Local Coverage Determination for Category III CPT® Codes (L33392)

Local Coverage Determination (LCD): Category III CPT® Codes (L33392)

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Contractor Information

Contract Contractor Name Contract Type Jurisdiction State(s) Number National Government Services, Inc. MAC - Part A 06101 - MAC A J - 06 Illinois National Government Services, Inc. MAC - Part B 06102 - MAC B J - 06 Illinois National Government Services, Inc. MAC - Part A 06201 - MAC A J - 06 Minnesota National Government Services, Inc. MAC - Part B 06202 - MAC B J - 06 Minnesota National Government Services, Inc. MAC - Part A 06301 - MAC A J - 06 Wisconsin National Government Services, Inc. MAC - Part B 06302 - MAC B J - 06 Wisconsin A and B and HHH National Government Services, Inc. 13101 - MAC A J - K Connecticut MAC A and B and HHH National Government Services, Inc. 13102 - MAC B J - K Connecticut MAC A and B and HHH New York - Entire National Government Services, Inc. 13201 - MAC A J - K MAC State A and B and HHH National Government Services, Inc. 13202 - MAC B J - K New York - Downstate MAC A and B and HHH National Government Services, Inc. 13282 - MAC B J - K New York - Upstate MAC A and B and HHH National Government Services, Inc. 13292 - MAC B J - K New York - Queens MAC A and B and HHH National Government Services, Inc. 14111 - MAC A J - K Maine MAC A and B and HHH National Government Services, Inc. 14112 - MAC B J - K Maine MAC A and B and HHH National Government Services, Inc. 14211 - MAC A J - K Massachusetts MAC A and B and HHH National Government Services, Inc. 14212 - MAC B J - K Massachusetts MAC A and B and HHH National Government Services, Inc. 14311 - MAC A J - K New Hampshire MAC A and B and HHH National Government Services, Inc. 14312 - MAC B J - K New Hampshire MAC A and B and HHH National Government Services, Inc. 14411 - MAC A J - K Rhode Island MAC A and B and HHH National Government Services, Inc. 14412 - MAC B J - K Rhode Island MAC A and B and HHH National Government Services, Inc. 14511 - MAC A J - K Vermont MAC A and B and HHH National Government Services, Inc. 14512 - MAC B J - K Vermont MAC Back to Top LCD Information

Document Information

LCD ID Original Effective Date

Printed on 1/25/2018. Page 1 of 22 L33392 For services performed on or after 10/01/2015

Original ICD-9 LCD ID Revision Effective Date L25275 For services performed on or after 01/01/2018

Revision Ending Date LCD Title N/A Category III CPT® Codes Retirement Date Proposed LCD in Comment Period N/A N/A Notice Period Start Date Source Proposed LCD N/A N/A Notice Period End Date AMA CPT / ADA CDT / AHA NUBC Copyright Statement N/A CPT only copyright 2002-2018 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association.

UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association (“AHA”), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA.” Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company.

CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1862(a)(1)(D) refers to limitations on items or devices that are investigational or experimental.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Printed on 1/25/2018. Page 2 of 22 CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 14,

10 Coverage of Medical Devices

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 23,

30 Services paid under the Medicare Physicians Fee Schedule

CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 13,

5.1 Reasonable and necessary provisions in LCDs

7.1 Evidence supporting LCDs.

Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

The American Medical Association (AMA) develops Current Procedural Terminology (CPT) Category III codes to allow for data collection concerning the use of "emerging technology, services, and procedures." 1 The creation of a CPT Category III code by the AMA "neither implies nor endorses clinical efficacy, safety or the applicability to clinical practice." 2

Because of the specific purpose these Category III codes serve, National Government Services will consider the item, service, or procedure represented by these codes to be not medically necessary, unless the item, service, or procedure is listed below under the "Indications and Limitations for Category III CPT Codes Considered Reasonable and Necessary" section of the LCD. If a provider believes that any Category III code, included in CPT Code Section, Group 1, qualifies for coverage (is proven to be safe and effective as well as reasonable and necessary), the provider may request coverage and inclusion of the Category III code in this LCD or in its own LCD through the LCD Reconsideration Process. Peer reviewed scientific evidence is required for consideration.

The "Indications and Limitations for Category III CPT Codes Considered Reasonable and Necessary" lists services for which past claim or other reviews have found the item, service, or procedure to be "reasonable and medically necessary." Coverage will be allowed when the service is delivered in clinical situations meeting criteria for medical necessity.

Note: Once a Category III CPT code is replaced by a Category I CPT code, the item, service, or procedure should not be presumed to be medically necessary.

1 Current Procedural Terminology (CPT®), Professional Edition, American Medical Association (2006), p. 429 2 Ibid, p. 429

Indications and Limitations:

Section 1862(a)(1)(A)* of the Social Security Act (SSA) is the statutory basis for denying payment for types of care, items, services, and procedures, not excluded by any other statutory clause while meeting all technical requirements for coverage, that are determined to be any of the following:

• Not generally accepted by the medical community as safe and effective in the setting and for the condition for which it is used; • Not proven safe and effective based on peer review or scientific literature; • Experimental; • Not medically necessary for a particular patient; • Furnished at a level, duration, or frequency that is not medically appropriate; • Not furnished in accordance with accepted standards of medical practice; or • Not furnished in a setting appropriate to the patient’s medical needs and condition.

Items and services must be established as safe and effective to be considered medically necessary. That is, the

Printed on 1/25/2018. Page 3 of 22 items and services must be:

• Consistent with the symptoms of diagnosis of the illness or injury under treatment; • Necessary for, and consistent with, generally accepted professional medical standards of care (e.g., not experimental); • Not furnished primarily for the convenience of the patient or of the provider or supplier; and • Furnished at the most appropriate level of care that can be provided safely and effectively to the patient.

Indications and Limitations of Coverage

The items, services, or procedures represented by the following Category III CPT Codes are considered medically necessary when the conditions of coverage are met:

CPT Code 0100T (Effective for dates of service on or after 06/01/2015) Coverage for the placement of a subconjunctival prosthesis receiver and pulse generator, and implantation of intraocular retinal electrode array, with vitrectomy will be allowed for the FDA-approved indications. If the procedure is denied as not medically necessary, the device will be denied also.

CPT Code 0184T (effective for dates of service on or after 02/01/2014) Transanal endoscopic microsurgery (TEM) is a minimally invasive surgical procedure that presents an alternative to laparoscopic surgical excision or open surgical excision for mid and proximally located rectal benign and selected malignant lesions.

Transanal endoscopic microsurgery (TEM) is considered medically necessary for patients who have one of the following conditions:

◦ benign rectal tumors (adenomas)

◦ malignant tumors (e.g., small, less than 3 cm, well to moderately differentiated malignant tumors, e.g., early stage Tis, T1N0 adenocarcinomas) within 8 cm of the anal verge and limited to less than 30% of the rectal circumference for which there is no evidence of nodal involvement and which can be removed with negative margins

◦ small rectal carcinoids (less than 2 cm in diameter)

• are medically unfit or unwilling to undergo radical resection and require palliative resection.

Transanal endoscopic microsurgery (TEM) is considered not medically necessary for all other indications (e.g., benign rectal strictures) because its effectiveness for indications other than the ones listed above has not been established.

CPT code 0249T (Effective for dates of service on or after June 1, 2014) NGS will cover CPT code 0249T (ligation, hemorrhoidal vascular bundle(s), including ultrasound guidance) effective for services rendered on or after June 1, 2014. NGS will allow services for Doppler-guided hemorrhoid artery ligation with or without mucopexy for Grade II or III hemorrhoids that have failed rubber band ligation or conservative treatment (behavior modification, high fiber diets to control constipation, and hydrocortisone cream or suppositories). Based on AMA CPT, it is not appropriate to submit the following CPT codes in addition to CPT code 0249T: 46020, 46221, 46250-46262, 46600, 46945, 46946, 76872, 76942, and 76998.

CPT codes 0295T, 0296T, 0297T and 0298T External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage will be allowed for the same indications as dynamic electrocardiography (e.g. Holter™ monitoring) codes. Printed on 1/25/2018. Page 4 of 22 Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

011x Hospital Inpatient (Including Medicare Part A) 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital - Laboratory Services Provided to Non-patients 018x Hospital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 071x Clinic - Rural Health 072x Clinic - Hospital Based or Independent Renal Dialysis Center 073x Clinic - Freestanding 074x Clinic - Outpatient Rehabilitation Facility (ORF) 076x Clinic - Community Mental Health Center 077x Clinic - Federally Qualified Health Center (FQHC) 085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.

