ACTION: Final DATE: 05/06/2020 9:34 AM Ohio Bureau of ... · 5/6/2020 · 1 unit = completed...

Ohio Bureau of Workers' Compensation2020 Hospital Outpatient Services

Appendix

Covered (C) The procedure or service is covered.

By Report (BR)

The procedure or service is not typically covered and will not routinely be reimbursed. Many of the -BR codes are unclassified/unspecified generic codes and are currently assigned a dollar amount of $0.00. Authorization and payment of codes identified as -BR require an individual analysis by the MCO prior to submission to BWC. The MCO analysis shall include researching the appropriateness of the code in relation to the service or procedure. If the pricing is listed at $0.00, the MCO shall perform a cost comparison to determine a reasonable price. The MCO shall utilize the price to negotiate a final reimbursement rate. The provider must submit a report to the MCO for reimbursement consideration.

Reasonable Cost (RC)

To calculate reasonable cost, the line item charge shall be multiplied by the hospital’s outpatient cost to charge ratio from the Medicare outpatient provider specific file in effect as of the calendar quarter immediately prior to the calendar quarter in which the hospital outpatient service was rendered. These services shall not be wage index adjusted.

Not Routinely Covered (NRC)

The procedure or service is not covered unless application of the Miller criteria requires an exception. See: OAC 4123-6-16.2(B)(1) through (B)(3). Where coverage is required, the pricing is listed on the fee schedule. If the pricing is listed at $0.00, the MCO shall perform a cost comparison to determine a reasonable price. The MCO shall utilize the price to negotiate a final reimbursement rate.

Never Covered (NC) The procedure or service is never covered.

The five character codes included in the Ohio Bureau of Workers’ Compensation (BWC) 2020 Hospital Outpatient Services Fee Schedule are obtained from Current Procedural Terminology (CPT®), copyright 2019 by the American Medical Association (AMA) and from the Health Care Procedure Coding System (HCPCS) National Level II Medicare codes.

CPT® is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians.

HCPCS are released by the Center for Medicare and Medicaid Services (CMS) as a listing of five character codes and descriptive terminology used for reporting supplies, materials and services by health care providers.

The responsibility for the content of the BWC 2020 Hospital Outpatient Services Fee Schedule is with the State of Ohio Bureau of Workers’ Compensation and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the BWC 2020 Hospital Outpatient Services Fee Schedule . No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT®. Any use of CPT® outside of the BWC 2020 Hospital Outpatient Services Fee Schedule should refer to the most current Current Procedural Terminology which contains the complete and most current listing of CPT® codes and descriptive terms. Applicable FARS/DFARS apply.

For the purposes of the BWC 2020 Hospital Outpatient Services Fee Schedule, services and/or supplies must be medically necessary for the treatment of the work related injury. The following definitions apply:

CPT only © 2019 American MedicalAssociation. All Rights Reserved.

Ohio BWC2020 Hospital Outpatient Services

Effective 5/1/2020 1

ENACTEDAppendix

4123-6-37.2

ACTION: Final DATE: 05/06/2020 9:34 AM

APPENDIX p(187405) pa(330699) d: (753200) ra(570888) print date: 05/06/2020 9:35 AM


Appendix

Modifiers BWC accepts all industry-standard modifiers as published with CPT codes by the AMA and published by CMS with HCPCS level II codes in effect on the billed date of service. The modifier code set includes 2-digit ambulance modifiers that specify trip origin and destination. Unless otherwise specified in this document, modifiers will not affect the outpatient payable amount calculated for a procedure.

Modifier 50 Bilateral procedure. Reimbursement is 150% of outpatient payable amount.

Modifier 52 Reduced services. Reimbursement is 50% of outpatient payable amount.

Modifier 53 Discontinued procedures. Reimbursement is 50% of outpatient payable amount unless justification for higher specified percentage is supported by medical records documentation submitted pursuant to By Report guidelines.

Modifier 73 Discounted outpatient procedure prior to administration of anesthesia. Reimbursement is 50% of outpatient payable amount.

Modifier 74 Discontinued procedure after administration of anesthesia. Reimbursement is 100% of outpatient payable amount.

Modifier 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. Reimbursement is 85% of the outpatient payable amount.

Modifier ER Items and services furnished by a provider-based off-campus emergency department. Reimbursement is 100% of outpatient payable amount.

Modifier FX X-ray taken using film. Reimbursement is 80% of the outpatient payable amount.

Modifier FY X-rays taken using computed radiography technology/cassette-based imaging. Reimbursement is 93% of the outpatient payable amount.

Modifier JG Drug or biological acquired with 340B drug pricing program discount. Reimbursement is Average Sales Price (ASP) minus 22.5%.

Modifier JW Drug amount discarded/not administered to any patient. Payable in addition to the drug amount administered.

Modifier NU New Equipment purchase.Modifier PN Non-excepted service provided at an off-campus, outpatient, provider-based department

of a hospital. Reimbursement is 40% of outpatient payable amount.

Modifier PO Excepted service provided at an off-campus, outpatient, provider-based department of a hospital. Reimbursement is 100% of outpatient payable amount.

Modifier 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). Reimbursement is 100% of the outpatient payable amount.





Appendix

Modifier QB Prescribed amounts of stationary oxygen for daytime use while at rest and nighttime use different and the average of the two amounts exceeds 4 liters per minute (LPM) and portable oxygen is prescribed. Reimbursement is 100% of the outpatient payable amount.

Modifier QE Prescribed amount of stationary oxygen while at rest is less than 1 liter per minute (LPM). Reimbursement is 100% of the outpatient payable amount.

Modifier QF Prescribed amount of stationary oxygen while at rest exceeds 4 liters per minute (LPM) and portable oxygen is prescribed. Reimbursement is 100% of the outpatient payable amount.

Modifier QG Prescribed amount of stationary oxygen while at rest is greater than 4 liters per minute (LPM). Reimbursement is 100% of the outpatient payable amount.

Modifier 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). Reimbursement is 100% of the outpatient payable amount.

Modifier RR Rental equipment component reimbursement.

Modifier TBDrug or biological acquired with 340B drug pricing program discount, reported for informational purposes. Reimbursement is Average Sales Price (ASP) + 6%.

Medically Unlikely Edits (MUE)

An MUE for a HCPCS/CPT code reflects the number of units of service a provider will use in most circumstances when treating an injured worker. Medical documentation supporting the necessity of additional units of service must be provided to an MCO when additional units of services beyond the listed MUE are necessary.





Appendix

Edit Number

Edit Description

10 Service submitted for denial11 Service submitted for FI review12 Questionable covered service18 Inpatient procedure24 Date out of OCE range45 Inpatient separate procedures not paid49 Service on same day as inpatient procedure59 Clinical trial requires diagnosis code Z00.00 as other than primary diagnosis68 Service provided prior to date of NCD approval69 Service provided outside approval period75 Incorrect billing of modifier FB or FC82 Charge exceed token charge ($1.01)83 Service provided on or after effective date of NCD non-coverage86 Manifestation code not allowed as principal diagnosis88 FQHC payment code not reported for FQHC claim89 FQHC claim lacks required qualifying visit code90 Incorrect revenue code reported for FQHC payment code91 Item or service not covered under FQHC PPS

104 Service not eligible for all-inclusive rate

Table 1 - I/OCE Edits Bypassed/Ignored by BWC





Appendix

Code Description Rate Units of ServiceW0637 Transitional Work Services $47.40 1 unit = 15 min

W0648 Physical reconditioning unsupervisedBy Report: not

to exceed $225.00

1 unit = 3 month period

W0702Occupational rehabilitation/work hardening Initial 2 hour session

$18.48 15 min; max units 8 per day

W0703Occupational rehabilitation/work hardening each additional hour

$18.13 15 min; max units 24 per day

W0710 Work Conditioning program, active treatment $16.57 15 min

W3050 Travel time, other vocational rehabilitation provider $3.89 1 unit = 6 min; units should not exceed 20

W3052 Mileage, other vocational rehabilitation provider $0.52 1 unit = 1 mile; units should not exceed 130

Z3050 Remain at Work (RAW) other provider travel time $3.89 1 unit = 6 min; units should not exceed 20

Z3052 Remain at Work (RAW) other provider mileage $0.52 1 unit = 1 mile; units should not exceed 130

Table 2 - BWC-Specific Hospital Outpatient Vocational Rehabilitation Codes





Appendix

Code Rate81277 RC81307 RC81308 RC81309 RC81479 $0.0081522 RC81542 RC81552 RC81599 $0.0095782 $0.0095783 $0.0096161 $0.0097010 $0.0097039 $0.0097139 $0.0097151 $0.0097152 $0.0097153 $0.0097154 $0.0097155 $0.0097156 $0.0097157 $0.0097158 $0.0097545 $0.0097546 $0.0097799 $0.0099460 $0.0099463 $0.0099464 $0.0099465 $0.0099466 $0.0099467 $0.000018U $0.000019U $0.000022U $0.000023U $0.000029U $0.000030U $0.000048U $0.000050U $0.000053U $0.000055U $0.00

Table 3 - Medicare OPPS Fee Schedule Items with BWC Rates





Appendix

Code Rate


0056U $0.000067U RC0069U RC0070U RC0071U RC0072U RC0073U RC0074U RC0075U RC0076U RC0078U RC0082U $0.000084U RC0086U RC0087U RC0088U RC0094U RC0101U RC0102U RC0103U RC0109U RC0111T RC0111U RC0112U RC0113U RC0114U RC0115U RC0118U RC0120U RC0129U RC0130U RC0131U RC0132U RC0133U RC0134U RC0135U RC0136U RC0137U RC0138U RC0140U RC0141U RC0142U RC





Appendix

Code Rate


0143U $0.000145U $0.000146U $0.000147U $0.000148U $0.000149U $0.000150U $0.000151U RC0152U RC0153U RC0154U RC0155U RC0156U RC0157U RC0158U RC0159U RC0160U RC0161U RC0162U RC0423T RC0500T RCA0425 $13.72A0426 $393.78A0427 $623.48A0428 $328.15A0429 $525.04A0430 $5,382.64A0431 $6,258.13A0432 $468.40A0433 $902.41A0434 $1,066.49A0435 $15.93A0436 $42.52A0999 $0.00A4563 $153.28A4575 $0.00A9285 $80.40A9901 $0.00C9399 RCC9899 RCE0446 $0.00E0604 $0.00





Appendix

Code Rate


E1500 RCE1510 RCE1520 RCE1530 RCE1540 RCE1550 RCE1560 RCE1570 RCE1575 RCE1580 RCE1590 RCE1592 RCE1594 RCE1600 RCE1610 RCE1615 RCE1620 RCE1625 RCE1630 RCE1632 RCE1635 RCE1636 RCE1637 RCE1639 RCE1699 RCG0068 $0.00G0069 $0.00G0070 $0.00G0466 RCG0467 RCG0468 RCG0469 RCG0470 RCG0490 RCG9140 RCK0672 $101.05K0744 $0.00K0745 $0.00K0746 $0.00L0112 $1,667.58L0113 $339.78L0120 $31.51





Appendix

Code Rate


L0130 $181.87L0140 $71.32L0150 $127.54L0160 $186.22L0170 $957.97L0172 $168.74L0174 $331.80L0180 $537.54L0190 $633.96L0200 $735.34L0220 $153.92L0450 $193.62L0452 $0.00L0454 $413.22L0455 $413.22L0456 $1,185.00L0457 $1,185.00L0458 $1,062.61L0460 $1,196.04L0462 $1,487.65L0464 $1,771.04L0466 $452.05L0467 $452.05L0468 $566.51L0469 $566.51L0470 $783.92L0472 $482.38L0480 $1,799.64L0482 $2,010.22L0484 $2,170.96L0486 $2,438.06L0488 $1,196.04L0490 $337.03L0491 $915.04L0492 $595.85L0621 $102.73L0622 $318.46L0623 $210.86L0624 $0.00L0625 $65.64L0626 $92.87L0627 $489.72





Appendix

Code Rate


L0628 $99.94L0629 $0.00L0630 $192.98L0631 $1,223.11L0632 $0.00L0633 $341.66L0634 $0.00L0635 $1,190.54L0636 $1,615.37L0637 $1,543.55L0638 $1,571.45L0639 $1,543.55L0640 $1,246.73L0641 $92.87L0642 $489.72L0643 $192.98L0648 $1,223.11L0649 $341.66L0650 $1,543.55L0651 $1,543.55L0700 $2,371.91L0710 $2,607.37L0810 $3,184.67L0820 $2,505.18L0830 $3,833.28L0859 $1,357.19L0861 $256.81L0970 $127.33L0972 $115.90L0974 $208.21L0976 $178.14L0978 $224.21L0980 $20.36L0982 $18.64L0984 $80.63L0999 $0.00L1000 $2,416.02L1001 RCL1005 $3,813.44L1010 $99.70L1020 $128.39L1025 $185.23





Appendix

Code Rate


L1030 $93.29L1040 $105.64L1050 $119.54L1060 $129.04L1070 $133.67L1080 $62.34L1085 $208.69L1090 $119.89L1100 $226.27L1110 $379.38L1120 $45.31L1200 $2,132.15L1210 $291.50L1220 $283.73L1230 $794.84L1240 $108.36L1250 $94.22L1260 $112.37L1270 $98.75L1280 $104.10L1290 $92.58L1300 $2,053.45L1310 $2,138.83L1499 $0.00L1600 $153.53L1610 $65.21L1620 $187.22L1630 $251.70L1640 $564.02L1650 $293.83L1652 $424.72L1660 $215.32L1680 $1,357.39L1685 $1,325.16L1686 $1,116.42L1690 $2,304.00L1700 $1,853.71L1710 $2,360.50L1720 $1,757.62L1730 $1,483.81L1755 $2,133.31L1810 $122.65





Appendix

Code Rate


L1812 $122.65L1820 $169.33L1830 $99.12L1831 $350.66L1832 $820.68L1833 $820.68L1834 $864.80L1836 $158.96L1840 $1,120.46L1843 $1,069.06L1844 $1,814.40L1845 $998.05L1846 $1,394.05L1847 $685.30L1848 $685.30L1850 $339.43L1851 $1,069.06L1852 $998.05L1860 $1,485.73L1900 $339.92L1902 $88.93L1904 $537.79L1906 $133.98L1907 $670.44L1910 $334.13L1920 $489.46L1930 $300.17L1932 $1,063.19L1940 $580.21L1945 $1,337.39L1950 $916.31L1951 $1,000.61L1960 $738.56L1970 $824.65L1971 $558.50L1980 $481.07L1990 $556.78L2000 $1,332.85L2005 $4,882.27L2006 RCL2010 $1,039.61L2020 $1,312.99





Appendix

Code Rate


L2030 $1,290.58L2034 $2,420.42L2035 $206.41L2036 $2,208.91L2037 $1,975.84L2038 $1,592.81L2040 $241.03L2050 $580.61L2060 $726.23L2070 $184.92L2080 $444.64L2090 $592.42L2106 $939.13L2108 $1,369.75L2112 $601.09L2114 $752.89L2116 $918.31L2126 $1,521.36L2128 $1,910.32L2132 $1,159.52L2134 $1,373.03L2136 $1,502.58L2180 $157.96L2182 $136.15L2184 $138.00L2186 $183.53L2188 $333.65L2190 $101.63L2192 $397.22L2200 $59.87L2210 $74.89L2220 $96.41L2230 $113.98L2232 $115.74L2240 $113.45L2250 $397.98L2260 $223.32L2265 $160.16L2270 $73.44L2275 $155.32L2280 $672.61L2300 $299.95





Appendix

Code Rate


L2310 $137.05L2320 $229.84L2330 $437.45L2335 $334.93L2340 $497.92L2350 $992.69L2360 $61.44L2370 $381.31L2375 $146.60L2380 $153.76L2385 $175.08L2387 $227.45L2390 $121.96L2395 $174.31L2397 $145.43L2405 $103.88L2415 $144.74L2425 $170.80L2430 $170.80L2492 $139.74L2500 $372.84L2510 $960.92L2520 $640.42L2525 $1,358.03L2526 $763.07L2530 $285.74L2540 $540.68L2550 $405.40L2570 $530.64L2580 $517.04L2600 $254.11L2610 $280.80L2620 $297.88L2622 $379.13L2624 $464.89L2627 $2,546.44L2628 $1,866.48L2630 $275.87L2640 $374.39L2650 $164.87L2660 $213.48L2670 $190.03





Appendix

Code Rate


L2680 $174.34L2750 $93.12L2755 $155.68L2760 $67.69L2768 $155.23L2780 $75.40L2785 $35.30L2795 $97.72L2800 $119.99L2810 $97.31L2820 $96.74L2830 $104.66L2840 $51.38L2850 $72.07L2999 $0.00L3000 $374.28L3001 $157.60L3002 $192.43L3003 $207.58L3010 $207.58L3020 $236.39L3030 $90.91L3031 $145.92L3040 $56.09L3050 $56.09L3060 $87.88L3070 $37.88L3080 $37.88L3090 $48.50L3100 $51.54L3140 $106.07L3150 $97.00L3160 $0.00L3170 $60.61L3201 $0.00L3202 $0.00L3203 $0.00L3204 $0.00L3206 $0.00L3207 $0.00L3208 RCL3209 RC





Appendix

Code Rate


L3211 $0.00L3212 RCL3213 RCL3214 $0.00L3224 $80.51L3225 $87.94L3230 $249.96L3250 $300.00L3251 $300.00L3252 $100.00L3253 $50.00L3254 $100.00L3255 $100.00L3257 $50.00L3265 $40.00L3300 $62.14L3310 $97.00L3320 $69.10L3330 $674.29L3332 $87.88L3334 $45.43L3340 $101.56L3350 $27.25L3360 $42.42L3370 $59.10L3380 $59.10L3390 $59.10L3400 $48.50L3410 $110.60L3420 $65.16L3430 $190.93L3440 $90.91L3450 $125.74L3455 $48.50L3460 $40.93L3465 $69.74L3470 $74.23L3480 $74.23L3485 $64.48L3500 $34.84L3510 $34.84L3520 $37.88





Appendix

Code Rate


L3530 $37.88L3540 $60.61L3550 $10.64L3560 $27.25L3570 $101.56L3580 $77.28L3590 $63.65L3595 $49.98L3600 $90.91L3610 $119.71L3620 $90.91L3630 $119.71L3640 $51.54L3649 $0.00L3650 $78.13L3660 $112.04L3670 $123.28L3671 $977.04L3674 $1,281.72L3675 $190.32L3677 $300.00L3678 $0.00L3702 $313.12L3710 $154.84L3720 $740.89L3730 $982.73L3740 $1,165.10L3760 $542.29L3761 $542.29L3762 $116.58L3763 $811.45L3764 $849.20L3765 $1,390.39L3766 $1,472.34L3806 $492.54L3807 $271.13L3808 $386.26L3809 $271.13L3900 $1,756.57L3901 $2,302.07L3904 $3,660.05L3905 $1,075.32





Appendix

Code Rate


L3906 $549.52L3908 $79.50L3912 $114.24L3913 $293.66L3915 $576.41L3916 $576.41L3917 $114.50L3918 $114.50L3919 $293.66L3921 $348.31L3923 $104.74L3924 $104.74L3925 $71.23L3927 $37.97L3929 $99.04L3930 $99.04L3931 $226.08L3933 $231.36L3935 $239.54L3956 $37.99L3960 $864.84L3961 $1,821.84L3962 $782.18L3967 $2,150.94L3971 $2,041.75L3973 $2,150.94L3975 $1,821.84L3976 $1,821.84L3977 $2,041.75L3978 $2,150.94L3980 $419.48L3981 $1,091.45L3982 $425.95L3984 $375.23L3995 $44.53L3999 $0.00L4000 $1,574.41L4002 $0.00L4010 $956.95L4020 $1,149.56L4030 $730.51L4040 $494.71





Appendix

Code Rate


L4045 $365.45L4050 $489.97L4055 $297.83L4060 $387.14L4070 $313.52L4080 $118.36L4090 $100.69L4100 $121.00L4110 $94.48L4130 $571.08L4205 $25.99L4210 $99.98L4350 $115.30L4360 $308.47L4361 $308.47L4370 $280.43L4386 $188.90L4387 $188.90L4392 $28.03L4394 $20.46L4396 $199.94L4397 $199.94L4398 $92.04L4631 $1,756.40L5000 $684.17L5010 $1,911.66L5020 $2,994.95L5050 $3,271.06L5060 $4,032.26L5100 $3,257.05L5105 $4,596.42L5150 $5,110.12L5160 $5,610.66L5200 $4,339.43L5210 $3,445.51L5220 $3,795.47L5230 $5,692.62L5250 $6,674.75L5270 $7,436.96L5280 $7,229.00L5301 $3,198.35L5312 $5,039.23





