reason(s)) M

✽ G9556 Final reports for CT, CTA, MRI or MRA of the chest or neck or ultrasound of the neck
with follow-up imaging not recommended M

✽ G9557 Final reports for CT, CTA, MRI or MRA studies of the chest or neck or ultrasound of
the neck without an incidentally found thyroid nodule <1.0 cm noted or no nodule found
M
Patient treated with a beta-lactam antibiotic as definitive therapy M
✽ G9558
✽ G9559 Documentation of medical reason(s) for not prescribing a beta-lactam antibiotic (e.g.,
allergy, intolerance to beta-lactam antibiotics) M

✽ G9560 Patient not treated with a beta-lactam antibiotic as definitive therapy, reason not given
M
Patients prescribed opiates for longer than six weeks M
✽ G9561
✽ G9562 Patients who had a follow-up evaluation conducted at least every three months during
opioid therapy M

✽ G9563 Patients who did not have a follow-up evaluation conducted at least every three months
during opioid therapy M

✽ G9573 Adult patients 18 years of age or older with major depression or dysthymia who did not
reach remission at six months as demonstrated by a six month (+/-60 days) PHQ-9 or
PHQ-9m score of less than five M

✽ G9574 Adult patients 18 years of age or older with major depression or dysthymia who did not
reach remission at six months as demonstrated by a six month (+/-60 days) PHQ-9 or
PHQ-9m score of less than five; either PHQ-9 or PHQ-9m score was not assessed or is

380
 greater than or equal to five M

Patients prescribed opiates for longer than six weeks M

✽ G9577
✽ G9578 Documentation of signed opioid treatment agreement at least once during opioid therapy
M

✽ G9579 No documentation of signed an opioid treatment agreement at least once during opioid
therapy M

Door to puncture time of less than 2 hours M

✽ G9580
Door to puncture time of greater than 2 hours, no reason given M
✽ G9582
Patients prescribed opiates for longer than 6 weeks M
✽ G9583
✽ G9584 Patient evaluated for risk of misuse of opiates by using a brief validated instrument (e.g.,
opioid risk tool, SOAPP-R) or patient interviewed at least once during opioid therapy
M
✽ G9585 Patient not evaluated for risk of misuse of opiates by using a brief validated instrument
(e.g., opioid risk tool, SOAPP-R) or patient not interviewed at least once during opioid
therapy M

✽ G9593 Pediatric patient with minor blunt head trauma classified as low risk according to the
pecarn Prediction Rules M

✽ G9594 Patient presented with a minor blunt head trauma and had a head CT ordered for trauma
by an emergency care provider M

✽ G9595 Patient has documentation of ventricular shunt, brain tumor, coagulopathy, including
thrombocytopenia M

✽ G9596 Pediatric patient had a head CT for trauma ordered by someone other than an emergency
care provider, or was ordered for a reason other than trauma M

✽ G9597 Pediatric patient with minor blunt head trauma not classified as low risk according to the
pecarn Prediction Rules M

✽ G9598 Aortic aneurysm 5.5-5.9 cm maximum diameter on centerline formatted CT or minor

diameter on axial formatted CT M

✽ G9599 Aortic aneurysm 6.0 cm or greater maximum diameter on centerline formatted CT or

minor diameter on axial formatted CT M

Symptomatic AAAS that required urgent/emergent (non-elective) repair M

✽ G9600
Patient discharge to home no later than post-operative day #7 M
✽ G9601
Patient not discharged to home by post-operative day #7 M
✽ G9602
Patient survey score improved from baseline following treatment M
✽ G9603
Patient survey results not available M
✽ G9604
Patient survey score did not improve from baseline following treatment M
✽ G9605
Intraoperative cystoscopy performed to evaluate for lower tract injury M
✽ G9606
✽ G9607 Documented medical reasons for not performing intraoperative cystoscopy (e.g., urethral
pathology precluding cystoscopy, any patient who has a congenital or acquired absence of
the urethra) or in the case of patient death M

Intraoperative cystoscopy not performed to evaluate for lower tract injury M

✽ G9608
Documentation of an order for antiplatelet agents M
✽ G9609
✽ G9610 Documentation of medical reason(s) in the patient’s record for not ordering anti-platelet
agents M

✽ G9611 Order for anti-platelet agents was not documented in the patient’s record, reason not
given M

✽ G9612 Photodocumentation of two or more cecal landmarks to establish a complete examination

M

✽ G9613 Documentation of post-surgical anatomy (e.g., right hemicolectomy, ileocecal resection,

etc.) M

Photodocumentation of less than two cecal landmarks (i.e., no cecal landmarks or only

381
✽ G9614 one cecal landmark) to establish a complete examination M

Preoperative assessment documented M

✽ G9615
✽ G9616 Documentation of reason(s) for not documenting a preoperative assessment (e.g., patient
with a gynecologic or other pelvic malignancy noted at the time of surgery) M

Preoperative assessment not documented, reason not given M

✽ G9617
✽ G9618 Documentation of screening for uterine malignancy or those that had an ultrasound
and/or endometrial sampling of any kind M

✽ G9620 Patient not screened for uterine malignancy, or those that have not had an ultrasound
and/or endometrial sampling of any kind, reason not given M

✽ G9621 Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use
using a systematic screening method and received brief counseling M

✽ G9622 Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol
use using a systematic screening method M

✽ G9623 Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g.,
limited life expectancy, other medical reasons) M

✽ G9624 Patient not screened for unhealthy alcohol use using a systematic screening method or
patient did not receive brief counseling if identified as an unhealthy alcohol user, reason
not given M

✽ G9625 Patient sustained bladder injury at the time of surgery or discovered subsequently up to 30
days postsurgery M

✽ G9626 Documented medical reason for reporting bladder injury (e.g., gynecologic or other pelvic
malignancy documented, concurrent surgery involving bladder pathology, injury that
occurs during urinary incontinence procedure, patient death from nonmedical causes not
related to surgery, patient died during procedure without evidence of bladder injury) M

✽ G9627 Patient did not sustain bladder injury at the time of surgery nor discovered subsequently
up to 30 days postsurgery M

382
✽ G9628 Patient sustained bowel injury at the time of surgery or discovered subsequently up to 30
days postsurgery M

✽ G9629 Documented medical reasons for not reporting bowel injury (e.g., gynecologic or other
pelvic malignancy documented, planned (e.g., not due to an unexpected bowel injury)
resection and/or re-anastomosis of bowel, or patient death from non-medical causes not
related to surgery, patient died during procedure without evidence of bowel injury) M

✽ G9630 Patient did not sustain a bowel injury at the time of surgery nor discovered subsequently
up to 30 days postsurgery M

✽ G9631 Patient sustained ureter injury at the time of surgery or discovered subsequently up to 30
days postsurgery M

✽ G9632 Documented medical reasons for not reporting ureter injury (e.g., gynecologic or other
pelvic malignancy documented, concurrent surgery involving bladder pathology, injury
that occurs during a urinary incontinence procedure, patient death from nonmedical
causes not related to surgery, patient died during procedure without evidence of ureter
injury) M

✽ G9633 Patient did not sustain ureter injury at the time of surgery nor discovered subsequently up
to 30 days postsurgery M

✽ G9634 Health-related quality of life assessed with tool during at least two visits and quality of life
score remained the same or improved M

✽ G9635 Health-related quality of life not assessed with tool for documented reason(s) (e.g., patient
has a cognitive or neuropsychiatric impairment that impairs his/her ability to complete the
HRQOL survey, patient has the inability to read and/or write in order to complete the
HRQOL questionnaire) M

✽ G9636 Health-related quality of life not assessed with tool during at least two visits or quality of
life score declined M

At least two orders for the same high-risk medications M

✽ G9637
At least two orders for the same high-risk medications not ordered M
✽ G9638
✽ G9639 Major amputation or open surgical bypass not required within 48 hours of the index
endovascular lower extremity revascularization procedure M

Documentation of planned hybrid or staged procedure M

✽ G9640
✽ G9641 Major amputation or open surgical bypass required within 48 hours of the index
endovascular lower extremity revascularization procedure M

Current smokers (e.g., cigarette, cigar, pipe, e-cigarette or marijuana) M

✽ G9642
Elective surgery M
✽ G9643
✽ G9644 Patients who abstained from smoking prior to anesthesia on the day of surgery or
procedure M

✽ G9645 Patients who did not abstain from smoking prior to anesthesia on the day of surgery or
procedure M

Patients with 90 day MRS score of 0 to 2 M

✽ G9646
Patients in whom MRS score could not be obtained at 90 day follow-up M
✽ G9647
Patients with 90 day MRS score greater than 2 M
✽ G9648
✽ G9649 Psoriasis assessment tool documented meeting any one of the specified benchmarks (e.g.,
PGA; 5-point or 6-point scale), body surface area (BSA), psoriasis area and severity index
(PASI) and/or dermatology life quality index) (DLQI)) M

✽ G9651 Psoriasis assessment tool documented not meeting any one of the specified benchmarks
(e.g., (pga; 5-point or 6-point scale), body surface area (bsa), psoriasis area and severity
index (pasi) and/or dermatology life quality index) (dlqi)) or psoriasis assessment tool not
documented M

Monitored anesthesia care (mac) M

✽ G9654
✽ G9655 A transfer of care protocol or handoff tool/checklist that includes the required key handoff
elements is used M

383
✽ G9656 Patient transferred directly from anesthetizing location to PACU or other non-ICU
location M

✽ G9658 A transfer of care protocol or handoff tool/checklist that includes the required key handoff
elements is not used M

✽ G9659 Patients greater than 85 years of age who did not have a history of colorectal cancer or
valid medical reason for the colonoscopy, including: iron deficiency anemia, lower
gastrointestinal bleeding, Crohn’s Disease (i.e., regional enteritis), familial adenomatous
polyposis, lynch syndrome (i.e., hereditary non-polyposis colorectal cancer), inflammatory
bowel disease, ulcerative colitis, abnormal finding of gastrointestinal tract, or changes in
bowel habits M

✽ G9660 Documentation of medical reason(s) for a colonoscopy performed on a patient greater

than 85 years of age (e.g., last colonoscopy incomplete, last colonoscopy had inadequate
prep, iron deficiency anemia, lower gastrointestinal bleeding, Crohn’s Disease (i.e.,
regional enteritis), familial history of adenomatous polyposis, lynch syndrome (i.e.,
hereditary non-polyposis colorectal cancer), inflammatory bowel disease, ulcerative colitis,
abnormal finding of gastrointestinal tract, or changes in bowel habits) M

✽ G9661 Patients greater than 85 years of age who received a routine colonoscopy for a reason other
than the following: an assessment of signs/symptoms of GI tract illness, and/or the patient
is considered high risk, and/or to follow-up on previously diagnosed advance lesions M

Previously diagnosed or have an active diagnosis of clinical ascvd M

✽ G9662
Any fasting or direct ldl-c laboratory test result = 190 mg/dL M
✽ G9663
✽ G9664 Patients who are currently statin therapy users or received an order (prescription) for statin
therapy M

✽ G9665 Patients who are not currently statin therapy users or did not receive an order
(prescription) for statin therapy M

✽ G9666 The highest fasting or direct ldl-c laboratory test result of 70-189 mg/dL in the
measurement period or two years prior to the beginning of the measurement period M

Patients with clinical ascvd diagnosis M

✽ G9674
Patients who have ever had a fasting or direct laboratory result of ldl-c = 190 mg/dl M
✽ G9675
✽ G9676 Patients aged 40 to 75 years at the beginning of the measurement period with type 1 or
type 2 diabetes and with an ldl-c result of 70-189 mg/dl recorded as the highest fasting or
direct laboratory test result in the measurement year or during the two years prior to the
beginning of the measurement period M

✽ G9678 Oncology care model (OCM) monthly enhanced oncology services (MEOS) payment for
OCM enhanced services. G9678 payments may only be made to OCM practitioners for
ocm beneficiaries for the furnishment of enhanced services as defined in the OCM
participation agreement B

✽ G9679 This code is for onsite acute care treatment of a nursing facility resident with pneumonia;
may only be billed once per day per beneficiary B

✽ G9680 This code is for onsite acute care treatment of a nursing facility resident with CHF; may
only be billed once per day per beneficiary B

✽ G9681 This code is for onsite acute care treatment of a resident with COPD or asthma; may only
be billed once per day per beneficiary B

✽ G9682 This code is for the onsite acute care treatment a nursing facility resident with a skin
infection; may only be billed once per day per beneficiary B

✽ G9683 Facility service(s) for the onsite acute care treatment of a nursing facility resident with
fluid or electrolyte disorder. (May only be billed once per day per beneficiary). This service
is for a demonstration project. B

✽ G9684 This code is for the onsite acute care treatment of a nursing facility resident for a UTI;
may only be billed once per day per beneficiary B

✽ G9685 Physician service or other qualified health care professional for the evaluation and
management of a beneficiary’s acute change in condition in a nursing facility. This service

384
 is for a demonstration project. M

G9686 Onsite nursing facility conference, that is separate and distinct from an evaluation ✖
and management visit, including qualified practitioner and at least one member of the
nursing facility interdisciplinary care team
Hospice services provided to patient any time during the measurement period M
✽ G9687
Patients using hospice services any time during the measurement period M
✽ G9688
Patient admitted for performance of elective carotid intervention M
✽ G9689
Patient receiving hospice services any time during the measurement period M
✽ G9690
Patient had hospice services any time during the measurement period M
✽ G9691
Hospice services received by patient any time during the measurement period M
✽ G9692
Patient use of hospice services any time during the measurement period M
✽ G9693
Hospice services utilized by patient any time during the measurement period M
✽ G9694
Long-acting inhaled bronchodilator prescribed M
✽ G9695
✽ G9696 Documentation of medical reason(s) for not prescribing a long-acting inhaled
bronchodilator M

✽ G9697 Documentation of patient reason(s) for not prescribing a long-acting inhaled

bronchodilator M

✽ G9698 Documentation of system reason(s) for not prescribing a long-acting inhaled

bronchodilator M

Long-acting inhaled bronchodilator not prescribed, reason not otherwise specified M

✽ G9699
Patients who use hospice services any time during the measurement period M
✽ G9700
✽ G9701 Children who are taking antibiotics in the 30 days prior to the date of the encounter
during which the diagnosis was established M

Patients who use hospice services any time during the measurement period M
✽ G9702
✽ G9703 Children who are taking antibiotics in the 30 days prior to the diagnosis of pharyngitis
M
AJCC breast cancer stage I: T1 mic or T1a documented M
✽ G9704
✽ G9705 AJCC breast cancer stage I: T1b (tumor >0.5 cm but <=1 cm in greatest dimension)
documented M

Low (or very low) risk of recurrence, prostate cancer M

✽ G9706
Patient received hospice services any time during the measurement period M
✽ G9707
✽ G9708 Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy
or for whom there is evidence of a right and a left unilateral mastectomy M

Hospice services used by patient any time during the measurement period M
✽ G9709
Patient was provided hospice services any time during the measurement period M
✽ G9710
Patients with a diagnosis or past history of total colectomy or colorectal cancer M
✽ G9711
✽ G9712 Documentation of medical reason(s) for prescribing or dispensing antibiotic (e.g.,
intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute
sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the
pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis/mastoiditis/bone infections, acute
lymphadenitis, impetigo, skin staph infections, pneumonia, gonococcal infections/venereal
disease/syphilis, chlamydia, inflammatory diseases, female reproductive organs), infections
of the kidney, cystitis/UTI, acne, HIV disease/asymptomatic HIV, cystic fibrosis,
disorders of the immune system, malignancy neoplasms, chronic bronchitis, emphysema,
bronchiectasis, extrinsic allergic alveolitis, chronic airway obstruction, chronic obstructive
asthma, pneumoconiosis and other lung disease due to external agents, other diseases of
the respiratory system, and tuberculosis M

Patients who use hospice services any time during the measurement period M
✽ G9713

385
✽ G9714 Patient is using hospice services any time during the measurement period M

Patients who use hospice services any time during the measurement period M
✽ G9715
✽ G9716 BMI is documented as being outside of normal limits, follow-up plan is not completed for
documented reason M

✽ G9717 Documentation stating the patient has an active diagnosis of depression or has a
diagnosed bipolar disorder, therefore screening or follow-up not required M

Hospice services for patient provided any time during the measurement period M
✽ G9718
✽ G9719 Patient is not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound,
dependent on helper pushing wheelchair, independent in wheelchair or minimal help in
wheelchair M

Hospice services for patient occurred any time during the measurement period M
✽ G9720
✽ G9721 Patient not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound,
dependent on helper pushing wheelchair, independent in wheelchair or minimal help in
wheelchair M

✽ G9722 Documented history of renal failure or baseline serum creatinine = 4.0 mg/dl; renal
transplant recipients are not considered to have preoperative renal failure, unless, since
transplantation the CR has been or is 4.0 or higher M

Hospice services for patient received any time during the measurement period M
✽ G9723
✽ G9724 Patients who had documentation of use of anticoagulant medications overlapping the
measurement year M

Patients who use hospice services any time during the measurement period M
✽ G9725
Patient refused to participate M
✽ G9726
✽ G9727 Patient unable to complete the knee FS prom at admission and discharge due to
blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate
proxy is not available M

Patient refused to participate M

✽ G9728
✽ G9729 Patient unable to complete the hip FS prom at admission and discharge due to blindness,
illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is
not available M

Patient refused to participate M

✽ G9730
✽ G9731 Patient unable to complete the foot/ankle FS prom at admission and discharge due to
blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate
proxy is not available M

Patient refused to participate M

✽ G9732
✽ G9733 Patient unable to complete the low back FS prom at admission and discharge due to
blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate
proxy is not available M

Patient refused to participate M

✽ G9734
✽ G9735 Patient unable to complete the shoulder FS prom at admission and discharge due to
blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate
proxy is not available M

Patient refused to participate M

✽ G9736
✽ G9737 Patient unable to complete the elbow/wrist/hand FS prom at admission and discharge due
to blindness, illiteracy, severe mental incapacity or language incompatibility and an
adequate proxy is not available M

Patient refused to participate M

✽ G9738
✽ G9739 Patient unable to complete the general orthopedic FS prom at admission and discharge
due to blindness, illiteracy, severe mental incapacity or language incompatibility and an
adequate proxy is not available M

Hospice services given to patient any time during the measurement period M

386
✽ G9740
Patients who use hospice services any time during the measurement period M
✽ G9741
Psychiatric symptoms assessed M
✽ G9742
Psychiatric symptoms not assessed, reason not otherwise specified M
✽ G9743
Patient not eligible due to active diagnosis of hypertension M
✽ G9744
✽ G9745 Documented reason for not screening or recommending a follow-up for high blood
pressure M

✽ G9746 Patient has mitral stenosis or prosthetic heart valves or patient has transient or reversible
cause of AF (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac surgery) M

Patient is undergoing palliative dialysis with a catheter M

✽ G9747
✽ G9748 Patient approved by a qualified transplant program and scheduled to receive a living donor
kidney transplant M

Patient is undergoing palliative dialysis with a catheter M

✽ G9749
✽ G9750 Patient approved by a qualified transplant program and scheduled to receive a living donor
kidney transplant M

Patient died at any time during the 24-month measurement period M

✽ G9751
Emergency surgery M
✽ G9752
✽ G9753 Documentation of medical reason for not conducting a search for DICOM format images
for prior patient CT imaging studies completed at nonaffiliated external healthcare
facilities or entities within the past 12 months that are available through a secure,
authorized, media-free, shared archive (e.g., trauma, acute myocardial infarction, stroke,
aortic aneurysm where time is of the essence) M

A finding of an incidental pulmonary nodule M

✽ G9754
✽ G9755 Documentation of medical reason(s) for not including a recommended interval and
modality for follow-up or for no follow-up, and source of recommendations (e.g., patients
with unexplained fever, immunocompromised patients who are at risk for infection) M

Surgical procedures that included the use of silicone oil M

✽ G9756
Surgical procedures that included the use of silicone oil M
✽ G9757
Patient in hospice at any time during the measurement period M
✽ G9758
History of preoperative posterior capsule rupture M
✽ G9759
Patients who use hospice services any time during the measurement period M
✽ G9760
Patients who use hospice services any time during the measurement period M
✽ G9761
✽ G9762 Patient had at least two HPV vaccines (with at least 146 days between the two) or three
HPV vaccines on or between the patient’s 9th and 13th birthdays M

✽ G9763 Patient did not have at least two HPV vaccines (with at least 146 days between the two)
or three HPV vaccines on or between the patient’s 9th and 13th birthdays M

Patient has been treated with systemic medication for psoriasis vulgaris M
✽ G9764
✽ G9765 Documentation that the patient declined change in medication or alternative therapies
were unavailable, has documented contraindications, or has not been treated with systemic
for at least six consecutive months (e.g., experienced adverse effects or lack of efficacy with
all other therapy options) in order to achieve better disease control as measured by PGA,
BSA, PASI, or DLQI M

✽ G9766 Patients who are transferred from one institution to another with a known diagnosis of
CVA for endovascular stroke treatment M

✽ G9767 Hospitalized patients with newly diagnosed CVA considered for endovascular stroke
treatment M

Patients who utilize hospice services any time during the measurement period M
✽ G9768
✽ G9769 Patient had a bone mineral density test in the past two years or received osteoporosis

387
 medication or therapy in the past 12 months M

Peripheral nerve block (PNB) M

✽ G9770
✽ G9771 At least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or
95.9 degrees Fahrenheit) achieved within the 30 minutes immediately before or the 15
minutes immediately after anesthesia end time M

✽ G9772 Documentation of one of the following medical reason(s) for not achieving at least 1 body
temperature measurement equal to or greater than 35.5 degrees Celsius (or 95.9 degrees
Fahrenheit) within the 30 minutes immediately before or the 15 minutes immediately
after anesthesia end time (e.g., emergency cases, intentional hypothermia, etc.) M

✽ G9773 At least 1 body temperature measurement equal to or greater than 35.5 degrees Celsius (or
95.9 degrees Fahrenheit) not achieved within the 30 minutes immediately before or the 15
minutes immediately after anesthesia end time, reason not given M

Patients who have had a hysterectomy M

✽ G9774
✽ G9775 Patient received at least 2 prophylactic pharmacologic anti-emetic agents of different
classes preoperatively and/or intraoperatively M

✽ G9776 Documentation of medical reason for not receiving at least 2 prophylactic pharmacologic
anti-emetic agents of different classes preoperatively and/or intraoperatively (e.g.,
intolerance or other medical reason) M

✽ G9777 Patient did not receive at least 2 prophylactic pharmacologic antiemetic agents of different
classes preoperatively and/or intraoperatively M

Patients who have a diagnosis of pregnancy M

✽ G9778
Patients who are breastfeeding M
✽ G9779
Patients who have a diagnosis of rhabdomyolysis M
✽ G9780
✽ G9781 Documentation of medical reason(s) for not currently being a statin therapy user or receive
an order (prescription) for statin therapy (e.g., patient with adverse effect, allergy or
intolerance to statin medication therapy, patients who are receiving palliative care, patients
with active liver disease or hepatic disease or insufficiency, and patients with end stage
renal disease [ESRD]) M

History of or active diagnosis of familial or pure hypercholesterolemia M

✽ G9782
✽ G9783 Documentation of patients with diabetes who have a most recent fasting or direct LDL-C
laboratory test result <70 mg/dl and are not taking statin therapy M

Pathologists/dermatopathologists providing a second opinion on a biopsy M

✽ G9784
✽ G9785 Pathology report diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma
(to include in situ disease) sent from the pathologist/dermatopathologist to the biopsying
clinician for review within 7 days from the time when the tissue specimen was received by
the pathologist M

✽ G9786 Pathology report diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma
(to include in situ disease) was not sent from the pathologist/dermatopathologist to the
biopsying clinician for review within 7 days from the time when the tissue specimen was
received by the pathologist M

Patient alive as of the last day of the measurement year M

✽ G9787
Most recent bp is less than or equal to 140/90 mm hg M
✽ G9788
✽ G9789 Blood pressure recorded during inpatient stays, emergency room visits, urgent care visits,
and patient selfreported BP’s (home and health fair BP results) M

Most recent BP is greater than 140/90 mm hg, or blood pressure not documented M
✽ G9790
Most recent tobacco status is tobacco free M
✽ G9791
Most recent tobacco status is not tobacco free M
✽ G9792
Patient is currently on a daily aspirin or other antiplatelet M
✽ G9793
✽ G9794 Documentation of medical reason(s) for not on a daily aspirin or other antiplatelet (e.g.,
history of gastrointestinal bleed, intra-cranial bleed, idiopathic thrombocytopenic purpura

388
 (ITP), gastric bypass or documentation of active anticoagulant use during the
measurement period) M

Patient is not currently on a daily aspirin or other antiplatelet M

✽ G9795
Patient is currently on a statin therapy M
✽ G9796
Patient is not on a statin therapy M
✽ G9797
✽ G9798 Discharge(s) for AMI between July 1 of the year prior measurement year to June 30 of the
measurement period M

✽ G9799 Patients with a medication dispensing event indicator of a history of asthma any time
during the patient’s history through the end of the measure period M

✽ G9800 Patients who are identified as having an intolerance or allergy to beta-blocker therapy
M
✽ G9801 Hospitalizations in which the patient was transferred directly to a non-acute care facility
for any diagnosis M

Patients who use hospice services any time during the measurement period M
✽ G9802
✽ G9803 Patient prescribed at least a 135 day treatment within the 180-day course of treatment
with beta-blockers post discharge for AMI M

✽ G9804 Patient was not prescribed at least a 135 day treatment within the 180-day course of
treatment with beta-blockers post discharge for AMI M

Patients who use hospice services any time during the measurement period M
✽ G9805
Patients who received cervical cytology or an HPV test M
✽ G9806
Patients who did not receive cervical cytology or an HPV test M
✽ G9807
✽ G9808 Any patients who had no asthma controller medications dispensed during the
measurement year M

Patients who use hospice services any time during the measurement period M
✽ G9809
Patient achieved a pDC of at least 75% for their asthma controller medication M
✽ G9810
✽ G9811 Patient did not achieve a pDC of at least 75% for their asthma controller medication
M
✽ G9812 Patient died including all deaths occurring during the hospitalization in which the
operation was performed, even if after 30 days, and those deaths occurring after discharge
from the hospital, but within 30 days of the procedure M

✽ G9813 Patient did not die within 30 days of the procedure or during the index hospitalization
M
Death occurring during the index acute care hospitalization M
✽ G9814
Death did not occur during the index acute care hospitalization M
✽ G9815
Death occurring after discharge from the hospital but within 30 days post procedure M
✽ G9816
Death did not occur after discharge from the hospital within 30 days post procedure M
✽ G9817
Documentation of sexual activity M
✽ G9818
Patients who use hospice services any time during the measurement period M
✽ G9819
Documentation of a chlamydia screening test with proper follow-up M
✽ G9820
No documentation of a chlamydia screening test with proper follow-up M
✽ G9821
✽ G9822 Women who had an endometrial ablation procedure during the year prior to the index
date (exclusive of the index date) M

Endometrial sampling or hysteroscopy with biopsy and results documented M

✽ G9823
Endometrial sampling or hysteroscopy with biopsy and results not documented M
✽ G9824
HER-2/neu negative or undocumented/unknown M
✽ G9825
Patient transferred to practice after initiation of chemotherapy M
✽ G9826
HER2-targeted therapies not administered during the initial course of treatment M
✽ G9827
HER2-targeted therapies administered during the initial course of treatment M
✽ G9828

389
 ✽ G9829 Breast adjuvant chemotherapy administered M

HER-2/neu positive M
✽ G9830
AJCC stage at breast cancer diagnosis = II or III M
✽ G9831
✽ G9832 AJCC stage at breast cancer diagnosis = I (Ia or Ib) and T-stage at breast cancer diagnosis
does not equal = T1, T1a, T1b M

Patient transfer to practice after initiation of chemotherapy M

✽ G9833
Patient has metastatic disease at diagnosis M
✽ G9834
Trastuzumab administered within 12 months of diagnosis M
✽ G9835
✽ G9836 Reason for not administering trastuzumab documented (e.g., patient declined, patient
died, patient transferred, contraindication or other clinical exclusion, neoadjuvant
chemotherapy or radiation not complete) M

Trastuzumab not administered within 12 months of diagnosis M

✽ G9837
Patient has metastatic disease at diagnosis M
✽ G9838
Anti-EGFR monoclonal antibody therapy M
✽ G9839
✽ G9840 Ras (KRas and NRas) gene mutation testing performed before initiation of anti-EGFR
MoAb M

✽ G9841 Ras (KRas and NRas) gene mutation testing not performed before initiation of anti-
EGFR MoAb M

Patient has metastatic disease at diagnosis M

✽ G9842
Ras (KRas and NRas) gene mutation M
✽ G9843
Patient did not receive anti-EGFR monoclonal antibody therapy M
✽ G9844
Patient received anti-EGFR monoclonal antibody therapy M
✽ G9845
Patients who died from cancer M
✽ G9846
Patient received chemotherapy in the last 14 days of life M
✽ G9847
Patient did not receive chemotherapy in the last 14 days of life M
✽ G9848
Patients who died from cancer M
✽ G9849
Patient had more than one emergency department visit in the last 30 days of life M
✽ G9850
Patient had one or less emergency department visits in the last 30 days of life M
✽ G9851
Patients who died from cancer M
✽ G9852
Patient admitted to the ICU in the last 30 days of life M
✽ G9853
Patient was not admitted to the ICU in the last 30 days of life M
✽ G9854
Patients who died from cancer M
✽ G9855
Patient was not admitted to hospice M
✽ G9856
Patient admitted to hospice M
✽ G9857
Patient enrolled in hospice M
✽ G9858
Patients who died from cancer M
✽ G9859
Patient spent less than three days in hospice care M
✽ G9860
Patient spent greater than or equal to three days in hospice care M
✽ G9861
✽ G9862 Documentation of medical reason(s) for not recommending at least a 10 year follow-up
interval (e.g., inadequate prep, familial or personal history of colonic polyps, patient had
no adenoma and age is = 66 years old, or life expectancy <10 years old, other medical
reasons) M

▶ ✽ G9873 First Medicare diabetes prevention program (MDPP) core session was attended by an
MDPP beneficiary under the MDPP expanded model (EM). A core session is an MDPP
service that: (1) is furnished by an MDPP supplier during months 1 through 6 of the

390
 MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-
approved DPP curriculum for core sessions. M

▶ ✽ G9874 Four total Medicare diabetes prevention program (MDPP) core sessions were attended by
an MDPP beneficiary under the mdpp expanded model (EM). A core session is an
MDPP service that: (1) is furnished by an MDPP supplier during months 1 through 6 of
the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a
CDC-approved DPP curriculum for core sessions. M

▶ ✽ G9875 Nine total Medicare diabetes prevention program (MDPP) core sessions were attended by
an MDPP beneficiary under the MDPP expanded model (EM). A core session is an
MDPP service that: (1) is furnished by an MDPP supplier during months 1 through 6 of
the MDPP services period; (2) is approximately 1 hour in length; and (3) adheres to a
CDC-approved DPP curriculum for core sessions. M

▶ ✽ G9876 Two Medicare diabetes prevention program (MDPP) core maintenance sessions (MS)
were attended by an MDPP beneficiary in months (mo) 7-9 under the mdpp expanded
model (EM). A core maintenance session is an MDPP service that: (1) is furnished by an
MDPP supplier during months 7 through 12 of the MDPP services period; (2) is
approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for
maintenance sessions. The beneficiary did not achieve at least 5% weight loss (WL) from
his/her baseline weight, as measured by at least one inperson weight measurement at a
core maintenance session in months 7-9. M

▶ ✽ G9877 Two Medicare diabetes prevention program (MDPP) core maintenance sessions (MS)
were attended by an MDPP beneficiary in months (mo) 10-12 under the MDPP
expanded model (EM). A core maintenance session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 7 through 12 of the MDPP services
period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP
curriculum for maintenance sessions. The beneficiary did not achieve at least 5% weight
loss (WL) from his/her baseline weight, as measured by at least one in-person weight
measurement at a core maintenance session in months 10-12. M

▶ ✽ G9878 Two Medicare diabetes prevention program (MDPP) core maintenance sessions (MS)
were attended by an MDPP beneficiary in months (mo) 7-9 under the MDPP expanded
model (EM). A core maintenance session is an MDPP service that: (1) is furnished by an
MDPP supplier during months 7 through 12 of the MDPP services period; (2) is
approximately 1 hour in length; and (3) adheres to a CDC-approved DPP curriculum for
maintenance sessions. The beneficiary achieved at least 5% weight loss (WL) from his/her
baseline weight, as measured by at least one inperson weight measurement at a core
maintenance session in months 7-9. M MIPS

▶ ✽ G9879 Two Medicare diabetes prevention program (MDPP) core maintenance sessions (MS)
were attended by an MDPP beneficiary in months (mo) 10-12 under the MDPP
expanded model (EM). A core maintenance session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 7 through 12 of the MDPP services
period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP
curriculum for maintenance sessions. The beneficiary achieved at least 5% weight loss
(WL) from his/her baseline weight, as measured by at least one in-person weight
measurement at a core maintenance session in months 10-12. M

▶ ✽ G9880 The MDPP beneficiary achieved at least 5% weight loss (WL) from his/her baseline
weight in months 1-12 of the MDPP services period under the MDPP expanded model
(EM). This is a one-time payment available when a beneficiary first achieves at least 5%
weight loss from baseline as measured by an in-person weight measurement at a core
session or core maintenance session. M

▶ ✽ G9881 The MDPP beneficiary achieved at least 9% weight loss (WL) from his/her baseline
weight in months 1-24 under the MDPP expanded model (EM). This is a one-time
payment available when a beneficiary first achieves at least 9% weight loss from baseline as
measured by an in-person weight measurement at a core session, core maintenance
session, or ongoing maintenance session. M

▶ ✽ G9882 Two Medicare diabetes prevention program (MDPP) ongoing maintenance sessions

391
 (MS) were attended by an MDPP beneficiary in months (mo) 13-15 under the MDPP
expanded model (EM). An ongoing maintenance session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 13 through 24 of the MDPP services
period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP
curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss
(WL) from his/her baseline weight, as measured by at least one inperson weight
measurement at an ongoing maintenance session in months 13-15. M

▶ ✽ G9883 Two Medicare diabetes prevention program (MDPP) ongoing maintenance sessions
(MS) were attended by an MDPP beneficiary in months (mo) 16-18 under the MDPP
expanded model (EM). An ongoing maintenance session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 13 through 24 of the MDPP services
period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP
curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss
(WL) from his/her baseline weight, as measured by at least one in-person weight
measurement at an ongoing maintenance session in months 16-18. M

▶ ✽ G9884 Two Medicare diabetes prevention program (MDPP) ongoing maintenance sessions
(MS) were attended by an MDPP beneficiary in months (mo) 19-21 under the MDPP
expanded model (EM). An ongoing maintenance session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 13 through 24 of the MDPP services
period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP
curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss
(WL) from his/her baseline weight, as measured by at least one in-person weight
measurement at an ongoing maintenance session in months 19-21. M

▶ ✽ G9885 Two Medicare diabetes prevention program (MDPP) ongoing maintenance sessions
(MS) were attended by an MDPP beneficiary in months (mo) 22-24 under the MDPP
expanded model (EM). An ongoing maintenance session is an MDPP service that: (1) is
furnished by an MDPP supplier during months 13 through 24 of the MDPP services
period; (2) is approximately 1 hour in length; and (3) adheres to a CDC-approved DPP
curriculum for maintenance sessions. The beneficiary maintained at least 5% weight loss
(WL) from his/her baseline weight, as measured by at least one in-person weight
measurement at an ongoing maintenance session in months 22-24. M

NOTE: The following codes do not imply that codes in other sections are necessarily covered.

Quality Measures: Miscellaneous

▶ ✽ G9890 Bridge payment: a one-time payment for the first Medicare diabetes prevention program
(MDPP) core session, core maintenance session, or ongoing maintenance session
furnished by an MDPP supplier to an MDPP beneficiary during months 1-24 of the
MDPP expanded model (EM) who has previously received MDPP services from a
different MDPP supplier under the MDPP expanded model. A supplier may only receive
one bridge payment per MDPP beneficiary. M

▶ ✽ G9891 MDPP session reported as a line-item on a claim for a payable MDPP expanded model
(EM) HCPCS code for a session furnished by the billing supplier under the MDPP
expanded model and counting toward achievement of the attendance performance goal for
the payable MDPP expanded model HCPCS code (this code is for reporting purposes
only) M

✽ G9890 Dilated macular exam performed, including documentation of the presence or absence of
macular thickening or geographic atrophy or hemorrhage and the level of macular
degeneration severity M

✽ G9891 Documentation of medical reason(s) for not performing a dilated macular examination
M
✽ G9892 Documentation of patient reason(s) for not performing a dilated macular examination
M
Dilated macular exam was not performed, reason not otherwise specified M
✽ G9893
✽ G9894 Androgen deprivation therapy prescribed/administered in combination with external
beam radiotherapy to the prostate M

392
✽ G9895 Documentation of medical reason(s) for not prescribing/administering androgen
deprivation therapy in combination with external beam radiotherapy to the prostate (e.g.,
salvage therapy) M

✽ G9896 Documentation of patient reason(s) for not prescribing/administering androgen

deprivation therapy in combination with external beam radiotherapy to the prostate M

✽ G9897 Patients who were not prescribed/administered androgen deprivation therapy in

combination with external beam radiotherapy to the prostate, reason not given M

✽ G9898 Patient age 65 or older in institutional special needs plans (SNP) or residing in long-term
care with POS code 32, 33, 34, 54, or 56 any time during the measurement period M

✽ G9899 Screening, diagnostic, film, digital or digital breast tomosynthesis (3D) mammography
results documented and reviewed M

✽ G9900 Screening, diagnostic, film, digital or digital breast tomosynthesis (3D) mammography
results were not documented and reviewed, reason not otherwise specified M

✽ G9901 Patient age 65 or older in institutional special needs plans (SNP) or residing in long-term
care with pos code 32, 33, 34, 54, or 56 any time during the measurement period M

Patient screened for tobacco use and identified as a tobacco user M

✽ G9902
Patient screened for tobacco use and identified as a tobacco non-user M
✽ G9903
✽ G9904 Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life
expectancy, other medical reason) M

Patient not screened for tobacco use, reason not given M

✽ G9905
✽ G9906 Patient identified as a tobacco user received tobacco cessation intervention (counseling
and/or pharmacotherapy) M

✽ G9907 Documentation of medical reason(s) for not providing tobacco cessation intervention
(e.g., limited life expectancy, other medical reason) M

✽ G9908 Patient identified as tobacco user did not receive tobacco cessation intervention
(counseling and/or pharmacotherapy), reason not given M

✽ G9909 Documentation of medical reason(s) for not providing tobacco cessation intervention if
identified as a tobacco user (e.g., limited life expectancy, other medical reason) M

✽ G9910 Patients age 65 or older in institutional special needs plans (SNP) or residing in long-term
care with pos code 32, 33, 34, 54, or 56 anytime during the measurement period M

✽ G9911 Clinically node negative (t1n0m0 or t2n0m0) invasive breast cancer before or after
neoadjuvant systemic therapy M

✽ G9912 Hepatitis B virus (HBV) status assessed and results interpreted prior to initiating anti-
TNF (tumor necrosis factor) therapy M

✽ G9913 Hepatitis B virus (HBV) status not assessed and results interpreted prior to initiating anti-
TNF (tumor necrosis factor) therapy, reason not given M

Patient receiving an anti-TNF agent M

✽ G9914
No record of HBV results documented M
✽ G9915
Functional status performed once in the last 12 months M
✽ G9916
✽ G9917 Documentation of medical reason(s) for not performing functional status (e.g., patient is
severely impaired and caregiver knowledge is limited, other medical reason) M

Functional status not performed, reason not otherwise specified M

✽ G9918
Screening performed and positive and provision of recommendations M
✽ G9919
Screening performed and negative M
✽ G9920
✽ G9921 No screening performed, partial screening performed or positive screen without
recommendations and reason is not given or otherwise specified M

✽ G9922 Safety concerns screen provided and if positive then documented mitigation
recommendations M

Safety concerns screen provided and negative M

✽ G9923

393
✽ G9924 Documentation of medical reason(s) for not providing safety concerns screen or for not
providing recommendations, orders or referrals for positive screen (e.g., patient in
palliative care, other medical reason) M

Safety concerns screening not provided, reason not otherwise specified M

✽ G9925
✽ G9926 Safety concerns screening positive screen is without provision of mitigation
recommendations, including but not limited to referral to other resources M

✽ G9927 Documentation of system reason(s) for not prescribing warfarin or another FDA-
approved anticoagulation due to patient being currently enrolled in a clinical trial related
to af/atrial flutter treatment M

Warfarin or another FDA-approved anticoagulant not prescribed, reason not given M

✽ G9928
✽ G9929 Patient with transient or reversible cause of AF (e.g., pneumonia, hyperthyroidism,
pregnancy, cardiac surgery) M

Patients who are receiving comfort care only M

✽ G9930
Documentation of CHA2DS2-VASc risk score of 0 or 1 M
✽ G9931
✽ G9932 Documentation of patient reason(s) for not having records of negative or managed
positive TB screen (e.g., patient does not return for mantoux (ppd) skin test evaluation)
M
Adenoma(s) or colorectal cancer detected during screening colonoscopy M
✽ G9933
✽ G9934 Documentation that neoplasm detected is only diagnosed as traditional serrated adenoma,
sessile serrated polyp, or sessile serrated adenoma M

Adenoma(s) or colorectal cancer not detected during screening colonoscopy M

✽ G9935
✽ G9936 Surveillance colonoscopy - personal history of colonic polyps, colon cancer, or other
malignant neoplasm of rectum, rectosigmoid junction, and anus M

Diagnostic colonoscopy M
✽ G9937
✽ G9938 Patients age 65 or older in institutional special needs plans (SNP) or residing in long-term
care with POS code 32, 33, 34, 54, or 56 any time during the measurement period M

Pathologists/dermatopathologists is the same clinician who performed the biopsy M

✽ G9939
✽ G9940 Documentation of medical reason(s) for not on a statin (e.g., pregnancy, in vitro
fertilization, clomiphene rx, esrd, cirrhosis, muscular pain and disease during the
measurement period or prior year) M

✽ G9941 Back pain was measured by the visual analog scale (VAS) within 3 months preoperatively
and at 3 months (6-20 weeks) postoperatively M

✽ G9942 Patient had any additional spine procedures performed on the same date as the lumbar
discectomy/laminotomy M

✽ G9943 Back pain was not measured by the visual analog scale (VAS) within three months
preoperatively and at three months (6-20 weeks) postoperatively M

✽ G9944 Back pain was measured by the visual analog scale (VAS) within three months
preoperatively and at one year (9 to 15 months) postoperatively M

✽ G9945 Patient had cancer, fracture or infection related to the lumbar spine or patient had
idiopathic or congenital scoliosis M

✽ G9946 Back pain was not measured by the visual analog scale (VAS) within three months
preoperatively and at one year (9 to 15 months) postoperatively M

✽ G9947 Leg pain was measured by the visual analog scale (VAS) within three months
preoperatively and at three months (6 to 20 weeks) postoperatively M

✽ G9948 Patient had any additional spine procedures performed on the same date as the lumbar
discectomy/laminotomy M

✽ G9949 Leg pain was not measured by the visual analog scale (VAS) within three months
preoperatively and at three months (6 to 20 weeks) postoperatively M

Patient exhibits 2 or more risk factors for post-operative vomiting M

✽ G9954
Cases in which an inhalational anesthetic is used only for induction M
✽ G9955

394
 ✽ G9956 Patient received combination therapy consisting of at least two prophylactic
pharmacologic anti-emetic agents of different classes preoperatively and/or
intraoperatively M

✽ G9957 Documentation of medical reason for not receiving combination therapy consisting of at
least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively
and/or intraoperatively (e.g., intolerance or other medical reason) M

✽ G9958 Patient did not receive combination therapy consisting of at least two prophylactic
pharmacologic anti-emetic agents of different classes preoperatively and/or
intraoperatively M

Systemic antimicrobials not prescribed M

✽ G9959
Documentation of medical reason(s) for prescribing systemic antimicrobials M
✽ G9960
Systemic antimicrobials prescribed M
✽ G9961
✽ G9962 Embolization endpoints are documented separately for each embolized vessel and ovarian
artery angiography or embolization performed in the presence of variant uterine artery
anatomy M

✽ G9963 Embolization endpoints are not documented separately for each embolized vessel or
ovarian artery angiography or embolization not performed in the presence of variant
uterine artery anatomy M

✽ G9964 Patient received at least one well-child visit with a PCP during the performance period
M
✽ G9965 Patient did not receive at least one well-child visit with a PCP during the performance
period M

✽ G9966 Children who were screened for risk of developmental, behavioral and social delays using a
standardized tool with interpretation and report M

✽ G9967 Children who were not screened for risk of developmental, behavioral and social delays
using a standardized tool with interpretation and report M

Patient was referred to another provider or specialist during the performance period M
✽ G9968
✽ G9969 Provider who referred the patient to another provider received a report from the provider
to whom the patient was referred M

✽ G9970 Provider who referred the patient to another provider did not receive a report from the
provider to whom the patient was referred M

✽ G9974 Dilated macular exam performed, including documentation of the presence or absence of
macular thickening or geographic atrophy or hemorrhage and the level of macular
degeneration severity M

✽ G9975 Documentation of medical reason(s) for not performing a dilated macular examination
M
✽ G9976 Documentation of patient reason(s) for not performing a dilated macular examination
M
Dilated macular exam was not performed, reason not otherwise specified M
✽ G9977
▶ ✽ G9978 Remote in-home visit for the evaluation and management of a new patient for use only in
a Medicare-approved bundled payments for care improvement advanced (BCPI advanced)
model episode of care, which requires these 3 key components: a problem focused history;
a problem focused examination; and straightforward medical decision making, furnished
in real time using interactive audio and video technology. Counseling and coordination of
care with other physicians, other qualified health care professionals or agencies are
provided consistent with the nature of the problem(s) and the needs of the patient or the
family or both. Usually, the presenting problem(s) are self limited or minor. Typically, 10
minutes are spent with the patient or family or both via real time, audio and video
intercommunications technology. B

▶ ✽ G9979 Remote in-home visit for the evaluation and management of a new patient for use only in
a Medicare-approved bundled payments for care improvement advanced (BCPI advanced)
model episode of care, which requires these 3 key components: an expanded problem
focused history; an expanded problem focused examination; straightforward medical
decision making, furnished in real time using interactive audio and video technology.

395
 Counseling and coordination of care with other physicians, other qualified health care
professionals or agencies are provided consistent with the nature of the problem(s) and the
needs of the patient or the family or both. Usually, the presenting problem(s) are of low to
moderate severity. Typically, 20 minutes are spent with the patient or family or both via
real time, audio and video intercommunications technology. B

▶ ✽ G9980 Remote in-home visit for the evaluation and management of a new patient for use only in
a Medicare-approved bundled payments for care improvement advanced (BCPI advanced)
model episode of care, which requires these 3 key components: a detailed history; a
detailed examination; medical decision making of low complexity, furnished in real time
using interactive audio and video technology. Counseling and coordination of care with
other physicians, other qualified health care professionals or agencies are provided
consistent with the nature of the problem(s) and the needs of the patient or the family or
both. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes
are spent with the patient or family or both via real time, audio and video
intercommunications technology. B

▶ ✽ G9981 Remote in-home visit for the evaluation and management of a new patient for use only in
a Medicare-approved bundled payments for care improvement advanced (BCPI advanced)
model episode of care, which requires these 3 key components: a comprehensive history; a
comprehensive examination; medical decision making of moderate complexity, furnished
in real time using interactive audio and video technology. Counseling and coordination of
care with other physicians, other qualified health care professionals or agencies are
provided consistent with the nature of the problem(s) and the needs of the patient or the
family or both. Usually, the presenting problem(s) are of moderate to high severity.
Typically, 45 minutes are spent with the patient or family or both via real time, audio and
video intercommunications technology. B

▶ ✽ G9982 Remote in-home visit for the evaluation and management of a new patient for use only in
a Medicare-approved bundled payments for care improvement advanced (BCPI advanced)
model episode of care, which requires these 3 key components: a comprehensive history; a
comprehensive examination; medical decision making of high complexity, furnished in
real time using interactive audio and video technology. Counseling and coordination of
care with other physicians, other qualified health care professionals or agencies are
provided consistent with the nature of the problem(s) and the needs of the patient or the
family or both. Usually, the presenting problem(s) are of moderate to high severity.
Typically, 60 minutes are spent with the patient or family or both via real time, audio and
video intercommunications technology. B

▶ ✽ G9983 Remote in-home visit for the evaluation and management of an established patient for use
only in a Medicareapproved bundled payments for care improvement advanced (BCPI
advanced) model episode of care, which requires at least 2 of the following 3 key
components: a problem focused history; a problem focused examination; straightforward
medical decision making, furnished in real time using interactive audio and video
technology. Counseling and coordination of care with other physicians, other qualified
health care professionals or agencies are provided consistent with the nature of the
problem(s) and the needs of the patient or the family or both. Usually, the presenting
problem(s) are self limited or minor. Typically, 10 minutes are spent with the patient or
family or both via real time, audio and video intercommunications technology. B

▶ ✽ G9984 Remote in-home visit for the evaluation and management of an established patient for use
only in a Medicareapproved bundled payments for care improvement advanced (BCPI
advanced) model episode of care, which requires at least 2 of the following 3 key
components: an expanded problem focused history; an expanded problem focused
examination; medical decision making of low complexity, furnished in real time using
interactive audio and video technology. Counseling and coordination of care with other
physicians, other qualified health care professionals or agencies are provided consistent
with the nature of the problem(s) and the needs of the patient or the family or both.
Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes
are spent with the patient or family or both via real time, audio and video
intercommunications technology. B

396
 ▶ ✽ G9985 Remote in-home visit for the evaluation and management of an established patient for use
only in a Medicareapproved bundled payments for care improvement advanced (BCPI
advanced) model episode of care, which requires at least 2 of the following 3 key
components: a detailed history; a detailed examination; medical decision making of
moderate complexity, furnished in real time using interactive audio and video technology.
Counseling and coordination of care with other physicians, other qualified health care
professionals or agencies are provided consistent with the nature of the problem(s) and the
needs of the patient or the family or both. Usually, the presenting problem(s) are of
moderate to high severity. Typically, 25 minutes are spent with the patient or family or
both via real time, audio and video intercommunications technology. B

▶ ✽ G9986 Remote in-home visit for the evaluation and management of an established patient for use
only in a Medicareapproved bundled payments for care improvement advanced (BCPI
advanced) model episode of care, which requires at least 2 of the following 3 key
components: a comprehensive history; a comprehensive examination; medical decision
making of high complexity, furnished in real time using interactive audio and video
technology. Counseling and coordination of care with other physicians, other qualified
health care professionals or agencies are provided consistent with the nature of the
problem(s) and the needs of the patient or the family or both. Usually, the presenting
problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the
patient or family or both via real time, audio and video intercommunications technology.
B
▶ ✽ G9987 Bundled payments for care improvement advanced (BCPI advanced) model home visit for
patient assessment performed by clinical staff for an individual not considered
homebound, including, but not necessarily limited to patient assessment of clinical status,
safety/fall prevention, functional status/ambulation, medication
reconciliation/management, compliance with orders/plan of care, performance of activities
of daily living, and ensuring beneficiary connections to community and other services; for
use only for a BCPI advanced model episode of care; may not be billed for a 30-day period
covered by a transitional care management code. B

BEHAVIORAL HEALTH AND/OR SUBSTANCE ABUSE

TREATMENT SERVICES (H0001-H9999)
NOTE: Used by Medicaid state agencies because no national code exists to meet the reporting
needs of these agencies.
H H0001 Alcohol and/or drug assessment
H H0002 Behavioral health screening to determine eligibility for admission to treatment program
H H0003 Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol
and/or drugs
H H0004 Behavioral health counseling and therapy, per 15 minutes
H H0005 Alcohol and/or drug services; group counseling by a clinician
H H0006 Alcohol and/or drug services; case management
H H0007 Alcohol and/or drug services; crisis intervention (outpatient)
H H0008 Alcohol and/or drug services; sub-acute detoxification (hospital inpatient)
H H0009 Alcohol and/or drug services; acute detoxification (hospital inpatient)
H H0010 Alcohol and/or drug services; sub-acute detoxification (residential addiction program
inpatient)
H H0011 Alcohol and/or drug services; acute detoxification (residential addiction program
inpatient)
H H0012 Alcohol and/or drug services; sub-acute detoxification (residential addiction program
outpatient)
H H0013 Alcohol and/or drug services; acute detoxification (residential addiction program

397
 outpatient)
H H0014 Alcohol and/or drug services; ambulatory detoxification
H H0015 Alcohol and/or drug services; intensive outpatient (treatment program that operates at
least 3 hours/day and at least 3 days/week and is based on an individualized treatment
plan), including assessment, counseling; crisis intervention, and activity therapies or
education
H H0016 Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory
setting)
H H0017 Behavioral health; residential (hospital residential treatment program), without room and
board, per diem
H H0018 Behavioral health; short-term residential (non-hospital residential treatment program),
without room and board, per diem
H H0019 Behavioral health; long-term residential (non-medical, non-acute care in a residential
treatment program where stay is typically longer than 30 days), without room and board,
per diem
H H0020 Alcohol and/or drug services; methadone administration and/or service (provision of the
drug by a licensed program)
H H0021 Alcohol and/or drug training service (for staff and personnel not employed by providers)
H H0022 Alcohol and/or drug intervention service (planned facilitation)
H H0023 Behavioral health outreach service (planned approach to reach a targeted population)
H H0024 Behavioral health prevention information dissemination service (one-way direct or non-
direct contact with service audiences to affect knowledge and attitude)
H H0025 Behavioral health prevention education service (delivery of services with target population
to affect knowledge, attitude and/or behavior)
H H0026 Alcohol and/or drug prevention process service, community-based (delivery of services to
develop skills of impactors)
H H0027 Alcohol and/or drug prevention environmental service (broad range of external activities
geared toward modifying systems in order to mainstream prevention through policy and
law)
H H0028 Alcohol and/or drug prevention problem identification and referral service (e.g., student
assistance and employee assistance programs), does not include assessment
H H0029 Alcohol and/or drug prevention alternatives service (services for populations that exclude
alcohol and other drug use, e.g., alcohol-free social events)
H H0030 Behavioral health hotline service
H H0031 Mental health assessment, by non-physician
H H0032 Mental health service plan development by non-physician
H H0033 Oral medication administration, direct observation
H H0034 Medication training and support, per 15 minutes
H H0035 Mental health partial hospitalization, treatment, less than 24 hours
H H0036 Community psychiatric supportive treatment, face-to-face, per 15 minutes
H H0037 Community psychiatric supportive treatment program, per diem
H H0038 Self-help/peer services, per 15 minutes
H H0039 Assertive community treatment, face-to-face, per 15 minutes
H H0040 Assertive community treatment program, per diem
H H0041 Foster care, child, non-therapeutic, per diem
H H0042 Foster care, child, non-therapeutic, per month
H H0043 Supported housing, per diem

398
H H0044 Supported housing, per month
H H0045 Respite care services, not in the home, per diem
H H0046 Mental health services, not otherwise specified
H H0047 Alcohol and/or other drug abuse services, not otherwise specified
H H0048 Alcohol and/or other drug testing: collection and handling only, specimens other than
blood
H H0049 Alcohol and/or drug screening
H H0050 Alcohol and/or drug services, brief intervention, per 15 minutes
H H1000 Prenatal care, at-risk assessment ♀
H H1001 Prenatal care, at-risk enhanced service; antepartum management ♀
H H1002 Prenatal care, at-risk enhanced service; care coordination ♀
H H1003 Prenatal care, at-risk enhanced service; education ♀
H H1004 Prenatal care, at-risk enhanced service; follow-up home visit ♀
H H1005 Prenatal care, at-risk enhanced service package (includes H1001-H1004) ♀
H H1010 Non-medical family planning education, per session
H H1011 Family assessment by licensed behavioral health professional for state defined purposes
H H2000 Comprehensive multidisciplinary evaluation
H H2001 Rehabilitation program, per 1/2 day
H H2010 Comprehensive medication services, per 15 minutes
H H2011 Crisis intervention service, per 15 minutes
H H2012 Behavioral health day treatment, per hour
H H2013 Psychiatric health facility service, per diem
H H2014 Skills training and development, per 15 minutes
H H2015 Comprehensive community support services, per 15 minutes
H H2016 Comprehensive community support services, per diem
H H2017 Psychosocial rehabilitation services, per 15 minutes
H H2018 Psychosocial rehabilitation services, per diem
H H2019 Therapeutic behavioral services, per 15 minutes
H H2020 Therapeutic behavioral services, per diem
H H2021 Community-based wrap-around services, per 15 minutes
H H2022 Community-based wrap-around services, per diem
H H2023 Supported employment, per 15 minutes
H H2024 Supported employment, per diem
H H2025 Ongoing support to maintain employment, per 15 minutes
H H2026 Ongoing support to maintain employment, per diem
H H2027 Psychoeducational service, per 15 minutes
H H2028 Sexual offender treatment service, per 15 minutes
H H2029 Sexual offender treatment service, per diem
H H2030 Mental health clubhouse services, per 15 minutes
H H2031 Mental health clubhouse services, per diem
H H2032 Activity therapy, per 15 minutes
Multisystemic therapy for juveniles, per 15 minutes

399
 H H2033
H H2034 Alcohol and/or drug abuse halfway house services, per diem
H H2035 Alcohol and/or other drug treatment program, per hour
H H2036 Alcohol and/or other drug treatment program, per diem
H H2037 Developmental delay prevention activities, dependent child of client, per 15 minutes

DRUGS OTHER THAN CHEMOTHERAPY DRUGS (J0100-J8999)

Injection
Injection, tetracycline, up to 250 mg N1 N
❂ J0120
Other: Achromycin
IOM: 100-02, 15, 50
✽ J0129 Injection, abatacept, 10 mg (code may be used for medicare when drug administered
under the direct supervision of a physician, not for use when drug is self-administered)
K2 K

Other: Orencia
Injection, abciximab, 10 mg N1 N
❂ J0130
Other: ReoPro
IOM: 100-02, 15, 50
Injection, acetaminophen, 10 mg N1 N
✽ J0131
Other: Ofirmev
Coding Clinic: 2012, Q1, P9
Injection, acetylcysteine, 100 mg N1 N
✽ J0132
Other: Acetadote
Injection, acyclovir, 5 mg N1 N
✽ J0133
Injection, adalimumab, 20 mg K2 K
✽ J0135
Other: Humira
IOM: 100-02, 15, 50
❂ J0153 Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds)
N1 N

Other: Adenocard, Adenoscan

Injection, adrenalin, epinephrine, 0.1 mg N1 N
❂ J0171
Other: AUVI-Q, Sus-Phrine
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8
Injection, aflibercept, 1 mg K2 K
✽ J0178
Other: Eylea
Injection, agalsidase beta, 1 mg K2 K
✽ J0180
Other: Fabrazyme
IOM: 100-02, 15, 50
Injection, aprepitant, 1 mg G
▶ ✽ J0185
Other: Emend
Injection, biperiden lactate, per 5 mg E2
❂ J0190
Other: Akineton
IOM: 100-02, 15, 50
Injection, alatrofloxacin mesylate, 100 mg E2
❂ J0200
Other: Trovan
IOM: 100-02, 15, 50

400
✽ J0202 Injection, alemtuzumab, 1 mg K2 K

Other: Lemtrada
Injection, alglucerase, per 10 units E2
❂ J0205
Other: Ceredase
IOM: 100-02, 15, 50
Injection, amifostine, 500 mg K2 K
❂ J0207
Other: Ethyol
IOM: 100-02, 15, 50
Injection, methyldopate HCL, up to 250 mg N1 N
❂ J0210
Other: Aldomet
IOM: 100-02, 15, 50
Injection, alefacept, 0.5 mg E2
✽ J0215
Injection, alglucosidase alfa, not otherwise specified, 10 mg K2 K
✽ J0220
Coding Clinic: 2013: Q2, P5; 2012, Q1, P9
Injection, alglucosidase alfa, (lumizyme), 10 mg K2 K
✽ J0221
Coding Clinic: 2013: Q2, P5