Printed on 1/25/2018. Page 5 of 22 020X Intensive Care Unit - General Classification 021X Coronary Care Unit - General Classification 024X All Inclusive Ancillary - General Classification 025X Pharmacy - General Classification 026X IV Therapy - General Classification 027X Medical/Surgical Supplies and Devices - General Classification 030X Laboratory - General Classification 031X Laboratory Pathology - General Classification 032X Radiology - Diagnostic - General Classification 033X Radiology - Therapeutic and/or Chemotherapy Administration - General Classification 034X Nuclear Medicine - General Classification 036X Operating Room Services - General Classification 040X Other Imaging Services - General Classification 048X Cardiology - General Classification

CPT/HCPCS Codes Group 1 Paragraph:

The Category III CPT codes listed below are considered not medically necessary:

Group 1 Codes: CEREBRAL PERFUSION ANALYSIS USING COMPUTED TOMOGRAPHY WITH CONTRAST ADMINISTRATION, 0042T INCLUDING POST-PROCESSING OF PARAMETRIC MAPS WITH DETERMINATION OF CEREBRAL BLOOD FLOW, CEREBRAL BLOOD VOLUME, AND MEAN TRANSIT TIME COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH 0054T IMAGE-GUIDANCE BASED ON FLUOROSCOPIC IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH 0055T IMAGE-GUIDANCE BASED ON CT/MRI IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0058T CRYOPRESERVATION; REPRODUCTIVE TISSUE, OVARIAN FOCUSED ULTRASOUND ABLATION OF UTERINE LEIOMYOMATA, INCLUDING MR GUIDANCE; TOTAL 0071T LEIOMYOMATA VOLUME LESS THAN 200 CC OF TISSUE FOCUSED ULTRASOUND ABLATION OF UTERINE LEIOMYOMATA, INCLUDING MR GUIDANCE; TOTAL 0072T LEIOMYOMATA VOLUME GREATER OR EQUAL TO 200 CC OF TISSUE TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING 0075T RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; INITIAL VESSEL TRANSCATHETER PLACEMENT OF EXTRACRANIAL VERTEBRAL ARTERY STENT(S), INCLUDING 0076T RADIOLOGIC SUPERVISION AND INTERPRETATION, OPEN OR PERCUTANEOUS; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0085T BREATH TEST FOR HEART TRANSPLANT REJECTION REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL 0095T INTERSPACE, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR 0098T APPROACH, EACH ADDITIONAL INTERSPACE, CERVICAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) EXTRACORPOREAL SHOCK WAVE INVOLVING MUSCULOSKELETAL SYSTEM, NOT OTHERWISE SPECIFIED, 0101T HIGH ENERGY EXTRACORPOREAL SHOCK WAVE, HIGH ENERGY, PERFORMED BY A PHYSICIAN, REQUIRING ANESTHESIA 0102T OTHER THAN LOCAL, INVOLVING LATERAL HUMERAL EPICONDYLE QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERPRETATION PER EXTREMITY; USING 0106T TOUCH PRESSURE STIMULI TO ASSESS LARGE DIAMETER SENSATION QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERPRETATION PER EXTREMITY; USING 0107T VIBRATION STIMULI TO ASSESS LARGE DIAMETER FIBER SENSATION QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERPRETATION PER EXTREMITY; USING 0108T COOLING STIMULI TO ASSESS SMALL NERVE FIBER SENSATION AND HYPERALGESIA QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERPRETATION PER EXTREMITY; USING HEAT 0109T -PAIN STIMULI TO ASSESS SMALL NERVE FIBER SENSATION AND HYPERALGESIA QUANTITATIVE SENSORY TESTING (QST), TESTING AND INTERPRETATION PER EXTREMITY; USING 0110T OTHER STIMULI TO ASSESS SENSATION

Printed on 1/25/2018. Page 6 of 22 0111T LONG-CHAIN (C20-22) OMEGA-3 FATTY ACIDS IN RED BLOOD CELL (RBC) MEMBRANES COMMON CAROTID INTIMA-MEDIA THICKNESS (IMT) STUDY FOR EVALUATION OF ATHEROSCLEROTIC 0126T BURDEN OR CORONARY HEART DISEASE RISK FACTOR ASSESSMENT COMPUTER-AIDED DETECTION, INCLUDING COMPUTER ALGORITHM ANALYSIS OF MRI IMAGE DATA FOR LESION DETECTION/CHARACTERIZATION, PHARMACOKINETIC ANALYSIS, WITH FURTHER PHYSICIAN 0159T REVIEW FOR INTERPRETATION, BREAST MRI (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY TO 0163T PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), EACH ADDITIONAL INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REMOVAL OF TOTAL DISC ARTHROPLASTY, (ARTIFICIAL DISC), ANTERIOR APPROACH, EACH ADDITIONAL 0164T INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR 0165T APPROACH, EACH ADDITIONAL INTERSPACE, LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) COMPUTER-AIDED DETECTION (CAD) (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR 0174T WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S), PERFORMED CONCURRENT WITH PRIMARY INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) COMPUTER-AIDED DETECTION (CAD) (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION AND REPORT, WITH OR 0175T WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES, CHEST RADIOGRAPH(S), PERFORMED REMOTE FROM PRIMARY INTERPRETATION REMOTE REAL-TIME INTERACTIVE VIDEO-CONFERENCED CRITICAL CARE, EVALUATION AND 0188T MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES REMOTE REAL-TIME INTERACTIVE VIDEO-CONFERENCED CRITICAL CARE, EVALUATION AND 0189T MANAGEMENT OF THE CRITICALLY ILL OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE) PLACEMENT OF INTRAOCULAR RADIATION SOURCE APPLICATOR (LIST SEPARATELY IN ADDITION TO 0190T PRIMARY PROCEDURE) ARTHRODESIS, PRE-SACRAL INTERBODY TECHNIQUE, DISC SPACE PREPARATION, DISCECTOMY, 0195T WITHOUT INSTRUMENTATION, WITH IMAGE GUIDANCE, INCLUDES BONE GRAFT WHEN PERFORMED; L5- S1 INTERSPACE ARTHRODESIS, PRE-SACRAL INTERBODY TECHNIQUE, DISC SPACE PREPARATION, DISCECTOMY, 0196T WITHOUT INSTRUMENTATION, WITH IMAGE GUIDANCE, INCLUDES BONE GRAFT WHEN PERFORMED; L4- L5 INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) MEASUREMENT OF OCULAR BLOOD FLOW BY REPETITIVE INTRAOCULAR PRESSURE SAMPLING, WITH 0198T INTERPRETATION AND REPORT PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY), UNILATERAL INJECTION(S), INCLUDING THE 0200T USE OF A BALLOON OR MECHANICAL DEVICE, WHEN USED, 1 OR MORE NEEDLES, INCLUDES IMAGING GUIDANCE AND BONE BIOPSY, WHEN PERFORMED PERCUTANEOUS SACRAL AUGMENTATION (SACROPLASTY), BILATERAL INJECTIONS, INCLUDING THE USE 0201T OF A BALLOON OR MECHANICAL DEVICE, WHEN USED, 2 OR MORE NEEDLES, INCLUDES IMAGING GUIDANCE AND BONE BIOPSY, WHEN PERFORMED POSTERIOR VERTEBRAL JOINT(S) ARTHROPLASTY (EG, FACET JOINT[S] REPLACEMENT), INCLUDING 0202T FACETECTOMY, LAMINECTOMY, FORAMINOTOMY, AND VERTEBRAL COLUMN FIXATION, INJECTION OF BONE CEMENT, WHEN PERFORMED, INCLUDING FLUOROSCOPY, SINGLE LEVEL, LUMBAR SPINE INTRAVASCULAR CATHETER-BASED CORONARY VESSEL OR GRAFT SPECTROSCOPY (EG, INFRARED) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING 0205T SUPERVISION, INTERPRETATION, AND REPORT, EACH VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) COMPUTERIZED DATABASE ANALYSIS OF MULTIPLE CYCLES OF DIGITIZED CARDIAC ELECTRICAL DATA FROM TWO OR MORE ECG LEADS, INCLUDING TRANSMISSION TO A REMOTE CENTER, APPLICATION OF 0206T MULTIPLE NONLINEAR MATHEMATICAL TRANSFORMATIONS, WITH CORONARY ARTERY OBSTRUCTION SEVERITY ASSESSMENT EVACUATION OF MEIBOMIAN GLANDS, AUTOMATED, USING HEAT AND INTERMITTENT PRESSURE, 0207T UNILATERAL 0208T PURE TONE AUDIOMETRY (THRESHOLD), AUTOMATED; AIR ONLY 0209T PURE TONE AUDIOMETRY (THRESHOLD), AUTOMATED; AIR AND BONE 0210T SPEECH AUDIOMETRY THRESHOLD, AUTOMATED; 0211T SPEECH AUDIOMETRY THRESHOLD, AUTOMATED; WITH SPEECH RECOGNITION COMPREHENSIVE AUDIOMETRY THRESHOLD EVALUATION AND SPEECH RECOGNITION (0209T, 0211T 0212T COMBINED), AUTOMATED Printed on 1/25/2018. Page 7 of 22 0213T INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT 0214T (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, CERVICAL OR THORACIC; 0215T THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT 0216T (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT 0217T (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT 0218T (OR NERVES INNERVATING THAT JOINT) WITH ULTRASOUND GUIDANCE, LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING 0219T IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; CERVICAL PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING 0220T IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; THORACIC PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING 0221T IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; LUMBAR PLACEMENT OF A POSTERIOR INTRAFACET IMPLANT(S), UNILATERAL OR BILATERAL, INCLUDING IMAGING AND PLACEMENT OF BONE GRAFT(S) OR SYNTHETIC DEVICE(S), SINGLE LEVEL; EACH 0222T ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND 0228T GUIDANCE, CERVICAL OR THORACIC; SINGLE LEVEL INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND 0229T GUIDANCE, CERVICAL OR THORACIC; EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND 0230T GUIDANCE, LUMBAR OR SACRAL; SINGLE LEVEL INJECTION(S), ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL, WITH ULTRASOUND 0231T GUIDANCE, LUMBAR OR SACRAL; EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION(S), PLATELET RICH PLASMA, ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND 0232T PREPARATION WHEN PERFORMED TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL 0234T SUPERVISION AND INTERPRETATION; RENAL ARTERY TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL 0235T SUPERVISION AND INTERPRETATION; VISCERAL ARTERY (EXCEPT RENAL), EACH VESSEL TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL 0236T SUPERVISION AND INTERPRETATION; ABDOMINAL AORTA TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL 0237T SUPERVISION AND INTERPRETATION; BRACHIOCEPHALIC TRUNK AND BRANCHES, EACH VESSEL TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL 0238T SUPERVISION AND INTERPRETATION; ILIAC ARTERY, EACH VESSEL INSERTION OF ANTERIOR SEGMENT AQUEOUS DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, 0253T INTERNAL APPROACH, INTO THE SUPRACHOROIDAL SPACE ENDOVASCULAR REPAIR OF ILIAC ARTERY BIFURCATION (EG, ANEURYSM, PSEUDOANEURYSM, ARTERIOVENOUS MALFORMATION, TRAUMA, DISSECTION) USING BIFURCATED ENDOGRAFT FROM THE 0254T COMMON ILIAC ARTERY INTO BOTH THE EXTERNAL AND INTERNAL ILIAC ARTERY, INCLUDING ALL SELECTIVE AND/OR NONSELECTIVE CATHETERIZATION(S) REQUIRED FOR DEVICE PLACEMENT AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, UNILATERAL INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY, WITH PREPARATION OF HARVESTED 0263T CELLS, MULTIPLE INJECTIONS, ONE LEG, INCLUDING ULTRASOUND GUIDANCE, IF PERFORMED; COMPLETE PROCEDURE INCLUDING UNILATERAL OR BILATERAL BONE MARROW HARVEST INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY, WITH PREPARATION OF HARVESTED 0264T CELLS, MULTIPLE INJECTIONS, ONE LEG, INCLUDING ULTRASOUND GUIDANCE, IF PERFORMED; COMPLETE PROCEDURE EXCLUDING BONE MARROW HARVEST