Appendix

Code Rate


L5321 $4,264.90L5331 $6,246.54L5341 $6,639.97L5400 $1,904.63L5410 $526.19L5420 $2,405.46L5430 $652.94L5450 $564.59L5460 $740.51L5500 $1,760.44L5505 $2,476.45L5510 $2,102.24L5520 $1,884.42L5530 $2,477.18L5535 $2,309.27L5540 $2,445.85L5560 $2,786.90L5570 $2,704.79L5580 $3,357.04L5585 $3,931.37L5590 $3,500.05L5595 $5,469.68L5600 $6,225.30L5610 $3,002.42L5611 $1,912.28L5613 $2,908.72L5614 $2,014.48L5616 $1,753.87L5617 $667.93L5618 $398.88L5620 $353.89L5622 $476.78L5624 $476.60L5626 $754.52L5628 $764.06L5629 $377.20L5630 $655.38L5631 $521.50L5632 $321.43L5634 $401.96L5636 $307.25L5637 $457.18





Appendix

Code Rate


L5638 $770.16L5639 $1,330.72L5640 $874.69L5642 $810.80L5643 $2,391.46L5644 $701.03L5645 $1,162.97L5646 $736.99L5647 $944.12L5648 $870.83L5649 $2,926.04L5650 $579.42L5651 $1,697.65L5652 $517.46L5653 $807.38L5654 $468.04L5655 $337.93L5656 $513.38L5658 $541.90L5661 $777.48L5665 $691.22L5666 $91.52L5668 $136.33L5670 $322.06L5671 $590.38L5672 $426.18L5673 $938.28L5676 $430.09L5677 $658.70L5678 $47.12L5679 $781.90L5680 $361.26L5681 $1,570.32L5682 $742.27L5683 $1,570.32L5684 $57.12L5685 $152.93L5686 $68.70L5688 $72.97L5690 $148.96L5692 $157.72L5694 $215.32





Appendix

Code Rate


L5695 $193.56L5696 $233.82L5697 $111.04L5698 $142.44L5699 $243.44L5700 $3,661.74L5701 $4,542.73L5702 $5,725.42L5703 $3,011.74L5704 $746.60L5705 $1,368.82L5706 $1,335.11L5707 $1,793.76L5710 $426.88L5711 $716.44L5712 $511.43L5714 $520.38L5716 $1,028.98L5718 $1,100.29L5722 $1,338.04L5724 $2,062.36L5726 $2,455.33L5728 $2,877.37L5780 $1,584.22L5781 $4,776.58L5782 $5,035.57L5785 $616.66L5790 $889.99L5795 $1,274.35L5810 $678.97L5811 $936.97L5812 $705.11L5814 $4,433.59L5816 $1,009.39L5818 $1,139.80L5822 $2,090.94L5824 $1,976.56L5826 $3,728.09L5828 $3,517.78L5830 $2,371.91L5840 $4,655.44L5845 $2,139.70





Appendix

Code Rate


L5848 $1,283.71L5850 $151.84L5855 $366.55L5856 $28,657.87L5857 $10,168.88L5858 $22,186.79L5859 $17,321.00L5910 $429.86L5920 $629.76L5925 $398.81L5930 $4,018.19L5940 $595.36L5950 $923.41L5960 $1,380.73L5961 $5,698.27L5962 $697.64L5964 $1,338.22L5966 $1,723.86L5968 $4,338.08L5969 $16,730.64L5970 $259.31L5971 $259.31L5972 $472.37L5973 $21,076.21L5974 $276.59L5975 $553.44L5976 $701.56L5978 $371.74L5979 $2,976.43L5980 $4,534.86L5981 $4,073.41L5982 $765.22L5984 $767.59L5985 $337.10L5986 $925.93L5987 $8,587.84L5988 $2,384.82L5990 $2,165.71L5999 $0.00L6000 $2,102.69L6010 $2,339.94L6020 $2,181.62





Appendix

Code Rate


L6026 $5,192.82L6050 $2,967.44L6055 $3,785.14L6100 $3,002.96L6110 $3,176.93L6120 $3,593.12L6130 $3,790.82L6200 $3,904.98L6205 $5,386.85L6250 $3,841.82L6300 $5,298.94L6310 $4,802.33L6320 $2,502.83L6350 $5,806.00L6360 $5,040.62L6370 $2,923.21L6380 $1,690.70L6382 $2,012.71L6384 $2,546.18L6386 $558.13L6388 $614.65L6400 $3,248.45L6450 $4,245.55L6500 $4,169.04L6550 $5,399.77L6570 $6,028.13L6580 $2,410.19L6582 $2,024.23L6584 $2,997.34L6586 $2,670.82L6588 $4,253.62L6590 $3,707.20L6600 $270.77L6605 $278.70L6610 $263.47L6611 $491.50L6615 $255.76L6616 $76.99L6620 $447.11L6621 $2,730.56L6623 $851.72L6624 $4,495.90





Appendix

Code Rate


L6625 $631.25L6628 $679.48L6629 $231.53L6630 $341.06L6632 $77.11L6635 $246.50L6637 $482.60L6638 $2,985.35L6640 $401.93L6641 $234.04L6642 $344.11L6645 $434.66L6646 $3,765.20L6647 $619.88L6648 $3,883.27L6650 $471.44L6655 $91.45L6660 $122.38L6665 $54.66L6670 $56.92L6672 $261.22L6675 $142.54L6676 $149.12L6677 $354.11L6680 $367.15L6682 $405.95L6684 $551.62L6686 $818.53L6687 $684.61L6688 $757.69L6689 $903.02L6690 $1,063.18L6691 $419.66L6692 $763.49L6693 $3,389.17L6694 $938.28L6695 $781.90L6696 $1,570.32L6697 $1,570.32L6698 $590.38L6703 $417.55L6704 $805.99





Appendix

Code Rate


L6706 $500.17L6707 $1,769.34L6708 $1,169.60L6709 $1,659.97L6711 $802.58L6712 $1,477.78L6713 $1,865.04L6714 $1,579.68L6715 $3,768.97L6721 $2,807.77L6722 $2,420.47L6805 $457.86L6810 $243.40L6880 $28,522.55L6881 $4,880.52L6882 $3,702.10L6883 $2,371.42L6884 $3,244.66L6885 $5,040.62L6890 $238.43L6895 $797.23L6900 $2,315.12L6905 $2,291.33L6910 $2,252.52L6915 $967.81L6920 $10,000.28L6925 $10,683.62L6930 $9,631.66L6935 $10,633.43L6940 $12,437.64L6945 $13,875.80L6950 $12,414.58L6955 $14,397.01L6960 $15,145.09L6965 $17,941.72L6970 $19,204.61L6975 $21,168.01L7007 $4,360.32L7008 $6,761.56L7009 $4,461.13L7040 $3,631.07L7045 $1,918.40





Appendix

Code Rate


L7170 $7,180.87L7180 $46,457.88L7181 $47,832.78L7185 $7,549.43L7186 $12,691.67L7190 $10,017.38L7191 $13,349.63L7259 $4,892.42L7360 $315.82L7362 $345.01L7364 $610.46L7366 $839.56L7367 $464.78L7368 $602.50L7400 $365.87L7401 $409.56L7402 $442.34L7403 $439.64L7404 $663.55L7405 $867.76L7499 $0.00L7510 $250.00L7520 $35.32L7700 $178.61L8000 $50.54L8001 $149.77L8002 $196.96L8010 RCL8015 $71.56L8020 $269.92L8030 $417.26L8031 $417.26L8032 $46.75L8033 RCL8035 $4,373.57L8039 $0.00L8040 $2,959.58L8041 $3,566.94L8042 $4,007.78L8043 $4,488.74L8044 $4,969.67L8045 $3,891.59





Appendix

Code Rate


L8046 $3,206.27L8047 $1,643.21L8048 $0.00L8049 $50.00L8300 $100.12L8310 $177.37L8320 $73.60L8330 $58.60L8400 $18.68L8410 $24.59L8415 $25.44L8417 $89.78L8420 $24.90L8430 $28.20L8435 $26.80L8440 $55.64L8460 $79.10L8465 $73.12L8470 $7.92L8480 $10.92L8485 $14.71L8499 $0.00L8500 $785.59L8501 $143.38L8505 $28.97L8507 $49.99L8509 $130.38L8510 $301.68L8511 $86.81L8512 $2.60L8513 $6.19L8514 $112.58L8515 $75.35L8615 $538.40L8616 $125.39L8617 $109.52L8618 $31.32L8619 $10,034.27L8621 $0.73L8622 $0.38L8623 $77.22L8624 $192.53





Appendix

Code Rate


L8625 $225.48L8627 $8,516.87L8628 $1,517.39L8629 $213.76L8681 $1,361.53L8683 $6,433.15L8684 $1,009.45L8689 $2,059.22L8691 $2,055.86L8693 $1,810.16L8694 $1,127.39L8695 $19.91L8696 $258.72L8698 $0.00L8701 $0.00L8702 $0.00P9603 RCP9604 RCQ0477 $926.20Q0478 $219.36Q0479 $14,329.92Q0480 $107,517.98Q0481 $17,346.82Q0482 $5,433.34Q0483 $22,382.90Q0484 $4,346.68Q0485 $419.69Q0486 $349.28Q0487 $407.47Q0488 RCQ0489 $19,404.76Q0490 $839.35Q0491 $1,319.56Q0492 $106.32Q0493 $302.69Q0494 $256.13Q0495 $4,986.53Q0496 $1,789.76Q0497 $558.85Q0498 $613.18Q0499 $199.24Q0500 $36.43





Appendix

Code Rate


Q0501 $609.64Q0502 $776.21Q0503 $1,552.34Q0504 $819.17Q0506 $1,019.62Q0507 RCQ0508 RCQ0509 RCQ3014 $30.91V2020 $89.28V2100 $55.19V2101 $53.02V2102 $91.68V2103 $46.44V2104 $47.88V2105 $56.94V2106 $63.08V2107 $56.18V2108 $56.34V2109 $78.46V2110 $63.36V2111 $76.79V2112 $86.75V2113 $87.72V2114 $103.94V2115 $104.76V2118 $114.00V2121 $102.80V2199 $0.00V2200 $62.14V2201 $66.58V2202 $82.52V2203 $64.00V2204 $65.86V2205 $73.01V2206 $85.72V2207 $72.44V2208 $71.17V2209 $83.56V2210 $90.04V2211 $87.65V2212 $91.75





Appendix

Code Rate


V2213 $96.48V2214 $100.82V2215 $125.89V2218 $128.29V2219 $59.18V2220 $52.56V2221 $104.84V2299 $0.00V2300 $84.95V2301 $104.17V2302 $97.33V2303 $81.77V2304 $82.73V2305 $92.41V2306 $95.15V2307 $90.60V2308 $98.82V2309 $103.42V2310 $108.02V2311 $124.72V2312 $114.32V2313 $124.80V2314 $127.57V2315 $141.62V2318 $174.11V2319 $78.59V2320 $82.91V2321 $139.60V2399 $0.00V2410 $122.04V2430 $129.18V2499 $0.00V2500 $109.21V2501 $154.97V2502 $209.99V2503 $202.81V2510 $145.62V2511 $215.83V2512 $248.44V2513 $250.28V2520 $145.10V2521 $287.34





Appendix

Code Rate


V2522 $210.28V2523 $220.76V2530 $352.96V2531 $646.37V2599 $0.00V2600 $33.60V2610 $80.00V2615 $0.00V2623 $1,119.20V2624 $72.25V2625 $572.24V2626 $236.80V2627 $1,697.64V2628 $361.10V2629 $0.00V2700 $53.22V2710 $87.25V2715 $17.10V2718 $36.94V2730 $30.94V2744 $21.16V2745 $12.19V2750 $23.76V2755 $19.90V2770 $23.16V2780 $14.88V2782 $76.85V2783 $86.66V2784 $56.36V2799 $0.00





Appendix

Code Rate22526 $747.6622527 $355.2172159 $540.2676390 $579.2380050 $88.9885060 $34.5788000 $0.0088005 $0.0088007 $0.0088020 $0.0088025 $0.0088027 $0.0088036 $0.0088037 $0.0088040 $821.2588045 $46.2590284 $0.0090389 $0.0090393 $0.0090399 $0.0090875 $85.9190876 $136.0692015 $27.3092310 $83.9292314 $49.6492340 $26.3292341 $33.7792342 $38.2292370 $22.8592551 $15.4192560 $26.8492590 $59.3092591 $80.9492592 $23.6392593 $35.6792594 $26.0392595 $39.0092613 $52.9992615 $46.6092617 $58.4993000 $23.15

Table 4 - Medicare OPPS Non-Covered Items with BWC Rates





Appendix

Code Rate


93010 $11.9393015 $96.9293016 $31.3293018 $20.8693040 $17.4893042 $9.9993224 $119.2393227 $37.2093228 $36.7893268 $267.7493272 $35.8093294 $43.2193295 $62.0093297 $37.2493298 $37.2493352 $45.1294004 $69.7594005 $128.2395120 $14.7295830 $130.7097014 $20.3697169 $96.0997170 $96.0997171 $96.0997172 $52.9797810 $43.2197811 $35.7697813 $46.6897814 $39.2398943 $33.2799058 $32.7499060 $109.2199172 $10.2599173 $3.7799183 $155.2699401 $34.7599402 $70.5199403 $105.2599404 $139.58A4600 $0.00J7330 $38,286.65





Appendix

Code Rate


J7605 $11.85J7606 $14.22J7608 $7.58J7611 $0.18J7612 $0.22J7613 $0.06J7614 $0.08J7633 $0.06J7634 $0.06J7670 $0.06J7682 $42.01





Appendix

Code Description Rate Unit

W0750 Nutritional counseling/weight control program, per hour $60.00 1 unit = 1 hour

W0751 Weight Control Program with FDA Approved Drugs $2,000.00 1 unit = completed program

W1000 CARF accredited/Hospital Based Chronic Pain Program/day $500.00 1 unit = per diem

W1001CARF accredited/Hospital Based Chronic Pain program preadmission evaluation, per day

$600.00 1 unit = per diem

W1002CARF accredited/Hospital Based Chronic Pain program 1/2 day

$250.00 1 unit = 4 hours

W1930Translator/Interpreter Services, per 15 minutes. Each 15 minutes is equal to one (1) unit of service.

$20.00 1 unit = 15 min

W5000

Monitored smoking cessation program with FDA approved prescription smoking deterrent drugs. Services for smoking cessation with prescription drugs, when the allowed lung condition presents a barrier to meeting established treatment goals and the Miller Criteria have been met.

$1,150.00 1 unit = completed program

W5001

Monitored smoking cessation program without FDA approved prescription smoking deterrent drugs. Services for smoking cessation, without prescription drugs when the allowed lung condition presents a barrier to meeting established treatment goals and the Miller Criteria have been met.

$575.00 1 unit = completed program

Z0430 Detox Program Assessment $192.48 1 unit = completed program

Z0450Partial hospitalization detox all inclusive per diem; ASAM 2.5; 4-8 hrs/day, 5-7 days/week

$427.40 1 unit = 1 day

Z0460Intensive outpt detox all inclusive per diem; ASAM 2.1; 3-4 hrs per day, min 3 days/week

$273.80 1 unit = 1 day

Table 5 - BWC Hospital Outpatient Local Codes





Appendix

CPT Code Status Indicator APC23472 J1 511527125 J1 511527132 J1 511527445 J1 511527702 J1 511527703 J1 5115

Table 6 - Base Payment for Inpatient-Only Services Covered in the Hospital Outpatient Setting





Appendix

General CategoryCode

CategoryRevenue

CodeRevenue Code Description

Outpatient Coverage

Code

CPT/HCPCS Code

RequiredHealth Insurance - PPS 002 0022 Skilled Nursing Facility PPS NC NA

0023 Home Health PPS NC NA

0024 Inpatient Rehabilitation Facility PPS NC NAAll Inclusive Rate

010 0100All-inclusive Room and Board Plus Ancillary NC NA

0101 All-Inclusive Room and Board NC NARoom & Board - Private 011 0110 General Classification NC NA(Medical or General) 0111 Medical/Surgical/Gyn NC NA

0112 OB NC NA0113 Pediatric NC NA0114 Psychiatric NC NA0115 Hospice NC NA0116 Detoxification NC NA0117 Oncology NC NA0118 Rehabilitation NC NA0119 Other NC NA

Room & Board - Semi-Private 012 0120 General Classification NC NATwo Bed (Medical or General) 0121 Medical/Surgical/Gyn NC NA


Room & Board - Semi-Private 013 0130 General Classification NC NA- Three and Four Beds 0131 Medical/Surgical/Gyn NC NA


Room & Board - Private 014 0140 General Classification NC NA

Table 7 - Revenue Codes





Appendix

(Deluxe) 0141 Medical/Surgical/Gyn NC NA0142 OB NC NA0143 Pediatric NC NA0144 Psychiatric NC NA0145 Hospice NC NA0146 Detoxification NC NA0147 Oncology NC NA0148 Rehabilitation NC NA0149 Other NC NA

Room & Board - Ward 015 0150 General Classification NC NA(Medical or General) 0151 Medical/Surgical/Gyn NC NA


Room & Board - Other 016 0160 General Classification NC NA0164 Sterile Environment NC NA0167 Self-Care NC NA0169 Other NC NA

Nursery 017 0170 General Classification NC NA0171 Newborn - Level I NC NA0172 Newborn - Level II NC NA0173 Newborn - Level III NC NA0174 Newborn - Level IV NC NA0179 Other NC NA

Leave of Absence 018 0180 General Classification NC NA0182 Patient Convenience NC NA0183 Therapeutic Leave NC NA0185 Hospitalization NC NA0189 Other Leave of Absence NC NA

Subacute Care 019 0190 General Classification NC NA0191 Subacute Care - Level I NC NA0192 Subacute Care - Level II NC NA0193 Subacute Care - Level III NC NA0194 Subacute Care - Level IV NC NA0199 Other Subacute Care NC NA

Intensive Care 020 0200 General Classification NC NA0201 Surgical NC NA0202 Medical NC NA0203 Pediatric NC NA0204 Psychiatric NC NA





Appendix

0206 Intermediate ICU NC NA0207 Burn Care NC NA0208 Trauma NC NA0209 Other Intensive Care NC NA

Coronary Care 021 0210 General Classification NC NA0211 Myocardial Infarction NC NA0212 Pulmonary Care NC NA0213 Heart Transplant NC NA0214 Intermediate ICU NC NA0219 Other Coronary Care NC NA

Special Charges 022 0220 General Classification NC NA0221 Admission Charges NC NA0222 Technical Support Charge NC NA0223 U.R. Service Charge NC NA0224 Late Discharge, Medically Nec. NC NA0229 Other Special Charges NC NA

Incremental Nursing 023 0230 General Classification NC NACharge 0231 Nursery NC NARate 0232 OB NC NA

0233 ICU NC NA0234 CCU NC NA0235 Hospice NC NA0239 Other NC NA

All Inclusive Ancillary 024 0240 General Classification NC NA0241 Basic NC NA0242 Comprehensive NC NA0243 Specialty NC NA0249 Other All Inclusive Ancillary NC NA

Pharmacy (Also see 063X, an 025 0250 General Classification C Nextension of 025X) 0251 Generic Drugs C N

0252 Non-Generic Drugs C N0253 Take Home Drugs NC NA

0254Drugs Incident to other Diagnostic services C N

0255 Drugs Incident to Radiology C N0256 Experimental Drugs NC NA0257 Non-Prescription Drugs C N0258 IV Solution C N0259 Other Pharmacy C N

IV Therapy 026 0260 General Classification C N0261 Infusion Pump C N0262 IV Therapy/Pharmacy C N0263 IV Therapy/Drug/Supply/Delivery C N0264 IV Therapy/Supplies C N0269 Other IV Therapy C N





Appendix

Medical/Surgical Supplies and 027 0270 General Classification C NDevices (Also see 062X, and 0271 Non Sterile Supply C Nextension of 027X) 0272 Sterile Supply C N

0273 Take Home Supplies C N0274 Prosthetic/Orthotic Devices C N0275 Pacemaker C N0276 Intraocular Lens C N0277 Oxygen-Take Home C N0278 Other Implant C N0279 Other Supplies/Devices C N

Oncology 028 0280 General Classification C N0289 Other Oncology C N

Durable Medical Equipment 029 0290 General Classification C N(Other than Renal) 0291 Rental C Y

0292 Purchase of New DME C Y0293 Purchase of Used DME C Y

0294Supplies/Drugs for DME Effectiveness (HHA only) NC NA

0299 Other Equipment C YLaboratory 030 0300 General Classification C Y

0301 Chemistry C Y0302 Immunology C Y0303 Renal Patient (home) C Y0304 Non-routine Dialysis C Y0305 Hematology C Y0306 Bacteriology & Microbiology C Y0307 Urology C Y0309 Other Laboratory C Y

Laboratory Pathological031 0310 General Classification C Y

0311 Cytology C Y0312 Histology C Y0314 Biopsy C Y0319 Other Laboratory Pathological C Y

Radiology - Diagnostic 032 0320 General Classification C Y0321 Angiocardiography C Y0322 Arthrography C Y0323 Arteriography C Y0324 Chest X-ray C Y0329 Other Radiology - Diagnostic C Y