❂ J0256 Injection, alpha 1-proteinase inhibitor (human), not otherwise specified, 10 mg

K2 K
Other: Prolastin, Zemaira
IOM: 100-02, 15, 50
Coding Clinic: 2012, Q1, P9
Injection, alpha 1 proteinase inhibitor (human), (glassia), 10 mg K2 K
❂ J0257
IOM: 100-02, 15, 50
Coding Clinic: 2012, Q1, P8
❂ J0270 Injection, alprostadil, per 1.25 mcg (Code may be used for Medicare when drug
administered under the direct supervision of a physician, not for use when drug is self-
administered) B

Other: Caverject, Prostaglandin E1, Prostin VR Pediatric

IOM: 100-02, 15, 50
❂ J0275 Alprostadil urethral suppository (Code may be used for Medicare when drug administered
under the direct supervision of a physician, not for use when drug is self-administered)
B

Other: Muse
IOM: 100-02, 15, 50
Injection, amikacin sulfate, 100 mg N1 N
✽ J0278
Injection, aminophylline, up to 250 mg N1 N
❂ J0280
IOM: 100-02, 15, 50
Injection, amiodarone hydrochloride, 30 mg N1 N
❂ J0282
Other: Cordarone
IOM: 100-02, 15, 50
Injection, amphotericin B, 50 mg N1 N
❂ J0285
Other: ABLC, Amphocin, Fungizone
IOM: 100-02, 15, 50
Injection, amphotericin B lipid complex, 10 mg K2 K
❂ J0287
Other: Abelcet
IOM: 100-02, 15, 50
Injection, amphotericin B cholesteryl sulfate complex, 10 mg E2
❂ J0288
IOM: 100-02, 15, 50
Injection, amphotericin B liposome, 10 mg K2 K
❂ J0289
Other: AmBisome

401
 IOM: 100-02, 15, 50
Injection, ampicillin sodium, 500 mg N1 N
❂ J0290
Other: Omnipen-N, Polycillin-N, Totacillin-N
IOM: 100-02, 15, 50
Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm N1 N
❂ J0295
Other: Omnipen-N, Polycillin-N, Totacillin-N, Unasyn
IOM: 100-02, 15, 50
Injection, amobarbital, up to 125 mg K2 K
❂ J0300
Other: Amytal
IOM: 100-02, 15, 50
Injection, succinylcholine chloride, up to 20 mg N1 N
❂ J0330
Other: Anectine, Quelicin, Surostrin
IOM: 100-02, 15, 50
Injection, anidulafungin, 1 mg N1 N
✽ J0348
Other: Eraxis
Injection, anistreplase, per 30 units E2
❂ J0350
Other: Eminase
IOM: 100-02, 15, 50
Injection, hydralazine hydrochloride, up to 20 mg N1 N
❂ J0360
Other: Apresoline
IOM: 100-02, 15, 50
Injection, apomorphine hydrochloride, 1 mg E2
✽ J0364
Injection, aprotinin, 10,000 KIU E2
❂ J0365
IOM: 100-02, 15, 50
Injection, metaraminol bitartrate, per 10 mg N1 N
❂ J0380
Other: Aramine
IOM: 100-02, 15, 50
Injection, chloroquine hydrochloride, up to 250 mg N1 N
❂ J0390
Benefit only for diagnosed malaria or amebiasis
Other: Aralen
IOM: 100-02, 15, 50
Injection, arbutamine HCL, 1 mg E2
❂ J0395
IOM: 100-02, 15, 50
Injection, aripiprazole, intramuscular, 0.25 mg K2 K
✽ J0400
Injection, aripiprazole, extended release, 1 mg K2 K
✽ J0401
Other: Abilify Maintena
Injection, azithromycin, 500 mg N1 N
❂ J0456
Other: Zithromax
IOM: 100-02, 15, 50
Injection, atropine sulfate, 0.01 mg N1 N
❂ J0461
IOM: 100-02, 15, 50
Injection, dimercaprol, per 100 mg K2 K
❂ J0470
Other: BAL In Oil
IOM: 100-02, 15, 50
Injection, baclofen, 10 mg K2 K
❂ J0475
Other: Gablofen, Lioresal
IOM: 100-02, 15, 50
Injection, baclofen 50 mcg for intrathecal trial K2 K
❂ J0476

402
 Other: Gablofen, Lioresal
IOM: 100-02, 15, 50
Injection, basiliximab, 20 mg K2 K
❂ J0480
Other: Simulect
IOM: 100-02, 15, 50
Injection, belatacept, 1 mg K2 K
✽ J0485
Other: Nulojix
Injection, belimumab, 10 mg K2 K
✽ J0490
Other: Benlysta
Coding Clinic: 2012, Q1, P9
Injection, dicyclomine HCL, up to 20 mg N1 N
❂ J0500
Other: Antispas, Bentyl, Dibent, Dilomine, Di-Spaz, Neoquess, Or-Tyl, Spasmoject
IOM: 100-02, 15, 50
Injection, benztropine mesylate, per 1 mg N1 N
❂ J0515
Other: Cogentin
IOM: 100-02, 15, 50
Injection, benralizumab, 1 mg G
▶ ✽ J0517
Other: Fasenra
Injection, bethanechol chloride, myotonachol or urecholine, up to 5 mg E2
❂ J0520
IOM: 100-02, 15, 50
✽ J0558 Injection, penicillin G benzathine and penicillin G procaine, 100,000 units
Other: Bicillin C-R N1 N
Coding Clinic: 2011, Q1, P8
Injection, penicillin G benzathine, 100,000 units K2 K
❂ J0561
Other: Bicillin L-A, Permapen
IOM: 100-02, 15, 50
Coding Clinic: 2013: Q2, P3; 2011, Q1, P8
Injection, bezlotoxumab, 10 mg K2 G
✽ J0565
Injection, cerliponase alfa, 1 mg G
▶ ✽ J0567
Other: Brineura
Buprenorphine implant, 74.2 mg K2 G
✽ J0570
Other: Probuphine System Kit
Coding Clinic: 2017, Q1, P9
Buprenorphine, oral, 1 mg E1
❂ J0571
Buprenorphine/naloxone, oral, less than or equal to 3 mg buprenorphine E1
❂ J0572
❂ J0573 Buprenorphine/naloxone, oral, greater than 3 mg, but less than or equal to 6 mg
buprenorphine E1

❂ J0574 Buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg
buprenorphine E1

Buprenorphine/naloxone, oral, greater than 10 mg buprenorphine E1

❂ J0575
Injection, bivalirudin, 1 mg N1 N
✽ J0583
Other: Angiomax
Injection, burosumab-twza 1 mg K
▶ ✽ J0584
Other: Crysvita
Injection, onabotulinumtoxinaA, 1 unit K2 K
❂ J0585
Other: Botox, Botox Cosmetic, Oculinum
IOM: 100-02, 15, 50
Injection, abobotulinumtoxinaA, 5 units K2 K
✽ J0586
Injection, rimabotulinumtoxinB, 100 units K2 K
❂ J0587

403
 Other: Myobloc, Nplate
IOM: 100-02, 15, 50
Injection, incobotulinumtoxin A, 1 unit K2 K
✽ J0588
Other: Xeomin
Coding Clinic: 2012, Q1, P9
Injection, buprenorphine hydrochloride, 0.1 mg N1 N
❂ J0592
Other: Buprenex
IOM: 100-02, 15, 50
Injection, busulfan, 1 mg K2 K
✽ J0594
Other: Myleran
Injection, butorphanol tartrate, 1 mg N1 N
✽ J0595
Injection, C1 esterase inhibitor (recombinant), ruconest, 10 units K2 K
✽ J0596
Injection, C-1 esterase inhibitor (human), Berinert, 10 units K2 K
✽ J0597
Coding Clinic: 2011, Q1, P7
Injection, C1 esterase inhibitor (human), cinryze, 10 units K2 K
✽ J0598
Injection, c-1 esterase inhibitor (human), (haegarda), 10 units G
▶ ✽ J0599
Other: Berinert
Injection, edetate calcium disodium, up to 1000 mg K2 K
❂ J0600
Other: Calcium Disodium Versenate
IOM: 100-02, 15, 50
Cinacalcet, oral, 1 mg, (for ESRD on dialysis) B
❂ J0604
Injection, etelcalcetide, 0.1 mg K2 K
❂ J0606
Injection, calcium gluconate, per 10 ml N1 N
❂ J0610
Other: Kaleinate
IOM: 100-02, 15, 50
Injection, calcium glycerophosphate and calcium lactate, per 10 ml N1 N
❂ J0620
Other: Calphosan
MCM: 2049
IOM: 100-02, 15, 50
Injection, calcitonin (salmon), up to 400 units K2 K
❂ J0630
Other: Calcimar, Calcitonin-salmon, Miacalcin
IOM: 100-02, 15, 50
Injection, calcitriol, 0.1 mcg N1 N
❂ J0636
Non-dialysis use
Other: Calcijex
IOM: 100-02, 15, 50
Injection, caspofungin acetate, 5 mg K2 K
✽ J0637
Other: Cancidas, Caspofungin
Injection, canakinumab, 1 mg K2 K
✽ J0638
Other: Ilaris
Injection, leucovorin calcium, per 50 mg N1 N
❂ J0640
Other: Wellcovorin
IOM: 100-02, 15, 50
Coding Clinic: 2009, Q1, P10
Injection, levoleucovorin calcium, 0.5 mg K2 K
❂ J0641
Part of treatment regimen for osteosarcoma
Injection, mepivacaine HCL, per 10 ml N1 N
❂ J0670
Other: Carbocaine, Isocaine HCl, Polocaine
IOM: 100-02, 15, 50

404
❂ J0690 Injection, cefezolin sodium, 500 mg N1 N

Other: Ancef, Kefzol, Zolicef

IOM: 100-02, 15, 50
Injection, cefepime HCL, 500 mg N1 N
✽ J0692
Other: Maxipime
Injection, cefoxitin sodium, 1 gm N1 N
❂ J0694
Other: Mefoxin
IOM: 100-02, 15, 50,
Cross Reference Q0090
Injection, ceftolozane 50 mg and tazobactam25 mg K2 K
✽ J0695
Other: Zerbaxa
Injection, ceftriaxone sodium, per 250 mg N1 N
❂ J0696
Other: Rocephin
IOM: 100-02, 15, 50
Injection, sterile cefuroxime sodium, per 750 mg N1 N
❂ J0697
Other: Kefurox, Zinacef
IOM: 100-02, 15, 50
Injection, cefotaxime sodium, per gm N1 N
❂ J0698
Other: Claforan
IOM: 100-02, 15, 50
❂ J0702 Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg
N1 N

Other: Betameth, Celestone Soluspan, Selestoject

IOM: 100-02, 15, 50
Injection, caffeine citrate, 5 mg N1 N
✽ J0706
Other: Cafcit, Cipro IV, Ciprofloxacin
Injection, cephapirin sodium, up to 1 gm E2
❂ J0710
Other: Cefadyl
IOM: 100-02, 15, 50
Injection, ceftaroline fosamil, 10 mg K2 K
✽ J0712
Other: Teflaro
Coding Clinic: 2012, Q1, P9
Injection, ceftazidime, per 500 mg N1 N
❂ J0713
Other: Fortaz, Tazicef
IOM: 100-02, 15, 50
Injection, ceftazidime and avibactam, 0.5 g/0.125 g K2 K
✽ J0714
Injection, ceftizoxime sodium, per 500 mg N1 N
❂ J0715
IOM: 100-02, 15, 50
Injection, centruroides immune F(ab)2, up to 120 milligrams K2 K
✽ J0716
Other: Anascorp
✽ J0717 Injection, certolizumab pegol, 1 mg (code may be used for Medicare when drug
administered under the direct supervision of a physician, not for use when drug is self-
administered) K2 K

Other: Cimzia
Injection, chloramphenicol sodium succinate, up to 1 gm N1 N
❂ J0720
Other: Chloromycetin Sodium Succinate
IOM: 100-02, 15, 50
Injection, chorionic gonadotropin, per 1,000 USP units N1 N
❂ J0725
Other: A.P.L., Chorex-5, Chorex-10, Chorignon, Choron-10, Chorionic Gonadotropin, Choron

405
 10, Corgonject-5, Follutein, Glukor, Gonic, Novarel, Pregnyl, Profasi HP
IOM: 100-02, 15, 50
Injection, clonidine hydrochloride (HCL), 1 mg N1 N
❂ J0735
Other: Duraclon
IOM: 100-02, 15, 50
Injection, cidofovir, 375 mg K2 K
❂ J0740
Other: Vistide
IOM: 100-02, 15, 50
Injection, cilastatin sodium; imipenem, per 250 mg N1 N
❂ J0743
Other: Primaxin
IOM: 100-02, 15, 50
Injection, ciprofloxacin for intravenous infusion, 200 mg N1 N
✽ J0744
Injection, codeine phosphate, per 30 mg N1 N
❂ J0745
IOM: 100-02, 15, 50
Injection, colistimethate sodium, up to 150 mg N1 N
❂ J0770
Other: Coly-Mycin M
IOM: 100-02, 15, 50
Injection, collagenase, clostridium histolyticum, 0.01 mg K2 K
✽ J0775
Other: Xiaflex
Coding Clinic: 2011, Q1, P7
Injection, prochlorperazine, up to 10 mg N1 N
❂ J0780
Other: Compa-Z, Compazine, Cotranzine, Ultrazine-10
IOM: 100-02, 15, 50
Injection, corticorelin ovine triflutate, 1 mcg K2 K
❂ J0795
Other: Acthrel
IOM: 100-02, 15, 50
Injection, corticotropin, up to 40 units K2 K
❂ J0800
Other: ACTH, Acthar
IOM: 100-02, 15, 50
J0833 Injection, cosyntropin, not otherwise specified, 0.25 mg ✖
Injection, cosyntropin, 0.25 mg N1 N
✽ J0834
Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram K2 K
✽ J0840
Other: Crofab
Coding Clinic: 2012, Q1, P9
Injection, crotalidae immune f(ab’)2 (equine), 120 mg K
▶ ✽ J0841
Other: Anavip
❂ J0850 Injection, cytomegalovirus immune globulin intravenous (human), per vial
Prophylaxis to prevent cytomegalovirus disease associated with transplantation of K2 K

kidney, lung, liver, pancreas, and heart.

Other: Cytogam
IOM: 100-02, 15, 50

406
 Injection, dalbavancin, 5 mg K2 K
✽ J0875
Other: Dalvance
Injection, daptomycin, 1 mg K2 K
✽ J0878
Other: Cubicin
Injection, darbepoetin alfa, 1 mcg (non-ESRD use) K2 K
❂ J0881
Other: Aranesp
Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis) K2 K
❂ J0882
Other: Aranesp
IOM: 100-02, 6, 10; 100-04, 4, 240
Injection, argatroban, 1 mg (for non-ESRD use) K2 K
❂ J0883
IOM: 100-02, 15, 50
Injection, argatroban, 1 mg (for ESRD on dialysis) K2 K
❂ J0884
IOM: 100-02, 15, 50
Injection, epoetin alfa, (for non-ESRD use), 1000 units K2 K
❂ J0885
Other: Epogen, Procrit
IOM: 100-02, 15, 50
Coding Clinic: 2006, Q2, P5
Injection, epoetin beta, 1 mcg, (for ESRD on dialysis) N1 N
❂ J0887
Other: Mircera
Injection, epoetin beta, 1 mcg, (for non ESRD use) K2 K
❂ J0888
Other: Mircera
Injection, peginesatide, 0.1 mg (for ESRD on dialysis) E1
✽ J0890
Other: Omontys
Injection, decitabine, 1 mg K2 K
✽ J0894
Indicated for treatment of myelodysplastic syndromes (MDS)
Other: Dacogen
Injection, deferoxamine mesylate, 500 mg N1 N
❂ J0895
Other: Desferal, Desferal mesylate
IOM: 100-02, 15, 50,
Cross Reference Q0087
Injection, denosumab, 1 mg K2 K
✽ J0897
Other: Prolia, Xgeva
Coding Clinic: 2016, Q1, P5; 2012, Q1, P9
Injection, brompheniramine maleate, per 10 mg N1 N
❂ J0945
Other: Codimal-A, Cophene-B, Dehist, Histaject, Nasahist B, ND Stat, Oraminic II, Sinusol-B
IOM: 100-02, 15, 50
Injection, depo-estradiol cypionate, up to 5 mg N1 N
❂ J1000
Other: DepGynogen, Depogen, Dura-Estrin, Estra-D, Estro-Cyp, Estroject LA, Estronol-LA
IOM: 100-02, 15, 50
Injection, methylprednisolone acetate, 20 mg N1 N
❂ J1020
Other: DepMedalone, Depoject, Depo-Medrol, Depopred, D-Med 80, Duralone, Medralone, M-
Prednisol, Rep-Pred
IOM: 100-02, 15, 50
Coding Clinic: 2005, Q3, P10
Injection, methylprednisolone acetate, 40 mg N1 N
❂ J1030
Other: DepMedalone, Depoject, Depo-Medrol, Depropred, D-Med 80, Duralone, Medralone, M-
Prednisol, Rep-Pred
IOM: 100-02, 15, 50
Coding Clinic: 2005, Q3, P10
Injection, methylprednisolone acetate, 80 mg N1 N
❂ J1040

407
 Other: DepMedalone, Depoject, Depo-Medrol, Depropred, D-Med 80, Duralone, Medralone, M-
Prednisol, Rep-Pred
IOM: 100-02, 15, 50
Injection, medroxyprogesterone acetate, 1 mg N1 N
✽ J1050
Other: Depo-Provera Contraceptive
Injection, testosterone cypionate, 1 mg N1 N
❂ J1071
Other: Andro-Cyp, Andro/Fem, Andronaq-LA, Andronate, De-Comberol, DepAndro,
DepAndrogyn, Depotest, Depo-Testadiol, Depo-Testosterone, Depotestrogen, Duratest, Duratestrin,
Menoject LA, Testa-C, Testadiate-Depo, Testaject-LA, Test-Estro Cypionates, Testoject-LA,
Coding Clinic: 2015, Q2, P7
Injection, dexamethasone acetate, 1 mg N1 N
❂ J1094
Other: Dalalone LA, Decadron LA, Decaject LA, Dexacen-LA-8, Dexasone L.A., Dexone-LA,
Solurex LA
IOM: 100-02, 15, 50
▶ ❂ J1095 Injection, dexamethasone 9%
Injection, dexamethasone sodium phosphate, 1 mg N1 N
❂ J1100
Other: Dalalone, Decadron Phosphate, Decaject, Dexacen-4, Dexone, Hexadrol Phosphate, Solurex
IOM: 100-02, 15, 50
Injection, dihydroergotamine mesylate, per 1 mg K2 K
❂ J1110
Other: D.H.E. 45
IOM: 100-02, 15, 50
Injection, acetazolamide sodium, up to 500 mg N1 N
❂ J1120
Other: Diamox
IOM: 100-02, 15, 50
Injection, diclofenac sodium, 0.5 mg K2 K
✽ J1130
Coding Clinic: 2017, Q1, P9
Injection, digoxin, up to 0.5 mg N1 N
❂ J1160
Other: Lanoxin
IOM: 100-02, 15, 50
Injection, digoxin immune Fab (ovine), per vial K2 K
❂ J1162
Other: DigiFab
IOM: 100-02, 15, 50
Injection, phenytoin sodium, per 50 mg N1 N
❂ J1165
Other: Dilantin
IOM: 100-02, 15, 50
Injection, hydromorphone, up to 4 mg N1 N
❂ J1170
Other: Dilaudid
IOM: 100-02, 15, 50
Injection, dyphylline, up to 500 mg E2
❂ J1180
Other: Dilor, Lufyllin
IOM: 100-02, 15, 50
Injection, dexrazoxane hydrochloride, per 250 mg K2 K
❂ J1190
Other: Totect, Zinecard
IOM: 100-02, 15, 50
Injection, diphenhydramine HCL, up to 50 mg N1 N
❂ J1200
Other: Bena-D, Benadryl, Benahist, Ben-Allergin, Benoject, Chlorothiazide sodium, Dihydrex,
Diphenacen-50, Hyrexin-50, Nordryl, Wehdryl
IOM: 100-02, 15, 50
Injection, chlorothiazide sodium, per 500 mg N1 N
❂ J1205
Other: Diuril

408
 IOM: 100-02, 15, 50
Injection, DMSO, dimethyl sulfoxide, 50%, 50 ml K2 K
❂ J1212
Other: Rimso-50
IOM: 100-02, 15, 50; 100-03, 4, 230.12
Injection, methadone HCL, up to 10 mg N1 N
❂ J1230
Other: Dolophine HCl
MCM: 2049
IOM: 100-02, 15, 50
Injection, dimenhydrinate, up to 50 mg N1 N
❂ J1240
Other: Dinate, Dommanate, Dramamine, Dramanate, Dramilin, Dramocen, Dramoject, Dymenate,
Hydrate, Marmine, Wehamine
IOM: 100-02, 15, 50
Injection, dipyridamole, per 10 mg N1 N
❂ J1245
Other: Persantine
IOM: 100-04, 15, 50; 100-04, 12, 30.6
Injection, dobutamine HCL, per 250 mg N1 N
❂ J1250
Other: Dobutrex
IOM: 100-02, 15, 50
Injection, dolasetron mesylate, 10 mg N1 N
❂ J1260
Other: Anzemet
IOM: 100-02, 15, 50
Injection, dopamine HCL, 40 mg N1 N
✽ J1265
Injection, doripenem, 10 mg N1 N
✽ J1267
Other: Donbax, Doribax
Injection, doxercalciferol, 1 mcg N1 N
✽ J1270
Other: Hectorol
Injection, ecallantide, 1 mg K2 K
✽ J1290
Other: Kalbitor
Coding Clinic: 2011, Q1, P7
Injection, eculizumab, 10 mg K2 K
✽ J1300
Other: Soliris
Injection, edaravone, 1 mg G
▶ ✽ J1301
Other: Radicava
Injection, amitriptyline HCL, up to 20 mg N1 N
❂ J1320
Other: Elavil, Enovil
IOM: 100-02, 15, 50
Injection, elosulfase alfa, 1 mg K2 K
✽ J1322
Injection, enfuvirtide, 1 mg E2
✽ J1324
Injection, epoprostenol, 0.5 mg N1 N
❂ J1325
Other: Flolan, Veletri
IOM: 100-02, 15, 50
Injection, eptifibatide, 5 mg K2 K
❂ J1327
Other: Integrilin
IOM: 100-02, 15, 50
Injection, ergonovine maleate, up to 0.2 mg N1 N
❂ J1330
Benefit limited to obstetrical diagnosis
IOM: 100-02, 15, 50
Injection, ertapenem sodium, 500 mg N1 N
✽ J1335
Other: Invanz

409
 ❂ J1364 Injection, erythromycin lactobionate, per 500 mg K2 K

IOM: 100-02, 15, 50

Injection, estradiol valerate, up to 10 mg N1 N
❂ J1380
Other: Delestrogen, Dioval, Duragen, Estra-L, Gynogen L.A., L.A.E. 20, Valergen
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8
Injection, estrogen conjugated, per 25 mg K2 K
❂ J1410
Other: Premarin
IOM: 100-02, 15, 50
Injection, eteplirsen, 10 mg K2 G
✽ J1428
Injection, ethanolamine oleate, 100 mg K2 K
❂ J1430
Other: Ethamolin
IOM: 100-02, 15, 50
Injection, estrone, per 1 mg E2
❂ J1435
Other: Estronol, Kestrone 5, Theelin Aqueous
IOM: 100-02, 15, 50
Injection, etidronate disodium, per 300 mg E1
❂ J1436
Other: Didronel
IOM: 100-02, 15, 50
❂ J1438 Injection, etanercept, 25 mg (Code may be used for Medicare when drug administered under
the direct supervision of a physician, not for use when drug is selfadministered.)
Other: Enbrel K2 K

IOM: 100-02, 15, 50

Injection, ferric carboxymaltose, 1 mg K2 K
✽ J1439
Other: Injectafer
Injection, filgrastim (G-CSF), excludes biosimilars, 1 mcg K2 K
❂ J1442
Other: Neupogen
Injection, ferric pyrophosphate citrate solution, 0.1 mg of iron N1 N
✽ J1443
Injection, TBO-filgrastim, 1 mcg K2 K
❂ J1447
Other: GRANIX
IOM: 100-02, 15, 50
Injection, fluconazole, 200 mg N1 N
❂ J1450
Other: Diflucan
IOM: 100-02, 15, 50
Injection, fomepizole, 15 mg K2 K
❂ J1451
IOM: 100-02, 15, 50
Injection, fomivirsen sodium, intraocular, 1.65 mg E2
❂ J1452
IOM: 100-02, 15, 50
Injection, fosaprepitant, 1 mg K2 K
✽ J1453
Prevents chemotherapy-induced nausea and vomiting
Other: Emend
Injection, fosnetupitant 235 mg and palonosetron 0.25 mg G
▶ ✽ J1454
Other: Akynzeo and Aloxi
Injection, foscarnet sodium, per 1000 mg K2 K
❂ J1455
Other: Foscavir
IOM: 100-02, 15, 50
Injection, gallium nitrate, 1 mg E2
✽ J1457
Injection, galsulfase, 1 mg K2 K
✽ J1458
Other: Naglazyme

410
✽ J1459 Injection, immune globulin (Privigen), intravenous, non-lyophilized (e.g., liquid), 500 mg
K2 K

Injection, gamma globulin, intramuscular, 1 cc K2 K

❂ J1460
Other: Gammar, GamaSTAN
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8
Injection, immune globulin (cuvitru), 100 mg K2 K
✽ J1555
Injection, immune globulin (Bivigam), 500 mg K2 K
✽ J1556
✽ J1557 Injection, immune globulin, (gammaplex), intravenous, non-lyophilized (e.g., liquid), 500 mg
K2 K
Coding Clinic: 2012, Q1, P9
Injection, immune globulin (hizentra), 100 mg K2 K
✽ J1559
Coding Clinic: 2011, Q1, P6
Injection, gamma globulin, intramuscular, over 10 cc K2 K
❂ J1560
Other: Gammar, GamaSTAN
IOM: 100-02, 15, 50
❂ J1561 Injection, immune globulin, (Gamunex-C/Gammaked), non-lyophilized (e.g., liquid), 500 mg
K2 K

IOM: 100-02, 15, 50

Coding Clinic: 2012, Q1, P9
Injection, immune globulin (Vivaglobin), 100 mg E2
✽ J1562
❂ J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified,
500 mg K2 K

Other: Carimune, Gammagard S/D, Polygam

IOM: 100-02, 15, 50
✽ J1568 Injection, immune globulin, (Octagam), intravenous, non-lyophilized (e.g., liquid), 500 mg
K2 K

❂ J1569 Injection, immune globulin, (Gammagard Liquid), non-lyophilized (e.g., liquid), 500 mg
K2 K

IOM: 100-02, 15, 50

Injection, ganciclovir sodium, 500 mg N1 N
❂ J1570
Other: Cytovene
IOM: 100-02, 15, 50
❂ J1571 Injection, hepatitis B immune globulin (HepaGam B), intramuscular, 0.5 ml
IOM: 100-02, 15, 50 K2 K
Coding Clinic: 2008, Q3, P7-8

❂ J1572 Injection, immune globulin, (flebogamma/flebogamma DIF) intravenous, non-lyophilized

(e.g., liquid), 500 mg K2 K

IOM: 100-02, 15, 50

Injection, hepatitis B immune globulin (HepaGam B), intravenous, 0.5 ml K2 K
✽ J1573
Coding Clinic: 2008, Q3, P8

✽ J1575 Injection, immune globulin/hyaluronidase (HYQVIA), 100 mg immunoglobulin

K2 K
Injection, Garamycin, gentamicin, up to 80 mg N1 N
❂ J1580
Other: Gentamicin Sulfate, Jenamicin
IOM: 100-02, 15, 50
Injection, glatiramer acetate, 20 mg K2 K
❂ J1595
Other: Copaxone
IOM: 100-02, 15, 50
✽ J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g., liquid), not otherwise specified,
500 mg N1 N

411
 Coding Clinic: 2011, P1, Q6
Injection, gold sodium thiomalate, up to 50 mg E2
❂ J1600
Other: Myochrysine
IOM: 100-02, 15, 50
Injection, golimumab, 1 mg, for intravenous use K2 K
✽ J1602
Other: Simponi Aria
Injection, glucagon hydrochloride, per 1 mg K2 K
❂ J1610
Other: GlucaGen, Glucagon Emergency
IOM: 100-02, 15, 50
Injection, gonadorelin hydrochloride, per 100 mcg E2
❂ J1620
Other: Factrel
IOM: 100-02, 15, 50
Injection, granisetron hydrochloride, 100 mcg N1 N
❂ J1626
Other: Kytril
IOM: 100-02, 15, 50
Injection, granisetron, extended-release, 0.1 mg K2 G
✽ J1627
Injection, guselkumab, 1 mg G
▶ ✽ J1628
Other: Tremfya
Injection, haloperidol, up to 5 mg N1 N
❂ J1630
Other: Haldol, Haloperidol Lactate
IOM: 100-02, 15, 50
Injection, haloperidol decanoate, per 50 mg N1 N
❂ J1631
IOM: 100-02, 15, 50
Injection, hemin, 1 mg K2 K
❂ J1640
Other: Panhematin
IOM: 100-02, 15, 50
Injection, heparin sodium, (heparin lock flush), per 10 units N1 N
❂ J1642
Other: Hep-Lock U/P, Vasceze
IOM: 100-02, 15, 50
Injection, heparin sodium, per 1000 units N1 N
❂ J1644
Other: Heparin Sodium (Porcine), Liquaemin Sodium
IOM: 100-02, 15, 50
Injection, dalteparin sodium, per 2500 IU N1 N
❂ J1645
Other: Fragmin
IOM: 100-02, 15, 50
Injection, enoxaparin sodium, 10 mg N1 N
✽ J1650
Other: Lovenox
Injection, fondaparinux sodium, 0.5 mg N1 N
❂ J1652
Other: Arixtra
IOM: 100-02, 15, 50
Injection, tinzaparin sodium, 1000 IU N1 N
✽ J1655
Other: Innohep
Injection, tetanus immune globulin, human, up to 250 units K2 K
❂ J1670
Indicated for transient protection against tetanus post-exposure to tetanus (Z23).
Other: Hyper-Tet
IOM: 100-02, 15, 50
Injection, histrelin acetate, 10 mcg B
❂ J1675
IOM: 100-02, 15, 50
Injection, hydrocortisone acetate, up to 25 mg N1 N
❂ J1700

412
 Other: Hydrocortone Acetate
IOM: 100-02, 15, 50
Injection, hydrocortisone sodium phosphate, up to 50 mg N1 N
❂ J1710
Other: A-hydroCort, Hydrocortone phosphate, Solu-Cortef
IOM: 100-02, 15, 50
Injection, hydrocortisone sodium succinate, up to 100 mg N1 N
❂ J1720
Other: A-HydroCort, Solu-Cortef
IOM: 100-02, 15, 50
Injection, hydroxyprogesterone caproate (makena), 10 mg K2 K
✽ J1726
Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg N1 N
✽ J1729
Injection, diazoxide, up to 300 mg E2
❂ J1730
Other: Hyperstat
IOM: 100-02, 15, 50
Injection, ibandronate sodium, 1 mg K2 K
✽ J1740
Other: Boniva
Injection, ibuprofen, 100 mg N1 N
✽ J1741
Other: Caldolor
Injection, ibutilide fumarate, 1 mg K2 K
❂ J1742
Other: Corvert
IOM: 100-02, 15, 50
Injection, idursulfase, 1 mg K2 K
✽ J1743
Other: Elaprase
Injection, icatibant, 1 mg K2 K
✽ J1744
Other: Firazyr
Injection, infliximab, excludes biosimilar, 10 mg K2 K
❂ J1745
Report total number of 10 mg increments administered For biosimilar, Inflectra, report Q5102
Other: Remicade
IOM: 100-02, 15, 50
Injection, ibalizumab-uiyk, 10 mg K
▶ ✽ J1746
Other: Trogarzo
Injection, iron dextran, 50 mg K2 K
❂ J1750
Other: Dexferrum, Imferon, Infed
IOM: 100-02, 15, 50
Injection, iron sucrose, 1 mg N1 N
✽ J1756
Other: Venofer
Injection, imiglucerase, 10 units K2 K
❂ J1786
Other: Cerezyme
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8
Injection, droperidol, up to 5 mg N1 N
❂ J1790
Other: Inapsine
IOM: 100-02, 15, 50
Injection, propranolol HCL, up to 1 mg N1 N
❂ J1800
Other: Inderal
IOM: 100-02, 15, 50
Injection, droperidol and fentanyl citrate, up to 2 ml ampule E1
❂ J1810
Other: Innovar
IOM: 100-02, 15, 50
Injection, insulin, per 5 units N1 N
❂ J1815

413
 Other: Humalog, Humulin, Lantus, Novolin, Novolog
IOM: 100-02, 15, 50; 100-03, 4, 280.14
Insulin for administration through DME (i.e., insulin pump) per 50 units N1 N
✽ J1817
Other: Apidra Solostar, Insulin Lispro, Humalog, Humulin, Novolin, Novolog
Injection, interferon beta-1a, 30 mcg K2 K
✽ J1826
Other: Avonex
Coding Clinic: 2011, Q2, P9; Q1, P8
❂ J1830 Injection, interferon beta-1b, 0.25 mg (Code may be used for Medicare when drug
administered under the direct supervision of a physician, not for use when drug is self-
administered) K2 K

Other: Betaseron
IOM: 100-02, 15, 50
Injection, isavuconazonium, 1 mg K2 K
✽ J1833
Injection, itraconazole, 50 mg E2
✽ J1835
Other: Sporanox
Injection, kanamycin sulfate, up to 500 mg N1 N
❂ J1840
Other: Kantrex, Klebcil
IOM: 100-02, 15, 50
Injection, kanamycin sulfate, up to 75 mg N1 N
❂ J1850
Other: Kantrex, Klebcil
IOM: 100-02, 15, 50
Coding Clinic: 2013: Q2, P3
Injection, ketorolac tromethamine, per 15 mg N1 N
❂ J1885
Other: Toradol
IOM: 100-02, 15, 50
Injection, cephalothin sodium, up to 1 gram N1 N
❂ J1890
Other: Keflin
IOM: 100-02, 15, 50
Injection, lanreotide, 1 mg K2 K
✽ J1930
Treats acromegaly and symptoms caused by neuroendocrine tumors
Other: Somatuline Depot
Injection, laronidase, 0.1 mg K2 K
✽ J1931
Other: Aldurazyme
Injection, furosemide, up to 20 mg N1 N
❂ J1940
Other: Furomide M.D., Lasix
MCM: 2049
IOM: 100-02, 15, 50
Injection, aripiprazole lauroxil, 1 mg K2 G
✽ J1942
Other: Aristada
Injection, lepirudin, 50 mg E2
❂ J1945
IOM: 100-02, 15, 50
Injection, leuprolide acetate (for depot suspension), per 3.75 mg K2 K
❂ J1950
Other: Lupron, Lupron Depot, Lupron Depot-Ped
IOM: 100-02, 15, 50
Injection, levetiracetam, 10 mg N1 N
✽ J1953
Other: Keppra
Injection, levocarnitine, per 1 gm B
❂ J1955
Other: Carnitor
IOM: 100-02, 15, 50

414
 ❂ J1956 Injection, levofloxacin, 250 mg N1 N

Other: Levaquin
IOM: 100-02, 15, 50
Injection, levorphanol tartrate, up to 2 mg N1 N
❂ J1960
Other: Levo-Dromoran
MCM: 2049
IOM: 100-02, 15, 50
Injection, hyoscyamine sulfate, up to 0.25 mg N1 N
❂ J1980
Other: Levsin
IOM: 100-02, 15, 50
Injection, chlordiazepoxide HCL, up to 100 mg N1 N
❂ J1990
Other: Librium
IOM: 100-02, 15, 50
Injection, lidocaine HCL for intravenous infusion, 10 mg N1 N
❂ J2001
Other: Caine-1, Caine-2, Dilocaine, L-Caine, Lidocaine in D5W, Lidoject, Nervocaine, Nulicaine,
Xylocaine
IOM: 100-02, 15, 50
Injection, lincomycin HCL, up to 300 mg N1 N
❂ J2010
Other: Lincocin
IOM: 100-02, 15, 50
Injection, linezolid, 200 mg N1 N
✽ J2020
Other: Zyvox
Injection, lorazepam, 2 mg N1 N
❂ J2060
Other: Ativan
IOM: 100-02, 15, 50
Loxapine for inhalation, 1 mg K
▶ ✽ J2062
Other: Adasuve
Injection, mannitol, 25% in 50 ml N1 N
❂ J2150
Other: Aridol
MCM: 2049
IOM: 100-02, 15, 50
Injection, mecasermin, 1 mg N1 N
✽ J2170
Other: Increlex
Injection, meperidine hydrochloride, per 100 mg N1 N
❂ J2175
Other: Demerol
IOM: 100-02, 15, 50
Injection, meperidine and promethazine HCL, up to 50 mg N1 N
❂ J2180
Other: Mepergan
IOM: 100-02, 15, 50
Injection, mepolizumab, 1 mg K2 G
✽ J2182
Injection, meropenem, 100 mg N1 N
✽ J2185
Other: Merrem
Inj., meropenem, vaborbactam G
▶ ✽ J2186
Other: Vabomere
Medicare Statute 1833(t)
Injection, methylergonovine maleate, up to 0.2 mg N1 N
❂ J2210
Benefit limited to obstetrical diagnoses for prevention and control of postpartum hemorrhage
Other: Methergine
IOM: 100-02, 15, 50

415
✽ J2212 Injection, methylnaltrexone, 0.1 mg N1 N

Other: Relistor
Injection, micafungin sodium, 1 mg N1 N
✽ J2248
Other: Mycamine
Injection, midazolam hydrochloride, per 1 mg N1 N
❂ J2250
Other: Versed
IOM: 100-02, 15, 50
Injection, milrinone lactate, 5 mg N1 N
❂ J2260
Other: Primacor
IOM: 100-02, 15, 50
Injection, minocycline hydrochloride, 1 mg K2 K
✽ J2265
Other: Minocine
Injection, morphine sulfate, up to 10 mg N1 N
❂ J2270
Other: Astramorph PF, Duramorph
IOM: 100-02, 15, 50
Coding Clinic: 2013, Q2, P4

❂ J2274 Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg

N1 N
Other: Duramorph, Infumorph
IOM: 100-03, 4, 280.1; 100-02, 15, 50
Injection, ziconotide, 1 mcg K2 K
❂ J2278
Other: Prialt
Injection, moxifloxacin, 100 mg N1 N
✽ J2280
Other: Avelox
Injection, nalbuphine hydrochloride, per 10 mg N1 N
❂ J2300
Other: Nubain
IOM: 100-02, 15, 50
Injection, naloxone hydrochloride, per 1 mg N1 N
❂ J2310
Other: Narcan
IOM: 100-02, 15, 50
Injection, naltrexone, depot form, 1 mg K2 K
✽ J2315
Other: Vivitrol
Injection, nandrolone decanoate, up to 50 mg K2 K
❂ J2320
Other: Anabolin LA 100, Androlone, Deca-Durabolin, Decolone, Hybolin Decanoate, Nandrobolic
LA, Neo-Durabolic
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8
Injection, natalizumab, 1 mg K2 K
✽ J2323
Other: Tysabri
Injection, nesiritide, 0.1 mg K2 K
❂ J2325
Other: Natrecor
IOM: 100-02, 15, 50
Injection, nusinersen, 0.1 mg K2 G
✽ J2326
Injection, ocrelizumab, 1 mg K2 G
✽ J2350
Injection, octreotide, depot form for intramuscular injection, 1 mg K2 K
✽ J2353
Other: Sandostatin LAR Depot
✽ J2354 Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg
N1 N

Other: Sandostatin LAR Depot

416
❂ J2355 Injection, oprelvekin, 5 mg K2 K

Other: Neumega
IOM: 100-02, 15, 50
Injection, omalizumab, 5 mg K2 K
✽ J2357
Other: Xolair
Injection, olanzapine, long-acting, 1 mg N1 N
✽ J2358
Other: Zyprexa Relprevv
Coding Clinic: 2011, Q1, P6
Injection, orphenadrine citrate, up to 60 mg N1 N
❂ J2360
Other: Antiflex, Banflex, Flexoject, Flexon, K-Flex, Myolin, Neocyten, Norflex, O-Flex, Orphenate
IOM: 100-02, 15, 50
Injection, phenylephrine HCL, up to 1 ml N1 N
❂ J2370
Other: Neo-Synephrine
IOM: 100-02, 15, 50
Injection, chloroprocaine hydrochloride, per 30 ml N1 N
❂ J2400
Other: Nesacaine, Nesacaine-MPF
IOM: 100-02, 15, 50
Injection, ondansetron hydrochloride, per 1 mg N1 N
❂ J2405
Other: Zofran
IOM: 100-02, 15, 50
Injection, oritavancin, 10 mg K2 K
❂ J2407
Other: Orbactiv
IOM: 100-02, 15, 50
Injection, oxymorphone HCL, up to 1 mg N1 N
❂ J2410
Other: Numorphan, Opana
IOM: 100-02, 15, 50
Injection, palifermin, 50 mcg K2 K
✽ J2425
Other: Kepivance
Injection, paliperidone palmitate extended release, 1 mg K2 K
✽ J2426
Other: Invega Sustenna
Coding Clinic: 2011, Q1, P7
Injection, pamidronate disodium, per 30 mg N1 N
❂ J2430
Other: Aredia
IOM: 100-02, 15, 50
Injection, papaverine HCL, up to 60 mg N1 N
❂ J2440
IOM: 100-02, 15, 50
Injection, oxytetracycline HCL, up to 50 mg E2
❂ J2460
Other: Terramycin IM
IOM: 100-02, 15, 50
Injection, palonosetron HCL, 25 mcg K2 K
✽ J2469
Example: 0.25 mgm dose = 10 units Example of use is acute, delayed, nausea and vomiting due
to chemotherapy
Other: Aloxi
Injection, paricalcitol, 1 mcg N1 N
❂ J2501
Other: Zemplar
IOM: 100-02, 15, 50
Injection, pasireotide long acting, 1 mg K2 K
✽ J2502
Other: Signifor LAR
Injection, pegaptanib sodium, 0.3 mg K2 K
✽ J2503
Other: Macugen

417
❂ J2504 Injection, pegademase bovine, 25 IU K2 K

Other: Adagen
IOM: 100-02, 15, 50
Injection, pegfilgrastim, 6 mg K2 K
✽ J2505
Report 1 unit per 6 mg.
Other: Neulasta
Injection, pegloticase, 1 mg K2 K
✽ J2507
Other: Krystexxa
Coding Clinic: 2012, Q1, P9
Injection, penicillin G procaine, aqueous, up to 600,000 units N1 N
❂ J2510
Other: Crysticillin, Duracillin AS, Pfizerpen AS, Wycillin
IOM: 100-02, 15, 50
Injection, pentastarch, 10% solution, 100 ml E2
❂ J2513
IOM: 100-02, 15, 50
Injection, pentobarbital sodium, per 50 mg K2 K
❂ J2515
Other: Nembutal sodium solution
IOM: 100-02, 15, 50
Injection, penicillin G potassium, up to 600,000 units N1 N
❂ J2540
Other: Pfizerpen-G
IOM: 100-02, 15, 50
❂ J2543 Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams)
N1 N
Other: Zosyn
IOM: 100-02, 15, 50
❂ J2545 Pentamidine isethionate, inhalation solution, FDA-approved final product, non-compounded,
administered through DME, unit dose form, per 300 mg B

Other: Nebupent
Injection, peramivir, 1 mg K2 K
✽ J2547
Injection, promethazine HCL, up to 50 mg N1 N
❂ J2550
Administration of phenergan suppository considered part of E/M encounter
Other: Anergan, Phenazine, Phenergan, Prorex, Prothazine, V-Gan
IOM: 100-02, 15, 50
Injection, phenobarbital sodium, up to 120 mg N1 N
❂ J2560
Other: Luminal Sodium
IOM: 100-02, 15, 50
Injection, plerixafor, 1 mg K2 K
✽ J2562
FDA approved for non-Hodgkin lymphoma and multiple myeloma in 2008.
Other: Mozobil
Injection, oxytocin, up to 10 units N1 N
❂ J2590
Other: Pitocin, Syntocinon
IOM: 100-02, 15, 50
Injection, desmopressin acetate, per 1 mcg K2 K
❂ J2597
Other: DDAVP
IOM: 100-02, 15, 50
Injection, prednisolone acetate, up to 1 ml N1 N
❂ J2650
Other: Key-Pred, Predalone, Predcor, Predicort, Predoject
IOM: 100-02, 15, 50
Injection, tolazoline HCL, up to 25 mg N1 N
❂ J2670
Other: Priscoline HCl
IOM: 100-02, 15, 50

418
❂ J2675 Injection, progesterone, per 50 mg N1 N

Other: Gesterol 50, Progestaject

IOM: 100-02, 15, 50
Injection, fluphenazine decanoate, up to 25 mg N1 N
❂ J2680
Other: Prolixin Decanoate
MCM: 2049
IOM: 100-02, 15, 50
N1 N
❂ J2690 Injection, procainamide HCL, up to 1 gm ♀
Benefit limited to obstetrical diagnoses
Other: Pronestyl, Prostaphlin
IOM: 100-02, 15, 50
Injection, oxacillin sodium, up to 250 mg N1 N
❂ J2700
Other: Bactocill
IOM: 100-02, 15, 50
Injection, propofol, 10 mg N1 N
✽ J2704
Other: Diprivan
Injection, neostigmine methylsulfate, up to 0.5 mg N1 N
❂ J2710
Other: Prostigmin
IOM: 100-02, 15, 50
Injection, protamine sulfate, per 10 mg N1 N
❂ J2720
IOM: 100-02, 15, 50
Injection, protein C concentrate, intravenous, human, 10 IU K2 K
✽ J2724
Other: Ceprotin
Injection, protirelin, per 250 mcg E2
❂ J2725
Other: Relefact TRH, Thypinone
IOM: 100-02, 15, 50
Injection, pralidoxime chloride, up to 1 gm N1 N
❂ J2730
Other: Protopam Chloride
IOM: 100-02, 15, 50
Injection, phentolamine mesylate, up to 5 mg K2 K
❂ J2760
Other: Regitine
IOM: 100-02, 15, 50
Injection, metoclopramide HCL, up to 10 mg N1 N
❂ J2765
Other: Reglan
IOM: 100-02, 15, 50
Injection, quinupristin/dalfopristin, 500 mg (150/350) K2 K
❂ J2770
Other: Synercid
IOM: 100-02, 15, 50
Injection, ranibizumab, 0.1 mg K2 K
✽ J2778
May be reported for exudative senile macular degeneration (wet AMD) with 67028 (RT or
LT)
Other: Lucentis
Injection, ranitidine hydrochloride, 25 mg N1 N
❂ J2780
Other: Zantac
IOM: 100-02, 15, 50
Injection, rasburicase, 0.5 mg K2 K
✽ J2783
Other: Elitek
Injection, regadenoson, 0.1 mg N1 N
✽ J2785
One billing unit equal to 0.1 mg of regadenoson

419
 Other: Lexiscan
Injection, reslizumab, 1 mg K2 G
✽ J2786
Coding Clinic: 2016, Q4, P9
▶ ✽ J2787 Riboflavin 5’-phosphate, ophthalmic solution, up to 3 mL
Other: Photrexa Viscous
Injection, Rho D immune globulin, human, minidose, 50 mcg (250 IU) N1 N
❂ J2788
Other: HypRho-D, MicRhoGAM, Rhesonativ, RhoGam
IOM: 100-02, 15, 50
Injection, Rho D immune globulin, human, full dose, 300 mcg (1500 IU) N1 N
❂ J2790
Administered to pregnant female to prevent hemolistic disease of newborn. Report 90384 to
private payer
Other: Gamulin Rh, Hyperrho S/D, HypRho-D, Rhesonativ, RhoGAM
IOM: 100-02, 15, 50
❂ J2791 Injection, Rho(D) immune globulin (human), (Rhophylac), intramuscular or intravenous, 100
IU N1 N

Agent must be billed per 100 IU in both physician office and hospital outpatient settings
Other: HypRho-D
IOM: 100-02, 15, 50
❂ J2792 Injection, Rho D immune globulin intravenous, human, solvent detergent, 100 IU
Other: Gamulin Rh, Hyperrho S/D, WinRHo-SDF K2 K

IOM: 100-02, 15, 50

Injection, rilonacept, 1 mg K2 K
❂ J2793
Other: Arcalyst
IOM: 100-02, 15, 50
Injection, risperidone, long acting, 0.5 mg K2 K
✽ J2794
Other: Risperdal Costa
Injection, ropivacaine hydrochloride, 1 mg N1 N
✽ J2795
Other: Naropin
Injection, romiplostim, 10 mcg K2 K
✽ J2796
Stimulates bone marrow megakarocytes to produce platelets (i.e., ITP)
Other: Nplate
Injection, rolapitant, 0.5 mg G
▶ ❂ J2797
Other: Varubi
Injection, methocarbamol, up to 10 ml N1 N
❂ J2800
Other: Robaxin
IOM: 100-02, 15, 50
Injection, sincalide, 5 mcg N1 N
✽ J2805
Other: Kinevac
Injection, theophylline, per 40 mg N1 N
❂ J2810
IOM: 100-02, 15, 50
Injection, sargramostim (GM-CSF), 50 mcg K2 K
❂ J2820
Other: Leukine, Prokine
IOM: 100-02, 15, 50
Injection, sebelipase alfa, 1 mg K2 G
✽ J2840
Injection, secretin, synthetic, human, 1 mcg K2 K
❂ J2850
Other: Chirhostim
IOM: 100-02, 15, 50
Injection, siltuximab, 10 mg K2 K
✽ J2860
Injection, aurothioglucose, up to 50 mg E2
❂ J2910

420
 Other: Solganal
IOM: 100-02, 15, 50
Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg N1 N
❂ J2916
Other: Ferrlecit, Nulecit
IOM: 100-02, 15, 50
Injection, methylprednisolone sodium succinate, up to 40 mg N1 N
❂ J2920
Other: A-MethaPred, Solu-Medrol
IOM: 100-02, 15, 50
Injection, methylprednisolone sodium succinate, up to 125 mg N1 N
❂ J2930
Other: A-MethaPred, Solu-Medrol
IOM: 100-02, 15, 50
Injection, somatrem, 1 mg E2
❂ J2940
IOM: 100-02, 15, 50,
Medicare Statute 1861s2b
Injection, somatropin, 1 mg K2 K
❂ J2941
Other: Genotropin, Humatrope, Nutropin, Omnitrope, Saizen, Serostim, Zorbtive
IOM: 100-02, 15, 50,
Medicare Statute 1861s2b
Injection, promazine HCL, up to 25 mg N1 N
❂ J2950
Other: Prozine-50, Sparine
IOM: 100-02, 15, 50
Injection, reteplase, 18.1 mg K2 K
❂ J2993
Other: Retavase
IOM: 100-02, 15, 50
Injection, streptokinase, per 250,000 IU N1 N
❂ J2995
Bill 1 unit for each 250,000 IU
Other: Kabikinase, Streptase
IOM: 100-02, 15, 50
Injection, alteplase recombinant, 1 mg K2 K
❂ J2997
Thrombolytic agent, treatment of occluded catheters. Bill units of 1 mg administered.
Other: Activase, Cathflo Activase
IOM: 100-02, 15, 50
Coding Clinic: 2014, Q1, P4
Injection, streptomycin, up to 1 gm N1 N
❂ J3000
IOM: 100-02, 15, 50
Injection, fentanyl citrate, 0.1 mg N1 N
❂ J3010
Other: Sublimaze
IOM: 100-02, 15, 50
❂ J3030 Injection, sumatriptan succinate, 6 mg (Code may be used for Medicare when drug
administered under the direct supervision of a physician, not for use when drug is self-
administered) N1 N

Other: Imitrex, Sumarel Dosepro

IOM: 100-02, 15, 150
Injection, taliglucerase alfa, 10 units K2 K
✽ J3060
Other: Elelyso
Injection, pentazocine, 30 mg K2 K
❂ J3070
Other: Talwin
IOM: 100-02, 15, 50
Injection, tedizolid phosphate, 1 mg K2 K
✽ J3090
Other: Sivextro

421
 ✽ J3095 Injection, televancin, 10 mg K2 K

Prescribed for the treatment of adults with complicated skin and skin structure infections
(cSSSI) of the following Gram-positive microorganisms: Staphylococcus aureus; Streptococcus
pyogenes, Streptococcus agalactiae, Streptococcus anginosusgroup. Separately payable under
the ASC payment system.
Other: Vibativ
Coding Clinic: 2011, Q1, P7
Injection, tenecteplase, 1 mg K2 K
✽ J3101
Other: TNKase
Injection, terbutaline sulfate, up to 1 mg N1 N
❂ J3105
Other: Brethine
IOM: 100-02, 15, 50
Injection, teriparatide, 10 mcg B
❂ J3110
Injection, testosterone enanthate, 1 mg N1 N
❂ J3121
Other: Andrest 90-4, Andro L.A. 200, Andro-Estro 90-4, Androgyn L.A, Andropository 100, Andryl
200, Deladumone, Deladumone OB, Delatest, Delatestadiol, Delatestryl, Ditate-DS, Dua-Gen
L.A., Duoval P.A., Durathate-200, Estra-Testrin, Everone, TEEV, Testadiate, Testone LA,
Testradiol 90/4, Testrin PA, Valertest
Injection, testosterone undecanoate, 1 mg K2 K
❂ J3145
Injection, chlorpromazine HCL, up to 50 mg N1 N
❂ J3230
Other: Ormazine, Thorazine
IOM: 100-02, 15, 50
Injection, thyrotropin alfa, 0.9 mg provided in 1.1 mg vial K2 K
❂ J3240
Other: Thyrogen
IOM: 100-02, 15, 50
Injection, tigecycline, 1 mg K2 K
✽ J3243
Injection, tildrakizumab, 1 mg E2
▶ ✽ J3245
Other: Ilumya
Injection, tirofiban HCL, 0.25 mg K2 K
✽ J3246
Other: Aggrastat
Injection, trimethobenzamide HCL, up to 200 mg N1 N
❂ J3250
Other: Arrestin, Ticon, Tigan, Tiject 20
IOM: 100-02, 15, 50
Injection, tobramycin sulfate, up to 80 mg N1 N
❂ J3260
Other: Nebcin
IOM: 100-02, 15, 50
Injection, tocilizumab, 1 mg K2 K
✽ J3262
Indicated for the treatment of adult patients with moderately to severely active rheumatoid
arthritis (RA) who have had an inadequate response to one or more tumor necrosis factor
(TNF) antagonist therapies.
Other: Actemra
Coding Clinic: 2011, Q1, P7
Injection, torsemide, 10 mg/ml N1 N
❂ J3265
Other: Demadex
IOM: 100-02, 15, 50
Injection, thiethylperazine maleate, up to 10 mg E2
❂ J3280
Other: Norzine, Torecan
IOM: 100-02, 15, 50
Injection, treprostinil, 1 mg K2 K
✽ J3285
Other: Remodulin

422
 ❂ J3300 Injection, triamcinolone acetonide, preservative free, 1 mg K2 K

Other: Cenacort A-40, Kenaject-40, Kenalog, Triam-A, Triesence, Tri-Kort, Trilog

Injection, triamcinolone acetonide, not otherwise specified, 10 mg N1 N
❂ J3301
Other: Cenacort A-40, Kenaject-40, Kenalog, Triam A, Triesence, Tri-Kort, Trilog
IOM: 100-02, 15, 50
Coding Clinic: 2013, Q2, P4
Injection, triamcinolone diacetate, per 5 mg N1 N
❂ J3302
Other: Amcort, Aristocort, Cenacort Forte, Trilone
IOM: 100-02, 15, 50
Injection, triamcinolone hexacetonide, per 5 mg N1 N
❂ J3303
Other: Aristospan
IOM: 100-02, 15, 50
▶ ❂ J3304 Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere
formulation, 1 mg G
Other: Zilretta
Injection, trimetrexate glucuronate, per 25 mg E2
❂ J3305
Other: NeuTrexin
IOM: 100-02, 15, 50
Injection, perphenazine, up to 5 mg N1 N
❂ J3310
Other: Trilafon
IOM: 100-02, 15, 50
Injection, triptorelin pamoate, 3.75 mg K2 K
❂ J3315
Other: Trelstar
IOM: 100-02, 15, 50
Injection, triptorelin, extended-release, 3.75 mg G
▶ ❂ J3316
Other: Trelstar, Trelstar Depot, Trelstar LA
Injection, spectinomycin dihydrochloride, up to 2 gm E2
❂ J3320
Other: Trobicin
IOM: 100-02, 15, 50
Injection, urea, up to 40 gm N1 N
❂ J3350
Other: Ureaphil
IOM: 100-02, 15, 50
Injection, urofollitropin, 75 IU E2
❂ J3355
Other: Bravelle, Metrodin
IOM: 100-02, 15, 50
Ustekinumab, for subcutaneous injection, 1 mg K2 K
✽ J3357
Other: Stelara
Coding Clinic: 2017, Q1, P3; 2016, Q4, P10; 2011, Q1, P7
Ustekinumab, for intravenous injection, 1 mg K2 G
✽ J3358
Cross Reference Q9989
Injection, diazepam, up to 5 mg N1 N
❂ J3360
Other: Valium, Zetran
IOM: 100-02, 15, 50
Coding Clinic: 2007, Q2, P6-7
Injection, urokinase, 5000 IU vial N1 N
❂ J3364
Other: Abbokinase
IOM: 100-02, 15, 50
Injection, IV, urokinase, 250,000 IU vial E2
❂ J3365
Other: Abbokinase
IOM: 100-02, 15, 50,

423
 Cross Reference Q0089
Injection, vancomycin HCL, 500 mg N1 N
❂ J3370
Other: Vancocin, Vancoled
IOM: 100-02, 15, 50; 100-03, 4, 280.14
Injection, vedolizumab, 1 mg K2 K
❂ J3380
Other: Entyvio
Injection, velaglucerase alfa, 100 units K2 K
✽ J3385
Enzyme replacement therapy in Gaucher Disease that results from a specific enzyme deficiency
in the body, caused by a genetic mutation received from both parents. Type 1 is the most
prevalent Ashkenazi Jewish genetic disease, occurring in one in every 1,000.
Other: VPRIV
Coding Clinic: 2011, Q1, P7
Injection, verteporfin, 0.1 mg K2 K
❂ J3396
Other: Visudyne
IOM: 100-03, 1, 80.2; 100-03, 1, 80.3
Injection, vestronidase alfa-vjbk, 1 mg K
▶ ✽ J3397
Other: Mepsevii
Injection, voretigene neparvovec-rzyl, 1 billion vector genomes G
▶ ✽ J3398
Other: Luxturna
Injection, triflupromazine HCL, up to 20 mg E2
❂ J3400
Other: Vesprin
IOM: 100-02, 15, 50
Injection, hydroxyzine HCL, up to 25 mg N1 N
❂ J3410
Other: Hyzine-50, Vistaject 25, Vistaril
IOM: 100-02, 15, 50
Injection, thiamine HCL, 100 mg N1 N
✽ J3411
Injection, pyridoxine HCL, 100 mg N1 N
✽ J3415
Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg N1 N
❂ J3420
Medicare carriers may have local coverage decisions regarding vitamin B12 injections that
provide reimbursement only for patients with certain types of anemia and other conditions.
Other: Berubigen, Betalin 12, Cobex, Redisol, Rubramin PC, Sytobex
IOM: 100-02, 15, 50; 100-03, 2, 150.6
Injection, phytonadione (vitamin K), per 1 mg N1 N
❂ J3430
Other: AquaMephyton, Konakion, Menadione, Synkavite, Vitamin K1
IOM: 100-02, 15, 50
Injection, voriconazole, 10 mg K2 K
❂ J3465
Other: VFEND
IOM: 100-02, 15, 50
Injection, hyaluronidase, up to 150 units N1 N
❂ J3470
Other: Amphadase, Wydase
IOM: 100-02, 15, 50
❂ J3471 Injection, hyaluronidase, ovine, preservative free, per 1 USP unit (up to 999 USP units)
N1 N