Printed on 1/25/2018. Page 8 of 22 0265T INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY, WITH PREPARATION OF HARVESTED CELLS, MULTIPLE INJECTIONS, ONE LEG, INCLUDING ULTRASOUND GUIDANCE, IF PERFORMED; UNILATERAL OR BILATERAL BONE MARROW HARVEST ONLY FOR INTRAMUSCULAR AUTOLOGOUS BONE MARROW CELL THERAPY IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM 0266T (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; LEAD ONLY, 0267T UNILATERAL (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) IMPLANTATION OR REPLACEMENT OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; PULSE 0268T GENERATOR ONLY (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) REVISION OR REMOVAL OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; TOTAL SYSTEM 0269T (INCLUDES GENERATOR PLACEMENT, UNILATERAL OR BILATERAL LEAD PLACEMENT, INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) REVISION OR REMOVAL OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; LEAD ONLY, UNILATERAL 0270T (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) REVISION OR REMOVAL OF CAROTID SINUS BAROREFLEX ACTIVATION DEVICE; PULSE GENERATOR ONLY 0271T (INCLUDES INTRA-OPERATIVE INTERROGATION, PROGRAMMING, AND REPOSITIONING, WHEN PERFORMED) INTERROGATION DEVICE EVALUATION (IN PERSON), CAROTID SINUS BAROREFLEX ACTIVATION SYSTEM, INCLUDING TELEMETRIC ITERATIVE COMMUNICATION WITH THE IMPLANTABLE DEVICE TO 0272T MONITOR DEVICE DIAGNOSTICS AND PROGRAMMED THERAPY VALUES, WITH INTERPRETATION AND REPORT (EG, BATTERY STATUS, LEAD IMPEDANCE, PULSE AMPLITUDE, PULSE WIDTH, THERAPY FREQUENCY, PATHWAY MODE, BURST MODE, THERAPY START/STOP TIMES EACH DAY); INTERROGATION DEVICE EVALUATION (IN PERSON), CAROTID SINUS BAROREFLEX ACTIVATION SYSTEM, INCLUDING TELEMETRIC ITERATIVE COMMUNICATION WITH THE IMPLANTABLE DEVICE TO MONITOR DEVICE DIAGNOSTICS AND PROGRAMMED THERAPY VALUES, WITH INTERPRETATION AND 0273T REPORT (EG, BATTERY STATUS, LEAD IMPEDANCE, PULSE AMPLITUDE, PULSE WIDTH, THERAPY FREQUENCY, PATHWAY MODE, BURST MODE, THERAPY START/STOP TIMES EACH DAY); WITH PROGRAMMING PERCUTANEOUS LAMINOTOMY/LAMINECTOMY (INTERLAMINAR APPROACH) FOR DECOMPRESSION OF NEURAL ELEMENTS, (WITH OR WITHOUT LIGAMENTOUS RESECTION, DISCECTOMY, FACETECTOMY 0274T AND/OR FORAMINOTOMY), ANY METHOD, UNDER INDIRECT IMAGE GUIDANCE (EG, FLUOROSCOPIC, CT), SINGLE OR MULTIPLE LEVELS, UNILATERAL OR BILATERAL; CERVICAL OR THORACIC TRANSCUTANEOUS ELECTRICAL MODULATION PAIN REPROCESSING (EG, SCRAMBLER THERAPY), EACH 0278T TREATMENT SESSION (INCLUDES PLACEMENT OF ELECTRODES) CORNEAL INCISIONS IN THE RECIPIENT CORNEA CREATED USING A LASER, IN PREPARATION FOR 0290T PENETRATING OR LAMELLAR KERATOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) VAGUS NERVE BLOCKING THERAPY (MORBID OBESITY); LAPAROSCOPIC IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, ANTERIOR AND POSTERIOR VAGAL TRUNKS ADJACENT TO 0312T ESOPHAGOGASTRIC JUNCTION (EGJ), WITH IMPLANTATION OF PULSE GENERATOR, INCLUDES PROGRAMMING VAGUS NERVE BLOCKING THERAPY (MORBID OBESITY); LAPAROSCOPIC REVISION OR REPLACEMENT OF 0313T VAGAL TRUNK NEUROSTIMULATOR ELECTRODE ARRAY, INCLUDING CONNECTION TO EXISTING PULSE GENERATOR VAGUS NERVE BLOCKING THERAPY (MORBID OBESITY); LAPAROSCOPIC REMOVAL OF VAGAL TRUNK 0314T NEUROSTIMULATOR ELECTRODE ARRAY AND PULSE GENERATOR 0315T VAGUS NERVE BLOCKING THERAPY (MORBID OBESITY); REMOVAL OF PULSE GENERATOR 0316T VAGUS NERVE BLOCKING THERAPY (MORBID OBESITY); REPLACEMENT OF PULSE GENERATOR VAGUS NERVE BLOCKING THERAPY (MORBID OBESITY); NEUROSTIMULATOR PULSE GENERATOR 0317T ELECTRONIC ANALYSIS, INCLUDES REPROGRAMMING WHEN PERFORMED MONITORING OF INTRAOCULAR PRESSURE FOR 24 HOURS OR LONGER, UNILATERAL OR BILATERAL, 0329T WITH INTERPRETATION AND REPORT 0330T TEAR FILM IMAGING, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT MYOCARDIAL SYMPATHETIC INNERVATION IMAGING, PLANAR QUALITATIVE AND QUANTITATIVE 0331T ASSESSMENT; MYOCARDIAL SYMPATHETIC INNERVATION IMAGING, PLANAR QUALITATIVE AND QUANTITATIVE 0332T ASSESSMENT; WITH TOMOGRAPHIC SPECT 0335T EXTRA-OSSEOUS SUBTALAR JOINT IMPLANT FOR TALOTARSAL STABILIZATION 0337T