Radiology - Therapeutic033 0330 General Classification C Y

and/or Chemotherapy 0331 Chemotherapy Administration - Injected C Y





Appendix

Administration 0332 Chemotherapy Admin. - Oral C Y0333 Radiation Therapy C Y0335 Chemotherapy Admin. - IV C Y0339 Other Radiology - Therapeutic C Y

Nuclear Medicine 034 0340 General Classification C Y0341 Diagnostic Procedures C Y0342 Therapeutic Procedures C Y0343 Diagnostic Radiopharmaceutical C N0344 Therapeutic Radiopharmaceutical C N0349 Other C Y

CT Scan 035 0350 General Classification C Y0351 Head Scan C Y0352 Body Scan C Y0359 Other CT Scan C Y

Operating Room Services 036 0360 General Classification C Y

0361 Minor Surgery C Y

0362 Organ Transplant-Other Than Kidney C Y0367 Kidney Transplant C Y0369 Other Operating Room Services C Y

Anesthesia 037 0370 General Classification C N0371 Anesthesia Incident to Radiology C N

0372Anesthesia Incident to Other Diagnostic Services C N

0374 Acupuncture C N0379 Other Anesthesia C N

Blood 038 0380 General Classification C Y0381 Packed Blood Cells C Y0382 Whole Blood C Y0383 Plasma C Y0384 Platelets C Y0385 Leucocytes C Y0386 Other Components C Y0387 Other Derivatives (Cryoprecipitate) C Y0389 Other Blood C Y

Blood and Blood Components 039 0390 General Classification C YAdministration, Processing 0391 Administration (Transfusions) C YStorage 0392 Processing and Storage C Y

0399 Other Processing and Storage C YOther Imaging Services

040 0400 General Classification C Y0401 Diagnostic Mammography C Y0402 Ultrasound C Y0403 Screening Mammography C Y





Appendix

0404 Positron Emission Tomography C Y0409 Other Imaging Service C Y

Respiratory Services 041 0410 General Classification C Y0412 Inhalation Services C Y0413 Hyperbaric Oxygen Therapy C Y0419 Other Respiratory Services C Y

Physical Therapy 042 0420 General Classification C Y0421 Visit Charge C Y0422 Hourly Charge C Y0423 Group Rate C Y0424 Evaluation or Re-evaluation C Y0429 Other Physical Therapy C Y

Occupational Therapy 043 0430 General Classification C Y0431 Visit Charge C Y0432 Hourly Charge C Y0433 Group Rate C Y0434 Evaluation or Re-evaluation C Y0439 Other Occupational Therapy C Y

Speech-Language Pathology 044 0440 General Classification C Y

0441 Visit Charge C Y0442 Hourly Charge C Y0443 Group Rate C Y0444 Evaluation or Re-evaluation C Y0449 Other Speech-Language Pathology C Y

Emergency Room 045 0450 General Classification C Y

0451EMTALA Emergency Medical Screening Services C Y

0452 ER Beyond EMTALA Screening Services C Y0456 Urgent Care C Y0459 Other Emergency Room C Y

Pulmonary Function 046 0460 General Classification C Y0469 Other Pulmonary Function C Y

Audiology 047 0470 General Classification C Y0471 Diagnostic C Y0472 Treatment C Y0479 Other Audiology C Y

Cardiology 048 0480 General Classification C Y0481 Cardiac Cath Lab C Y0482 Stress Test C Y0483 Echocardiography C Y0489 Other Cardiology C Y

Ambulatory Surgical Care 049 0490 General Classification C Y

0499 Other Ambulatory Surgical Care C Y





Appendix

Outpatient Services 050 0500 General Classification NC NA0509 Other Outpatient Service NC NA

Clinic 051 0510 General Classification C Y0511 Chronic Pain Center C Y0512 Dental Clinic C Y0513 Psychiatric Clinic C Y0514 OB-GYN Clinic C Y0515 Pediatric Clinic C Y0516 Urgent Care Clinic C Y0517 Family Practice Clinic C Y0519 Other Clinic C Y

Free-Standing Clinic 052 0520 General Classification NC NA0521 Rural Health-Clinic NC NA0522 Rural Health-Home NC NA0523 Family Practice Clinic NC NA

0524Visit by RHC/FQHC Practitioner - SNF (Covered by Part A) NC NA

0525

Visit by RHC/FQHC Practitioner - SNF(not a Covered Part A Stay) or NF or ICF MR or Other Residential Facility NC NA

0526 Urgent Care Clinic NC NA

0527Visiting Nurse Service(s)- in a Home Health Shortage Area NC NA

0528Visit by RHC/FQHC Practitioner to Other Site NC NA

0529 Other Freestanding Clinic NC NAOsteopathic Services 053 0530 General Classification C Y

0531 Osteopathic Therapy C Y0539 Other Osteopathic Services C Y

Ambulance 054 0540 General Classification NC NA0541 Supplies NC NA0542 Medical Transport NC NA0543 Heart Mobile NC NA0544 Oxygen NC NA0545 Air Ambulance NC NA0546 Neonatal Ambulance Service NC NA0547 Pharmacy NC NA0548 Telephone Transmission EKG NC NA0549 Other Ambulance NC NA

Skilled Nursing 055 0550 General Classification NC NA0551 Visit Charge NC NA0552 Hourly Charge NC NA0559 Other Skilled Nursing NC NA

Medical Social Services 056 0560 General Classification NC NA0561 Visit Charge NC NA





Appendix

0562 Hourly Charge NC NA0569 Other Medical Social Services NC NA

Home Health - Home Health 057 0570 General Classification NC NAAide 0571 Visit Charge NC NA

0572 Hourly Charge NC NA0579 Other Home Health Aide NC NA

Home Health - Other Visits 058 0580 General Classification NC NA

0581 Visit Charge NC NA0582 Hourly Charge NC NA0583 Assessment NC NA0589 Other Home Health Visit NC NA

Home Health Service 059 0590 General Classification NC NAHome Health - Oxygen

060 0600 General Classification NC NA

0601 Oxygen - State/Equip/Supply/or Cont NC NA

0602Oxygen - State/Equip/Supply/ under 1 LPM NC NA

0603 Oxygen - State/Equip/Over 4 LPM NC NA0604 Oxygen - Portable Add-on NC NA0609 Other Oxygen NC NA

Magnetic Resonance 061 0610 General Classification C Y Technology (MRT) 0611 MRI - Brain (Including Brainstem) C Y

0612 MRI - Spinal Cord (Incl. Spine) C Y0614 MRI - Other C Y0615 MRA - Head and Neck C Y0616 MRA - Lower Extremities C Y0618 MRA - Other C Y0619 Other MRT C Y

Medical/Surgical 062 0621 Supplies Incident to Radiology C YSupplies Extension

0622Supplies Incident to Other Diagnostic Services C Y

of 027X 0623 Surgical Dressings C Y0624 FDA Investigational Devices NC NA

Pharmacy - Extension of 025X 063 0631 Single Source Drug C N

0632 Multiple Source Drug C N0633 Restrictive Prescription C N

0634Erythropoietin (EPO) Less Than 10,000 Units C Y

0635Erythropoietin (EPO) 10,000 or More Units C Y

0636 Drugs Requiring Detailed Coding C Y0637 Self-administrable Drugs NC NA

Home IV Therapy Services 064 0640 General Classification NC NA





Appendix

0641 Nonroutine Nursing, Central Line NC NA0642 IV Site Care, Central Line NC NA0643 IV Start/Change, Peripheral Line NC NA0644 Nonroutine Nurs., Peripheral line NC NA

0645 Training, Patient/Caregiver, Central Line NC NA0646 Training, Disabled, Central Line NC NA

0647Training, Patient/Caregiver, Peripheral Line NC NA

0648Training, Disabled Patient, Peripheral Line NC NA

0649 Other IV Therapy Services NC NAHospice Service 065 0650 General Classification NC NA

0651 Routine Home Care NC NA0652 Continuous Home Care NC NA0655 Inpatient Respite Care NC NA0656 General IP Care (Non-respite) NC NA0657 Physician Services NC NA

0658 Hospice Room & Board - Nursing Facility NC NA0659 Other Hospice Service NC NA

Respite Care 066 0660 General Classification NC NA0661 Hourly Charge/Nursing NC NA

0662Hourly Charge/Aid/Homemaker/Companion NC NA

0663 Daily Respite Charge NC NA0669 Other Respite Charge NC NA

Outpatient Special Residence 067 0670 General Classification NC NACharge 0671 Hospital Based NC NA

0672 Contracted NC NA0679 Other Special Residence Charge NC NA

Trauma Response (Charge 068 0681 Level I C Nfor Trauma Team Activation) 0682 Level II C N

0683 Level III C N0684 Level IV C N0689 Other Trauma Response C N

Pre-Hospice/Palliative Care 069 0690 General Classification C YServices 0691 Visit Charge C Y

0692 Hourly Charge C Y0693 Evaluation C Y0694 Consultation and Education C Y0695 Inpatient Care NC NA0696 Physician Services C Y





Appendix

0699Other Pre-Hospice/Palliative Care Services C Y

Cast Room 070 0700 General Classification C NRecovery Room 071 0710 General Classification C NLabor Room/Delivery 072 0720 General Classification C N

0721 Labor C N0722 Delivery C N0723 Circumcision NC NA0724 Birthing Center C N0729 Other Labor Room/Delivery C N

EKG/ECG (Electrocardiogram) 073 0730 General Classification C Y

0731 Holter Monitor C Y0732 Telemetry C Y0739 Other EKG/ECG C Y

EEG (Electroencephalogram)

074 0740 General Classification C YGastro-Intestinal Services 075 0750 General Classification C YSpecialty Services 076 0760 Specialty Services - General C Y

0761 Treatment Room C Y0762 Observation Room Hours C Y0769 Other Specialty Services C Y

Preventive Care Services077 0770 General Classification C Y

0771 Vaccine Administration C YTelemedicine 078 0780 General Classification C YExtra-Corporeal Shock Wave Therapy 079 0790 General Classification C YInpatient Renal Dialysis

080 0800 General Classification NC NA0801 Inpatient Hemodialysis NC NA0802 Inpatient Peritoneal (Non-CAPD) NC NA

0803Inpatient Continuous Ambulatory Peritoneal Dialysis (CAPD) NC NA

0804Inpatient Continuous Cycling Peritoneal Dialysis (CCPD) NC NA

0809 Other Inpatient Dialysis NC NAAcquisition of Body 081 0810 General Classification C YComponents 0811 Living Donor C Y

0812 Cadaver Donor C Y0813 Unknown Donor C Y

0814Unsuccessful Organ Search Donor Bank Charges C Y

0815 Stem Cells - Allogeneic C Y0819 Other Donor C Y





Appendix

Hemodialysis - Outpatient or 082 0820 General Classification C YHome

0821 Hemodialysis/Composite or Other Rate C Y0822 Home Supplies C Y0823 Home Equipment C Y0824 Maintenance/100% C Y0825 Support Services C Y0826 Hemodialysis – Shorter C Y0829 Other Outpatient Hemodialysis C Y

Peritoneal Dialysis - 083 0830 General Classification C YOutpatient or Home

0831Peritoneal Dialysis/Composite or Other Rate C Y

0832 Home Supplies C Y0833 Home Equipment C Y0834 Maintenance/100% C Y0835 Support Services C Y0839 Other OP Peritoneal Dialysis C Y

Continuous Ambulatory084 0840 General Classification C Y

Peritoneal Dialysis (CAPD) - 0841 CAPD/Composite or Other Rate C YOutpatient or Home 0842 Home Supplies C Y

0843 Home Equipment C Y0844 Maintenance 100% C Y0845 Support Services C Y0849 Other Outpatient CAPD C Y

Continuous Cycling Peritoneal 085 0850 General Classification C YDialysis (CCPD) - Outpatient 0851 CCPD/Composite or Other Rate C Yor Home 0852 Home Supplies C Y

0853 Home Equipment C Y0854 Maintenance 100% C Y0855 Support Services C Y0859 Other Outpatient CCPD C Y

Magnetocephalography (MEG) 086 0860 General Classification C Y

0861 MEG C YCell/Gene Therapy 087 0870 General Classification C Y

0871 Cell Collection C Y

0872Specialized Biologic Processing and Storage - Prior to Transport C Y

0873Storage and Processing after Receipt of Cells from Manufacturer C Y

0874 Infusion of Modfied Cells C Y0875 Injection of Modified Cells C Y

Miscellaneous Dialysis 088 0880 General Classification C Y





Appendix

0881 Ultrafiltration C Y0882 Home Dialysis Aid Visit C Y0883 Other Miscellaneous Dialysis C Y

Pharmacy - Extension of 025x and 063x 089 0891

Special Processed Drugs - FDA Approved Cell Therapy C Y

Behavioral Health 090 0900 General Classification C YTreatments/Services (Also 0901 Electroshock Treatment C Ysee 091X, an extension of 0902 Milieu Therapy C Y090X) 0903 Play Therapy C Y

0904 Activity Therapy C Y0905 IOP - Psychiatric NC NA0906 IOP - Chemical Dependency NC NA0907 Day Treatment NC NA

Behavioral Health 091 0911 Rehabilitation C YTreatments/Services

0912 Partial Hospitalization - Less Intensive C Y -Extension of 090X 0913 Partial Hospitalization - Intensive C Y

0914 Individual Therapy C Y0915 Group Therapy C Y0916 Family Therapy C Y0917 Bio Feedback C Y0918 Testing C Y

0919Other Behavioral Health Treatment/Services C Y

Other Diagnostic Services 092 0920 General Classification C Y

0921 Peripheral Vascular Lab C Y0922 Electromyogram C Y0923 Pap Smear NC NA0924 Allergy Test C Y0925 Pregnancy Test C Y0929 Other Diagnostic Services C Y

Medical Rehabilitation Day 093 0931 Half Day NC NAProgram 0932 Full Day NC NAOther Therapeutic Services 094 0940 General Classification C Y(Also see 095X, an extension 0941 Recreational Therapy C Yof 094X) 0942 Education/Training C Y

0943 Cardiac Rehabilitation C Y0944 Drug Rehabilitation C Y0945 Alcohol Rehabilitation C Y

0946 Complex Medical Equipment - Routine C Y





Appendix

0947Complex Medical Equipment - Ancillary C Y

0948 Pulmonary Rehabilitation C Y0949 Other Therapeutic Service C Y

Other Therapeutic Services - 095 0951 Athletic Training C YExt. of 094X 0952 Kinesiotherapy C Y

0953Chemical Dependency (Drug N and Alcohol) NC NA

Professional Fees (Also see 096 0960 General Classification NC NA097X and 098X) 0961 Psychiatric NC NA

0962 Ophthalmology NC NA0963 Anesthesiologist (MD) NC NA0964 Anesthetist (CRNA) NC NA0969 Other Professional Fee NC NA

Professional Fees (Extension 097 0971 Laboratory NC NAof 096X) 0972 Radiology - Diagnostic NC NA

0973 Radiology - Therapeutic NC NA0974 Radiology - Nuclear Medicine NC NA0975 Operating Room NC NA0976 Respiratory Therapy NC NA0977 Physical Therapy NC NA0978 Occupational Therapy NC NA0979 Speech Pathology NC NA

Professional Fees (Extension 098 0981 Emergency Room NC NAof 096X and 097X) 0982 Outpatient Services NC NA

0983 Clinic NC NA0984 Medical Social Services NC NA0985 EKG NC NA0986 EEG NC NA0987 Hospital Visit NC NA0988 Consultation NC NA0989 Private Duty Nurse NC NA

Patient Convenience Items 099 0990 General Classification NC NA

0991 Cafeteria/Guest Tray NC NA0992 Private Linen Service NC NA0993 Telephone/Telegraph NC NA0994 TV/Radio NC NA0995 Nonpatient Room Rentals NC NA0996 Late Discharge Charge NC NA0997 Admission Kits NC NA0998 Beauty Shop/Barber NC NA0999 Other Patient Convenience Item NC NA





Appendix

Behavioral Health Accommodations 100 1000 General Classification NC NA

1001 Res.Treatment - Psychiatric NC NA1002 Res. Treatment - Chem. Dep. C N1003 Supervised Living NC NA1004 Halfway House NC NA1005 Group Home NC NA

1006Outdoor/Wilderness Behavioral Healthcare NC NA

Alternative Therapy Services 210 2100 General Classification NC NA

2101 Acupuncture C Y2102 Acupressure NC NA2103 Massage NC NA2104 Reflexology NC NA2105 Biofeedback NC NA2106 Hypnosis NC NA2109 Other Alternative Therapy NC NA

Adult Care310 3101

Adult Day Care, Medical and Social - Hourly NC NA

3102 Adult Day Care, Social - Hourly NC NA

3103Adult Day Care, Medical and Social, Daily NC NA

3104 Adult Day Care, Social - Daily NC NA3105 Adult Foster Care - Daily NC NA3109 Other Adult Care NC NA





Appendix

HCPCS/CPT Code

Outpatient Hospital Services MUE Values

0001U 10002M 10002U 10003M 10003U 10004M 10005U 10006M 10006U 10007M 10007U 10008U 10009U 20010U 20011M 10011U 10012M 10012U 10013M 10013U 10014U 10016U 10017U 10018U 10019U 10021U 10022U 20023U 10024U 10025U 10026U 10027U 10029U 10030U 10031U 10032U 10033U 10034U 10035U 10036U 10037U 10038U 10039U 1

Table 8 - MUE Values





Appendix

HCPCS/CPT Code



0040U 10041U 10042T 10042U 10043U 10044U 10045U 10046U 10047U 10048U 10049U 10050U 10051U 10052U 10053U 10054T 10054U 10055T 10055U 10056U 10058T 10058U 10059U 10060U 10061U 10062U 10063U 10064U 20065U 20066U 10067U 20068U 10069U 10070U 10071T 10071U 10072T 10072U 10073U 10074U 10075T 10075U 10076T 1





Appendix

HCPCS/CPT Code



0076U 10077U 20078U 10079U 00080U 10082U 00083U 10084U 10085T 00085U 10086U 10087U 10088U 10089U 10090U 10091U 10092U 10093U 10094U 10095T 10095U 10096U 10097U 10098T 20098U 10099U 10100T 10100U 10101T 10101U 10102T 20102U 10103U 10105U 10106T 40106U 10107T 40107U 10108T 40108U 10109T 40109U 10110T 4





Appendix

HCPCS/CPT Code



0110U 10111T 10111U 10112U 10113U 10114U 10115U 10116U 10117U 10118U 10119U 10120U 10121U 10122U 10123U 10124U 10125U 10126T 10126U 10127U 10128U 10129U 10130U 10131U 10132U 10133U 10134U 10135U 10136U 10137U 10138U 10163T 10164T 40165T 40174T 10175T 10184T 10191T 20198T 21996 1

0200T 10201T 10202T 1





Appendix

HCPCS/CPT Code



0207T 20208T 10209T 10210T 10211T 10212T 10213T 10214T 10215T 10216T 10217T 10218T 10219T 10220T 10221T 10222T 10228T 10229T 20230T 10231T 20232T 10234T 20235T 20236T 10237T 20238T 20253T 10263T 10264T 10265T 10266T 10267T 10268T 10269T 10270T 10271T 10272T 10273T 10274T 10275T 10278T 10290T 10295T 1





Appendix

HCPCS/CPT Code








Appendix

HCPCS/CPT Code



0577T 10578T 10579T 10580T 10583T 20584T 10585T 10586T 10587T 10588T 10589T 10590T 10591T 10592T 10593T 110004 310005 110006 310007 110008 310009 110010 310011 110012 310021 110030 210035 110036 310040 110060 110061 110080 110081 110120 310121 210140 210160 310180 211000 111001 111004 111005 111006 1





Appendix

HCPCS/CPT Code



11008 111010 211011 211012 211042 111043 111044 111045 1211046 411047 411055 111056 111057 111102 111103 611104 111105 311106 111107 211200 111201 011300 511301 611302 411303 311305 411306 411307 311308 211310 411311 411312 311313 311400 311401 311402 311403 211404 211406 211420 311421 311422 311423 2





Appendix

HCPCS/CPT Code



11424 211426 211440 411441 311442 311443 211444 211446 211450 111451 111462 111463 111470 311471 211600 211601 211602 311603 211604 211606 211620 211621 211622 211623 211624 211626 211640 211641 211642 311643 211644 211646 211719 111720 111721 111730 111732 411740 211750 611755 211760 411762 211765 4





Appendix

HCPCS/CPT Code



11770 111771 111772 111900 111901 111920 111921 111922 111950 111951 111952 111954 111960 211970 211971 211976 111980 111981 111982 111983 112001 112002 112004 112005 112006 112007 112011 112013 112014 112015 112016 112017 112018 112020 212021 312031 112032 112034 112035 112036 112037 112041 112042 1