Other: Vitrase
Injection, hyaluronidase, ovine, preservative free, per 1000 USP units N1 N
❂ J3472
Injection, hyaluronidase, recombinant, 1 USP unit N1 N
❂ J3473
Other: Hylenex
IOM: 100-02, 15, 50
Injection, magnesium sulfate, per 500 mg N1 N
❂ J3475

424
 IOM: 100-02, 15, 50
Injection, potassium chloride, per 2 meq N1 N
❂ J3480
IOM: 100-02, 15, 50
Injection, zidovudine, 10 mg N1 N
❂ J3485
Other: Retrovir
IOM: 100-02, 15, 50
Injection, ziprasidone mesylate, 10 mg N1 N
✽ J3486
Other: Geodon
Injection, zoledronic acid, 1 mg N1 N
✽ J3489
Other: Reclast, Zometra
Unclassified drugs N1 N
❂ J3490
Bill on paper. Bill one unit. Identify drug and total dosage in “Remarks” field.
Other: Acthib, Aminocaproic Acid, Baciim, Bacitracin, Benzocaine, Bumetanide, Bupivacaine,
Cefotetan, Ciprofloxacin, Cleocin Phosphate, Clindamycin, Cortisone Acetate Micronized, Definity,
Diprivan, Doxy, Engerix-B, Ethanolamine, Famotidine, Ganirelix, Gonal-F, Hyaluronic Acid,
Marcaine, Metronidazole, Nafcillin, Naltrexone, Ovidrel, Pegasys, Peg-Intron, Penicillin G Sodium,
Propofol, Protonix, Recombivax, Rifadin, Rifampin, Sensorcaine-MPF, Smz-TMP, Sufentanil
Citrate, Testopel Pellets, Testosterone, Treanda, Valcyte, Veritas Collagen Matrix
IOM: 100-02, 15, 50
Coding Clinic: 2017, Q1, P1-3, P8; 2014, Q2, P6; 2013, Q2, P3-4
Edetate disodium, per 150 mg E1
H J3520
Other: Chealamide, Disotate, Endrate ethylenediamine-tetra-acetic
IOM: 100-03, 1, 20.21; 100-03, 1, 20.22
Nasal vaccine inhalation N1 N
❂ J3530
IOM: 100-02, 15, 50
Drug administered through a metered dose inhaler E1
H J3535
Other: Ipratropium bromide
IOM: 100-02, 15, 50
Laetrile, amygdalin, vitamin B-17 E1
H J3570
IOM: 100-03, 1, 30.7
Unclassified biologics N1 N
✽ J3590
Bill on paper. Bill one unit. Identify drug and total dosage in “Remarks” field.
Coding Clinic: 2017, Q1, P1-3; 2016, Q4, P10
Unclassified drug or biological used for ESRD on dialysis B
▶ ✽ J3591
Infusion, normal saline solution, 1000 cc N1 N
❂ J7030
Other: Sodium Chloride
IOM: 100-02, 15, 50
Infusion, normal saline solution, sterile (500 ml = 1 unit) N1 N
❂ J7040
Other: Sodium Chloride
IOM: 100-02, 15, 50
5% dextrose/normal saline (500 ml = 1 unit) N1 N
❂ J7042
Other: Dextrose-Nacl
IOM: 100-02, 15, 50
Infusion, normal saline solution, 250 cc N1 N
❂ J7050
Other: Sodium Chloride
IOM: 100-02, 15, 50
5% dextrose/water (500 ml = 1 unit) N1 N
❂ J7060
IOM: 100-02, 15, 50
Infusion, D 5 W, 1000 cc N1 N
❂ J7070
Other: Dextrose

425
 IOM: 100-02, 15, 50
Infusion, dextran 40, 500 ml N1 N
❂ J7100
Other: Gentran, LMD, Rheomacrodex
IOM: 100-02, 15, 50
Infusion, dextran 75, 500 ml N1 N
❂ J7110
Other: Gentran 75
IOM: 100-02, 15, 50
Ringer’s lactate infusion, up to 1000 cc N1 N
❂ J7120
Replacement fluid or electrolytes.
Other: Potassium Chloride
IOM: 100-02, 15, 50
5% dextrose in lactated ringers infusion, up to 1000 cc N1 N
❂ J7121
IOM: 100-02, 15, 50
Hypertonic saline solution, 1 ml N1 N
❂ J7131
IOM: 100-02, 15, 50
Coding Clinic: 2012, Q1, P9

Clotting Factors
Injection, emicizumab-kxwh, 0.5 mg G
▶ ✽ J7170
Other: Hemlibra
Injection, Factor X, (human), 1 IU K2 K
✽ J7175
Coding Clinic: 2017, Q1, P9
Injection, human fibrinogen concentrate (fibryga), 1 mg K
▶ ✽ J7177
Injection, human fibrinogen concentrate, not otherwise specified, 1 mg K2 K
✽ J7178
Other: Riastap
Injection, von Willebrand factor (recombinant), (vonvendi), 1 IU VWF:RCo K2 G
❂ J7179
Coding Clinic: 2017, Q1, P9
Injection, factor XIII (antihemophilic factor, human), 1 IU K2 K
✽ J7180
Other: Corifact
Coding Clinic: 2012, Q1, P8
Injection, factor XIII a-subunit, (recombinant), per IU K2 K
✽ J7181
✽ J7182 Injection, factor VIII, (antihemophilic factor, recombinant), (novoeight), per IU
K2 K
Injection, von Willebrand factor complex (human), wilate, 1 IU VWF:RCo K2 K
❂ J7183
IOM: 100-02, 15, 50
Coding Clinic: 2012, Q1, P9
Injection, Factor VIII (antihemophilic factor, recombinant) (Xyntha), per IU K2 K
✽ J7185
❂ J7186 Injection, anti-hemophilic factor VIII/von Willebrand factor complex (human), per factor VIII
IU K2 K

Other: Alphanate
IOM: 100-02, 15, 50
Injection, von Willebrand factor complex (HUMATE-P), per IU VWF:RCo K2 K
❂ J7187
Other: Humate-P Low Dilutent
IOM: 100-02, 15, 50
Injection, factor VIII (antihemophilic factor, recombinant), (obizur), per IU K2 K
❂ J7188
IOM: 100-02, 15, 50
Factor VIIa (anti-hemophilic factor, recombinant), per 1 mcg K2 K
❂ J7189
Other: NovoSeven
IOM: 100-02, 15, 50
Factor VIII anti-hemophilic factor, human, per IU K2 K
❂ J7190

426
 Other: Alphanate/von Willebrand factor complex, Hemofil M, Koate DVI, Koate-HP, Kogenate,
Monoclate-P, Recombinate
IOM: 100-02, 15, 50
Factor VIII, anti-hemophilic factor (porcine), per IU E2
❂ J7191
Other: Hyate:C, Koate-HP, Kogenate, Monoclate-P, Recombinate
IOM: 100-02, 15, 50
❂ J7192 Factor VIII (anti-hemophilic factor, recombinant) per IU, not otherwise specified
Other: Advate, Helixate FS, Kogenate FS, Koate-HP, Recombinate, Xyntha K2 K

IOM: 100-02, 15, 50

Factor IX (anti-hemophilic factor, purified, non-recombinant) per IU K2 K
❂ J7193
Other: AlphaNine SD, Mononine, Proplex
IOM: 100-02, 15, 50
Factor IX, complex, per IU K2 K
❂ J7194
Other: Bebulin, Konyne-80, Profilnine Heat-treated, Profilnine SD, Proplex SXT, Proplex T
IOM: 100-02, 15, 50
❂ J7195 Injection, Factor IX (anti-hemophilic factor, recombinant) per IU, not otherwise specified
K2 K

Other: Benefix, Profiline, Proplex T

IOM: 100-02, 15, 50
Injection, antithrombin recombinant, 50 IU E2
✽ J7196
Other: ATryn, Feiba VH Immuno
Coding Clinic: 2011, Q1, P6
Anti-thrombin III (human), per IU K2 K
❂ J7197
Other: Thrombate III
IOM: 100-02, 15, 50
Anti-inhibitor, per IU K2 K
❂ J7198
Diagnosis examples: D66 Congenital Factor VIII disorder; D67 Congenital Factor IX
disorder; D68.0 VonWillebrand’s disease
Other: Autoplex T, Feiba NF, Hemophilia clotting factors
IOM: 100-02, 15, 50; 100-03, 2, 110.3
Hemophilia clotting factor, not otherwise classified B
❂ J7199
Other: Autoplex T
IOM: 100-02, 15, 50; 100-03, 2, 110.3
Injection, factor IX, (antihemophilic factor, recombinant), rixubis, per IU K2 K
❂ J7200
IOM: 100-02, 15, 50
Injection, factor IX, fc fusion protein (recombinant), alprolix, 1 IU K2 K
❂ J7201
IOM: 100-02, 15, 50
Injection, Factor IX, albumin fusion protein, (recombinant), idelvion, 1 IU K2 G
❂ J7202
Coding Clinic: 2016, Q4, P9
Injection factor ix, (antihemophilic factor, recombinant), glycopegylated, (rebinyn), 1 iu G
▶ ❂ J7203
Other: Profilnine SD, Bebulin VH, Bebulin, Proplex T
Injection, factor VIII Fc fusion protein (recombinant), per IU K2 K
❂ J7205
Other: Eloctate
Injection, Factor VIII, (antihemophilic factor, recombinant), PEGylated, 1 IU K2 G
❂ J7207
Other: Adynovate
Injection, Factor VIII, (antihemophilic factor, recombinant), (Nuwiq), 1 IU K2 G
✽ J7209

427
428
 Injection, Factor VIII, (antihemophilic factor, recombinant), (afstyla), 1 i.u. K2 G
✽ J7210
Injection, Factor VIII, (antihemophilic factor, recombinant), (kovaltry), 1 i.u. K2 K
✽ J7211

Contraceptives
Levonorgestrel-releasing intrauterine contraceptive system, (kyleena), 19.5 mg E1
H J7296
Medicare Statute 1862(a)(1)
Cross Reference Q9984
Levonorgestrel-releasing intrauterine contraceptive system (liletta), 52 mg E1
H J7297
Medicare Statute 1862(a)(1)
Levonorgestrel-releasing intrauterine contraceptive system (mirena), 52 mg E1
H J7298
Medicare Statute 1862(a)(1)
Intrauterine copper contraceptive E1
H J7300
Report IUD insertion with 58300. Bill usual and customary charge.
Other: Paragard T 380 A
Medicare Statute 1862a1
Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg E1
H J7301
Medicare Statute 1862(a)(1)
E1
H J7303 Contraceptive supply, hormone containing vaginal ring, each ♀
Medicare Statute 1862.1
E1
H J7304 Contraceptive supply, hormone containing patch, each ♀
Only billed by Family Planning Clinics
Medicare Statute 1862.1
Levonorgestrel (contraceptive) implant system, including implants and supplies E1
H J7306
Etonogestrel (contraceptive) implant system, including implant and supplies E1
H J7307

Aminolevulinic Acid HCL

✽ J7308 Aminolevulinic acid HCL for topical administration, 20%, single unit dosage form (354 mg)
K2 K

Other: Levulan Kerastick

Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 gram N1 N
❂ J7309
Other: Metvixia
Coding Clinic: 2011, Q1, P6

Ganciclovir
Ganciclovir, 4.5 mg, long-acting implant E2
❂ J7310
IOM: 100-02, 15, 50

Ophthalmic Drugs
Fluocinolone acetonide, intravitreal implant K2 K
✽ J7311
Treatment of chronic noninfectious posterior segment uveitis
Other: Retisert
Injection, dexamethasone, intravitreal implant, 0.1 mg K2 K
✽ J7312
To bill for Ozurdex services submit the following codes: J7312 and 67028 with the modifier
-22 (for the increased work difficulty and increased risk). Indicated for the treatment of
macular edema occurring after branch retinal vein occlusion (BRVO) or central retinal vein
occlusion (CRVO) and noninfectious uveitis affecting the posterior segment of the eye.
Other: Ozurdex
Coding Clinic: 2011, Q1, P7
Injection, fluocinolone acetonide, intravitreal implant, 0.01 mg K2 K
✽ J7313

429
 Other: Iluvien
Mitomycin, ophthalmic, 0.2 mg N1 N
✽ J7315
Other: Mitosol, Mutamycin
Coding Clinic: 2016, Q4, P8; 2014, Q2, P6
Injection, ocriplasmin, 0.125 mg K2 K
✽ J7316
Other: Jetrea

Hyaluronan
Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg G
▶ ✽ J7318
Other: Morisu
Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg K2 K
✽ J7320
✽ J7321 Hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection, per dose
K2 K

Therapeutic goal is to restore viscoelasticity of synovial hyaluronan, thereby decreasing pain,

improving mobility and restoring natural protective functions of hyaluronan in joint
Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg K2 G
✽ J7322
Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose K2 K
✽ J7323
Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose K2 K
✽ J7324
✽ J7325 Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg
K2 K
Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose K2 K
✽ J7326
Coding Clinic: 2012, Q1, P8
Hyaluronan or derivative, monovisc, for intra-articular injection, per dose K2 K
✽ J7327
Hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg K2 G
✽ J7328
Hyaluronan or derivative, trivisc, for intra-articular injection, 1 mg E2
▶ ✽ J7329

Miscellaneous Drugs
Autologous cultured chondrocytes, implant B
✽ J7330
Other: Carticel
Coding Clinic: 2010, Q4, P3
Capsaicin 8% patch, per square centimeter K2 K
✽ J7336
Other: Qutenza
Carbidopa 5 mg/levodopa 20 mg enteral suspension, 100 ml K2 K
✽ J7340
Other: Duopa
Instillation, ciprofloxacin otic suspension, 6 mg K2 G
✽ J7342
Aminolevulinic acid hcl for topical administration, 10% gel, 10 mg K2 G
❂ J7345

Immunosuppressive Drugs (Includes Non-injectibles)

Azathioprine, oral, 50 mg N1 N
❂ J7500
Other: Azasan, Imuran
IOM: 100-02, 15, 50
Azathioprine, parenteral, 100 mg K2 K
❂ J7501
Other: Imuran
IOM: 100-02, 15, 50
Cyclosporine, oral, 100 mg N1 N
❂ J7502
Other: Gengraf, Neoral, Sandimmune
IOM: 100-02, 15, 50
Tacrolimus, extended release, (Envarsus XR), oral, 0.25 mg K2 G
❂ J7503
IOM: 100-02, 15, 50

430
 ❂ J7504 Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg
K2 K
Other: Atgam
IOM: 100-02, 15, 50; 100-03, 2, 110.3
Muromonab-CD3, parenteral, 5 mg K2 K
❂ J7505
Other: Monoclonal antibodies (parenteral)
IOM: 100-02, 15, 50
Tacrolimus, immediate release, oral, 1 mg N1 N
❂ J7507
Other: Prograf
IOM: 100-02, 15, 50
Tacrolimus, extended release, (Astagraf XL), oral, 0.1 mg N1 N
❂ J7508
IOM: 100-02, 15, 50
Methylprednisolone oral, per 4 mg N1 N
❂ J7509
Other: Medrol
IOM: 100-02, 15, 50
Prednisolone oral, per 5 mg N1 N
❂ J7510
Other: Delta-Cortef, Flo-Pred, Orapred
IOM: 100-02, 15, 50
✽ J7511 Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25 mg
Other: Thymoglobulin K2 K

Prednisone, immediate release or delayed release, oral, 1 mg N1 N

❂ J7512
Other: Cyclosporine
IOM: 100-02, 15, 50
Daclizumab, parenteral, 25 mg E2
❂ J7513
Other: Zenapax
IOM: 100-02, 15, 50
Cyclosporine, oral, 25 mg N1 N
✽ J7515
Other: Gengraf, Neoral, Sandimmune
Cyclosporin, parenteral, 250 mg N1 N
✽ J7516
Other: Sandimmune
Mycophenolate mofetil, oral, 250 mg N1 N
✽ J7517
Other: CellCept
Mycophenolic acid, oral, 180 mg N1 N
❂ J7518
Other: Myfortic
IOM: 100-04, 4, 240; 100-4, 17, 80.3.1
Sirolimus, oral, 1 mg N1 N
❂ J7520
Other: Rapamune
IOM: 100-02, 15, 50
Tacrolimus, parenteral, 5 mg K2 K
❂ J7525
Other: Prograf
IOM: 100-02, 15, 50
Everolimus, oral, 0.25 mg N1 N
❂ J7527
Other: Zortress
IOM: 100-02, 15, 50
Immunosuppressive drug, not otherwise classified N1 N
❂ J7599
Bill on paper. Bill one unit. Identify drug and total dosage in “Remarks” field.
IOM: 100-02, 15, 50

Inhalation Solutions

431
✽ J7604 Acetylcysteine, inhalation solution, compounded product, administered through DME, unit
dose form, per gram M

Other: Mucomyst (unit dose form), Mucosol

✽ J7605 Arformoterol, inhalation solution, FDA approved final product, non-compounded,
administered through DME, unit dose form, 15 mcg M

Maintenance treatment of bronchoconstriction in patients with chronic obstructive pulmonary

disease (COPD).
Other: Brovana
✽ J7606 Formoterol fumarate, inhalation solution, FDA approved final product, non-compounded,
administered through DME, unit dose form, 20 mcg M

Other: Perforomist
✽ J7607 Levalbuterol, inhalation solution, compounded product, administered through DME,
concentrated form, 0.5 mg M

❂ J7608 Acetylcysteine, inhalation solution, FDA-approved final product, noncompounded,

administered through DME, unit dose form, per gram M

Other: Mucomyst, Mucosol

✽ J7609 Albuterol, inhalation solution, compounded product, administered through DME, unit dose,
1 mg M

Patient’s home, medications—such as a albuterol when administered through a nebulizer—are

considered DME and are payable under Part B.
Other: Proventil, Ventolin, Xopenex
✽ J7610 Albuterol, inhalation solution, compounded product, administered through DME,
concentrated form, 1 mg M

Other: Proventil, Ventolin, Xopenex

❂ J7611 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered
through DME, concentrated form, 1 mg M

Report once for each milligram administered. For example, 2 mg of concentrated albuterol
(usually diluted with saline), reported with J7611×2.
Other: Proventil, Ventolin, Xopenex
❂ J7612 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded,
administered through DME, concentrated form, 0.5 mg M

Other: Xopenex
❂ J7613 Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered
through DME, unit dose, 1 mg M

Other: Accuneb, Proventil, Ventolin, Xopenex

❂ J7614 Levalbuterol, inhalation solution, FDA-approved final product, non-compounded,
administered through DME, unit dose, 0.5 mg M

Other: Xopenex
✽ J7615 Levalbuterol, inhalation solution, compounded product, administered through DME, unit
dose, 0.5 mg M

❂ J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product,
non-compounded, administered through DME M

Other: DuoNeb
✽ J7622 Beclomethasone, inhalation solution, compounded product, administered through DME, unit
dose form, per mg M

✽ J7624 Betamethasone, inhalation solution, compounded product, administered through DME, unit
dose form, per mg M

✽ J7626 Budesonide inhalation solution, FDA-approved final product, non-compounded,

administered through DME, unit dose form, up to 0.5 mg M

Other: Pulmicort
✽ J7627 Budesonide, inhalation solution, compounded product, administered through DME, unit dose

432
 form, up to 0.5 mg M

Other: Pulmicort Respules

❂ J7628 Bitolterol mesylate, inhalation solution, compounded product, administered through DME,
concentrated form, per milligram M

Other: Tornalate
❂ J7629 Bitolterol mesylate, inhalation solution, compounded product, administered through DME,
unit dose form, per milligram M

Other: Tornalate
❂ J7631 Cromolyn sodium, inhalation solution, FDA-approved final product, non-compounded,
administered through DME, unit dose form, per 10 mg M

Other: Intal
✽ J7632 Cromolyn sodium, inhalation solution, compounded product, administered through DME,
unit dose form, per 10 mg M

Other: Intal
✽ J7633 Budesonide, inhalation solution, FDA-approved final product, non-compounded,
administered through DME, concentrated form, per 0.25 mg M

Other: Pulmicort Respules

✽ J7634 Budesonide, inhalation solution, compounded product, administered through DME,
concentrated form, per 0.25 mg M

Other: Pulmicort Respules

❂ J7635 Atropine, inhalation solution, compounded product, administered through DME,
concentrated form, per milligram M

❂ J7636 Atropine, inhalation solution, compounded product, administered through DME, unit dose
form, per milligram M

❂ J7637 Dexamethasone, inhalation solution, compounded product, administered through DME,

concentrated form, per milligram M

❂ J7638 Dexamethasone, inhalation solution, compounded product, administered through DME, unit
dose form, per milligram M

❂ J7639 Dornase alfa, inhalation solution, FDA-approved final product, non-compounded,

administered through DME, unit dose form, per milligram M

Other: Pulmozyme
✽ J7640 Formoterol, inhalation solution, compounded product, administered through DME, unit dose
form, 12 mcg E1

✽ J7641 Flunisolide, inhalation solution, compounded product, administered through DME, unit dose,
per milligram M

❂ J7642 Glycopyrrolate, inhalation solution, compounded product, administered through DME,

concentrated form, per milligram M

❂ J7643 Glycopyrrolate, inhalation solution, compounded product, administered through DME, unit
dose form, per milligram M

❂ J7644 Ipratropium bromide, inhalation solution, FDA-approved final product, non-compounded,

administered through DME, unit dose form, per milligram M

Other: Atrovent
✽ J7645 Ipratropium bromide, inhalation solution, compounded product, administered through DME,
unit dose form, per milligram M

Other: Atrovent
✽ J7647 Isoetharine HCL, inhalation solution, compounded product, administered through DME,
concentrated form, per milligram M

Other: Bronkosol
❂ J7648 Isoetharine HCL, inhalation solution, FDA-approved final product, noncompounded,
administered through DME, concentrated form, per milligram M

Other: Bronkosol

433
❂ J7649 Isoetharine HCL, inhalation solution, FDA-approved final product, noncompounded,
administered through DME, unit dose form, per milligram M

Other: Bronkosol
✽ J7650 Isoetharine HCL, inhalation solution, compounded product, administered through DME,
unit dose form, per milligram M

Other: Bronkosol
✽ J7657 Isoproterenol HCL, inhalation solution, compounded product, administered through DME,
concentrated form, per milligram M

Other: Isuprel
❂ J7658 Isoproterenol HCL inhalation solution, FDA-approved final product, noncompounded,
administered through DME, concentrated form, per milligram M

Other: Isuprel
❂ J7659 Isoproterenol HCL, inhalation solution, FDA-approved final product, noncompounded,
administered through DME, unit dose form, per milligram M

Other: Isuprel
✽ J7660 Isoproterenol HCL, inhalation solution, compounded product, administered through DME,
unit dose form, per milligram M

Other: Isuprel
Mannitol, administered through an inhaler, 5 mg N1 N
✽ J7665
Other: Aridol
✽ J7667 Metaproterenol sulfate, inhalation solution, compounded product, concentrated form, per 10
mg M

Other: Alupent, Metaprel

❂ J7668 Metaproterenol sulfate, inhalation solution, FDA-approved final product, non-compounded,
administered through DME, concentrated form, per 10 mg M

Other: Alupent, Metaprel

❂ J7669 Metaproterenol sulfate, inhalation solution, FDA-approved final product, non-compounded,
administered through DME, unit dose form, per 10 mg M

Other: Alupent, Metaprel

✽ J7670 Metaproterenol sulfate, inhalation solution, compounded product, administered through
DME, unit dose form, per 10 mg M

Other: Alupent, Metaprel

✽ J7674 Methacholine chloride administered as inhalation solution through a nebulizer, per 1 mg
N1 N

Other: Provocholine
✽ J7676 Pentamidine isethionate, inhalation solution, compounded product, administered through
DME, unit dose form, per 300 mg M

Other: NebuPent, Pentam

❂ J7680 Terbutaline sulfate, inhalation solution, compounded product, administered through DME,
concentrated form, per milligram M

Other: Brethine
❂ J7681 Terbutaline sulfate, inhalation solution, compounded product, administered through DME,
unit dose form, per milligram M

Other: Brethine
❂ J7682 Tobramycin, inhalation solution, FDA-approved final product, non-compounded unit dose
form, administered through DME, per 300 mg M

Other: Bethkis, Kitabis PAK, Tobi

❂ J7683 Triamcinolone, inhalation solution, compounded product, administered through DME,
concentrated form, per milligram M

❂ J7684 Triamcinolone, inhalation solution, compounded product, administered through DME, unit
dose form, per milligram M

434
 Other: Triamcinolone acetonide
✽ J7685 Tobramycin, inhalation solution, compounded product, administered through DME, unit
dose form, per 300 mg M

Other: Tobi
✽ J7686 Treprostinil, inhalation solution, FDA-approved final product, non-compounded,
administered through DME, unit dose form, 1.74 mg M

Other: Tyvaso

Not Otherwise Classified/Specified

NOC drugs, inhalation solution administered through DME M
❂ J7699
Other: Gentamicin Sulfate
NOC drugs, other than inhalation drugs, administered through DME N1 N
❂ J7799
Bill on paper. Bill one unit and identify drug and total dosage in the “Remark” field.
Other: Cuvitru, Epinephrine, Mannitol, Osmitrol, Phenylephrine, Resectisol, Sodium chloride
IOM: 100-02, 15, 110.3
Compounded drug, not otherwise classified N1 N
❂ J7999
Coding Clinic: 2017, Q1, P1-2; 2016, Q4, P8
Antiemetic drug, rectal/suppository, not otherwise specified B
❂ J8498
Other: Compazine, Compro, Phenadoz, Phenergan, Prochlorperazine, Promethazine, Promethegan
Medicare Statute 1861(s)2t
Prescription drug, oral, non chemotherapeutic, NOS E1
H J8499
Other: Acyclovir, Calcitrol, Cromolyn Sodium, OFEV, Valganciclovir HCL, Zovirax
IOM: 100-02, 15, 50
Coding Clinic: 2013, Q2, P4

Oral Anti-Cancer Drugs

Aprepitant, oral, 5 mg K2 K
❂ J8501
Other: Emend
Busulfan; oral, 2 mg N1 N
❂ J8510
Other: Myleran
IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
Cabergoline, oral, 0.25 mg E1
H J8515
IOM: 100-02, 15, 50; 100-04, 4, 240
Capecitabine, oral, 150 mg N1 N
❂ J8520
Other: Xeloda
IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
Capecitabine, oral, 500 mg N1 N
❂ J8521
Other: Xeloda
IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
Cyclophosphamide; oral, 25 mg N1 N
❂ J8530
Other: Cytoxan
IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
Dexamethasone, oral, 0.25 mg N1 N
❂ J8540
Other: Decadron, Dexone, Dexpak, Locort
Medicare Statute 1861(s)2t
Etoposide; oral, 50 mg K2 K
❂ J8560
Other: VePesid
IOM: 100-02, 15, 50; 100-04, 4, 230.1; 100-04, 4, 240; 100-04, 17, 80.1.1
Fludarabine phosphate, oral, 10 mg E2
✽ J8562
Other: Fludara, Oforta

435
 Coding Clinic: 2011, Q1, P9
Gefitinib, oral, 250 mg E2
❂ J8565
Other: Iressa
Antiemetic drug, oral, not otherwise specified N1 N
❂ J8597
Medicare Statute 1861(s)2t
Melphalan; oral, 2 mg N1 N
❂ J8600
Other: Alkeran
IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
Methotrexate; oral, 2.5 mg N1 N
❂ J8610
Other: Rheumatrex, Trexall
IOM: 100-02, 15, 50; 100-04, 4, 240; 100-04, 17, 80.1.1
Nabilone, oral, 1 mg E2
✽ J8650
Netupitant 300 mg and palonosetron 0.5 mg, oral K2 K
❂ J8655
Other: Akynzeo
Coding Clinic: 2015, Q4, P4
Rolapitant, oral, 1 mg K2 K
❂ J8670
Other: Varubi
Temozolomide, oral, 5 mg N1 N
❂ J8700
Other: Temodar
IOM: 100-02, 15, 50; 100-04, 4, 240
Topotecan, oral, 0.25 mg K2 K
✽ J8705
Treatment for ovarian and lung cancers, etc. Report J9350 (Topotecan, 4 mg) for intravenous
version
Other: Hycamtin
Prescription drug, oral, chemotherapeutic, NOS B
❂ J8999
Other: Anastrozole, Arimidex, Aromasin, Droxia, Erivedge, Flutamide, Gleevec, Hydrea,
Hydroxyurea, Leukeran, Matulane, Megestrol Acetate, Mercaptopurine, Nolvadex, Tamoxifen
Citrate
IOM: 100-02, 15, 50; 100-04, 4, 250; 100-04, 17, 80.1.1; 100-04, 17, 80.1.2

CHEMOTHERAPY DRUGS (J9000-J9999)

NOTE: These codes cover the cost of the chemotherapy drug only, not to include the
administration
Injection, doxorubicin hydrochloride, 10 mg N1 N
❂ J9000
Other: Adriamycin, Rubex
IOM: 100-02, 15, 50
Coding Clinic: 2007, Q4, P5
Injection, aldesleukin, per single use vial K2 K
❂ J9015
Other: Proleukin
IOM: 100-02, 15, 50
Injection, arsenic trioxide, 1 mg K2 K
✽ J9017
Other: Trisenox
Injection, asparaginase (Erwinaze), 1,000 IU K2 K
❂ J9019
IOM: 100-02, 15, 50
Injection, asparaginase, not otherwise specified 10,000 units N1 N
❂ J9020
IOM: 100-02, 15, 50
Injection, atezolizumab, 10 mg K2 G
✽ J9022
Injection, avelumab, 10 mg K2 G
✽ J9023
Injection, azacitidine, 1 mg K2 K
✽ J9025

436
 ✽ J9027 Injection, clofarabine, 1 mg K2 K

Other: Clolar
BCG (intravesical), per instillation K2 K
❂ J9031
Other: TheraCys, Tice BCG
IOM: 100-02, 15, 50
Injection, belinostat, 10 mg K2 K
✽ J9032
Other: Beleodaq
Injection, bendamustine HCL (treanda), 1 mg K2 K
✽ J9033
Treatment for form of non-Hodgkin’s lymphoma; standard administration time is as an
intravenous infusion over 30 minutes
Other: Treanda
Injection, bendamustine hcl (bendeka), 1 mg K2 G
✽ J9034
Coding Clinic: 2017, Q1, P10
Injection, bevacizumab, 10 mg K2 K
✽ J9035
For malignant neoplasm of breast, considered J9207.
Other: Avastin
Coding Clinic: 2013, Q3, P9, Q2, P8
Injection, blinatumomab, 1 mcg K2 K
✽ J9039
Other: Blincyto
Injection, bleomycin sulfate, 15 units N1 N
❂ J9040
Other: Blenoxane
IOM: 100-02, 15, 50
Injection, bortezomib (velcade), 0.1 mg K2 K
✽ J9041
Other: Velcade
Injection, brentuximab vedotin, 1 mg K2 K
✽ J9042
Other: Adcetris
Injection, cabazitaxel, 1 mg K2 K
✽ J9043
Other: Jevtana
Coding Clinic: 2012, Q1, P9
Injection, bortezomib, not otherwise specified, 0.1 mg K
▶ ✽ J9044
Other: Velcade
Injection, carboplatin, 50 mg N1 N
❂ J9045
Other: Paraplatin
IOM: 100-02, 15, 50
Injection, carfilzomib, 1 mg K2 K
✽ J9047
Other: Kyprolis
Injection, carmustine, 100 mg K2 K
❂ J9050
Other: BiCNU
IOM: 100-02, 15, 50
Injection, cetuximab, 10 mg K2 K
✽ J9055
Other: Erbitux
Injection, copanlisib, 1 mg G
▶ ✽ J9057
Other: Aliqopa
Injection, cisplatin, powder or solution, 10 mg N1 N
❂ J9060
Other: Plantinol AQ
IOM: 100-02, 15, 50
Coding Clinic: 2013, Q2, P6; 2011, Q1, P8
Injection, cladribine, per 1 mg K2 K
❂ J9065
Other: Leustatin
IOM: 100-02, 15, 50

437
 ❂ J9070 Cyclophosphamide, 100 mg K2 K

Other: Cytoxan, Neosar

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P8-9
Injection, cytarabine liposome, 10 mg K2 K
✽ J9098
Other: DepoCyt
Injection, cytarabine, 100 mg N1 N
❂ J9100
Other: Cytosar-U
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P9
Injection, dactinomycin, 0.5 mg K2 K
❂ J9120
Other: Cosmegen
IOM: 100-02, 15, 50
Dacarbazine, 100 mg N1 N
❂ J9130
Other: DTIC-Dome
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P9
Injection, daratumumab, 10 mg K2 G
❂ J9145
Other: Darzalex
IOM: 100-02, 15, 50
Injection, daunorubicin, 10 mg K2 K
❂ J9150
Other: Cerubidine
IOM: 100-02, 15, 50
Injection, daunorubicin citrate, liposomal formulation, 10 mg E2
❂ J9151
Other: Daunoxome
IOM: 100-02, 15, 50
njection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine G
▶ ✽ J9153
Other: Vyxeos
Injection, degarelix, 1 mg K2 K
✽ J9155
Report 1 unit for every 1 mg.
Other: Firmagon
Injection, denileukin diftitox, 300 mcg E2
✽ J9160
Injection, diethylstilbestrol diphosphate, 250 mg E2
❂ J9165
Other: Stilphostrol
IOM: 100-02, 15, 50
Injection, docetaxel, 1 mg K2 K
❂ J9171
Report 1 unit for every 1 mg.
Other: Docefrez, Taxotere
IOM: 100-02, 15, 50
Coding Clinic: 2012, Q1, P9
Injection, durvalumab, 10 mg G
▶ ✽ J9173
Other: Imfinzi
Injection, Elliott’s B solution, 1 ml N1 N
❂ J9175
IOM: 100-02, 15, 50
Injection, elotuzumab, 1 mg K2 G
✽ J9176
Other: Empliciti
Injection, epirubicin HCL, 2 mg N1 N
✽ J9178
Other: Ellence
Injection, eribulin mesylate, 0.1 mg K2 K
✽ J9179
Other: Halaven

438
❂ J9181 Injection, etoposide, 10 mg N1 N

Other: Etopophos, Toposar

Injection, fludarabine phosphate, 50 mg K2 K
❂ J9185
Other: Fludara
IOM: 100-02, 15, 50
Injection, fluorouracil, 500 mg N1 N
❂ J9190
Other: Adrucil
IOM: 100-02, 15, 50
Injection, floxuridine, 500 mg N1 N
❂ J9200
Other: FUDR
IOM: 100-02, 15, 50
Injection, gemcitabine hydrochloride, 200 mg N1 N
❂ J9201
Other: Gemzar
IOM: 100-02, 15, 50
Goserelin acetate implant, per 3.6 mg K2 K
❂ J9202
Other: Zoladex
IOM: 100-02, 15, 50
Injection, gemtuzumab ozogamicin, 0.1 mg K2 G
✽ J9203
Injection, irinotecan liposome, 1 mg K2 G
❂ J9205
Other: ONIVYDE
IOM: 100-02, 15, 50
Injection, irinotecan, 20 mg N1 N
❂ J9206
Other: Camptosar
IOM: 100-02, 15, 50
Injection, ixabepilone, 1 mg K2 K
✽ J9207
Other: Ixempra Kit
Injection, ifosfamide, 1 gm N1 N
❂ J9208
Other: Ifex
IOM: 100-02, 15, 50
Injection, mesna, 200 mg N1 N
❂ J9209
Other: Mesnex
IOM: 100-02, 15, 50
Injection, idarubicin hydrochloride, 5 mg K2 K
❂ J9211
Other: Idamycin PFS
IOM: 100-02, 15, 50
Injection, interferon alfacon-1, recombinant, 1 mcg N1 N
❂ J9212
Other: Amgen, Infergen
IOM: 100-02, 15, 50
Injection, interferon, alfa-2a, recombinant, 3 million units N1 N
❂ J9213
Other: Roferon-A
IOM: 100-02, 15, 50
Injection, interferon, alfa-2b, recombinant, 1 million units K2 K
❂ J9214
Other: Intron-A
IOM: 100-02, 15, 50
Injection, interferon, alfa-n3 (human leukocyte derived), 250,000 IU E2
❂ J9215
Other: Alferon N
IOM: 100-02, 15, 50
Injection, interferon, gamma-1B, 3 million units K2 K
❂ J9216
Other: Actimmune

439
 IOM: 100-02, 15, 50
Leuprolide acetate (for depot suspension), 7.5 mg K2 K
❂ J9217
Other: Eligard, Lupron Depot
IOM: 100-02, 15, 50
Coding Clinic: 2015, Q3, P3
Leuprolide acetate, per 1 mg K2 K
❂ J9218
Other: Lupron
IOM: 100-02, 15, 50
Coding Clinic: 2015, Q3, P3
Leuprolide acetate implant, 65 mg E2
❂ J9219
Other: Viadur
IOM: 100-02, 15, 50
Histrelin implant (Vantas), 50 mg K2 K
❂ J9225
IOM: 100-02, 15, 50
Histrelin implant (Supprelin LA), 50 mg K2 K
❂ J9226
Other: Vantas
IOM: 100-02, 15, 50
Injection, ipilimumab, 1 mg K2 K
✽ J9228
Other: Yervoy
Coding Clinic: 2012, Q1, P9
Injection, inotuzumab ozogamicin, 0.1 mg G
▶ ✽ J9229
Other: Besponsa
Injection, mechlorethamine hydrochloride, (nitrogen mustard), 10 mg K2 K
❂ J9230
Other: Mustargen
IOM: 100-02, 15, 50
Injection, melphalan hydrochloride, 50 mg K2 K
❂ J9245
Other: Alkeran, Evomela
IOM: 100-02, 15, 50
Methotrexate sodium, 5 mg N1 N
❂ J9250
Other: Folex
IOM: 100-02, 15, 50
Methotrexate sodium, 50 mg N1 N
❂ J9260
Other: Folex
IOM: 100-02, 15, 50
Injection, nelarabine, 50 mg K2 K
✽ J9261
Other: Arranon
Injection, omacetaxine mepesuccinate, 0.01 mg K2 K
✽ J9262
Other: Synribo
Injection, oxaliplatin, 0.5 mg N1 N
✽ J9263
Eloxatin, platinum-based anticancer drug that destroys cancer cells
Other: Eloxatin
Coding Clinic: 2009, Q1, P10
Injection, paclitaxel protein-bound particles, 1 mg K2 K
✽ J9264
Other: Abraxane
Injection, pegaspargase, per single dose vial K2 K
❂ J9266
Other: Oncaspar
IOM: 100-02, 15, 50
Injection, paclitaxel, 1 mg N1 N
❂ J9267
Other: Taxol
Injection, pentostatin, 10 mg K2 K
❂ J9268

440
 Other: Nipent
IOM: 100-02, 15, 50
Injection, plicamycin, 2.5 mg N1 N
❂ J9270
Other: Mithracin
IOM: 100-02, 15, 50
Injection, pembrolizumab, 1 mg K2 K
✽ J9271
Other: Keytruda
Injection, mitomycin, 5 mg K2 K
❂ J9280
Other: Mitosol, Mutamycin
IOM: 100-02, 15, 50
Coding Clinic: 2016, Q4, P8; 2014, Q2, P6; 2011, Q1, P9
Injection, olaratumab, 10 mg K2 G
✽ J9285
Injection, mitoxantrone hydrochloride, per 5 mg K2 K
❂ J9293
Other: Novantrone
IOM: 100-02, 15, 50
Injection, necitumumab, 1 mg K2 G
✽ J9295
Other: Portrazza
Injection, nivolumab, 1 mg K2 K
❂ J9299
Other: Opdivo
Injection, obinutuzumab, 10 mg K2 K
✽ J9301
Other: Gazyva
Injection, ofatumumab, 10 mg K2 K
✽ J9302
Other: Arzerra
Coding Clinic: 2011, Q1, P7
Injection, panitumumab, 10 mg K2 K
✽ J9303
Other: Vectibix
Injection, pemetrexed, 10 mg K2 K
✽ J9305
Other: Alimta
Injection, pertuzumab, 1 mg K2 K
✽ J9306
Other: Perjeta
Injection, pralatrexate, 1 mg K2 K
✽ J9307
Other: Folotyn
Coding Clinic: 2011, Q1, P7
Injection, ramucirumab, 5 mg K2 K
✽ J9308
Other: Cyramza
J9310 Injection, rituximab, 100 mg ✖
Injection, rituximab 10 mg and hyaluronidase G
▶ ❂ J9311
Other: Rituxan
Injection, rituximab, 10 mg K
▶ ❂ J9312
Other: Rituxan
Injection, romidepsin, 1 mg K2 K
✽ J9315
Other: Istodax
Coding Clinic: 2011, Q1, P7
Injection, streptozocin, 1 gram K2 K
❂ J9320
Other: Zanosar
IOM: 100-02, 15, 50
Injection, talimogene laherparepvec, per 1 million plaque forming units K2 G
✽ J9325
Other: Imlygic
Injection, temozolomide, 1 mg K2 K
✽ J9328

441
 Intravenous formulation, not for oral administration
Other: Temodar
Injection, temsirolimus, 1 mg K2 K
✽ J9330
Treatment for advanced renal cell carcinoma; standard administration is intravenous infusion
greater than 30-60 minutes
Other: Torisel
Injection, thiotepa, 15 mg K2 K
❂ J9340
Other: Tepadina, Triethylene thio Phosphoramide/T
IOM: 100-02, 15, 50
Injection, topotecan, 0.1 mg N1 N
✽ J9351
Other: Hycamtin
Coding Clinic: 2011, Q1, P9
Injection, trabectedin, 0.1 mg K2 G
✽ J9352
Other: Yondelis
Injection, ado-trastuzumab emtansine, 1 mg K2 K
✽ J9354
Other: Kadcyla
Injection, trastuzumab, 10 mg K2 K
✽ J9355
Other: Herceptin
Injection, valrubicin, intravesical, 200 mg K2 K
❂ J9357
Other: Valstar
IOM: 100-02, 15, 50
Injection, vinblastine sulfate, 1 mg N1 N
❂ J9360
Other: Alkaban-AQ, Velban, Velsar
IOM: 100-02, 15, 50
Vincristine sulfate, 1 mg N1 N
❂ J9370
Other: Oncovin, Vincasar PFS
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P9
Injection, vincristine sulfate liposome, 1 mg K2 K
✽ J9371
Injection, vinorelbine tartrate, 10 mg N1 N
❂ J9390
Other: Navelbine
IOM: 100-02, 15, 50
Injection, fulvestrant, 25 mg K2 K
✽ J9395
Other: Faslodex
Injection, ziv-aflibercept, 1 mg K2 K
✽ J9400
Other: Zaltrap
Injection, porfimer sodium, 75 mg K2 K
❂ J9600
Other: Photofrin
IOM: 100-02, 15, 50
Not otherwise classified, antineoplastic drugs N1 N
❂ J9999
Bill on paper, bill one unit, and identify drug and total dosage in “Remarks” field. Include
invoice of cost or NDC number in “Remarks” field.
Other: Imlygic, Yondelis
IOM: 100-02, 15, 50; 100-03, 2, 110.2
Coding Clinic: 2017, Q1, P3; 2013, Q2, P3

TEMPORARY CODES ASSIGNED TO DME REGIONAL

CARRIERS (K0000-K9999)
NOTE: This section contains national codes assigned by CMS on a temporary basis and for the

442
exclusive use of the durable medical equipment regional carriers (DMERC).

Wheelchairs and Accessories

Standard wheelchair Y
✽ K0001
Capped rental
Standard hemi (low seat) wheelchair Y
✽ K0002
Capped rental
Lightweight wheelchair Y
✽ K0003
Capped rental
High strength, lightweight wheelchair Y
✽ K0004
Capped rental
Ultralightweight wheelchair Y
✽ K0005
Capped rental. Inexpensive and routinely purchased DME
Heavy duty wheelchair Y
✽ K0006
Capped rental
Extra heavy duty wheelchair Y
✽ K0007
Capped rental
Custom manual wheelchair/base Y
❂ K0008
Other manual wheelchair/base Y
✽ K0009
Not otherwise classified
Standard - weight frame motorized/power wheelchair Y
✽ K0010
Capped rental. Codes K0010-K0014 are not for manual wheelchairs with add-on power
packs. Use the appropriate code for the manual wheelchair base provided (K0001-K0009) and
code K0460.
✽ K0011 Standard - weight frame motorized/power wheelchair with programmable control parameters
for speed adjustment, tremor dampening, acceleration control and braking Y

Capped rental. A patient who requires a power wheelchair usually is totally nonambulatory
and has severe weakness of the upper extremities due to a neurologic or muscular
disease/condition.
Lightweight portable motorized/power wheelchair Y
✽ K0012
Capped rental
Custom motorized/power wheelchair base Y
❂ K0013
Other motorized/power wheelchair base Y
✽ K0014
Capped rental
Detachable, non-adjustable height armrest, replacement only, each Y
✽ K0015
Inexpensive and routinely purchased DME
Detachable, adjustable height armrest, base, replacement only, each Y
✽ K0017
Inexpensive and routinely purchased DME
Detachable, adjustable height armrest, upper portion, replacement only, each Y
✽ K0018
Inexpensive and routinely purchased DME
Arm pad, replacement only, each Y
✽ K0019
Inexpensive and routinely purchased DME
Fixed, adjustable height armrest, pair Y
✽ K0020
Inexpensive and routinely purchased DME
High mount flip-up footrest, each Y
✽ K0037
Inexpensive and routinely purchased DME
Leg strap, each Y
✽ K0038
Inexpensive and routinely purchased DME

443
✽ K0039 Leg strap, H style, each Y

Inexpensive and routinely purchased DME

Adjustable angle footplate, each Y
✽ K0040
Inexpensive and routinely purchased DME
Large size footplate, each Y
✽ K0041
Inexpensive and routinely purchased DME
Standard size footplate, replacement only, each Y
✽ K0042
Inexpensive and routinely purchased DME
Footrest, lower extension tube, replacement only, each Y
✽ K0043
Inexpensive and routinely purchased DME
Footrest, upper hanger bracket, replacement only, each Y
✽ K0044
Inexpensive and routinely purchased DME
Footrest, complete assembly, replacement only, each Y
✽ K0045
Inexpensive and routinely purchased DME
Elevating legrest, lower extension tube, replacement only, each Y
✽ K0046
Inexpensive and routinely purchased DME
Elevating legrest, upper hanger bracket, replacement only, each Y
✽ K0047
Inexpensive and routinely purchased DME
Ratchet assembly, replacement only Y
✽ K0050
Inexpensive and routinely purchased DME
Cam release assembly, footrest or legrests, replacement only, each Y
✽ K0051
Inexpensive and routinely purchased DME
Swing-away, detachable footrests, replacement only, each Y
✽ K0052
Inexpensive and routinely purchased DME
Elevating footrests, articulating (telescoping), each Y
✽ K0053
Inexpensive and routinely purchased DME
✽ K0056 Seat height less than 17” or equal to or greater than 21” for a high strength, lightweight, or
ultralightweight wheelchair Y

Inexpensive and routinely purchased DME

Spoke protectors, each Y
✽ K0065
Inexpensive and routinely purchased DME
✽ K0069 Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each
Y

Inexpensive and routinely purchased DME

✽ K0070 Rear wheel assembly, complete, with pneumatic tire, spokes or molded, replacement only, each
Y

Inexpensive and routinely purchased DME

Front caster assembly, complete, with pneumatic tire, replacement only, each Y
✽ K0071
Caster assembly includes a caster fork (E2396), wheel rim, and tire. Inexpensive and routinely
purchased DME
✽ K0072 Front caster assembly, complete, with semi-pneumatic tire, replacement only, each
Y
Inexpensive and routinely purchased DME
Caster pin lock, each Y
✽ K0073
Inexpensive and routinely purchased DME
Front caster assembly, complete, with solid tire, replacement only, each Y
✽ K0077
Drive belt for power wheelchair, replacement only Y
✽ K0098
Inexpensive and routinely purchased DME
IV hanger, each Y
✽ K0105

444
 Inexpensive and routinely purchased DME
Wheelchair component or accessory, not otherwise specified Y
✽ K0108
Elevating leg rests, pair (for use with capped rental wheelchair base) Y
❂ K0195
Medically necessary replacement items are covered if rollabout chair or transport chair covered
IOM: 100-03, 4, 280.1

Infusion Pump, Supplies, and Batteries

❂ K0455 Infusion pump used for uninterrupted parenteral administration of medication (e.g.,
epoprostenol or treprostinol) Y

An EIP may also be referred to as an external insulin pump, ambulatory pump, or mini-
infuser. CMN/DIF required. Frequent and substantial service DME.
IOM: 100-03, 1, 50.3
Temporary replacement for patient owned equipment being repaired, any type Y
❂ K0462
Only report for maintenance and service for an item for which initial claim was paid. The term
power mobility device (PMD) includes power operated vehicles (POVs) and power
wheelchairs (PWCs). Not Otherwise Classified.
IOM: 100-04, 20, 40.1
❂ K0552 Supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each
Y

Supplies
IOM: 100-03, 1, 50.3
❂ K0553 Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies
and accessories, 1 month supply = 1 unit of service Y

❂ K0554 Receiver (monitor), dedicated, for use with therapeutic glucose continuous monitor system
Y

✽ K0601 Replacement battery for external infusion pump owned by patient, |silver oxide, 1.5 volt, each
Y

Inexpensive and routinely purchased DME

✽ K0602 Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each
Y

Inexpensive and routinely purchased DME

Figure 18 Infusion pump.

✽ K0603 Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each
Y

Inexpensive and routinely purchased DME

✽ K0604 Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each
Y

Inexpensive and routinely purchased DME

✽ K0605 Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each
Y

Inexpensive and routinely purchased DME

445
Defibrillator and Accessories
✽ K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
Y

Capped rental
✽ K0607 Replacement battery for automated external defibrillator, garment type only, each
Inexpensive and routinely purchased DME Y

Replacement garment for use with automated external defibrillator, each Y

✽ K0608
Inexpensive and routinely purchased DME
✽ K0609 Replacement electrodes for use with automated external defibrillator, garment type only, each
Y

Supplies

Miscellaneous
✽ K0669 Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or
no written coding verification from DME PDAC Y
Inexpensive and routinely purchased DME
✽ K0672 Addition to lower extremity orthosis, removable soft interface, all components, replacement
only, each A

Prosthetics/Orthotics
Controlled dose inhalation drug delivery system Y
✽ K0730
Inexpensive and routinely purchased DME
✽ K0733 Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell,
absorbed glassmat) Y

Inexpensive and routinely purchased DME

✽ K0738 Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen
cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and
tubing Y

Oxygen and oxygen equipment

✽ K0739 Repair or nonroutine service for durable medical equipment other than oxygen equipment
requiring the skill of a technician, labor component, per 15 minutes Y

H K0740 Repair or nonroutine service for oxygen equipment requiring the skill of a technician, labor
component, per 15 minutes E1

Suction pump, home model, portable, for use on wounds Y

✽ K0743
✽ K0744 Absorptive wound dressing for use with suction pump, home model, portable, pad size 16
square inches or less A

✽ K0745 Absorptive wound dressing for use with suction pump, home model, portable, pad size more
than 16 square inches but less than or equal to 48 square inches A

✽ K0746 Absorptive wound dressing for use with suction pump, home model, portable, pad size greater
than 48 square inches A

Power Mobility Devices

✽ K0800 Power operated vehicle, group 1 standard, patient weight capacity up to and including 300
pounds Y

Power mobility device (PMD) includes power operated vehicles (POVs) and power
wheelchairs (PWCs). Inexpensive and routinely purchased DME
✽ K0801 Power operated vehicle, group 1 heavy duty, patient weight capacity 301 to 450 pounds
Y

Inexpensive and routinely purchased DME

✽ K0802 Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds
Y

446
 Inexpensive and routinely purchased DME
✽ K0806 Power operated vehicle, group 2 standard, patient weight capacity up to and including 300
pounds Y

Inexpensive and routinely purchased DME

✽ K0807 Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 pounds
Y

Inexpensive and routinely purchased DME

✽ K0808 Power operated vehicle, group 2 very heavy duty, patient weight capacity 451 to 600 pounds
Y

Inexpensive and routinely purchased DME

Power operated vehicle, not otherwise classified Y
✽ K0812
Not Otherwise Classified.
✽ K0813 Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0814 Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and
including 300 pounds Y

Capped rental
✽ K0815 Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to
and including 300 pounds Y

Capped rental
✽ K0816 Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and
including 300 pounds Y

Capped rental
✽ K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up
to and including 300 pounds Y

Capped rental
✽ K0821 Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and
including 300 pounds Y

Capped rental
✽ K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and
including 300 pounds Y

Capped rental
✽ K0823 Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and
including 300 pounds Y

Capped rental
✽ K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to
450 pounds Y

Capped rental
✽ K0825 Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301 to 450
pounds Y

Capped rental
✽ K0826 Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451
to 600 pounds Y

Capped rental
✽ K0827 Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600
pounds Y

Capped rental
✽ K0828 Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601
pounds or more Y

447
 Capped rental
✽ K0829 Power wheelchair, group 2 extra heavy duty, captains chair, patient weight 601 pounds or
more Y

Capped rental
✽ K0830 Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0831 Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to
and including 300 pounds Y

✽ K0835 Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0836 Power wheelchair, group 2 standard, single power option, captains chair, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0837 Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds Y

Capped rental
✽ K0838 Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weight
capacity 301 to 450 pounds Y

Capped rental
✽ K0839 Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient
weight capacity 451 to 600 pounds Y

Capped rental
✽ K0840 Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient
weight capacity 601 pounds or more Y

Capped rental
✽ K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient
weight capacity up to and including 300 pounds Y

Capped rental
✽ K0842 Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0843 Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds Y

Capped rental
✽ K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and
including 300 pounds Y

Capped rental
✽ K0849 Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and
including 300 pounds Y

Capped rental
✽ K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to
450 pounds Y

Capped rental
✽ K0851 Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450
pounds Y

Capped rental
✽ K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451
to 600 pounds Y

Capped rental

448
✽ K0853 Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity 451 to 600
pounds Y

Capped rental
✽ K0854 Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601
pounds or more Y

Capped rental
✽ K0855 Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601
pounds or more Y

Capped rental
✽ K0856 Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0857 Power wheelchair, group 3 standard, single power option, captains chair, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0858 Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient
weight 301 to 450 pounds Y

Capped rental
✽ K0859 Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight
capacity 301 to 450 pounds Y

Capped rental
✽ K0860 Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient
weight capacity 451 to 600 pounds Y

Capped rental
✽ K0861 Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient
weight capacity up to and including 300 pounds Y

Capped rental
✽ K0862 Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds Y

Capped rental
✽ K0863 Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back,
patient weight capacity 451 to 600 pounds Y

Capped rental
✽ K0864 Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back,
patient weight capacity 601 pounds or more Y

Capped rental
✽ K0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and
including 300 pounds Y

Capped rental
✽ K0869 Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and
including 300 pounds Y

Capped rental
✽ K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to
450 pounds Y

Capped rental
✽ K0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451
to 600 pounds Y

Capped rental
✽ K0877 Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight
capacity up to and including 300 pounds Y

Capped rental

449
 ✽ K0878 Power wheelchair, group 4 standard, single power option, captains chair, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds Y

Capped rental
✽ K0880 Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient
weight 451 to 600 pounds Y

Capped rental
✽ K0884 Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient
weight capacity up to and including 300 pounds Y

Capped rental
✽ K0885 Power wheelchair, group 4 standard, multiple power option, captains chair, patient weight
capacity up to and including 300 pounds Y

Capped rental
✽ K0886 Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient
weight capacity 301 to 450 pounds Y

Capped rental
✽ K0890 Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight
capacity up to and including 125 pounds Y

Capped rental
✽ K0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient
weight capacity up to and including 125 pounds Y

Capped rental
Power wheelchair, not otherwise classified Y
✽ K0898
Power mobility device, not coded by DME PDAC or does not meet criteria Y
✽ K0899

Customized DME: Other than Wheelchair

Customized durable medical equipment, other than wheelchair Y
❂ K0900

450
Figure 19 (A) Flexible cervical collar. (B) Adjustable cervical collar.

ORTHOTICS (L0100-L4999)
NOTE: DMEPOS fee schedule https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html

Cervical Orthotics
✽ L0112 Cranial cervical orthosis, congenital torticollis type, with or without soft interface material,
adjustable range of motion joint, custom fabricated A

✽ L0113 Cranial cervical orthosis, torticollis type, with or without joint, with or without soft interface
material, prefabricated, includes fitting and adjustment A

Cervical, flexible, non-adjustable, prefabricated, off-the-shelf (foam collar) A

✽ L0120
Cervical orthoses, including soft and rigid devices may be used as nonoperative management for
cervical trauma
Cervical, flexible, thermoplastic collar, molded to patient A
✽ L0130
Cervical, semi-rigid, adjustable (plastic collar) A
✽ L0140
✽ L0150 Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)
A

✽ L0160 Cervical, semi-rigid, wire frame occipital/mandibular support, prefabricated, off-theshelf

A

Cervical, collar, molded to patient model A

✽ L0170
✽ L0172 Cervical, collar, semi-rigid thermoplastic foam, two-piece, prefabricated, off-theshelf
A

✽ L0174 Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension, prefabricated,
off-the-shelf A

Multiple Post Collar: Cervical

Cervical, multiple post collar, occipital/mandibular supports, adjustable A
✽ L0180
✽ L0190 Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (SOMI,
Guilford, Taylor types) A

✽ L0200 Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic
extension A

451
Thoracic Rib Belt
Thoracic, rib belt, custom fabricated A
✽ L0220

Thoracic-Lumbar-Sacral Orthotics
✽ L0450 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to
reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and
closures, prefabricated, off-theshelf A

Used to immobilize specified area of spine, and is generally worn under clothing
✽ L0452 TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to
reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and
closures, custom fabricated A

Figure 20 Thoracic-Lumbar-Sacral Orthosis (TLSO).

✽ L0454 TLSO flexible, provides trunk support, extends from sacrococcygeal junction to above T-9
vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to
reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and
closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise A

Used to immobilize specified areas of spine; and is generally designed to be worn under clothing;
not specifically designed for patients in wheelchairs
✽ L0455 TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9
vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to
reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and
closures, prefabricated, off-theshelf A

✽ L0456 TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior
apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine,
restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load
on the intervertebral disks, includes straps and closures, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an
individual with expertise A

✽ L0457 TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior
apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine,
restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load
on the intervertebral disks, includes straps and closures, prefabricated, off-theshelf
A
✽ L0458 TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior
extends from the sacrococcygeal junction and terminates just inferior to the scapular spine,
anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion

452
 in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic
and stabilizing closures, includes straps and closures, prefabricated, includes fitting and
adjustment A

To meet Medicare’s definition of body jacket, orthosis has to have rigid plastic shell that circles
trunk with overlapping edges and stabilizing closures, and entire circumference of shell must be
made of same rigid material.
✽ L0460 TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior
extends from the sacrococcygeal junction and terminates just inferior to the scapular spine,
anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk
motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping
plastic and stabilizing closures, includes straps and closures, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an
individual with expertise A

✽ L0462 TLSO, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior
extends from the sacrococcygeal junction and terminates just inferior to the scapular spine,
anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk
motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping
plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and
adjustment A

✽ L0464 TLSO, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior
extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior
extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in
sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and
stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
A

✽ L0466 TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures
and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to
reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an individual with expertise
A

✽ L0467 TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures
and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to
reduce load on intervertebral disks, prefabricated, off-theshelf A

✽ L0468 TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps,
closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength
provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and
coronal planes, produces intracavitary pressure to reduce load on intervertebral disks,
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise A

✽ L0469 TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps,
closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength
provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and
coronal planes, produces intracavitary pressure to reduce load on intervertebral disks,
prefabricated, off-the-shelf A

✽ L0470 TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps,
closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided
by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular
extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides
intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the
frame, prefabricated, includes fitting and adjustment A

✽ L0472 TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis
pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and
lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal,
coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes
fitting and adjustment A

453
✽ L0480 TLSO, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps
and closures, posterior extends from sacrococcygeal junction and terminates just inferior to
scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior
opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved
plaster or CAD-CAM model, custom fabricated A

Figure 21 Thoracic-lumbar-sacral orthosis (TLSO) Jewett flexion control.