Printed on 1/25/2018. Page 9 of 22 ENDOTHELIAL FUNCTION ASSESSMENT, USING PERIPHERAL VASCULAR RESPONSE TO REACTIVE HYPEREMIA, NON-INVASIVE (EG, BRACHIAL ARTERY ULTRASOUND, PERIPHERAL ARTERY TONOMETRY), UNILATERAL OR BILATERAL TRANSCATHETER RENAL SYMPATHETIC DENERVATION, PERCUTANEOUS APPROACH INCLUDING ARTERIAL PUNCTURE, SELECTIVE CATHETER PLACEMENT(S) RENAL ARTERY(IES), FLUOROSCOPY, CONTRAST 0338T INJECTION(S), INTRAPROCEDURAL ROADMAPPING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS, FLUSH AORTOGRAM AND DIAGNOSTIC RENAL ANGIOGRAPHY WHEN PERFORMED; UNILATERAL TRANSCATHETER RENAL SYMPATHETIC DENERVATION, PERCUTANEOUS APPROACH INCLUDING ARTERIAL PUNCTURE, SELECTIVE CATHETER PLACEMENT(S) RENAL ARTERY(IES), FLUOROSCOPY, CONTRAST 0339T INJECTION(S), INTRAPROCEDURAL ROADMAPPING AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS, FLUSH AORTOGRAM AND DIAGNOSTIC RENAL ANGIOGRAPHY WHEN PERFORMED; BILATERAL 0341T QUANTITATIVE PUPILLOMETRY WITH INTERPRETATION AND REPORT, UNILATERAL OR BILATERAL 0342T THERAPEUTIC APHERESIS WITH SELECTIVE HDL DELIPIDATION AND PLASMA REINFUSION 0346T ULTRASOUND, ELASTOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0347T PLACEMENT OF INTERSTITIAL DEVICE(S) IN BONE FOR RADIOSTEREOMETRIC ANALYSIS (RSA) RADIOLOGIC EXAMINATION, RADIOSTEREOMETRIC ANALYSIS (RSA); SPINE, (INCLUDES CERVICAL, 0348T THORACIC AND LUMBOSACRAL, WHEN PERFORMED) RADIOLOGIC EXAMINATION, RADIOSTEREOMETRIC ANALYSIS (RSA); UPPER EXTREMITY(IES), 0349T (INCLUDES SHOULDER, ELBOW, AND WRIST, WHEN PERFORMED) RADIOLOGIC EXAMINATION, RADIOSTEREOMETRIC ANALYSIS (RSA); LOWER EXTREMITY(IES), 0350T (INCLUDES HIP, PROXIMAL FEMUR, KNEE, AND ANKLE, WHEN PERFORMED) OPTICAL COHERENCE TOMOGRAPHY OF BREAST OR AXILLARY LYMPH NODE, EXCISED TISSUE, EACH 0351T SPECIMEN; REAL-TIME INTRAOPERATIVE OPTICAL COHERENCE TOMOGRAPHY OF BREAST OR AXILLARY LYMPH NODE, EXCISED TISSUE, EACH 0352T SPECIMEN; INTERPRETATION AND REPORT, REAL-TIME OR REFERRED 0353T OPTICAL COHERENCE TOMOGRAPHY OF BREAST, SURGICAL CAVITY; REAL-TIME INTRAOPERATIVE OPTICAL COHERENCE TOMOGRAPHY OF BREAST, SURGICAL CAVITY; INTERPRETATION AND REPORT, 0354T REAL-TIME OR REFERRED GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), COLON, WITH 0355T INTERPRETATION AND REPORT INSERTION OF DRUG-ELUTING IMPLANT (INCLUDING PUNCTAL DILATION AND IMPLANT REMOVAL WHEN 0356T PERFORMED) INTO LACRIMAL CANALICULUS, EACH 0357T CRYOPRESERVATION; IMMATURE OOCYTE(S) BIOELECTRICAL IMPEDANCE ANALYSIS WHOLE BODY COMPOSITION ASSESSMENT, WITH 0358T INTERPRETATION AND REPORT BEHAVIOR IDENTIFICATION ASSESSMENT, BY THE PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FACE-TO-FACE WITH PATIENT AND CAREGIVER(S), INCLUDES ADMINISTRATION OF STANDARDIZED AND NON-STANDARDIZED TESTS, DETAILED BEHAVIORAL HISTORY, PATIENT 0359T OBSERVATION AND CAREGIVER INTERVIEW, INTERPRETATION OF TEST RESULTS, DISCUSSION OF FINDINGS AND RECOMMENDATIONS WITH THE PRIMARY GUARDIAN(S)/CAREGIVER(S), AND PREPARATION OF REPORT OBSERVATIONAL BEHAVIORAL FOLLOW-UP ASSESSMENT, INCLUDES PHYSICIAN OR OTHER QUALIFIED 0360T HEALTH CARE PROFESSIONAL DIRECTION WITH INTERPRETATION AND REPORT, ADMINISTERED BY ONE TECHNICIAN; FIRST 30 MINUTES OF TECHNICIAN TIME, FACE-TO-FACE WITH THE PATIENT OBSERVATIONAL BEHAVIORAL FOLLOW-UP ASSESSMENT, INCLUDES PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL DIRECTION WITH INTERPRETATION AND REPORT, ADMINISTERED BY ONE 0361T TECHNICIAN; EACH ADDITIONAL 30 MINUTES OF TECHNICIAN TIME, FACE-TO-FACE WITH THE PATIENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE) EXPOSURE BEHAVIORAL FOLLOW-UP ASSESSMENT, INCLUDES PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL DIRECTION WITH INTERPRETATION AND REPORT, ADMINISTERED BY PHYSICIAN 0362T OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL WITH THE ASSISTANCE OF ONE OR MORE TECHNICIANS; FIRST 30 MINUTES OF TECHNICIAN(S) TIME, FACE-TO-FACE WITH THE PATIENT EXPOSURE BEHAVIORAL FOLLOW-UP ASSESSMENT, INCLUDES PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL DIRECTION WITH INTERPRETATION AND REPORT, ADMINISTERED BY PHYSICIAN 0363T OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL WITH THE ASSISTANCE OF ONE OR MORE TECHNICIANS; EACH ADDITIONAL 30 MINUTES OF TECHNICIAN(S) TIME, FACE-TO-FACE WITH THE PATIENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN, FACE-TO-FACE WITH 0364T ONE PATIENT; FIRST 30 MINUTES OF TECHNICIAN TIME ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN, FACE-TO-FACE WITH 0365T ONE PATIENT; EACH ADDITIONAL 30 MINUTES OF TECHNICIAN TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Printed on 1/25/2018. Page 10 of 22 0366T GROUP ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN, FACE-TO-FACE WITH TWO OR MORE PATIENTS; FIRST 30 MINUTES OF TECHNICIAN TIME GROUP ADAPTIVE BEHAVIOR TREATMENT BY PROTOCOL, ADMINISTERED BY TECHNICIAN, FACE-TO-FACE 0367T WITH TWO OR MORE PATIENTS; EACH ADDITIONAL 30 MINUTES OF TECHNICIAN TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION ADMINISTERED BY PHYSICIAN OR 0368T OTHER QUALIFIED HEALTH CARE PROFESSIONAL WITH ONE PATIENT; FIRST 30 MINUTES OF PATIENT FACE-TO-FACE TIME ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION ADMINISTERED BY PHYSICIAN OR 0369T OTHER QUALIFIED HEALTH CARE PROFESSIONAL WITH ONE PATIENT; EACH ADDITIONAL 30 MINUTES OF PATIENT FACE-TO-FACE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) FAMILY ADAPTIVE BEHAVIOR TREATMENT GUIDANCE, ADMINISTERED BY PHYSICIAN OR OTHER 0370T QUALIFIED HEALTH CARE PROFESSIONAL (WITHOUT THE PATIENT PRESENT) MULTIPLE-FAMILY GROUP ADAPTIVE BEHAVIOR TREATMENT GUIDANCE, ADMINISTERED BY PHYSICIAN 0371T OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (WITHOUT THE PATIENT PRESENT) ADAPTIVE BEHAVIOR TREATMENT SOCIAL SKILLS GROUP, ADMINISTERED BY PHYSICIAN OR OTHER 0372T QUALIFIED HEALTH CARE PROFESSIONAL FACE-TO-FACE WITH MULTIPLE PATIENTS EXPOSURE ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION REQUIRING TWO OR 0373T MORE TECHNICIANS FOR SEVERE MALADAPTIVE BEHAVIOR(S); FIRST 60 MINUTES OF TECHNICIANS' TIME, FACE-TO-FACE WITH PATIENT EXPOSURE ADAPTIVE BEHAVIOR TREATMENT WITH PROTOCOL MODIFICATION REQUIRING TWO OR MORE TECHNICIANS FOR SEVERE MALADAPTIVE BEHAVIOR(S); EACH ADDITIONAL 30 MINUTES OF 0374T TECHNICIANS' TIME FACE-TO-FACE WITH PATIENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, INCLUDING DISCECTOMY WITH 0375T END PLATE PREPARATION (INCLUDES OSTEOPHYTECTOMY FOR NERVE ROOT OR SPINAL CORD DECOMPRESSION AND MICRODISSECTION), CERVICAL, THREE OR MORE LEVELS 0377T ANOSCOPY WITH DIRECTED SUBMUCOSAL INJECTION OF BULKING AGENT FOR FECAL INCONTINENCE VISUAL FIELD ASSESSMENT, WITH CONCURRENT REAL TIME DATA ANALYSIS AND ACCESSIBLE DATA STORAGE WITH PATIENT INITIATED DATA TRANSMITTED TO A REMOTE SURVEILLANCE CENTER FOR UP 0378T TO 30 DAYS; REVIEW AND INTERPRETATION WITH REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL VISUAL FIELD ASSESSMENT, WITH CONCURRENT REAL TIME DATA ANALYSIS AND ACCESSIBLE DATA STORAGE WITH PATIENT INITIATED DATA TRANSMITTED TO A REMOTE SURVEILLANCE CENTER FOR UP 0379T TO 30 DAYS; TECHNICAL SUPPORT AND PATIENT INSTRUCTIONS, SURVEILLANCE, ANALYSIS, AND TRANSMISSION OF DAILY AND EMERGENT DATA REPORTS AS PRESCRIBED BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL COMPUTER-AIDED ANIMATION AND ANALYSIS OF TIME SERIES RETINAL IMAGES FOR THE MONITORING 0380T OF DISEASE PROGRESSION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT EXTERNAL HEART RATE AND 3-AXIS ACCELEROMETER DATA RECORDING UP TO 14 DAYS TO ASSESS CHANGES IN HEART RATE AND TO MONITOR MOTION ANALYSIS FOR THE PURPOSES OF DIAGNOSING 0381T NOCTURNAL EPILEPSY SEIZURE EVENTS; INCLUDES REPORT, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL EXTERNAL HEART RATE AND 3-AXIS ACCELEROMETER DATA RECORDING UP TO 14 DAYS TO ASSESS CHANGES IN HEART RATE AND TO MONITOR MOTION ANALYSIS FOR THE PURPOSES OF DIAGNOSING 0382T NOCTURNAL EPILEPSY SEIZURE EVENTS; INCLUDES REPORT, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, REVIEW AND INTERPRETATION ONLY EXTERNAL HEART RATE AND 3-AXIS ACCELEROMETER DATA RECORDING FROM 15 TO 30 DAYS TO ASSESS CHANGES IN HEART RATE TO MONITOR MOTION ANALYSIS FOR THE PURPOSES OF DIAGNOSING 0383T NOCTURNAL EPILEPSY SEIZURE EVENTS; INCLUDES REPORT, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL EXTERNAL HEART RATE AND 3-AXIS ACCELEROMETER DATA RECORDING FROM 15 TO 30 DAYS TO ASSESS CHANGES IN HEART RATE TO MONITOR MOTION ANALYSIS FOR THE PURPOSES OF DIAGNOSING 0384T NOCTURNAL EPILEPSY SEIZURE EVENTS; INCLUDES REPORT, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, REVIEW AND INTERPRETATION ONLY EXTERNAL HEART RATE AND 3-AXIS ACCELEROMETER DATA RECORDING MORE THAN 30 DAYS TO ASSESS CHANGES IN HEART RATE TO MONITOR MOTION ANALYSIS FOR THE PURPOSES OF DIAGNOSING 0385T NOCTURNAL EPILEPSY SEIZURE EVENTS; INCLUDES REPORT, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL 0386T