Appendix

HCPCS/CPT Code



12044 112045 112046 112047 112051 112052 112053 112054 112055 112056 112057 113100 113101 113102 913120 113121 113122 913131 113132 113133 713151 113152 113153 213160 214000 214001 214020 214021 214040 214041 314060 214061 214301 214302 814350 215002 115003 915004 115005 215040 115050 115100 115101 9





Appendix

HCPCS/CPT Code



15110 115111 215115 115116 215120 115121 515130 115131 215135 115136 115150 115151 115152 215155 115156 115157 115200 115201 715220 115221 915240 115241 915260 115261 615271 115272 315273 115274 615275 115276 315277 115278 315570 215572 215574 215576 215600 215610 215620 215630 215650 115730 115731 1





Appendix

HCPCS/CPT Code



15733 215734 415736 215738 315740 215750 215756 215757 215758 215760 215769 115770 215771 115773 115775 115776 115777 115780 115781 115782 115783 115786 115787 215788 115789 115792 115793 115819 115820 115821 115822 115823 115824 115825 115826 115828 115829 115830 115832 115833 115834 115835 115836 1





Appendix

HCPCS/CPT Code



15837 215838 115839 215840 115841 215842 215845 215847 115850 115851 115852 115860 115876 115877 115878 115879 115920 115922 115931 115933 115934 115935 115936 115937 115940 215941 215944 215945 215946 215950 215951 215952 215953 215956 215958 215999 116000 116020 116025 116030 116035 116036 217000 1





Appendix

HCPCS/CPT Code



17003 1317004 117106 117107 117108 117110 117111 117250 417260 717261 717262 617263 317264 317266 217270 617271 417272 517273 417274 217276 217280 617281 517282 417283 417284 217286 217311 417312 617313 317314 417315 1517340 117360 117380 117999 119000 219001 519020 219030 119081 119082 219083 119084 2





Appendix

HCPCS/CPT Code



19085 119086 219100 419101 319105 219110 119112 219120 119125 119126 319281 119282 219283 119284 219285 119286 219287 119288 219294 219296 119297 219298 119300 119301 119302 119303 119305 119306 119307 119316 119318 119324 119325 119328 119330 119340 119342 119350 119355 119357 119361 119364 119366 1





Appendix

HCPCS/CPT Code



19367 119368 119369 119370 119371 119380 119396 119499 120100 220101 220102 320103 320150 220200 220205 320206 320220 320225 220240 420245 320250 120251 220500 220501 220520 220525 420526 120527 220550 520551 520552 120553 120555 120600 620604 420605 220606 220610 220611 220612 220615 120650 420660 1





Appendix

HCPCS/CPT Code



20661 120662 120663 120664 120665 120670 320680 320690 220692 220693 220694 220696 220697 420802 120805 120808 120816 320822 320824 120827 120838 120900 220902 220910 120912 120920 120922 120924 220930 120931 120932 120933 120934 120936 120937 120938 120939 120950 220955 120956 120957 120962 120969 2





Appendix

HCPCS/CPT Code



20970 120972 220973 120974 120975 120979 120982 120983 120985 220999 121010 121011 421012 321013 221014 221015 121016 221025 221026 221029 121030 121031 221032 121034 121040 221044 121045 121046 221047 221048 221049 121050 121060 121070 121073 121076 121077 121079 121080 121081 121082 121083 121084 1





Appendix

HCPCS/CPT Code



21085 121086 121087 121088 121089 121100 121110 221116 121120 121121 121122 121123 121125 221127 221137 121138 121139 121141 121142 121143 121145 121146 121147 121150 121151 121154 121155 121159 121160 121172 121175 121179 121180 121181 121182 121183 121184 121188 121193 121194 121195 121196 121198 1





Appendix

HCPCS/CPT Code



21199 121206 121208 121209 121210 221215 221230 221235 221240 121242 121243 121244 121245 221246 221247 121248 221249 221255 121256 121260 121261 121263 121267 121268 121270 121275 121280 121282 121295 121296 121299 121310 121315 121320 121325 121330 121335 121336 121337 121338 121339 121340 121343 1





Appendix

HCPCS/CPT Code



21344 121345 121346 121347 121348 121355 121356 121360 121365 121366 121385 121386 121387 121390 121395 121400 121401 121406 121407 121408 121421 121422 121423 121431 121432 121433 121435 121436 121440 221445 221450 121451 121452 121453 121454 121461 121462 121465 121470 121480 121485 121490 121497 1





Appendix

HCPCS/CPT Code



21499 121501 321502 121510 121550 221552 221554 221555 221556 221557 121558 121600 521601 221602 121603 121610 121615 121616 121620 121627 121630 121632 121685 121700 121705 121720 121725 121740 121742 121743 121750 121811 121812 121813 121820 121825 121899 121920 221925 221930 521931 321932 221933 2





Appendix

HCPCS/CPT Code



21935 121936 122010 222015 222100 122101 122102 122103 322110 122112 122114 122116 322206 122207 122208 522210 122212 122214 122216 622220 122222 122224 122226 422310 122315 122318 122319 122325 122326 122327 122328 622505 122510 122511 122512 322513 122514 122515 422526 122527 122532 122533 122534 3





Appendix

HCPCS/CPT Code



22548 122551 122552 522554 122556 122558 122585 522586 122590 122595 122600 122610 122612 122614 1322630 122632 422633 122634 422800 122802 122804 122808 122810 122812 122818 122819 122830 122840 122841 022842 122843 122844 122845 122846 122847 122848 122849 122850 122852 122853 422854 422855 122856 1





Appendix

HCPCS/CPT Code



22857 122858 122859 422861 122862 122864 122865 122867 122868 122869 122870 122899 122900 322901 222902 422903 322904 122905 122999 123000 123020 123030 223031 123035 123040 123044 123065 223066 223071 223073 223075 223076 223077 123078 123100 123101 123105 123106 123107 123120 123125 123130 123140 1





Appendix

HCPCS/CPT Code



23145 123146 123150 123155 123156 123170 123172 123174 123180 123182 123184 123190 123195 123200 123210 123220 123330 223333 123334 123335 123350 123395 123397 123400 123405 223406 123410 123412 123415 123420 123430 123440 123450 123455 123460 123462 123465 123466 123470 123472 123473 123474 123480 1





Appendix

HCPCS/CPT Code



23485 123490 123491 123500 123505 123515 123520 123525 123530 123532 123540 123545 123550 123552 123570 123575 123585 123600 123605 123615 123616 123620 123625 123630 123650 123655 123660 123665 123670 123675 123680 123700 123800 123802 123900 123920 123921 123929 123930 223931 223935 224000 124006 1





Appendix

HCPCS/CPT Code



24065 224066 224071 224073 224075 524076 424077 124079 124100 124101 124102 124105 124110 124115 124116 124120 124125 124126 124130 124134 124136 124138 124140 124145 124147 124149 124150 124152 124155 124160 124164 124200 324201 324220 124300 124301 224305 424310 224320 224330 124331 124332 124340 1





Appendix

HCPCS/CPT Code



24341 224342 224343 124344 124345 124346 124357 124358 124359 224360 124361 124362 124363 124365 124366 124370 124371 124400 124410 124420 124430 124435 124470 124495 124498 124500 124505 124515 124516 124530 124535 124538 124545 124546 124560 124565 124566 124575 124576 124577 124579 124582 124586 1





Appendix

HCPCS/CPT Code



24587 124600 124605 124615 124620 124635 124640 124650 124655 124665 124666 124670 124675 124685 124800 124802 124900 124920 124925 124930 124931 124935 124940 124999 125000 225001 125020 125023 125024 125025 125028 425031 225035 225040 125065 225066 225071 325073 225075 625076 325077 125078 125085 1





Appendix

HCPCS/CPT Code



25100 125101 125105 125107 125109 425110 225111 125112 125115 125116 125118 525119 125120 125125 125126 125130 125135 125136 125145 125150 125151 125170 125210 225215 125230 125240 125246 125248 325250 125251 125259 125260 725263 425265 425270 825272 425274 425275 225280 925290 1025295 925300 125301 1





Appendix

HCPCS/CPT Code



25310 525312 425315 125316 125320 125332 125335 125337 125350 125355 125360 125365 125370 125375 125390 125391 125392 125393 125394 125400 125405 125415 125420 125425 125426 125430 125431 125440 125441 125442 125443 125444 125445 125446 125447 425449 125450 125455 125490 125491 125492 125500 125505 1





Appendix

HCPCS/CPT Code



25515 125520 125525 125526 125530 125535 125545 125560 125565 125574 125575 125600 125605 125606 125607 125608 125609 125622 125624 125628 125630 125635 125645 125650 125651 125652 125660 125670 125671 125675 125676 125680 125685 125690 125695 125800 125805 125810 125820 125825 125830 125900 125905 1





Appendix

HCPCS/CPT Code



25907 125909 125915 125920 125922 125924 125927 125929 125931 125999 126010 226011 326020 426025 126030 126034 226035 126037 126040 126045 126055 526060 526070 226075 326080 326100 126105 226110 226111 426113 326115 426116 226117 226118 126121 126123 126125 426130 126135 426140 226145 626160 426170 4





Appendix

HCPCS/CPT Code



26180 426185 126200 226205 126210 226215 226230 226235 226236 226250 226260 126262 126320 426340 426341 226350 626352 226356 426357 226358 226370 326372 126373 226390 226392 226410 426412 326415 226416 226418 426420 326426 426428 226432 226433 226434 226437 426440 626442 526445 526449 526450 626455 6





Appendix

HCPCS/CPT Code



26460 426471 426474 426476 426477 226478 626479 426480 426483 426485 426489 226490 326492 226494 126496 126497 226498 126499 226500 326502 226508 126510 426516 126517 126518 126520 426525 426530 426531 426535 326536 426540 426541 426542 426545 426546 226548 326550 126551 126553 126554 126555 226556 2





Appendix

HCPCS/CPT Code



26560 226561 226562 226565 226567 326568 226580 126587 226590 226591 426593 826596 126600 226605 326607 226608 426615 326641 126645 126650 126665 126670 226675 126676 226685 326686 326700 226705 326706 226715 326720 426725 326727 326735 426740 326742 326746 326750 326755 226756 226765 326770 326775 2





Appendix

HCPCS/CPT Code



26776 426785 326820 126841 126842 126843 226844 226850 526852 226860 126861 426862 126863 226910 426951 826952 426989 126990 226991 126992 227000 127001 127003 127005 127006 127025 127027 127030 127033 127035 127036 127040 227041 327043 227045 327047 227048 227049 127050 127052 127054 127057 127059 1





Appendix

HCPCS/CPT Code



27060 127062 127065 127066 127067 127070 127071 127075 127076 127077 127078 127080 127086 127087 127090 127091 127093 127095 127096 127097 127098 127100 127105 127110 127111 127120 127122 127125 127130 127132 127134 127137 127138 127140 127146 127147 127151 127156 127158 127161 127165 127170 127175 1





Appendix

HCPCS/CPT Code



27176 127177 127178 127179 127181 127185 127187 127197 127198 127200 127202 127215 027216 027217 027218 027220 127222 127226 127227 127228 127230 127232 127235 127236 127238 127240 127244 127245 127246 127248 127250 127252 127253 127254 127256 127257 127258 127259 127265 127266 127267 127268 127269 1





Appendix

HCPCS/CPT Code



27275 227279 127280 127282 127284 127286 127290 127295 127299 127301 327303 227305 127306 127307 127310 127323 227324 327325 127326 127327 527328 327329 127330 127331 127332 127333 127334 127335 127337 327339 427340 127345 127347 127350 127355 127356 127357 127358 127360 227364 127365 127369 127372 2





Appendix

HCPCS/CPT Code



27380 127381 127385 227386 227390 127391 127392 127393 127394 127395 127396 127397 127400 127403 127405 227407 227409 127412 127415 127416 127418 127420 127422 127424 127425 127427 127428 127429 127430 127435 127437 127438 127440 127441 127442 127443 127445 127446 127447 127448 127450 127454 127455 1





Appendix

HCPCS/CPT Code



27457 127465 127466 127468 127470 127472 127475 127477 127479 127485 127486 127487 127488 127495 127496 127497 127498 127499 127500 127501 127502 127503 127506 127507 127508 127509 127510 127511 127513 127514 127516 127517 127519 127520 127524 127530 127532 127535 127536 127538 127540 127550 127552 1





Appendix

HCPCS/CPT Code



27556 127557 127558 127560 127562 127566 127570 127580 127590 127591 127592 127594 127596 127598 127599 127600 127601 127602 127603 227604 227605 127606 127607 227610 127612 127613 327614 327615 127616 127618 327619 227620 127625 127626 127630 227632 327634 227635 127637 127638 127640 127641 127645 1





Appendix

HCPCS/CPT Code



27646 127647 127648 127650 127652 127654 127656 127658 227659 227664 227665 227675 127676 127680 227681 127685 227686 327687 127690 227691 227692 427695 127696 127698 227700 127702 127703 127704 127705 127707 127709 127712 127715 127720 127722 127724 127725 127726 127727 127730 127732 127734 127740 1





Appendix

HCPCS/CPT Code



27742 127745 127750 127752 127756 127758 127759 127760 127762 127766 127767 127768 127769 127780 127781 127784 127786 127788 127792 127808 127810 127814 127816 127818 127822 127823 127824 127825 127826 127827 127828 127829 127830 127831 127832 127840 127842 127846 127848 127860 127870 127871 127880 1





Appendix

HCPCS/CPT Code



27881 127882 127884 127886 127888 127889 127892 127893 127894 127899 128001 228002 328003 228005 328008 228010 428011 428020 228022 328024 428035 128039 228041 228043 428045 428046 128047 128050 228052 228054 228055 128060 128062 128070 228072 428080 328086 228088 228090 228092 228100 128102 128103 1





Appendix

HCPCS/CPT Code



28104 228106 128107 128108 228110 128111 128112 428113 128114 128116 128118 128119 128120 228122 428124 428126 428130 128140 328150 428153 428160 528171 128173 228175 228190 328192 228193 228200 428202 228208 428210 228220 128222 128225 128226 128230 128232 628234 628238 128240 128250 128260 128261 1





Appendix

HCPCS/CPT Code



28262 128264 128270 628272 628280 128285 428286 128288 428289 128291 128292 128295 128296 128297 128298 128299 128300 128302 128304 128305 128306 128307 128308 428309 128310 128312 428313 428315 128320 128322 228340 228341 228344 128345 228360 128400 128405 128406 128415 128420 128430 128435 128436 1





Appendix

HCPCS/CPT Code



28445 128446 128450 228455 328456 228465 328470 228475 528476 428485 528490 128495 128496 128505 128510 428515 428525 428530 128531 128540 128545 128546 128555 128570 128575 128576 128585 128600 228605 228606 328615 528630 228635 228636 428645 428660 428665 328666 428675 328705 128715 128725 128730 1





Appendix

HCPCS/CPT Code



28735 128737 128740 128750 128755 128760 128800 128805 128810 528820 628825 828890 128899 129000 129010 129015 129035 129040 129044 129046 129049 129055 129058 129065 129075 129085 129086 229105 129125 129126 129130 329131 229200 129240 129260 129280 229305 129325 129345 129355 129358 129365 129405 1





Appendix

HCPCS/CPT Code



29425 129435 129440 129445 129450 129505 129515 129520 129530 129540 129550 129580 129581 129584 129700 229705 129710 129720 129730 129740 129750 129799 129800 129804 129805 129806 129807 129819 129820 129821 129822 129823 129824 129825 129826 129827 129828 129830 129834 129835 129836 129837 129838 1





Appendix

HCPCS/CPT Code



29840 129843 129844 129845 129846 129847 129848 129850 129851 129855 129856 129860 129861 129862 129863 129866 129867 129868 129870 129871 129873 129874 129875 129876 129877 129879 129880 129881 129882 129883 129884 129885 129886 129887 129888 129889 129891 129892 129893 129894 129895 129897 129898 1





Appendix

HCPCS/CPT Code



29899 129900 229901 229902 229904 129905 129906 129907 129914 129915 129916 129999 130000 130020 130100 230110 130115 130117 230118 130120 130124 230125 130130 130140 130150 130160 130200 130210 130220 130300 130310 130320 130400 130410 130420 130430 130435 130450 130460 130462 130465 130520 130540 1





Appendix

HCPCS/CPT Code



30545 130560 130580 230600 130620 130630 130801 130802 130901 130903 130905 130906 130915 130920 130930 130999 131000 131002 131020 131030 131032 131040 131050 131051 131070 131075 131080 131081 131084 131085 131086 131087 131090 131200 131201 131205 131225 131230 131231 131233 131235 131237 131238 1





Appendix

HCPCS/CPT Code



31239 131240 131241 131253 131254 131255 131256 131257 131259 131267 131276 131287 131288 131290 131291 131292 131293 131294 131295 131296 131297 131298 131299 131300 131360 131365 131367 131368 131370 131375 131380 131382 131390 131395 131400 131420 131500 231502 131505 131510 131511 131512 131513 1





Appendix

HCPCS/CPT Code



31515 131520 131525 131526 131527 131528 131529 131530 131531 131535 131536 131540 131541 131545 131546 131551 131552 131553 131554 131560 131561 131570 131571 131572 131573 131574 131575 131576 131577 131578 131579 131580 131584 131587 131590 131591 131592 131599 131600 131601 131603 131605 131610 1





Appendix

HCPCS/CPT Code



31611 131612 131613 131614 131615 131622 131623 131624 131625 131626 131627 131628 131629 131630 131631 131632 231633 231634 131635 131636 131637 231638 131640 131641 131643 131645 131646 231647 131648 131649 231651 331652 131653 131654 131660 131661 131717 131720 331725 131730 131750 131755 131760 1





Appendix

HCPCS/CPT Code



31766 131770 231775 131780 131781 131785 131786 131800 131805 131820 131825 131830 131899 132035 132036 132096 132097 132098 132100 132110 132120 132124 132140 132141 132150 132151 132160 132200 232215 132220 132225 132310 132320 132400 232405 232440 132442 132445 132480 132482 132484 232486 132488 1





Appendix

HCPCS/CPT Code



32491 132501 132503 132504 132505 132506 332507 232540 132550 232551 232552 232553 132554 232555 232556 232557 232560 132561 132562 132601 132604 132606 132607 132608 132609 132650 132651 132652 132653 132654 132655 132656 132658 132659 132661 132662 132663 132664 132665 132666 132667 332668 232669 2





Appendix

HCPCS/CPT Code



32670 132671 132672 132673 132674 132701 132800 132810 132815 132820 132850 132851 132852 132853 132854 132855 132856 132900 132905 132906 132940 132960 132994 132997 132998 132999 133016 133017 133018 133019 133020 133025 133030 133031 133050 133120 133130 133140 133141 133202 133203 133206 133207 1





Appendix

HCPCS/CPT Code



33208 133210 133211 133212 133213 133214 133215 233216 133217 133218 133220 133221 133222 133223 133224 133225 133226 133227 133228 133229 133230 133231 133233 133234 133235 133236 133237 133238 133240 133241 133243 133244 133249 133250 133251 133254 133255 133256 133257 133258 133259 133261 133262 1





Appendix

HCPCS/CPT Code



33263 133264 133265 133266 133270 133271 133272 133273 133274 133275 133285 133286 133289 133300 133305 133310 133315 133320 133321 133322 133330 133335 133340 133361 133362 133363 133364 133365 133366 133367 133368 133369 133390 133391 133404 133405 133406 133410 133411 133412 133413 133414 133415 1





Appendix

HCPCS/CPT Code



33416 133417 133418 133419 133420 133422 133425 133426 133427 133430 133440 133460 133463 133464 133465 133468 133470 133471 133474 133475 133476 133477 133478 133496 133500 133501 133502 133503 133504 133505 133506 133507 133508 133510 133511 133512 133513 133514 133516 133517 133518 133519 133521 1





Appendix

HCPCS/CPT Code



33522 133523 133530 133533 133534 133535 133536 133542 133545 133548 133572 333600 133602 133606 133608 133610 133611 133612 133615 133617 133619 133620 133621 133622 133641 133645 133647 133660 133665 133670 133675 133676 133677 133681 133684 133688 133690 133692 133694 133697 133702 133710 133720 1





Appendix

HCPCS/CPT Code



33722 133724 133726 133730 133732 133735 133736 133737 133750 133755 133762 133764 133766 133767 133768 133770 133771 133774 133775 133776 133777 133778 133779 133780 133781 133782 133783 133786 133788 133800 133802 133803 133813 133814 133820 133822 133824 133840 133845 133851 133852 133853 133858 1





Appendix

HCPCS/CPT Code



33859 133863 133864 133866 133871 133875 133877 133880 133881 133883 133884 233886 133889 133891 133910 133915 133916 133917 133920 133922 133924 133925 133926 133927 133928 133929 133930 133933 133935 133940 133944 133945 133946 133947 133948 133949 133951 133952 133953 133954 133955 133956 133957 1