✽ L0482 TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and
closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular
spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening,
restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or
CAD-CAM model, custom fabricated A

✽ L0484 TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps
and closures, posterior extends from sacrococcygeal junction and terminates just inferior to
scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is
enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and
transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated
A

✽ L0486 TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and
closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular
spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by
overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes,
includes a carved plaster or CAD-CAM model, custom fabricated A

✽ L0488 TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and
closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular
spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening,
restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes
fitting and adjustment A

✽ L0490 TLSO, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced
anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and
terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid,
anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated,
includes fitting and adjustment A

✽ L0491 TLSO, sagittal-coronal control, modular segmented spinal system, two rigid plastic shells,
posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular
spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk
motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and

454
 stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
A

✽ L0492 TLSO, sagittal-coronal control, modular segmented spinal system, three rigid plastic shells,
posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular
spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk
motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and
stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
A

Sacroilliac Orthotics
✽ L0621 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac
joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-
theshelf A

✽ L0622 Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac
joint, includes straps, closures, may include pendulous abdomen design, custom fabricated
A

Type of custom-fabricated device for which impression of specific body part is made (e.g., by
means of plaster cast, or CAD-CAM [computer-aided design] technology); impression then
used to make specific patient model
✽ L0623 Sacroiliac orthosis, provides pelvicsacral support, with rigid or semi-rigid panels over the sacrum
and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include
pendulous abdomen design, prefabricated, off-theshelf A

✽ L0624 Sacroiliac orthosis, provides pelvicsacral support, with rigid or semi-rigid panels placed over the
sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may
include pendulous abdomen design, custom fabricated A

Custom fitted

Lumbar Orthotics
✽ L0625 Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5
vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes
straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated,
off-theshelf A

✽ L0626 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to
below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs,
includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design,
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise A

✽ L0627 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from
L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral
discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design,
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise A

Lumbar-Sacral Orthotics
✽ L0628 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from
sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the
intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous
abdomen design, prefabricated, off-theshelf A

✽ L0629 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from
sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the
intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous
abdomen design, custom fabricated A

Custom fitted

455
✽ L0630 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from
sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the
intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps,
pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled,
or otherwise customized to fit a specific patient by an individual with expertise A

Figure 22 Lumbar-sacral orthosis.

✽ L0631 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior
extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce
load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps,
pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled,
or otherwise customized to fit a specific patient by an individual with expertise A

✽ L0632 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior
extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce
load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps,
pendulous abdomen design, custom fabricated A

Custom fitted
✽ L0633 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior
extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral
frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes
straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design,
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise A

✽ L0634 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior
extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral
frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes
straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom
fabricated A

Custom fitted
✽ L0635 Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s),
lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction
to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary
pressure to reduce load on intervertebral discs, includes straps, closures, may include padding,
anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment
A

✽ L0636 Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels,
lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction
to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary

456
 pressure to reduce load on intervertebral discs, includes straps, closures, may include padding,
anterior panel, pendulous abdomen design, custom fabricated A

Custom fitted
✽ L0637 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels,
posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid
lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs,
includes straps, closures, may include padding, shoulder straps, pendulous abdomen design,
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise A

✽ L0638 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels,
posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid
lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs,
includes straps, closures, may include padding, shoulder straps, pendulous abdomen design,
custom fabricated A

✽ L0639 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from
sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid,
produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is
provided by overlapping rigid material and stabilizing closures, includes straps, closures, may
include soft interface, pendulous abdomen design, prefabricated item that has been trimmed,
bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with
expertise A

Characterized by rigid plastic shell that encircles trunk with overlapping edges and stabilizing
closures and provides high degree of immobility
✽ L0640 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from
sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid,
produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is
provided by overlapping rigid material and stabilizing closures, includes straps, closures, may
include soft interface, pendulous abdomen design, custom fabricated A

Custom fitted

Lumbar Orthotics
✽ L0641 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to
below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs,
includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design,
prefabricated, off-theshelf A

✽ L0642 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from
L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral
discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design,
prefabricated, off-theshelf A

Lumbar-Sacral Orthotics
✽ L0643 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from
sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the
intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps,
pendulous abdomen design, prefabricated, off-theshelf A

✽ L0648 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior
extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce
load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps,
pendulous abdomen design, prefabricated, off-theshelf A

✽ L0649 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior
extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral
frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes
straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design,
prefabricated, off-theshelf A

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✽ L0650 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s),
posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid
lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs,
includes straps, closures, may include padding, shoulder straps, pendulous abdomen design,
prefabricated, off-the-shelf A

✽ L0651 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from
sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid,
produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is
provided by overlapping rigid material and stabilizing closures, includes straps, closures, may
include soft interface, pendulous abdomen design, prefabricated, off-theshelf A

Cervical-Thoracic-Lumbar-Sacral
✽ L0700 Cervical-thoracic-lumbar-sacralorthoses (CTLSO), anterior-posteriorlateral control, molded to
patient model (Minerva type) A

✽ L0710 CTLSO, anterior-posterior-lateralcontrol, molded to patient model, with interface material

(Minerva type) A

HALO Procedure
HALO procedure, cervical halo incorporated into jacket vest A
✽ L0810
HALO procedure, cervical halo incorporated into plaster body jacket A
✽ L0820
HALO procedure, cervical halo incorporated into Milwaukee type orthosis A
✽ L0830
✽ L0859 Addition to HALO procedure, magnetic resonance image compatible systems, rings and pins,
any material A

Addition to HALO procedure, replacement liner/interface material A

✽ L0861

Figure 23 Halo device.

Additions to Spinal Orthotics

NOTE: TLSO - Thoraci-lumbar-sacral orthoses/Spinal orthoses may be prefabricated, prefitted, or
custom fabricated. Conservative treatment for back pain may include the use of spinal orthoses.

TLSO, corset front A

✽ L0970
LSO, corset front A
✽ L0972
TLSO, full corset A
✽ L0974
LSO, full corset A
✽ L0976
Axillary crutch extension A
✽ L0978
Peroneal straps, prefabricated, off-the-shelf, pair A
✽ L0980
Stocking supporter grips, prefabricated, off-the-shelf, set of four (4) A
✽ L0982

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 Convenience item
Protective body sock, prefabricated, off-the-shelf, each A
✽ L0984
Garment made of cloth or similar material that is worn under spinal orthosis and is not primarily
medical in nature
Addition to spinal orthosis, not otherwise specified A
✽ L0999

Orthotic Devices: Scoliosis Procedures

NOTE: Orthotic care of scoliosis differs from other orthotic care in that the treatment is more
dynamic in nature and uses ongoing continual modification of the orthosis to the patient’s
changing condition. This coding structure uses the proper names, or eponyms, of the procedures
because they have historic and universal acceptance in the profession. It should be recognized that
variations to the basic procedures described by the founders/developers are accepted in various
medical and orthotic practices throughout the country. All procedures include a model of patient
when indicated.

✽ L1000 Cervical-thoracic-lumbar-sacral orthosis (CTLSO) (Milwaukee), inclusive of furnishing initial

orthosis, including model A

✽ L1001 Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting
and adjustment A

Figure 24 Milwaukee CTLSO.

✽ L1005 Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment
A
✽ L1010 Addition to cervical-thoracic-lumbarsacral orthosis (CTLSO) or scoliosis orthosis, axilla sling
A

Addition to CTLSO or scoliosis orthosis, kyphosis pad A

✽ L1020
Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating A
✽ L1025
Addition to CTLSO or scoliosis orthosis, lumbar bolster pad A
✽ L1030
Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad A
✽ L1040
Addition to CTLSO or scoliosis orthosis, sternal pad A
✽ L1050
Addition to CTLSO or scoliosis orthosis, thoracic pad A
✽ L1060
Addition to CTLSO or scoliosis orthosis, trapezius sling A
✽ L1070
Addition to CTLSO or scoliosis orthosis, outrigger A
✽ L1080
✽ L1085 Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions
A
Addition to CTLSO or scoliosis orthosis, lumbar sling A
✽ L1090

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✽ L1100 Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather A

✽ L1110 Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model
A

Addition to CTLSO, scoliosis orthosis, cover for upright, each A

✽ L1120

Thoracic-Lumbar-Sacral (Low Profile)

✽ L1200 Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initial orthosis only
A
Addition to TLSO, (low profile), lateral thoracic extension A
✽ L1210
Addition to TLSO, (low profile), anterior thoracic extension A
✽ L1220
Addition to TLSO, (low profile), Milwaukee type superstructure A
✽ L1230
Addition to TLSO, (low profile), lumbar derotation pad A
✽ L1240
Addition to TLSO, (low profile), anterior ASIS pad A
✽ L1250
Addition to TLSO, (low profile), anterior thoracic derotation pad A
✽ L1260
Addition to TLSO, (low profile), abdominal pad A
✽ L1270
Addition to TLSO, (low profile), rib gusset (elastic), each A
✽ L1280
Addition to TLSO, (low profile), lateral trochanteric pad A
✽ L1290

Other Scoliosis Procedures

Other scoliosis procedure, body jacket molded to patient model A
✽ L1300
Other scoliosis procedure, postoperative body jacket A
✽ L1310
Spinal orthosis, not otherwise specified A
✽ L1499

Orthotic Devices: Lower Limb (L1600-L3649)

NOTE: the procedures in L1600-L2999 are considered as base or basic proceduresand may be
modified by listing procedure from the Additions Sections and adding them to the base procedure.

Hip: Flexible
✽ L1600 Hip orthosis, abduction control of hip joints, flexible, frejka type with cover, prefabricated item
that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient
by an individual with expertise A

✽ L1610 Hip orthosis, abduction control of hip joints, flexible, (frejka cover only), prefabricated item that
has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by
an individual with expertise A

✽ L1620 Hip orthosis, abduction control of hip joints, flexible, (Pavlik harness), prefabricated item that
has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by
an individual with expertise A

✽ L1630 Hip orthosis, abduction control of hip joints, semi-flexible (Von Rosen type), custom-fabricated
A

✽ L1640 Hip orthosis, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs,
customfabricated A

✽ L1650 Hip orthosis, abduction control of hip joints, static, adjustable, (Ilfled type), prefabricated,
includes fitting and adjustment A

✽ L1652 Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated,
includes fitting and adjustment, any type A

✽ L1660 Hip orthosis, abduction control of hip joints, static, plastic, prefabricated, includes fitting and
adjustment A

✽ L1680 Hip orthosis, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion

460
 control, thigh cuffs (Rancho hip action type), custom fabrication A

✽ L1685 Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated
A

✽ L1686 Hip orthosis, abduction control of hip joint, postoperative hip abduction type, prefabricated,
includes fitting and adjustment A

✽ L1690 Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal
rotation control, prefabricated, includes fitting and adjustment A

Figure 25 Thoracic-hipknee-ankle orthosis (THKAO).

Legg Perthes
Legg-Perthes orthosis, (Toronto type), custom-fabricated A
✽ L1700
Legg-Perthes orthosis, (Newington type), custom-fabricated A
✽ L1710
Legg-Perthes orthosis, trilateral, (Tachdjian type), customfabricated A
✽ L1720
Legg-Perthes orthosis, (Scottish Rite type), custom-fabricated A
✽ L1730
Legg-Perthes orthosis, (Patten bottom type), custom-fabricated A
✽ L1755

Knee (KO)
✽ L1810 Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded,
assembled, or otherwise customized to fit a specific patient by an individual with expertise
A

Knee orthosis, elastic with joints, prefabricated, off-theshelf A

✽ L1812
✽ L1820 Knee orthosis, elastic with condylar pads and joints, with or without patellar control,
prefabricated, includes fitting and adjustment A

Figure 26 Hip orthosis.

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Figure 27 Knee orthosis.

Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-theshelf A

✽ L1830
✽ L1831 Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and
adjustment A

✽ L1832 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid
support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise A

✽ L1833 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid
support, prefabricated, off-the-shelf A

Knee orthosis, without knee joint, rigid, custom-fabricated A

✽ L1834
✽ L1836 Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-theshelf
A

✽ L1840 Knee orthosis, derotation, mediallateral, anterior cruciate ligament, custom fabricated
A

✽ L1843 Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint
(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus
adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise A

✽ L1844 Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint
(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus
adjustment, custom fabricated A

✽ L1845 Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint
(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus
adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise A

✽ L1846 Knee orthrosis, double upright, thigh and calf, with adjustable flexion and extension joint
(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus
adjustment, custom fabricated A

✽ L1847 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s),
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise A

Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s),

462
✽ L1848 prefabricated, off-the-shelf A

Knee orthosis, Swedish type, prefabricated, off-theshelf A

✽ L1850
✽ L1851 Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint
(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus
adjustment, prefabricated, off-theshelf A

✽ L1852 Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint
(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus
adjustment, prefabricated, off-theshelf A

✽ L1860 Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (SK)
A

Ankle-Foot (AFO)
✽ L1900 Ankle foot orthosis (AFO), spring wire, dorsiflexion assist calf band, customfabricated
A

✽ L1902 Ankle orthosis, ankle gauntlet or similiar, with or without joints, prefabricated, off-theshelf
A

✽ L1904 Ankle orthosis, ankle gauntlet or similiar, with or without joints, custom fabricated
A
Ankle foot orthosis, multiligamentus ankle support, prefabricated, off-theshelf A
✽ L1906
✽ L1907 Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated
A

✽ L1910 Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated,
includes fitting and adjustment A

✽ L1920 Ankle foot orthosis, single upright with static or adjustable stop (Phelps or Perlstein type),
custom fabricated A

✽ L1930 Ankle-foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment
A

✽ L1932 AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes
fitting and adjustment A

Ankle foot orthosis, plastic or other material, custom fabricated A

✽ L1940
✽ L1945 Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated
A

✽ L1950 Ankle foot orthosis, spiral, (Institute of Rehabilitation Medicine type), plastic, custom fabricated
A

✽ L1951 Ankle foot orthosis, spiral, (Institute of Rehabilitative Medicine type), plastic or other material,
prefabricated, includes fitting and adjustment A

Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated A

✽ L1960
Ankle foot orthosis, plastic, with ankle joint, custom fabricated A
✽ L1970
✽ L1971 Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and
adjustment A

463
Figure 28 Ankle-foot orthosis (AFO).

✽ L1980 Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single
bar ‘BK’ orthosis), custom fabricated A

✽ L1990 Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double
bar ‘BK’ orthosis), custom fabricated A

Hip-Knee-Ankle-Foot (or Any Combination)

NOTE: L2000, L2020, and L2036 are base procedures to be used with any knee joint. L2010 and
L2030 are to be used only with no knee joint.
✽ L2000 Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf
bands/cuffs (single bar ‘AK’ orthosis), customfabricated A

✽ L2005 Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock
and swing phase release, any type activation; includes ankle joint, any type, custom fabricated
A

✽ L2010 Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs
(single bar ‘AK’ orthosis), without knee joint, customfabricated A

✽ L2020 Knee ankle foot orthosis, double upright, free knee, free ankle, solid stirrup, thigh and calf
bands/cuffs (double bar ‘AK’ orthosis), custom fabricated A

✽ L2030 Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs
(double bar ‘AK’ orthosis), without knee joint, custom fabricated A

Figure 29 Knee-ankle-foot orthosis (KAFO).

464
✽ L2034 Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial
lateral rotation control, with or without free motion ankle, custom fabricated A

✽ L2035 Knee ankle foot orthosis, full plastic, static (pediatric size), without free motion ankle,
prefabricated, includes fitting and adjustment A

✽ L2036 Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or
without free motion ankle, custom fabricated A

✽ L2037 Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or
without free motion ankle, custom fabricated A

✽ L2038 Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom
fabricated A

Torsion Control: Hip-Knee-Ankle-Foot (TLSO)

✽ L2040 Hip knee ankle foot orthosis, torsion control, bilateral rotation straps, pelvic band/belt, custom
fabricated A

✽ L2050 Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, hip joint, pelvic band/belt,
custom fabricated A

✽ L2060 Hip knee ankle foot orthosis, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic
band/belt, custom fabricated A

Figure 30 Hip-knee-ankle-foot orthosis (HKAFO).

✽ L2070 Hip knee ankle foot orthosis, torsion control, unilateral rotation straps, pelvic band/belt, custom
fabricated A

✽ L2080 Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, hip joint, pelvic band/belt,
custom fabricated A

✽ L2090 Hip knee ankle foot orthosis, torsion control, unilateral torsion cable, ball bearing hip joint,
pelvic band/belt, custom fabricated A

Fracture Orthotics: Ankle-Foot and Knee-Ankle-Foot

✽ L2106 Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting
material, custom fabricated A

✽ L2108 Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom fabricated
A
✽ L2112 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting
and adjustment A

✽ L2114 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes
fitting and adjustment A

✽ L2116 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting

465
 and adjustment A

✽ L2126 Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type
casting material, custom fabricated A

✽ L2128 Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom fabricated
A

✽ L2132 KAFO, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment
A

✽ L2134 KAFO, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment
A

✽ L2136 KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and
adjustment A

Additions to Fracture Orthotics

✽ L2180 Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints
A
Addition to lower extremity fracture orthosis, drop lock knee joint A
✽ L2182
Addition to lower extremity fracture orthosis, limited motion knee joint A
✽ L2184
✽ L2186 Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type
A

Addition to lower extremity fracture orthosis, quadrilateral brim A

✽ L2188
Addition to lower extremity fracture orthosis, waist belt A
✽ L2190
✽ L2192 Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt
A

Additions to Lower Extremity Orthotics

Addition to lower extremity, limited ankle motion, each joint A
✽ L2200
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint A
✽ L2210
✽ L2220 Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint
A
Addition to lower extremity, split flat caliper stirrups and plate attachment A
✽ L2230
✽ L2232 Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for
custom fabricated orthosis only A

Addition to lower extremity, round caliper and plate attachment A

✽ L2240
✽ L2250 Addition to lower extremity, foot plate, molded to patient model, stirrup attachment
A
Addition to lower extremity, reinforced solid stirrup (Scott-Craig type) A
✽ L2260
Addition to lower extremity, long tongue stirrup A
✽ L2265
✽ L2270 Addition to lower extremity, varus/valgus correction (‘T’) strap, padded/lined or malleolus pad
A

✽ L2275 Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

A

Addition to lower extremity, molded inner boot A

✽ L2280
✽ L2300 Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable
A

Addition to lower extremity, abduction bar-straight A

✽ L2310
✽ L2320 Addition to lower extremity, nonmolded lacer, for custom fabricated orthosis only
A
✽ L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
A

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 Used whether closure is lacer or Velcro
Addition to lower extremity, anterior swing band A
✽ L2335
Addition to lower extremity, pre-tibial shell, molded to patient model A
✽ L2340
✽ L2350 Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for
‘PTB’ and ‘AFO’ orthoses) A

Addition to lower extremity, extended steel shank A

✽ L2360
Addition to lower extremity, Patten bottom A
✽ L2370
Addition to lower extremity, torsion control, ankle joint and half solid stirrup A
✽ L2375
Addition to lower extremity, torsion control, straight knee joint, each joint A
✽ L2380
Addition to lower extremity, straight knee joint, heavy duty, each joint A
✽ L2385
✽ L2387 Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot
orthosis, each joint A

Addition to lower extremity, offset knee joint, each joint A

✽ L2390
Addition to lower extremity, offset knee joint, heavy duty, each joint A
✽ L2395
Addition to lower extremity orthosis, suspension sleeve A
✽ L2397

Additions to Straight Knee or Offset Knee Joints

Addition to knee joint, drop lock, each A
✽ L2405
✽ L2415 Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material,
each joint A

Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint A
✽ L2425
✽ L2430 Addition to knee joint, ratchet lock for active and progressive knee extension, each joint
A
Addition to knee joint, lift loop for drop lock ring A
✽ L2492

Additions to Thigh/Weight Bearing Gluteal/Ischial Weight Bearing

✽ L2500 Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring
A

✽ L2510 Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model
A

✽ L2520 Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted
A

✽ L2525 Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim
molded to patient model A

✽ L2526 Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim,
custom fitted A

Addition to lower extremity, thighweight bearing, lacer, nonmolded A

✽ L2530
✽ L2540 Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model
A
Addition to lower extremity, thigh/weight bearing, high roll cuff A
✽ L2550

Additions to Pelvic and Thoracic Control

✽ L2570 Addition to lower extremity, pelvic control, hip joint, Clevis type two position joint, each
A

Addition to lower extremity, pelvic control, pelvic sling A

✽ L2580
✽ L2600 Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, each
A

✽ L2610 Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each

467
 A

Addition to lower extremity, pelvic control, hip joint, heavy duty, each A
✽ L2620
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each A
✽ L2622
✽ L2624 Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction
control, each A

✽ L2627 Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip
joint and cables A

✽ L2628 Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables
A

Addition to lower extremity, pelvic control, band and belt, unilateral A

✽ L2630
Addition to lower extremity, pelvic control, band and belt, bilateral A
✽ L2640
Addition to lower extremity, pelvic and thoracic control, gluteal pad, each A
✽ L2650
Addition to lower extremity, thoracic control, thoracic band A
✽ L2660
Addition to lower extremity, thoracic control, paraspinal uprights A
✽ L2670
Addition to lower extremity, thoracic control, lateral support uprights A
✽ L2680

General Additions
Addition to lower extremity orthosis, plating chrome or nickel, per bar A
✽ L2750
✽ L2755 Addition to lower extremity orthosis, high strength, lightweight material, all hybrid
lamination/prepreg composite, per segment, for custom fabricated orthosis only A

✽ L2760 Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for
growth) A

Orthotic side bar disconnect device, per bar A

✽ L2768
Addition to lower extremity orthosis, non-corrosive finish, per bar A
✽ L2780
Addition to lower extremity orthosis, drop lock retainer, each A
✽ L2785
Addition to lower extremity orthosis, knee control, full kneecap A
✽ L2795
✽ L2800 Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use with
custom fabricated orthosis only A

Addition to lower extremity orthosis, knee control, condylar pad A

✽ L2810
✽ L2820 Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
A

Only report if soft interface provided, either leather or other material

✽ L2830 Addition to lower extremity orthosis, soft interface for molded plastic, above knee section
A

Addition to lower extremity orthosis, tibial length sock, fracture or equal, each A
✽ L2840
Addition to lower extremity orthosis, femoral length sock, fracture or equal, each A
✽ L2850
H L2861 Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism
for custom fabricated orthotics only, each E1

Lower extremity orthoses, not otherwise specified A

✽ L2999

468
Figure 31 Foot inserts.

Foot (Orthopedic Shoes) (L3000-L3649)

Inserts
❂ L3000 Foot, insert, removable, molded to patient model, ‘UCB’ type, Berkeley shell, each
If both feet casted and supplied with an orthosis, bill L3000-LT and L3000-RT A

IOM: 100-02, 15, 290

Foot, insert, removable, molded to patient model, Spenco, each A
❂ L3001
IOM: 100-02, 15, 290
Foot, insert, removable, molded to patient model, Plastazote or equal, each A
❂ L3002
IOM: 100-02, 15, 290
Foot, insert, removable, molded to patient model, silicone gel, each A
❂ L3003
IOM: 100-02, 15, 290
❂ L3010 Foot, insert, removable, molded to patient model, longitudinal arch support, each
IOM: 100-02, 15, 290 A

❂ L3020 Foot, insert, removable, molded to patient model, longitudinal/metatarsal support, each
A

IOM: 100-02, 15, 290

Foot, insert, removable, formed to patient foot, each A
❂ L3030
IOM: 100-02, 15, 290
✽ L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight
material, all hybrid lamination/prepreg composite, each A

Figure 32 Arch support.

Arch Support, Removable, Premolded

Foot, arch support, removable, premolded, longitudinal, each A
❂ L3040
IOM: 100-02, 15, 290
Foot, arch support, removable, premolded, metatarsal, each A
❂ L3050
IOM: 100-02, 15, 290
Foot, arch support, removable, premolded, longitudinal/metatarsal, each A
❂ L3060
IOM: 100-02, 15, 290

Arch Support, Non-removable, Attached to Shoe

Foot, arch support, non-removable attached to shoe, longitudinal, each A
❂ L3070
IOM: 100-02, 15, 290
Foot, arch support, non-removable attached to shoe, metatarsal, each A
❂ L3080
IOM: 100-02, 15, 290
❂ L3090 Foot, arch support, non-removable attached to shoe, longitudinal/metatarsal, each
A

469
 IOM: 100-02, 15, 290
Hallus-valgus night dynamic splint, prefabricated, off-theshelf A
❂ L3100
IOM: 100-02, 15, 290

Figure 33 Hallux valgus splint.

Abduction and Rotation Bars

Foot, abduction rotation bar, including shoes A
❂ L3140
IOM: 100-02, 15, 290
Foot, abduction rotation bar, without shoes A
❂ L3150
IOM: 100-02, 15, 290
Foot, adjustable shoe-styled positioning device A
✽ L3160
Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each A
❂ L3170
IOM: 100-02, 15, 290

Orthopedic Footwear
Orthopedic shoe, oxford with supinator or pronator, infant A
❂ L3201
IOM: 100-02, 15, 290
Orthopedic shoe, oxford with supinator or pronator, child A
❂ L3202
IOM: 100-02, 15, 290
Orthopedic shoe, oxford with supinator or pronator, junior A
❂ L3203
IOM: 100-02, 15, 290
Orthopedic shoe, hightop with supinator or pronator, infant A
❂ L3204
IOM: 100-02, 15, 290
Orthopedic shoe, hightop with supinator or pronator, child A
❂ L3206
IOM: 100-02, 15, 290
Orthopedic shoe, hightop with supinator or pronator, junior A
❂ L3207
IOM: 100-02, 15, 290
Surgical boot, infant, each A
❂ L3208
IOM: 100-02, 15, 100

Figure 34 Molded custom shoe.

470
 Surgical boot, each, child A
❂ L3209
IOM: 100-02, 15, 100
Surgical boot, each, junior A
❂ L3211
IOM: 100-02, 15, 100
Benesch boot, pair, infant A
❂ L3212
IOM: 100-02, 15, 100
Benesch boot, pair, child A
❂ L3213
IOM: 100-02, 15, 100
Benesch boot, pair, junior A
❂ L3214
IOM: 100-02, 15, 100
E1
H L3215 Orthopedic footwear, ladies shoe, oxford, each ♀
Medicare Statute 1862a8
E1
H L3216 Orthopedic footwear, ladies shoe, depth inlay, each ♀
Medicare Statute 1862a8
E1
H L3217 Orthopedic footwear, ladies shoe, hightop, depth inlay, each ♀
Medicare Statute 1862a8
E1
H L3219 Orthopedic footwear, mens shoe, oxford, each ♂
Medicare Statute 1862a8
E1
H L3221 Orthopedic footwear, mens shoe, depth inlay, each ♂
Medicare Statute 1862a8
E1
H L3222 Orthopedic footwear, mens shoe, hightop, depth inlay, each ♂
Medicare Statute 1862a8
❂ L3224 Orthopedic footwear, ladies shoe, oxford, used as an integral part of a brace (orthosis)
A
♀
IOM: 100-02, 15, 290
❂ L3225 Orthopedic footwear, mens shoe, oxford, used as an integral part of a brace (orthosis)
A
♀
IOM: 100-02, 15, 290
Orthopedic footwear, custom shoe, depth inlay, each A
❂ L3230
IOM: 100-02, 15, 290
❂ L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
A
IOM: 100-02, 15, 290
Foot, shoe molded to patient model, silicone shoe, each A
❂ L3251
IOM: 100-02, 15, 290
❂ L3252 Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each
IOM: 100-02, 15, 290 A

Foot, molded shoe Plastazote (or similar), custom fitted, each A

❂ L3253
IOM: 100-02, 15, 290
Non-standard size or width A
❂ L3254
IOM: 100-02, 15, 290
Non-standard size or length A
❂ L3255
IOM: 100-02, 15, 290
Orthopedic footwear, additional charge for split size A
❂ L3257
IOM: 100-02, 15, 290
Surgical boot/shoe, each E1
❂ L3260
IOM: 100-02, 15, 100
Plastazote sandal, each A

471
✽ L3265

Shoe Lifts
Lift, elevation, heel, tapered to metatarsals, per inch A
❂ L3300
IOM: 100-02, 15, 290
Lift, elevation, heel and sole, Neoprene, per inch A
❂ L3310
IOM: 100-02, 15, 290
Lift, elevation, heel and sole, cork, per inch A
❂ L3320
IOM: 100-02, 15, 290
Lift, elevation, metal extension (skate) A
❂ L3330
IOM: 100-02, 15, 290
Lift, elevation, inside shoe, tapered, up to one-half inch A
❂ L3332
IOM: 100-02, 15, 290
Lift, elevation, heel, per inch A
❂ L3334
IOM: 100-02, 15, 290

Shoe Wedges
Heel wedge, SACH A
❂ L3340
IOM: 100-02, 15, 290
Heel wedge A
❂ L3350
IOM: 100-02, 15, 290
Sole wedge, outside sole A
❂ L3360
IOM: 100-02, 15, 290
Sole wedge, between sole A
❂ L3370
IOM: 100-02, 15, 290
Clubfoot wedge A
❂ L3380
IOM: 100-02, 15, 290
Outflare wedge A
❂ L3390
IOM: 100-02, 15, 290
Metatarsal bar wedge, rocker A
❂ L3400
IOM: 100-02, 15, 290
Metatarsal bar wedge, between sole A
❂ L3410
IOM: 100-02, 15, 290
Full sole and heel wedge, between sole A
❂ L3420
IOM: 100-02, 15, 290

Shoe Heels
Heel, counter, plastic reinforced A
❂ L3430
IOM: 100-02, 15, 290
Heel, counter, leather reinforced A
❂ L3440
IOM: 100-02, 15, 290
Heel, SACH cushion type A
❂ L3450
IOM: 100-02, 15, 290
Heel, new leather, standard A
❂ L3455
IOM: 100-02, 15, 290
Heel, new rubber, standard A
❂ L3460
IOM: 100-02, 15, 290
Heel, Thomas with wedge A
❂ L3465

472
 IOM: 100-02, 15, 290
Heel, Thomas extended to ball A
❂ L3470
IOM: 100-02, 15, 290
Heel, pad and depression for spur A
❂ L3480
IOM: 100-02, 15, 290
Heel, pad, removable for spur A
❂ L3485
IOM: 100-02, 15, 290

Orthopedic Shoe Additions: Other

Orthopedic shoe addition, insole, leather A
❂ L3500
IOM: 100-02, 15, 290
Orthopedic shoe addition, insole, rubber A
❂ L3510
IOM: 100-02, 15, 290
Orthopedic shoe addition, insole, felt covered with leather A
❂ L3520
IOM: 100-02, 15, 290
Orthopedic shoe addition, sole, half A
❂ L3530
IOM: 100-02, 15, 290
Orthopedic shoe addition, sole, full A
❂ L3540
IOM: 100-02, 15, 290
Orthopedic shoe addition, toe tap standard A
❂ L3550
IOM: 100-02, 15, 290
Orthopedic shoe addition, toe tap, horseshoe A
❂ L3560
IOM: 100-02, 15, 290
Orthopedic shoe addition, special extension to instep (leather with eyelets) A
❂ L3570
IOM: 100-02, 15, 290
Orthopedic shoe addition, convert instep to Velcro closure A
❂ L3580
IOM: 100-02, 15, 290
Orthopedic shoe addition, convert firm shoe counter to soft counter A
❂ L3590
IOM: 100-02, 15, 290
Orthopedic shoe addition, March bar A
❂ L3595
IOM: 100-02, 15, 290

Transfer or Replacement
Transfer of an orthosis from one shoe to another, caliper plate, existing A
❂ L3600
IOM: 100-02, 15, 290
Transfer of an orthosis from one shoe to another, caliper plate, new A
❂ L3610
IOM: 100-02, 15, 290
Transfer of an orthosis from one shoe to another, solid stirrup, existing A
❂ L3620
IOM: 100-02, 15, 290
Transfer of an orthosis from one shoe to another, solid stirrup, new A
❂ L3630
IOM: 100-02, 15, 290
❂ L3640 Transfer of an orthosis from one shoe to another, Dennis Browne splint (Riveton), both shoes
A

IOM: 100-02, 15, 290

Orthopedic shoe, modification, addition or transfer, not otherwise specified A
❂ L3649
IOM: 100-02, 15, 290

Orthotic Devices: Upper Limb

473
NOTE: The procedures in this section are considered as base or basic procedures and may be
modified by listing procedures from the Additions section and adding them to the base procedure.

Shoulder
✽ L3650 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
A

✽ L3660 Shoulder orthosis, figure of eight design abduction restrainer, canvas and webbing, prefabricated,
off-theshelf A

✽ L3670 Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-theshelf
A

✽ L3671 Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps,
custom fabricated, includes fitting and adjustment A

✽ L3674 Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar,
with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom
fabricated, includes fitting and adjustment A

✽ L3675 Shoulder orthosis, vest type abduction restrainer, canvas webbing type or equal, prefabricated,
off-theshelf A

❂ L3677 Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps,
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise A

✽ L3678 Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps,
prefabricated, off-theshelf A

Figure 35 Elbow orthoses.

Elbow
✽ L3702 Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes
fitting and adjustment A

Elbow orthosis, elastic with metal joints, prefabricated, off-theshelf A

✽ L3710
✽ L3720 Elbow orthosis, double upright with forearm/arm cuffs, free motion, custom fabricated
A

✽ L3730 Elbow orthosis, double upright with forearm/arm cuffs, extension/flexion assist, custom
fabricated A

✽ L3740 Elbow orthosis, double upright with forearm/arm cuffs, adjustable position lock with active
control, custom fabricated A

✽L3760 Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an
individual with expertise A

Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf A
✽ L3761
✽ L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-theshelf
A

✽ L3763 Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom
fabricated, includes fitting and adjustment A

✽ L3764 Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles,

474
 may include soft interface, straps, custom fabricated, includes fitting and adjustment
A
✽ L3765 Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom
fabricated, includes fitting and adjustment A

✽ L3766 Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands,
turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
A

Wrist-Hand-Finger Orthosis (WHFO)

✽ L3806 Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic
bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and
adjustment A

✽ L3807 Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent,
molded, assembled, or otherwise customized to fit a specific patient by an individual with
expertise A

✽ L3808 Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps,
custom fabricated, includes fitting and adjustment A

✽ L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type
A
H L3891 Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism
for custom fabricated orthotics only, each E1

✽ L3900 Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/flexion, finger
flexion/extension, wrist or finger driven, custom fabricated A

✽ L3901 Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/flexion, finger
flexion/extension, cable driven, custom fabricated A

Wrist hand finger orthosis, external powered, electric, custom fabricated A

✽ L3904

Other Upper Extremity Orthotics

✽ L3905 Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may
include soft interface, straps, custom fabricated, includes fitting and adjustment A

✽ L3906 Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated,
includes fitting and adjustment A

✽ L3908 Wrist hand orthosis, wrist extension control cock-up, non-molded, prefabricated, off-theshelf
A

✽ L3912 Hand finger orthosis (HFO), flexion glove with elastic finger control, prefabricated, off-theshelf
A

✽ L3913 Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated,
includes fitting and adjustment A

✽ L3915 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may
include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled,
or otherwise customized to fit a specific patient by an individual with expertise A

✽ L3916 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may
include soft interface, straps, prefabricated, off-theshelf A

✽ L3917 Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent,
molded, assembled, or otherwise customized to fit a specific patient by an individual with
expertise A

Hand orthosis, metacarpal fracture orthosis, prefabricated, off-theshelf A

✽ L3918
✽ L3919 Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes
fitting and adjustment A

✽ L3921 Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may
include soft interface, straps, custom fabricated, includes fitting and adjustment A

✽ L3923 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that

475
 has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by
an individual with expertise A

✽ L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-theshelf
A

✽ L3925 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), non torsion
joint/spring, extension/flexion, may include soft interface material, prefabricated, off-theshelf
A

✽ L3927 Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without

joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material,
prefabricated, off-theshelf A

✽ L3929 Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic
bands/springs, may include soft interface material, straps, prefabricated item that has been
trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an
individual with expertise A

✽ L3930 Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic
bands/springs, may include soft interface material, straps, prefabricated, off-theshelf
A
✽ L3931 Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic
bands/springs, may include soft interface material, straps, prefabricated, includes fitting and
adjustment A

✽ L3933 Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and
adjustment A

✽ L3935 Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting
and adjustment A

Addition of joint to upper extremity orthosis, any material, per joint A

✽ L3956

476
Shoulder-Elbow-Wrist-Hand Orthotics (SEWHO) (L3960-L3973)
✽ L3960 Shoulder elbow wrist hand orthosis, abduction positioning, airplane design, prefabricated,
includes fitting and adjustment A

✽ L3961 Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft
interface, straps, custom fabricated, includes fitting and adjustment A

✽ L3962 Shoulder elbow wrist hand orthosis, abduction positioning, Erb’s palsy design, prefabricated,
includes fitting and adjustment A

✽ L3967 Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component
and support bar, without joints, may include soft interface, straps, custom fabricated, includes
fitting and adjustment A

✽ L3971 Shoulder elbow wrist hand orthosis, shoulder cap design, includes one or more nontorsion joints,
elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting
and adjustment A

✽ L3973 Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component
and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include
soft interface, straps, custom fabricated, includes fitting and adjustment A

Shoulder-Elbow-Wrist-Hand-Finger Orthotics
✽ L3975 Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft
interface, straps, custom fabricated, includes fitting and adjustment A

✽ L3976 Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic
component and support bar, without joints, may include soft interface, straps, custom fabricated,
includes fitting and adjustment A

✽ L3977 Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more nontorsion
joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes
fitting and adjustment A

✽ L3978 Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic
component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles,
may include soft interface, straps, custom fabricated, includes fitting and adjustment
A

Fracture Orthorics
✽ L3980 Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment
A

✽ L3981 Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or
without joints, forearm section, may include soft interface, straps, includes fitting and
adjustments A

✽ L3982 Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment
A

✽ L3984 Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment
A
Addition to upper extremity orthosis, sock, fracture or equal, each A
✽ L3995
Upper limb orthosis, not otherwise specified A
✽ L3999

Repairs
Replace girdle for spinal orthosis (CTLSO or SO) A
✽ L4000
Replacement strap, any orthosis, includes all components, any length, any type A
✽ L4002

Replace trilateral socket brim A

✽ L4010
Replace quadrilateral socket brim, molded to patient model A
✽ L4020

477
✽ L4040 Replace molded thigh lacer, for custom fabricated orthosis only A

Replace non-molded thigh lacer, for custom fabricated orthosis only A

✽ L4045
Replace molded calf lacer, for custom fabricated orthosis only A
✽ L4050
Replace non-molded calf lacer, for custom fabricated orthosis only A
✽ L4055
Replace high roll cuff A
✽ L4060
Replace proximal and distal upright for KAFO A
✽ L4070
Replace metal bands KAFO, proximal thigh A
✽ L4080
Replace metal bands KAFO-AFO, calf or distal thigh A
✽ L4090
Replace leather cuff KAFO, proximal thigh A
✽ L4100
Replace leather cuff KAFO-AFO, calf or distal thigh A
✽ L4110
Replace pretibial shell A
✽ L4130
Repair of orthotic device, labor component, per 15 minutes A
❂ L4205
IOM: 100-02, 15, 110.2
Repair of orthotic device, repair or replace minor parts A
❂ L4210
IOM: 100-02, 15, 110.2; 100-02, 15, 120

Ancillary Orthotic Services

✽ L4350 Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel),
prefabricated, off-theshelf A

✽ L4360 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface
material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise
customized to fit a specific patient by an individual with expertise A

Noncovered when walking boots used primarily to relieve pressure, especially on sole of foot, or
are used for patients with foot ulcers
✽ L4361 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface
material, prefabricated, off-theshelf A

Pneumatic full leg splint, prefabricated, off-the-shelf A

✽ L4370
✽ L4386 Walking boot, non-pneumatic, with or without joints, with or without interface material,
prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to
fit a specific patient by an individual with expertise A

✽ L4387 Walking boot, non-pneumatic, with or without joints, with or without interface material,
prefabricated, off-the-shelf A

Replacement, soft interface material, static AFO A

✽ L4392
Replace soft interface material, foot drop splint A
✽ L4394
✽ L4396 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for
positioning, may be used for minimal ambulation, prefabricated item that has been trimmed,
bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with
expertise A

✽ L4397 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for
positioning, may be used for minimal ambulation, prefabricated, off-theshelf A

Foot drop splint, recumbent positioning device, prefabricated, off-theshelf A

✽ L4398
✽ L4631 Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial
shell, soft interface, custom arch support, plastic or other material, includes straps and closures,
custom fabricated A

478
Figure 36 Partial foot.

PROSTHETICS (L5000-L9999)
Lower Limb (L5000-L5999)
NOTE: The procedures in this section are considered as base or basic proceduresand may be
modified by listing items/procedures or special materials from the Additions section and adding
them to the base procedure.

Partial Foot
Partial foot, shoe insert with longitudinal arch, toe filler A
❂ L5000
IOM: 100-02, 15, 290
Partial foot, molded socket, ankle height, with toe filler A
❂ L5010
IOM: 100-02, 15, 290
Partial foot, molded socket, tibial tubercle height, with toe filler A
❂ L5020
IOM: 100-02, 15, 290

Ankle
Ankle, Symes, molded socket, SACH foot A
✽ L5050
Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot A
✽ L5060

Figure 37 Ankle Symes.

Below Knee
Below knee, molded socket, shin, SACH foot A
✽ L5100

479
✽ L5105 Below knee, plastic socket, joints and thigh lacer, SACH foot A

Knee Disarticulation
✽ L5150 Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot
A

✽ L5160 Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee
joints, shin, SACH foot A

Above Knee
Above knee, molded socket, single axis constant friction knee, shin, SACH foot A
✽ L5200
✽ L5210 Above knee, short prosthesis, no knee joint (‘stubbies’), with foot blocks, no ankle joints, each
A

✽ L5220 Above knee, short prosthesis, no knee joint (‘stubbies’), with articulated ankle/foot, dynamically
aligned, each A

✽ L5230 Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot
A

Hip Disarticulation
✽ L5250 Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee,
shin, SACH foot A

✽ L5270 Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction
knee, shin, SACH foot A

Figure 38 Above knee.

Hemipelvectomy
✽ L5280 Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee,
shin, SACH foot A

Endoskeletal
Below knee, molded socket, shin, SACH foot, endoskeletal system A
✽ L5301
✽ L5312 Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot,
endoskeletal system A

✽ L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee
A

Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis

480
✽ L5331 knee, SACH foot A

✽ L5341 Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee,
SACH foot A

Immediate Postsurgical or Early Fitting Procedures

✽ L5400 Immediate post surgical or early fitting, application of initial rigid dressing, including fitting,
alignment, suspension, and one cast change, below knee A

✽ L5410 Immediate post surgical or early fitting, application of initial rigid dressing, including fitting,
alignment and suspension, below knee, each additional cast change and realignment
A
✽ L5420 Immediate post surgical or early fitting, application of initial rigid dressing, including fitting,
alignment and suspension and one cast change ‘AK’ or knee disarticulation A

✽ L5430 Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting,
alignment, and suspension, ‘AK’ or knee disarticulation, each additional cast change and
realignment A

✽ L5450 Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, below
knee A

✽ L5460 Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, above
knee A

Initial Prosthesis
✽ L5500 Initial, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot, plaster
socket, direct formed A

✽ L5505 Initial, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no
cover, SACH foot, plaster socket, direct formed A

Preparatory Prosthesis
✽ L5510 Preparatory, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot,
plaster socket, molded to model A

✽ L5520 Preparatory, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot,
thermoplastic or equal, direct formed A

✽ L5530 Preparatory, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot,
thermoplastic or equal, molded to model A

✽ L5535 Preparatory, below knee ‘PTB’ type socket, non-alignable system, no cover, SACH foot,
prefabricated, adjustable open end socket A

✽ L5540 Preparatory, below knee ‘PTB’ type socket, non-alignable system, pylon, no cover, SACH foot,
laminated socket, molded to model A

✽ L5560 Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon,
no cover, SACH foot, plaster socket, molded to model A

✽ L5570 Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon,
no cover, SACH foot, thermoplastic or equal, direct formed A

✽ L5580 Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon,
no cover, SACH foot, thermoplastic or equal, molded to model A

✽ L5585 Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon,
no cover, SACH foot, prefabricated adjustable open end socket A

✽ L5590 Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon,
no cover, SACH foot, laminated socket, molded to model A

✽ L5595 Preparatory, hip disarticulationhemipelvectomy, pylon, no cover, SACH foot, thermoplastic or

equal, molded to patient model A

✽ L5600 Preparatory, hip disarticulationhemipelvectomy, pylon, no cover, SACH foot, laminated socket,
molded to patient model A

481
Additions to Lower Extremity
✽ L5610 Addition to lower extremity, endoskeletal system, above knee, hydracadence system
A
✽ L5611 Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4 bar linkage,
with friction swing phase control A

✽ L5613 Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4 bar linkage,
with hydraulic swing phase control A

✽ L5614 Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage,
with pneumatic swing phase control A

✽ L5616 Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction
swing phase control A

✽ L5617 Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each
A

Additions to Test Sockets

Addition to lower extremity, test socket, Symes A
✽ L5618
Addition to lower extremity, test socket, below knee A
✽ L5620
Addition to lower extremity, test socket, knee disarticulation A
✽ L5622
Addition to lower extremity, test socket, above knee A
✽ L5624
Addition to lower extremity, test socket, hip disarticulation A
✽ L5626
Addition to lower extremity, test socket, hemipelvectomy A
✽ L5628

Additions to Socket Variations

Addition to lower extremity, below knee, acrylic socket A
✽ L5629
Addition to lower extremity, Symes type, expandable wall socket A
✽ L5630
Addition to lower extremity, above knee or knee disarticulation, acrylic socket A
✽ L5631
Addition to lower extremity, Symes type, ‘PTB’ brim design socket A
✽ L5632
Addition to lower extremity, Symes type, posterior opening (Canadian) socket A
✽ L5634
Addition to lower extremity, Symes type, medial opening socket A
✽ L5636
Addition to lower extremity, below knee, total contact A
✽ L5637
Addition to lower extremity, below knee, leather socket A
✽ L5638
Addition to lower extremity, below knee, wood socket A
✽ L5639
Addition to lower extremity, knee disarticulation, leather socket A
✽ L5640
Addition to lower extremity, above knee, leather socket A
✽ L5642
✽ L5643 Addition to lower extremity, hip disarticulation, flexible inner socket, external frame
A
Addition to lower extremity, above knee, wood socket A
✽ L5644
Addition to lower extremity, below knee, flexible inner socket, external frame A
✽ L5645
Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket A
✽ L5646
Addition to lower extremity, below knee, suction socket A
✽ L5647
Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket A
✽ L5648
Addition to lower extremity, ischial containment/narrow M-L socket A
✽ L5649
✽ L5650 Additions to lower extremity, total contact, above knee or knee disarticulation socket
A
Addition to lower extremity, above knee, flexible inner socket, external frame A
✽ L5651

482
✽ L5652 Addition to lower extremity, suction suspension, above knee or knee disarticulation socket
A

Addition to lower extremity, knee disarticulation, expandable wall socket A

✽ L5653

Additions to Socket Insert and Suspension

✽ L5654 Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or equal)
A

✽ L5655 Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or
equal) A

✽ L5656 Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast,
Plastazote or equal) A

✽ L5658 Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or
equal) A

Addition to lower extremity, socket insert, multi-durometer Symes A

✽ L5661
Addition to lower extremity, socket insert, multi-durometer, below knee A
✽ L5665
Addition to lower extremity, below knee, cuff suspension A
✽ L5666
Addition to lower extremity, below knee, molded distal cushion A
✽ L5668
✽ L5670 Addition to lower extremity, below knee, molded supracondylar suspension (‘PTS’ or similar)
A

✽ L5671 Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle,
lanyard or equal), excludes socket insert A

Addition to lower extremity, below knee, removable medial brim suspension A

✽ L5672
✽ L5673 Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or
prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism
A

Additions to lower extremity, below knee, knee joints, single axis, pair A
✽ L5676
Additions to lower extremity, below knee, knee joints, polycentric, pair A
✽ L5677
Additions to lower extremity, below knee, joint covers, pair A
✽ L5678
✽ L5679 Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or
prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking
mechanism A

Addition to lower extremity, below knee, thigh lacer, nonmolded A

✽ L5680
✽ L5681 Addition to lower extremity, below knee/above knee, custom fabricated socket insert for
congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or
without locking mechanism, initial only (for other than initial, use code L5673 or L5679)
A

Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded A

✽ L5682
✽ L5683 Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other
than congenital or atypical traumatic amputee, silicone gel, elastomeric, or equal, for use with or
without locking mechanism, initial only (for other than initial, use code L5673 or L5679)
A

Addition to lower extremity, below knee, fork strap A

✽ L5684
✽ L5685 Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without
valve, any material, each A

Addition to lower extremity, below knee, back check (extension control) A

✽ L5686
Addition to lower extremity, below knee, waist belt, webbing A
✽ L5688
Addition to lower extremity, below knee, waist belt, padded and lined A
✽ L5690
Addition to lower extremity, above knee, pelvic control belt, light A
✽ L5692

483
✽ L5694 Addition to lower extremity, above knee, pelvic control belt, padded and lined A

✽ L5695 Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal,
each A

Addition to lower extremity, above knee or knee disarticulation, pelvic joint A

✽ L5696
Addition to lower extremity, above knee or knee disarticulation, pelvic band A
✽ L5697
✽ L5698 Addition to lower extremity, above knee or knee disarticulation, Silesian bandage
A
All lower extremity prostheses, shoulder harness A
✽ L5699

Replacement Sockets
Replacement, socket, below knee, molded to patient model A
✽ L5700
✽ L5701 Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to
patient model A

✽ L5702 Replacement, socket, hip disarticulation, including hip joint, molded to patient model
A

✽ L5703 Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot,
replacement only A

Protective Covers
Custom shaped protective cover, below knee A
✽ L5704
Custom shaped protective cover, above knee A
✽ L5705
Custom shaped protective cover, knee disarticulation A
✽ L5706
Custom shaped protective cover, hip disarticulation A
✽ L5707

Additions to Exoskeletal–Knee-Shin System

Addition, exoskeletal knee-shin system, single axis, manual lock A
✽ L5710
✽ L5711 Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light material
A

✽ L5712 Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control
(safety knee) A

✽ L5714 Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control
A

✽ L5716 Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock
A
✽ L5718 Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control
A

✽ L5722 Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase
control A

Addition, exoskeletal knee-shin system, single axis, fluid swing phase control A
✽ L5724
✽ L5726 Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control
A

✽ L5728 Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control
A

✽ L5780 Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase
control A

Vacuum Pumps
✽ L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and
moisture evacuation system A

Addition to lower limb prosthesis, vacuum pump, residual limb volume management and

484
✽ L5782 moisture evacuation system, heavy duty A

Component Modification
✽ L5785 Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber, or equal)
A

✽ L5790 Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber, or equal)
A

✽ L5795 Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber, or
equal) A

Endoskeletal
Addition, endoskeletal knee-shin system, single axis, manual lock A
✽ L5810
✽ L5811 Addition, endoskeletal knee-shin system, single axis, manual lock, ultralight material
A

✽ L5812 Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control
(safety knee) A

✽ L5814 Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical
stance phase lock A

✽ L5816 Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock
A
✽ L5818 Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance phase control
A

✽ L5822 Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase
control A

Addition, endoskeletal knee-shin system, single axis, fluid swing phase control A
✽ L5824
✽ L5826 Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with
miniature high activity frame A

✽ L5828 Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control
A

✽ L5830 Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control
A

✽ L5840 Addition, endoskeletal knee/shin system, 4-bar linkage or multiaxial, pneumatic swing phase
control A

Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable A

✽ L5845
✽ L5848 Addition to endoskeletal, knee-shin system, fluid stance extension, dampening feature, with or
without adjustability A

✽ L5850 Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist
A

✽ L5855 Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist
A
✽ L5856 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control
feature, swing and stance phase; includes electronic sensor(s), any type A

✽ L5857 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control
feature, swing phase only; includes electronic sensor(s), any type A

✽ L5858 Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control
feature, stance phase only, includes electronic sensor(s), any type A

✽ L5859 Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and
programmable flexion/extension assist control, includes any type motor(s) A

Addition, endoskeletal system, below knee, alignable system A

✽ L5910
✽ L5920 Addition, endoskeletal system, above knee or hip disarticulation, alignable system
A
✽ L5925 Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual

485
 lock A

Addition, endoskeletal system, high activity knee control frame A

✽ L5930
✽ L5940 Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)
A

✽ L5950 Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)
A

✽ L5960 Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber, or
equal) A

✽ L5961 Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation
control, with or without flexion, and/or extension control A

✽ L5962 Addition, endoskeletal system, below knee, flexible protective outer surface covering system
A

✽ L5964 Addition, endoskeletal system, above knee, flexible protective outer surface covering system
A

✽ L5966 Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering
system A

Additions to Ankle and/or Foot

✽ L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature
A

✽ L5969 Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s)
A

All lower extremity prostheses, foot, external keel, SACH foot A

✽ L5970
✽ L5971 All lower extremity prosthesis, solid ankle cushion keel (SACH) foot, replacement only
A

All lower extremity prostheses (foot, flexible keel) A

✽ L5972
✽ L5973 Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar
flexion control, includes power source A

All lower extremity prostheses, foot, single axis ankle/foot A

✽ L5974
✽ L5975 All lower extremity prostheses, combination single axis ankle and flexible keel foot
A
✽ L5976 All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)
A
All lower extremity prostheses, foot, multiaxial ankle/foot A
✽ L5978
✽ L5979 All lower extremity prostheses, multiaxial ankle, dynamic response foot, one piece system
A

All lower extremity prostheses, flex foot system A

✽ L5980
All lower extremity prostheses, flexwalk system or equal A
✽ L5981
All exoskeletal lower extremity prostheses, axial rotation unit A
✽ L5982
✽ L5984 All endoskeletal lower extremity prostheses, axial rotation unit, with or without adjustability
A

All endoskeletal lower extremity prostheses, dynamic prosthetic pylon A

✽ L5985
All lower extremity prostheses, multiaxial rotation unit (‘MCP’ or equal) A
✽ L5986
All lower extremity prostheses, shank foot system with vertical loading pylon A
✽ L5987
Addition to lower limb prosthesis, vertical shock reducing pylon feature A
✽ L5988
Addition to lower extremity prosthesis, user adjustable heel height A
✽ L5990
Lower extremity prosthesis, not otherwise specified A
✽ L5999

486
Upper Limb (L6000-L7600)
NOTE: The procedures in L6000-L6599 are considered as base or basic procedures and may be
modified by listing procedures from the additions sections. The base procedures include only
standard friction wrist and control cable system unless otherwise specified.

Partial Hand
Partial hand, thumb remaining A
✽ L6000
Partial hand, little and/or ring finger remaining A
✽ L6010
Partial hand, no finger remaining A
✽ L6020
✽ L6026 Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended,
inner socket with removable forearm section, electrodes and cables, two batteries, charger,
myoelectric control of terminal device, excludes terminal device(s) A

Figure 39 Partial hand.

Wrist Disarticulation
Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad A
✽ L6050
✽ L6055 Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad
A

Below Elbow
Below elbow, molded socket, flexible elbow hinge, triceps pad A
✽ L6100
Below elbow, molded socket, (Muenster or Northwestern suspension types) A
✽ L6110
Below elbow, molded double wall split socket, step-up hinges, half cuff A
✽ L6120
✽ L6130 Below elbow, molded double wall split socket, stump activated locking hinge, half cuff
A

Elbow Disarticulation
Elbow disarticulation, molded socket, outside locking hinge, forearm A
✽ L6200
✽ L6205 Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm
A

Above Elbow
Above elbow, molded double wall socket, internal locking elbow, forearm A
✽ L6250

487
Shoulder Disarticulation
✽ L6300 Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking
elbow, forearm A

Shoulder disarticulation, passive restoration (complete prosthesis) A

✽ L6310
Shoulder disarticulation, passive restoration (shoulder cap only) A
✽ L6320

Interscapular Thoracic
✽ L6350 Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking
elbow, forearm A

Interscapular thoracic, passive restoration (complete prosthesis) A

✽ L6360
Interscapular thoracic, passive restoration (shoulder cap only) A
✽ L6370

Immediate and Early Postsurgical Procedures

✽ L6380 Immediate post surgical or early fitting, application of initial rigid dressing, including fitting
alignment and suspension of components, and one cast change, wrist disarticulation or below
elbow A

✽ L6382 Immediate post surgical or early fitting, application of initial rigid dressing including fitting
alignment and suspension of components, and one cast change, elbow disarticulation or above
elbow A

✽ L6384 Immediate post surgical or early fitting, application of initial rigid dressing including fitting
alignment and suspension of components, and one cast change, shoulder disarticulation or
interscapular thoracic A

✽ L6386 Immediate post surgical or early fitting, each additional cast change and realignment
A
Immediate post surgical or early fitting, application of rigid dressing only A
✽ L6388

Molded Socket
✽ L6400 Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping
A

✽ L6450 Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue
shaping A

✽ L6500 Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping
A

✽ L6550 Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue
shaping A

✽ L6570 Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue
shaping A

Preparatory Prosthetic
✽ L6580 Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible
elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal
pylon, no cover, molded to patient model A

✽ L6582 Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow
hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no
cover, direct formed A

✽ L6584 Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist,
locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover,
molded to patient model A

✽ L6586 Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking
elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, direct

488
 formed A

✽ L6588 Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder
joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no
cover, molded to patient model A

✽ L6590 Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint,
locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover,
direct formed A

Additions to Upper Limb

NOTE: The following procedures/modifications/components may be added to other base
procedures. The items in this section should reflect the additional complexity of each modification
procedure, in addition to base procedure, at the time of the original order.
Upper extremity additions, polycentric hinge, pair A
✽ L6600
Upper extremity additions, single pivot hinge, pair A
✽ L6605
Upper extremity additions, flexible metal hinge, pair A
✽ L6610
✽ L6611 Addition to upper extremity prosthesis, external powered, additional switch, any type
A
Upper extremity addition, disconnect locking wrist unit A
✽ L6615
✽ L6616 Upper extremity addition, additional disconnect insert for locking wrist unit, each
A
Upper extremity addition, flexion/extension wrist unit, with or without friction A
✽ L6620
✽ L6621 Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with
external powered terminal device A

Upper extremity addition, spring assisted rotational wrist unit with latch release A
✽ L6623
Upper extremity addition, flexion/extension and rotation wrist unit A
✽ L6624
Upper extremity addition, rotation wrist unit with cable lock A
✽ L6625
Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal A
✽ L6628
✽ L6629 Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or
equal A

Upper extremity addition, stainless steel, any wrist A

✽ L6630
Upper extremity addition, latex suspension sleeve, each A
✽ L6632
Upper extremity addition, lift assist for elbow A
✽ L6635
Upper extremity addition, nudge control elbow lock A
✽ L6637

Figure 40 Upper extremity addition.