Printed on 1/25/2018. Page 11 of 22 EXTERNAL HEART RATE AND 3-AXIS ACCELEROMETER DATA RECORDING MORE THAN 30 DAYS TO ASSESS CHANGES IN HEART RATE TO MONITOR MOTION ANALYSIS FOR THE PURPOSES OF DIAGNOSING NOCTURNAL EPILEPSY SEIZURE EVENTS; INCLUDES REPORT, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, REVIEW AND INTERPRETATION ONLY HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, SKIN SURFACE APPLICATION, PER FRACTION, 0394T INCLUDES BASIC DOSIMETRY, WHEN PERFORMED HIGH DOSE RATE ELECTRONIC BRACHYTHERAPY, INTERSTITIAL OR INTRACAVITARY TREATMENT, PER 0395T FRACTION, INCLUDES BASIC DOSIMETRY, WHEN PERFORMED INTRA-OPERATIVE USE OF KINETIC BALANCE SENSOR FOR IMPLANT STABILITY DURING KNEE 0396T REPLACEMENT ARTHROPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP), WITH OPTICAL ENDOMICROSCOPY 0397T (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) MAGNETIC RESONANCE IMAGE GUIDED HIGH INTENSITY FOCUSED ULTRASOUND (MRGFUS), 0398T STEREOTACTIC ABLATION LESION, INTRACRANIAL FOR MOVEMENT DISORDER INCLUDING STEREOTACTIC NAVIGATION AND FRAME PLACEMENT WHEN PERFORMED MYOCARDIAL STRAIN IMAGING (QUANTITATIVE ASSESSMENT OF MYOCARDIAL MECHANICS USING 0399T IMAGE-BASED ANALYSIS OF LOCAL MYOCARDIAL DYNAMICS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) MULTI-SPECTRAL DIGITAL SKIN LESION ANALYSIS OF CLINICALLY ATYPICAL CUTANEOUS PIGMENTED 0400T LESIONS FOR DETECTION OF MELANOMAS AND HIGH RISK MELANOCYTIC ATYPIA; ONE TO FIVE LESIONS MULTI-SPECTRAL DIGITAL SKIN LESION ANALYSIS OF CLINICALLY ATYPICAL CUTANEOUS PIGMENTED 0401T LESIONS FOR DETECTION OF MELANOMAS AND HIGH RISK MELANOCYTIC ATYPIA; SIX OR MORE LESIONS COLLAGEN CROSS-LINKING OF CORNEA (INCLUDING REMOVAL OF THE CORNEAL EPITHELIUM AND 0402T INTRAOPERATIVE PACHYMETRY WHEN PERFORMED) PREVENTIVE BEHAVIOR CHANGE, INTENSIVE PROGRAM OF PREVENTION OF DIABETES USING A 0403T STANDARDIZED DIABETES PREVENTION PROGRAM CURRICULUM, PROVIDED TO INDIVIDUALS IN A GROUP SETTING, MINIMUM 60 MINUTES, PER DAY 0404T TRANSCERVICAL UTERINE FIBROID(S) ABLATION WITH ULTRASOUND GUIDANCE, RADIOFREQUENCY OVERSIGHT OF THE CARE OF AN EXTRACORPOREAL LIVER ASSIST SYSTEM PATIENT REQUIRING REVIEW OF STATUS, REVIEW OF LABORATORIES AND OTHER STUDIES, AND REVISION OF ORDERS AND LIVER 0405T ASSIST CARE PLAN (AS APPROPRIATE), WITHIN A CALENDAR MONTH, 30 MINUTES OR MORE OF NON- FACE-TO-FACE TIME 0406T NASAL ENDOSCOPY, SURGICAL, ETHMOID SINUS, PLACEMENT OF DRUG ELUTING IMPLANT; NASAL ENDOSCOPY, SURGICAL, ETHMOID SINUS, PLACEMENT OF DRUG ELUTING IMPLANT; WITH 0407T BIOPSY, POLYPECTOMY OR DEBRIDEMENT INSERTION OR REPLACEMENT OF PERMANENT CARDIAC CONTRACTILITY MODULATION SYSTEM, 0408T INCLUDING CONTRACTILITY EVALUATION WHEN PERFORMED, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; PULSE GENERATOR WITH TRANSVENOUS ELECTRODES INSERTION OR REPLACEMENT OF PERMANENT CARDIAC CONTRACTILITY MODULATION SYSTEM, 0409T INCLUDING CONTRACTILITY EVALUATION WHEN PERFORMED, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; PULSE GENERATOR ONLY INSERTION OR REPLACEMENT OF PERMANENT CARDIAC CONTRACTILITY MODULATION SYSTEM, 0410T INCLUDING CONTRACTILITY EVALUATION WHEN PERFORMED, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; ATRIAL ELECTRODE ONLY INSERTION OR REPLACEMENT OF PERMANENT CARDIAC CONTRACTILITY MODULATION SYSTEM, 0411T INCLUDING CONTRACTILITY EVALUATION WHEN PERFORMED, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; VENTRICULAR ELECTRODE ONLY 0412T REMOVAL OF PERMANENT CARDIAC CONTRACTILITY MODULATION SYSTEM; PULSE GENERATOR ONLY REMOVAL OF PERMANENT CARDIAC CONTRACTILITY MODULATION SYSTEM; TRANSVENOUS ELECTRODE 0413T (ATRIAL OR VENTRICULAR) REMOVAL AND REPLACEMENT OF PERMANENT CARDIAC CONTRACTILITY MODULATION SYSTEM PULSE 0414T GENERATOR ONLY REPOSITIONING OF PREVIOUSLY IMPLANTED CARDIAC CONTRACTILITY MODULATION TRANSVENOUS 0415T ELECTRODE (ATRIAL OR VENTRICULAR LEAD) RELOCATION OF SKIN POCKET FOR IMPLANTED CARDIAC CONTRACTILITY MODULATION PULSE 0416T GENERATOR PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED 0417T VALUES WITH ANALYSIS, INCLUDING REVIEW AND REPORT, IMPLANTABLE CARDIAC CONTRACTILITY MODULATION SYSTEM 0418T

Printed on 1/25/2018. Page 12 of 22 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER, IMPLANTABLE CARDIAC CONTRACTILITY MODULATION SYSTEM DESTRUCTION OF NEUROFIBROMA, EXTENSIVE (CUTANEOUS, DERMAL EXTENDING INTO 0419T SUBCUTANEOUS); FACE, HEAD AND NECK, GREATER THAN 50 NEUROFIBROMAS DESTRUCTION OF NEUROFIBROMA, EXTENSIVE (CUTANEOUS, DERMAL EXTENDING INTO 0420T SUBCUTANEOUS); TRUNK AND EXTREMITIES, EXTENSIVE, GREATER THAN 100 NEUROFIBROMAS TRANSURETHRAL WATERJET ABLATION OF PROSTATE, INCLUDING CONTROL OF POST-OPERATIVE BLEEDING, INCLUDING ULTRASOUND GUIDANCE, COMPLETE (VASECTOMY, MEATOTOMY, 0421T CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED WHEN PERFORMED) 0422T TACTILE BREAST IMAGING BY COMPUTER-AIDED TACTILE SENSORS, UNILATERAL OR BILATERAL 0423T SECRETORY TYPE II PHOSPHOLIPASE A2 (SPLA2-IIA) INSERTION OR REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP 0424T APNEA; COMPLETE SYSTEM (TRANSVENOUS PLACEMENT OF RIGHT OR LEFT STIMULATION LEAD, SENSING LEAD, IMPLANTABLE PULSE GENERATOR) INSERTION OR REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP 0425T APNEA; SENSING LEAD ONLY INSERTION OR REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP 0426T APNEA; STIMULATION LEAD ONLY INSERTION OR REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP 0427T APNEA; PULSE GENERATOR ONLY REMOVAL OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; PULSE 0428T GENERATOR ONLY REMOVAL OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; SENSING LEAD 0429T ONLY REMOVAL OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; STIMULATION 0430T LEAD ONLY REMOVAL AND REPLACEMENT OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP 0431T APNEA, PULSE GENERATOR ONLY REPOSITIONING OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; 0432T STIMULATION LEAD ONLY REPOSITIONING OF NEUROSTIMULATOR SYSTEM FOR TREATMENT OF CENTRAL SLEEP APNEA; SENSING 0433T LEAD ONLY INTERROGATION DEVICE EVALUATION IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM FOR 0434T CENTRAL SLEEP APNEA PROGRAMMING DEVICE EVALUATION OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM 0435T FOR CENTRAL SLEEP APNEA; SINGLE SESSION PROGRAMMING DEVICE EVALUATION OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM 0436T FOR CENTRAL SLEEP APNEA; DURING SLEEP STUDY IMPLANTATION OF NON-BIOLOGIC OR SYNTHETIC IMPLANT (EG, POLYPROPYLENE) FOR FASCIAL 0437T REINFORCEMENT OF THE ABDOMINAL WALL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) MYOCARDIAL CONTRAST PERFUSION ECHOCARDIOGRAPHY, AT REST OR WITH STRESS, FOR 0439T ASSESSMENT OF MYOCARDIAL ISCHEMIA OR VIABILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ABLATION, PERCUTANEOUS, CRYOABLATION, INCLUDES IMAGING GUIDANCE; UPPER EXTREMITY 0440T DISTAL/PERIPHERAL NERVE ABLATION, PERCUTANEOUS, CRYOABLATION, INCLUDES IMAGING GUIDANCE; LOWER EXTREMITY 0441T DISTAL/PERIPHERAL NERVE ABLATION, PERCUTANEOUS, CRYOABLATION, INCLUDES IMAGING GUIDANCE; NERVE PLEXUS OR OTHER 0442T TRUNCAL NERVE (EG, BRACHIAL PLEXUS, PUDENDAL NERVE) REAL-TIME SPECTRAL ANALYSIS OF PROSTATE TISSUE BY FLUORESCENCE SPECTROSCOPY, INCLUDING 0443T IMAGING GUIDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INITIAL PLACEMENT OF A DRUG-ELUTING OCULAR INSERT UNDER ONE OR MORE EYELIDS, INCLUDING 0444T FITTING, TRAINING, AND INSERTION, UNILATERAL OR BILATERAL SUBSEQUENT PLACEMENT OF A DRUG-ELUTING OCULAR INSERT UNDER ONE OR MORE EYELIDS, 0445T INCLUDING RE-TRAINING, AND REMOVAL OF EXISTING INSERT, UNILATERAL OR BILATERAL CREATION OF SUBCUTANEOUS POCKET WITH INSERTION OF IMPLANTABLE INTERSTITIAL GLUCOSE 0446T SENSOR, INCLUDING SYSTEM ACTIVATION AND PATIENT TRAINING REMOVAL OF IMPLANTABLE INTERSTITIAL GLUCOSE SENSOR FROM SUBCUTANEOUS POCKET VIA 0447T INCISION 0448T