Appendix

HCPCS/CPT Code



33958 133959 133962 133963 133964 133965 133966 133967 133968 133969 133970 133971 133973 133974 133975 133976 133977 133978 133979 133980 133981 133982 133983 133984 133985 133986 133987 133988 133989 133990 133991 133992 133993 133999 134001 134051 134101 134111 234151 134201 134203 134401 134421 1





Appendix

HCPCS/CPT Code



34451 134471 134490 134501 134502 134510 234520 134530 134701 134702 134703 134704 134705 134706 134707 134708 134709 334710 134711 234712 134713 134714 134715 134716 134717 234718 234808 134812 134813 134820 134830 134831 134832 134833 134834 134839 134841 134842 134843 134844 134845 134846 134847 1





Appendix

HCPCS/CPT Code



34848 135001 135002 135005 135011 135013 135021 135022 135045 135081 135082 135091 135092 135102 135103 135111 135112 135121 135122 135131 135132 135141 135142 135151 135152 135180 235182 235184 235188 235189 135190 235201 235206 235207 335211 335216 235221 335226 335231 235236 235241 235246 235251 2





Appendix

HCPCS/CPT Code



35256 235261 135266 235271 235276 235281 235286 235301 235302 135303 135304 135305 135306 235311 135321 135331 135341 335351 135355 135361 135363 135371 135372 135390 135400 135500 235501 135506 135508 135509 135510 135511 135512 135515 135516 135518 135521 135522 135523 135525 135526 135531 135533 1





Appendix

HCPCS/CPT Code



35535 135536 135537 135538 135539 135540 135556 135558 135560 135563 135565 135566 135570 135571 135572 235583 135585 235587 135600 235601 135606 135612 135616 135621 135623 135626 335631 435632 135633 135634 135636 135637 135638 135642 135645 135646 135647 135650 135654 135656 135661 135663 135665 1





Appendix

HCPCS/CPT Code



35666 235671 235681 135682 135683 135685 235686 135691 135693 135694 135695 135697 235700 235701 135800 235820 235840 235860 235870 135875 235876 235879 235881 135883 135884 135901 135903 235905 135907 136000 436002 236005 236010 236011 436012 436013 236014 236015 436100 236140 336160 236200 236215 2





Appendix

HCPCS/CPT Code



36216 236217 236218 236221 136222 136223 136224 136225 136226 136227 136228 236245 336246 436247 236248 236251 136252 136253 136254 136260 136261 136262 136299 136400 136405 136406 136410 336415 236416 636420 236425 236430 136440 136450 136455 136456 136460 236465 136466 136468 236470 136471 136473 1





Appendix

HCPCS/CPT Code



36474 136475 136476 236478 136479 236481 136482 136483 236500 436510 136511 136512 136513 136514 136516 136522 136555 236556 236557 236558 236560 236561 236563 136565 136566 136568 236569 236570 236571 236572 136573 136575 236576 236578 236580 236581 236582 236583 236584 236585 236589 236590 236591 2





Appendix

HCPCS/CPT Code



36592 136593 236595 236596 236597 236598 236600 436620 336625 236640 136660 136680 136800 136810 136815 136818 136819 136820 136821 236823 136825 136830 236831 136832 236833 136835 136838 136860 236861 236901 136902 136903 136904 136905 136906 136907 136908 136909 137140 137145 137160 137180 137181 1





Appendix

HCPCS/CPT Code



37182 137183 137184 137185 237186 237187 137188 137191 137192 137193 137195 137197 237200 237211 137212 137213 137214 137215 137216 037217 137218 137220 137221 137222 237223 237224 137225 137226 137227 137228 137229 137230 137231 137232 237233 237234 237235 237236 137237 237238 137239 237241 237242 2





Appendix

HCPCS/CPT Code



37243 137244 237246 137247 237248 137249 337252 137253 537500 137501 137565 137600 137605 137606 137607 137609 137615 237616 137617 337618 237619 137650 137660 137700 137718 137722 137735 137760 137761 137765 137766 137780 137785 137788 137790 137799 138100 138101 138102 138115 138120 138129 138200 1





Appendix

HCPCS/CPT Code



38204 138205 138206 138207 138208 138209 138210 138211 138212 138213 138214 138215 138220 138221 138222 138230 138232 138240 138241 138242 138243 138300 138305 138308 138380 138381 138382 138500 238505 238510 138520 138525 138530 138531 138542 138550 138555 138562 138564 138570 138571 138572 138573 1





Appendix

HCPCS/CPT Code



38589 138700 138720 138724 138740 138745 138746 138747 138760 138765 138770 138780 138790 138792 138794 138900 138999 139000 139010 139200 139220 139401 139402 139499 139501 139503 139540 139541 139545 139560 139561 139599 140490 240500 240510 240520 240525 240527 240530 240650 240652 240654 240700 1





Appendix

HCPCS/CPT Code



40701 140702 140720 140761 140799 140800 240801 240804 140805 240806 240808 240810 240812 240814 440816 240818 240819 240820 240830 240831 240840 140842 140843 140844 140845 140899 141000 141005 141006 241007 241008 241009 241010 141015 241016 141017 241018 241019 141100 241105 241108 241110 241112 2





Appendix

HCPCS/CPT Code



41113 241114 241115 141116 241120 141130 141135 141140 141145 141150 141153 141155 141250 241251 241252 241510 141512 141520 141530 141599 141800 241805 141806 141820 441821 241822 141823 141825 241826 241827 241828 441830 241850 241870 241872 441874 441899 142000 142100 242104 242106 242107 242120 1





Appendix

HCPCS/CPT Code



42140 142145 142160 142180 142182 142200 142205 142210 142215 142220 142225 142226 142227 142235 142260 142280 142281 142299 142300 242305 242310 242320 242330 142335 242340 142400 242405 242408 142409 142410 142415 142420 142425 142426 142440 142450 142500 242505 242507 142509 142510 142550 242600 1





Appendix

HCPCS/CPT Code



42650 242660 242665 242699 142700 242720 142725 142800 342804 142806 142808 242809 142810 142815 142820 142821 142825 142826 142830 142831 142835 142836 142842 142844 142845 142860 142870 142890 142892 142894 142900 142950 142953 142955 142960 142961 142962 142970 142971 142972 142999 143020 143030 1





Appendix

HCPCS/CPT Code



43045 143100 143101 143107 143108 143112 143113 143116 143117 143118 143121 143122 143123 143124 143130 143135 143180 143191 143192 143193 143194 143195 143196 143197 143198 143200 143201 143202 143204 143205 143206 143210 143211 143212 143213 143214 143215 143216 143217 143220 143226 143227 143229 1





Appendix

HCPCS/CPT Code



43231 143232 143233 143235 143236 143237 143238 143239 143240 143241 143242 143243 143244 143245 143246 143247 143248 143249 143250 143251 143252 143253 143254 143255 243257 143259 143260 143261 143262 243263 143264 143265 143266 143270 143273 143274 243275 143276 243277 343278 143279 143280 143281 1





Appendix

HCPCS/CPT Code



43282 143283 143284 143285 143286 143287 143288 143289 143300 143305 143310 143312 143313 143314 143320 143325 143327 143328 143330 143331 143332 143333 143334 143335 143336 143337 143338 143340 143341 143351 143352 143360 143361 143400 143405 143410 143415 143420 143425 143450 143453 143460 143496 1





Appendix

HCPCS/CPT Code



43499 143500 143501 143502 143510 143520 143605 143610 243611 243620 143621 143622 143631 143632 143633 143634 143635 143640 143641 143644 143645 143647 143648 143651 143652 143653 143659 143752 243753 143754 143755 143756 143757 143761 243762 243763 243770 143771 143772 143773 143774 143775 143800 1





Appendix

HCPCS/CPT Code



43810 143820 143825 143830 143831 143832 143840 243842 043843 143845 143846 143847 143848 143850 143855 143860 143865 143870 143880 143881 143882 143886 143887 143888 143999 144005 144010 144015 144020 244021 144025 144050 144055 144100 144110 144111 144120 144121 244125 144126 144127 144128 244130 2





Appendix

HCPCS/CPT Code



44132 144133 144135 144136 144137 144139 144140 244141 144143 144144 144145 144146 144147 144150 144151 144155 144156 144157 144158 144160 144180 144186 144187 144188 144202 144203 244204 244205 144206 144207 144208 144210 144211 144212 144213 144227 144238 144300 144310 244312 144314 144316 144320 1





Appendix

HCPCS/CPT Code



44322 144340 144345 144346 144360 144361 144363 144364 144365 144366 144369 144370 144372 144373 144376 144377 144378 144379 144380 144381 144382 144384 144385 144386 144388 144389 144390 144391 144392 144394 144401 144402 144403 144404 144405 144406 144407 144408 144500 144602 144603 144604 144605 1





Appendix

HCPCS/CPT Code



44615 344620 244625 144626 144640 244650 244660 144661 144680 144700 144701 144705 144715 144720 244721 244799 144800 144820 144850 144899 144900 144950 144955 144960 144970 144979 145000 145005 145020 145100 245108 145110 145111 145112 145113 145114 145116 145119 145120 145121 145123 145126 145130 1





Appendix

HCPCS/CPT Code



45135 145136 145150 145160 145171 245172 245190 145300 145303 145305 145307 145308 145309 145315 145317 145320 145321 145327 145330 145331 145332 145333 145334 145335 145337 145338 145340 145341 145342 145346 145347 145349 145350 145378 145379 145380 145381 145382 145384 145385 145386 145388 145389 1





Appendix

HCPCS/CPT Code



45390 145391 145392 145393 145395 145397 145398 145399 145400 145402 145499 145500 145505 145520 145540 145541 145550 145560 145562 145563 145800 145805 145820 145825 145900 145905 145910 145915 145990 145999 146020 246030 146040 246045 246050 246060 246070 146080 146083 246200 146220 146221 146230 1





Appendix

HCPCS/CPT Code



46250 146255 146257 146258 146260 146261 146262 146270 146275 146280 146285 146288 146320 246500 146505 146600 146601 146604 146606 146607 146608 146610 146611 146612 146614 146615 146700 146705 146706 146707 146710 146712 146715 146716 146730 146735 146740 146742 146744 146746 146748 146750 146751 1





Appendix

HCPCS/CPT Code



46753 146754 146760 146761 146900 146910 146916 146917 146922 146924 146930 146940 146942 146945 146946 146947 146948 146999 147000 347001 347010 147015 147100 347120 247122 147125 147130 147133 147135 147140 147141 147142 147143 147144 147145 147146 247147 147300 247350 147360 147361 147362 147370 1





Appendix

HCPCS/CPT Code



47371 147379 147380 147381 147382 147383 147399 147400 147420 147425 147460 147480 147490 147531 247532 147533 147534 247535 147536 247537 147538 247539 247540 247541 147542 247543 147544 147550 147552 147553 147554 147555 147556 147562 147563 147564 147570 147579 147600 147605 147610 147612 147620 1





Appendix

HCPCS/CPT Code



47700 147701 147711 147712 147715 147720 147721 147740 147741 147760 147765 147780 147785 147800 147801 147802 147900 147999 148000 148001 148020 148100 148102 148105 148120 148140 148145 148146 148148 148150 148152 148153 148154 148155 148160 048400 148500 148510 148520 148540 148545 148547 148548 1





Appendix

HCPCS/CPT Code



48550 148551 148552 248554 148556 148999 149000 149002 149010 149020 249040 249060 249062 149082 149083 249084 149180 249185 249203 149204 149205 149215 149220 149250 149255 149320 149321 149322 149323 149324 149325 149326 149327 149329 149400 149402 149405 249406 249407 149411 149412 149418 149419 1





Appendix

HCPCS/CPT Code



49421 149422 149423 249424 349425 149426 149427 149428 149429 149435 149436 149440 149441 149442 149446 149450 149451 149452 149460 149465 149491 149492 149495 149496 149500 149501 149505 149507 149520 149521 149525 149540 149550 149553 149555 149557 149560 249561 149565 249566 249568 249570 149572 1





Appendix

HCPCS/CPT Code



49580 149582 149585 149587 149590 149600 149605 149606 149610 149611 149650 149651 149652 249653 249654 149655 149656 149657 149659 149900 149904 149905 149906 149999 150010 150020 150040 150045 150060 150065 150070 150075 150080 150081 150100 150120 150125 150130 150135 150200 150205 150220 150225 1





Appendix

HCPCS/CPT Code



50230 150234 150236 150240 150250 150280 150290 150300 150320 150323 150325 150327 250328 150329 150340 150360 150365 150370 150380 150382 150384 150385 150386 150387 150389 150390 250391 150396 150400 150405 150430 250431 250432 250433 250434 250435 250436 150437 150500 150520 150525 150526 150540 1





Appendix

HCPCS/CPT Code



50541 150542 150543 150544 150545 150546 150547 150548 150549 150551 150553 150555 150557 150561 150562 150570 150572 150574 150575 150576 150580 150590 150592 150593 150600 150605 150606 150610 150620 150630 150650 150660 150684 150686 250688 250690 250693 250694 250695 250700 150705 250706 250715 1





Appendix

HCPCS/CPT Code



50722 150725 150727 150728 150740 150750 150760 150770 150780 150782 150783 150785 150800 150810 150815 150820 150825 150830 150840 150845 150860 150900 150920 250930 250940 150945 150947 150948 150949 150951 150953 150955 150957 150961 150970 150972 150974 150976 150980 151020 151030 151040 151045 2





Appendix

HCPCS/CPT Code



51050 151060 151065 151080 151100 151101 151102 151500 151520 151525 151530 151535 151550 151555 151565 151570 151575 151580 151585 151590 151595 151596 151597 151600 151605 151610 151700 151701 251702 251703 251705 251710 151715 151720 151725 151726 151727 151728 151729 151736 151741 151784 151785 1





Appendix

HCPCS/CPT Code



51792 151797 151798 151800 151820 151840 151841 151845 151860 151865 151880 151900 151920 151925 151940 151960 151980 151990 151992 151999 152000 152001 152005 252007 152010 152204 152214 152224 152234 152235 152240 152250 152260 152265 152270 152275 152276 152277 152281 152282 152283 152285 152287 1





Appendix

HCPCS/CPT Code



52290 152300 152301 152305 152310 152315 252317 152318 152320 152325 152327 152330 152332 152334 152341 152342 152343 152344 152345 152346 152351 152352 152353 152354 152355 152356 152400 152402 152441 152442 652450 152500 152601 152630 152640 152647 152648 152649 152700 153000 153010 153020 153025 1





Appendix

HCPCS/CPT Code



53040 153060 153080 153085 153200 153210 153215 153220 153230 153235 153240 153250 153260 153265 153270 153275 153400 153405 153410 153415 153420 153425 153430 153431 153440 153442 153444 153445 153446 153447 153448 153449 153450 153460 153500 153502 153505 153510 153515 153520 153600 153601 153605 1





Appendix

HCPCS/CPT Code



53620 153621 153660 153661 153665 153850 153852 153854 153855 153860 153899 154000 154001 154015 154050 154055 154056 154057 154060 154065 154100 254105 254110 154111 154112 154115 154120 154125 154130 154135 154150 154160 154161 154162 154163 154164 154200 154205 154220 154230 154231 154235 154240 1





Appendix

HCPCS/CPT Code



54250 154300 154304 154308 154312 154316 154318 154322 154324 154326 154328 154332 154336 154340 154344 154348 154352 154360 154380 154385 154390 154400 154401 154405 154406 154408 154410 154411 154415 154416 154417 154420 154430 154435 154437 154438 154440 154450 154500 154505 154512 154520 154522 1





Appendix

HCPCS/CPT Code



54530 154535 154550 154560 154600 154620 154640 154650 154660 154670 154680 154690 154692 154699 154700 154800 154830 154840 154860 154861 154865 154900 154901 155000 155040 155041 155060 155100 255110 155120 155150 155175 155180 155200 155250 155300 155400 155500 155520 155530 155535 155540 155550 1





Appendix

HCPCS/CPT Code



55559 155600 155605 155650 155680 155700 155705 155706 155720 155725 155801 155810 155812 155815 155821 155831 155840 155842 155845 155860 155862 155865 155866 155870 155873 155874 155875 155876 155899 155920 155970 155980 156405 256420 156440 156441 156442 156501 156515 156605 156606 656620 156625 1





Appendix

HCPCS/CPT Code



56630 156631 156632 156633 156634 156637 156640 156700 156740 156800 156805 156810 156820 156821 157000 157010 157020 157022 157023 157061 157065 157100 257105 257106 157107 157109 157110 157111 157112 157120 157130 157135 257150 157155 157156 157160 157170 157180 157200 157210 157220 157230 157240 1





Appendix

HCPCS/CPT Code



57250 157260 157265 157267 257268 157270 157280 157282 157283 157284 157285 157287 157288 157289 157291 157292 157295 157296 157300 157305 157307 157308 157310 157311 157320 157330 157335 157400 157410 157415 157420 157421 157423 157425 157426 157452 157454 157455 157456 157460 157461 157500 157505 1





Appendix

HCPCS/CPT Code



57510 157511 157513 157520 157522 157530 157531 157540 157545 157550 157555 157556 157558 157700 157720 157800 158100 158110 158120 158140 158145 158146 158150 158152 158180 158200 158210 158240 158260 158262 158263 158267 158270 158275 158280 158285 158290 158291 158292 158293 158294 158300 058301 1





Appendix

HCPCS/CPT Code



58321 158322 158323 158340 158345 158346 158350 158353 158356 158400 158410 158520 158540 158541 158542 158543 158544 158545 158546 158548 158550 158552 158553 158554 158555 158558 158559 158560 158561 158562 158563 158565 158570 158571 158572 158573 158575 158578 158579 158600 158605 158611 158615 1





Appendix

HCPCS/CPT Code



58660 158661 158662 158670 158671 158672 158673 158674 158679 158700 158720 158740 158750 158752 158760 158770 158800 158805 158820 158822 158825 158900 158920 158925 158940 158943 158950 158951 158952 158953 158954 158956 158957 158958 158960 158970 158974 158976 258999 159000 259001 259012 259015 2





Appendix

HCPCS/CPT Code



59020 259025 259030 259050 259051 259070 259072 259074 259076 259100 159120 159121 159130 159135 159136 159140 159150 159151 159160 159200 159300 159320 159325 159350 159400 159409 259410 159412 159414 159425 159426 159430 159510 159514 159515 159525 159610 159612 259614 159618 159620 159622 159812 1





Appendix

HCPCS/CPT Code



59820 159821 159830 159840 159841 159850 159851 159852 159855 159856 159857 159866 159870 159871 159897 159898 159899 160000 160100 360200 260210 160212 160220 160225 160240 160252 160254 160260 160270 160271 160280 160281 160300 260500 160502 160505 160512 160520 160521 160522 160540 160545 160600 1





Appendix

HCPCS/CPT Code



60605 160650 160659 160699 161000 161001 161020 261026 261050 161055 161070 261105 161107 161108 161120 161140 161150 161151 161154 161156 161210 161215 161250 161253 161304 161305 161312 261313 261314 261315 161316 161320 261321 161322 161323 161330 161333 161340 161343 161345 161450 161458 161460 1





Appendix

HCPCS/CPT Code



61500 161501 161510 161512 161514 261516 161517 161518 161519 161520 161521 161522 161524 261526 161530 161531 161533 261534 161535 261536 161537 161538 161539 161540 161541 161543 161544 161545 161546 161548 161550 161552 161556 161557 161558 161559 161563 261564 161566 161567 161570 161571 161575 1





Appendix

HCPCS/CPT Code



61576 161580 161581 161582 161583 161584 161585 161586 161590 161591 161592 161595 161596 161597 161598 161600 161601 161605 161606 161607 161608 161611 161613 161615 161616 161618 261619 261623 261624 261626 261630 161635 261640 061641 061642 061645 161650 161651 261680 161682 161684 161686 161690 1





Appendix

HCPCS/CPT Code



61692 161697 261698 161700 261702 161703 161705 161708 161710 161711 161720 161735 161750 261751 261760 161770 161781 161782 161783 161790 161791 161796 161797 461798 161799 461800 161850 161860 161863 161864 161867 161868 261870 161880 161885 161886 161888 162000 162005 162010 162100 162115 162117 1





Appendix

HCPCS/CPT Code



62120 162121 162140 162141 162142 262143 262145 262146 262147 162148 162160 162161 162162 162163 162164 162165 162180 162190 162192 162194 162200 162201 162220 162223 162225 262230 262252 262256 162258 162263 162264 162267 262268 162269 262270 262272 262273 262280 162281 162282 162284 162287 162290 5





Appendix

HCPCS/CPT Code



62291 462292 162294 162302 162303 162304 162305 162320 162321 162322 162323 162324 162325 162326 162327 162328 262329 162350 162351 162355 162360 162361 162362 162365 162367 162368 162369 162370 162380 263001 163003 163005 163011 163012 163015 163016 163017 163020 163030 163035 463040 163042 163043 4