✽ L6638 Upper extremity addition to prosthesis, electric locking feature, only for use with manually
powered elbow A

489
✽ L6640 Upper extremity additions, shoulder abduction joint, pair A

Upper extremity addition, excursion amplifier, pulley type A

✽ L6641
Upper extremity addition, excursion amplifier, lever type A
✽ L6642
Upper extremity addition, shoulder flexion-abduction joint, each A
✽ L6645
✽ L6646 Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction
friction control, for use with body powered or external powered system A

Upper extremity addition, shoulder lock mechanism, body powered actuator A

✽ L6647
Upper extremity addition, shoulder lock mechanism, external powered actuator A
✽ L6648
Upper extremity addition, shoulder universal joint, each A
✽ L6650
Upper extremity addition, standard control cable, extra A
✽ L6655
Upper extremity addition, heavy duty control cable A
✽ L6660
Upper extremity addition, Teflon, or equal, cable lining A
✽ L6665
Upper extremity addition, hook to hand, cable adapter A
✽ L6670
Upper extremity addition, harness, chest or shoulder, saddle type A
✽ L6672
Upper extremity addition, harness, (e.g., figure of eight type), single cable design A
✽ L6675
Upper extremity addition, harness, (e.g., figure of eight type), dual cable design A
✽ L6676
✽ L6677 Upper extremity addition, harness, triple control, simultaneous operation of terminal device and
elbow A

Upper extremity addition, test socket, wrist disarticulation or below elbow A

✽ L6680
Upper extremity addition, test socket, elbow disarticulation or above elbow A
✽ L6682
✽ L6684 Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic
A
Upper extremity addition, suction socket A
✽ L6686
✽ L6687 Upper extremity addition, frame type socket, below elbow or wrist disarticulation
A
✽ L6688 Upper extremity addition, frame type socket, above elbow or elbow disarticulation
A
Upper extremity addition, frame type socket, shoulder disarticulation A
✽ L6689
Upper extremity addition, frame type socket, interscapularthoracic A
✽ L6690
Upper extremity addition, removable insert, each A
✽ L6691
Upper extremity addition, silicone gel insert or equal, each A
✽ L6692
Upper extremity addition, locking elbow, forearm counterbalance A
✽ L6693
✽ L6694 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from
existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with
locking mechanism A

✽ L6695 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from
existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with
locking mechanism A

✽ L6696 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket
insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with
or without locking mechanism, initial only (for other than initial, use code L6694 or L6695)
A

✽ L6697 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket
insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal,
for use with or without locking mechanism, initial only (for other than initial, use code L6694 or
L6695) A

✽ L6698 Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes
socket insert A

490
Terminal Devices (L6703-L6882)
Terminal device, passive hand/mitt, any material, any size A
✽ L6703
Terminal device, sport/recreational/work attachment, any material, any size A
✽ L6704
✽ L6706 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined
A

✽ L6707 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined
A

Terminal device, hand, mechanical, voluntary opening, any material, any size A
✽ L6708
Terminal device, hand, mechanical, voluntary closing, any material, any size A
✽ L6709
✽ L6711 Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined,
pediatric A

✽ L6712 Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined,
pediatric A

✽ L6713 Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric
A

✽ L6714 Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric
A

✽ L6715 Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement
A

✽ L6721 Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any
size, lined or unlined A

Figure 41 Terminal devices, hand and hook.

✽ L6722 Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size,
lined or unlined A

Addition to terminal device, modifier wrist unit A

❂ L6805
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Addition to terminal device, precision pinch device A
❂ L6810
IOM: 100-02, 15, 120; 100-04, 3, 10.4
✽ L6880 Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp
pattern or combination of grasp patterns, includes motor(s) A

✽ L6881 Automatic grasp feature, addition to upper limb electric prosthetic terminal device
A
❂ L6882 Microprocessor control feature, addition to upper limb prosthetic terminal device
IOM: 100-02, 15, 120; 100-04, 3, 10.4 A

491
Replacement Sockets
✽ L6883 Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or
without external power A

✽ L6884 Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or
without external power A

✽ L6885 Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for
use with or without external power A

Hand Restoration
✽ L6890 Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated,
includes fitting and adjustment A

✽ L6895 Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated
A

✽ L6900 Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or
one finger remaining A

✽ L6905 Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple
fingers remaining A

✽ L6910 Hand restoration (casts, shading and measurements included), partial hand, with glove, no
fingers remaining A

✽ L6915 Hand restoration (shading, and measurements included), replacement glove for above
A

External Power
✽ L6920 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto
Bock or equal switch, cables, two batteries and one charger, switch control of terminal device
A

✽ L6925 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto
Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal
device A

✽ L6930 Below elbow, external power, selfsuspended inner socket, removable forearm shell, Otto Bock or
equal switch, cables, two batteries and one charger, switch control of terminal device
A

✽ L6935 Below elbow, external power, selfsuspended inner socket, removable forearm shell, Otto Bock or
equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
A

✽ L6940 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside
locking hinges, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch
control of terminal device A

✽ L6945 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside
locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger,
myoelectronic control of terminal device A

✽ L6950 Above elbow, external power, molded inner socket, removable humeral shell, internal locking
elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control
of terminal device A

✽ L6955 Above elbow, external power, molded inner socket, removable humeral shell, internal locking
elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger,
myoelectronic control of terminal device A

✽ L6960 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder
bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device A

✽ L6965 Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder
bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables,

492
 two batteries and one charger, myoelectronic control of terminal device A

✽ L6970 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder
bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two
batteries and one charger, switch control of terminal device A

✽ L6975 Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder
bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables,
two batteries and one charger, myoelectronic control of terminal device A

Additions to Electronic Hand or Hook

Electric hand, switch or myoelectric controlled, adult A
✽ L7007
Electric hand, switch or myoelectric controlled, pediatric A
✽ L7008
Electric hook, switch or myoelectric controlled, adult A
✽ L7009
Prehensile actuator, switch controlled A
✽ L7040
Electric hook, switch or myoelectric controlled, pediatric A
✽ L7045

Figure 42 Electronic elbow.

Additions to Electronic Elbow

Electronic elbow, Hosmer or equal, switch controlled A
✽ L7170
✽ L7180 Electronic elbow, microprocessor sequential control of elbow and terminal device
A
✽ L7181 Electronic elbow, microprocessor simultaneous control of elbow and terminal device
A
Electronic elbow, adolescent, Variety Village or equal, switch controlled A
✽ L7185
Electronic elbow, child, Variety Village or equal, switch controlled A
✽ L7186
✽ L7190 Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled
A
Electronic elbow, child, Variety Village or equal, myoelectronically controlled A
✽ L7191

Wrist
Electronic wrist rotator, any type A
✽ L7259

Battery Components
Six volt battery, each A
✽ L7360
Battery charger, six volt, each A
✽ L7362
Twelve volt battery, each A
✽ L7364
Battery charger, twelve volt, each A
✽ L7366
Lithium ion battery, rechargeable, replacement A
✽ L7367
Lithium ion battery charger, replacement only A
✽ L7368

493
Additions
✽ L7400 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material
(titanium, carbon fiber or equal) A

✽ L7401 Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium,
carbon fiber or equal) A

✽ L7402 Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight

material (titanium, carbon fiber or equal) A

✽ L7403 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material
A

✽ L7404 Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material
A
✽ L7405 Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic
material A

Other/Repair
Upper extremity prosthesis, not otherwise specified A
✽ L7499
Repair of prosthetic device, repair or replace minor parts A
❂ L7510
IOM: 100-02, 15, 110.2; 100-02, 15, 120; 100-04, 32, 100
Repair prosthetic device, labor component, per 15 minutes A
✽ L7520
Prosthetic donning sleeve, any material, each E1
H L7600
Medicare Statute 1862(1)(a)

General

Prosthetic Socket Insert

Gasket or seal, for use with prosthetic socket insert, any type, each A
✽ L7700

Penile Prosthetics
E1
H L7900 Male vacuum erection system ♂
Medicare Statute 1834a
Tension ring, for vacuum erection device, any type, replacement only, each E1
H L7902
Medicare Statute 1834a

Breast Prosthetics
❂ L8000 Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type
A
♀
IOM: 100-02, 15, 120
❂ L8001 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size,
A
any type ♀
IOM: 100-02, 15, 120
❂ L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any
A
type ♀
IOM: 100-02, 15, 120
A
❂ L8010 Breast prosthesis, mastectomy sleeve ♀
IOM: 100-02, 15, 120
A
❂ L8015 External breast prosthesis garment, with mastectomy form, post mastectomy ♀
IOM: 100-02, 15, 120
A
❂ L8020 Breast prosthesis, mastectomy form ♀

494
 IOM: 100-02, 15, 120
A
❂ L8030 Breast prosthesis, silicone or equal, without integral adhesive ♀
IOM: 100-02, 15, 120
Breast prosthesis, silicone or equal, with integral adhesive A
❂ L8031
IOM: 100-02, 15, 120
Nipple prosthesis, reusable, any type, each A
✽ L8032
A
❂ L8035 Custom breast prosthesis, post mastectomy, molded to patient model ♀
IOM: 100-02, 15, 120
A
✽ L8039 Breast prosthesis, not otherwise specified ♀

Figure 43 Implant breast prosthesis.

Nasal, Orbital, Auricular Prostherics

Nasal prosthesis, provided by a non-physician A
✽ L8040
Midfacial prosthesis, provided by a non-physician A
✽ L8041
Orbital prosthesis, provided by a non-physician A
✽ L8042
Upper facial prosthesis, provided by a non-physician A
✽ L8043
Hemi-facial prosthesis, provided by a non-physician A
✽ L8044
Auricular prosthesis, provided by a non-physician A
✽ L8045
Partial facial prosthesis, provided by a non-physician A
✽ L8046
Nasal septal prosthesis, provided by a non-physician A
✽ L8047
Unspecified maxillofacial prosthesis, by report, provided by a non-physician A
✽ L8048
✽ L8049 Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments,
provided by a non-physician A

495
Figure 44 (A) Nasal prosthesis, (B) Auricular prosthesis.

Trusses
Truss, single with standard pad A
❂ L8300
IOM: 100-02, 15, 120; 100-03, 4, 280.11; 100-03, 4, 280.12; 100-04, 4, 240
Truss, double with standard pads A
❂ L8310
IOM: 100-02, 15, 120; 100-03, 4, 280.11; 100-03, 4, 280.12; 100-04, 4, 240
Truss, addition to standard pad, water pad A
❂ L8320
IOM: 100-02, 15, 120; 100-03, 4, 280.11; 100-03, 4, 280.12; 100-04, 4, 240
A
❂ L8330 Truss, addition to standard pad, scrotal pad ♂
IOM: 100-02, 15, 120; 100-03, 4, 280.11; 100-03, 4, 280.12; 100-04, 4, 240

Prosthetic Socks
Prosthetic sheath, below knee, each A
❂ L8400
IOM: 100-02, 15, 200
Prosthetic sheath, above knee, each A
❂ L8410
IOM: 100-02, 15, 200
Prosthetic sheath, upper limb, each A
❂ L8415
IOM: 100-02, 15, 200
✽ L8417 Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each
A
Prosthetic sock, multiple ply, below knee, each A
❂ L8420

496
 IOM: 100-02, 15, 200
Prosthetic sock, multiple ply, above knee, each A
❂ L8430
IOM: 100-02, 15, 200
Prosthetic sock, multiple ply, upper limb, each A
❂ L8435
IOM: 100-02, 15, 200
Prosthetic shrinker, below knee, each A
❂ L8440
IOM: 100-02, 15, 200
Prosthetic shrinker, above knee, each A
❂ L8460
IOM: 100-02, 15, 200
Prosthetic shrinker, upper limb, each A
❂ L8465
IOM: 100-02, 15, 200
Prosthetic sock, single ply, fitting, below knee, each A
❂ L8470
IOM: 100-02, 15, 200
Prosthetic sock, single ply, fitting, above knee, each A
❂ L8480
IOM: 100-02, 15, 200
Prosthetic sock, single ply, fitting, upper limb, each A
❂ L8485
IOM: 100-02, 15, 200

Unlisted
Unlisted procedure for miscellaneous prosthetic services A
✽ L8499

Prosthetic Implants (L8500-L9900)

Larynx, Tracheoesophageal
Artificial larynx, any type A
❂ L8500
IOM: 100-02, 15, 120; 100-03, 1, 50.2; 100-04, 4, 240
Tracheostomy speaking valve A
❂ L8501
IOM: 100-03, 1, 50.4
Artificial larynx replacement battery/accessory, any type A
✽ L8505
Tracheo-esophageal voice prosthesis, patient inserted, any type, each A
✽ L8507
✽ L8509 Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type
A

Voice amplifier A
❂ L8510
IOM: 100-03, 1, 50.2
✽ L8511 Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each
A

✽ L8512 Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only,
per 10 A

✽ L8513 Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement
only, each A

497
 Tracheoesophageal puncture dilator, replacement only, each A
✽ L8514
✽ L8515 Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each
A

Breast
N1 N
❂ L8600 Implantable breast prosthesis, silicone or equal ♀
IOM: 100-02, 15, 120; 100-3, 2, 140.2

Bulking Agents
❂ L8603 Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping
and necessary supplies N1 N
Bill on paper, acquisition cost invoice required
IOM: 100-03, 4, 280.1
✽ L8604 Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, urinary tract, 1 ml,
includes shipping and necessary supplies N1 N

✽ L8605 Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml,
includes shipping and necessary supplies N1 N

❂ L8606 Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and
necessary supplies N1 N

Bill on paper, acquisition cost invoice required

IOM: 100-03, 4, 280.1
❂ L8607 Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary
supplies N1 N

IOM: 100-03, 4, 280.1

Eye and Ear

▶ ✽ L8608 Miscellaneous external component, supply or accessory for use with the Argus II retinal
prosthesis system N

Artificial cornea N1 N
✽ L8609
Ocular implant N1 N
❂ L8610
IOM: 100-02, 15, 120
Aqueous shunt N1 N
❂ L8612
IOM: 100-02, 15, 120
Cross Reference Q0074
Ossicula implant N1 N
❂ L8613
IOM: 100-02, 15, 120
Cochlear device, includes all internal and external components N1 N
❂ L8614
IOM: 100-02, 15, 120; 100-03, 1, 50.3
Headset/headpiece for use with cochlear implant device, replacement A
❂ L8615
IOM: 100-03, 1, 50.3
Microphone for use with cochlear implant device, replacement A
❂ L8616
IOM: 100-03, 1, 50.3
Transmitting coil for use with cochlear implant device, replacement A
❂ L8617
IOM: 100-03, 1, 50.3
❂ L8618 Transmitter cable for use with cochlear implant device or auditory osseointegrated device,
replacement A

IOM: 100-03, 1, 50.3

❂ L8619 Cochlear implant, external speech processor and controller, integrated system, replacement
A

498
 IOM: 100-03, 1, 50.3
✽ L8621 Zinc air battery for use with cochlear implant device and auditory osseointegrated sound
processors, replacement, each A

✽ L8622 Alkaline battery for use with cochlear implant device, any size, replacement, each
A

✽ L8623 Lithium ion battery for use with cochlear implant device speech processor, other than ear
level, replacement, each A

✽ L8624 Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech
processor, ear level, replacement, each A

❂ L8625 External recharging system for battery for use with cochlear implant or auditory
osseointegrated device, replacement only, each A
IOM: 103-03, PART 1, 50.3
Cochlear implant, external speech processor, component, replacement A
❂ L8627
IOM: 103-03, PART 1, 50.3
Cochlear implant, external controller component, replacement A
❂ L8628
IOM: 103-03, PART 1, 50.3
❂ L8629 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement
A

IOM: 103-03, PART 1, 50.3

Hand and Foot

Metacarpophalangeal joint implant N1 N
❂ L8630
IOM: 100-02, 15, 120
❂ L8631 Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or
cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes,
includes entire system) N1 N

IOM: 100-02, 15, 120

Metatarsal joint implant N1 N
❂ L8641
IOM: 100-02, 15, 120
Hallux implant N1 N
❂ L8642
May be billed by ambulatory surgical center or surgeon
IOM: 100-02, 15, 120
Cross Reference Q0073
Interphalangeal joint spacer, silicone or equal, each N1 N
❂ L8658
IOM: 100-02, 15, 120
❂ L8659 Interphalangeal finger joint replacement, 2 or more pieces, metal (e.g., stainless steel or cobalt
chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size
N1 N
IOM: 100-02, 15, 120

499
Figure 45 Metacarpophalangeal implant.

Vascular
Vascular graft material, synthetic, implant N1 N
❂ L8670
IOM: 100-02, 15, 120

Neurostimulator
Implantable neurostimulator, pulse generator, any type N1 N
❂ L8679
IOM: 100-03, 4, 280.4
Implantable neurostimulator electrode, each E1
H L8680
Related CPT codes: 43647, 63650, 63655, 64553, 64555, 64560, 64561, 64565, 64573,
64575, 64577, 64580, 64581.
❂ L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse
generator, replacement only A

IOM: 100-03, 4, 280.4

Implantable neurostimulator radiofrequency receiver N1 N
❂ L8682
IOM: 100-03, 4, 280.4
❂ L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator
radiofrequency receiver A

IOM: 100-03, 4, 280.4

❂ L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator
receiver for bowel and bladder management, replacement A

IOM: 100-03, 4, 280.4

H L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
E1

Related CPT codes: 61885, 64590, 63685.

H L8686 Implantable neurostimulator pulse generator, single array, nonrechargeable, includes
extension E1

Related CPT codes: 61885, 64590, 63685.

H L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
E1

Related CPT codes: 64590, 63685, 61886.

H L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
E1

Related CPT codes: 61885, 64590, 63685.

❂ L8689 External recharging system for battery (internal) for use with implantable neurostimulator,

500
 replacement only A

IOM: 100-03, 4, 280.4

Miscellaneous Orthotic and Prosthetic Components, Services, and Supplies

✽ L8690 Auditory osseointegrated device, includes all internal and external components
Related CPT codes: 69714, 69715, 69717, 69718. N1 N

✽ L8691 Auditory osseointegrated device, external sound processor, excludes transducer/actuator,

replacement only, each A

H L8692 Auditory osseointegrated device, external sound processor, used without osseointegration,
body worn, includes headband or other means of external attachment E1

Medicare Statute 1862(a)(7)

Auditory osseointegrated device abutment, any length, replacement only A
✽ L8693
Auditory osseointegrated device, transducer/actuator, replacement only, each A
✽ L8694
❂ L8695 External recharging system for battery (external) for use with implantable neurostimulator,
replacement only A

IOM: 100-03, 4, 280.4

❂ L8696 Antenna (external) for use with implantable diaphragmatic/phrenic nerve stimulation device,
replacement, each A

Miscellaneous component, supply or accessory for use with total artificial heart system A
▶ ❂ L8698
Prosthetic implant, not otherwise specified N1 N
✽ L8699
▶ ✽ L8701 Powered upper extremity range of motion assist device, elbow, wrist, hand with single or
double upright(s), includes microprocessor, sensors, all components and accessories, custom
fabricated A

▶ ✽ L8702 Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or
double upright(s), includes microprocessor, sensors, all components and accessories, custom
fabricated A

✽ L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS “L”
code N1 N

OTHER MEDICAL SERVICES (M0000-M0301)

Pain screened as moderate to severe M
▶ ✽ M1000
▶ ✽ M1001 Plan of care to address moderate to severe pain documented on or before the date of the
second visit with a clinician M

▶ ✽ M1002 Plan of care for moderate to severe pain not documented on or before the date of the second
visit with a clinician, reason not given M

▶ ✽ M1003 TB screening performed and results interpreted within twelve months prior to initiation of
first-time biologic disease modifying anti-rheumatic drug therapy for RA M

▶ ✽ M1004 Documentation of medical reason for not screening for TB or interpreting results (i.e.,
patient positive for TB and documentation of past treatment; patient who has recently
completed a course of anti-TB therapy) M

TB screening not performed or results not interpreted, reason not given M

▶ ✽ M1005
Disease activity not assessed, reason not given M
▶ ✽ M1006
>=50% of total number of a patient’s outpatient RA encounters assessed M
▶ ✽ M1007
<50% of total number of a patient’s outpatient RA encounters assessed M
▶ ✽ M1008
Patient treatment and final evaluation complete M
▶ ✽ M1009
Patient treatment and final evaluation complete M
▶ ✽ M1010
Patient treatment and final evaluation complete M
▶ ✽ M1011

501
▶ ✽ M1012 Patient treatment and final evaluation complete M

Patient treatment and final evaluation complete M

▶ ✽ M1013
Patient treatment and final evaluation complete M
▶ ✽ M1014
Patient treatment and final evaluation complete M
▶ ✽ M1015
Female patients unable to bear children M
▶ ✽ M1016
Patient admitted to palliative care services M
▶ ✽ M1017
▶ ✽ M1018 Patients with an active diagnosis or history of cancer (except basal cell and squamous cell skin
carcinoma), patients who are heavy tobacco smokers, lung cancer screening patients M

▶ ✽ M1019 Adolescent patients 12 to 17 years of age with major depression or dysthymia who reached
remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or
PHQ-9m score of less than five M

▶ ✽ M1020 Adolescent patients 12 to 17 years of age with major depression or dysthymia who did not
reach remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or
PHQ-9m score of less than 5. Either PHQ-9 or PHQ-9m score was not assessed or is
greater than or equal to 5 M

Patient had only urgent care visits during the performance period M
▶ ✽ M1021
Patients who were in hospice at any time during the performance period M
▶ ✽ M1022
▶ ✽ M1023 Adolescent patients 12 to 17 years of age with major depression or dysthymia who reached
remission at six months as demonstrated by a six month (+/-60 days) PHQ-9 or PHQ-9m
score of less than five M

▶ ✽ M1024 Adolescent patients 12 to 17 years of age with major depression or dysthymia who did not
reach remission at six months as demonstrated by a six month (+/-60 days) PHQ-9 or PHQ-
9m score of less than five. Either PHQ-9 or PHQ-9m score was not assessed or is greater
than or equal to five M

Patients who were in hospice at any time during the performance period M
▶ ✽ M1025
Patients who were in hospice at any time during the performance period M
▶ ✽ M1026
Imaging of the head (CT or MRI) was obtained M
▶ ✽ M1027
▶ ✽ M1028 Documentation of patients with primary headache diagnosis and imaging other than CT or
MRI obtained M

Imaging of the head (CT or MRI) was not obtained, reason not given M
▶ ✽ M1029
Patients with clinical indications for imaging of the head M
▶ ✽ M1030
Patients with no clinical indications for imaging of the head M
▶ ✽ M1031
Adults currently taking pharmacotherapy for OUD M
▶ ✽ M1032
Pharmacotherapy for OUD initiated after June 30th of performance period M
▶ ✽ M1033
▶ ✽ M1034 Adults who have at least 180 days of continuous pharmacotherapy with a medication
prescribed for OUD without a gap of more than seven days M

▶ ✽ M1035 Adults who are deliberately phased out of medication assisted treatment (MAT) prior to 180
days of continuous treatment M

▶ ✽ M1036 Adults who have not had at least 180 days of continuous pharmacotherapy with a medication
prescribed for oud without a gap of more than seven days M

Patients with a diagnosis of lumbar spine region cancer at the time of the procedure M
▶ ✽ M1037
Patients with a diagnosis of lumbar spine region fracture at the time of the procedure M
▶ ✽ M1038
Patients with a diagnosis of lumbar spine region infection at the time of the procedure M
▶ ✽ M1039
Patients with a diagnosis of lumbar idiopathic or congenital scoliosis M
▶ ✽ M1040
▶ ✽ M1041 Patient had cancer, fracture or infection related to the lumbar spine or patient had idiopathic
or congenital scoliosis M

▶ ✽ M1042 Functional status measurement with score was obtained utilizing the Oswestry Disability

502
 Index (ODI version 2.1a) patient reported outcome tool within three months preoperatively
and at one year (9 to 15 months) postoperatively M

▶ ✽ M1043 Functional status measurement with score was not obtained utilizing the Oswestry Disability
Index (ODI version 2.1a) patient reported outcome tool within three months preoperatively
and at one year (9 to 15 months) postoperatively M

▶ ✽ M1044 Functional status was measured by the Oswestry Disability Index (ODI version 2.1a) patient
reported outcome tool within three months preoperatively and at one year (9 to 15 months)
postoperatively M

▶ ✽ M1045 Functional status measurement with score was obtained utilizing the Oxford Knee Score
(OKS) patient reported outcome tool within three months preoperatively and at one year (9
to 15 months) postoperatively M

▶ ✽ M1046 Functional status measurement with score was not obtained utilizing the Oxford Knee Score
(OKS) patient reported outcome tool within three months preoperatively and at one year (9
to 15 months) postoperatively M

▶ ✽ M1047 Functional status was measured by the Oxford Knee Score (OKS) patient reported outcome
tool within three months preoperatively and at one year (9 to 15 months) postoperatively M
▶ ✽ M1048 Functional status measurement with score was obtained utilizing the Oswestry Disability
Index (ODI version 2.1a) patient reported outcome tool within three months preoperatively
and at three months (6 to 20 weeks) postoperatively M

▶ ✽ M1049 Functional status measurement with score was not obtained utilizing the Oswestry Disability
Index (ODI version 2.1a) patient reported outcome tool within three months preoperatively
and at three months (6 to 20 weeks) postoperatively M

▶ ✽ M1050 Functional status was measured by the Oswestry Disability Index (ODI version 2.1a) patient
reported outcome tool within three months preoperatively and at three months (6 to 20
weeks) postoperatively M

▶ ✽ M1051 Patient had cancer, fracture or infection related to the lumbar spine or patient had idiopathic
or congenital scoliosis M

▶ ✽ M1052 Leg pain was not measured by the visual analog scale (VAS) within three months
preoperatively and at one year (9 to 15 months) postoperatively M

▶ ✽ M1053 Leg pain was measured by the visual analog scale (VAS) within three months preoperatively
and at one year (9 to 15 months) postoperatively M

Patient had only urgent care visits during the performance period M
▶ ✽ M1054
Aspirin or another antiplatelet therapy used M
▶ ✽ M1055
▶ ✽ M1056 Prescribed anticoagulant medication during the performance period, history of gi bleeding,
history of intracranial bleeding, bleeding disorder and specific provider documented reasons:
allergy to aspirin or anti-platelets, use of nonsteroidal anti-inflammatory agents, drug-drug
interaction, uncontrolled hypertension >180/110 mmhg or gastroesophageal reflux disease M
Aspirin or another antiplatelet therapy not used, reason not given M
▶ ✽ M1057
▶ ✽ M1058 Patient was a permanent nursing home resident at any time during the performance period
M
▶ ✽ M1059 Patient was in hospice or receiving palliative care at any time during the performance period
M
Patient died prior to the end of the performance period M
▶ ✽ M1060
Patient pregnancy M
▶ ✽ M1061
Patient immunocompromised M
▶ ✽ M1062
Patients receiving high doses of immunosuppressive therapy M
▶ ✽ M1063
Shingrix vaccine documented as administered or previously received M
▶ ✽ M1064
▶ ✽ M1065 Shingrix vaccine was not administered for reasons documented by clinician (e.g., patient
administered vaccine other than shingrix, patient allergy or other medical reasons, patient
declined or other patient reasons, vaccine not available or other system reasons) M

Shingrix vaccine not documented as administered, reason not given M

▶ ✽ M1066
Hospice services for patient provided any time during the measurement period M

503
▶ ✽ M1067
Adults who are not ambulatory M
▶ ✽ M1068
Patient screened for future fall risk M
▶ ✽ M1069
Patient not screened for future fall risk, reason not given M
▶ ✽ M1070
▶ ✽ M1071 Patient had any additional spine procedures performed on the same date as the lumbar
discectomy/laminotomy M

Cellular therapy E1
H M0075
Prolotherapy E1
H M0076
Prolotherapy stimulates production of new ligament tissue. Not covered by Medicare.
Intragastric hypothermia using gastric freezing E1
H M0100
IV chelation therapy (chemical endarterectomy) E1
H M0300
Fabric wrapping of abdominal aneurysm E1
H M0301
Treatment for abdominal aneurysms that involves wrapping aneurysms with cellophane or
fascia lata. Fabric wrapping of abdominal aneurysms is not a covered Medicare procedure.

LABORATORY SERVICES (P0000-P9999)

Chemistry and Toxicology Tests
Cephalin floculation, blood A
❂ P2028
This code appears on a CMS list of codes that represent obsolete and unreliable tests and
procedures. Verify before reporting.
IOM: 100-03, 4, 300.1
Congo red, blood A
❂ P2029
This code appears on a CMS list of codes that represent obsolete and unreliable tests and
procedures. Verify before reporting.
IOM: 100-03, 4, 300.1
Hair analysis (excluding arsenic) E1
H P2031
IOM: 100-03, 4, 300.1
Thymol turbidity, blood A
❂ P2033
This code appears on a CMS list of codes that represent obsolete and unreliable tests and
procedures. Verify before reporting.
IOM: 100-03, 4, 300.1
Mucoprotein, blood (seromucoid) (medical necessity procedure) A
❂ P2038
This code appears on a CMS list of codes that represent obsolete and unreliable tests and
procedures. Verify before reporting.
IOM: 100-03, 4, 300.1

Pathology Screening Tests

❂ P3000 Screening Papanicolaou smear, cervical or vaginal, up to three smears, by technician under
A
physician supervision ♀
Co-insurance and deductible waived
Assign for Pap smear ordered for screening purposes only, conventional method, performed
by technician
IOM: 100-03, 3, 190.2,
Laboratory Certification: Cytology
❂ P3001 Screening Papanicolaou smear, cervical or vaginal, up to three smears, requiring
B
interpretation by physician ♀
Co-insurance and deductible waived
Report professional component for Pap smears requiring physician interpretation. There are

504
 CPT codes assigned for diagnostic Paps, such as, 88141; HCPCS are for screening Paps.
IOM: 100-03, 3, 190.2
Laboratory Certification: Cytology

Microbiology Tests
Culture, bacterial, urine; quantitative, sensitivity study E1
H P7001
Cross Reference CPT
Laboratory Certification: Bacteriology

Miscellaneous Pathology
Blood (whole), for transfusion, per unit R
❂ P9010
Blood furnished on an outpatient basis, subject to Medicare Part B blood deductible;
applicable to first 3 pints of whole blood or equivalent units of packed red cells in calendar
year
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Blood, split unit R
❂ P9011
Reports all splitting activities of any blood component
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Cryoprecipitate, each unit R
❂ P9012
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Red blood cells, leukocytes reduced, each unit R
❂ P9016
IOM: 100-01, 3, 20.5; 100-02, 1, 10
❂ P9017 Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit
IOM: 100-01, 3, 20.5; 100-02, 1, 10 R

Platelets, each unit R

❂ P9019
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Platelet rich plasma, each unit R
❂ P9020
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Red blood cells, each unit R
❂ P9021
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Red blood cells, washed, each unit R
❂ P9022
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Plasma, pooled multiple donor, solvent/detergent treated, frozen, each unit R
❂ P9023
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Platelets, leukocytes reduced, each unit R
❂ P9031
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Platelets, irradiated, each unit R
❂ P9032
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Platelets, leukocytes reduced, irradiated, each unit R
❂ P9033
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Platelets, pheresis, each unit R
❂ P9034
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Platelets, pheresis, leukocytes reduced, each unit R
❂ P9035
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Platelets, pheresis, irradiated, each unit R
❂ P9036
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Platelets, pheresis, leukocytes reduced, irradiated, each unit R
❂ P9037
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Red blood cells, irradiated, each unit R
❂ P9038

505
 IOM: 100-01, 3, 20.5; 100-02, 1, 10
Red blood cells, deglycerolized, each unit R
❂ P9039
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Red blood cells, leukocytes reduced, irradiated, each unit R
❂ P9040
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Infusion, albumin (human), 5%, 50 ml K2 K
✽ P9041
Infusion, plasma protein fraction (human), 5%, 50 ml R
❂ P9043
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Plasma, cryoprecipitate reduced, each unit R
❂ P9044
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Infusion, albumin (human), 5%, 250 ml K2 K
✽ P9045
Infusion, albumin (human), 25%, 20 ml K2 K
✽ P9046
Infusion, albumin (human), 25%, 50 ml K2 K
✽ P9047
Infusion, plasma protein fraction (human), 5%, 250 ml R
✽ P9048
Granulocytes, pheresis, each unit E2
✽ P9050
Whole blood or red blood cells, leukocytes reduced, CMV-negative, each unit R
❂ P9051
Medicare Statute 1833(t)
Platelets, HLA-matched leukocytes reduced, apheresis/pheresis, each unit R
❂ P9052
Medicare Statute 1833(t)
Platelets, pheresis, leukocytes reduced, CMV-negative, irradiated, each unit R
❂ P9053
Freezing and thawing are reported separately, see Transmittal 1487 (Hospital outpatient)
Medicare Statute 1833(t)
❂ P9054 Whole blood or red blood cells, leukocytes reduced, frozen, deglycerol, washed, each unit
R

Medicare Statute 1833(t)

Platelets, leukocytes reduced, CMVnegative, apheresis/pheresis, each unit R
❂ P9055
Medicare Statute 1833(t)
Whole blood, leukocytes reduced, irradiated, each unit R
❂ P9056
Medicare Statute 1833(t)
❂ P9057 Red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit
R

Medicare Statute 1833(t)

Red blood cells, leukocytes reduced, CMV-negative, irradiated, each unit R
❂ P9058
Medicare Statute 1833(t)
Fresh frozen plasma between 8-24 hours of collection, each unit R
❂ P9059
Medicare Statute 1833(t)
Fresh frozen plasma, donor retested, each unit R
❂ P9060
Medicare Statute 1833(t)
Plasma, pooled multiple donor, pathogen reduced, frozen, each unit R
❂ P9070
Medicare Statute 1833(T)
Plasma (single donor), pathogen reduced, frozen, each unit R
❂ P9071
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Medicare Statute 1833T
Platelets, pheresis, pathogen-reduced, each unit R
❂ P9073
IOM: 100-01, 3, 20.5; 100-02, 1, 10
Medicare Statute 1833T
Pathogen(s) test for platelets S
❂ P9100
IOM: 100-03, 4, 300.1

506
Travel Allowance for Specimen Collection
❂ P9603 Travel allowance one way in connection with medically necessary laboratory specimen
collection drawn from home bound or nursing home bound patient; prorated miles actually
traveled A

Fee for clinical laboratory travel (P9603) is $1.025 per mile for CY2015.
IOM: 100-04, 16, 60
❂ P9604 Travel allowance one way in connection with medically necessary laboratory specimen
collection drawn from home bound or nursing home bound patient; prorated trip charge
A

For CY2010, the fee for clinical laboratory travel is $10.30 per flat rate trip for CY2015.
IOM: 100-04, 16, 60

Catheterization for Specimen Collection

Catheterization for collection of specimen, single patient, all places of service A
❂ P9612
NCCI edits indicate that when 51701 is comprehensive or is a Column 1 code, P9612 cannot
be reported. When the catheter insertion is a component of another procedure, do not report
straight catheterization separately.
IOM: 100-04, 16, 60
Coding Clinic: 2007, Q3, P7
Catheterization for collection of specimen(s) (multiple patients) N
❂ P9615
IOM: 100-04, 16, 60

TEMPORARY CODES ASSIGNED BY CMS (Q0000-Q9999)

Cardiokymography
Cardiokymography Q1
❂ Q0035
Report modifier 26 if professional component only
IOM: 100-03, 1, 20.24

Infusion Therapy
Infusion therapy, using other than chemotherapeutic drugs, per visit B
❂ Q0081
IV piggyback only assigned one time per patient encounter per day. Report for hydration or
the intravenous administration of antibiotics, antiemetics, or analgesics. Bill on paper.
Requires a report.
IOM: 100-03, 4, 280.14
Coding Clinic: 2004, Q2, P11; Q1, P5, 8; 2002, Q2, P10; Q1, P7

Chemotherapy Administration
✽ Q0083 Chemotherapy administration by other than infusion technique only (e.g., subcutaneous,
intramuscular, push), per visit B
Coding Clinic: 2002, Q1, P7
Chemotherapy administration by infusion technique only, per visit B
❂ Q0084
IOM: 100-03, 4, 280.14
Coding Clinic: 2004, Q2, P11; 2002, Q1, P7
✽ Q0085 Chemotherapy administration by both infusion technique and other technique(s) (e.g.,
subcutaneous, intramuscular, push), per visit B
Coding Clinic: 2002, Q1, P7

Smear Preparation
❂ Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal
S
smear to laboratory ♀

507
 Medicare does not cover comprehensive preventive medicine services; however, services
described by G0101 and Q0091 (only for Medicare patients) are covered. Includes the
services necessary to procure and transport the specimen to the laboratory.
IOM: 100-03, 3, 190.2
Coding Clinic: 2002, Q4, P8

Portable X-ray Setup

Set-up portable x-ray equipment N
❂ Q0092
IOM: 100-04, 13, 90

Miscellaneous Lab Services

Wet mounts, including preparations of vaginal, cervical or skin specimens A
✽ Q0111
Laboratory Certification: Bacteriology, My cology, Parasitology
All potassium hydroxide (KOH) preparations A
✽ Q0112
Laboratory Certification: Mycology
Pinworm examinations A
✽ Q0113
Laboratory Certification: Parasitology
A
✽ Q0114 Fern test ♀
Laboratory Certification: Routine chemistry
A
✽ Q0115 Post-coital direct, qualitative examinations of vaginal or cervical mucous ♀
Laboratory Certification: Hematology

Drugs
✽ Q0138 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)
K2 K
Feraheme is FDA approved for chronic kidney disease.
Other: Feraheme
✽ Q0139 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD on dialysis)
K2 K

Other: Feraheme
Azithromycin dihydrate, oral, capsules/powder, 1 gm E1
H Q0144
Other: Zithromax, Zmax
✽ Q0161 Chlorpromazine hydrochloride, 5 mg, oral, FDA approved prescription antiemetic, for use as
a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy
treatment, not to exceed a 48 hour dosage regimen N1 N

❂ Q0162 Ondansetron 1 mg, oral, FDA-approved prescription anti-emetic, for use as a complete
therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to
exceed a 48 hour dosage regimen N1 N

Other: Zofran
Medicare Statute 4557
Coding Clinic: 2012, Q1, P9

❂ Q0163 Diphenhydramine hydrochloride, 50 mg, oral, FDA approved prescription anti-emetic, for
use as a complete therapeutic substitute for an IV antiemetic at time of chemotherapy
treatment not to exceed a 48 hour dosage regimen N1 N

Other: Alercap, Alertab, Allergy Relief Medicine, Allermax, Anti-Hist, Antihistamine, Banophen,
Complete Allergy Medication, Complete Allergy medicine, Diphedryl, Diphenhist,
Diphenhydramine, Dormin Sleep Aid, Genahist, Geridryl, Good Sense Antihistamine Allergy
Relief, Good Sense Nighttime Sleep Aid, Mediphedryl, Night Time Sleep Aid, Nytol Quickcaps,
Nytol Quickgels maximum strength, Quality Choice Sleep Aid, Quality Choice Rest Simply,
Rapidpaq Dicopanol, Rite Aid Allergy, Serabrina La France, Siladryl Allergy, Silphen, Simply
Sleep, Sleep Tabs, Sleepinal, Sominex, Twilite, Valu-Dryl Allergy

508
 Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0164 Prochlorperazine maleate, 5 mg, oral, FDA approved prescription anti-emetic, for use as a
complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment,
not to exceed a 48 hour dosage regimen N1 N

Other: Compazine
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0166 Granisetron hydrochloride, 1 mg, oral, FDA approved prescription anti-emetic, for use as a
complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment,
not to exceed a 24 hour dosage regimen N1 N

Other: Kytril
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0167 Dronabinol, 2.5 mg, oral, FDA approved prescription anti-emetic, for use as a complete
therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to
exceed a 48 hour dosage regimen N1 N

Other: Marinol
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10

❂ Q0169 Promethazine hydrochloride, 12.5 mg, oral, FDA approved prescription antiemetic, for use
as a complete therapeutic substitute for an IV antiemetic at the time of chemotherapy
treatment, not to exceed a 48 hour dosage regimen N1 N

Other: Anergan, Chlorpromazine, Hydroxyzine Pamoate, Phenazine, Phenergan, Prorex,

Prothazine, V-Gan
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10

❂ Q0173 Trimethobenzamide hydrochloride, 250 mg, oral, FDA approved prescription anti-emetic,
for use as a complete therapeutic substitute for an IV anti-emetic at the time of
chemotherapy treatment, not to exceed a 48 hour dosage regimen N1 N

Other: Arrestin, Ticon, Tigan, Tiject

Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0174 Thiethylperazine maleate, 10 mg, oral, FDA approved prescription anti-emetic, for use as a
complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment,
not to exceed a 48 hour dosage regimen E2

Other: Torecan
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10

❂ Q0175 Perphenazine, 4 mg, oral, FDA approved prescription anti-emetic, for use as a complete
therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to
exceed a 48 hour dosage regimen N1 N

Medicare Statute 4557

Coding Clinic: 2012, Q2, P10
❂ Q0177 Hydroxyzine pamoate, 25 mg, oral, FDA approved prescription anti-emetic, for use as a
complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment,
not to exceed a 48 hour dosage regimen N1 N

Other: Vistaril
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10

❂ Q0180 Dolasetron mesylate, 100 mg, oral, FDA approved prescription anti-emetic, for use as a
complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment,
not to exceed a 24 hour dosage regimen N1 N

Other: Anzemet

509
 Medicare Statute 4557
Coding Clinic: 2012, Q2, P10
❂ Q0181 Unspecified oral dosage form, FDA approved prescription anti-emetic, for use as a complete
therapeutic substitute for a IV anti-emetic at the time of chemotherapy treatment, not to
exceed a 48 hour dosage regimen N1 N
Medicare Statute 4557
Coding Clinic: 2012, Q2, P10

Figure 46 Ventricular assist device.

Ventricular Assist Devices

❂ Q0477 Power module patient cable for use with electric or electric/pneumatic ventricular assist
device, replacement only A

❂ Q0478 Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type
A

CMS has determined the reasonable useful lifetime is one year. Add modifier RA to claims
to report when battery is replaced because it was lost, stolen, or irreparably damaged.
❂ Q0479 Power module for use with electric or electric/pneumatic ventricular assist device,
replacemment only A

CMS has determined the reasonable useful lifetime is one year. Add modifier RA in cases
where the battery is being replaced because it was lost, stolen, or irreparably damaged.
Driver for use with pneumatic ventricular assist device, replacement only A
❂ Q0480
❂ Q0481 Microprocessor control unit for use with electric ventricular assist device, replacement only
A

❂ Q0482 Microprocessor control unit for use with electric/pneumatic combination ventricular assist
device, replacement only A

❂ Q0483 Monitor/display module for use with electric ventricular assist device, replacement only
A

❂ Q0484 Monitor/display module for use with electric or electric/pneumatic ventricular assist device,
replacement only A

❂ Q0485 Monitor control cable for use with electric ventricular assist device, replacement only
A

❂ Q0486 Monitor control cable for use with electric/pneumatic ventricular assist device, replacement
only A

❂ Q0487 Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device,
replacement only A

Power pack base for use with electric ventricular assist device, replacement only A
❂ Q0488
❂ Q0489 Power pack base for use with electric/pneumatic ventricular assist device, replacement only
A

510
 ❂ Q0490 Emergency power source for use with electric ventricular assist device, replacement only
A

❂ Q0491 Emergency power source for use with electric/pneumatic ventricular assist device,
replacement only A

❂ Q0492 Emergency power supply cable for use with electric ventricular assist device, replacement only
A

❂ Q0493 Emergency power supply cable for use with electric/pneumatic ventricular assist device,
replacement only A

❂ Q0494 Emergency hand pump for use with electric or electric/pneumatic ventricular assist device,
replacement only A

❂ Q0495 Battery/power pack charger for use with electric or electric/pneumatic ventricular assist
device, replacement only A

❂ Q0496 Battery, other than lithium-ion, for use with electric or electric/pneumatic ventricular assist
device, replacement only A
Reasonable useful lifetime is 6 months (CR3931).
❂ Q0497 Battery clips for use with electric or electric/pneumatic ventricular assist device, replacement
only A

❂ Q0498 Holster for use with electric or electric/pneumatic ventricular assist device, replacement only
A

❂ Q0499 Belt/vest/bag for use to carry external peripheral components of any type ventricular assist
device, replacement only A

❂ Q0500 Filters for use with electric or electric/pneumatic ventricular assist device, replacement only
A

❂ Q0501 Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement
only A

Mobility cart for pneumatic ventricular assist device, replacement only A

❂ Q0502
Battery for pneumatic ventricular assist device, replacement only, each A
❂ Q0503
Reasonable useful lifetime is 6 months (CR3931).
❂ Q0504 Power adapter for pneumatic ventricular assist device, replacement only, vehicle type
A

❂ Q0506 Battery, lithium-ion, for use with electric or electric/pneumatic, ventricular assist device,
replacement only A

Reasonable useful lifetime is 12 months. Add -RA for replacement if lost, stolen, or
irreparable damage.
❂ Q0507 Miscellaneous supply or accessory for use with an external ventricular assist device
A
❂ Q0508 Miscellaneous supply or accessory for use with an implanted ventricular assist device
A

❂ Q0509 Miscellaneous supply or accessory for use with any implanted ventricular assist device for
which payment was not made under Medicare Part A A

Pharmacy: Supply and Dispensing Fee

❂ Q0510 Pharmacy supply fee for initial immunosuppressive drug(s), first month following transplant
B

❂ Q0511 Pharmacy supply fee for oral anticancer, oral anti-emetic or immunosuppressive drug(s); for
the first prescription in a 30-day period B

❂ Q0512 Pharmacy supply fee for oral anticancer, oral anti-emetic or immunosuppressive drug(s); for a
subsequent prescription in a 30-day period B

Pharmacy dispensing fee for inhalation drug(s); per 30 days B

❂ Q0513
Pharmacy dispensing fee for inhalation drug(s); per 90 days B
❂ Q0514

511
Sermorelin Acetate
Injection, sermorelin acetate, 1 microgram E2
❂ Q0515
IOM: 100-02, 15, 50

New Technology: Intraocular Lens

❂ Q1004 New technology intraocular lens category 4 as defined in Federal Register notice
E1
❂ Q1005 New technology intraocular lens category 5 as defined in Federal Register notice
E1

Solutions and Drugs

❂ Q2004 Irrigation solution for treatment of bladder calculi, for example renacidin, per 500 ml
N1 N
IOM: 100-02, 15, 50
Medicare Statute 1861S2B
Injection, fosphenytoin, 50 mg phenytoin equivalent K2 K
❂ Q2009
IOM: 100-02, 15, 50
Medicare Statute 1861S2B
Injection, teniposide, 50 mg K2 K
❂ Q2017
IOM: 100-02, 15, 50
Medicare Statute 1861S2B
Injection, radiesse, 0.1 ml E2
❂ Q2026
Coding Clinic: 2010, Q3, P8
Injection, sculptra, 0.5 mg E2
❂ Q2028
❂ Q2034 Influenza virus vaccine, split virus, for intramuscular use (Agriflu) Sipuleucel-t, minimum of
50 million autologous CD54+ cells activated with PAP-GM-CSF, including leukapheresis
and all other preparatory procedures, per infusion L1 L

IOM: 100-02, 15, 50

❂ Q2035 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,
for intramuscular use (Afluria) L1 L

Preventive service; no deductible

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P7; 2010, Q4, P8-9

❂ Q2036 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,
for intramuscular use (Flulaval) L1 L

Preventive service; no deductible

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P7; 2010, Q4, P8-9

❂ Q2037 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older,
for intramuscular use (Fluvirin) L1 L

Preventive service; no deductible

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P7; 2010, Q4, P8-9

❂ Q2038 Influenza virus vaccine, split virus, when administered to individuals 3 years of age or older,
for intramuscular use (Fluzone) L1 L

Preventive service; no deductible

IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P7; 2010, Q4, P8-9
Influenza virus vaccine, not otherwise specified L1 L
❂ Q2039
Preventive service; no deductible
IOM: 100-02, 15, 50
Coding Clinic: 2011, Q1, P7; 2010, Q4, P8-9

512
 Q2040 Tisagenlecleucel, up to 250 million car-positive viable T cells, including leukapheresis and
dose preparation procedures, per infusion ✖
▶ ❂ Q2041 Axicabtagene ciloleucel, up to 200 million autologous anti-CD 19 CAR-positive viable T
cells, including leukapheresis and dose preparation procedures, per therapeutic dose G

▶ ❂ Q2042 Tisagenlecleucel, up to 600 million CAR-positive viable T cells, including leukapheresis and
dose preparation procedures, per therapeutic dose G

❂ Q2043 Sipuleucel-T, minimum of 50 million autologous CD54+ cells activated with PAP-GM-
CSF, including leukapheresis and all other preparatory procedures, per infusion
Other: Provenge K2 K
Coding Clinic: 2012, Q2, P7; Q1, P7, 9; 2011, Q3, P9
✽ Q2049 Injection, doxorubicin hydrochloride, liposomal, imported lipodox, 10 mg
Coding Clinic: 2012, Q3, P10 K2 K

❂ Q2050 Injection, doxorubicin hydrochloride, liposomal, not otherwise specified, 10 mg

Other: Doxil K2 K

IOM: 100-02, 15, 50

❂ Q2052 Services, supplies and accessories used in the home under the Medicare intravenous immune
globulin (IVIG) demonstration E1
Coding Clinic: 2014, Q2, P6

Brachytherapy Radioelements
Radioelements for brachytherapy, any type, each B
❂ Q3001
IOM: 100-04, 12, 70; 100-04, 13, 20

Telehealth
Telehealth originating site facility fee A
✽ Q3014
Effective January of each year, the fee for telehealth services is increased by the Medicare
Economic Index (MEI). The telehealth originating facility site fee (HCPCS code Q3014)
for 2011 was 80 percent of the lesser of the actual charge or $24.10.

Drugs
Injection, interferon beta-1a, 1 mcg for intramuscular use K2 K
❂ Q3027
Other: Avonex
IOM: 100-02, 15, 50
Injection, interferon beta-1a, 1 mcg for subcutaneous use E1
H Q3028

Skin Test
Collagen skin test N1 N
❂ Q3031
IOM: 100-03, 4, 280.1

Supplies: Cast
Q4001-Q4051: Payment on a reasonable charge basis is required for splints, casts by regulations
contained in 42 CFR 405.501.
Casting supplies, body cast adult, with or without head, plaster B
✽ Q4001
Cast supplies, body cast adult, with or without head, fiberglass B
✽ Q4002
Cast supplies, shoulder cast, adult (11 years +), plaster B
✽ Q4003
Cast supplies, shoulder cast, adult (11 years +), fiberglass B
✽ Q4004
Cast supplies, long arm cast, adult (11 years +), plaster B
✽ Q4005
Cast supplies, long arm cast, adult (11 years +), fiberglass B
✽ Q4006
Cast supplies, long arm cast, pediatric (0-10 years), plaster B
✽ Q4007

513
✽ Q4008 Cast supplies, long arm cast, pediatric (0-10 years), fiberglass B

Cast supplies, short arm cast, adult (11 years +), plaster B
✽ Q4009
Cast supplies, short arm cast, adult (11 years +), fiberglass B
✽ Q4010
Cast supplies, short arm cast, pediatric (0-10 years), plaster B
✽ Q4011
Cast supplies, short arm cast, pediatric (0-10 years), fiberglass B
✽ Q4012
✽ Q4013 Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), plaster
B

✽ Q4014 Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), fiberglass
B

✽ Q4015 Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years), plaster
B

✽ Q4016 Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years),
fiberglass B

Cast supplies, long arm splint, adult (11 years +), plaster B
✽ Q4017
Cast supplies, long arm splint, adult (11 years +), fiberglass B
✽ Q4018
Cast supplies, long arm splint, pediatric (0-10 years), plaster B
✽ Q4019
Cast supplies, long arm splint, pediatric (0-10 years), fiberglass B
✽ Q4020
Cast supplies, short arm splint, adult (11 years +), plaster B
✽ Q4021
Cast supplies, short arm splint, adult (11 years +), fiberglass B
✽ Q4022
Cast supplies, short arm splint, pediatric (0-10 years), plaster B
✽ Q4023
Cast supplies, short arm splint, pediatric (0-10 years), fiberglass B
✽ Q4024
Cast supplies, hip spica (one or both legs), adult (11 years +), plaster B
✽ Q4025
Cast supplies, hip spica (one or both legs), adult (11 years +), fiberglass B
✽ Q4026
Cast supplies, hip spica (one or both legs), pediatric (0-10 years), plaster B
✽ Q4027
✽ Q4028 Cast supplies, hip spica (one or both legs), pediatric (0-10 years), fiberglass
B
Cast supplies, long leg cast, adult (11 years +), plaster B
✽ Q4029
Cast supplies, long leg cast, adult (11 years +), fiberglass B
✽ Q4030
Cast supplies, long leg cast, pediatric (0-10 years), plaster B
✽ Q4031
Cast supplies, long leg cast, pediatric (0-10 years), fiberglass B
✽ Q4032
Cast supplies, long leg cylinder cast, adult (11 years +), plaster B
✽ Q4033
Cast supplies, long leg cylinder cast, adult (11 years +), fiberglass B
✽ Q4034
Cast supplies, long leg cylinder cast, pediatric (0-10 years), plaster B
✽ Q4035
Cast supplies, long leg cylinder cast, pediatric (0-10 years), fiberglass B
✽ Q4036
Cast supplies, short leg cast, adult (11 years +), plaster B
✽ Q4037
Cast supplies, short leg cast, adult (11 years +), fiberglass B
✽ Q4038
Cast supplies, short leg cast, pediatric (0-10 years), plaster B
✽ Q4039

514
Figure 47 Finger splint.

Cast supplies, short leg cast, pediatric (0-10 years), fiberglass B

✽ Q4040
Cast supplies, long leg splint, adult (11 years +), plaster B
✽ Q4041
Cast supplies, long leg splint, adult (11 years +), fiberglass B
✽ Q4042
Cast supplies, long leg splint, pediatric (0-10 years), plaster B
✽ Q4043
Cast supplies, long leg splint, pediatric (0-10 years), fiberglass B
✽ Q4044
Cast supplies, short leg splint, adult (11 years +), plaster B
✽ Q4045
Cast supplies, short leg splint, adult (11 years +), fiberglass B
✽ Q4046
Cast supplies, short leg splint, pediatric (0-10 years), plaster B
✽ Q4047
Cast supplies, short leg splint, pediatric (0-10 years), fiberglass B
✽ Q4048
Finger splint, static B
✽ Q4049
Cast supplies, for unlisted types and materials of casts B
✽ Q4050
✽ Q4051 Splint supplies, miscellaneous (includes thermoplastics, strapping, fasteners, padding and
other supplies) B

Drugs
✽ Q4074 Iloprost, inhalation solution, FDA-approved final product, non-compounded, administered
through DME, unit dose form, up to 20 micrograms Y

Other: Ventavis
Injection, epoetin alfa, 100 units (for ESRD on dialysis) N
❂ Q4081
Other: Epogen, Procrit
✽ Q4082 Drug or biological, not otherwise classified, Part B drug competitive acquisition program
(CAP) B

515
Skin Substitutes
Skin substitute, not otherwise specified N1 N
✽ Q4100
Coding Clinic: 2018, Q2, P3; 2012, Q2, P7
Apligraf, per square centimeter N1 N
✽ Q4101
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
Oasis Wound Matrix, per square centimeter N1 N
✽ Q4102
Coding Clinic: 2012, Q3, P8; Q2, P7; 2011, Q1, P9
Oasis Burn Matrix, per square centimeter N1 N
✽ Q4103
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
✽ Q4104 Integra Bilayer Matrix Wound Dressing (BMWD), per square centimeter
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9; 2010, Q2, P8 N1 N

✽ Q4105 Integra Dermal Regeneration Template (DRT,) or integra omnigraft dermal regeneration
matrix, per square centimeter N1 N
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9; 2010, Q2, P8
Dermagraft, per square centimeter N1 N
✽ Q4106
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
Graftjacket, per square centimeter N1 N
✽ Q4107
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
Integra Matrix, per square centimeter N1 N
✽ Q4108
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9; 2010, Q2, P8
Primatrix, per square centimeter N1 N
✽ Q4110
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
GammaGraft, per square centimeter N1 N
✽ Q4111
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
Cymetra, injectable, 1 cc N1 N
✽ Q4112
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
GraftJacket Xpress, injectable, 1 cc N1 N
✽ Q4113
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
Integra Flowable Wound Matrix, injectable, 1 cc N1 N
✽ Q4114
Coding Clinic: 2012, Q2, P7; 2010, Q2, P8
Alloskin, per square centimeter N1 N
✽ Q4115
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
Alloderm, per square centimeter N1 N
✽ Q4116
Coding Clinic: 2012, Q2, P7; 2011, Q1, P9
Hyalomatrix, per square centimeter N1 N
✽ Q4117
IOM: 100-02, 15, 50
Matristem micromatrix, 1 mg N1 N
✽ Q4118
Coding Clinic: 2013, Q4, P2; 2012, Q2, P7; 2011, Q1, P6
Theraskin, per square centimeter N1 N
✽ Q4121
Coding Clinic: 2012, Q2, P7; 2011, Q1, P6
Dermacell, per square centimeter N1 N
✽ Q4122
Coding Clinic: 2012, Q2, P7; Q1, P8
AlloSkin RT, per square centimeter N1 N
✽ Q4123
Oasis Ultra Tri-layer Wound Matrix, per square centimeter N1 N
✽ Q4124
Coding Clinic: 2012, Q2, P7; Q1, P9
Arthroflex, per square centimeter N1 N
✽ Q4125
Memoderm, dermaspan, tranzgraft or integuply, per square centimeter N1 N
✽ Q4126
Talymed, per square centimeter N1 N
✽ Q4127
FlexHD, Allopatch HD, or Matrix HD, per square centimeter N1 N
✽ Q4128
Strattice TM, per square centimeter N1 N
✽ Q4130
Coding Clinic: 2012, Q2, P7

516
 Q4131 Epifix, per square centimeter ✖
Grafix core and GrafixPL core, per square centimeter N1 N
✽ Q4132
✽ Q4133 Grafix prime, GrafixPL prime, stravix and stravixpl, per square centimeter
N1 N
Hmatrix, per square centimeter N1 N
✽ Q4134
Mediskin, per square centimeter N1 N
✽ Q4135
Ez-derm, per square centimeter N1 N
✽ Q4136
Amnioexcel, amnioexcel plus or biodexcel, per square centimeter N1 N
✽ Q4137
Biodfence dryflex, per square centimeter N1 N
✽ Q4138
Amniomatrix or biodmatrix, injectable, 1 cc N1 N
✽ Q4139
Biodfence, per square centimeter N1 N
✽ Q4140
Alloskin ac, per square centimeter N1 N
✽ Q4141
XCM biologic tissue matrix, per square centimeter N1 N
✽ Q4142
Repriza, per square centimeter N1 N
✽ Q4143
Epifix, injectable, 1 mg N1 N
✽ Q4145
Tensix, per square centimeter N1 N
✽ Q4146
✽ Q4147 Architect, architect PX, or architect FX, extracellular matrix, per square centimeter
N1 N

Neox cord 1K, Neox cord RT, or Clarix cord 1K, per square centimeter N1 N
✽ Q4148
Excellagen, 0.1 cc N1 N
✽ Q4149
AlloWrap DS or dry, per square centimeter N1 N
✽ Q4150
Amnioband or guardian, per square centimeter N1 N
✽ Q4151
DermaPure, per square centimeter N1 N
✽ Q4152
Dermavest and Plurivest, per square centimeter N1 N
✽ Q4153
Biovance, per square centimeter N1 N
✽ Q4154
Neoxflo or clarixflo, 1 mg N1 N
✽ Q4155
Neox 100 or Clarix 100, per square centimeter N1 N
✽ Q4156
Revitalon, per square centimeter N1 N
✽ Q4157
Kerecis Omega3, per square centimeter N1 N
✽ Q4158
Affinity, per square centimeter N1 N
✽ Q4159
Nushield, per square centimeter N1 N
✽ Q4160
Bio-ConneKt Wound Matrix, per square centimeter N1 N
✽ Q4161
Woundex flow, BioSkin flow 0.5 cc N1 N
✽ Q4162
Woundex, BioSkin per square centimeter N1 N
✽ Q4163
Helicoll, per square centimeter N1 N
✽ Q4164
Keramatrix, per square centimeter N1 N
✽ Q4165
Cytal, per square centimeter N1 N
✽ Q4166
Coding Clinic: 2017, Q1, P10
TruSkin, per square centimeter N1 N
✽ Q4167
Coding Clinic: 2017, Q1, P10
AmnioBand, 1 mg N1 N
✽ Q4168
Coding Clinic: 2017, Q1, P10
Artacent wound, per square centimeter N1 N
✽ Q4169
Coding Clinic: 2017, Q1, P10

517
 ✽ Q4170 Cygnus, per square centimeter N1 N
Coding Clinic: 2017, Q1, P10
Interfyl, 1 mg N1 N
✽ Q4171
Coding Clinic: 2017, Q1, P10
Q4172 Puraply or puraply am, per square centimeter ✖
PalinGen or PalinGen XPlus, per square centimeter N1 N
✽ Q4173
Coding Clinic: 2017, Q1, P10
PalinGen or ProMatrX, 0.36 mg per 0.25 cc N1 N
✽ Q4174
Coding Clinic: 2017, Q1, P10
Miroderm, per square centimeter N1 N
✽ Q4175
Coding Clinic: 2017, Q1, P10
Neopatch, per square centimeter N1 N
✽ Q4176
Floweramnioflo, 0.1 cc N1 N
✽ Q4177
Floweramniopatch, per square centimeter N1 N
✽ Q4178
Flowerderm, per square centimeter N1 N
✽ Q4179
Revita, per square centimeter N1 N
✽ Q4180
Amnio wound, per square centimeter N1 N
✽ Q4181
Transcyte, per square centimeter N1 N
✽ Q4182
Surgigraft, per square centimeter N
▶ ✽ Q4183
Cellesta, per square centimeter N
▶ ✽ Q4184
Cellesta flowable amnion (25 mg per cc); per 0.5 cc N
▶ ✽ Q4185
Epifix, per square centimeter N
▶ ✽ Q4186
Epicord, per square centimeter N
▶ ✽ Q4187
Amnioarmor, per square centimeter N
▶ ✽ Q4188
Artacent ac, 1 mg N
▶ ✽ Q4189
Artacent ac, per square centimeter N
▶ ✽ Q4190
Restorigin, per square centimeter N
▶ ✽ Q4191
Restorigin, 1 cc N
▶ ✽ Q4192
Coll-e-derm, per square centimeter N
▶ ✽ Q4193
Novachor, per square centimeter N
▶ ✽ Q4194
Puraply, per square centimeter G
▶ ✽ Q4195
Puraply am, per square centimeter G
▶ ✽ Q4196
Puraply xt, per square centimeter N
▶ ✽ Q4197
Genesis amniotic membrane, per square centimeter N
▶ ✽ Q4198
Skin te, per square centimeter N
▶ ✽ Q4200
Matrion, per square centimeter N
▶ ✽ Q4201
Keroxx (2.5g/cc), 1cc N
▶ ✽ Q4202
Derma-gide, per square centimeter N
▶ ✽ Q4203
Xwrap, per square centimeter N
▶ ✽ Q4204

Hospice Care
Hospice or home health care provided in patient’s home/residence B
❂ Q5001
Hospice or home health care provided in assisted living facility B
❂ Q5002
❂ Q5003 Hospice care provided in nursing long term care facility (LTC) or non-skilled nursing

518
 facility (NF) B

Hospice care provided in skilled nursing facility (SNF) B

❂ Q5004
Hospice care provided in inpatient hospital B
❂ Q5005
Hospice care provided in inpatient hospice facility B
❂ Q5006
Hospice care provided in an inpatient hospice facility. These are residential facilities,
which are places for patients to live while receiving routine home care or continuous home
care. These hospice residential facilities are not certified by Medicare or Medicaid for
provision of General Inpatient (GIP) or respite care, and regulations at 42 CFR
418.202(e) do not allow provision of GIP or respite care at hospice residential facilities.
Hospice care provided in long term care facility B
❂ Q5007
Hospice care provided in inpatient psychiatric facility B
❂ Q5008
Hospice or home health care provided in place not otherwise specified (NOS) B
❂ Q5009
Hospice home care provided in a hospice facility B
❂ Q5010

Biosimilar Drugs
Injection, filgrastim-sndz, biosimilar, (zarxio), 1 microgram K2 G
❂ Q5101
Other: Zarxio
Q5102 Injection, infliximab, biosimilar, 10 mg ✖
Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg G
▶ ❂ Q5103
Other: Remicade, Inflectra, Renflexis
Injection, infliximab-abda, biosimilar, (renflexis), 10 mgn K2 G
▶ ❂ Q5104
Other: Remicade
Injection, epoetin alfa, biosimilar, (retacrit) (for ESRD on dialysis), 100 units K2 G
▶ ❂ Q5105
Other: Retacrit
Injection, epoetin alfa, biosimilar, (retacrit) (for non-ESRD use), 1000 units G
▶ ❂ Q5106
Other: Retacrit
Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg E2
▶ ❂ Q5107
Other: Avastin
Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg K
▶ ❂ Q5108
Other: Neulasta
Injection, infliximab-qbtx, biosimilar, (ixifi), 10 mg E2
▶ ❂ Q5109
Other: Remicade, Inflectra, Renflexis
Injection, filgrastim-aafi, biosimilar, (nivestym), 1 microgram K
▶ ❂ Q5110
Other: Nivestym

Contrast Agents
Injection, sulfur hexafluoride lipid microspheres, per ml N1 N
✽ Q9950
Other: Lumason
❂ Q9951 Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml
N1 N
IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8
Injection, iron-based magnetic resonance contrast agent, per ml N1 N
❂ Q9953
IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8
Oral magnetic resonance contrast agent, per 100 ml N1 N
❂ Q9954
IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8
Injection, perflexane lipid microspheres, per ml N1 N
✽ Q9955

519
 Coding Clinic: 2012, Q3, P8
Injection, octafluoropropane microspheres, per ml N1 N
✽ Q9956
Other: Optison
Coding Clinic: 2012, Q3, P8
Injection, perflutren lipid microspheres, per ml N1 N
✽ Q9957
Other: Definity
Coding Clinic: 2012, Q3, P8
❂ Q9958 High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml
Other: Conray 30, Cysto-Conray II, Cystografin N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
❂ Q9959 High osmolar contrast material, 150-199 mg/ml iodine concentration, per ml
IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90 N1 N
Coding Clinic: 2012, Q3, P8; 2007, Q1, P6

❂ Q9960 High osmolar contrast material, 200-249 mg/mliodine concentration, per ml

Other: Conray 43 N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8; 2007, Q1, P6

❂ Q9961 High osmolar contrast material, 250-299 mg/mliodine concentration, per ml

Other: Conray, Cholografin Meglumine N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8; 2007, Q1, P6

❂ Q9962 High osmolar contrast material, 300-349 mg/ml iodine concentration, per ml
IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90 N1 N
Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
❂ Q9963 High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml
Other: Gastrografin, MD-76R, MD Gastroview, Sinografin N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
❂ Q9964 High osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml
N1 N
IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8; 2007, Q1, P6
Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml N1 N
❂ Q9965
Other: Omnipaque
IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90
Coding Clinic: 2012, Q3, P8
❂ Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml
Other: Isovue, Omnipaque, Optiray, Ultravist 240, Visipaque N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8

❂ Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml
Other: Hexabrix 320, Isovue, Omnipaque, Optiray, Oxilan, Ultravist, Vispaque N1 N

IOM: 100-04, 12, 70; 100-04, 13, 20; 100-04, 13, 90

Coding Clinic: 2012, Q3, P8
✽ Q9968 Injection, non-radioactive, noncontrast, visualization adjunct (e.g., Methylene Blue,
Isosulfan Blue), 1 mg K2 K

❂ Q9969 Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study
dose K

Radiopharmaceuticals
Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries K2 G
❂ Q9982
Other: Vizamyl

520
 ❂ Q9983 Florbetaben F18, diagnostic, per study dose, up to 8.1 millicuries K2 G

Other: Neuraceq
Injection, buprenorphine extendedrelease (sublocade), less than or equal to 100 mg G
▶ ✽ Q9991
Other: Subutex, Buprenex, Belbuca, Probuphine, Butrans
Injection, buprenorphine extendedrelease (sublocade), greater than 100 mg G
▶ ✽ Q9992
Other: Subutex, Buprenex, Belbuca, Probuphine, Butrans

DIAGNOSTIC RADIOLOGY SERVICES (R0000-R9999)

Transportation/Setup of Portable Equipment
❂ R0070 Transportation of portable x-ray equipment and personnel to home or nursing home, per
trip to facility or location, one patient seen B

CMS Transmittal B03-049; specific instructions to contractors on pricing

IOM: 100-04, 13, 90; 100-04, 13, 90.3
❂ R0075 Transportation of portable x-ray equipment and personnel to home or nursing home, per
trip to facility or location, more than one patient seen B

This code would not apply to the x-ray equipment if stored at the location where the x-ray
was performed (e.g., a nursing home).
IOM: 100-04, 13, 90; 100-04, 13, 90.3
Transportation of portable ECG to facility or location, per patient B
❂ R0076
EKG procedure code 93000 or 93005 must be submitted on same claim as transportation
code. Bundled status on physician fee schedule
IOM: 100-01, 5, 90.2; 100-02, 15, 80; 100-03, 1, 20.15; 100-04, 13, 90; 100-04, 16, 10;
100-04, 16, 110.4

TEMPORARY NATIONAL CODES ESTABLISHED BY PRIVATE

PAYERS (S0000-S9999)
NOTE: Medicare and other federal payers do not recognize “S” codes; however, S codes may be
useful for claims to some private insurers.