Printed on 1/25/2018. Page 13 of 22 REMOVAL OF IMPLANTABLE INTERSTITIAL GLUCOSE SENSOR WITH CREATION OF SUBCUTANEOUS POCKET AT DIFFERENT ANATOMIC SITE AND INSERTION OF NEW IMPLANTABLE SENSOR, INCLUDING SYSTEM ACTIVATION INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND 0451T THERAPEUTIC PARAMETERS; COMPLETE SYSTEM (COUNTERPULSATION DEVICE, VASCULAR GRAFT, IMPLANTABLE VASCULAR HEMOSTATIC SEAL, MECHANO-ELECTRICAL SKIN INTERFACE AND SUBCUTANEOUS ELECTRODES) INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION 0452T VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; AORTIC COUNTERPULSATION DEVICE AND VASCULAR HEMOSTATIC SEAL INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION 0453T VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; MECHANO-ELECTRICAL SKIN INTERFACE INSERTION OR REPLACEMENT OF A PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION 0454T VENTRICULAR ASSIST SYSTEM, ENDOVASCULAR APPROACH, AND PROGRAMMING OF SENSING AND THERAPEUTIC PARAMETERS; SUBCUTANEOUS ELECTRODE REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; 0455T COMPLETE SYSTEM (AORTIC COUNTERPULSATION DEVICE, VASCULAR HEMOSTATIC SEAL, MECHANO- ELECTRICAL SKIN INTERFACE AND ELECTRODES) REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; 0456T AORTIC COUNTERPULSATION DEVICE AND VASCULAR HEMOSTATIC SEAL REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; 0457T MECHANO-ELECTRICAL SKIN INTERFACE REMOVAL OF PERMANENTLY IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM; 0458T SUBCUTANEOUS ELECTRODE RELOCATION OF SKIN POCKET WITH REPLACEMENT OF IMPLANTED AORTIC COUNTERPULSATION 0459T VENTRICULAR ASSIST DEVICE, MECHANO-ELECTRICAL SKIN INTERFACE AND ELECTRODES REPOSITIONING OF PREVIOUSLY IMPLANTED AORTIC COUNTERPULSATION VENTRICULAR ASSIST 0460T DEVICE; SUBCUTANEOUS ELECTRODE REPOSITIONING OF PREVIOUSLY IMPLANTED AORTIC COUNTERPULSATION VENTRICULAR ASSIST 0461T DEVICE; AORTIC COUNTERPULSATION DEVICE PROGRAMMING DEVICE EVALUATION (IN PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE MECHANO-ELECTRICAL SKIN INTERFACE AND/OR EXTERNAL DRIVER TO TEST THE FUNCTION OF THE 0462T DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, INCLUDING REVIEW AND REPORT, IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, PER DAY INTERROGATION DEVICE EVALUATION (IN PERSON) WITH ANALYSIS, REVIEW AND REPORT, INCLUDES 0463T CONNECTION, RECORDING AND DISCONNECTION PER PATIENT ENCOUNTER, IMPLANTABLE AORTIC COUNTERPULSATION VENTRICULAR ASSIST SYSTEM, PER DAY SUPRACHOROIDAL INJECTION OF A PHARMACOLOGIC AGENT (DOES NOT INCLUDE SUPPLY OF 0465T MEDICATION) INSERTION OF CHEST WALL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY, INCLUDING 0466T CONNECTION TO PULSE GENERATOR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REVISION OR REPLACEMENT OF CHEST WALL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY, 0467T INCLUDING CONNECTION TO EXISTING PULSE GENERATOR 0468T REMOVAL OF CHEST WALL RESPIRATORY SENSOR ELECTRODE OR ELECTRODE ARRAY OPTICAL COHERENCE TOMOGRAPHY (OCT) FOR MICROSTRUCTURAL AND MORPHOLOGICAL IMAGING OF 0470T SKIN, IMAGE ACQUISITION, INTERPRETATION, AND REPORT; FIRST LESION OPTICAL COHERENCE TOMOGRAPHY (OCT) FOR MICROSTRUCTURAL AND MORPHOLOGICAL IMAGING OF 0471T SKIN, IMAGE ACQUISITION, INTERPRETATION, AND REPORT; EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DEVICE EVALUATION, INTERROGATION, AND INITIAL PROGRAMMING OF INTRAOCULAR RETINAL ELECTRODE ARRAY (EG, RETINAL PROSTHESIS), IN PERSON, WITH ITERATIVE ADJUSTMENT OF THE 0472T IMPLANTABLE DEVICE TO TEST FUNCTIONALITY, SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, INCLUDING VISUAL TRAINING, WITH REVIEW AND REPORT BY A QUALIFIED HEALTH CARE PROFESSIONAL DEVICE EVALUATION AND INTERROGATION OF INTRAOCULAR RETINAL ELECTRODE ARRAY (EG, RETINAL 0473T PROSTHESIS), IN PERSON, INCLUDING REPROGRAMMING AND VISUAL TRAINING, WHEN PERFORMED, WITH REVIEW AND REPORT BY A QUALIFIED HEALTH CARE PROFESSIONAL RECORDING OF FETAL MAGNETIC CARDIAC SIGNAL USING AT LEAST 3 CHANNELS; PATIENT RECORDING AND STORAGE, DATA SCANNING WITH SIGNAL EXTRACTION, TECHNICAL ANALYSIS AND RESULT, AS 0475T WELL AS SUPERVISION, REVIEW, AND INTERPRETATION OF REPORT BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL

Printed on 1/25/2018. Page 14 of 22 0476T RECORDING OF FETAL MAGNETIC CARDIAC SIGNAL USING AT LEAST 3 CHANNELS; PATIENT RECORDING, DATA SCANNING, WITH RAW ELECTRONIC SIGNAL TRANSFER OF DATA AND STORAGE RECORDING OF FETAL MAGNETIC CARDIAC SIGNAL USING AT LEAST 3 CHANNELS; SIGNAL EXTRACTION, 0477T TECHNICAL ANALYSIS, AND RESULT RECORDING OF FETAL MAGNETIC CARDIAC SIGNAL USING AT LEAST 3 CHANNELS; REVIEW, 0478T INTERPRETATION, REPORT BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL FRACTIONAL ABLATIVE LASER FENESTRATION OF BURN AND TRAUMATIC SCARS FOR FUNCTIONAL 0479T IMPROVEMENT; FIRST 100 CM2 OR PART THEREOF, OR 1% OF BODY SURFACE AREA OF INFANTS AND CHILDREN FRACTIONAL ABLATIVE LASER FENESTRATION OF BURN AND TRAUMATIC SCARS FOR FUNCTIONAL IMPROVEMENT; EACH ADDITIONAL 100 CM2, OR EACH ADDITIONAL 1% OF BODY SURFACE AREA OF 0480T INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION(S), AUTOLOGOUS WHITE BLOOD CELL CONCENTRATE (AUTOLOGOUS PROTEIN SOLUTION), 0481T ANY SITE, INCLUDING IMAGE GUIDANCE, HARVESTING AND PREPARATION, WHEN PERFORMED ABSOLUTE QUANTITATION OF MYOCARDIAL BLOOD FLOW, POSITRON EMISSION TOMOGRAPHY (PET), 0482T REST AND STRESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) TRANSCATHETER MITRAL VALVE IMPLANTATION/REPLACEMENT (TMVI) WITH PROSTHETIC VALVE; 0483T PERCUTANEOUS APPROACH, INCLUDING TRANSSEPTAL PUNCTURE, WHEN PERFORMED TRANSCATHETER MITRAL VALVE IMPLANTATION/REPLACEMENT (TMVI) WITH PROSTHETIC VALVE; 0484T TRANSTHORACIC EXPOSURE (EG, THORACOTOMY, TRANSAPICAL) OPTICAL COHERENCE TOMOGRAPHY (OCT) OF MIDDLE EAR, WITH INTERPRETATION AND REPORT; 0485T UNILATERAL OPTICAL COHERENCE TOMOGRAPHY (OCT) OF MIDDLE EAR, WITH INTERPRETATION AND REPORT; 0486T BILATERAL 0487T BIOMECHANICAL MAPPING, TRANSVAGINAL, WITH REPORT PREVENTIVE BEHAVIOR CHANGE, ONLINE/ELECTRONIC STRUCTURED INTENSIVE PROGRAM FOR 0488T PREVENTION OF DIABETES USING A STANDARDIZED DIABETES PREVENTION PROGRAM CURRICULUM, PROVIDED TO AN INDIVIDUAL, PER 30 DAYS AUTOLOGOUS ADIPOSE-DERIVED REGENERATIVE CELL THERAPY FOR SCLERODERMA IN THE HANDS; ADIPOSE TISSUE HARVESTING, ISOLATION AND PREPARATION OF HARVESTED CELLS INCLUDING 0489T INCUBATION WITH CELL DISSOCIATION ENZYMES, REMOVAL OF NON-VIABLE CELLS AND DEBRIS, DETERMINATION OF CONCENTRATION AND DILUTION OF REGENERATIVE CELLS AUTOLOGOUS ADIPOSE-DERIVED REGENERATIVE CELL THERAPY FOR SCLERODERMA IN THE HANDS; 0490T MULTIPLE INJECTIONS IN ONE OR BOTH HANDS ABLATIVE LASER TREATMENT, NON-CONTACT, FULL FIELD AND FRACTIONAL ABLATION, OPEN WOUND, 0491T PER DAY, TOTAL TREATMENT SURFACE AREA; FIRST 20 SQ CM OR LESS ABLATIVE LASER TREATMENT, NON-CONTACT, FULL FIELD AND FRACTIONAL ABLATION, OPEN WOUND, 0492T PER DAY, TOTAL TREATMENT SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NEAR-INFRARED SPECTROSCOPY STUDIES OF LOWER EXTREMITY WOUNDS (EG, FOR OXYHEMOGLOBIN 0493T MEASUREMENT) SURGICAL PREPARATION AND CANNULATION OF MARGINAL (EXTENDED) CADAVER DONOR LUNG(S) TO 0494T EX VIVO ORGAN PERFUSION SYSTEM, INCLUDING DECANNULATION, SEPARATION FROM THE PERFUSION SYSTEM, AND COLD PRESERVATION OF THE ALLOGRAFT PRIOR TO IMPLANTATION, WHEN PERFORMED INITIATION AND MONITORING MARGINAL (EXTENDED) CADAVER DONOR LUNG(S) ORGAN PERFUSION SYSTEM BY PHYSICIAN OR QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING PHYSIOLOGICAL AND LABORATORY ASSESSMENT (EG, PULMONARY ARTERY FLOW, PULMONARY ARTERY PRESSURE, LEFT 0495T ATRIAL PRESSURE, PULMONARY VASCULAR RESISTANCE, MEAN/PEAK AND PLATEAU AIRWAY PRESSURE, DYNAMIC COMPLIANCE AND PERFUSATE GAS ANALYSIS), INCLUDING BRONCHOSCOPY AND X RAY WHEN PERFORMED; FIRST TWO HOURS IN STERILE FIELD INITIATION AND MONITORING MARGINAL (EXTENDED) CADAVER DONOR LUNG(S) ORGAN PERFUSION SYSTEM BY PHYSICIAN OR QUALIFIED HEALTH CARE PROFESSIONAL, INCLUDING PHYSIOLOGICAL AND LABORATORY ASSESSMENT (EG, PULMONARY ARTERY FLOW, PULMONARY ARTERY PRESSURE, LEFT 0496T ATRIAL PRESSURE, PULMONARY VASCULAR RESISTANCE, MEAN/PEAK AND PLATEAU AIRWAY PRESSURE, DYNAMIC COMPLIANCE AND PERFUSATE GAS ANALYSIS), INCLUDING BRONCHOSCOPY AND X RAY WHEN PERFORMED; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) EXTERNAL PATIENT-ACTIVATED, PHYSICIAN- OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL- 0497T PRESCRIBED, ELECTROCARDIOGRAPHIC RHYTHM DERIVED EVENT RECORDER WITHOUT 24 HOUR ATTENDED MONITORING; IN-OFFICE CONNECTION 0498T