Appendix

HCPCS/CPT Code



63044 463045 163046 163047 163048 563050 163051 163055 163056 163057 363064 163066 163075 163076 363077 163078 363081 163082 663085 163086 263087 163088 363090 163091 363101 163102 163103 363170 163172 163173 163180 163182 163185 163190 163191 163194 163195 163196 163197 163198 163199 163200 163250 1





Appendix

HCPCS/CPT Code



63251 163252 163265 163266 163267 163268 163270 163271 163272 163273 163275 163276 163277 163278 163280 163281 163282 163283 163285 163286 163287 163290 163295 163300 163301 163302 163303 163304 163305 163306 163307 163308 363600 263610 163620 163621 263650 263655 163661 163662 163663 163664 163685 1





Appendix

HCPCS/CPT Code



63688 163700 163702 163704 163706 163707 163709 163710 163740 163741 163744 163746 164400 464405 164408 164415 164416 164417 164418 164420 264421 364425 164430 164435 164445 164446 164447 164448 164449 164450 1064451 264454 264455 164461 164462 164463 164479 164480 464483 164484 464486 164487 164488 1





Appendix

HCPCS/CPT Code



64489 164490 164491 164492 164493 164494 164495 164505 164510 164517 164520 164530 164553 164555 264561 164566 164568 164569 164570 164575 264580 264581 264585 264590 164595 164600 264605 164610 164611 164612 164615 164616 164617 164620 564624 264625 264630 164632 164633 164634 464635 164636 464640 5





Appendix

HCPCS/CPT Code



64642 164643 364644 164645 364646 164647 164650 164653 164680 164681 164702 264704 464708 364712 164713 164714 164716 264718 164719 164721 164722 464726 264727 264732 164734 164736 164738 164740 164742 164744 164746 164755 164760 164763 164766 164771 264772 264774 264776 164778 164782 264783 264784 3





Appendix

HCPCS/CPT Code



64786 164787 464788 564790 164792 264795 264802 164804 164809 164818 164820 464821 164822 164823 164831 164832 364834 164835 164836 164837 264840 164856 264857 264858 164859 264861 164862 164864 264865 164866 164868 164872 164874 164876 164885 164886 164890 264891 264892 264893 264895 264896 264897 2





Appendix

HCPCS/CPT Code



64898 264901 264902 164905 164907 164910 364911 264912 364913 364999 165091 165093 165101 165103 165105 165110 165112 165114 165125 165130 165135 165140 165150 165155 165175 165205 165210 165220 165222 165235 165260 165265 165270 165272 165273 165275 165280 165285 165286 165290 165400 165410 165420 1





Appendix

HCPCS/CPT Code



65426 165430 165435 165436 165450 165600 165710 165730 165750 165755 165756 165757 165760 065765 065767 065770 165771 065772 165775 165778 165779 165780 165781 165782 165785 165800 165810 165815 165820 165850 165855 165860 165865 165870 165875 165880 165900 165920 165930 166020 166030 166130 166150 1





Appendix

HCPCS/CPT Code



66155 166160 166170 166172 166174 166175 166179 166180 166183 166184 166185 166225 166250 166500 166505 166600 166605 166625 166630 166635 166680 166682 166700 166710 166711 166720 166740 166761 166762 166770 166820 166821 166825 166830 166840 166850 166852 166920 166930 166940 166982 166983 166984 1





Appendix

HCPCS/CPT Code



66985 166986 166987 266988 266990 166999 167005 167010 167015 167025 167027 167028 167030 167031 167036 167039 167040 167041 167042 167043 167101 167105 167107 167108 167110 167113 167115 167120 167121 167141 167145 167208 167210 167218 167220 167221 167225 167227 167228 167229 167250 167255 167299 1





Appendix

HCPCS/CPT Code



67311 167312 167314 167316 167318 167320 267331 167332 167334 167335 167340 267343 167345 167346 167399 167400 167405 167412 167413 167414 167415 167420 167430 167440 167445 167450 167500 167505 167515 167550 167560 167570 167599 167700 267710 167715 167800 167801 167805 167808 167810 267820 167825 1





Appendix

HCPCS/CPT Code



67830 167835 167840 367850 367875 167880 167882 167900 167901 167902 167903 167904 167906 167908 167909 167911 267912 167914 267915 267916 267917 267921 267922 267923 267924 267930 267935 267938 267950 267961 267966 267971 167973 167974 167975 167999 168020 168040 168100 168110 168115 168130 168135 1





Appendix

HCPCS/CPT Code



68200 168320 168325 168326 168328 168330 168335 168340 168360 168362 168371 168399 168400 168420 168440 268500 168505 168510 168520 168525 168530 168540 168550 168700 168705 268720 168745 168750 168760 468761 468770 168801 468810 168811 168815 168816 168840 168850 168899 169000 169005 169020 169090 0





Appendix

HCPCS/CPT Code



69100 369105 169110 169120 169140 169145 169150 169155 169200 169205 169209 169210 169220 169222 169300 169310 169320 169399 169420 169421 169424 169433 169436 169440 169450 169501 169502 169505 169511 169530 169535 169540 169550 169552 169554 169601 169602 169603 169604 169605 169610 169620 169631 1





Appendix

HCPCS/CPT Code



69632 169633 169635 169636 169637 169641 169642 169643 169644 169645 169646 169650 169660 169661 169662 169666 169667 169670 169676 169700 169710 069711 169714 169715 169717 169718 169720 169725 169740 169745 169799 169801 169805 169806 169905 169910 169915 169930 169949 169950 169955 169960 169970 1





Appendix

HCPCS/CPT Code



69979 169990 170010 170015 170030 270100 270110 270120 170130 170134 170140 270150 170160 170170 270190 170200 270210 170220 170240 170250 270260 170300 170310 170320 170328 170330 170332 270336 170350 170355 170360 270370 170371 170380 270390 270450 370460 170470 270480 170481 170482 170486 170487 1





Appendix

HCPCS/CPT Code



70488 170490 170491 170492 170496 270498 270540 170542 170543 170544 270545 170546 170547 170548 170549 170551 270552 270553 270554 170555 170557 170558 170559 171045 471046 371047 271048 171100 271101 271110 171111 171120 171130 171250 271260 271270 171275 171550 171551 171552 171555 172020 472040 3





Appendix

HCPCS/CPT Code



72050 172052 172070 172072 172074 172080 172081 172082 172083 172084 172100 272110 172114 172120 172125 172126 172127 172128 172129 172130 172131 172132 172133 172141 172142 172146 172147 172148 172149 172156 172157 172158 172159 172170 272190 172191 172192 172193 172194 172195 172196 172197 172198 1





Appendix

HCPCS/CPT Code



72200 272202 172220 172240 172255 172265 172270 172275 172285 472295 573000 273010 273020 273030 473040 273050 173060 273070 273080 273085 273090 273092 273100 273110 373115 273120 273130 373140 373200 273201 273202 273206 273218 273219 273220 273221 273222 273223 273225 273501 273502 273503 273521 2





Appendix

HCPCS/CPT Code



73522 273523 273525 273551 273552 273560 473562 373564 473565 173580 273590 373592 273600 273610 373615 273620 273630 373650 273660 273700 273701 273702 273706 273718 273719 273720 273721 373722 273723 273725 274018 374019 274021 274022 274150 174160 174170 174174 174175 174176 274177 274178 174181 1





Appendix

HCPCS/CPT Code



74182 174183 174185 174190 174210 174220 174230 174235 174240 274246 174248 174250 174251 174261 174262 174263 074270 174280 174283 174290 174300 174301 174328 174329 174330 174340 174355 174360 174363 274400 174410 174415 174420 274425 274430 174440 174445 174450 174455 174470 274485 274710 174712 1





Appendix

HCPCS/CPT Code



74713 274740 174742 274775 175557 175559 175561 175563 175565 175571 175572 175573 175574 175600 175605 175625 175630 175635 175705 2075710 275716 175726 375731 175733 175736 275741 175743 175746 175756 275774 775801 175803 175805 175807 175809 175810 175820 275822 175825 175827 175831 175833 175840 1





Appendix

HCPCS/CPT Code



75842 175860 275870 175872 175880 175885 175887 175889 175891 175893 275894 275898 275901 175902 275956 175957 175958 275959 175970 175984 275989 276000 376010 276080 376098 376100 276101 176102 176120 176125 176140 076376 276377 276380 276390 176391 176496 176497 176498 176499 176506 176510 276511 2





Appendix

HCPCS/CPT Code



76512 276513 276514 176516 176519 176529 276536 176604 176641 276642 276700 176705 276706 176770 176775 276776 276800 176801 176802 276805 176810 276811 176812 276813 176814 276815 176816 276817 176818 276819 276820 376821 276825 276826 276827 276828 276830 176831 176856 176857 176870 176872 176873 1





Appendix

HCPCS/CPT Code



76881 276882 276885 176886 176932 176936 176937 276940 176941 376942 176945 176946 176948 176965 276970 276975 176977 176978 176979 376981 176982 176983 276998 176999 177001 277002 177003 177011 177012 177013 177014 277021 177022 177046 177047 177048 177049 177053 277054 277061 177062 177063 177065 1





Appendix

HCPCS/CPT Code



77066 177067 177071 177072 177073 177074 177075 177076 177077 177078 177080 177081 177084 177085 177086 177261 177262 177263 177280 277285 177290 177293 177295 177299 177300 1077301 177306 177307 177316 177317 177318 177321 177331 377332 477333 277334 1077336 177338 177370 177371 177372 177373 177385 2





Appendix

HCPCS/CPT Code



77386 277387 277399 177401 177402 277407 277412 277417 177423 177424 177425 177427 177431 177432 177435 177469 177470 177499 177520 277522 277523 277525 277600 177605 177610 177615 177620 177750 177761 177762 177763 177767 277768 277770 277771 277772 277778 177789 277790 177799 178012 178013 178014 1





Appendix

HCPCS/CPT Code



78015 178016 178018 178020 178070 178071 178072 178075 178099 178102 178103 178104 178110 178111 178120 178121 178122 178130 178135 178140 178185 178191 178195 178199 178201 178202 178215 178216 178226 178227 178230 178231 178232 178258 178261 178262 178264 178265 178266 178267 178268 178278 278282 1





Appendix

HCPCS/CPT Code



78290 178291 178299 178300 178305 178306 178315 178350 078351 078399 178414 178428 178429 178430 178431 178432 178433 178434 178445 178451 178452 178453 178454 178456 178457 178458 178459 178466 178468 178469 178472 178473 178481 178483 178491 178492 178494 178496 178499 178579 178580 178582 178597 1





Appendix

HCPCS/CPT Code



78598 178599 178600 178601 178605 178606 178608 178609 078610 178630 178635 178645 178650 178660 178699 178700 178701 178707 178708 178709 178725 178730 178740 178761 178799 178800 178801 178802 178803 178804 178808 178811 178812 178813 178814 178815 178816 178830 178831 178832 178999 179005 179101 1





Appendix

HCPCS/CPT Code



79200 179300 179403 179440 179445 179999 180047 280048 280050 180051 480053 180055 180061 180069 180074 180076 180081 180145 180150 280155 180156 280157 280158 280159 280162 280163 180164 280165 180168 280169 280170 280171 180173 280175 180176 180177 180178 280180 180183 180184 280185 280186 280187 1





Appendix

HCPCS/CPT Code



80188 280190 280192 280194 280195 280197 280198 280199 180200 280201 280202 280203 180230 180235 180280 180299 380305 180306 180307 180320 280321 180322 180323 180324 180325 180326 180327 180328 180329 280330 180331 180332 180333 180334 180335 180336 180337 180338 180339 280340 180341 180342 180343 1





Appendix

HCPCS/CPT Code



80344 180345 280346 180347 180348 180349 180350 180351 180352 180353 180354 180355 180356 180357 180358 180359 180360 180361 280362 180363 180364 180365 280366 180367 180368 180369 180370 180371 180372 180373 180374 180375 180376 180377 180400 180402 180406 180408 180410 180412 180414 180415 180416 1





Appendix

HCPCS/CPT Code



80417 180418 180420 180422 180424 180426 180428 180430 180432 180434 180435 180436 180438 180439 180500 180502 181000 281001 281002 281003 281005 281007 181015 281020 181025 181050 281099 181105 181106 181107 181108 181109 181110 181111 181112 181120 181121 181161 181162 181163 181164 181165 181166 1





Appendix

HCPCS/CPT Code



81167 181170 181171 181172 181173 181174 181175 181176 181177 181178 181179 181180 181181 181182 181183 181184 181185 181186 181187 181188 181189 181190 181200 181201 181202 181203 181204 181205 181206 181207 181208 181209 181210 181212 181215 181216 181217 181218 181219 181220 181221 181222 181223 1





Appendix

HCPCS/CPT Code



81224 181225 181226 181227 181228 181229 181230 181231 181232 181233 181234 181235 181236 181237 181238 181239 181240 181241 181242 181243 181244 181245 181246 181247 181248 181249 181250 181251 181252 181253 181254 181255 181256 181257 181258 181259 181260 181261 181262 181263 181264 181265 181266 2





Appendix

HCPCS/CPT Code



81267 181268 481269 181270 181271 181272 181273 181274 181275 181276 181277 181283 181284 181285 181286 181287 181288 181289 181290 181291 181292 181293 181294 181295 181296 181297 181298 181299 181300 181301 181302 181303 181304 181305 181306 181310 181311 181312 181313 181314 181315 181316 181317 1





Appendix

HCPCS/CPT Code



81318 181319 181320 181321 181322 181323 181324 181325 181326 181327 181328 181329 181330 181331 181332 181333 181334 181335 181336 181337 181340 181341 181342 181343 181344 181345 181346 181350 181355 181361 181362 181363 181364 181370 181371 181372 181373 281374 181375 181376 581377 281378 181379 1





Appendix

HCPCS/CPT Code



81380 281381 381382 681383 281400 281401 381402 181403 381404 381405 281406 381407 181408 181410 181411 181412 181413 181414 181415 181416 281417 181420 181422 181425 181426 281427 181430 181431 181432 181433 181434 181435 181436 181437 181438 181439 181440 181442 181443 181445 181448 181450 181455 1





Appendix

HCPCS/CPT Code



81460 181465 181470 181471 181479 381490 181493 181500 181503 181504 181506 181507 181508 181509 181510 181511 181512 181518 181519 181520 181521 181522 181525 181528 181535 181536 1181538 181539 181540 181541 181542 181545 181551 181595 181596 181599 182009 382010 382013 182016 182017 182024 482030 1





Appendix

HCPCS/CPT Code



82040 182042 282043 182044 182045 182075 282085 182088 282103 182104 182105 182106 282107 182108 182120 182127 182128 282131 282135 182136 282139 282140 282143 282150 482154 182157 182160 182163 182164 182172 282175 282180 182190 282232 282239 182240 182247 282248 282252 182261 182270 182271 382272 1





Appendix

HCPCS/CPT Code



82274 182286 182300 182306 182308 182310 482330 482331 182340 182355 282360 282365 282370 282373 182374 282375 482376 282378 182379 182380 182382 182383 182384 282387 182390 182397 482415 182435 282436 182438 182441 182465 182480 282482 182485 182495 182507 182523 182525 282528 182530 482533 582540 1





Appendix

HCPCS/CPT Code



82542 682550 382552 382553 382554 282565 282570 382575 182585 182595 182600 182607 182608 182610 182615 182626 182627 182633 182634 182638 182642 182652 182656 182657 282658 282664 282668 182670 282671 182672 182677 182679 182693 282696 182705 182710 182715 382725 182726 182728 182731 182735 182746 1





Appendix

HCPCS/CPT Code



82747 182757 182759 182760 182775 182776 182777 182784 682785 182787 482800 282805 382810 482820 182930 182938 182941 182943 182945 482946 182947 582950 382951 182952 382955 182960 182963 182965 182977 182978 182979 182985 183001 183002 183003 583006 183009 183010 183012 183013 183014 183015 183018 4





Appendix

HCPCS/CPT Code



83020 283021 283026 183030 183033 183036 183037 183045 183050 283051 183060 183065 183068 183069 183070 183080 283088 183090 283150 183491 183497 183498 283500 183505 183516 583518 183519 583520 883525 483527 183528 183540 283550 183570 183582 183586 183593 183605 283615 383625 183630 183631 183632 1





Appendix

HCPCS/CPT Code



83633 183655 283661 383662 483663 383664 383670 183690 283695 183698 183700 183701 183704 183718 183719 183721 183722 183727 183735 483775 183785 183789 483825 283835 283857 183861 283864 183872 283873 183874 483876 183880 183883 483885 283915 183916 283918 283919 183921 283930 283935 283937 183945 2





Appendix

HCPCS/CPT Code



83950 183951 183970 483986 283987 183992 283993 184030 184035 184060 184066 184075 284078 184080 184081 184085 184087 184100 284105 184106 184110 184112 184119 184120 184126 184132 384133 284134 184135 184138 184140 184143 284144 184145 184146 384150 284152 184153 184154 184155 184156 184157 284160 2





Appendix

HCPCS/CPT Code



84163 184165 184166 284181 384182 684202 184203 184206 184207 184210 184220 184228 184233 184234 184235 184238 384244 284252 184255 284260 184270 184275 184285 184295 284300 284302 184305 184307 184311 284315 184375 184376 184377 184378 284379 184392 184402 184403 284410 184425 184430 184431 184432 1





Appendix

HCPCS/CPT Code



84436 184437 184439 184442 184443 484445 184446 184449 184450 184460 184466 184478 184479 184480 184481 184482 184484 484485 184488 184490 184510 184512 384520 284525 184540 284545 184550 184560 284577 184578 184580 184583 184585 184586 184588 184590 184591 184597 184600 284620 184630 284681 184702 2





Appendix

HCPCS/CPT Code



84703 184704 184830 184999 185002 185004 285007 185008 185009 185013 185014 485018 485025 485027 485032 285041 185044 185045 185046 185048 285049 285055 185060 185097 285130 185170 185175 185210 285220 285230 285240 285244 185245 285246 285247 285250 285260 285270 285280 285290 285291 185292 185293 1





Appendix

HCPCS/CPT Code



85300 285301 185302 185303 285305 285306 285307 285335 285337 185345 185347 985348 485360 185362 285366 185370 185378 285379 285380 285384 285385 185390 385396 185397 285400 185410 185415 285420 285421 185441 185445 185460 185461 185475 185520 385525 285530 185536 185540 185547 185549 185555 185557 1





Appendix

HCPCS/CPT Code



85576 785597 185598 185610 485611 285612 185613 385635 185651 185652 185660 285670 285675 185705 185730 485732 485810 285999 186000 686001 2086005 686008 2086021 186022 186023 386038 186039 186060 186063 186077 186078 186079 186140 186141 186146 386147 486148 386152 186153 186155 186156 186157 186160 4





Appendix

HCPCS/CPT Code



86161 286162 186171 286200 186215 186225 186226 186235 1086255 586256 986277 186280 186294 186300 286301 186304 186305 186308 186309 186310 186316 286317 686318 286320 186325 286327 186329 386331 1286332 186334 286335 286336 186337 186340 186341 186343 186344 186352 186353 786355 186356 786357 186359 1





Appendix

HCPCS/CPT Code



86360 186361 186367 286376 286382 386384 186386 186403 386406 286430 286431 286480 186481 186485 186486 286490 186510 186580 186590 186592 286593 286602 386603 286609 1486611 486612 286615 686617 286618 286619 286622 286625 186628 386631 686632 386635 486638 686641 286644 286645 186648 286651 286652 2





Appendix

HCPCS/CPT Code



86653 286654 286658 1286663 286664 286665 286666 486668 286671 386674 386677 386682 286684 286687 186688 186689 286692 286694 286695 286696 286698 386701 186702 286703 186704 186705 186706 286707 186708 186709 186710 486711 286713 386717 886720 286723 286727 286732 286735 286738 286741 286744 286747 2





Appendix

HCPCS/CPT Code



86750 486753 386756 286757 686759 286762 286765 286768 586771 286774 286777 286778 286780 286784 186787 286788 286789 286790 486793 286794 186800 186803 186804 186805 1286806 286807 286808 186812 186813 186816 186817 186821 186825 186826 886828 286829 286830 286831 286832 286833 186834 186835 186849 1





Appendix

HCPCS/CPT Code



86850 386860 286870 686880 486885 386886 386890 286891 286900 386901 386902 4086905 2886906 186910 086911 086920 1986922 1086923 1086930 386931 486940 386941 386945 586950 186960 386965 486971 686972 286975 286976 286977 286999 187003 187015 387045 387046 687071 287073 287075 687076 487077 687081 487084 1





Appendix

HCPCS/CPT Code



87086 387088 387101 387102 487103 287106 487107 487109 287110 287118 387140 387143 287149 1187150 1287152 187153 387164 287166 287168 287169 287172 187176 387177 387181 1287184 887185 487186 1287187 387188 1487190 1087197 187206 687207 387209 487210 487220 387230 287250 187252 487253 387254 1087255 287260 1