Non-Medicare Drugs
H S0012 Butorphanol tartrate, nasal spray, 25 mg
H S0014 Tacrine hydrochloride, 10 mg
H S0017 Injection, aminocaproic acid, 5 grams
H S0020 Injection, bupivacaine hydrochloride, 30 ml
H S0021 Injection, cefoperazone sodium, 1 gram
H S0023 Injection, cimetidine hydrochloride, 300 mg
H S0028 Injection, famotidine, 20 mg
H S0030 Injection, metronidazole, 500 mg
H S0032 Injection, nafcillin sodium, 2 grams
H S0034 Injection, ofloxacin, 400 mg
H S0039 Injection, sulfamethoxazole and trimethoprim, 10 ml
H S0040 Injection, ticarcillin disodium and clavulanate potassium, 3.1 grams
H S0073 Injection, aztreonam, 500 mg
H S0074 Injection, cefotetan disodium, 500 mg
H S0077 Injection, clindamycin phosphate, 300 mg

521
H S0078 Injection, fosphenytoin sodium, 750 mg
H S0080 Injection, pentamidine isethionate, 300 mg
H S0081 Injection, piperacillin sodium, 500 mg
H S0088 Imatinib, 100 mg
H S0090 Sildenafil citrate, 25 mg
H S0091 Granisetron hydrochloride, 1 mg (for circumstances falling under the Medicare Statute,
use Q0166)
H S0092 Injection, hydromorphone hydrochloride, 250 mg (loading dose for infusion pump)
H S0093 Injection, morphine sulfate, 500 mg (loading dose for infusion pump)
H S0104 Zidovudine, oral, 100 mg
H S0106 Bupropion HCl sustained release tablet, 150 mg, per bottle of 60 tablets
H S0108 Mercaptopurine, oral, 50 mg
H S0109 Methadone, oral, 5 mg
H S0117 Tretinoin, topical, 5 grams
H S0119 Ondansetron, oral, 4 mg (for circumstances falling under the Medicare statute, use
HCPCS Q code)
H S0122 Injection, menotropins, 75 IU
H S0126 Injection, follitropin alfa, 75 IU
H S0128 Injection, follitropin beta, 75 IU
H S0132 Injection, ganirelix acetate, 250 mcg
H S0136 Clozapine, 25 mg
H S0137 Didanosine (DDI), 25 mg
H S0138 Finasteride, 5 mg
H S0139 Minoxidil, 10 mg
H S0140 Saquinavir, 200 mg
H S0142 Colistimethate sodium, inhalation solution administered through DME, concentrated
form, per mg
H S0145 Injection, pegylated interferon alfa-2a, 180 mcg per ml
H S0148 Injection, pegylated interferon ALFA-2b, 10 mcg
H S0155 Sterile dilutant for epoprostenol, 50 ml
H S0156 Exemestane, 25 mg
H S0157 Becaplermin gel 0.01%, 0.5 gm
H S0160 Dextroamphetamine sulfate, 5 mg
H S0164 Injection, pantoprazole sodium, 40 mg
H S0166 Injection, olanzapine, 2.5 mg
H S0169 Calcitrol, 0.25 microgram
H S0170 Anastrozole, oral, 1 mg
H S0171 Injection, bumetanide, 0.5 mg
H S0172 Chlorambucil, oral, 2 mg
H S0174 Dolasetron mesylate, oral 50 mg (for circumstances falling under the Medicare Statute,
use Q0180)
H S0175 Flutamide, oral, 125 mg
H S0176 Hydroxyurea, oral, 500 mg

522
 H S0177 Levamisole hydrochloride, oral, 50 mg
H S0178 Lomustine, oral, 10 mg
H S0179 Megestrol acetate, oral, 20 mg
H S0182 Procarbazine hydrochloride, oral, 50 mg
H S0183 Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the Medicare
Statute, use Q0164)
H S0187 Tamoxifen citrate, oral, 10 mg
H S0189 Testosterone pellet, 75 mg
H S0190 Mifepristone, oral, 200 mg
H S0191 Misoprostol, oral 200 mcg
H S0194 Dialysis/stress vitamin supplement, oral, 100 capsules
H S0197 Prenatal vitamins, 30-day supply ♀

Provider Services
H S0199 Medically induced abortion by oral ingestion of medication including all associated
services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by
HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of
abortion) except drugs ♀
H S0201 Partial hospitalization services, less than 24 hours, per diem
H S0207 Paramedic intercept, non-hospitalbased ALS service (non-voluntary), non-transport
H S0208 Paramedic intercept, hospital-based ALS service (non-voluntary), nontransport
H S0209 Wheelchair van, mileage, per mile
H S0215 Non-emergency transportation; mileage per mile
H S0220 Medical conference by a physician with interdisciplinary team of health professionals or
representatives of community agencies to coordinate activities of patient care (patient is
present); approximately 30 minutes
H S0221 Medical conference by a physician with interdisciplinary team of health professionals or
representatives of community agencies to coordinate activities of patient care (patient is
present); approximately 60 minutes
H S0250 Comprehensive geriatric assessment and treatment planning performed by assessment
team
H S0255 Hospice referral visit (advising patient and family of care options) performed by nurse,
social worker, or other designated staff
H S0257 Counseling and discussion regarding advance directives or end of life care planning and
decisions, with patient and/or surrogate (list separately in addition to code for appropriate
evaluation and management service)
H S0260 History and physical (outpatient or office) related to surgical procedure (list separately in
addition to code for appropriate evaluation and management service)
H S0265 Genetic counseling, under physician supervision, each 15 minutes
H S0270 Physician management of patient home care, standard monthly case rate (per 30 days)
H S0271 Physician management of patient home care, hospice monthly case rate (per 30 days)
H S0272 Physician management of patient home care, episodic care monthly case rate (per 30 days)
H S0273 Physician visit at member’s home, outside of a capitation arrangement
H S0274 Nurse practitioner visit at member’s home, outside of a capitation arrangement
H S0280 Medical home program, comprehensive care coordination and planning, initial plan
H S0281 Medical home program, comprehensive care coordination and planning, maintenance of
plan

523
 H S0285 Colonoscopy consultation performed prior to a screening colonoscopy procedure
H S0302 Completed Early Periodic Screening Diagnosis and Treatment (EPSDT) service (list in
addition to code for appropriate evaluation and management service)
H S0310 Hospitalist services (list separately in addition to code for appropriate evaluation and
management service)
H S0311 Comprehensive management and care coordination for advanced illness, per calendar
month
H S0315 Disease management program; initial assessment and initiation of the program
H S0316 Disease management program; follow-up/reassessment
H S0317 Disease management program; per diem
H S0320 Telephone calls by a registered nurse to a disease management program member for
monitoring purposes; per month
H S0340 Lifestyle modification program for management of coronary artery disease, including all
supportive services; first quarter/stage
H S0341 Lifestyle modification program for management of coronary artery disease, including all
supportive services; second or third quarter/stage
H S0342 Lifestyle modification program for management of coronary artery disease, including all
supportive services; fourth quarter/stage
H S0353 Treatment planning and care coordination management for cancer, initial treatment
H S0354 Treatment planning and care coordination management for cancer, established patient
with a change of regimen
H S0390 Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive
maintenance in specific medical conditions (e.g., diabetes), per visit
H S0395 Impression casting of a foot performed by a practitioner other than the manufacturer of
the orthotic
H S0400 Global fee for extracorporeal shock wave lithotripsy treatment of kidney stone(s)

Vision Supplies
H S0500 Disposable contact lens, per lens
H S0504 Single vision prescription lens (safety, athletic, or sunglass), per lens
H S0506 Bifocal vision prescription lens (safety, athletic, or sunglass), per lens
H S0508 Trifocal vision prescription lens (safety, athletic, or sunglass), per lens
H S0510 Non-prescription lens (safety, athletic, or sunglass), per lens
H S0512 Daily wear specialty contact lens, per lens
H S0514 Color contact lens, per lens
H S0515 Scleral lens, liquid bandage device, per lens
H S0516 Safety eyeglass frames
H S0518 Sunglasses frames
H S0580 Polycarbonate lens (list this code in addition to the basic code for the lens)
H S0581 Nonstandard lens (list this code in addition to the basic code for the lens)
H S0590 Integral lens service, miscellaneous services reported separately
H S0592 Comprehensive contact lens evaluation
H S0595 Dispensing new spectacle lenses for patient supplied frame
H S0596 Phakic intraocular lens for correction of refractive error

Screening and Examinations

524
 H S0601 Screening proctoscopy
H S0610 Annual gynecological examination, new patient ♀
H S0612 Annual gynecological examination, established patient ♀
H S0613 Annual gynecological examination; clinical breast examination without pelvic evaluation ♀
H S0618 Audiometry for hearing aid evaluation to determine the level and degree of hearing loss
H S0620 Routine ophthalmological examination including refraction; new patient
Many non-Medicare vision plans may require code for routine encounter, no complaints
H S0621 Routine ophthalmological examination including refraction; established patient
Many non-Medicare vision plans may require code for routine encounter, no complaints
H S0622 Physical exam for college, new or established patient (list separately) in addition to
appropriate evaluation and management code

Provider Services and Supplies

H S0630 Removal of sutures; by a physician other than the physician who originally closed the
wound
H S0800 Laser in situ keratomileusis (LASIK)

Figure 48 Phototherapeutic keratectomy (PRK).

H S0810 Photorefractive keratectomy (PRK)

H S0812 Phototherapeutic keratectomy (PTK)
H S1001 Deluxe item, patient aware (list in addition to code for basic item)
H S1002 Customized item (list in addition to code for basic item)
H S1015 IV tubing extension set
H S1016 Non-PVC (polyvinyl chloride) intravenous administration set, for use with drugs that are
not stable in PVC (e.g., paclitaxel)
H S1030 Continuous noninvasive glucose monitoring device, purchase (for physician interpretation
of data, use CPT code)
H S1031 Continuous noninvasive glucose monitoring device, rental, including sensor, sensor
replacement, and download to monitor (for physician interpretation of data, use CPT
code)
H S1034 Artificial pancreas device system (e.g., low glucose suspend (LGS) feature) including
continuous glucose monitor, blood glucose device, insulin pump and computer algorithm
that communicates with all of the devices
H S1035 Sensor; invasive (e.g., subcutaneous), disposable, for use with artificial pancreas device
system
H S1036 Transmitter; external, for use with artificial pancreas device system

525
 H S1037 Receiver (monitor); external, for use with artificial pancreas device system
H S1040 Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom
fabricated, includes fitting and adjustment(s)
H S1090 Mometasone furoate sinus implant, 370 micrograms
H S2053 Transplantation of small intestine and liver allografts
H S2054 Transplantation of multivisceral organs
H S2055 Harvesting of donor multivisceral organs, with preparation and maintenance of allografts;
from cadaver donor
H S2060 Lobar lung transplantation
H S2061 Donor lobectomy (lung) for transplantation, living donor
H S2065 Simultaneous pancreas kidney transplantation
H S2066 Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of
the flap, microvascular transfer, closure of donor site and shaping the flap into a breast,
unilateral ♀
H S2067 Breast reconstruction of a single breast with “stacked” deep inferior epigastric perforator
(DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the
flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast,
unilateral ♀
H S2068 Breast reconstruction with deep inferior epigastric perforator (DIEP) flap, or superficial
inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular
transfer, closure of donor site and shaping the flap into a breast, unilateral ♀
H S2070 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with endoscopic laser treatment
of ureteral calculi (includes ureteral catheterization)
H S2079 Laparoscopic esophagomyotomy (Heller type)
H S2080 Laser-assisted uvulopalatoplasty (LAUP)
H S2083 Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of
saline

Figure 49 Gastric band.

H S2095 Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method,
using yttrium-90 microspheres
H S2102 Islet cell tissue transplant from pancreas; allogeneic
H S2103 Adrenal tissue transplant to brain
H S2107 Adoptive immunotherapy i.e. development of specific anti-tumor reactivity (e.g., tumor-
infiltrating lymphocyte therapy) per course of treatment
H S2112 Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)

526
H S2115 Osteotomy, periacetabular, with internal fixation
H S2117 Arthroereisis, subtalar
H S2118 Metal-on-metal total hip resurfacing, including acetabular and femoral components
H S2120 Low density lipoprotein (LDL) apheresis using heparin-induced extracorporeal LDL
precipitation
H S2140 Cord blood harvesting for transplantation, allogeneic
H S2142 Cord blood-derived stem cell transplantation, allogeneic
H S2150 Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or
autologous, harvesting, transplantation, and related complications; including: pheresis and
cell preparation/storage; marrow ablative therapy; drugs, supplies, hospitalization with
outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services;
and the number of days of pre- and post-transplant care in the global definition
H S2152 Solid organ(s), complete or segmental, single organ or combination of organs; deceased or
living donor(s), procurement, transplantation, and related complications; including: drugs;
supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic,
emergency, and rehabilitative services, and the number of days of pre- and post-transplant
care in the global definition
H S2202 Echosclerotherapy
H S2205 Minimally invasive direct coronary artery bypass surgery involving minithoracotomy or
mini-sternotomy surgery, performed under direct vision; using arterial graft(s), single
coronary arterial graft
H S2206 Minimally invasive direct coronary artery bypass surgery involving minithoracotomy or
mini-sternotomy surgery, performed under direct vision; using arterial graft(s), two
coronary arterial grafts
H S2207 Minimally invasive direct coronary artery bypass surgery involving minithoracotomy or
mini-sternotomy surgery, performed under direct vision; using venous graft only, single
coronary venous graft
H S2208 Minimally invasive direct coronary artery bypass surgery involving minithoracotomy or
mini-sternotomy surgery, performed under direct vision; using single arterial and venous
graft(s), single venous graft
H S2209 Minimally invasive direct coronary artery bypass surgery involving minithoracotomy or
mini-sternotomy surgery, performed under direct vision; using two arterial grafts and
single venous graft
H S2225 Myringotomy, laser-assisted
H S2230 Implantation of magnetic component of semi-implantable hearing device on ossicles in
middle ear
H S2235 Implantation of auditory brain stem implant
H S2260 Induced abortion, 17 to 24 weeks ♀
H S2265 Induced abortion, 25 to 28 weeks ♀
H S2266 Induced abortion, 29 to 31 weeks ♀
H S2267 Induced abortion, 32 weeks or greater ♀
H S2300 Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy
H S2325 Hip core decompression
Coding Clinic: 2017, Q3, P1

H S2340 Chemodenervation of abductor muscle(s) of vocal cord

H S2341 Chemodenervation of adductor muscle(s) of vocal cord
H S2342 Nasal endoscopy for post-operative debridement following functional endoscopic sinus
surgery, nasal and/or sinus cavity(s), unilateral or bilateral
H S2348 Decompression procedure, percutaneous, of nucleus pulpous of intervertebral disc, using

527
 radiofrequency energy, single or multiple levels, lumbar
H S2350 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including
osteophytectomy; lumbar, single interspace
H S2351 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s) including
osteophytectomy; lumbar, each additional interspace (list separately in addition to code for
primary procedure)
H S2400 Repair, congenital diaphragmatic hernia in the fetus using temporary tracheal occlusion,
procedure performed in utero ♀
H S2401 Repair, urinary tract obstruction in the fetus, procedure performed in utero ♀
H S2402 Repair, congenital cystic adenomatoid malformation in the fetus, procedure performed in
utero ♀
H S2403 Repair, extralobar pulmonary sequestration in the fetus, procedure performed in utero ♀

H S2404 Repair, myelomeningocele in the fetus, procedure performed in utero ♀

H S2405 Repair of sacrococcygeal teratoma in the fetus, procedure performed in utero ♀
H S2409 Repair, congenital malformation of fetus, procedure performed in utero, not otherwise
classified ♀
H S2411 Fetoscopic laser therapy for treatment of twin-to-twin transfusion syndrome
H S2900 Surgical techniques requiring use of robotic surgical system (list separately in addition to
code for primary procedure)
Coding Clinic: 2010, Q2, P6

H S3000 Diabetic indicator; retinal eye exam, dilated, bilateral

H S3005 Performance measurement, evaluation of patient self assessment, depression
H S3600 STAT laboratory request (situations other than S3601)
H S3601 Emergency STAT laboratory charge for patient who is homebound or residing in a
nursing facility
❂ S3620 Newborn metabolic screening panel, includes test kit, postage and the laboratory tests
specified by the state for inclusion in this panel (e.g., galactose; hemoglobin,
electrophoresis; hydroxyprogesterone, 17-D; phenylalanine (PKU); and thyroxine, total)

H S3630 Eosinophil count, blood, direct

H S3645 HIV-1 antibody testing of oral mucosal transudate
H S3650 Saliva test, hormone level; during menopause ♀
H S3652 Saliva test, hormone level; to assess preterm labor risk ♀
H S3655 Antisperm antibodies test (immunobead) ♀
H S3708 Gastrointestinal fat absorption study
H S3722 Dose optimization by area under the curve (AUC) analysis, for infusional 5-fluorouracil

Genetic Testing
H S3800 Genetic testing for amyotrophic lateral sclerosis (ALS)
H S3840 DNA analysis for germline mutations of the RET proto-oncogene for susceptibility to
multiple endocrine neoplasia type 2
H S3841 Genetic testing for retinoblastoma
H S3842 Genetic testing for von Hippel-Lindau disease
H S3844 DNA analysis of the connexin 26 gene (GJB2) for susceptibility to congenital, profound
deafness
H S3845 Genetic testing for alpha-thalassemia

528
 H S3846 Genetic testing for hemoglobin E betathalassemia
H S3849 Genetic testing for Niemann-Pick disease
H S3850 Genetic testing for sickle cell anemia
H S3852 DNA analysis for APOE epilson 4 allele for susceptibility to Alzheimer’s disease
H S3853 Genetic testing for myotonic muscular dystrophy
H S3854 Gene expression profiling panel for use in the management of breast cancer treatment ♀
H S3861 Genetic testing, sodium channel, voltage-gated, type V, alpha subunit (SCN5A) and
variants for suspected Brugada syndrome
H S3865 Comprehensive gene sequence analysis for hypertrophic cardiomyopathy
H S3866 Genetic analysis for a specific gene mutation for hypertrophic cardiomyopathy (HCM) in
an individual with a known HCM mutation in the family
H S3870 Comparative genomic hybridization (CGH) microarray testing for developmental delay,
autism spectrum disorder and/or intellectual disability

Other Tests
H S3900 Surface electromyography (EMG)
H S3902 Ballistrocardiogram
H S3904 Masters two step
Bill on paper. Requires a report.

Obstetric and Fertility Services

H S4005 Interim labor facility global (labor occurring but not resulting in delivery) ♀
H S4011 In vitro fertilization; including but not limited to identification and incubation of mature
oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization
for determination of development ♀
H S4013 Complete cycle, gamete intrafallopian transfer (GIFT), case rate ♀
H S4014 Complete cycle, zygote intrafallopian transfer (ZIFT), case rate ♀
H S4015 Complete in vitro fertilization cycle, not otherwise specified, case rate ♀
H S4016 Frozen in vitro fertilization cycle, case rate ♀
H S4017 Incomplete cycle, treatment cancelled prior to stimulation, case rate ♀
H S4018 Frozen embryo transfer procedure cancelled before transfer, case rate ♀
H S4020 In vitro fertilization procedure cancelled before aspiration, case rate ♀
H S4021 In vitro fertilization procedure cancelled after aspiration, case rate ♀
H S4022 Assisted oocyte fertilization, case rate ♀
H S4023 Donor egg cycle, incomplete, case rate ♀
H S4025 Donor services for in vitro fertilization (sperm or embryo), case rate
H S4026 Procurement of donor sperm from sperm bank ♂
H S4027 Storage of previously frozen embryos ♀
H S4028 Microsurgical epididymal sperm aspiration (MESA) ♂
H S4030 Sperm procurement and cryopreservation services; initial visit ♂
H S4031 Sperm procurement and cryopreservation services; subsequent visit ♂
H S4035 Stimulated intrauterine insemination (IUI), case rate ♀
H S4037 Cryopreserved embryo transfer, case rate ♀
H S4040 Monitoring and storage of cryopreserved embryos, per 30 days ♀

529
 H S4042 Management of ovulation induction (interpretation of diagnostic tests and studies, non-
face-to-face medical management of the patient), per cycle ♀
H S4981 Insertion of levonorgestrel-releasing intrauterine system ♀
H S4989 Contraceptive intrauterine device (e.g., Progestasert IUD), including implants and
supplies ♀

Therapeutic Substances and Medications

H S4990 Nicotine patches, legend
H S4991 Nicotine patches, non-legend
H S4993 Contraceptive pills for birth control ♀
Only billed by Family Planning Clinics
H S4995 Smoking cessation gum
H S5000 Prescription drug, generic
H S5001 Prescription drug, brand name

Figure 50 IUD.

H S5010 5% dextrose and 0.45% normal saline, 1000 ml

H S5012 5% dextrose with potassium chloride, 1000 ml
H S5013 5% dextrose/0.45% normal saline with potassium chloride and magnesium sulfate, 1000
ml
H S5014 5% dextrose/0.45% normal saline with potassium chloride and magnesium sulfate, 1500
ml

Home Care Services

H S5035 Home infusion therapy, routine service of infusion device (e.g., pump maintenance)
H S5036 Home infusion therapy, repair of infusion device (e.g., pump repair)
H S5100 Day care services, adult; per 15 minutes
H S5101 Day care services, adult; per half day
H S5102 Day care services, adult; per diem
H S5105 Day care services, center-based; services not included in program fee, per diem
H S5108 Home care training to home care client, per 15 minutes
H S5109 Home care training to home care client, per session

530
 H S5110 Home care training, family; per 15 minutes
H S5111 Home care training, family; per session
H S5115 Home care training, non-family; per 15 minutes
H S5116 Home care training, non-family; per session
H S5120 Chore services; per 15 minutes
H S5121 Chore services; per diem
H S5125 Attendant care services; per 15 minutes
H S5126 Attendant care services; per diem
H S5130 Homemaker service, NOS; per 15 minutes
H S5131 Homemaker service, NOS; per diem
H S5135 Companion care, adult (e.g., IADL/ADL); per 15 minutes
H S5136 Companion care, adult (e.g., IADL/ADL); per diem
H S5140 Foster care, adult; per diem
H S5141 Foster care, adult; per month
H S5145 Foster care, therapeutic, child; per diem
H S5146 Foster care, therapeutic, child; per month
H S5150 Unskilled respite care, not hospice; per 15 minutes
H S5151 Unskilled respite care, not hospice; per diem
H S5160 Emergency response system; installation and testing
H S5161 Emergency response system; service fee, per month (excludes installation and testing)
H S5162 Emergency response system; purchase only
H S5165 Home modifications; per service
H S5170 Home delivered meals, including preparation; per meal
H S5175 Laundry service, external, professional; per order
H S5180 Home health respiratory therapy, initial evaluation
H S5181 Home health respiratory therapy, NOS, per diem
H S5185 Medication reminder service, non-face-to-face; per month
H S5190 Wellness assessment, performed by non-physician
H S5199 Personal care item, NOS, each

Home Infusion Therapy

H S5497 Home infusion therapy, catheter care/maintenance, not otherwise classified; includes
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S5498 Home infusion therapy, catheter care/maintenance, simple (single lumen), includes
administrative services, professional pharmacy services, care coordination and all necessary
supplies and equipment, (drugs and nursing visits coded separately), per diem
H S5501 Home infusion therapy, catheter care/maintenance, complex (more than one lumen),
includes administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded separately), per diem
H S5502 Home infusion therapy, catheter care/maintenance, implanted access device, includes
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment, (drugs and nursing visits coded separately), per diem (use this
code for interim maintenance of vascular access not currently in use)
H S5517 Home infusion therapy, all supplies necessary for restoration of catheter patency or

531
 declotting
H S5518 Home infusion therapy, all supplies necessary for catheter repair
H S5520 Home infusion therapy, all supplies (including catheter) necessary for a peripherally
inserted central venous catheter (PICC) line insertion
Bill on paper. Requires a report.
H S5521 Home infusion therapy, all supplies (including catheter) necessary for a midline catheter
insertion
H S5522 Home infusion therapy, insertion of peripherally inserted central venous catheter (PICC),
nursing services only (no supplies or catheter included)
H S5523 Home infusion therapy, insertion of midline central venous catheter, nursing services only
(no supplies or catheter included)

Insulin Services
H S5550 Insulin, rapid onset, 5 units
H S5551 Insulin, most rapid onset (Lispro or Aspart); 5 units
H S5552 Insulin, intermediate acting (NPH or Lente); 5 units
H S5553 Insulin, long acting; 5 units
H S5560 Insulin delivery device, reusable pen; 1.5 ml size
H S5561 Insulin delivery device, reusable pen; 3 ml size
H S5565 Insulin cartridge for use in insulin delivery device other than pump; 150 units
H S5566 Insulin cartridge for use in insulin delivery device other than pump; 300 units

Figure 51 Nova pen.

H S5570 Insulin delivery device, disposable pen (including insulin); 1.5 ml size
H S5571 Insulin delivery device, disposable pen (including insulin); 3 ml size

Imaging
H S8030 Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy
H S8035 Magnetic source imaging
H S8037 Magnetic resonance cholangiopancreatography (MRCP)
H S8040 Topographic brain mapping
H S8042 Magnetic resonance imaging (MRI), low-field
H S8055 Ultrasound guidance for multifetal pregnancy reduction(s), technical component (only to
be used when the physician doing the reduction procedure does not perform the
ultrasound, guidance is included in the CPT code for multifetal pregnancy reduction -
59866) ♀
H S8080 Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including
supply of radiopharmaceutical ♀
H S8085 Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-head coincidence
detection system (nondedicated PET scan)
H S8092 Electron beam computed tomography (also known as ultrafast CT, cine CT)

532
Assistive Breathing Supplies
H S8096 Portable peak flow meter
H S8097 Asthma kit (including but not limited to portable peak expiratory flow meter, instructional
video, brochure, and/or spacer)
H S8100 Holding chamber or spacer for use with an inhaler or nebulizer; without mask
H S8101 Holding chamber or spacer for use with an inhaler or nebulizer; with mask
H S8110 Peak expiratory flow rate (physician services)
H S8120 Oxygen contents, gaseous, 1 unit equals 1 cubic foot
H S8121 Oxygen contents, liquid, 1 unit equals 1 pound
H S8130 Interferential current stimulator, 2 channel
H S8131 Interferential current stimulator, 4 channel
H S8185 Flutter device
H S8186 Swivel adapter
H S8189 Tracheostomy supply, not otherwise classified
H S8210 Mucus trap

533
Miscellaneous Supplies and Services
H S8265 Haberman feeder for cleft lip/palate
H S8270 Enuresis alarm, using auditory buzzer and/or vibration device
H S8301 Infection control supplies, not otherwise specified
H S8415 Supplies for home delivery of infant
H S8420 Gradient pressure aid (sleeve and glove combination), custom made
H S8421 Gradient pressure aid (sleeve and glove combination), ready made
H S8422 Gradient pressure aid (sleeve), custom made, medium weight
H S8423 Gradient pressure aid (sleeve), custom made, heavy weight
H S8424 Gradient pressure aid (sleeve), ready made
H S8425 Gradient pressure aid (glove), custom made, medium weight
H S8426 Gradient pressure aid (glove), custom made, heavy weight
H S8427 Gradient pressure aid (glove), ready made
H S8428 Gradient pressure aid (gauntlet), ready made
H S8429 Gradient pressure exterior wrap
H S8430 Padding for compression bandage, roll
H S8431 Compression bandage, roll
H S8450 Splint, prefabricated, digit (specify digit by use of modifier)
H S8451 Splint, prefabricated, wrist or ankle
H S8452 Splint, prefabricated, elbow
H S8460 Camisole, post-mastectomy
H S8490 Insulin syringes (100 syringes, any size)
H S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-
on-one contact with the patient
H S8940 Equestrian/Hippotherapy, per session
H S8948 Application of a modality (requiring constant provider attendance) to one or more areas;
low-level laser; each 15 minutes
H S8950 Complex lymphedema therapy, each 15 minutes
H S8990 Physical or manipulative therapy performed for maintenance rather than restoration
H S8999 Resuscitation bag (for use by patient on artificial respiration during power failure or other
catastrophic event)
H S9001 Home uterine monitor with or without associated nursing services ♀
H S9007 Ultrafiltration monitor
H S9024 Paranasal sinus ultrasound
H S9025 Omnicardiogram/cardiointegram
H S9034 Extracorporeal shockwave lithotripsy for gall stones (if performed with ERCP, use 43265)
H S9055 Procuren or other growth factor preparation to promote wound healing
H S9056 Coma stimulation per diem
H S9061 Home administration of aerosolized drug therapy (e.g., pentamidine); administrative
services, professional pharmacy services, care coordination, all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
H S9083 Global fee urgent care centers

534
 H S9088 Services provided in an urgent care center (list in addition to code for service)
H S9090 Vertebral axial decompression, per session
H S9097 Home visit for wound care
H S9098 Home visit, phototherapy services (e.g., Bili-Lite), including equipment rental, nursing
services, blood draw, supplies, and other services, per diem
H S9110 Telemonitoring of patient in their home, including all necessary equipment; computer
system, connections, and software; maintenance; patient education and support; per
month
H S9117 Back school, per visit
H S9122 Home health aide or certified nurse assistant, providing care in the home; per hour
H S9123 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)
H S9124 Nursing care, in the home; by licensed practical nurse, per hour
H S9125 Respite care, in the home, per diem
H S9126 Hospice care, in the home, per diem
H S9127 Social work visit, in the home, per diem
H S9128 Speech therapy, in the home, per diem
H S9129 Occupational therapy, in the home, per diem
H S9131 Physical therapy; in the home, per diem
H S9140 Diabetic management program, follow-up visit to non-MD provider
H S9141 Diabetic management program, follow-up visit to MD provider
H S9145 Insulin pump initiation, instruction in initial use of pump (pump not included)
H S9150 Evaluation by ocularist
H S9152 Speech therapy, re-evaluation

Home Management of Pregnancy

H S9208 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) ♀
H S9209 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) ♀
H S9211 Home management of gestational hypertension, includes administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately); per diem (do not use this code with
any home infusion per diem code) ♀
H S9212 Home management of postpartum hypertension, includes administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem (do not use this code with
any home infusion per diem code) ♀
H S9213 Home management of preeclampsia, includes administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and
nursing services coded separately); per diem (do not use this code with any home infusion
per diem code) ♀
H S9214 Home management of gestational diabetes, includes administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and

535
 nursing visits coded separately); per diem (do not use this code with any home infusion
per diem code) ♀

Home Infusion Therapy

H S9325 Home infusion therapy, pain management infusion; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment, (drugs and
nursing visits coded separately), per diem (do not use this code with S9326, S9327 or
S9328)
H S9326 Home infusion therapy, continuous (twenty-four hours or more) pain management
infusion; administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded separately), per diem
H S9327 Home infusion therapy, intermittent (less than twenty-four hours) pain management
infusion; administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded separately), per diem
H S9328 Home infusion therapy, implanted pump pain management infusion; administrative
services, professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
H S9329 Home infusion therapy, chemotherapy infusion; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem (do not use this code with S9330 or S9331)
H S9330 Home infusion therapy, continuous (twenty-four hours or more) chemotherapy infusion;
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S9331 Home infusion therapy, intermittent (less than twenty-four hours) chemotherapy
infusion; administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded separately), per diem
H 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
H S9336 Home infusion therapy, continuous anticoagulant infusion therapy (e.g., heparin),
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S9338 Home infusion therapy, immunotherapy, administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment (drug and nursing
visits coded separately), per diem
H S9339 Home therapy; peritoneal dialysis, administrative services, professional pharmacy services,
care coordination and all necessary supplies and equipment (drugs and nursing visits coded
separately), per diem
H S9340 Home therapy; enteral nutrition; administrative services, professional pharmacy services,
care coordination, and all necessary supplies and equipment (enteral formula and nursing
visits coded separately), per diem
H S9341 Home therapy; enteral nutrition via gravity; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment (enteral formula and
nursing visits coded separately), per diem
H S9342 Home therapy; enteral nutrition via pump; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment (enteral formula and
nursing visits coded separately), per diem
H S9343 Home therapy; enteral nutrition via bolus; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment (enteral formula and
nursing visits coded separately), per diem
H S9345 Home infusion therapy, anti-hemophilic agent infusion therapy (e.g., Factor VIII);
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem

536
H S9346 Home infusion therapy, alpha-1-proteinase inhibitor (e.g., Prolastin); administrative
services, professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
H S9347 Home infusion therapy, uninterrupted, long-term, controlled rate intravenous or
subcutaneous infusion therapy (e.g., Epoprostenol); administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
H S9348 Home infusion therapy, sympathomimetic/inotropic agent infusion therapy (e.g.,
Dobutamine); administrative services, professional pharmacy services, care coordination,
all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
H S9349 Home infusion therapy, tocolytic infusion therapy; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
H S9351 Home infusion therapy, continuous or intermittent anti-emetic infusion therapy;
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and visits coded separately), per diem
H S9353 Home infusion therapy, continuous insulin infusion therapy; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
H S9355 Home infusion therapy, chelation therapy; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment (drugs and nursing
visits coded separately), per diem
H S9357 Home infusion therapy, enzyme replacement intravenous therapy (e.g., Imiglucerase);
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S9359 Home infusion therapy, anti-tumor necrosis factor intravenous therapy (e.g., Infliximab);
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S9361 Home infusion therapy, diuretic intravenous therapy; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
H S9363 Home infusion therapy, anti-spasmotic therapy; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
H S9364 Home infusion therapy, total parenteral nutrition (TPN); administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs
other than in standard formula, and nursing visits coded separately) per diem (do not use
with home infusion codes S9365-S9368 using daily volume scales)
H S9365 Home infusion therapy, total parenteral nutrition (TPN); one liter per day, administrative
services, professional pharmacy services, care coordination, and all necessary supplies and
equipment including standard TPN formula (lipids, specialty amino acid formulas, drugs
other than in standard formula and nursing visits coded separately), per diem
H S9366 Home infusion therapy, total parenteral nutrition (TPN); more than one liter but no more
than two liters per day, administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment including standard TPN formula
(lipids, specialty amino acid formulas, drugs other than in standard formula and nursing
visits coded separately), per diem
H S9367 Home infusion therapy, total parenteral nutrition (TPN); more than two liters but no
more than three liters per day, administrative services, professional pharmacy services, care
coordination, and all necessary supplies and equipment including standard TPN formula
(lipids, specialty amino acid formulas, drugs other than in standard formula and nursing
visits coded separately), per diem
H S9368 Home infusion therapy, total parenteral nutrition (TPN); more than three liters per day,

537
 administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (including standard TPN formula; lipids, specialty amino acid
formulas, drugs other than in standard formula and nursing visits coded separately), per
diem
H S9370 Home therapy, intermittent anti-emetic injection therapy; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
H S9372 Home therapy; intermittent anticoagulant injection therapy (e.g., heparin); administrative
services, professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem (do not use this code for
flushing of infusion devices with heparin to maintain patency)
H S9373 Home infusion therapy, hydration therapy; administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment (drugs and nursing
visits coded separately), per diem (do not use with hydration therapy codes S9374-S9377
using daily volume scales)
H S9374 Home infusion therapy, hydration therapy; one liter per day, administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
H S9375 Home infusion therapy, hydration therapy; more than one liter but no more than two
liters per day, administrative services, professional pharmacy services, care coordination,
and all necessary supplies and equipment (drugs and nursing visits coded separately), per
diem
H S9376 Home infusion therapy, hydration therapy; more than two liters but no more than three
liters per day, administrative services, professional pharmacy services, care coordination,
and all necessary supplies and equipment (drugs and nursing visits coded separately), per
diem
H S9377 Home infusion therapy, hydration therapy; more than three liters per day, administrative
services, professional pharmacy services, care coordination, and all necessary supplies
(drugs and nursing visits coded separately), per diem
H S9379 Home infusion therapy, infusion therapy, not otherwise classified; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem

Miscellaneous Supplies and Services

H S9381 Delivery or service to high risk areas requiring escort or extra protection, per visit
H S9401 Anticoagulation clinic, inclusive of all services except laboratory tests, per session
H S9430 Pharmacy compounding and dispensing services
H S9433 Medical food nutritionally complete, administered orally, providing 100% of nutritional
intake
H S9434 Modified solid food supplements for inborn errors of metabolism
H S9435 Medical foods for inborn errors of metabolism
H S9436 Childbirth preparation/Lamaze classes, non-physician provider, per session ♀
H S9437 Childbirth refresher classes, non-physician provider, per session ♀
H S9438 Cesarean birth classes, non-physician provider, per session ♀
H S9439 VBAC (vaginal birth after cesarean) classes, non-physician provider, per session ♀
H S9441 Asthma education, non-physician provider, per session
H S9442 Birthing classes, non-physician provider, per session ♀
H S9443 Lactation classes, non-physician provider, per session ♀
H S9444 Parenting classes, non-physician provider, per session
H S9445 Patient education, not otherwise classified, non-physician provider, individual, per session

538
 H S9446 Patient education, not otherwise classified, non-physician provider, group, per session
H S9447 Infant safety (including CPR) classes, non-physician provider, per session
H S9449 Weight management classes, non-physician provider, per session
H S9451 Exercise classes, non-physician provider, per session
H S9452 Nutrition classes, non-physician provider, per session
H S9453 Smoking cessation classes, non-physician provider, per session
H S9454 Stress management classes, non-physician provider, per session
H S9455 Diabetic management program, group session
H S9460 Diabetic management program, nurse visit
H S9465 Diabetic management program, dietitian visit
H S9470 Nutritional counseling, dietitian visit
H S9472 Cardiac rehabilitation program, non-physician provider, per diem
H S9473 Pulmonary rehabilitation program, non-physician provider, per diem
H S9474 Enterostomal therapy by a registered nurse certified in enterostomal therapy, per diem
H S9475 Ambulatory setting substance abuse treatment or detoxification services, per diem
H S9476 Vestibular rehabilitation program, non-physician provider, per diem
H S9480 Intensive outpatient psychiatric services, per diem
H S9482 Family stabilization services, per 15 minutes
H S9484 Crisis intervention mental health services, per hour
H S9485 Crisis intervention mental health services, per diem

Home Therapy Services

H S9490 Home infusion therapy, corticosteroid infusion; administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
H S9494 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately) per diem (do not use this code with
home infusion codes for hourly dosing schedules S9497-S9504)
H S9497 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 3 hours;
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S9500 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours;
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S9501 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours;
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S9502 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 8 hours,
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S9503 Home infusion therapy, antibiotic, antiviral, or antifungal; once every 6 hours;
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S9504 Home infusion therapy, antibiotic, antiviral, or antifungal; once every 4 hours;
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
Routine venipuncture for collection of specimen(s), single home bound, nursing home, or

539
 H S9529 skilled nursing facility patient
H S9537 Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, G-CSF,
GM-CSF); administrative services, professional pharmacy services, care coordination, and
all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
H S9538 Home transfusion of blood product(s); administrative services, professional pharmacy
services, care coordination, and all necessary supplies and equipment (blood products,
drugs, and nursing visits coded separately), per diem
H S9542 Home injectable therapy; not otherwise classified, including administrative services,
professional pharmacy services, care coordination, and all necessary supplies and
equipment (drugs and nursing visits coded separately), per diem
H S9558 Home injectable therapy; growth hormone, including administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
H S9559 Home injectable therapy; interferon, including administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
H S9560 Home injectable therapy; hormonal therapy (e.g., Leuprolide, Goserelin), including
administrative services, professional pharmacy services, care coordination, and all necessary
supplies and equipment (drugs and nursing visits coded separately), per diem
H S9562 Home injectable therapy, palivizumab, including administrative services, professional
pharmacy services, care coordination, and all necessary supplies and equipment (drugs and
nursing visits coded separately), per diem
H S9590 Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity);
including administrative services, professional pharmacy services, care coordination, and
all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
H S9810 Home therapy; professional pharmacy services for provision of infusion, specialty drug
administration, and/or disease state management, not otherwise classified, per hour (do
not use this code with any per diem code)

Other Services and Fees

H S9900 Services by journal-listed Christian Science Practitioner for the purpose of healing, per
diem
H S9901 Services by a journal-listed Christian Science nurse, per hour
H S9960 Ambulance service, conventional air service, nonemergency transport, one way (fixed
wing)
H S9961 Ambulance service, conventional air service, nonemergency transport, one way (rotary
wing)
H S9970 Health club membership, annual
H S9975 Transplant related lodging, meals and transportation, per diem
H S9976 Lodging, per diem, not otherwise classified
H S9977 Meals, per diem, not otherwise specified
H S9981 Medical records copying fee, administrative
H S9982 Medical records copying fee, per page
H S9986 Not medically necessary service (patient is aware that service not medically necessary)
H S9988 Services provided as part of a Phase I clinical trial
H S9989 Services provided outside of the United States of America (list in addition to code(s) for
services(s))
H S9990 Services provided as part of a Phase II clinical trial
H S9991 Services provided as part of a Phase III clinical trial
H S9992 Transportation costs to and from trial location and local transportation costs (e.g., fares

540
 for taxicab or bus) for clinical trial participant and one caregiver/companion
H S9994 Lodging costs (e.g., hotel charges) for clinical trial participant and one
caregiver/companion
H S9996 Meals for clinical trial participant and one caregiver/companion
H S9999 Sales tax

TEMPORARY NATIONAL CODES ESTABLISHED BY

MEDICAID (T1000-T9999)
Not Valid For Medicare
H T1000 Private duty/independent nursing service(s) - licensed, up to 15 minutes
H T1001 Nursing assessment/evaluation
H T1002 RN services, up to 15 minutes
H T1003 LPN/LVN services, up to 15 minutes
H T1004 Services of a qualified nursing aide, up to 15 minutes
H T1005 Respite care services, up to 15 minutes
H T1006 Alcohol and/or substance abuse services, family/couple counseling
H T1007 Alcohol and/or substance abuse services, treatment plan development and/or modification
H T1009 Child sitting services for children of the individual receiving alcohol and/or substance
abuse services
H T1010 Meals for individuals receiving alcohol and/or substance abuse services (when meals not
included in the program)
H T1012 Alcohol and/or substance abuse services, skills development
H T1013 Sign language or oral interpretive services, per 15 minutes
H T1014 Telehealth transmission, per minute, professional services bill separately
H T1015 Clinic visit/encounter, all-inclusive
H T1016 Case Management, each 15 minutes
H T1017 Targeted Case Management, each 15 minutes
H T1018 School-based individualized education program (IEP) services, bundled
H T1019 Personal care services, per 15 minutes, not for an inpatient or resident of a hospital,
nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may
not be used to identify services provided by home health aide or certified nurse assistant)
H T1020 Personal care services, per diem, not for an inpatient or resident of a hospital, nursing
facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be
used to identify services provided by home health aide or certified nurse assistant)
H T1021 Home health aide or certified nurse assistant, per visit
H T1022 Contracted home health agency services, all services provided under contract, per day
H T1023 Screening to determine the appropriateness of consideration of an individual for
participation in a specified program, project or treatment protocol, per encounter
H T1024 Evaluation and treatment by an integrated, specialty team contracted to provide
coordinated care to multiple or severely handicapped children, per encounter
H T1025 Intensive, extended multidisciplinary services provided in a clinic setting to children with
complex medical, physical, mental and psychosocial impairments, per diem
H T1026 Intensive, extended multidisciplinary services provided in a clinic setting to children with
complex medical, physical, medical and psychosocial impairments, per hour
H T1027 Family training and counseling for child development, per 15 minutes

541
H T1028 Assessment of home, physical and family environment, to determine suitability to meet
patient’s medical needs
H T1029 Comprehensive environmental lead investigation, not including laboratory analysis, per
dwelling
H T1030 Nursing care, in the home, by registered nurse, per diem
H T1031 Nursing care, in the home, by licensed practical nurse, per diem
H T1040 Medicaid certified community behavioral health clinic services, per diem
H T1041 Medicaid certified community behavioral health clinic services, per month
H T1502 Administration of oral, intramuscular and/or subcutaneous medication by health care
agency/professional, per visit
H T1503 Administration of medication, other than oral and/or injectable, by a health care
agency/professional, per visit
H T1505 Electronic medication compliance management device, includes all components and
accessories, not otherwise classified
H T1999 Miscellaneous therapeutic items and supplies, retail purchases, not otherwise classified;
identify product in “remarks”
H T2001 Non-emergency transportation; patient attendant/escort
H T2002 Non-emergency transportation; per diem
H T2003 Non-emergency transportation; encounter/trip
H T2004 Non-emergency transport; commercial carrier, multi-pass
H T2005 Non-emergency transportation: stretcher van
H T2007 Transportation waiting time, air ambulance and non-emergency vehicle, one-half (1/2)
hour increments
H T2010 Preadmission screening and resident review (PASRR) level I identification screening, per
screen
H T2011 Preadmission screening and resident review (PASRR) level II evaluation, per evaluation
H T2012 Habilitation, educational, waiver; per diem
H T2013 Habilitation, educational, waiver; per hour
H T2014 Habilitation, prevocational, waiver; per diem
H T2015 Habilitation, prevocational, waiver; per hour
H T2016 Habilitation, residential, waiver; per diem
H T2017 Habilitation, residential, waiver; 15 minutes
H T2018 Habilitation, supported employment, waiver; per diem
H T2019 Habilitation, supported employment, waiver; per 15 minutes
H T2020 Day habilitation, waiver; per diem
H T2021 Day habilitation, waiver; per 15 minutes
H T2022 Case management, per month
H T2023 Targeted case management; per month
H T2024 Service assessment/plan of care development, waiver
H T2025 Waiver services; not otherwise specified (NOS)
H T2026 Specialized childcare, waiver; per diem
H T2027 Specialized childcare, waiver; per 15 minutes
H T2028 Specialized supply, not otherwise specified, waiver
H T2029 Specialized medical equipment, not otherwise specified, waiver

542
H T2030 Assisted living, waiver; per month
H T2031 Assisted living; waiver, per diem
H T2032 Residential care, not otherwise specified (NOS), waiver; per month
H T2033 Residential care, not otherwise specified (NOS), waiver; per diem
H T2034 Crisis intervention, waiver; per diem
H T2035 Utility services to support medical equipment and assistive technology/devices, waiver
H T2036 Therapeutic camping, overnight, waiver; each session
H T2037 Therapeutic camping, day, waiver; each session
H T2038 Community transition, waiver; per service
H T2039 Vehicle modifications, waiver; per service
H T2040 Financial management, self-directed, waiver; per 15 minutes
H T2041 Supports brokerage, self-directed, waiver; per 15 minutes
H T2042 Hospice routine home care; per diem
H T2043 Hospice continuous home care; per hour
H T2044 Hospice inpatient respite care; per diem
H T2045 Hospice general inpatient care; per diem
H T2046 Hospice long term care, room and board only; per diem
H T2048 Behavioral health; long-term care residential (non-acute care in a residential treatment
program where stay is typically longer than 30 days), with room and board, per diem
H T2049 Non-emergency transportation; stretcher van, mileage; per mile
H T2101 Human breast milk processing, storage and distribution only ♀
H T4521 Adult sized disposable incontinence product, brief/diaper, small, each
IOM: 100-03, 4, 280.1
H T4522 Adult sized disposable incontinence product, brief/diaper, medium, each
IOM: 100-03, 4, 280.1
H T4523 Adult sized disposable incontinence product, brief/diaper, large, each
IOM: 100-03, 4, 280.1
H T4524 Adult sized disposable incontinence product, brief/diaper, extra large, each
IOM: 100-03, 4, 280.1
H T4525 Adult sized disposable incontinence product, protective underwear/pull-on, small size,
each
IOM: 100-03, 4, 280.1
H T4526 Adult sized disposable incontinence product, protective underwear/pull-on, medium size,
each
IOM: 100-03, 4, 280.1
H T4527 Adult sized disposable incontinence product, protective underwear/pull-on, large size,
each
IOM: 100-03, 4, 280.1
H T4528 Adult sized disposable incontinence product, protective underwear/pull-on, extra large
size, each
IOM: 100-03, 4, 280.1
H T4529 Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each
IOM: 100-03, 4, 280.1
H T4530 Pediatric sized disposable incontinence product, brief/diaper, large size, each
IOM: 100-03, 4, 280.1
H T4531 Pediatric sized disposable incontinence product, protective underwear/pull-on,

543
 small/medium size, each
IOM: 100-03, 4, 280.1
H T4532 Pediatric sized disposable incontinence product, protective underwear/pull-on, large size,
each
IOM: 100-03, 4, 280.1
H T4533 Youth sized disposable incontinence product, brief/diaper, each
IOM: 100-03, 4, 280.1
H T4534 Youth sized disposable incontinence product, protective underwear/pull-on, each
IOM: 100-03, 4, 280.1
H T4535 Disposable liner/shield/guard/pad/undergarment, for incontinence, each
IOM: 100-03, 4, 280.1
H T4536 Incontinence product, protective underwear/pull-on, reusable, any size, each
IOM: 100-03, 4, 280.1
H T4537 Incontinence product, protective underpad, reusable, bed size, each
IOM: 100-03, 4, 280.1
H T4538 Diaper service, reusable diaper, each diaper
IOM: 100-03, 4, 280.1
H T4539 Incontinence product, diaper/brief, reusable, any size, each
IOM: 100-03, 4, 280.1
H T4540 Incontinence product, protective underpad, reusable, chair size, each
IOM: 100-03, 4, 280.1
H T4541 Incontinence product, disposable underpad, large, each
H T4542 Incontinence product, disposable underpad, small size, each
H T4543 Adult sized disposable incontinence product, protective brief/diaper, above extra large,
each
IOM: 100-03, 4, 280.1
H T4544 Adult sized disposable incontinence product, protective underwear/pull-on, above extra
large, each
IOM: 100-03, 4, 280.1
▶ H T4545 Incontinence product, disposable, penile wrap, each ♂
H T5001 Positioning seat for persons with special orthopedic needs, supply, not otherwise specified
H T5999 Supply, not otherwise specified

VISION SERVICES (V0000-V2999)

Frames
Frames, purchases A
❂ V2020
Includes cost of frame/replacement and dispensing fee. One unit of service represents one
pair of eyeglass frames.
IOM: 100-02, 15, 120
Deluxe frame E1
H V2025
Not a benefit. Billing deluxe framessubmit V2020 on one line; V2025 on second line.
IOM: 100-04, 1, 30.3.5

If a CPT procedure code for supply of spectacles or a permanent prosthesis is reported, recode
with the specific lens type listed below.

Single Vision Lenses

544
 ✽ V2100 Sphere, single vision, plano to plus or minus 4.00, per lens A

Sphere, single vision, plus or minus 4.12 to plus or minus 7.00d, per lens A
✽ V2101
Sphere, single vision, plus or minus 7.12 to plus or minus 20.00d, per lens A
✽ V2102
✽ V2103 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder,
per lens A

✽ V2104 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder,
per lens A

✽ V2105 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder,
per lens A

✽ V2106 Spherocylinder, single vision, plano to plus or minus 4.00d sphere, over 6.00d cylinder,
per lens A

✽ V2107 Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00 sphere, .12 to
2.00d cylinder, per lens A

✽ V2108 Spherocylinder, single vision, plus or minus 4.25d to plus or minus 7.00d sphere, 2.12 to
4.00d cylinder, per lens A

✽ V2109 Spherocylinder, single vision, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to
6.00d cylinder, per lens A

✽ V2110 Sperocylinder, single vision, plus or minus 4.25 to 7.00d sphere, over 6.00d cylinder, per
lens A

✽ V2111 Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, .25 to
2.25d cylinder, per lens A

✽ V2112 Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25d to
4.00d cylinder, per lens A

✽ V2113 Spherocylinder, single vision, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to
6.00d cylinder, per lens A

Spherocylinder, single vision, sphere over plus or minus 12.00d, per lens A
✽ V2114
Lenticular, (myodisc), per lens, single vision A
✽ V2115
Aniseikonic lens, single vision A
✽ V2118
Lenticular lens, per lens, single A
❂ V2121
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Not otherwise classified, single vision lens A
✽ V2199
Bill on paper. Requires report of type of single vision lens and optical lab invoice.