Printed on 1/25/2018. Page 15 of 22 EXTERNAL PATIENT-ACTIVATED, PHYSICIAN- OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL- PRESCRIBED, ELECTROCARDIOGRAPHIC RHYTHM DERIVED EVENT RECORDER WITHOUT 24 HOUR ATTENDED MONITORING; REVIEW AND INTERPRETATION BY A PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PER 30 DAYS WITH AT LEAST ONE PATIENT-GENERATED TRIGGERED EVENT CYSTOURETHROSCOPY, WITH MECHANICAL DILATION AND URETHRAL THERAPEUTIC DRUG DELIVERY 0499T FOR URETHRAL STRICTURE OR STENOSIS, INCLUDING FLUOROSCOPY, WHEN PERFORMED INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), HUMAN PAPILLOMAVIRUS (HPV) FOR 0500T FIVE OR MORE SEPARATELY REPORTED HIGH-RISK HPV TYPES (EG, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (IE, GENOTYPING) NONINVASIVE ESTIMATED CORONARY FRACTIONAL FLOW RESERVE (FFR) DERIVED FROM CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY DATA USING COMPUTATION FLUID DYNAMICS PHYSIOLOGIC SIMULATION SOFTWARE ANALYSIS OF FUNCTIONAL DATA TO ASSESS THE SEVERITY OF CORONARY 0501T ARTERY DISEASE; DATA PREPARATION AND TRANSMISSION, ANALYSIS OF FLUID DYNAMICS AND SIMULATED MAXIMAL CORONARY HYPEREMIA, GENERATION OF ESTIMATED FFR MODEL, WITH ANATOMICAL DATA REVIEW IN COMPARISON WITH ESTIMATED FFR MODEL TO RECONCILE DISCORDANT DATA, INTERPRETATION AND REPORT NONINVASIVE ESTIMATED CORONARY FRACTIONAL FLOW RESERVE (FFR) DERIVED FROM CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY DATA USING COMPUTATION FLUID DYNAMICS PHYSIOLOGIC 0502T SIMULATION SOFTWARE ANALYSIS OF FUNCTIONAL DATA TO ASSESS THE SEVERITY OF CORONARY ARTERY DISEASE; DATA PREPARATION AND TRANSMISSION NONINVASIVE ESTIMATED CORONARY FRACTIONAL FLOW RESERVE (FFR) DERIVED FROM CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY DATA USING COMPUTATION FLUID DYNAMICS PHYSIOLOGIC 0503T SIMULATION SOFTWARE ANALYSIS OF FUNCTIONAL DATA TO ASSESS THE SEVERITY OF CORONARY ARTERY DISEASE; ANALYSIS OF FLUID DYNAMICS AND SIMULATED MAXIMAL CORONARY HYPEREMIA, AND GENERATION OF ESTIMATED FFR MODEL NONINVASIVE ESTIMATED CORONARY FRACTIONAL FLOW RESERVE (FFR) DERIVED FROM CORONARY COMPUTED TOMOGRAPHY ANGIOGRAPHY DATA USING COMPUTATION FLUID DYNAMICS PHYSIOLOGIC 0504T SIMULATION SOFTWARE ANALYSIS OF FUNCTIONAL DATA TO ASSESS THE SEVERITY OF CORONARY ARTERY DISEASE; ANATOMICAL DATA REVIEW IN COMPARISON WITH ESTIMATED FFR MODEL TO RECONCILE DISCORDANT DATA, INTERPRETATION AND REPORT

Group 2 Paragraph:

ONLY the CPT/HCPCS codes listed below are considered medically necessary:

Group 2 Codes: PLACEMENT OF A SUBCONJUNCTIVAL RETINAL PROSTHESIS RECEIVER AND PULSE GENERATOR, AND 0100T IMPLANTATION OF INTRAOCULAR RETINAL ELECTRODE ARRAY, WITH VITRECTOMY EXCISION OF RECTAL TUMOR, TRANSANAL ENDOSCOPIC MICROSURGICAL APPROACH (IE, TEMS), 0184T INCLUDING MUSCULARIS PROPRIA (IE, FULL THICKNESS) 0249T LIGATION, HEMORRHOIDAL VASCULAR BUNDLE(S), INCLUDING ULTRASOUND GUIDANCE EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY 0295T CONTINUOUS RHYTHM RECORDING AND STORAGE; INCLUDES RECORDING, SCANNING ANALYSIS WITH REPORT, REVIEW AND INTERPRETATION EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY 0296T CONTINUOUS RHYTHM RECORDING AND STORAGE; RECORDING (INCLUDES CONNECTION AND INITIAL RECORDING) EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY 0297T CONTINUOUS RHYTHM RECORDING AND STORAGE; SCANNING ANALYSIS WITH REPORT EXTERNAL ELECTROCARDIOGRAPHIC RECORDING FOR MORE THAN 48 HOURS UP TO 21 DAYS BY 0298T CONTINUOUS RHYTHM RECORDING AND STORAGE; REVIEW AND INTERPRETATION

ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: N/A

Group 1 Codes: ICD-10 Codes Description XX000 Not Applicable

ICD-10 Codes that DO NOT Support Medical Necessity

Printed on 1/25/2018. Page 16 of 22 Group 1 Paragraph:

Not applicable

Group 1 Codes: ICD-10 Codes Description XX000 Not Applicable

ICD-10 Additional Information Back to Top General Information

Associated Information Documentation Requirements: The patient's medical record must contain documentation that fully supports the medical necessity for Category III CPT codes as they are covered by Medicare. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, results of pertinent diagnostic tests or procedures, and any other records that describe or support the evaluation and treatment of the patient.

Appendices: Not applicable

Utilization Guidelines: Not applicable

Sources of Information The bibliography is attached below as a separate document in the "Associated Information" section and presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses in the attached document.

Bibliography

N/A

Revision Revision History History Revision History Explanation Reason(s) for Change Date Number Due to the annual CPT coding update, the following range of CPT codes was added to the “CPT/HCPCS Codes” section- Group 1, effective for services rendered on or after 1/1/2018: 0479T- 0504T.

Due to the annual CPT coding update, the following CPT codes • Revisions Due To 01/01/2018 R26 were deleted, effective 12/31/2017: 0178T-0180T, 0293T- CPT/HCPCS Code 0294T, 0299T, 0300T- 0310T. Changes

CPT code 0340T was replaced by 32994; 0438T was replaced by 55874; 0051T-0053T range was replaced by 33527-33529; 0255T was replaced by 0254T.

Printed on 1/25/2018. Page 17 of 22 Revision Revision History History Revision History Explanation Reason(s) for Change Date Number DATE (01/01/2018): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

CPT code 0191T and associated ICD10 Diagnosis codes were removed from the “ICD-10 Codes that Support Medical Necessity” section and from the “Coverage Indications, Limitations and/or Medical Necessity” section. Please refer to L37244 Micro-Invasive Glaucoma Surgery, effective for services rendered on or after 12/01/2017.

CPT codes 0376T, 0449T, 0474T, and 0450T were removed from • Provider 12/01/2017 R25 the “CPT/HCPCS Codes” section-Group 1. Please refer to L37244 Education/Guidance Micro-Invasive Glaucoma Surgery, effective for services on or after 12/01/2017.

DATE (12/01/2017): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. Based on NCD 20.8.4 Leadless Pacemakers, CPT codes 0387T, 0389T, 0390T, and 0391T were removed from the LCD, effective for services rendered on or after January 18, 2017.

Removed CPT code 0388T from the LCD, effective for services rendered on or after January 1, 2016. • Provider

Education/Guidance • Typographical Error 09/01/2017 R24 DATE (08/15/2017): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict • Other (NCD 20.8.4 Leadless coverage which requires comment and notice. This Pacemakers) revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Corrected typographical error in Revision History.

• Provider Based on NCD 20.8.4 Leadless Pacemakers, CPT Education/Guidance 09/01/2017 R23 codes 0387T, 0388T, 0389T, 03090T, and 0391T were • Other (NCD 20.8.4 removed from the LCD, effective for services rendered Leadless on or after January 18, 2017. Pacemakers )

Printed on 1/25/2018. Page 18 of 22 Revision Revision History History Revision History Explanation Reason(s) for Change Date Number DATE (08/15/2017): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Added CPT code range 0470T-0478T, effective for services rendered on or after July 1, 2017.