Appendix

HCPCS/CPT Code



87265 187267 187269 187270 187271 187272 187273 187274 187275 187276 187278 187279 187280 187281 187283 187285 187290 187299 187300 287301 187305 187320 187324 287327 187328 287329 287332 187335 187336 187337 187338 187339 187340 187341 187350 187380 187385 287389 187390 187391 187400 287420 187425 1





Appendix

HCPCS/CPT Code



87427 287430 187449 387450 287451 287471 187472 187475 187476 187480 187481 687482 187483 187485 187486 187487 187490 187491 387492 187493 287495 187496 187497 287498 187500 187501 187502 187503 187505 187506 187507 187510 187511 187512 187516 187517 187520 187521 187522 187525 187526 187527 187528 1





Appendix

HCPCS/CPT Code



87529 287530 287531 187532 187533 187534 187535 187536 187537 187538 187539 187540 187541 187542 187550 187551 287552 187555 187556 187557 187560 187561 187562 187563 387580 187581 187582 187590 187591 387592 187623 187624 187625 187631 187632 187633 187634 187640 187641 187650 187651 187652 187653 1





Appendix

HCPCS/CPT Code



87660 187661 187662 287797 387798 2187799 387800 287801 387802 287803 387804 387806 187807 287808 187809 287810 287850 187880 287899 687900 187901 187902 187903 187904 1487905 287906 287910 187912 187999 188000 188005 188007 188012 088014 088016 088020 188025 188027 188028 088029 088036 188037 188040 1





Appendix

HCPCS/CPT Code



88045 188099 088104 588106 588108 688112 688120 288121 288125 188130 188140 188141 188142 188143 188147 188148 188150 188152 188153 188155 188160 488161 488162 388164 188165 188166 188167 188172 788173 788174 188175 188177 688182 288184 288185 3588187 288188 288189 288199 188230 288233 288235 288237 4





Appendix

HCPCS/CPT Code



88239 388240 388241 388245 188248 188249 188261 288262 288263 188264 188267 288269 288271 1688272 1288273 388274 588275 1288280 188283 588285 1088289 188291 088299 188300 488302 488304 588305 1688307 888309 388311 488312 988313 888314 688319 1188321 188323 188325 188329 288331 1188332 1388333 488334 588341 13





Appendix

HCPCS/CPT Code



88342 388344 688346 288348 188350 888355 188356 388358 288360 688361 688362 188363 288364 388365 488366 288367 388368 388369 388371 188372 188373 388374 588375 188377 588380 188381 188387 288388 188399 188720 188738 188740 188741 188749 189049 189050 289051 289055 289060 289125 289160 189190 189220 2





Appendix

HCPCS/CPT Code



89230 189240 189250 189251 189253 189254 189255 189257 189258 189259 189260 189261 189264 189268 189272 189280 189281 189290 189291 189300 189310 189320 189321 189322 189325 189329 189330 189331 189335 189337 189342 189343 189344 189346 189352 189353 189354 189356 289398 190281 090283 090284 190287 0





Appendix

HCPCS/CPT Code



90288 090291 090296 190371 1090375 2090376 2090378 490384 090385 190386 090389 190393 190396 190399 190460 990461 890471 190472 890473 190474 190476 190477 190581 190585 190586 190587 190619 190620 190621 190625 190630 190632 190633 190634 190636 190644 190647 190648 190649 190650 190651 190653 190654 1





Appendix

HCPCS/CPT Code



90655 190656 190657 190658 190660 190661 190662 190664 190666 190667 190668 190670 190672 190673 190674 190675 190676 190680 190681 190682 190685 190686 190687 190688 190689 190690 190691 190696 190697 190698 190700 190702 190707 190710 190713 190714 190715 190716 190717 190723 090732 190733 190734 1





Appendix

HCPCS/CPT Code



90736 190738 190739 190740 190743 190744 190746 190747 190748 090749 190750 190756 190785 390791 190792 290832 390833 390834 390836 390837 390838 390839 190840 490845 190846 290847 290849 290853 490863 190865 190867 190868 190869 190870 290875 190876 190880 190882 090885 190887 190889 190899 190901 1





Appendix

HCPCS/CPT Code



90912 190913 390935 190937 190940 190945 190947 190951 190952 190953 190954 190955 190956 190957 190958 190959 190960 190961 190962 190963 190964 190965 190966 190967 190968 190969 190970 190989 190993 190997 190999 191010 191013 191020 191022 191030 191034 191035 191037 191038 191040 191065 291110 1





Appendix

HCPCS/CPT Code



91111 191112 191117 191120 191122 191132 191133 191200 191299 192002 192004 192012 192014 192015 192018 192019 192020 192025 192060 192065 192071 292072 192081 192082 192083 192100 192132 192133 192134 192136 192145 192201 192202 192227 192228 192230 292235 192240 192242 192250 192260 192265 192270 1





Appendix

HCPCS/CPT Code



92273 192274 192283 192284 192285 192286 192287 192310 192311 192312 192313 192314 192315 192316 192317 192325 192326 292340 192341 192342 192352 192353 192354 192355 192358 192370 192371 192499 192502 192504 192507 192508 192511 192512 192516 192520 192521 192522 192523 192524 192526 192531 192532 1





Appendix

HCPCS/CPT Code



92533 492534 192537 192538 192540 192541 192542 192544 192545 192546 192547 192548 192549 192550 192551 192552 192553 192555 192556 192557 192558 092559 092560 192561 192562 192563 192564 192565 192567 192568 192570 192571 192572 192575 192576 192577 192579 192582 192583 192584 192585 192586 192587 1





Appendix

HCPCS/CPT Code



92588 192590 192591 192592 192593 192594 192595 192596 192597 192601 192602 192603 192604 192605 192606 192607 192608 492609 192610 192611 192612 192613 192614 192615 192616 192617 192618 192620 192621 492625 192626 192627 692630 092633 092640 192700 192920 392921 692924 292925 692928 392929 692933 2





Appendix

HCPCS/CPT Code



92934 692937 292938 692941 192943 292944 392950 292953 292960 292961 192970 192971 192973 292974 192975 192977 192978 192979 292986 192987 192990 192992 192993 192997 192998 293000 393005 593010 593015 193016 193017 193018 193024 193025 193040 393041 393042 393050 193224 193225 193226 193227 193228 1





Appendix

HCPCS/CPT Code



93229 193260 193261 193264 193268 193270 193271 193272 193278 193279 193280 193281 193282 193283 193284 193285 193286 293287 293288 193289 193290 193291 193292 193293 193294 193295 193296 193297 193298 193303 193304 193306 193307 193308 193312 193313 193314 193315 193316 193317 193318 193320 193321 1





Appendix

HCPCS/CPT Code



93325 193350 193351 193352 193355 193356 193451 193452 193453 193454 193455 193456 193457 193458 193459 193460 193461 193462 193463 193464 193503 293505 193530 193531 193532 193533 193561 193562 193563 193564 193565 193566 193567 193568 193571 193572 293580 193581 193582 193583 193590 193591 193592 2





Appendix

HCPCS/CPT Code



93600 193602 193603 193609 193610 193612 193613 193615 193616 193618 193619 193620 193621 193622 193623 193624 193631 193640 193641 193642 193644 193650 193653 193654 193655 293656 193657 293660 193662 193668 193701 193702 193724 193740 193745 193750 193770 193784 193786 193788 193790 193792 193793 1





Appendix

HCPCS/CPT Code



93797 293798 293799 193880 193882 193886 193888 193890 193892 193893 193895 193922 293923 293924 193925 193926 193930 193931 193970 193971 193975 193976 193978 193979 193980 193981 193990 293998 194002 194003 194004 194005 194010 194011 194012 194013 194014 194015 194016 194060 194070 194150 294200 1





Appendix

HCPCS/CPT Code



94250 194375 194400 194450 194452 194453 194610 294617 194618 194621 194640 194642 194644 194645 494660 194662 194664 194667 194668 594669 494680 194681 194690 194726 194727 194728 194729 194750 194760 194761 194762 194770 194772 194774 194775 194776 194777 194780 194781 294799 195004 8095012 295017 27





Appendix

HCPCS/CPT Code



95018 1995024 4095027 9095028 3095044 8095052 2095056 195060 195065 195070 195071 195076 195079 295115 195117 195120 195125 095130 095131 095132 095133 095134 095144 3095145 1095146 1095147 1095148 1095149 1095165 3095170 1095180 895199 195249 195250 195251 195700 195705 195706 195707 195708 195709 195710 195711 1





Appendix

HCPCS/CPT Code



95712 195713 195714 195715 195716 195717 195718 195719 195720 195721 195722 195723 195724 195725 195726 195782 095783 095800 195801 195803 195805 195806 195807 195808 195810 195811 195812 195813 195816 195819 195822 195824 195829 195830 195836 195851 395852 195857 195860 195861 195863 195864 195865 1





Appendix

HCPCS/CPT Code



95866 195867 195868 195869 195870 495872 495873 195874 195875 295885 495886 495887 195905 295907 195908 195909 195910 195911 195912 195913 195921 195922 195923 195924 195925 195926 195927 195928 195929 195930 195933 195937 495938 195939 195940 2095941 895943 195954 195955 195957 195958 195961 195962 3





Appendix

HCPCS/CPT Code



95965 195966 195967 395970 195971 195972 195976 195977 195980 195981 195982 195983 195984 1195990 195991 195992 195999 196000 196001 196002 196003 196004 196020 196040 496105 396110 396112 196113 696116 196121 396125 296127 296130 196131 796132 196133 796136 196137 1196138 196139 1196146 196156 196158 1





Appendix

HCPCS/CPT Code



96159 496160 396161 096164 196165 696167 196168 696360 296361 2496365 296366 2496367 496368 196369 196370 396371 196372 596373 396374 196375 696376 1096377 196379 296401 496402 296405 196406 196409 196411 396413 196415 896416 196417 396420 296422 296423 296425 196440 196446 196450 196521 296522 196523 2





Appendix

HCPCS/CPT Code



96542 196549 196567 196570 196571 296573 196574 196900 196902 196904 196910 196912 196913 196920 196921 196922 196931 196932 196933 196934 296935 296936 296999 197010 097012 197014 197016 197018 197022 197024 197026 197028 197032 497033 497034 297035 297036 397039 197110 897112 697113 697116 497124 4





Appendix

HCPCS/CPT Code



97129 197130 397139 197140 697150 297151 097152 097153 097154 097155 097156 097157 097158 097161 197162 197163 197164 197165 197166 197167 197168 197169 197170 197171 197172 197530 697533 497535 897537 897542 897545 097546 097597 197598 897602 197605 197606 197607 197608 197610 197750 1697755 897760 6





Appendix

HCPCS/CPT Code



97761 697763 697799 197802 897803 897804 697810 197811 397813 197814 398925 198926 198927 198928 198929 198940 198941 198942 198943 198960 098961 098962 098966 098967 098968 098970 198971 198972 199000 099001 099002 199024 199026 099027 099050 199051 199053 199056 199058 199060 199070 199071 199075 0





Appendix

HCPCS/CPT Code



99078 399080 199082 199091 199100 199116 199135 199140 299151 199152 299153 1299155 199156 199157 699170 199172 199173 199174 099175 199177 199183 199184 199188 199190 199191 199192 199195 299199 199201 199202 199203 199204 199205 199211 299212 299213 299214 299215 299217 199218 199219 199220 199221 0





Appendix

HCPCS/CPT Code



99222 099223 099224 199225 199226 199231 099232 099233 099234 199235 199236 199238 099239 099241 099242 099243 099244 099245 099251 099252 099253 099254 099255 099281 299282 299283 299284 299285 299288 199291 199292 899304 199305 199306 199307 199308 199309 199310 199315 199316 199318 199324 199325 1





Appendix

HCPCS/CPT Code



99326 199327 199328 199334 199335 199336 199337 199339 199340 199341 199342 199343 199344 199345 199347 199348 199349 199350 199354 199355 499356 199357 199358 199359 199360 199366 299367 199368 299374 199375 099377 199378 099379 199380 199381 099382 099383 099384 099385 099386 099387 099391 099392 0





Appendix

HCPCS/CPT Code



99393 099394 099395 099396 099397 099401 199402 199403 199404 199406 199407 199408 099409 099411 099412 099415 199416 399421 199422 199423 199429 099441 099442 099443 099446 199447 199448 199449 199450 099451 199452 199453 199454 199455 199456 199457 199458 299460 099461 199462 099463 099464 099465 0





Appendix

HCPCS/CPT Code



99466 099467 099468 099469 099471 099472 099473 199474 199475 099476 099477 099478 099479 099480 099483 199484 199485 199486 499487 199489 499490 199491 199492 199493 199494 299495 199496 199497 199498 399499 199500 099501 099502 099503 099504 099505 099506 099507 099509 099510 099511 099512 099600 0





Appendix

HCPCS/CPT Code



99601 099602 099605 099606 099607 0A0021 0A0080 0A0090 0A0100 0A0110 0A0120 0A0130 0A0140 0A0160 0A0170 0A0180 0A0190 0A0200 0A0210 0A0225 0A0380 0A0382 0A0384 0A0390 0A0392 0A0394 0A0396 0A0398 0A0420 0A0422 0A0424 0A0425 250A0426 2A0427 2A0428 2A0429 2A0430 1A0431 1A0432 1A0433 1A0434 2A0435 999A0436 300





Appendix

HCPCS/CPT Code



A0888 0A0998 0A0999 1A4206 1A4207 1A4208 4A4209 6A4210 0A4211 1A4212 2A4213 5A4215 9A4216 25A4217 4A4218 20A4220 1A4221 1A4222 2A4223 1A4224 1A4225 1A4230 1A4231 1A4232 0A4233 0A4234 0A4235 1A4236 0A4244 1A4245 1A4246 1A4247 1A4248 10A4250 0A4252 0A4253 0A4255 0A4256 1A4257 0A4258 0A4259 0A4261 0A4262 4





Appendix

HCPCS/CPT Code








Appendix

HCPCS/CPT Code



A9589 1A9600 7A9604 1A9606 224A9698 3A9700 2A9900 0A9901 0A9999 0B4034 0B4035 0B4036 0B4081 0B4082 0B4083 0B4087 0B4088 0B4100 0B4102 0B4103 0B4104 0B4149 0B4150 0B4152 0B4153 0B4154 0B4155 0B4157 0B4158 0B4159 0B4160 0B4161 0B4162 0B4164 0B4168 0B4172 0B4176 0B4178 0B4180 0B4185 0B4189 0B4193 0B4197 0





Appendix

HCPCS/CPT Code



B4199 0B4216 0B4220 0B4222 0B4224 0B5000 0B5100 0B5200 0B9002 0B9004 0B9006 0B9998 0B9999 0C1713 20C1714 4C1715 45C1716 4C1717 10C1719 99C1721 1C1722 1C1724 5C1725 9C1726 5C1727 4C1728 5C1729 6C1730 4C1731 2C1732 3C1733 3C1749 1C1750 2C1751 3C1752 2C1753 2C1754 2C1755 2C1756 2C1757 6C1758 2C1759 2C1760 4





Appendix

HCPCS/CPT Code



C1762 4C1763 4C1764 1C1765 4C1766 4C1767 2C1768 3C1769 9C1770 3C1771 1C1772 1C1773 3C1776 10C1777 2C1778 4C1779 2C1780 2C1781 4C1782 1C1783 2C1784 2C1785 1C1786 1C1787 2C1788 2C1789 2C1813 1C1814 2C1815 1C1816 2C1817 1C1818 2C1819 4C1820 2C1821 4C1822 1C1823 1C1830 2C1840 1C1841 1C1842 0C1874 5C1875 4





Appendix

HCPCS/CPT Code








Appendix

HCPCS/CPT Code



C9606 1C9607 1C9608 2C9725 1C9726 2C9727 1C9728 1C9733 1C9734 1C9738 1C9739 1C9740 1C9745 1C9747 1C9749 1C9751 1C9752 1C9753 3C9754 1C9755 1C9898 1D0150 1D0240 1D0250 2D0270 1D0272 1D0274 1D0277 1D0412 0D0416 1D0431 1D0460 1D0484 1D0485 1D0601 0D0602 0D0603 0D1510 2D1516 1D1517 1D1520 2D1526 1D1527 1





Appendix

HCPCS/CPT Code



D1575 4D1999 0D4260 4D4263 4D4264 3D4270 4D4273 1D4277 0D4278 0D4355 1D4381 12D5282 0D5283 0D5876 0D5911 1D5912 1D5951 0D5983 1D5984 1D5985 1D6052 0D7111 20D7140 32D7210 32D7220 6D7230 6D7240 6D7241 6D7250 32D7260 1D7261 1D7283 4D7288 2D7321 4D9110 1D9130 0D9230 1D9248 1D9613 0D9930 1D9944 2D9945 2D9946 2





Appendix

HCPCS/CPT Code



D9950 1D9951 1D9952 1D9961 0D9990 0E0100 0E0105 0E0110 0E0111 0E0112 0E0113 0E0114 0E0116 0E0117 0E0118 0E0130 0E0135 0E0140 0E0141 0E0143 0E0144 0E0147 0E0148 0E0149 0E0153 0E0154 0E0155 0E0156 0E0157 0E0158 0E0159 0E0160 0E0161 0E0162 0E0163 0E0165 0E0167 0E0168 0E0170 0E0171 0E0172 0E0175 0E0181 0





Appendix

HCPCS/CPT Code



E0182 0E0184 0E0185 0E0186 0E0187 0E0188 0E0189 0E0190 0E0191 0E0193 0E0194 0E0196 0E0197 0E0198 0E0199 0E0200 0E0202 0E0203 0E0205 0E0210 0E0215 0E0217 0E0218 0E0221 0E0225 0E0231 0E0232 0E0235 0E0236 0E0239 0E0240 0E0241 0E0242 0E0243 0E0244 0E0245 0E0246 0E0247 0E0248 0E0249 0E0250 0E0251 0E0255 0





Appendix

HCPCS/CPT Code








Appendix

HCPCS/CPT Code



E8000 0E8001 0E8002 0G0008 1G0009 1G0010 1G0027 1G0068 0G0069 0G0070 0G0071 1G0076 1G0077 1G0078 1G0079 1G0080 1G0081 1G0082 1G0083 1G0084 1G0085 1G0086 1G0087 1G0101 1G0102 1G0103 1G0104 1G0105 1G0106 1G0108 8G0109 12G0117 1G0118 1G0120 1G0121 1G0122 0G0123 1G0124 1G0127 1G0128 1G0129 6G0130 1G0141 1





Appendix

HCPCS/CPT Code



G0143 1G0144 1G0145 1G0147 1G0148 1G0166 2G0168 2G0175 1G0176 5G0177 5G0179 1G0180 1G0181 1G0182 1G0186 1G0219 0G0235 1G0237 8G0238 8G0239 2G0245 1G0246 1G0247 1G0248 1G0249 3G0250 1G0252 0G0255 0G0257 1G0259 2G0260 2G0268 1G0269 2G0270 8G0271 4G0276 1G0277 5G0278 1G0279 1G0281 1G0282 0G0283 1G0288 1





Appendix

HCPCS/CPT Code








Appendix

HCPCS/CPT Code



G9978 2G9979 2G9980 2G9981 2G9982 2G9983 2G9984 2G9985 2G9986 2G9987 2J0120 1J0129 100J0130 6J0131 400J0132 300J0133 1200J0135 8J0153 180J0171 120J0178 4J0180 140J0185 130J0190 0J0200 0J0202 12J0205 0J0207 4J0210 16J0215 0J0220 20J0221 300J0222 300J0256 1600J0257 1400J0270 32J0275 1J0278 15J0280 10J0282 70J0285 5J0287 60J0288 0J0289 115





Appendix

HCPCS/CPT Code



J0290 24J0291 500J0295 12J0300 8J0330 50J0348 200J0350 0J0360 6J0364 6J0365 0J0380 1J0390 0J0395 0J0400 120J0401 400J0456 4J0461 800J0470 2J0475 8J0476 2J0480 1J0485 1500J0490 160J0500 4J0515 6J0517 30J0520 0J0558 24J0561 24J0565 200J0567 300J0570 4J0571 0J0572 0J0573 0J0574 0J0575 0J0583 1250J0584 90J0585 600J0586 300J0587 300J0588 600





Appendix

HCPCS/CPT Code








Appendix

HCPCS/CPT Code



J9268 1J9270 0J9271 300J9280 12J9285 200J9293 8J9295 800J9299 480J9301 100J9302 200J9303 90J9305 150J9306 840J9307 80J9308 280J9311 160J9312 150J9313 600J9315 40J9320 4J9325 400J9328 400J9330 50J9340 4J9351 120J9352 40J9354 600J9355 105J9356 60J9357 4J9360 40J9370 4J9371 5J9390 36J9395 20J9400 500J9600 4K0001 0K0002 0K0003 0K0004 0K0005 0K0006 0