Bifocal Lenses
Sphere, bifocal, plano to plus or minus 4.00d, per lens A
✽ V2200
Sphere, bifocal, plus or minus 4.12 to plus or minus 7.00d, per lens A
✽ V2201
Sphere, bifocal, plus or minus 7.12 to plus or minus 20.00d, per lens A
✽ V2202
✽ V2203 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per
lens A

✽ V2204 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 2.12 to 4.00d cylinder, per
lens A

✽ V2205 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00d cylinder, per
lens A

✽ V2206 Spherocylinder, bifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens
A

✽ V2207 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, .12 to 2.00d
cylinder, per lens A

✽ V2208 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d
cylinder, per lens A

545
 ✽ V2209 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d
cylinder, per lens A

✽ V2210 Spherocylinder, bifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d
cylinder, per lens A

✽ V2211 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, .25 to 2.25d
cylinder, per lens A

✽ V2212 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d
cylinder, per lens A

✽ V2213 Spherocylinder, bifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d
cylinder, per lens A

Spherocylinder, bifocal, sphere over plus or minus 12.00d, per lens A

✽ V2214
Lenticular (myodisc), per lens, bifocal A
✽ V2215
Aniseikonic, per lens, bifocal A
✽ V2218
Bifocal seg width over 28 mm A
✽ V2219
Bifocal add over 3.25d A
✽ V2220
Lenticular lens, per lens, bifocal A
❂ V2221
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Specialty bifocal (by report) A
✽ V2299
Bill on paper. Requires report of type of specialty bifocal lens and optical lab invoice.

Trifocal Lenses
Sphere, trifocal, plano to plus or minus 4.00d, per lens A
✽ V2300
Sphere, trifocal, plus or minus 4.12 to plus or minus 7.00d per lens A
✽ V2301
Sphere, trifocal, plus or minus 7.12 to plus or minus 20.00, per lens A
✽ V2302
✽ V2303 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, .12 to 2.00d cylinder, per
lens A

✽ V2304 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 2.25-4.00d cylinder, per lens
A

✽ V2305 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 4.25 to 6.00 cylinder, per
lens A

✽ V2306 Spherocylinder, trifocal, plano to plus or minus 4.00d sphere, over 6.00d cylinder, per lens
A

✽ V2307 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, .12 to 2.00d
cylinder, per lens A

✽ V2308 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 2.12 to 4.00d
cylinder, per lens A

✽ V2309 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, 4.25 to 6.00d
cylinder, per lens A

✽ V2310 Spherocylinder, trifocal, plus or minus 4.25 to plus or minus 7.00d sphere, over 6.00d
cylinder, per lens A

✽ V2311 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, .25 to 2.25d
cylinder, per lens A

✽ V2312 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 2.25 to 4.00d
cylinder, per lens A

✽ V2313 Spherocylinder, trifocal, plus or minus 7.25 to plus or minus 12.00d sphere, 4.25 to 6.00d
cylinder, per lens A

Spherocylinder, trifocal, sphere over plus or minus 12.00d, per lens A

✽ V2314
Lenticular, (myodisc), per lens, trifocal A
✽ V2315

546
 ✽ V2318 Aniseikonic lens, trifocal A

Trifocal seg width over 28 mm A

✽ V2319
Trifocal add over 3.25d A
✽ V2320
Lenticular lens, per lens, trifocal A
❂ V2321
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Specialty trifocal (by report) A
✽ V2399
Bill on paper. Requires report of type of trifocal lens and optical lab invoice.

Variable Asphericity/Sphericity Lenses

Variable asphericity lens, single vision, full field, glass or plastic, per lens A
✽ V2410
Variable asphericity lens, bifocal, full field, glass or plastic, per lens A
✽ V2430
Variable sphericity lens, other type A
✽ V2499
Bill on paper. Requires report of other ptical lab invoice.

Contact Lenses
If a CPT procedure code for supply of contact lens is reported, recode with specific lens type listed
below (per lens).
Contact lens, PMMA, spherical, per lens A
✽ V2500
Requires prior authorization for patients under age 21.
Contact lens, PMMA, toric or prism ballast, per lens A
✽ V2501
Requires prior authorization for clients under age 21.
Contact lens, PMMA, bifocal, per lens A
✽ V2502
Requires prior authorization for clients under age 21. Bill on paper. Requires optical lab
invoice.
Contact lens PMMA, color vision deficiency, per lens A
✽ V2503
Requires prior authorization for clients under age 21. Bill on paper. Requires optical lab
invoice.
Contact lens, gas permeable, spherical, per lens A
✽ V2510
Requires prior authorization for clients under age 21.
Contact lens, gas permeable, toric, prism ballast, per lens A
✽ V2511
Requires prior authorization for clients under age 21.
Contact lens, gas permeable, bifocal, per lens A
✽ V2512
Requires prior authorization for clients under age 21.
Contact lens, gas permeable, extended wear, per lens A
✽ V2513
Requires prior authorization for clients under age 21.
Contact lens, hydrophilic, spherical, per lens A
❂ V2520
Requires prior authorization for clients under age 21.
IOM: 100-03, 1, 80.1; 100-03, 1, 80.4
Contact lens, hydrophilic, toric, or prism ballast, per lens A
❂ V2521
Requires prior authorization for clients under age 21.
IOM: 100-03, 1, 80.1; 100-03, 1, 80.4
Contact lens, hydrophilic, bifocal, per lens A
❂ V2522
Requires prior authorization for clients under age 21.
IOM: 100-03, 1, 80.1; 100-03, 1, 80.4
Contact lens, hydrophilic, extended wear, per lens A
❂ V2523
Requires prior authorization for clients under age 21.
IOM: 100-03, 1, 80.1; 100-03, 1, 80.4
✽ V2530 Contact lens, scleral, gas impermeable, per lens (for contact lens modification, see 92325)

547
 A

Requires prior authorization for clients under age 21.

❂ V2531 Contact lens, scleral, gas permeable, per lens (for contact lens modification, see 92325)
A

Requires prior authorization for clients under age 21. Bill on paper. Requires optical lab
invoice.
IOM: 100-03, 1, 80.5
Contact lens, other type A
✽ V2599
Requires prior authorization for clients under age 21. Bill on paper. Requires report of
other type of contact lens and optical invoice.

Low Vision Aids

If a CPT procedure code for supply of low vision aid is reported, recode with specific systems
listed below.
Hand held low vision aids and other nonspectacle mounted aids A
✽ V2600
Requires prior authorization.
Single lens spectacle mounted low vision aids A
✽ V2610
Requires prior authorization.
✽ V2615 Telescopic and other compound lens system, including distance vision telescopic, near
vision telescopes and compound microscopic lens system A

Requires prior authorization. Bill on paper. Requires optical lab invoice.

Prosthetic Eye
Prosthetic eye, plastic, custom A
❂ V2623
DME regional carrier. Requires prior authorization. Bill on paper. Requires optical lab
invoice.
Polishing/resurfacing of ocular prosthesis A
✽ V2624
Requires prior authorization. Bill on paper. Requires optical lab invoice.
Enlargement of ocular prosthesis A
✽ V2625
Requires prior authorization. Bill on paper. Requires optical lab invoice.
Reduction of ocular prosthesis A
✽ V2626
Requires prior authorization. Bill on paper. Requires optical lab invoice.
Scleral cover shell A
❂ V2627
DME regional carrier
Requires prior authorization. Bill on paper. Requires optical lab invoice.
IOM: 100-03, 4, 280.2
Fabrication and fitting of ocular conformer A
✽ V2628
Requires prior authorization. Bill on paper. Requires optical lab invoice.
Prosthetic eye, other type A
✽ V2629
Requires prior authorization. Bill on paper. Requires optical lab invoice.

Intraocular Lenses
Anterior chamber intraocular lens N1 N
❂ V2630
IOM: 100-02, 15, 120
Iris supported intraocular lens N1 N
❂ V2631
IOM: 100-02, 15, 120
Posterior chamber intraocular lens N1 N
❂ V2632
IOM: 100-02, 15, 120

548
Figure 52 Posterior intraocular lens.

Miscellaneous Vision Services

Balance lens, per lens A
✽ V2700
Deluxe lens feature E1
H V2702
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Slab off prism, glass or plastic, per lens A
✽ V2710
Prism, per lens A
✽ V2715
Press-on lens, Fresnel prism, per lens A
✽ V2718
Special base curve, glass or plastic, per lens A
✽ V2730
Tint, photochromatic, per lens A
❂ V2744
Requires prior authorization.
IOM: 100-02, 15, 120; 100-04, 3, 10.4
❂ V2745 Addition to lens, tint, any color, solid, gradient or equal, excludes photochroatic, any lens
material, per lens A

Includes photochromatic lenses (V2744) used as sunglasses, which are prescribed in

addition to regular prosthetic lenses for aphakic patient will be denied as not medically
necessary.
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Anti-reflective coating, per lens A
❂ V2750
Requires prior authorization.
IOM: 100-02, 15, 120; 100-04, 3, 10.4
U-V lens, per lens A
❂ V2755
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Eye glass case E1
✽ V2756
Scratch resistant coating, per lens E1
✽ V2760
Mirror coating, any type, solid, gradient or equal, any lens material, per lens B
❂ V2761
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Polarization, any lens material, per lens E1
❂ V2762
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Occluder lens, per lens A
✽ V2770
Requires prior authorization.
Oversize lens, per lens A
✽ V2780
Requires prior authorization.

549
 ✽ V2781 Progressive lens, per lens B

Requires prior authorization.

❂ V2782 Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens
A

Do not bill in addition to V2784

IOM: 100-02, 15, 120; 100-04, 3, 10.4
❂ V2783 Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass,
excludes polycarbonate, per lens A

Do not bill in addition to V2784

IOM: 100-02, 15, 120; 100-04, 3, 10.4
Lens, polycarbonate or equal, any index, per lens A
❂ V2784
Covered only for patients with functional vision in one eye-in this situation, an impact-
resistant material is covered for both lenses if eyeglasses are covered. Claims with V2784
that do not meet this coverage criterion will be denied as not medically necessary.
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Processing, preserving and transporting corneal tissue F4 F
✽ V2785
For ASC, bill on paper. Must attach eye bank invoice to claim. For Hospitals, bill charges
for corneal tissue to receive cost based reimbursement.
IOM: 100- 4, 4, 200.1
Specialty occupational multifocal lens, per lens E1
❂ V2786
IOM: 100-02, 15, 120; 100-04, 3, 10.4
Astigmatism correcting function of intraocular lens E1
H V2787
Medicare Statute 1862(a)(7)
Presbyopia correcting function of intraocular lens E1
H V2788
Medicare Statute 1862a7
Amniotic membrane for surgical reconstruction, per procedure N1 N
✽ V2790
✽ V2797 Vision supply, accessory and/or service component of another HCPCS vision code
E1
Vision item or service, miscellaneous A
✽ V2799
Bill on paper. Requires report of miscellaneous service and optical lab invoice.

HEARING SERVICES (V5000-V5999)

These codes are for non-physician services.

Assessments and Evaluations

Hearing screening E1
H V5008
IOM: 100-02, 16, 90
Assessment for hearing aid E1
H V5010
Medicare Statute 1862a7
Fitting/orientation/checking of hearing aid E1
H V5011
Medicare Statute 1862a7
Repair/modification of a hearing aid E1
H V5014
Medicare Statute 1862a7
Conformity evaluation E1
H V5020
Medicare Statute 1862a7

Monaural Hearing Aid

Hearing aid, monaural, body worn, air conduction E1
H V5030
Medicare Statute 1862a7

550
 H V5040 Hearing aid, monaural, body worn, bone conduction E1
Medicare Statute 1862a7
Hearing aid, monaural, in the ear E1
H V5050
Medicare Statute 1862a7
Hearing aid, monaural, behind the ear E1
H V5060
Medicare Statute 1862a7

Miscellaneous Services and Supplies

Glasses, air conduction E1
H V5070
Medicare Statute 1862a7
Glasses, bone conduction E1
H V5080
Medicare Statute 1862a7
Dispensing fee, unspecified hearing aid E1
H V5090
Medicare Statute 1862a7
Semi-implantable middle ear hearing prosthesis E1
H V5095
Medicare Statute 1862a7
Hearing aid, bilateral, body worn E1
H V5100
Medicare Statute 1862a7
Dispensing fee, bilateral E1
H V5110
Medicare Statute 1862a7

Hearing Aids
Binaural, body E1
H V5120
Medicare Statute 1862a7
Binaural, in the ear E1
H V5130
Medicare Statute 1862a7
Binaural, behind the ear E1
H V5140
Medicare Statute 1862a7
Binaural, glasses E1
H V5150
Medicare Statute 1862a7
Dispensing fee, binaural E1
H V5160
Medicare Statute 1862a7
V5170 Hearing aid, CROS, in the ear ✖
Hearing aid, contralateral routing device, monaural, in the ear (ITE) E1
▶ H V5171
Medicare Statute 1862a7
Hearing aid, contralateral routing device, monaural, in the canal (ITC) E1
▶ H V5172
Medicare Statute 1862a7
V5180 Hearing aid, CROS, behind the ear ✖
Hearing aid, contralateral routing device, monaural, behind the ear (BTE) E1
▶ H V5181
Medicare Statute 1862a7
Hearing aid, contralateral routing, monaural, glasses E1
H V5190
Medicare Statute 1862a7
Dispensing fee, contralateral, monaural E1
H V5200
Medicare Statute 1862a7
V5210 Hearing aid, BICROS, in the ear ✖
Hearing aid, contralateral routing system, binaural, ITE/ITE E1
▶ H V5211
Medicare Statute 1862a7
Hearing aid, contralateral routing system, binaural, ITE/ITC E1
▶ H V5212
Medicare Statute 1862a7

551
▶ H V5213 Hearing aid, contralateral routing system, binaural, ITE/BTE E1
Medicare Statute 1862a7
Hearing aid, contralateral routing system, binaural, ITC/ITC E1
▶ H V5214
Medicare Statute 1862a7
Hearing aid, contralateral routing system, binaural, ITC/BTE E1
▶ H V5215
Medicare Statute 1862a7
V5220 Hearing aid, contralateral, monaural, behind the ear ✖
Hearing aid, contralateral routing system, binaural, BTE/BTE E1
▶ H V5221
Medicare Statute 1862a7
Hearing aid, contralateral routing system, binaural, glasses E1
H V5230
Medicare Statute 1862a7
Dispensing fee, contralateral routing system, binaural E1
H V5240
Medicare Statute 1862a7
Dispensing fee, monaural hearing aid, any type E1
H V5241
Medicare Statute 1862a7
Hearing aid, analog, monaural, CIC (completely in the ear canal) E1
H V5242
Medicare Statute 1862a7
Hearing aid, analog, monaural, ITC (in the canal) E1
H V5243
Medicare Statute 1862a9
Hearing aid, digitally programmable analog, monaural, CIC E1
H V5244
Medicare Statute 1862a7
Hearing aid, digitally programmable, analog, monaural, ITC E1
H V5245
Medicare Statute 1862a7
Hearing aid, digitally programmable analog, monaural, ITE (in the ear) E1
H V5246
Medicare Statute 1862a7
Hearing aid, digitally programmable analog, monaural, BTE (behind the ear) E1
H V5247
Medicare Statute 1862a7
Hearing aid, analog, binaural, CIC E1
H V5248
Medicare Statute 1862a7
Hearing aid, analog, binaural, ITC E1
H V5249
Medicare Statute 1862a7
Hearing aid, digitally programmable analog, binaural, CIC E1
H V5250
Medicare Statute 1862a7
Hearing aid, digitally programmable analog, binaural, ITC E1
H V5251
Medicare Statute 1862a7
Hearing aid, digitally programmable, binaural, ITE E1
H V5252
Medicare Statute 1862a7
Hearing aid, digitally programmable, binaural, BTE E1
H V5253
Medicare Statute 1862a7
Hearing aid, digital, monaural, CIC E1
H V5254
Medicare Statute 1862a7
Hearing aid, digital, monaural, ITC E1
H V5255
Medicare Statute 1862a7
Hearing aid, digital, monaural, ITE E1
H V5256
Medicare Statute 1862a7
Hearing aid, digital, monaural, BTE E1
H V5257
Medicare Statute 1862a7
Hearing aid, digital, binaural, CIC E1
H V5258
Medicare Statute 1862a7

552
 H V5259 Hearing aid, digital, binaural, ITC E1
Medicare Statute 1862a7
Hearing aid, digital, binaural, ITE E1
H V5260
Medicare Statute 1862a7
Hearing aid, digital, binaural, BTE E1
H V5261
Medicare Statute 1862a7
Hearing aid, disposable, any type, monaural E1
H V5262
Medicare Statute 1862a7
Hearing aid, disposable, any type, binaural E1
H V5263
Medicare Statute 1862a7
Ear mold/insert, not disposable, any type E1
H V5264
Medicare Statute 1862a7
Ear mold/insert, disposable, any type E1
H V5265
Medicare Statute 1862a7
Battery for use in hearing device E1
H V5266
Medicare Statute 1862a7
Hearing aid or assistive listening device/supplies/accessories, not otherwise specified E1
H V5267
Medicare Statute 1862a7

Assistive Listening Devices

Assistive listening device, telephone amplifier, any type E1
H V5268
Medicare Statute 1862a7
Assistive listening device, alerting, any type E1
H V5269
Medicare Statute 1862a7
Assistive listening device, television amplifier, any type E1
H V5270
Medicare Statute 1862a7
Assistive listening device, television caption decoder E1
H V5271
Medicare Statute 1862a7
Assistive listening device, TDD E1
H V5272
Medicare Statute 1862a7
Assistive listening device, for use with cochlear implant E1
H V5273
Medicare Statute 1862a7
Assistive listening device, not otherwise specified E1
H V5274
Medicare Statute 1862a7
Ear impression, each E1
H V5275
Medicare Statute 1862a7
H V5281 Assistive listening device, personal FM/DM system, monaural (1 receiver, transmitter,
microphone), any type E1

Medicare Statute 1862a7

H V5282 Assistive listening device, personal FM/DM system, binaural (2 receivers, transmitter,
microphone), any type E1

Medicare Statute 1862a7

Assistive listening device, personal FM/DM neck, loop induction receiver E1
H V5283
Medicare Statute 1862a7
Assistive listening device, personal FM/DM, ear level receiver E1
H V5284
Medicare Statute 1862a7
Assistive listening device, personal FM/DM, direct audio input receiver E1
H V5285
Medicare Statute 1862a7
Assistive listening device, personal blue tooth FM/DM receiver E1
H V5286

553
 Medicare Statute 1862a7
H V5287 Assistive listening device, personal FM/DM receiver, not otherwise specified
Medicare Statute 1862a7 E1

H V5288 Assistive listening device, personal FM/DM transmitter assistive listening device
E1
Medicare Statute 1862a7
H V5289 Assistive listening device, personal FM/DM adapter/boot coupling device for receiver, any
type E1

Medicare Statute 1862a7

Assistive listening device, transmitter microphone, any type E1
H V5290
Medicare Statute 1862a7

Other Supllies and Miscellaneous Services

Hearing aid, not otherwise classified E1
H V5298
Medicare Statute 1862a7
Hearing service, miscellaneous B
❂ V5299
IOM: 100-02, 16, 90

Repair/Modification
H V5336 Repair/modification of augmentative communicative system or device (excludes adaptive
hearing aid) E1
Medicare Statute 1862a7

Speech, Language, and Pathology Screening

These codes are for non-physician services.
Speech screening E1
H V5362
Medicare Statute 1862a7
Language screening E1
H V5363
Medicare Statute 1862a7
Dysphagia screening E1
H V5364
Medicare Statute 1862a7

◀ New Revised ✔ Reinstated deleted Deleted H Not covered or valid by Medicare ❂ Special coverage
instructions ✽ Carrier discretion Bill Part B MAC Bill DME MAC MIPS Quantity Physician
Quantity Hospital ♀ Female only ♂ Male only Age DMEPOS A2-Z3 ASC Payment Indicator A-Y
ASC Status Indicator Coding Clinic

554
 APPENDIX A
Jurisdiction List for DMEPOS HCPCS Codes
Deleted codes are valid for dates of service on or before the date of deletion. The jurisdiction list includes codes that are not payable by
Medicare. Please consult the Medicare contractor in whose jurisdiction a claim would be filed in order to determine coverage under Medicare.
NOTE: All Local Carrier language has been changed to Part B MAC

HCPCS DESCRIPTION JURISDICTION

A0021 - Ambulance Services Part B MAC
A0999
A4206 - Medical, Surgical, and Self- Part B MAC if incident to a physician’s service (not separately payable). If other,
A4209 Administered Injection Supplies DME MAC.
A4210 Needle Free Injection Device DME MAC
A4211 Medical, Surgical, and Self- Part B MAC if incident to a physician’s service (not separately payable). If other,
Administered Injection Supplies DME MAC.
A4212 Non Coring Needle or Stylet with or Part B MAC
without Catheter
A4213 - Medical, Surgical, and Self- Part B MAC if incident to a physician’s service (not separately payable). If other,
A4215 Administered Injection Supplies DME MAC.
A4216 - Saline Part B MAC if incident to a physician’s service (not separately payable). If other,
A4218 DME MAC.
A4220 Refill Kit for Implantable Pump Part B MAC
A4221 - Self-Administered Injection and DME MAC
A4236 Diabetic Supplies
A4244 - Medical, Surgical, and Self- Part B MAC if incident to a physician’s service (not separately payable). If other,
A4250 Administered Injection Supplies DME MAC.
A4252 - Diabetic Supplies DME MAC
A4259
A4261 Cervical Cap for Contraceptive Use Part B MAC
A4262 - Lacrimal Duct Implants Part B MAC
A4263
A4264 Contraceptive Implant Part B MAC
A4265 Paraffin Part B MAC if incident to a physician’s service (not separately payable). If other,
DME MAC.
A4266 - Contraceptives Part B MAC
A4269
A4270 Endoscope Sheath Part B MAC
A4280 Accessory for Breast Prosthesis DME MAC
A4281 - Accessory for Breast Pump DME MAC
A4286
A4290 Sacral Nerve Stimulation Test Lead Part B MAC
A4300 - Implantable Catheter Part B MAC
A4301
A4305 - Disposable Drug Delivery System Part B MAC if incident to a physician’s service (not separately payable). If other,
A4306 DME MAC.
A4310 - Incontinence Supplies/Urinary If provided in the physician’s office for a temporary condition, the item is incident
A4358 Supplies to the physician’s service & billed to the Part B MAC.
If provided in the physician’s office or other place of service for a permanent
condition, the item is a prosthetic device & billed to the DME MAC.
A4360 - Urinary Supplies If provided in the physician’s office for a temporary condition, the item is incident
A4435 to the physician’s service & billed to the Part B MAC.
If provided in the physician’s office or other place of service for a permanent
condition, the item is a prosthetic device & billed to the DME MAC.
A4450 - Tape; Adhesive Remover Part B MAC if incident to a physician’s service (not separately payable), or if
A4456 supply for implanted prosthetic device. If other, DME MAC.
A4458-A4459 Enema Bag/System DME MAC

555
A4461-A4463 Surgical Dressing Holders Part B MAC if incident to a physician’s service (not separately payable). If other,
DME MAC.
A4465 - Non-elastic Binder and Garment, DME MAC
A4467 Strap, Covering
A4470 Gravlee Jet Washer Part B MAC
A4480 Vabra Aspirator Part B MAC
A4481 Tracheostomy Supply Part B MAC if incident to a physician’s service (not separately payable). If other,
DME MAC.
A4483 Moisture Exchanger DME MAC
A4490 - Surgical Stockings DME MAC
A4510
A4520 Diapers DME MAC
A4550 Surgical Trays Part B MAC
A4553 - Underpads DME MAC
A4554
A4555 - Electrodes; Lead Wires; Conductive Part B MAC if incident to a physician’s service (not separately payable). If other,
A4558 Paste DME MAC.
A4559 Coupling Gel Part B MAC if incident to a physician’s service (not separately payable). If other,
DME MAC.
A4561 - Pessary Part B MAC
A4562
A4565-A4566 Sling Part B MAC
A4570 Splint Part B MAC
A4575 Topical Hyperbaric Oxygen DME MAC
Chamber, Disposable
A4580 - Casting Supplies & Material Part B MAC
A4590
A4595 TENS Supplies Part B MAC if incident to a physician’s service (not separately payable). If other,
DME MAC.
A4600 Sleeve for Intermittent Limb DME MAC
Compression Device
A4601-A4602 Lithium Replacement Batteries DME MAC
A4604 Tubing for Positive Airway Pressure DME MAC
Device
A4605 Tracheal Suction Catheter DME MAC
A4606 Oxygen Probe for Oximeter DME MAC
A4608 Transtracheal Oxygen Catheter DME MAC
A4611 - Oxygen Equipment Batteries and DME MAC
A4613 Supplies
A4614 Peak Flow Rate Meter Part B MAC if incident to a physician’s service (not separately payable). If other,
DME MAC.
A4615 - Oxygen & Tracheostomy Supplies Part B MAC if incident to a physician’s service (not separately payable). If other,
A4629 DME MAC.
A4630 - DME Supplies DME MAC
A4640
A4641 - Imaging Agent; Contrast Material Part B MAC
A4642
A4648 Tissue Marker, Implanted Part B MAC
A4649 Miscellaneous Surgical Supplies Part B MAC if incident to a physician’s service (not separately payable), or if
supply for implanted prosthetic device or implanted DME. If other, DME MAC.
A4650 Implantable Radiation Dosimeter Part B MAC
A4651 - Supplies for ESRD DME MAC (not separately payable)
A4932
A5051 - Additional Ostomy Supplies If provided in the physician’s office for a temporary condition, the item is incident
A5093 to the physician’s service & billed to the Part B MAC.
If provided in the physician’s office or other place of service for a permanent
condition, the item is a prosthetic device & billed to the DME MAC.
A5102 - Additional Incontinence and If provided in the physician’s office for a temporary condition, the item is incident
A5200 Ostomy Supplies to the physician’s service & billed to the Part B MAC.
If provided in the physician’s office or other place of service for a permanent
condition, the item is a prosthetic device & billed to the DME MAC.

556
A5500 - Therapeutic Shoes DME MAC
A5513
A6000 Non-Contact Wound Warming DME MAC
Cover
A6010-A6024 Surgical Dressing Part B MAC if incident to a physician’s service (not separately payable) or if supply
for implanted prosthetic device or implanted DME. If other, DME MAC.
A6025 Silicone Gel Sheet Part B MAC if incident to a physician’s service (not separately payable) or if supply
for implanted prosthetic device or implanted DME. If other, DME MAC.
A6154 - Surgical Dressing Part B MAC if incident to a physician’s service (not separately payable) or if supply
A6411 for implanted prosthetic device or implanted DME. If other, DME MAC.
A6412 Eye Patch Part B MAC if incident to a physician’s service (not separately payable) or if supply
for implanted prosthetic device or implanted DME. If other, DME MAC.
A6413 Adhesive Bandage Part B MAC if incident to a physician’s service (not separately payable) or if supply
for implanted prosthetic device or implanted DME. If other, DME MAC.
A6441 - Surgical Dressings Part B MAC if incident to a physician’s service (not separately payable) or if supply
A6512 for implanted prosthetic device or implanted DME. If other, DME MAC.
A6513 Compression Burn Mask DME MAC
A6530 - Compression Gradient Stockings DME MAC
A6549
A6550 Supplies for Negative Pressure DME MAC
Wound Therapy Electrical Pump
A7000 - Accessories for Suction Pumps DME MAC
A7002
A7003 - Accessories for Nebulizers, DME MAC
A7039 Aspirators and Ventilators
A7040 - Chest Drainage Supplies Part B MAC
A7041
A7044 - Respiratory Accessories DME MAC
A7047
A7048 Vacuum Drainage Supply Part B MAC
A7501-A7527 Tracheostomy Supplies DME MAC
A8000-A8004 Protective Helmets DME MAC
A9150 Non-Prescription Drugs Part B MAC
A9152 - Vitamins Part B MAC
A9153
A9155 Artificial Saliva Part B MAC
A9180 Lice Infestation Treatment Part B MAC
A9270 Noncovered Items or Services DME MAC
A9272 Disposable Wound Suction Pump DME MAC
A9273 Hot Water Bottles, Ice Caps or DME MAC
Collars, and Heat and/or Cold
Wraps
A9274 - Glucose Monitoring DME MAC
A9278
A9279 Monitoring Feature/Device DME MAC
A9280 Alarm Device DME MAC
A9281 Reaching/Grabbing Device DME MAC
A9282 Wig DME MAC
A9283 Foot Off Loading Device DME MAC
A9284- A9286 Non-electric Spirometer, Inversion DME MAC
Devices and Hygienic Items
A9300 Exercise Equipment DME MAC
A9500 - Supplies for Radiology Procedures Part B MAC
A9700
A9900 Miscellaneous DME Supply or Part B MAC if used with implanted DME. If other, DME MAC.
Accessory
A9901 Delivery DME MAC
A9999 Miscellaneous DME Supply or Part B MAC if used with implanted DME. If other, DME MAC.
Accessory

557
B4034 - B9999 Enteral and Parenteral Therapy DME MAC
D0120 - Dental Procedures Part B MAC
D9999
E0100 - Canes DME MAC
E0105
E0110 - Crutches DME MAC
E0118
E0130 - Walkers DME MAC
E0159
E0160 - Commodes DME MAC
E0175
E0181 - Decubitus Care Equipment DME MAC
E0199
E0200 - Heat/Cold Applications DME MAC
E0239
E0240 - Bath and Toilet Aids DME MAC
E0248
E0249 Pad for Heating Unit DME MAC
E0250 - Hospital Beds DME MAC
E0304
E0305 - Hospital Bed Accessories DME MAC
E0326
E0328 - Pediatric Hospital Beds DME MAC
E0329
E0350 - Electronic Bowel Irrigation System DME MAC
E0352
E0370 Heel Pad DME MAC
E0371 - Decubitus Care Equipment DME MAC
E0373
E0424 - Oxygen and Related Respiratory DME MAC
E0484 Equipment
E0485 - Oral Device to Reduce Airway DME MAC
E0486 Collapsibility
E0487 Electric Spirometer DME MAC
E0500 IPPB Machine DME MAC
E0550 - Compressors/Nebulizers DME MAC
E0585
E0600 Suction Pump DME MAC
E0601 CPAP Device DME MAC
E0602 - Breast Pump DME MAC
E0604
E0605 Vaporizer DME MAC
E0606 Drainage Board DME MAC
E0607 Home Blood Glucose Monitor DME MAC
E0610 - Pacemaker Monitor DME MAC
E0615
E0616 Implantable Cardiac Event Recorder Part B MAC
E0617 External Defibrillator DME MAC
E0618 - Apnea Monitor DME MAC
E0619
E0620 Skin Piercing Device DME MAC
E0621 - Patient Lifts DME MAC
E0636
E0637 - Standing Devices/Lifts DME MAC
E0642
E0650 - Pneumatic Compressor and DME MAC
E0676 Appliances
E0691 - Ultraviolet Light Therapy Systems DME MAC
E0694
E0700 Safety Equipment DME MAC

558
E0705 Transfer Board DME MAC
E0710 Restraints DME MAC
E0720 - Electrical Nerve Stimulators DME MAC
E0745
E0746 EMG Device Part B MAC
E0747 - Osteogenic Stimulators DME MAC
E0748
E0749 Implantable Osteogenic Stimulators Part B MAC
E0755- E0770 Stimulation Devices DME MAC
E0776 IV Pole DME MAC
E0779 - External Infusion Pumps DME MAC
E0780
E0781 Ambulatory Infusion Pump DME MAC
E0782 - Infusion Pumps, Implantable Part B MAC
E0783
E0784 Infusion Pumps, Insulin DME MAC
E0785 - Implantable Infusion Pump Catheter Part B MAC
E0786
E0791 Parenteral Infusion Pump DME MAC
E0830 Ambulatory Traction Device DME MAC
E0840 - Traction Equipment DME MAC
E0900
E0910 - Trapeze/Fracture Frame DME MAC
E0930
E0935 - Passive Motion Exercise Device DME MAC
E0936
E0940 Trapeze Equipment DME MAC
E0941 Traction Equipment DME MAC
E0942 - Orthopedic Devices DME MAC
E0945
E0946 - Fracture Frame DME MAC
E0948
E0950 - Wheelchairs DME MAC
E1298
E1300 - Whirlpool Equipment DME MAC
E1310
E1352 - Additional Oxygen Related DME MAC
E1392 Equipment
E1399 Miscellaneous DME Part B MAC if implanted DME. If other, DME MAC.
E1405 - Additional Oxygen Equipment DME MAC
E1406
E1500 - Artificial Kidney Machines and DME MAC (not separately payable)
E1699 Accessories
E1700 - TMJ Device and Supplies DME MAC
E1702
E1800 - Dynamic Flexion Devices DME MAC
E1841
E1902 Communication Board DME MAC
E2000 Gastric Suction Pump DME MAC
E2100 - Blood Glucose Monitors with DME MAC
E2101 Special Features
E2120 Pulse Generator for Tympanic DME MAC
Treatment of Inner Ear
E2201 - Wheelchair Accessories DME MAC
E2397
E2402 Negative Pressure Wound Therapy DME MAC
Pump
E2500 - Speech Generating Device DME MAC
E2599

559
E2601 - Wheelchair Cushions and DME MAC
E2633 Accessories
E8000 - Gait Trainers DME MAC
E8002
G0008 - Misc. Professional Services Part B MAC
G0329
G0333 Dispensing Fee DME MAC
G0337 - Misc. Professional Services Part B MAC
G0365
G0372 Misc. Professional Services Part B MAC
G0378 - Misc. Professional Services Part B MAC
G0490
G0491-G9977
J0120 - J3570 Injection Part B MAC if incident to a physician’s service or used in an implanted infusion
pump. If other, DME MAC.
J3590 Unclassified Biologicals Part B MAC
J7030 - J7131 Miscellaneous Drugs and Solutions Part B MAC if incident to a physician’s service or used in an implanted infusion
pump. If other, DME MAC.
J7175-J7179 Clotting Factors Part B MAC
J7180 - J7195 Antihemophilic Factor Part B MAC
J7196 - J7197 Antithrombin III Part B MAC
J7198 Anti-inhibitor; per I.U. Part B MAC
J7199 - J7211 Other Hemophilia Clotting Factors Part B MAC
J7296 - J7307 Contraceptives Part B MAC
J7308 - J7309 Aminolevulinic Acid HCL Part B MAC
J7310 Ganciclovir, Long-Acting Implant Part B MAC
J7311 - J7316 Ophthalmic Drugs Part B MAC
J7320 - J7328 Hyaluronan Part B MAC
J7330 Autologous Cultured Chondrocytes, Part B MAC
Implant
J7336 Capsaicin Part B MAC
J7340 Carbidopa/Levodopa Part B MAC if incident to a physician’s service or used in an implanted infusion
pump. If other, DME MAC.
J7342 - J7345 Ciprofloxacin otic & Topical Part B MAC
Aminolevulinic Acid
J7500 - J7599 Immunosuppressive Drugs Part B MAC if incident to a physician’s service or used in an implanted infusion
pump. If other, DME MAC.
J7604 - J7699 Inhalation Solutions Part B MAC if incident to a physician’s service. If other, DME MAC.
J7799 -J7999 NOC Drugs, Other than Inhalation Part B MAC if incident to a physician’s service or used in an implanted infusion
Drugs pump. If other, DME MAC.
J8498 Anti-emetic Drug DME MAC
J8499 Prescription Drug, Oral, Non Part B MAC if incident to a physician’s service. If other, DME MAC.
Chemotherapeutic
J8501 - J8999 Oral Anti-Cancer Drugs DME MAC
J9000 - J9999 Chemotherapy Drugs Part B MAC if incident to a physician’s service or used in an implanted infusion
pump. If other, DME MAC.
K0001 - Wheelchairs DME MAC
K0108
K0195 Elevating Leg Rests DME MAC
K0455 Infusion Pump used for DME MAC
Uninterrupted Administration of
Epoprostenal
K0462 Loaner Equipment DME MAC
K0552 - External Infusion Pump Supplies & DME MAC
K0605 Continuous Glucose Monitor
K0606 - Defibrillator Accessories DME MAC
K0609
K0669 Wheelchair Cushion DME MAC
K0672 Soft Interface for Orthosis DME MAC

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K0730 Inhalation Drug Delivery System DME MAC
K0733 Power Wheelchair Accessory DME MAC
K0738 Oxygen Equipment DME MAC
K0739 Repair or Nonroutine Service for Part B MAC if implanted DME. If other, DME MAC
DME
K0740 Repair or Nonroutine Service for DME MAC
Oxygen Equipment
K0743 - Suction Pump and Dressings DME MAC
K0746
K0800 - Power Mobility Devices DME MAC
K0899
K0900 Custom DME, other than DME MAC
Wheelchair
L0112 - L4631 Orthotics DME MAC
L5000 - L5999 Lower Limb Prosthetics DME MAC
L6000 - L7499 Upper Limb Prosthetics DME MAC
L7510 - L7520 Repair of Prosthetic Device Part B MAC if repair of implanted prosthetic device. If other, DME MAC.
L7600 - L8485 Prosthetics DME MAC
L8499 Unlisted Procedure for Part B MAC if implanted prosthetic device. If other, DME MAC.
Miscellaneous Prosthetic Services
L8500 - L8501 Artificial Larynx; Tracheostomy DME MAC
Speaking Valve
L8505 Artificial Larynx Accessory DME MAC
L8507 Voice Prosthesis, Patient Inserted DME MAC
L8509 Voice Prosthesis, Inserted by a Part B MAC for dates of service on or after 10/01/2010. DME MAC for dates of
Licensed Health Care Provider service prior to 10/01/2010
L8510 Voice Prosthesis DME MAC
L8511 - L8515 Voice Prosthesis Part B MAC if used with tracheoesophageal voice prostheses inserted by a licensed
health care provider. If other, DME MAC
L8600 - L8699 Prosthetic Implants Part B MAC
L9900 Miscellaneous Orthotic or Prosthetic Part B MAC if used with implanted prosthetic device. If other, DME MAC.
Component or Accessory
M0075 - Medical Services Part B MAC
M0301
P2028 - P9615 Laboratory Tests Part B MAC
Q0035 Cardio-kymography Part B MAC
Q0081 Infusion Therapy Part B MAC
Q0083 - Chemotherapy Administration Part B MAC
Q0085
Q0091 Smear Preparation Part B MAC
Q0092 Portable X-ray Setup Part B MAC
Q0111 - Miscellaneous Lab Services Part B MAC
Q0115
Q0138-Q0139 Ferumoxytol Injection Part B MAC
Q0144 Azithromycin Dihydrate Part B MAC if incident to a physician’s service. If other, DME MAC.
Q0161 - Anti-emetic DME MAC
Q0181
Q0477 - Ventricular Assist Devices Part B MAC
Q0509
Q0510 - Drug Dispensing Fees DME MAC
Q0514
Q0515 Sermorelin Acetate Part B MAC
Q1004 - New Technology IOL Part B MAC
Q1005
Q2004 Irrigation Solution Part B MAC
Q2009 Fosphenytoin Part B MAC
Q2017 Teniposide Part B MAC
Q2026-Q2028 Injectable Dermal Fillers Part B MAC

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Q2034 - Influenza Vaccine Part B MAC
Q2039
Q2040 - Cellular Immunotherapy Part B MAC
Q2043
Q2049-Q2050 Doxorubicin Part B MAC if incident to a physician’s service or used in an implanted infusion
pump. If other, DME MAC.
Q2052 IVIG Demonstration DME MAC
Q3001 Supplies for Radiology Procedures Part B MAC
Q3014 Telehealth Originating Site Facility Part B MAC
Fee
Q3027 - Vaccines Part B MAC
Q3028
Q3031 Collagen Skin Test Part B MAC
Q4001 - Splints and Casts Part B MAC
Q4051
Q4074 Inhalation Drug Part B MAC if incident to a physician’s service. If other, DME MAC.
Q4081 Epoetin Part B MAC
Q4082 Drug Subject to Competitive Part B MAC
Acquisition Program
Q4100 - Skin Substitutes Part B MAC
Q4182
Q5001 - Hospice Services Part B MAC
Q5010
Q5101-Q5102 Injection Part B MAC if incident to a physician’s service or used in an implanted infusion
pump. If other, DME MAC.
Q9950 - Imaging Agents Part B MAC
Q9954
Q9955 - Microspheres Part B MAC
Q9957
Q9958 - Imaging Agents Part B MAC
Q9969
Q9982-Q9983 Supplies for Radiology Procedures Part B MAC
R0070 - Diagnostic Radiology Services Part B MAC
R0076
V2020 - Frames DME MAC
V2025
V2100 - Lenses DME MAC
V2513
V2520 - Hydrophilic Contact Lenses Part B MAC if incident to a physician’s service. If other, DME MAC.
V2523
V2530 - Contact Lenses, Scleral DME MAC
V2531
V2599 Contact Lens, Other Type Part B MAC if incident to a physician’s service. If other, DME MAC.
V2600 - Low Vision Aids DME MAC
V2615
V2623 - Prosthetic Eyes DME MAC
V2629
V2630 - Intraocular Lenses Part B MAC
V2632
V2700 - Miscellaneous Vision Service DME MAC
V2780
V2781 Progressive Lens DME MAC
V2782 - Lenses DME MAC
V2784
V2785 Processing—Corneal Tissue Part B MAC
V2786 Lens DME MAC
V2787 - Intraocular Lenses Part B MAC
V2788
V2790 Amniotic Membrane Part B MAC
V2797 Vision Supply DME MAC

562
V2799 Miscellaneous Vision Service DME MAC
V5008 - Hearing Services Part B MAC
V5299
V5336 Repair/Modification of DME MAC
Augmentative Communicative
System or Device
V5362 - Speech Screening Part B MAC
V5364

563
 APPENDIX B
GENERAL CORRECT CODING POLICIES FOR NATIONAL
CORRECT CODING INITIATIVE POLICY MANUAL FOR
MEDICARE SERVICES
Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2017 American Medical Association. All rights
reserved.
CPT® is a registered trademark of the American Medical Association.
Applicable FARS\DFARS Restrictions Apply to Government Use.
Fee schedules, relative value units, conversion factors, prospective payment systems, and/or related components are not assigned by the AMA,
are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense
medical services. The AMA assumes no liability for the data contained or not contained herein.

Chapter I
Revision Date 1/1/2018
GENERAL CORRECT CODING POLICIES
A. Introduction
Healthcare providers utilize HCPCS/CPT codes to report medical services performed on patients to
Medicare Carriers (A/B MACs processing practitioner service claims) and Fiscal Intermediaries (FIs).
HCPCS (Healthcare Common Procedure Coding System) consists of Level I CPT (Current Procedural
Terminology) codes and Level II codes. CPT codes are defined in the American Medical Association’s
(AMA) CPT Manual which is updated and published annually. HCPCS Level II codes are defined by the
Centers for Medicare & Medicaid Services (CMS) and are updated throughout the year as necessary.
Changes in CPT codes are approved by the AMA CPT Editorial Panel which meets three times per year.

CPT and HCPCS Level II codes define medical and surgical procedures performed on patients. Some
procedure codes are very specific defining a single service (e.g., CPT code 93000 (electrocardiogram)) while
other codes define procedures consisting of many services (e.g., CPT code 58263 (vaginal hysterectomy with
removal of tube(s) and ovary(s) and repair of enterocele)). Because many procedures can be performed by
different approaches, different methods, or in combination with other procedures, there are often multiple
HCPCS/CPT codes defining similar or related procedures.

CPT and HCPCS Level II code descriptors usually do not define all services included in a procedure. There
are often services inherent in a procedure or group of procedures. For example, anesthesia services include
certain preparation and monitoring services.

The CMS developed the NCCI to prevent inappropriate payment of services that should not be reported
together. Prior to April 1, 2012, NCCI PTP edits were placed into either the “Column One/Column Two
Correct Coding Edit Table” or the “Mutually Exclusive Edit Table.” However, on April 1, 2012, the edits in
the “Mutually Exclusive Edit Table” were moved to the “Column One/Column Two Correct Coding Edit
Table” so that all the NCCI PTP edits are currently contained in this single table. Combining the two tables
simplifies researching NCCI edits and online use of NCCI tables. Each edit table contains edits which are
pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a column one and
column two HCPCS/CPT code. If a provider reports the two codes of an edit pair, the column two code is
denied, and the column one code is eligible for payment. However, if it is clinically appropriate to utilize an
NCCI-associated modifier, both the column one and column two codes are eligible for payment. (NCCI-
associated modifiers and their appropriate use are discussed elsewhere in this chapter.)

When the NCCI was first established and during its early years, the “Column One/Column Two Correct
Coding Edit Table” was termed the “Comprehensive/Component Edit Table.” This latter terminology was a

564
misnomer. Although the column two code is often a component of a more comprehensive column one code,
this relationship is not true for many edits. In the latter type of edit the code pair edit simply represents two
codes that should not be reported together. For example, a provider shall not report a vaginal hysterectomy
code and total abdominal hysterectomy code together.

In this chapter, Sections B–Q address various issues relating to NCCI PTP edits.

Medically Unlikely Edits (MUEs) prevent payment for an inappropriate number/quantity of the same service
on a single day. An MUE for a HCPCS/CPT code is the maximum number of units of service (UOS) under
most circumstances reportable by the same provider for the same beneficiary on the same date of service. The
ideal MUE value for a HCPCS/CPT code is one that allows the vast majority of appropriately coded claims
to pass the MUE. More information concerning MUEs is discussed in Section V of this chapter.

In this Manual many policies are described utilizing the term “physician.” Unless indicated differently the
usage of this term does not restrict the policies to physicians only but applies to all practitioners, hospitals,
providers, or suppliers eligible to bill the relevant HCPCS/CPT codes pursuant to applicable portions of the
Social Security Act (SSA) of 1965, the Code of Federal Regulations (CFR), and Medicare rules. In some
sections of this Manual, the term “physician” would not include some of these entities because specific rules
do not apply to them. For example, Anesthesia Rules [e.g., CMS Internet-only Manual, Publication 100-04
(Medicare Claims Processing Manual), Chapter 12 (Physician/Non-Physician Practitioners), Section
50(Payment for Anesthesiology Services)] and Global Surgery Rules [e.g., CMS Internet-only Manual,
Publication 100-04 (Medicare Claims Processing Manual), Chapter 12 (Physician/Non-Physician
Practitioners), Section 40 (Surgeons and Global Surgery)] do not apply to hospitals.

Providers reporting services under Medicare’s hospital outpatient prospective payment system (OPPS) shall
report all services in accordance with appropriate Medicare Internet-only Manual (IOM) instructions.

Physicians must report services correctly. This manual discusses general coding principles in Chapter I and
principles more relevant to other specific groups of HCPCS/CPT codes in the other chapters. There are
certain types of improper coding that physicians must avoid.

Procedures shall be reported with the most comprehensive CPT code that describes the services performed.
Physicians must not unbundle the services described by a HCPCS/CPT code. Some examples follow:

• A physician shall not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT
code describes these services. For example if a physician performs a vaginal hysterectomy on a uterus
weighing less than 250 grams with bilateral salpingo-oophorectomy, the physician shall report CPT code
58262 (Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)). The
physician shall not report CPT code 58260 (Vaginal hysterectomy, for uterus 250 g or less;) plus CPT code
58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)).
• A physician shall not fragment a procedure into component parts. For example, if a physician performs an
anal endoscopy with biopsy, the physician shall report CPT code 46606 (Anoscopy; with biopsy, single or
multiple). It is improper to unbundle this procedure and report CPT code 46600(Anoscopy; diagnostic,…)
plus CPT code 45100 (Biopsy of anorectal wall, anal approach…). The latter code is not intended to be
utilized with an endoscopic procedure code.
• A physician shall not unbundle a bilateral procedure code into two unilateral procedure codes. For example
if a physician performs bilateral mammography, the physician shall report CPT code 77066 (Diagnostic
mammography … bilateral). The physician shall not report CPT code 77065 (Diagnostic mammography …
unilateral) with two units of service or 77065LT plus 77065RT.
• A physician shall not unbundle services that are integral to a more comprehensive procedure. For example,
surgical access is integral to a surgical procedure. A physician shall not report CPT code 49000 (Exploratory
laparotomy,…) when performing an open abdominal procedure such as a total abdominal colectomy (e.g.,
CPT code 44150).

Physicians must avoid downcoding. If a HCPCS/CPT code exists that describes the services performed, the
physician must report this code rather than report a less comprehensive code with other codes describing the
services not included in the less comprehensive code. For example if a physician performs a unilateral partial
mastectomy with axillary lymphadenectomy, the provider shall report CPT code 19302 (Mastectomy,

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partial…; with axillary lymphadenectomy). A physician shall not report CPT code 19301 (Mastectomy,
partial…) plus CPT code 38745 (Axillary lymphadenectomy; complete).

Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that
code have been performed. For example, if a physician performs a superficial axillary lymphadenectomy (CPT
code 38740), the physician shall not report CPT code 38745 (Axillary lymphadenectomy; complete).

Physicians must report units of service correctly. Each HCPCS/CPT code has a defined unit of service for
reporting purposes. A physician shall not report units of service for a HCPCS/CPT code using a criterion that
differs from the code’s defined unit of service. For example, some therapy codes are reported in fifteen minute
increments (e.g., CPT codes 97110-97124). Others are reported per session (e.g., CPT codes 92507, 92508).
A physician shall not report a “per session” code using fifteen minute increments. CPT code 92507 or 92508
should be reported with one unit of service on a single date of service.

MUE and NCCI PTP edits are based on services provided by the same physician to the same beneficiary on
the same date of service. Physicians shall not inconvenience beneficiaries nor increase risks to beneficiaries by
performing services on different dates of service to avoid MUE or NCCI PTP edits.

In 2010 the CPT Manual modified the numbering of codes so that the sequence of codes as they appear in the
CPT Manual does not necessarily correspond to a sequential numbering of codes. In the National Correct
Coding Initiative Policy Manual for Medicare Services, use of a numerical range of codes reflects all codes that
numerically fall within the range regardless of their sequential order in the CPT Manual.

This chapter addresses general coding principles, issues, and policies. Many of these principles, issues, and
policies are addressed further in subsequent chapters dealing with specific groups of HCPCS/CPT codes. In
this chapter examples are often utilized to clarify principles, issues, or policies. The examples do not represent
the only codes to which the principles, issues, or policies apply.

B. Coding Based on Standards of Medical/Surgical Practice

Most HCPCS/CPT code defined procedures include services that are integral to them. Some of these integral
services have specific CPT codes for reporting the service when not performed as an integral part of another
procedure. (For example, CPT code 36000 (introduction of needle or intracatheter into a vein) is integral to
all nuclear medicine procedures requiring injection of a radiopharmaceutical into a vein. CPT code 36000 is
not separately reportable with these types of nuclear medicine procedures. However, CPT code 36000 may be
reported alone if the only service provided is the introduction of a needle into a vein. Other integral services
do not have specific CPT codes. (For example, wound irrigation is integral to the treatment of all wounds and
does not have a HCPCS/CPT code.) Services integral to HCPCS/CPT code defined procedures are included
in those procedures based on the standards of medical/surgical practice. It is inappropriate to separately report
services that are integral to another procedure with that procedure.

Many NCCI PTP edits are based on the standards of medical/surgical practice. Services that are integral to
another service are component parts of the more comprehensive service. When integral component services
have their own HCPCS/CPT codes, NCCI PTP edits place the comprehensive service in column one and
the component service in column two. Since a component service integral to a comprehensive service is not
separately reportable, the column two code is not separately reportable with the column one code.

Some services are integral to large numbers of procedures. Other services are integral to a more limited
number of procedures. Examples of services integral to a large number of procedures include:

• Cleansing, shaving and prepping of skin

• Draping and positioning of patient
• Insertion of intravenous access for medication administration
• Insertion of urinary catheter
• Sedative administration by the physician performing a procedure (see Chapter II, Anesthesia Services)
• Local, topical or regional anesthesia administered by the physician performing the procedure
• Surgical approach including identification of anatomical landmarks, incision, evaluation of the surgical field,
debridement of traumatized tissue, lysis of adhesions, and isolation of structures limiting access to the

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 surgical field such as bone, blood vessels, nerve, and muscles including stimulation for identification or
monitoring
• Surgical cultures
• Wound irrigation
• Insertion and removal of drains, suction devices, and pumps into same site
• Surgical closure and dressings
• Application, management, and removal of postoperative dressings and analgesic devices (peri-incisional)
• Application of TENS unit
• Institution of Patient Controlled Anesthesia
• Preoperative, intraoperative and postoperative documentation, including photographs, drawings, dictation,
or transcription as necessary to document the services provided
• Surgical supplies, except for specific situations where CMS policy permits separate payment

Although other chapters in this Manual further address issues related to the standards of medical/surgical
practice for the procedures covered by that chapter, it is not possible because of space limitations to discuss all
NCCI PTP edits based on the principle of the standards of medical/surgical practice. However, there are
several general principles that can be applied to the edits as follows:

1. The component service is an accepted standard of care when performing the comprehensive service.
2. The component service is usually necessary to complete the comprehensive service.
3. The component service is not a separately distinguishable procedure when performed with the
comprehensive service.

Specific examples of services that are not separately reportable because they are components of more
comprehensive services follow:

Medical:

1. Since interpretation of cardiac rhythm is an integral component of the interpretation of an

electrocardiogram, a rhythm strip is not separately reportable.
2. Since determination of ankle/brachial indices requires both upper and lower extremity Doppler studies, an
upper extremity Doppler study is not separately reportable.
3. Since a cardiac stress test includes multiple electrocardiograms, an electrocardiogram is not separately
reportable.

Surgical:

1. Since a myringotomy requires access to the tympanic membrane through the external auditory canal,
removal of impacted cerumen from the external auditory canal is not separately reportable.
2. A “scout” bronchoscopy to assess the surgical field, anatomic landmarks, extent of disease, etc., is not
separately reportable with an open pulmonary procedure such as a pulmonary lobectomy. By contrast, an
initial diagnostic bronchoscopy is separately reportable. If the diagnostic bronchoscopy is performed at the
same patient encounter as the open pulmonary procedure and does not duplicate an earlier diagnostic
bronchoscopy by the same or another physician, the diagnostic bronchoscopy may be reported with
modifier –58 appended to the open pulmonary procedure code to indicate a staged procedure. A cursory
examination of the upper airway during a bronchoscopy with the bronchoscope shall not be reported
separately as a laryngoscopy. However, separate endoscopies of anatomically distinct areas with different
endoscopes may be reported separately (e.g., thoracoscopy and mediastinoscopy).
3. If an endoscopic procedure is performed at the same patient encounter as a non-endoscopic procedure to
ensure no intraoperative injury occurred or verify the procedure was performed correctly, the endoscopic
procedure is not separately reportable with the non-endoscopic procedure.
4. Since a colectomy requires exposure of the colon, the laparotomy and adhesiolysis to expose the colon are
not separately reportable.

C. Medical/Surgical Package
Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work.

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When multiple procedures are performed at the same patient encounter, there is often overlap of the pre-
procedure and post-procedure work. Payment methodologies for surgical procedures account for the overlap
of the pre-procedure and post-procedure work.

The component elements of the pre-procedure and postprocedure work for each procedure are included
component services of that procedure as a standard of medical/surgical practice. Some general guidelines
follow:

1. Many invasive procedures require vascular and/or airway access. The work associated with obtaining the
required access is included in the pre-procedure or intra-procedure work. The work associated with
returning a patient to the appropriate post-procedure state is included in the postprocedure work.

Airway access is necessary for general anesthesia and is not separately reportable. There is no CPT code for
elective endotracheal intubation. CPT code 31500 describes an emergency endotracheal intubation and shall
not be reported for elective endotracheal intubation. Visualization of the airway is a component part of an
endotracheal intubation, and CPT codes describing procedures that visualize the airway (e.g., nasal
endoscopy, laryngoscopy, bronchoscopy) shall not be reported with an endotracheal intubation. These CPT
codes describe diagnostic and therapeutic endoscopies, and it is a misuse of these codes to report visualization
of the airway for endotracheal intubation.

Intravenous access (e.g., CPT codes 36000, 36400, 36410) is not separately reportable when performed with
many types of procedures (e.g., surgical procedures, anesthesia procedures, radiological procedures requiring
intravenous contrast, nuclear medicine procedures requiring intravenous radiopharmaceutical).

After vascular access is achieved, the access must be maintained by a slow infusion (e.g., saline) or injection of
heparin or saline into a “lock”. Since these services are necessary for maintenance of the vascular access, they
are not separately reportable with the vascular access CPT codes or procedures requiring vascular access as a
standard of medical/surgical practice. CPT codes 37211-37214 (Transcatheter therapy with infusion for
thrombolysis) shall not be reported for use of an anticoagulant to maintain vascular access.

The global surgical package includes the administration of fluids and drugs during the operative procedure.
CPT codes 96360-96377 shall not be reported separately for that operative procedure. Under OPPS, the
administration of fluids and drugs during or for an operative procedure are included services and are not
separately reportable (e.g., CPT codes 96360-96377).

When a procedure requires more invasive vascular access services (e.g., central venous access, pulmonary artery
access), the more invasive vascular service is separately reportable if it is not typical of the procedure and the
work of the more invasive vascular service has not been included in the valuation of the procedure.

Insertion of a central venous access device (e.g., central venous catheter, pulmonary artery catheter) requires
passage of a catheter through central venous vessels and, in the case of a pulmonary artery catheter, through
the right atrium and ventricle. These services often require the use of fluoroscopic guidance. Separate
reporting of CPT codes for right heart catheterization, selective venous catheterization, or pulmonary artery
catheterization is not appropriate when reporting a CPT code for insertion of a central venous access device.
Since CPT code 77001 describes fluoroscopic guidance for central venous access device procedures, CPT
codes for more general fluoroscopy (e.g., 76000, 76001, 77002) shall not be reported separately.

2. Medicare Anesthesia Rules prevent separate payment for anesthesia services by the same physician
performing a surgical or medical procedure. The physician performing a surgical or medical procedure
shall not report CPT codes 96360-96377 for the administration of anesthetic agents during the
procedure. If it is medically reasonable and necessary that a separate provider (anesthesia practitioner)
perform anesthesia services (e.g., monitored anesthesia care) for a surgical or medical procedure, a
separate anesthesia service may be reported by the second provider.

Under OPPS, anesthesia for a surgical procedure is an included service and is not separately reportable. For
example, a provider shall not report CPT codes 96360-96377 for anesthesia services.

When anesthesia services are not separately reportable, physicians and facilities shall not unbundle
components of anesthesia and report them in lieu of an anesthesia code.

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3. If an endoscopic procedure is performed at the same patient encounter as a non-endoscopic procedure to
ensure no intraoperative injury occurred or verify the procedure was performed correctly, the endoscopic
procedure is not separately reportable with the non-endoscopic procedure.
4. Many procedures require cardiopulmonary monitoring either by the physician performing the procedure
or an anesthesia practitioner. Since these services are integral to the procedure, they are not separately
reportable. Examples of these services include cardiac monitoring, pulse oximetry, and ventilation
management (e.g., 93000-93010, 93040-93042, 94760, 94761, 94770).
5. A biopsy performed at the time of another more extensive procedure (e.g., excision, destruction, removal)
is separately reportable under specific circumstances.

If the biopsy is performed on a separate lesion, it is separately reportable. This situation may be reported with
anatomic modifiers or modifier -59.

If the biopsy is performed on the same lesion on which a more extensive procedure is performed, it is
separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more
extensive procedure, and the decision to proceed with the more extensive procedure is based on the diagnosis
established by the pathologic examination. The biopsy is not separately reportable if the pathologic
examination at the time of surgery is for the purpose of assessing margins of resection or verifying
resectability. When separately reportable modifier -58 may be reported to indicate that the biopsy and the
more extensive procedure were planned or staged procedures.

If a biopsy is performed and submitted for pathologic evaluation that will be completed after the more
extensive procedure is performed, the biopsy is not separately reportable with the more extensive procedure.