Based on reconsideration requests to provide coverage for CPT code 0438T– December 2016 and July 2017, the responses to the requests for reconsideration to provide coverage for CPT code 0438T were added as an attachment to the “Associated Documents" section of the LCD. No changes were made in • Provider coverage. Education/Guidance • Revisions Due To 08/01/2017 R22 CPT/HCPCS Code Added a bibliography to Sources of Information document Changes related to Reconsideration Requests for CPT code 0438T. • Reconsideration Request DATE (08/01/2017): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Based on a reconsideration request to provide coverage for Hypoglossal Nerve Stimulation for OSA - 0466T, 0467T, 0468T – • Request for April 2017, the response to the request for reconsideration to Coverage by a 03/16/2017 R21 provide coverage for Hypoglossal Nerve Stimulation for OSA was Practitioner (Part added as an attachment to the “Associated Documents" section B) of the LCD. No changes were made in coverage. CPT codes 0333T and 0464T were removed from the CPT/HCPCS Code section- Group1- Category III CPT codes considered not • Provider 03/16/2017 R20 medically necessary. Refer to LCD L36831 Visual Education/Guidance Electrophysiology Testing, effective for services rendered on or after 3/16/2017. The effective date for the addition of ICD-10-CM code H40.1110 • Typographical 01/01/2017 R19 to the ICD-10 Codes that Support Medical Necessity -Group 1 Error 0191T, has been corrected from 10/01/2015 to 10/01/2016. Added ICD-10-CM code H40.1110 to the ICD-10 Codes that • Provider 01/01/2017 R18 Support Medical Necessity -Group 1 0191T, effective for services Education/Guidance rendered on or after 10/01/2015. Added the following language to define the process to request coverage to the Abstract section: "If a provider believes that any Category III code, included in CPT Code Section, Group 1, qualifies for coverage (is proven to be safe and effective as well • Revisions Due To 01/01/2017 R17 as reasonable and necessary), the provider may request CPT/HCPCS Code coverage and inclusion of the Category III code in this LCD Changes through the LCD Reconsideration Process. Peer reviewed scientific evidence is required for consideration.

Printed on 1/25/2018. Page 19 of 22 Revision Revision History History Revision History Explanation Reason(s) for Change Date Number CPT code 0019T has been deleted and should be reported under CPT code 20999; CPT code 0169T has been deleted and should be reported under CPT code 64999; CPT code 0171T has been deleted and should be reported under CPT code 22867; CPT code 0172T has been deleted and should be reported under CPT code 22868, 22870; HCPCS Code C1821 has been deleted; CPT code range 0282T-0285T has been deleted and should be reported under CPT code 64999; CPT code 0286T has been deleted and should be reported under CPT code 76499; CPT code 0287T has been deleted; CPT code range 0288T-0289T has been deleted and should be reported under CPT code 46999; CPT code 0291T has been deleted and should be reported under CPT code 92978; CPT code 0292T has been deleted and should be reported under CPT code 92979. CPT code 0336T has been deleted and should be reported with code 58674. CPT code 0392T has been deleted and should be reported with code 43284. CPT code 0393T has been deleted and should be reported with CPT code 43285.

Added CPT code range 0446T-0468T to CPT/HCPCS Section Group 1.

Based on the CPT/HCPCS annual update, the descriptions for the following codes have been changed:0274T, 0409T, 0415T, 0418T, 0419T, 0420T, 0434T, 0437T, 0439T, 0443T Added multiple 2017 ICD-10-CM codes to the ICD-10 Codes that • Revisions Due To 10/01/2016 R16 Support Medical Necessity section (Group 2) due to the annual ICD-10-CM Code ICD-10-CM update. Changes Based on a reconsideration request to provide coverage for CPT codes 0394T, received on 03/10/2016, sources reviewed were added to the “Associated Documents" section of the LCD as an attachment. No changes were made in coverage.

Based on a reconsideration request to provide coverage for CPT codes 0394T-0395T, received on 03/9/2016, sources reviewed • Revisions Due To were added to the “Associated Documents" section of the LCD as CPT/HCPCS Code 07/01/2016 R15 an attachment. No changes were made in coverage. Changes • Reconsideration Based on a reconsideration request to provide coverage for CPT Request codes 0406T-0407T, received on 04/27/2016, sources reviewed were added to the “Associated Documents" section of the LCD as an attachment. No changes were made in coverage.

Added CPT code range 0437T- 0445T to CPT/HCPCS Section Group 1, effective for services rendered on or after 07/01/2016. • Provider Education/Guidance Based on CMS final decision memorandum for Percutaneous Left • Other (CMS final Atrial Appendage Closure (LAAC) (CAG-00445N), LC, CPT code decision memorandum for 02/08/2016 R14 0281T has been deleted, effective for services rendered on or after February 8, 2016. Percutaneous Left Atrial Appendage Closure (LAAC) (CAG-00445N), LC.) • Request for Added ICD-10-CM code H40.89 to support medical necessity of Coverage by a 01/01/2016 R13 CPT code 0191T, effective for services rendered on or after Practitioner (Part 10/01/2015. B) Description changes were made to CPT codes 0419T-0421T due • Revisions Due To 01/01/2016 R12 to the annual HCPCS update for 2016, effective for services CPT/HCPCS Code rendered on or after 01/01/2016. Changes 01/01/2016 R11 Printed on 1/25/2018. Page 20 of 22 Revision Revision History History Revision History Explanation Reason(s) for Change Date Number Added the following 2016 CPT code ranges to the CPT/HCPCS • Revisions Due To Code Section, Group1 (CPT codes that are considered not CPT/HCPCS Code medically necessary) effective for services rendered on or after Changes 1/1/2016: 0394T-0399T and 0400T-0436T, effective for services rendered on or after 1/1/2016.

Deleted the following CPT codes from Group 1, effective for services rendered on or after 1/1/2016: 0099T was replaced by 65785; 0103T was replaced by 84999; 0123T was replaced by 66999; 0182T was replaced by (see 0394T, 0395T); 0223T was replaced by 93799; 0224T was replaced by 93799; 0225T was replaced by 93799; 0233T was replaced by 88749; 0240T was replaced by 91010; 0241T was replaced by 91013; 0243T was replaced by 94799; 0244T was replaced by 94799; 0262T was replaced by 33477; 0311T was replaced by 93050.

CPT code 0262T, effective for services rendered on or after August 4, 2015, was replaced by CPT code 33477, effective for services rendered on or after 1/1/2016.

Added CPT code 0100T- Coverage for the placement of a subconjunctival prosthesis receiver and pulse generator, and implantation of intraocular retinal electrode array, with • Provider 10/01/2015 R10 vitrectomy to the CPT/HCPCS Code section (Group 2). CPT code Education/Guidance 0100T will be allowed for the FDA-approved indications, effective for dates of service on or after 06/01/2015. Based on a reconsideration request to provide coverage for CPT codes 0392T-0393T, received on 07/21/2015, sources reviewed were added to the “Associated Documents" section of the LCD as an attachment. No changes were made in coverage. • Reconsideration 10/01/2015 R9 Request Based on a reconsideration request to provide coverage for CPT code 0336T, received on 06/24/2015, sources reviewed were added to the “Associated Documents" section of the LCD as an attachment. No changes were made in coverage. Added HCPCS code C1821, and the following language applicable to 0171T and 0172T section: Coverage for the device will be • Provider 10/01/2015 R8 allowed for the FDA-approved indications. If the procedure is Education/Guidance denied as not medically necessary, the device will be denied also. CPT codes 0392T and 0393T were added to the CPT/HCPCS • Provider 10/01/2015 R7 section of codes that are considered not medically necessary. Education/Guidance • Provider 10/01/2015 R6 Bill type codes added Education/Guidance CPT code 0275T was removed from the LCD because Article A51849 for Percutaneous Laminotomy/Laminectomy (Intralaminar Approach) (0275T) was retired effective January 9, 2014. CMS issued a Decision Memo for Percutaneous Image- guided Lumbar Decompression for Lumbar Spinal Stenosis (CAG- 00433N) which replaced Article A51849. • Provider 10/01/2015 R5 Education/Guidance The following CPT codes were omitted in error from the group of CPT codes that are considered not medically necessary: CPT codes 0071T and 0072T, effective for services rendered on or after 1/1/2005 and CPT codes 0234T through 0244T, effective for services rendered on or after 1/1/2011.

• Provider 10/01/2015 R4 Education/Guidance

Printed on 1/25/2018. Page 21 of 22 Revision Revision History History Revision History Explanation Reason(s) for Change Date Number Deleted the following outdated ICD-10-CM group regarding CPT codes 0171T and 0172T: For dates of service prior to 10/01/2010, the following ICD-10-CM codes that support medical necessity includes but is not limited to: G96.9*, M48.06. *The ICD-10-CM code G96.9 (Disorder of central nervous system, unspecified) may be used for neurogenic intermittent claudication. CPT code 0357T has been added to the group of CPT codes that • Provider 10/01/2015 R3 are considered not medically necessary. Education/Guidance CPT code 0345T has been deleted from the Category III CPT® Codes LCD, effective for services rendered on or after 8/7/2014.

• Provider 10/01/2015 R2 The National Coverage Decision (NCD) - Transcatheter Mitral Valve Repair (TMVR)- allows coverage for TMVR, based on Education/Guidance guidance provided in the NCD- Transcatheter Mitral Valve Repair (TMVR) (20.33) and in billing instructions in Med Learn Matters Article (MLM9002). The ICD10 version of the LCD has been updated to incorporate • Provider 10/01/2015 R1 cahnges in the ICD9 version. Education/Guidance Back to Top Associated Documents

Attachments Sources of Information (PDF - 512 KB ) Hypoglossal Nerve Stimulation-OSA (PDF - 731 KB ) CPT Code 0438T-Reconsideration (PDF - 216 KB )