Appendix

HCPCS/CPT Code



K0007 0K0008 0K0009 0K0010 0K0011 0K0012 0K0013 0K0014 0K0015 0K0017 0K0018 0K0019 0K0020 0K0037 0K0038 0K0039 0K0040 0K0041 0K0042 0K0043 0K0044 0K0045 0K0046 0K0047 0K0050 0K0051 0K0052 0K0053 0K0056 0K0065 0K0069 0K0070 0K0071 0K0072 0K0073 0K0077 0K0098 0K0105 0K0108 0K0195 0K0455 0K0462 0K0552 0





Appendix

HCPCS/CPT Code



K0553 0K0554 0K0601 0K0602 0K0603 0K0604 0K0605 0K0606 0K0607 0K0608 0K0609 0K0669 0K0672 4K0730 0K0733 0K0738 0K0740 0K0743 0K0800 0K0801 0K0802 0K0806 0K0807 0K0808 0K0812 0K0813 0K0814 0K0815 0K0816 0K0820 0K0821 0K0822 0K0823 0K0824 0K0825 0K0826 0K0827 0K0828 0K0829 0K0830 0K0831 0K0835 0K0836 0





Appendix

HCPCS/CPT Code



K0837 0K0838 0K0839 0K0840 0K0841 0K0842 0K0843 0K0848 0K0849 0K0850 0K0851 0K0852 0K0853 0K0854 0K0855 0K0856 0K0857 0K0858 0K0859 0K0860 0K0861 0K0862 0K0863 0K0864 0K0868 0K0869 0K0870 0K0871 0K0877 0K0878 0K0879 0K0880 0K0884 0K0885 0K0886 0K0890 0K0891 0K0898 1K0899 0K0900 0L0112 1L0113 1L0120 1





Appendix

HCPCS/CPT Code



L0130 1L0140 1L0150 1L0160 1L0170 1L0172 1L0174 1L0180 1L0190 1L0200 1L0220 1L0450 1L0452 1L0454 1L0455 1L0456 1L0457 1L0458 1L0460 1L0462 1L0464 1L0466 1L0467 1L0468 1L0469 1L0470 1L0472 1L0480 1L0482 1L0484 1L0486 1L0488 1L0490 1L0491 1L0492 1L0621 1L0622 1L0623 1L0624 1L0625 1L0626 1L0627 1L0628 1





Appendix

HCPCS/CPT Code








Appendix

HCPCS/CPT Code



L8658 3L8659 4L8670 3L8679 3L8680 0L8681 1L8682 2L8683 1L8684 1L8685 0L8686 0L8687 0L8688 0L8689 1L8690 2L8691 1L8692 0L8693 1L8694 1L8695 1L8696 1L8701 1L8702 1M0075 0M0076 0M0100 0M0300 0M0301 0P2028 1P2029 1P2031 0P2033 1P2038 1P3000 1P3001 1P7001 0P9010 4P9011 4P9012 12P9016 12P9017 24P9019 12P9020 5





Appendix

HCPCS/CPT Code



P9021 8P9022 12P9023 15P9031 12P9032 12P9033 12P9034 4P9035 4P9036 4P9037 4P9038 4P9039 2P9040 8P9041 100P9043 10P9044 20P9045 20P9046 40P9047 20P9048 2P9050 1P9051 4P9052 3P9053 3P9054 2P9055 2P9056 3P9057 4P9058 4P9059 15P9060 4P9070 15P9071 15P9073 4P9100 12P9603 100P9604 2P9612 1P9615 1Q0035 1Q0081 2Q0083 2Q0084 2





Appendix

HCPCS/CPT Code



Q0085 2Q0091 1Q0092 2Q0111 2Q0112 3Q0113 1Q0114 1Q0115 1Q0138 510Q0139 510Q0144 0Q0161 66Q0162 24Q0163 6Q0164 8Q0166 2Q0167 108Q0169 12Q0173 5Q0174 0Q0175 6Q0177 16Q0180 1Q0181 2Q0477 1Q0478 1Q0479 1Q0480 1Q0481 1Q0482 1Q0483 1Q0484 1Q0485 1Q0486 1Q0487 1Q0488 1Q0489 1Q0490 1Q0491 1Q0492 1Q0493 1Q0494 1Q0495 1





Appendix

HCPCS/CPT Code








Appendix

HCPCS/CPT Code



Q9963 240Q9964 0Q9966 250Q9967 300Q9969 3Q9982 1Q9983 1Q9991 1Q9992 1R0070 2R0075 2R0076 1V2020 1V2025 0V2100 2V2101 2V2102 2V2103 2V2104 2V2105 2V2106 2V2107 2V2108 2V2109 2V2110 2V2111 2V2112 2V2113 2V2114 2V2115 2V2118 2V2121 2V2199 2V2200 2V2201 2V2202 2V2203 2V2204 2V2205 2V2206 2V2207 2V2208 2V2209 2





Appendix

HCPCS/CPT Code



V2210 2V2211 2V2212 2V2213 2V2214 2V2215 2V2218 2V2219 2V2220 2V2221 2V2299 2V2300 2V2301 2V2302 2V2303 2V2304 2V2305 2V2306 2V2307 2V2308 2V2309 2V2310 2V2311 2V2312 2V2313 2V2314 2V2315 2V2318 2V2319 2V2320 2V2321 2V2399 2V2410 2V2430 2V2499 2V2500 2V2501 2V2502 2V2503 2V2510 2V2511 2V2512 2V2513 2





Appendix

HCPCS/CPT Code








Appendix

HCPCS/CPT Code



V5364 0





Appendix

Code Coverage Status10080 NRC10081 NRC11400 NRC11401 NRC11402 NRC11403 NRC11404 NRC11406 NRC11420 NRC11421 NRC11422 NRC11423 NRC11424 NRC11426 NRC11440 NRC11441 NRC11442 NRC11443 NRC11444 NRC11446 NRC11450 NRC11451 NRC11462 NRC11463 NRC11470 NRC11471 NRC11770 NRC11771 NRC11772 NRC11920 NRC11921 NRC11950 NRC11951 NRC11952 NRC11954 NRC15769 NRC15771 NRC15773 NRC15775 NRC15776 NRC15780 NRC15781 NRC

Table 9 - BWC Hospital Outpatient Item Coverage Status





Appendix

Code Coverage Status


15782 NRC15783 NRC15789 NRC15819 NRC15820 NRC15821 NRC15822 NRC15823 NRC15830 NRC15832 NRC15833 NRC15834 NRC15835 NRC15836 NRC15837 NRC15838 NRC15839 NRC15850 NRC15851 NRC19300 NRC19316 NRC19318 NRC19324 NRC19325 NRC19340 NRC19342 NRC19350 NRC19355 NRC19357 NRC19361 NRC19364 NRC19366 NRC19367 NRC19368 NRC19369 NRC19370 NRC19371 NRC19380 NRC19396 NRC19499 NRC21029 NRC21030 NRC





Appendix








Appendix



21196 NRC21198 NRC21199 NRC21206 NRC21209 NRC21247 NRC21280 NRC21282 NRC21295 NRC21296 NRC21600 NRC21602 BR21603 BR21610 NRC21615 NRC21616 NRC21620 NRC21627 NRC21630 NRC21632 NRC21685 NRC21700 NRC21705 NRC21720 NRC21725 NRC21740 NRC21742 NRC21743 NRC22800 NRC22802 NRC22804 NRC22808 NRC22810 NRC22812 NRC22818 NRC22819 NRC24640 NRC25450 NRC25455 NRC25490 NRC25491 NRC25492 NRC





Appendix








Appendix



33017 BR33018 NRC33019 BR33140 NRC33141 NRC33202 NRC33203 NRC33206 NRC33207 NRC33208 NRC33210 NRC33211 NRC33212 NRC33213 NRC33214 NRC33215 NRC33216 NRC33217 NRC33218 NRC33220 NRC33222 NRC33223 NRC33224 NRC33226 NRC33236 NRC33237 NRC33238 NRC33240 NRC33243 NRC33249 NRC33250 NRC33251 NRC33254 NRC33255 NRC33256 NRC33257 NRC33258 NRC33259 NRC33261 NRC33265 NRC33266 NRC33274 NRC





Appendix








Appendix



38213 NRC38214 NRC38215 NRC38230 NRC38240 NRC38241 NRC38242 NRC38308 NRC38380 NRC38381 NRC38382 NRC39200 NRC39499 BR39503 NRC39540 NRC39541 NRC39599 BR40500 NRC40510 NRC40520 NRC40525 NRC40527 NRC40530 NRC40700 NRC40701 NRC40702 NRC40720 NRC40761 NRC40806 NRC41010 NRC41120 NRC41130 NRC41135 NRC41140 NRC41145 NRC41150 NRC41153 NRC41155 NRC41510 NRC41512 NRC41520 NRC41530 NRC





Appendix








Appendix



48153 NRC48154 NRC48155 NRC48400 NRC48500 NRC48510 NRC48520 NRC48540 NRC48545 NRC48547 NRC48548 NRC48551 NRC48552 NRC48554 NRC48556 NRC48999 NRC49013 BR49014 BR49020 NRC49040 NRC49060 NRC49062 NRC49250 NRC49255 NRC49322 NRC49323 NRC49324 NRC49325 NRC49419 NRC49421 NRC49423 NRC49425 NRC49436 NRC49491 NRC49492 NRC49495 NRC49496 NRC49500 NRC49501 NRC49580 NRC49582 NRC49906 NRC





Appendix








Appendix



78491 NRC78492 NRC78494 NRC78499 NRC78608 NRC78707 NRC78708 NRC78709 NRC78740 NRC78761 NRC78811 NRC78812 NRC78813 NRC78814 NRC78815 NRC78816 NRC79403 NRC79440 NRC79445 NRC81277 NRC81307 NRC81308 NRC81309 NRC81479 NRC81522 NRC81542 NRC81552 NRC81599 NRC86927 NRC88000 BR88005 BR88007 BR88020 BR88025 BR88027 BR88036 BR88037 BR90284 BR90296 NRC90378 NRC90389 BR90393 BR





Appendix



90396 NRC90399 BR90630 NRC90653 NRC90654 NRC90655 NRC90656 NRC90657 NRC90661 NRC90662 NRC90670 NRC90672 NRC90673 NRC90674 NRC90682 NRC90685 NRC90686 NRC90687 NRC90688 NRC90689 NRC90732 NRC90739 NRC90740 NRC90743 NRC90744 NRC90747 NRC90756 NRC90867 NRC90868 NRC90869 NRC90935 NRC90945 NRC91065 NRC91117 NRC92601 NRC92602 NRC92603 NRC92604 NRC92960 NRC92961 NRC92986 NRC92987 NRC





Appendix



92990 NRC92992 NRC92993 NRC92997 NRC93229 NRC93303 NRC93304 NRC93315 NRC93316 NRC93530 NRC93531 NRC93532 NRC93533 NRC93580 NRC93581 NRC93590 NRC93591 NRC93668 NRC93724 NRC93745 NRC93797 NRC93798 NRC93799 NRC94013 NRC95249 NRC95250 NRC95782 NC95783 NC95800 NRC95857 NRC96000 NRC96001 NRC96002 NRC96161 NC97010 NC97039 BR97139 BR97151 NC97152 NC97153 NC97154 NC97155 NC





Appendix



97156 NC97157 NC97158 NC97545 NC97546 NC97799 BR99170 NRC99184 NRC99190 NRC99191 NRC99192 NRC99406 NRC99407 NRC99460 NC99462 NC99463 NC99464 NC99465 NC99466 NC99467 NC99468 NC99469 NC99471 NC99472 NC99475 NC99476 NC99477 NC99478 NC99479 NC99480 NC99483 NRC0018U BR0019U BR0022U BR0023U BR0029U BR0030U BR0048U BR0050U BR0053U BR0055U NRC0056U BR





Appendix



0067U NRC0069U NRC0070U NRC0071U NRC0072U NRC0073U NRC0074U NRC0075U NRC0076U NRC0078U NRC0082U NC0084U NRC0086U NRC0087U NRC0088U NRC0094U NRC0100T NRC0101T NRC0101U NRC0102T NRC0102U NRC0103U NRC0109U NRC0111T NRC0111U NRC0112U NRC0113U NRC0114U NRC0115U NRC0118U NRC0120U NRC0129U NRC0130U NRC0131U NRC0132U NRC0133U NRC0134U NRC0135U NRC0136U NRC0137U NRC0138U NRC0140U NRC





Appendix



0141U NRC0142U NRC0143U NC0145U NC0146U NC0147U NC0148U NC0149U NC0150U NC0151U NRC0152U NRC0153U NRC0154U NRC0155U NRC0156U NRC0157U NRC0158U NRC0159U NRC0160U NRC0161U NRC0162U NRC0191T NRC0200T NRC0201T NRC0213T NRC0216T NRC0228T NRC0230T NRC0238T NRC0253T NRC0263T NRC0264T NRC0265T NRC0270T NRC0271T NRC0274T NRC0275T NRC0308T NRC0313T NRC0314T NRC0315T NRC0316T NRC





Appendix



0331T NRC0332T NRC0335T NRC0338T NRC0339T NRC0342T NRC0394T NRC0395T NRC0402T NRC0408T NRC0409T NRC0410T NRC0411T NRC0414T NRC0415T NRC0416T NRC0419T NRC0420T NRC0421T NRC0423T NRC0424T NRC0425T NRC0426T NRC0427T NRC0428T NRC0429T NRC0430T NRC0431T NRC0432T NRC0433T NRC0434T NRC0440T NRC0441T NRC0442T NRC0446T NRC0448T NRC0449T NRC0465T NRC0467T NRC0468T NRC0479T NRC0491T NRC





Appendix



0500T NRC0508T NRC0511T NRC0512T NRC0524T NRC0525T NRC0526T NRC0527T NRC0548T NRC0549T NRC0550T NRC0551T NRC0558T NRC0566T NRC0587T NRC0588T NRCA0432 NRCA0999 BRA4575 NRCA4600 BRA9527 NRCA9530 NRCA9543 NRCA9563 NRCA9600 NRCA9606 NRCA9901 NRCC1716 NRCC1717 NRCC1719 NRCC2616 NRCC2634 NRCC2635 NRCC2636 NRCC2638 NRCC2639 NRCC2640 NRCC2641 NRCC2642 NRCC2643 NRCC2645 NRCC2698 NRC





Appendix



C2699 NRCC9046 NRCC9047 NRCC9132 NRCC9257 NRCC9399 NRCC9482 NRCC9488 NRCC9725 NRCC9727 NRCC9728 NRCC9745 NRCC9749 NRCC9752 NRCC9754 NRCC9755 NRCC9899 NRCD0600 NRCD2999 NRCD4260 NRCD4263 NRCD4264 NRCD4268 NRCD4270 NRCD4273 NRCD4355 NRCD4381 NRCD5911 NRCD5912 NRCD5983 NRCD5984 NRCD5985 NRCD5987 NRCD7111 NRCD7230 NRCD7240 NRCD7241 NRCD7260 NRCD7291 NRCD7940 NRCE0446 NRCE0604 NRC





Appendix



E1500 NRCE1510 NRCE1520 NRCE1530 NRCE1540 NRCE1550 NRCE1560 NRCE1570 NRCE1575 NRCE1580 NRCE1590 NRCE1592 NRCE1594 NRCE1600 NRCE1610 NRCE1615 NRCE1620 NRCE1625 NRCE1630 NRCE1632 NRCE1635 NRCE1636 NRCE1637 NRCE1639 NRCE1699 NRCG0068 NCG0069 NCG0070 NCG0130 NRCG0276 NRCG0429 NRCG0466 NRCG0467 NRCG0468 NRCG0469 NRCG0470 NRCG0490 NRCG9140 NRCJ0129 NRCJ0135 NRCJ0179 NRCJ0180 NRC





Appendix



J0202 NRCJ0220 NRCJ0222 NRC J0256 NRCJ0291 NRCJ0300 NRCJ0401 NRCJ0480 NRCJ0565 NRCJ0567 NRCJ0570 NRCJ0584 NRCJ0593 NRCJ0594 NRCJ0596 NRCJ0597 NRCJ0598 NRCJ0599 NRCJ0600 NRCJ0606 NRCJ0630 NRCJ0638 NRCJ0717 NRCJ0775 NRCJ0795 NRCJ0800 NRCJ0841 NRCJ1096 NRCJ1097 NRCJ1162 NRCJ1212 NRCJ1290 NRCJ1300 NRCJ1303 NRCJ1322 NRCJ1327 NRCJ1410 NRCJ1428 NRCJ1430 NRCJ1438 NRCJ1451 NRCJ1455 NRC





Appendix



J1458 NRCJ1459 NRCJ1555 NRCJ1559 NRCJ1566 NRCJ1575 NRCJ1595 NRCJ1602 NRCJ1610 NRCJ1628 NRCJ1640 NRCJ1726 NRCJ1729 NRCJ1740 NRCJ1742 NRCJ1743 NRCJ1745 NRCJ1746 NRCJ1786 NRCJ1830 NRCJ1931 NRCJ1943 NRCJ1944 NRCJ2182 NRCJ2186 NRCJ2315 NRCJ2323 NRCJ2325 NRCJ2326 NRCJ2350 NRCJ2355 NRCJ2426 NRCJ2504 NRCJ2547 NRCJ2562 NRCJ2597 NRCJ2724 NRCJ2760 NRCJ2778 NRCJ2786 NRCJ2792 NRCJ2796 NRC





Appendix



J2798 NRCJ2840 NRCJ2850 NRCJ2860 NRCJ2941 NRCJ3031 NRCJ3060 NRCJ3095 NRCJ3111 NRCJ3145 NRCJ3245 NRCJ3262 NRCJ3285 NRCJ3304 NRCJ3357 NRCJ3358 NRCJ3380 NRCJ3385 NRCJ3396 NRCJ3397 NRCJ3398 NRCJ7170 NRCJ7177 NRCJ7179 NRCJ7181 NRCJ7203 NRCJ7207 NRCJ7208 NRCJ7209 NRCJ7210 NRCJ7308 NRCJ7311 NRCJ7313 NRCJ7314 NRCJ7316 NRCJ7326 NRCJ7330 BRJ7342 NRCJ7345 NRCJ7501 NRCJ7504 NRCJ7511 NRC





Appendix



J7525 NRCJ9210 NRCJ9226 NRCK0744 NCK0745 NCK0746 NCL0452 NRCL0623 NRCL0624 NRCL0629 NRCL0632 NRCL0634 NRCL0978 NRCL0999 BRL1000 NRCL1001 NRCL1005 NRCL1010 NRCL1020 NRCL1025 NRCL1030 NRCL1040 NRCL1050 NRCL1060 NRCL1070 NRCL1080 NRCL1085 NRCL1090 NRCL1100 NRCL1110 NRCL1120 NRCL1270 NRCL1280 NRCL1290 NRCL1300 NRCL1310 NRCL1499 BRL1600 NRCL1610 NRCL1620 NRCL1630 NRCL1640 NRC





Appendix



L1650 NRCL1700 NRCL1710 NRCL1720 NRCL1730 NRCL1755 NRCL2006 NRCL2035 NRCL2040 NRCL2050 NRCL2060 NRCL2070 NRCL2080 NRCL2090 NRCL2999 BRL3100 NRCL3140 NRCL3150 NRCL3160 NRCL3201 NRCL3202 NRCL3203 NRCL3204 NRCL3206 NRCL3207 NRCL3208 NRCL3209 NRCL3211 NRCL3212 NRCL3213 NRCL3214 NRCL3649 BRL3678 BRL3999 BRL4002 BRL5999 BRL7008 NRCL7045 NRCL7180 NRCL7181 NRCL7185 NRCL7186 NRC





Appendix



L7190 NRCL7191 NRCL7499 BRL8010 NRCL8033 NRCL8039 NRCL8048 BRL8499 BRL8615 NRCL8616 NRCL8617 NRCL8618 NRCL8619 NRCL8621 NRCL8622 NRCL8623 NRCL8624 NRCL8627 NRCL8628 NRCL8629 NRCL8691 NRCL8698 NRCL8701 BRL8702 BRP9041 NRCP9045 NRCP9046 NRCP9047 NRCP9603 NRCP9604 NRCQ0139 NRCQ0478 NRCQ0479 NRCQ0480 NRCQ0488 NRCQ0507 NRCQ0508 NRCQ0509 NRCQ2035 NRCQ2036 NRCQ2037 NRCQ2038 NRC





Appendix



Q2039 NRCQ2041 NRCQ2042 NRCQ2043 NRCQ5103 NRCQ5104 NRCQ5105 NRCQ9968 NRCV2199 BRV2299 BRV2399 BRV2499 BRV2599 BRV2615 NRCV2629 BRV2710 NRCV2715 NRCV2718 NRCV2730 NRCV2744 NRCV2750 NRCV2799 BR




ACTION: Final DATE: 05/06/2020 9:34 AM Ohio Bureau of ... · 5/6/2020 · 1 unit = completed...

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Transcript of ACTION: Final DATE: 05/06/2020 9:34 AM Ohio Bureau of ... · 5/6/2020 · 1 unit = completed...