If a single lesion is biopsied multiple times, only one biopsy code may be reported with a single unit of service.
If multiple lesions are non-endoscopically biopsied, a biopsy code may be reported for each lesion appending a
modifier indicating that each biopsy was performed on a separate lesion. For endoscopic biopsies, multiple
biopsies of a single or multiple lesions are reported with one unit of service of the biopsy code. If it is
medically reasonable and necessary to submit multiple biopsies of the same or different lesions for separate
pathologic examination, the medical record must identify the precise location and separate nature of each
biopsy.

6. Exposure and exploration of the surgical field is integral to an operative procedure and is not separately
reportable. For example, an exploratory laparotomy (CPT code 49000) is not separately reportable with
an intra-abdominal procedure. If exploration of the surgical field results in additional procedures other
than the primary procedure, the additional procedures may generally be reported separately. However, a
procedure designated by the CPT code descriptor as a “separate procedure” is not separately reportable if
performed in a region anatomically related to the other procedure(s) through the same skin incision,
orifice, or surgical approach.
7. If a definitive surgical procedure requires access through diseased tissue (e.g., necrotic skin, abscess,
hematoma, seroma), a separate service for this access (e.g., debridement, incision and drainage) is not
separately reportable. Types of procedures to which this principle applies include, but are not limited to, -
ectomy, -otomy, excision, resection, -plasty, insertion, revision, replacement, relocation, removal or
closure. For example, debridement of skin and subcutaneous tissue at the site of an abdominal incision
made to perform an intra-abdominal procedure is not separately reportable. (See Chapter IV, Section H
(General Policy Statements), Subsection #11 for guidance on reporting debridement with open fractures
and dislocations.)
8. If removal, destruction, or other form of elimination of a lesion requires coincidental elimination of other
pathology, only the primary procedure may be reported. For example, if an area of pilonidal disease
contains an abscess, incision and drainage of the abscess during the procedure to excise the area of
pilonidal disease is not separately reportable.
9. An excision and removal (–ectomy) includes the incision and opening (–otomy) of the organ. A
HCPCS/CPT code for an –otomy procedure shall not be reported with an –ectomy code for the same
organ.
10. Multiple approaches to the same procedure are mutually exclusive of one another and shall not be
reported separately.

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For example, both a vaginal hysterectomy and abdominal hysterectomy should not be reported separately.

11. If a procedure utilizing one approach fails and is converted to a procedure utilizing a different approach,
only the completed procedure may be reported. For example, if a laparoscopic hysterectomy is converted
to an open hysterectomy, only the open hysterectomy procedure code may be reported.
12. If a laparoscopic procedure fails and is converted to an open procedure, the physician shall not report a
diagnostic laparoscopy in lieu of the failed laparoscopic procedure. For example, if a laparoscopic
cholecystectomy is converted to an open cholecystectomy, the physician shall not report the failed
laparoscopic cholecystectomy nor a diagnostic laparoscopy.
13. If a diagnostic endoscopy is the basis for and precedes an open procedure, the diagnostic endoscopy may
be reported with modifier -58 appended to the open procedure code. However, the medical record must
document the medical reasonableness and necessity for the diagnostic endoscopy. A scout endoscopy to
assess anatomic landmarks and extent of disease is not separately reportable with an open procedure.
When an endoscopic procedure fails and is converted to another surgical procedure, only the completed
surgical procedure may be reported. The endoscopic procedure is not separately reportable with the
completed surgical procedure.
14. Treatment of complications of primary surgical procedures is separately reportable with some limitations.
The global surgical package for an operative procedure includes all intra-operative services that are
normally a usual and necessary part of the procedure. Additionally the global surgical package includes all
medical and surgical services required of the surgeon during the postoperative period of the surgery to
treat complications that do not require return to the operating room. Thus, treatment of a complication
of a primary surgical procedure is not separately reportable (1) if it represents usual and necessary care in
the operating room during the procedure or (2) if it occurs postoperatively and does not require return to
the operating room. For example, control of hemorrhage is a usual and necessary component of a surgical
procedure in the operating room and is not separately reportable. Control of postoperative hemorrhage is
also not separately reportable unless the patient must be returned to the operating room for treatment. In
the latter case, the control of hemorrhage may be separately reportable with modifier -78.

D. Evaluation and Management (E&M) Services

Medicare Global Surgery Rules define the rules for reporting evaluation and management (E&M) services
with procedures covered by these rules. This section summarizes some of the rules.

All procedures on the Medicare Physician Fee Schedule are assigned a Global period of 000, 010, 090, XXX,
YYY, ZZZ, or MMM. The global concept does not apply to XXX procedures. The global period for YYY
procedures is defined by the Carrier (A/B MAC processing practitioner service claims). All procedures with a
global period of ZZZ are related to another procedure, and the applicable global period for the ZZZ code is
determined by the related procedure. Procedures with a global period of MMM are maternity procedures.

Since NCCI PTP edits are applied to same day services by the same provider to the same beneficiary, certain
Global Surgery Rules are applicable to NCCI. An E&M service is separately reportable on the same date of
service as a procedure with a global period of 000, 010, or 090 under limited circumstances.

If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M is
performed on the same date of service as a major surgical procedure for the purpose of deciding whether to
perform this surgical procedure, the E&M service is separately reportable with modifier –57. Other
preoperative E&M services on the same date of service as a major surgical procedure are included in the global
payment for the procedure and are not separately reportable. NCCI does not contain edits based on this rule
because Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits.

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general
E&M services on the same date of service as the minor surgical procedure are included in the payment for the
procedure. The decision to perform a minor surgical procedure is included in the payment for the minor
surgical procedure and shall not be reported separately as an E&M service. However, a significant and
separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is
separately reportable with modifier -25. The E&M service and minor surgical procedure do not require
different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting

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E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify
reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many,
but not all, possible edits based on these principles.

Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy
and immunization status, obtains informed consent, and performs the repair, an E&M service is not
separately reportable. However, if the physician also performs a medically reasonable and necessary full
neurological examination, an E&M service may be separately reportable.

For major and minor surgical procedures, postoperative E&M services related to recovery from the surgical
procedure during the postoperative period are included in the global surgical package as are E&M services
related to complications of the surgery. Postoperative visits unrelated to the diagnosis for which the surgical
procedure was performed unless related to a complication of surgery may be reported separately on the same
day as a surgical procedure with modifier 24 (“Unrelated Evaluation and Management Service by the Same
Physician or Other Qualified Health Care Professional During a Postoperative Period”).

Procedures with a global surgery indicator of “XXX” are not covered by these rules. Many of these “XXX”
procedures are performed by physicians and have inherent pre-procedure, intra-procedure, and post-procedure
work usually performed each time the procedure is completed. This work shall not be reported as a separate
E&M code. Other “XXX” procedures are not usually performed by a physician and have no physician work
relative value units associated with them. A physician shall not report a separate E&M code with these
procedures for the supervision of others performing the procedure or for the interpretation of the procedure.
With most “XXX” procedures, the physician may, however, perform a significant and separately identifiable
E&M service on the same date of service which may be reported by appending modifier -25 to the E&M
code. This E&M service may be related to the same diagnosis necessitating performance of the “XXX”
procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the
“XXX” procedure, or time for interpreting the result of the “XXX” procedure. Appending modifier -25 to a
significant, separately identifiable E&M service when performed on the same date of service as an “XXX”
procedure is correct coding.

E. Modifiers and Modifier Indicators

1. The AMA CPT Manual and CMS define modifiers that may be appended to HCPCS/CPT codes to
provide additional information about the services rendered. Modifiers consist of two alphanumeric
characters.

Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the
modifier. A modifier shall not be appended to a HCPCS/CPT code solely to bypass an NCCI PTP edit if the
clinical circumstances do not justify its use. If the Medicare program imposes restrictions on the use of a
modifier, the modifier may only be used to bypass an NCCI PTP edit if the Medicare restrictions are fulfilled.

Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI edit include:
Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI

Global surgery modifiers: -24, -25, -57, -58, -78, -79

Other modifiers: -27,-59, -91, XE, XS, XP, XU

Modifiers 76 (“repeat procedure or service by same physician”) and 77 (“repeat procedure by another
physician”) are not NCCI-associated modifiers. Use of either of these modifiers does not bypass an NCCI
PTP edit.

Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of “0” indicates that NCCI-
associated modifiers cannot be used to bypass the edit. A modifier indicator of “1” indicates that NCCI-
associated modifiers may be used to bypass an edit under appropriate circumstances. A modifier indicator of
“9” indicates that the edit has been deleted, and the modifier indicator is not relevant.

It is very important that NCCI-associated modifiers only be used when appropriate. In general these

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circumstances relate to separate patient encounters, separate anatomic sites or separate specimens. (See
subsequent discussion of modifiers in this section.) Most edits involving paired organs or structures (e.g., eyes,
ears, extremities, lungs, kidneys) have NCCI PTP modifier indicators of “1” because the two codes of the
code pair edit may be reported if performed on the contralateral organs or structures. Most of these code pairs
should not be reported with NCCI-associated modifiers when performed on the ipsilateral organ or structure
unless there is a specific coding rationale to bypass the edit. The existence of the NCCI PTP edit indicates
that the two codes generally cannot be reported together unless the two corresponding procedures are
performed at two separate patient encounters or two separate anatomic locations. However, if the two
corresponding procedures are performed at the same patient encounter and in contiguous structures, NCCI-
associated modifiers generally should not be utilized.

The appropriate use of most of these modifiers is straightforward. However, further explanation is provided
about modifiers -25, -58, and -59. Although modifier -22 is not a modifier that bypasses an NCCI PTP edit,
its use is occasionally relevant to an NCCI PTP edit and is discussed below.

a) Modifier -22: Modifier -22 is defined by the CPT Manual as “Increased Procedural Services.” This
modifier shall not be reported unless the service(s) performed is(are) substantially more extensive than the usual
service(s) included in the procedure described by the HCPCS/CPT code reported.

Occasionally a provider may perform two procedures that should not be reported together based on an NCCI
PTP edit. If the edit allows use of NCCI-associated modifiers to bypass it and the clinical circumstances
justify use of one of these modifiers, both services may be reported with the NCCI-associated modifier.
However, if the NCCI PTP edit does not allow use of NCCI-associated modifiers to bypass it and the
procedure qualifies as an unusual procedural service, the physician may report the column one HCPCS/CPT
code of the NCCI PTP edit with modifier -22. The Carrier (A/B MAC processing practitioner service
claims) may then evaluate the unusual procedural service to determine whether additional payment is justified.

For example, CMS limits payment for CPT code 69990 (micro-surgical techniques, requiring use of
operating microscope …) to procedures listed in the Internet-only Manual (IOM) (Claims Processing Manual,
Publication 100-04, 12-§20.4.5). If a physician reports CPT code 69990 with two other CPT codes and one
of the codes is not on this list, an NCCI PTP edit with the code not on the list will prevent payment for CPT
code 69990. Claims processing systems do not determine which procedure is linked with CPT code 69990. In
situations such as this, the physician may submit his claim to the local carrier (A/B MAC processing
practitioner service claims) for readjudication appending modifier 22 to the CPT code. Although the carrier
(A/B MAC processing practitioner service claims) cannot override an NCCI PTP edit that does not allow use
of NCCI-associated modifiers, the carrier (A/B MAC processing practitioner service claims) has discretion to
adjust payment to include use of the operating microscope based on modifier 22.

b) Modifier -25: The CPT Manual defines modifier -25 as a “significant, separately identifiable evaluation
and management service by the same physician or other qualified health care professional on the same day of
the procedure or other service.” Modifier -25 may be appended to an evaluation and management (E&M)
CPT code to indicate that the E&M service is significant and separately identifiable from other services
reported on the same date of service. The E&M service may be related to the same or different diagnosis as
the other procedure(s).

Modifier -25 may be appended to E&M services reported with minor surgical procedures (global period of
000 or 010 days) or procedures not covered by global surgery rules (global indicator of XXX). Since minor
surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work
inherent in the procedure, the provider shall not report an E&M service for this work. Furthermore, Medicare
Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the
decision to perform a minor surgical procedure whether the patient is a new or established patient.

c) Modifier -58: Modifier -58 is defined by the CPT Manual as a “staged or related procedure or service by
the same physician or other qualified health care professional during the postoperative period.” It may be used
to indicate that a procedure was followed by a second procedure during the post-operative period of the first
procedure. This situation may occur because the second procedure was planned prospectively, was more
extensive than the first procedure, or was therapy after a diagnostic surgical service. Use of modifier -58 will
bypass NCCI PTP edits that allow use of NCCI-associated modifiers.

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If a diagnostic endoscopic procedure results in the decision to perform an open procedure, both procedures
may be reported with modifier -58 appended to the HCPCS/CPT code for the open procedure. However, if
the endoscopic procedure preceding an open procedure is a “scout” procedure to assess anatomic landmarks
and/or extent of disease, it is not separately reportable.

Diagnostic endoscopy is never separately reportable with another endoscopic procedure of the same organ(s)
when performed at the same patient encounter. Similarly, diagnostic laparoscopy is never separately reportable
with a surgical laparoscopic procedure of the same body cavity when performed at the same patient encounter.

If a planned laparoscopic procedure fails and is converted to an open procedure, only the open procedure may
be reported. The failed laparoscopic procedure is not separately reportable. The NCCI contains many, but not
all, edits bundling laparoscopic procedures into open procedures. Since the number of possible code
combinations bundling a laparoscopic procedure into an open procedure is much greater than the number of
such edits in NCCI, the principle stated in this paragraph is applicable regardless of whether the selected code
pair combination is included in the NCCI tables. A provider shall not select laparoscopic and open
HCPCS/CPT codes to report because the combination is not included in the NCCI tables.

d) Modifier -59: Modifier -59 is an important NCCI-associated modifier that is often used incorrectly. For
the NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic
sites or different patient encounters. One function of NCCI PTP edits is to prevent payment for codes that
report overlapping services except in those instances where the services are “separate and distinct.” Modifier 59
shall only be used if no other modifier more appropriately describes the relationships of the two or more
procedure codes. The CPT Manual defines modifier -59 as follows:

Modifier -59: Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a
procedure or service was distinct or independent from other non E/M services performed on the same day.
Modifier -59 is used to identify procedures/services other than E/M services that are not normally reported
together, but are appropriate under the circumstances. Documentation must support a different session,
different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or
separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same
day by the same individual. However, when another already established modifier is appropriate, it should be
used rather than modifier -59. Only if no more descriptive modifier is available, and the use of modifier -59
best explains the circumstances, should modifier -59 be used. Note: Modifier 59 should not be appended to an
E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same
date, see modifier 25.

NCCI PTP edits define when two procedure HCPCS/CPT codes may not be reported together except under
special circumstances. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be
reported together when the two procedures are performed at different anatomic sites or different patient
encounters. Carrier (A/B MAC processing practitioner service claims) processing systems utilize NCCI-
associated modifiers to allow payment of both codes of an edit. Modifier -59 and other NCCI-associated
modifiers shall NOT be used to bypass an NCCI PTP edit unless the proper criteria for use of the modifier
are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated
modifier used.

Some examples of the appropriate use of modifier -59 are contained in the individual chapter policies.

One of the common misuses of modifier -59 is related to the portion of the definition of modifier -59
allowing its use to describe “different procedure or surgery.” The code descriptors of the two codes of a code
pair edit usually represent different procedures or surgeries. The edit indicates that the two
procedures/surgeries cannot be reported together if performed at the same anatomic site and same patient
encounter. The provider cannot use modifier -59 for such an edit based on the two codes being different
procedures/surgeries. However, if the two procedures/surgeries are performed at separate anatomic sites or at
separate patient encounters on the same date of service, modifier -59 may be appended to indicate that they
are different procedures/surgeries on that date of service.

There are several exceptions to this general principle about misuse of modifier -59 that apply to some code
pair edits for procedures performed at the same patient encounter.

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(1) When a diagnostic procedure precedes a surgical or non-surgical therapeutic procedure and is the basis on
which the decision to perform the surgical or non-surgical therapeutic procedure is made, that diagnostic
procedure may be considered to be a separate and distinct procedure as long as (a) it occurs before the
therapeutic procedure and is not interspersed with services that are required for the therapeutic
intervention; (b) it clearly provides the information needed to decide whether to proceed with the
therapeutic procedure; and (c) it does not constitute a service that would have otherwise been required
during the therapeutic intervention. If the diagnostic procedure is an inherent component of the surgical
or non-surgical therapeutic procedure, it shall not be reported separately.
(2) When a diagnostic procedure follows a surgical procedure or non-surgical therapeutic procedure, that
diagnostic procedure may be considered to be a separate and distinct procedure as long as (a)it occurs
after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled
with services that are only required for the therapeutic intervention, and (b) it does not constitute a
service that would have otherwise been required during the therapeutic intervention. If the post-
procedure diagnostic procedure is an inherent component or otherwise included (or not separately
payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it shall
not be reported separately.
(3) There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is
a measure of time (e.g., per 15 minutes, per hour). If two separate and distinct timed services are
provided in separate and distinct time blocks, modifier 59 may be used to identify the services. The
separate and distinct time blocks for the two services may be sequential to one another or split. When
the two services are split, the time block for one service may be followed by a time block for the second
service followed by another time block for the first service. All Medicare rules for reporting timed
services are applicable. For example, the total time is calculated for all related timed services performed.
The number of reportable units of service is based on the total time, and these units of service are
allocated between the HCPCS/CPT codes for the individual services performed. The physician is not
permitted to perform multiple services, each for the minimal reportable time, and report each of these as
separate units of service. (e.g., A physician or therapist performs eight minutes of neuromuscular
reeducation (CPT code 97112) and eight minutes of therapeutic exercises (CPT code 97110). Since the
physician or therapist performed 16 minutes of related timed services, only one unit of service may be
reported for one, not each, of these codes.)

Use of modifier -59 to indicate different procedures/surgeries does not require a different diagnosis for each
HCPCS/CPT coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of
modifier -59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at
different anatomic sites or separate patient encounters.

From an NCCI perspective, the definition of different anatomic sites includes different organs, different
anatomic regions, or different lesions in the same organ. It does not include treatment of contiguous structures
of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment
of a single anatomic site. Treatment of posterior segment structures in the ipsilateral eye constitutes treatment
of a single anatomic site. Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral
shoulder constitutes treatment of a single anatomic site.

If the same procedure is performed at different anatomic sites, it does not necessarily imply that a
HCPCS/CPT code may be reported with more than one unit of service (UOS) for the procedure.
Determining whether additional UOS may be reported depends in part upon the HCPCS/CPT code
descriptor including the definition of the code’s unit of service, when present.

Example #1: The column one/column two code edit with column one CPT code 38221 (Diagnostic bone
marrow biopsy) and column two CPT code 38220 (Diagnostic bone marrow, aspiration) includes two distinct
procedures when performed at separate anatomic sites (e.g., contralateral iliac bones) or separate patient
encounters. In these circumstances, it would be acceptable to use modifier -59. However, if both 38221 and
38220 are performed on the same iliac bone at the same patient encounter which is the usual practice, modifier
-59 shall NOT be used. Although CMS does not allow separate payment for CPT code 38220 with CPT
code 38221 when bone marrow aspiration and biopsy are performed on the same iliac bone at a single patient
encounter, a physician may report CPT code 38222 Diagnostic bone marrow; biopsy(ies) and aspiration(s).

Example #2: The procedure to procedure edit with column one CPT code 11055 (paring or cutting of benign

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hyperkeratotic lesion …) and column two CPT code 11720 (debridement of nail(s) by any method; 1 to 5)
may be bypassed with modifier 59 only if the paring/cutting of a benign hyperkeratotic lesion is performed on
a different digit (e.g., toe) than one that has nail debridement. Modifier 59 shall not be used to bypass the edit
if the two procedures are performed on the same digit.

e) Modifiers XE, XS, XP, XU: These modifiers were effective January 1, 2015. These modifiers were
developed to provide greater reporting specificity in situations where modifier 59 was previously reported and
may be utilized in lieu of modifier 59 whenever possible. (Modifier 59 should only be utilized if no other more
specific modifier is appropriate.) Although NCCI will eventually require use of these modifiers rather than
modifier 59 with certain edits, physicians may begin using them for claims with dates of service on or after
January 1, 2015. The modifiers are defined as follows:

XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This
modifier shall only be used to describe separate encounters on the same date of service.

XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”

XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”

XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap
usual components of the main service”

F. Standard Preparation/Monitoring Services for Anesthesia

With few exceptions anesthesia HCPCS/CPT codes do not specify the mode of anesthesia for a particular
procedure. Regardless of the mode of anesthesia, preparation and monitoring services are not separately
reportable with anesthesia service HCPCS/CPT codes when performed in association with the anesthesia
service. However, if the provider of the anesthesia service performs one or more of these services prior to and
unrelated to the anticipated anesthesia service or after the patient is released from the anesthesia practitioner’s
postoperative care, the service may be separately reportable with modifier -59.

G. Anesthesia Service Included in the Surgical Procedure

Under the CMS Anesthesia Rules, with limited exceptions, Medicare does not allow separate payment for
anesthesia services performed by the physician who also furnishes the medical or surgical service. In this case,
payment for the anesthesia service is included in the payment for the medical or surgical procedure. For
example, separate payment is not allowed for the physician’s performance of local, regional, or most other
anesthesia including nerve blocks if the physician also performs the medical or surgical procedure. However,
Medicare allows separate reporting for moderate conscious sedation services (CPT codes 99151-99153) when
provided by same physician performing a medical or surgical procedure except for those procedures listed in
Appendix G of the CPT Manual.

CPT codes describing anesthesia services (00100-01999) or services that are bundled into anesthesia shall not
be reported in addition to the surgical or medical procedure requiring the anesthesia services if performed by
the same physician. Examples of improperly reported services that are bundled into the anesthesia service
when anesthesia is provided by the physician performing the medical or surgical procedure include
introduction of needle or intracatheter into a vein (CPT code 36000), venipuncture (CPT code 36410),
intravenous infusion/injection (CPT codes 96360-96368, 96374-96377) or cardiac assessment (e.g., CPT
codes 93000-93010, 93040-93042). However, if these services are not related to the delivery of an anesthetic
agent, or are not an inherent component of the procedure or global service, they may be reported separately.

The physician performing a surgical or medical procedure shall not report an epidural/subarachnoid injection
(CPT codes 62320-62327) or nerve block (CPT codes 64400-64530) for anesthesia for that procedure.

H. HCPCS/CPT Procedure Code Definition

The HCPCS/CPT code descriptors of two codes are often the basis of an NCCI PTP edit. If two

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HCPCS/CPT codes describe redundant services, they shall not be reported separately. Several general
principles follow:

1. A family of CPT codes may include a CPT code followed by one or more indented CPT codes. The first
CPT code descriptor includes a semicolon. The portion of the descriptor of the first code in the family
preceding the semicolon is a common part of the descriptor for each subsequent code of the family. For
example,
CPT code 70120 Radiologic examination, mastoids; less than 3 views per side
CPT code 70130 Complete, minimum of 3 views per side

The portion of the descriptor preceding the semicolon (“Radiologic examination, mastoids”) is common to
both CPT codes 70120 and 70130. The difference between the two codes is the portion of the descriptors
following the semicolon. Often as in this case, two codes from a family may not be reported separately. A
physician cannot report CPT codes 70120 and 70130 for a procedure performed on ipsilateral mastoids at the
same patient encounter. It is important to recognize, however, that there are numerous circumstances when it
may be appropriate to report more than one code from a family of codes. For example, CPT codes 70120 and
70130 may be reported separately if the two procedures are performed on contralateral mastoids or at two
separate patient encounters on the same date of service.

2. If a HCPCS/CPT code is reported, it includes all components of the procedure defined by the descriptor.
For example, CPT code 58291 includes a vaginal hysterectomy with “removal of tube(s) and/or ovary(s).”
A physician cannot report a salpingo-oophorectomy (CPT code 58720) separately with CPT code 58291.
3. CPT code descriptors often define correct coding relationships where two codes may not be reported
separately with one another at the same anatomic site and/or same patient encounter. A few examples
follow:
a) A “partial” procedure is not separately reportable with a “complete” procedure.
b) A “partial” procedure is not separately reportable with a “total” procedure.
c) A “unilateral” procedure is not separately reportable with a “bilateral” procedure.
d) A “single” procedure is not separately reportable with a “multiple” procedure.
e) A “with” procedure is not separately reportable with a “without” procedure.
f) An “initial” procedure is not separately reportable with a “subsequent” procedure.

I. CPT Manual and CMS Coding Manual Instructions

CMS often publishes coding instructions in its rules, manuals, and notices. Physicians must utilize these
instructions when reporting services rendered to Medicare patients.

The CPT Manual also includes coding instructions which may be found in the “Introduction”, individual
chapters, and appendices. In individual chapters the instructions may appear at the beginning of a chapter, at
the beginning of a subsection of the chapter, or after specific CPT codes. Physicians should follow CPT
Manual instructions unless CMS has provided different coding or reporting instructions.

The American Medical Association publishes CPT Assistant which contains coding guidelines. CMS does not
review nor approve the information in this publication. In the development of NCCI PTP edits, CMS
occasionally disagrees with the information in this publication. If a physician utilizes information from CPT
Assistant to report services rendered to Medicare patients, it is possible that Medicare Carriers (A/B MACs
processing practitioner service claims) and Fiscal Intermediaries may utilize different criteria to process claims.

J. CPT “Separate Procedure” Definition

If a CPT code descriptor includes the term “separate procedure”, the CPT code may not be reported
separately with a related procedure. CMS interprets this designation to prohibit the separate reporting of a
“separate procedure” when performed with another procedure in an anatomically related region often through
the same skin incision, orifice, or surgical approach.

A CPT code with the “separate procedure” designation may be reported with another procedure if it is
performed at a separate patient encounter on the same date of service or at the same patient encounter in an

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anatomically unrelated area often through a separate skin incision, orifice, or surgical approach. Modifier -59
or a more specific modifier (e.g., anatomic modifier) may be appended to the “separate procedure” CPT code
to indicate that it qualifies as a separately reportable service.

K. Family of Codes
The CPT Manual often contains a group of codes that describe related procedures that may be performed in
various combinations. Some codes describe limited component services, and other codes describe various
combinations of component services. Physicians must utilize several principles in selecting the correct code to
report:

1. A HCPCS/CPT code may be reported if and only if all services described by the code are performed.
2. The HCPCS/CPT code describing the services performed shall be reported. A physician shall not report
multiple codes corresponding to component services if a single comprehensive code describes the services
performed. There are limited exceptions to this rule which are specifically identified in this Manual.
3. HCPCS/CPT code(s) corresponding to component service(s) of other more comprehensive HCPCS/CPT
code(s) shall not be reported separately with the more comprehensive HCPCS/CPT code(s) that include
the component service(s).
4. If the HCPCS/CPT codes do not correctly describe the procedure(s) performed, the physician shall report
a “not otherwise specified” CPT code rather than a HCPCS/CPT code that most closely describes the
procedure(s) performed.

L. More Extensive Procedure

The CPT Manual often describes groups of similar codes differing in the complexity of the service. Unless
services are performed at separate patient encounters or at separate anatomic sites, the less complex service is
included in the more complex service and is not separately reportable. Several examples of this principle
follow:

1. If two procedures only differ in that one is described as a “simple” procedure and the other as a “complex”
procedure, the “simple” procedure is included in the “complex” procedure and is not separately reportable
unless the two procedures are performed at separate patient encounters or at separate anatomic sites.
2. If two procedures only differ in that one is described as a “simple” procedure and the other as a
“complicated” procedure, the “simple” procedure is included in the “complicated” procedure and is not
separately reportable unless the two procedures are performed at separate patient encounters or at separate
anatomic sites.
3. If two procedures only differ in that one is described as a “limited” procedure and the other as a “complete”
procedure, the “limited” procedure is included in the “complete” procedure and is not separately reportable
unless the two procedures are performed at separate patient encounters or at separate anatomic sites.
4. If two procedures only differ in that one is described as an “intermediate” procedure and the other as a
“comprehensive” procedure, the “intermediate” procedure is included in the “comprehensive” procedure
and is not separately reportable unless the two procedures are performed at separate patient encounters or
at separate anatomic sites.
5. If two procedures only differ in that one is described as a “superficial” procedure and the other as a “deep”
procedure, the “superficial” procedure is included in the “deep” procedure and is not separately reportable
unless the two procedures are performed at separate patient encounters or at separate anatomic sites.
6. If two procedures only differ in that one is described as an “incomplete” procedure and the other as a
“complete” procedure, the “incomplete” procedure is included in the “complete” procedure and is not
separately reportable unless the two procedures are performed at separate patient encounters or at separate
anatomic sites.
7. If two procedures only differ in that one is described as an “external” procedure and the other as an
“internal” procedure, the “external” procedure is included in the “internal” procedure and is not separately
reportable unless the two procedures are performed at separate patient encounters or at separate anatomic
sites.

M. Sequential Procedure

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Some surgical procedures may be performed by different surgical approaches. If an initial surgical approach to
a procedure fails and a second surgical approach is utilized at the same patient encounter, only the
HCPCS/CPT code corresponding to the second surgical approach may be reported. If there are different
HCPCS/CPT codes for the two different surgical approaches, the two procedures are considered “sequential”,
and only the HCPCS/CPT code corresponding to the second surgical approach may be reported. For
example, a physician may begin a cholecystectomy procedure utilizing a laparoscopic approach and have to
convert the procedure to an open abdominal approach. Only the CPT code for the open cholecystectomy may
be reported. The CPT code for the failed laparoscopic cholecystectomy is not separately reportable.

N. Laboratory Panel
The CPT Manual defines organ and disease specific panels of laboratory tests. If a laboratory performs all tests
included in one of these panels, the laboratory may report the CPT code for the panel or the CPT codes for
the individual tests. If the laboratory repeats one of these component tests as a medically reasonable and
necessary service on the same date of service, the CPT code corresponding to the repeat laboratory test may be
reported with modifier -91 appended.

O. Misuse of Column Two Code with Column One Code (Misuse of Code
Edit Rationale)
CMS manuals and instructions often describe groups of HCPCS/CPT codes that should not be reported
together for the Medicare program. Edits based on these instructions are often included as misuse of column
two code with column one code.

A HCPCS/CPT code descriptor does not include exhaustive information about the code. Physicians who are
not familiar with a HCPCS/CPT code may incorrectly report the code in a context different than intended.
The NCCI has identified HCPCS/CPT codes that are incorrectly reported with other HCPCS/CPT codes
as a result of the misuse of the column two code with the column one code. If these edits allow use of NCCI-
associated modifiers (modifier indicator of “1”), there are limited circumstances when the column two code
may be reported on the same date of service as the column one code. Two examples follow:

1. Three or more HCPCS/CPT codes may be reported on the same date of service. Although the column
two code is misused if reported as a service associated with the column one code, the column two code may
be appropriately reported with a third HCPCS/CPT code reported on the same date of service. For
example, CMS limits separate payment for use of the operating microscope for microsurgical techniques
(CPT code 69990) to a group of procedures listed in the online Claims Processing Manual (Chapter 12,
Section 20.4.5 (Allowable Adjustments)). The NCCI has edits with column one codes of surgical
procedures not listed in this section of the manual and column two CPT code of 69990. Some of these
edits allow use of NCCI-associated modifiers because the two services listed in the edit may be performed
at the same patient encounter as a third procedure for which CPT code 69990 is separately reportable.
2. There may be limited circumstances when the column two code is separately reportable with the column
one code. For example, the NCCI has an edit with column one CPT code of 80061 (lipid profile) and
column two CPT code of 83721 (LDL cholesterol by direct measurement). If the triglyceride level is less
than 400 mg/dl, the LDL is a calculated value utilizing the results from the lipid profile for the calculation,
and CPT code 83721 is not separately reportable. However, if the triglyceride level is greater than 400
mg/dl, the LDL may be measured directly and may be separately reportable with CPT code 83721
utilizing an NCCI-associated modifier to bypass the edit.

Misuse of code as an edit rationale may be applied to procedure to procedure edits where the column two code
is not separately reportable with the column one code based on the nature of the column one coded procedure.
This edit rationale may also be applied to code pairs where use of the column two code with the column one
code is deemed to be a coding error.

P. Mutually Exclusive Procedures

Many procedure codes cannot be reported together because they are mutually exclusive of each other.

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Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient
encounter. An example of a mutually exclusive situation is the repair of an organ that can be performed by two
different methods. Only one method can be chosen to repair the organ. A second example is a service that can
be reported as an “initial” service or a “subsequent” service. With the exception of drug administration services,
the initial service and subsequent service cannot be reported at the same patient encounter.

Q. Gender-Specific Procedures (formerly Designation of Sex)

The descriptor of some HCPCS/CPT codes includes a gender-specific restriction on the use of the code.
HCPCS/CPT codes specific for one gender should not be reported with HCPCS/CPT codes for the
opposite gender. For example, CPT code 53210 describes a total urethrectomy including cystostomy in a
female, and CPT code 53215 describes the same procedure in a male. Since the patient cannot have both the
male and female procedures performed, the two CPT codes cannot be reported together.

R. Add-on Codes
Some codes in the CPT Manual are identified as “add-on” codes which describe a service that can only be
reported in addition to a primary procedure. CPT Manual instructions specify the primary procedure code(s)
for most add-on codes. For other add-on codes, the primary procedure code(s) is(are) not specified. When the
CPT Manual identifies specific primary codes, the add-on code shall not be reported as a supplemental service
for other HCPCS/CPT codes not listed as a primary code.

Add-on codes permit the reporting of significant supplemental services commonly performed in addition to
the primary procedure. By contrast, incidental services that are necessary to accomplish the primary procedure
(e.g., lysis of adhesions in the course of an open cholecystectomy) are not separately reportable with an add-on
code. Similarly, complications inherent in an invasive procedure occurring during the procedure are not
separately reportable. For example, control of bleeding during an invasive procedure is considered part of the
procedure and is not separately reportable.

In general, NCCI procedure to procedure edits do not include edits with most add-on codes because edits
related to the primary procedure(s) are adequate to prevent inappropriate payment for an add-on coded
procedure. (I.e., if an edit prevents payment of the primary procedure code, the add-on code shall not be paid.)
However, NCCI does include edits for some add-on codes when coding edits related to the primary
procedures must be supplemented. Examples include edits with add-on HCPCS/CPT codes 69990
(microsurgical techniques requiring use of operating microscope) and 95940/95941/G0453 (intraoperative
neurophysiology testing).

HCPCS/CPT codes that are not designated as add-on codes shall not be misused as an add-on code to report
a supplemental service. A HCPCS/CPT code may be reported if and only if all services described by the CPT
code are performed. A HCPCS/CPT code shall not be reported with another service because a portion of the
service described by the HCPCS/CPT code was performed with the other procedure. For example: If an
ejection fraction is estimated from an echocardiogram study, it would be inappropriate to additionally report
CPT code 78472 (cardiac blood pool imaging with ejection fraction) with the echocardiography (CPT code
93307). Although the procedure described by CPT code 78472 includes an ejection fraction, it is measured by
gated equilibrium with a radionuclide which is not utilized in echocardiography.

S. Excluded Service
The NCCI does not address issues related to HCPCS/CPT codes describing services that are excluded from
Medicare coverage or are not otherwise recognized for payment under the Medicare program.

T. Unlisted Procedure Codes

The CPT Manual includes codes to identify services or procedures not described by other HCPCS/CPT
codes. These unlisted procedure codes are generally identified as XXX99 or XXXX9 codes and are located at
the end of each section or subsection of the manual. If a physician provides a service that is not accurately

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described by other HCPCS/CPT codes, the service shall be reported utilizing an unlisted procedure code. A
physician shall not report a CPT code for a specific procedure if it does not accurately describe the service
performed. It is inappropriate to report the best fit HCPCS/CPT code unless it accurately describes the
service performed, and all components of the HCPCS/CPT code were performed. Since unlisted procedure
codes may be reported for a very diverse group of services, the NCCI generally does not include edits with
these codes.

U. Modified, Deleted, and Added Code Pairs/Edits

Information moved to Introduction chapter, Section (Purpose), Page Intro-5 of this Manual.

V. Medically Unlikely Edits (MUEs)

To lower the Medicare Fee-For-Service Paid Claims Error Rate, CMS has established units of service edits
referred to as Medically Unlikely Edit(s) (MUEs).

An MUE for a HCPCS/CPT code is the maximum number of units of service (UOS) under most
circumstances allowable by the same provider for the same beneficiary on the same date of service. The ideal
MUE value for a HCPCS/CPT code is the unit of service that allows the vast majority of appropriately coded
claims to pass the MUE.

All practitioner claims submitted to Carriers (A/B MACs processing practitioner service claims), outpatient
facility services claims (Type of Bill 13X, 14X, 85X) submitted to Fiscal Intermediaries (A/B MACs
processing facility claims), and supplier claims submitted to Durable Medical Equipment (DME) MACs are
tested against MUEs.

Prior to April 1, 2013, each line of a claim was adjudicated separately against the MUE value for the
HCPCS/CPT code reported on that claim line. If the units of service on that claim line exceeded the MUE
value, the entire claim line was denied.

In the April 1, 2013 version of MUEs, CMS began introducing date of service (DOS) MUEs. Over time
CMS will convert many, but not all, MUEs to DOS MUEs. Since April 1, 2013, MUEs are adjudicated
either as claim line edits or DOS edits. If the MUE is adjudicated as a claim line edit, the units of service
(UOS) on each claim line are compared to the MUE value for the HCPCS/CPT code on that claim line. If
the UOS exceed the MUE value, all UOS on that claim line are denied. If the MUE is adjudicated as a DOS
MUE, all UOS on each claim line for the same date of service for the same HCPCS/CPT code are summed,
and the sum is compared to the MUE value. If the summed UOS exceed the MUE value, all UOS for the
HCPCS/CPT code for that date of service are denied. Denials due to claim line MUEs or DOS MUEs may
be appealed to the local claims processing contractor. DOS MUEs are utilized for HCPCS/CPT codes where
it would be extremely unlikely that more UOS than the MUE value would ever be performed on the same
date of service for the same patient.

The MUE files on the CMS NCCI website display an “MUE Adjudication Indicator” (MAI) for each
HCPCS/CPT code. An MAI of “1” indicates that the edit is a claim line MUE. An MAI of “2” or “3”
indicates that the edit is a DOS MUE.

If a HCPCS/CPT code has an MUE that is adjudicated as a claim line edit, appropriate use of CPT
modifiers (e.g., -59, -76, -77, -91, anatomic) may be used to the same HCPCS/CPT code on separate lines of
a claim. Each line of the claim with that HCPCS/CPT code will be separately adjudicated against the MUE
value for that HCPCS/CPT code. Claims processing contractors have rules limiting use of these modifiers
with some HCPCS/CPT codes.

MUEs for HCPCS codes with an MAI of “2” are absolute date of service edits. These are “per day edits based
on policy”. HCPCS codes with an MAI of “2” have been rigorously reviewed and vetted within CMS and
obtain this MAI designation because UOS on the same date of service (DOS) in excess of the MUE value
would be considered impossible because it was contrary to statute, regulation or subregulatory guidance. This
subregulatory guidance includes clear correct coding policy that is binding on both providers and CMS claims

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processing contractors. Limitations created by anatomical or coding limitations are incorporated in correct
coding policy, both in the HIPAA mandated coding descriptors and CMS approved coding guidance as well
as specific guidance in CMS and NCCI manuals. For example, it would be contrary to correct coding policy
to report more than one unit of service for CPT 94002 “ventilation assist and management … initial day”
because such usage could not accurately describe two initial days of management occurring on the same date
of service as would be required by the code descriptor. As a result, claims processing contractors are instructed
that an MAI of “2” denotes a claims processing restriction for which override during processing, reopening, or
redetermination would be contrary to CMS policy.

MUEs for HCPCS codes with an MAI of “3” are “per day edits based on clinical benchmarks”. MUEs
assigned an MAI of “3” are based on criteria (e.g., nature of service, prescribing information) combined with
data such that it would be possible but medically highly unlikely that higher values would represent correctly
reported medically necessary services. If contractors have evidence (e.g., medical review) that UOS in excess of
the MUE value were actually provided, were correctly coded and were medically necessary, the contractor may
bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening or
redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal.

Both the MAI and MUE value for each HCPCS/CPT code are based on one or more of the following
criteria:

(1) Anatomic considerations may limit units of service based on anatomic structures. For example,
a) The MUE value for an appendectomy is “1” since there is only one appendix.
b) The MUE for a knee brace is “2” because there are two knees and Medicare policy does not cover back-up
equipment.
c) The MUE value for a lumbar spine procedure reported per lumbar vertebra or per lumbar interspace cannot
exceed “5” since there are only five lumbar vertebrae or interspaces.
d) The MUE value for a procedure reported per lung lobe cannot exceed “5” since there are only five lung lobes
(three in right lung and two in left Lung).
(2) CPT code descriptors/CPT coding instructions in the CPT Manual may limit units of service. For
example,
a) A procedure described as the “initial 30 minutes” would have an MUE value of 1 because of the use of
the term “initial”. A different code may be reported for additional time.
b) If a code descriptor uses the plural form of the procedure, it must not be reported with multiple units of service.
For example, if the code descriptor states “biopsies”, the code is reported with “1” unit of service regardless of
the number of biopsies performed.
c) The MUE value for a procedure with “per day”, “per week”, or “per month” in its code descriptor is “1” because
MUEs are based on number of services per day of service.
d) The MUE value of a code for a procedure described as “unilateral” is “1” if there is a different code for the
procedure described as “bilateral”.
e) The code descriptors of a family of codes may define different levels of service, each having an MUE of “1”.
For example, CPT codes 78102-78104 describe bone marrow imaging. CPT code 78102 is reported for
imaging a “limited area”. CPT code 78103 is reported for imaging “multiple areas”. CPT code 78104 is
reported for imaging the “whole body”.
f) The MUE value for CPT code 86021 (Antibody identification; leukocyte antibodies) is “1” because the code
descriptor is plural including testing for any and all leukocyte antibodies. On a single date of service only one
specimen from a patient would be tested for leukocyte antibodies.
(3) Edits based on established CMS policies may limit units of service (UOS). For example,
a) The MUE value for a surgical or diagnostic procedure may be based on the bilateral surgery indicator on
the Medicare Physician Fee Schedule Database(MPFSDB)
i. If the bilateral surgery indicator is “0”, a bilateral procedure must be reported with “1” UOS. There is no
additional payment for the code if reported as a unilateral or bilateral procedure because of anatomy or
physiology. Alternatively, the code descriptor may specifically state that the procedure is a unilateral
procedure, and there is a separate code for a bilateral procedure.
ii. If the bilateral surgery indicator is “1”, a bilateral surgical procedure must be reported with “1” UOS and
modifier 50 (bilateral modifier). A bilateral diagnostic procedure may be reported with “2” UOS on one
claim line, “1” UOS and modifier 50 on one claim line, or “1” UOS with modifier RT on one claim line
plus “1” UOS and modifier LT on a second claim line.
iii. If the bilateral surgery indicator is “2”, a bilateral procedure must be reported with “1” UOS. The

581
 procedure is priced as a bilateral procedure because (1) the code descriptor defines the procedure as
bilateral; (2) the code descriptor states that the procedure is performed unilaterally or bilaterally; or (3) the
procedure is usually performed as a bilateral procedure.
iv. If the bilateral surgery indicator is “3”, a bilateral surgical procedure must be reported with “1” UOS and
modifier 50 (bilateral modifier). A bilateral diagnostic procedure may be reported with “2” UOS on one
claim line, “1” UOS and modifier 50 on one claim line, or 1 UOS with modifier RT on one claim line
plus “1” UOS and modifier LT on a second claim line.
b) The MUE value for a code may be “1” where the code descriptor does not specify a UOS and CMS considers
the default UOS to be “per day”.
c) The MUE value for a code may be “0” because the code is listed as invalid, not covered, bundled, not
separately payable, statutorily excluded, not reasonable and necessary, etc. based on
i. The Medicare Physician Fee Schedule Database
ii. Outpatient Prospective Payment System Addendum B
iii. Alpha-Numeric HCPCS Code File
iv. DMEPOS Jurisdiction List
v. Medicare Internet-Only Manual
(4) The nature of an analyte may limit units of service and is in general determined by one of three
considerations:
a) The nature of the specimen may limit the units of service. For example, CPT code 81575 describes a
creatinine clearance test and has an MUE of “1” because the test requires a 24 hour urine collection.
b) The physiology, pathophysiology, or clinical application of the analyte is such that a maximum unit of
service for a single date of service can be determined. For example, the MUE for CPT code 82747
(RBC folic acid) is “1” because the test result would not be expected to change during a single day, and thus
it is not necessary to perform the test more than once on a single date of service.
(5) The nature of a procedure/service may limit units of service and is in general determined by the amount
of time required to perform a procedure/service (e.g., overnight sleep studies) or clinical application of a
procedure/service (e.g., motion analysis tests).
a) The MUE for many surgical or medical procedures is “1” because the procedure is rarely, if ever, performed
more than one time per day (e.g., colonoscopy, motion analysis tests).
b) The MUE value for a procedure is “1” because of the amount of time required to perform the procedure (e.g.,
overnight sleep study).
(6) The nature of equipment may limit units of service and is in general determined by the number of items
of equipment that would be utilized (e.g., cochlear implant or wheelchair). For example, the MUE value
for a wheelchair code is “1” because only one wheelchair is used at one time and Medicare policy does not cover
back-up equipment.
(7) Although clinical judgment considerations and determinations are based on input from numerous
physicians and certified coders are sometimes initially utilized to establish some MUE values, these values are
subsequently validated or changed based on submitted and/or paid claims data.
(8) Prescribing information is based on FDA labeling as well as off-label information published in CMS
approved drug compendia. See below for additional information about how prescribing information is utilized
in determining MUE values.
(9) Submitted and paid claims data (100%) from a six month period is utilized to ascertain the distribution
pattern of UOS typically reported for a given HCPCS/CPT code.
(10) Published policies of the Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs)
may limit units of service for some durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).
For example,
a) The MUE values for many ostomy and urological supply codes, nebulizer codes, and CPAP accessory codes are
typically based on a three month supply of items.
b) The MUE values for surgical dressings, parenteral and enteral nutrition, immunosuppressive drugs, and oral
anti-cancer drugs are typically based on a one month supply.
c) The MUE values take into account the requirement for reporting certain codes with date spans.
d) The MUE value of a code may be 0 if the item is noncovered, not medically necessary, or not separately
payable.
e) The MUE value of a code may be 0 if the code is invalid for claim submission to the DME MAC.

UOS denied based on an MUE may be appealed. Because a denial of services due to an MUE is a coding
denial, not a medical necessity denial, the presence of an Advanced Beneficiary Notice of Noncoverage (ABN)

582
shall not shift liability to the beneficiary for UOS denied based on an MUE. If during reopening or
redetermination medical records are provided with respect to an MUE denial for an edit with an MAI of “3”,
contractors will review the records to determine if the provider actually furnished units in excess of the MUE,
if the codes were used correctly, and whether the services were medically reasonable and necessary. If the units
were actually provided but one of the other conditions is not met, a change in denial reason may be warranted
(for example, a change from the MUE denial based on incorrect coding to a determination that the
item/service is not reasonable and necessary under section 1862(a)(1)). This may also be true for certain edits
with an MAI of “1”. CMS interprets the notice delivery requirements under §1879 of the Social Security Act
(the Act) as applying to situations in which a provider expects the initial claim determination to be a
reasonable and necessary denial. Consistent with NCCI guidance, denials resulting from MUEs are not based
on any of the statutory provisions that give liability protection to beneficiaries under section 1879 of the Social
Security Act. Thus, ABN issuance based on an MUE is NOT appropriate. A provider/supplier may not issue
an ABN in connection with services denied due to an MUE and cannot bill the beneficiary for units of service
denied based on an MUE.

HCPCS J code and drug related C and Q code MUEs are based on prescribing information and 100% claims
data for a six month period of time. Utilizing the prescribing information the highest total daily dose for each
drug was determined. This dose and its corresponding units of service were evaluated against paid and
submitted claims data. Some of the guiding principles utilized in developing these edits are as follows:

(1) If the prescribing information defined a maximum daily dose, this value was used to determine the MUE
value. For some drugs there is an absolute maximum daily dose. For others there is a maximum
“recommended” or “usual” dose. In the latter of the two cases, the daily dose calculation was evaluated
against claims data.
(2) If the maximum daily dose calculation is based on actual body weight, a dose based on a weight range of
110-150 kg was evaluated against the claims data. If the maximum daily dose calculation is based on
ideal body weight, a dose based on a weight range of 90-110 kg was evaluated against claims data. If the
maximum daily dose calculation is based on body surface area (BSA), a dose based on a BSA range of
2.4-3.0 square meters was evaluated against claims data.
(3) For “as needed” (PRN) drugs and drugs where maximum daily dose is based on patient response,
prescribing information and claims data were utilized to establish MUE values.
(4) Published off label usage of a drug was considered for the maximum daily dose calculation.
(5) The MUE values for some drug codes are set to 0. The rationale for such values include but are not
limited to: discontinued manufacture of drug, non-FDA approved compounded drug, practitioner MUE
values for oral antineoplastic, oral anti-emetic, and oral immune suppressive drugs which should be billed
to the DME MACs, and outpatient hospital MUE values for inhalation drugs which should be billed to
the DME MACs, and Practitioner/ASC MUE values for HCPCS C codes describing medications that
would not be related to a procedure performed in an ASC.

Non-drug related HCPCS/CPT codes may be assigned an MUE of 0 for a variety of reasons including, but
not limited to: outpatient hospital MUE value for surgical procedure only performed as an inpatient
procedure, noncovered service, bundled service, or packaged service.

The MUE files on the CMS NCCI website display an “Edit Rationale” for each HCPCS/CPT code.
Although an MUE may be based on several rationales, only one is displayed on the website. One of the listed
rationales is “Data.” This rationale indicates that 100% claims data from a six month period of time was the
major factor in determining the MUE value. If a physician appeals an MUE denial for a HCPCS/CPT code
where the MUE is based on “Data,” the reviewer will usually confirm that (1) the correct code is reported; (2)
the correct UOS is utilized; (3) the number of reported UOS were performed; and (4) all UOS were medically
reasonable and necessary.

The first MUEs were implemented January 1, 2007. Additional MUEs are added on a quarterly basis on the
same schedule as NCCI updates. Prior to implementation proposed MUEs are sent to numerous national
healthcare organizations for a sixty day review and comment period.

Many surgical procedures may be performed bilaterally. Instructions in the CMS Internet-only Manual
(Publication 100-04 Medicare Claims Processing Manual, Chapter 12 (Physicians/Non-Physician
Practitioners), Section 40.7.B. and Chapter 4 (Part B Hospital (Including Inpatient Hospital Part B and

583
OPPS)), Section 20.6.2 require that bilateral surgical procedures be reported using modifier 50 with one unit
of service. If a bilateral surgical procedure is performed at different sites bilaterally, one unit of service may be
reported for each site. That is, the HCPCS/CPT code may be reported with modifier 50 and one unit of
service for each site at which it was performed bilaterally.

Some A/B MACs allow providers to report repetitive services performed over a range of dates on a single line
of a claim with multiple units of service. If a provider reports services in this fashion, the provider should
report the “from date” and “to date” on the claim line. Contractors are instructed to divide the units of service
reported on the claim line by the number of days in the date span and round to the nearest whole number.
This number is compared to the MUE value for the code on the claim line.

Suppliers billing services to the DME MACs typically report some HCPCS codes for supply items for a
period exceeding a single day. The DME MACs have billing rules for these codes. For some codes the DME
MACs require that the “from date” and “to date” be reported. The MUEs for these codes are based on the
maximum number of units of service that may be reported for a single date of service. For other codes the
DME MACs permit multiple days’ supply items to be reported on a single claim line where the “from date”
and “to date” are the same. The DME MACs have rules allowing supply items for a maximum number of
days to be reported at one time for each of these types of codes. The MUE values for these codes are based on
the maximum number of days that may be reported at one time. As with all MUEs, the MUE value does not
represent a utilization guideline. Suppliers shall not assume that they may report units of service up to the
MUE value on each date of service. Suppliers may only report supply items that are medically reasonable and
necessary.

Most MUE values are set so that a provider or supplier would only very occasionally have a claim line denied.
If a provider encounters a code with frequent denials due to the MUE, or frequent use of a CPT modifier to
bypass the MUE, the provider or supplier should consider the following: (1) Is the HCPCS/CPT code being
used correctly? (2) Is the unit of service being counted correctly? (3) Are all reported services medically
reasonable and necessary? and (4) Why does the provider’s or supplier’s practice differ from national patterns?
A provider or supplier may choose to discuss these questions with the local Medicare contractor or a national
healthcare organization whose members frequently perform the procedure.

Most MUE values are published on the CMS MUE webpage

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html. However, some MUE values are
not published and are confidential. These values shall not be published in oral or written form by any party
that acquires one or more of them.

MUEs are not utilization edits. Although the MUE value for some codes may represent the commonly
reported units of service (e.g., MUE of “1” for appendectomy), the usual units of service for many
HCPCS/CPT codes is less than the MUE value. Claims reporting units of service less than the MUE value
may be subject to review by claims processing contractors, Program Safeguard Contractors (PSCs), Zoned
Program Integrity Contractors (ZPICs), Recovery Audit Contractors (RACs), and Department of Justice
(DOJ).

Since MUEs are coding edits rather than medical necessity edits, claims processing contractors may have units
of service edits that are more restrictive than MUEs. In such cases, the more restrictive claims processing
contractor edit would be applied to the claim. Similarly, if the MUE is more restrictive than a claims
processing contractor edit, the more restrictive MUE would apply.

A provider, supplier, healthcare organization, or other interested party may request reconsideration of an
MUE value for a HCPCS/CPT code. A written request proposing an alternative MUE with rationale may be
sent to:

National Correct Coding Initiative

Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
Fax: 317-571-1745

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W. Add-on Code Edit Tables
Add-on codes are discussed in Chapter I, Section R (Add-on Codes). CMS publishes a list of add-on codes
and their primary codes annually prior to January 1. The list is updated quarterly based on the AMA’s “CPT
Errata” documents or implementation of new HCPCS/CPT add-on codes. CMS identifies add-on codes and
their primary codes based on CPT Manual instructions, CMS interpretation of HCPCS/CPT codes, and
CMS coding instructions.

The NCCI program includes three Add-on Code Edit Tables, one table for each of three “Types” of add-on
codes. Each table lists the add-on code with its primary codes. An add-on code, with one exception, is eligible
for payment if and only if one of its primary codes is also eligible for payment.

The “Type I Add-on Code Edit Table” lists add-on codes for which the CPT Manual or HCPCS tables
define all acceptable primary codes. Claims processing contractors should not allow other primary codes with
Type I add-on codes. CPT code 99292 (Critical care, evaluation and management of the critically ill or
critically injured patient; each additional 30 minutes (List separately in addition to code for primary service))
is included as a Type I add-on code since its only primary code is CPT code 99291 (Critical care, evaluation
and management of the critically ill or critically injured patient; first 30-74 minutes). For Medicare purposes,
CPT code 99292 may be eligible for payment to a physician without CPT code 99291 if another physician of
the same specialty and physician group reports and is paid for CPT code 99291.

The “Type II Add-on Code Edit Table” lists add-on codes for which the CPT Manual and HCPCS tables
do not define any primary codes. Claims processing contractors should develop their own lists of acceptable
primary codes.

The “Type III Add-on Code Edit Table” lists add-on codes for which the CPT Manual or HCPCS tables
define some, but not all, acceptable primary codes. Claims processing contractors should allow the listed
primary codes for these add-on codes but may develop their own lists of additional acceptable primary codes.

Although the add-on code and primary code are normally reported for the same date of service, there are
unusual circumstances where the two services may be reported for different dates of service (e.g., CPT codes
99291 and 99292).

The first Add-On Code edit tables were implemented April 1, 2013. For subsequent years, new Add-On
Code edit tables will be published to be effective for January 1 of the new year based on changes in the new
year’s CPT Manual. CMS also issues quarterly updates to the Add-On Code edit tables if required due to
publication of new HCPCS/CPT codes or changes in add-on codes or their primary codes. The changes in
the quarterly update files (April 1, July 1, or October 1) are retroactive to the implementation date of that
year’s annual Add-On Code edit files unless the files specify a different effective date for a change. Since the
first Add-On Code edit files were implemented on April 1, 2013, changes in the July 1 and October 1
quarterly updates for 2013 were retroactive to April 1, 2013 unless the files specified a different effective date
for a change.

585
FIGURE CREDITS
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2. From Franklin I, Dawson P, Rodway A: Essentials of Clinical Surgery, ed 2, 2012, Saunders.
3. Modified from Grosfeld J et al: Pediatric surgery, ed 7, Philadelphia, 2012, Mosby.
4. Modified from Hsu J, Michael J, Fisk J: AAOS atlas of orthoses and assistive devices, ed 4, Philadelphia, 2008, Mosby.
5. From Wold G: Basic Geriatric Nursing, ed 5, St. Louis, 2011, Mosby.
6. Modified from Roberts J, Hedges J: Clinical procedures in emergency medicine, ed 6, St. Louis, 2013, Saunders.
7. From Auerbach P: Wilderness medicine, ed 7, Philadelphia, 2016, Mosby. (Courtesy Black Diamond Equipment, Ltd.)
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9. Modified from Abeloff M et al: Clinical oncology, ed 5, Philadelphia, 2013, Churchill Livingstone.
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11. Modified from Duthie E, Katz P, Malone M: Practice of geriatrics, ed 4, Philadelphia, 2007, Saunders.
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Hudson, NH 03051)
19. A From Auerbach P: Wilderness medicine, ed 7, Philadelphia, 2016, Mosby. B Modified from Hsu J, Michael J, Fisk J: AAOS atlas of
orthoses and assistive devices, ed 4, Philadelphia, 2008, Mosby.
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1359-374.
31. Modified from Lusardi M, Nielsen C: Orthotics and prosthetics in rehabilitation, ed 3, St. Louis, 2013, Butterworth-Heinemann.
32. From Hsu J, Michael J, Fisk J: AAOS atlas of orthoses and assistive devices, ed 4, Philadelphia, 2008, Mosby.
33. (Original to book.)
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35. Modified from Hsu J, Michael J, Fisk J: AAOS atlas of orthoses and assistive devices, ed 4, Philadelphia, 2008, Mosby.
36. From Coughlin, Michael J., Roger A. Mann, and Charles L. Saltzman. Surgery of the Foot and Ankle, ed 9, Philadelphia, 2013, Mosby.
37. From Canale S: Campbell’s operative orthopaedics, ed 12, St. Louis, 2012, Mosby.
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39. From Pedretti, Lorraine Williams, Heidi McHugh. Pendleton, and Winifred Schultz-Krohn. Pedretti’s Occupational Therapy: Practice Skills
for Physical Dysfunction, ed 7, St. Louis, 2013, Elsevier.
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41. From Lusardi M, Nielsen C: Orthotics and prosthetics in rehabilitation, ed 3, St. Louis, 2013, Butterworth-Heinemann. (Courtesy Michael
Curtain)
42. Schickendantz, Mark S. “Diagnosis and Treatment of Elbow Disorders in the Overhead Athlete.” Hand Clinics 18.1 (2002): 65-75.
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Saunders.
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Philadelphia, 2012, Mosby, 2012. From Subburaj, K., C. Nair, S. Rajesh, S.m. Meshram, and B. Ravi. “Rapid Development of Auricular
Prosthesis Using CAD and Rapid Prototyping Technologies.” International Journal of Oral and Maxillofacial Surgery 36.10 (2007): 938-43.
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46. Modified from Mann D: Heart failure: a companion to Braunwald’s heart disease, ed 3, Philadelphia, 2015, Saunders.
47. Modified from Roberts J, Hedges J: Clinical procedures in emergency medicine, ed 6, Philadelphia, 2013, Saunders.
48. From Yanoff M, Duker J: Ophthalmology, ed 4, St. Louis, 2014, Mosby.
49. From Feldman M, Friedman L, Brandt L: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2015, Saunders.
50. From Katz V et al: Comprehensive gynecology, ed 7, Philadelphia, 2016, Mosby.
51. From Young A, Proctor D: Kinn’s the medical assistant, ed 13, St. Louis, 2016, Saunders.
52. From Yanoff M, Duker J: Ophthalmology, ed 4, St. Louis, 2014, Mosby.

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