FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 77057 Screening mammography, bilateral (two view film study of each breast) Screening mammogram -TC -Technical/Facility Component  Two views of each breast -26 -Professional Component  Performed on an asymptomatic woman G0202 Screening mammography producing direct digital image, bilateral, all views Digital screening mammogram -TC -Technical/Facility Component  Two views of each breast -26 -Professional Component  Performed on an asymptomatic woman 77055 Mammography; unilateral Diagnostic mammogram -TC -Technical/Facility Component  Two or more views of one breast -26 -Professional Component  Performed on a symptomatic woman G0206 Diagnostic mammography, producing direct digital image, unilateral, all Digital diagnostic mammogram -TC views  Two or more views of one breast -26 -Technical/Facility Component  Performed on a symptomatic woman -Professional Component 77056 Mammography; bilateral Diagnostic mammogram -TC -Technical/Facility Component  Two or more views of each breast -26 -Professional Component  Performed on a symptomatic woman G0204 Diagnostic mammography, producing direct digital image, bilateral, all Digital diagnostic mammogram -TC views  Two or more views of each breast -26 -Technical/Facility Component  Performed on a symptomatic woman -Professional Component 88141 Cytopathology, cervical or vaginal (any reporting system); requiring Pap test interpretation by physician (List separately in addition to code for technical  Laboratory professional services service)  Use in conjunction with codes 88142, 88143, 88164, 88165 when physician interpretation of Pap test is required

FY17 1 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 88142 Cytopathology, cervical or vaginal (any reporting system), collected in Thin Prep Pap test preservative fluid, automated thin layer preparation; manual screening under  Laboratory technical services physician supervision  Manual screening  Professional component indicated by 88141 when physician interpretation required 88143 Cytopathology, cervical or vaginal (any reporting system), collected in Thin Prep Pap test - Rescreening preservative fluid, automated thin layer preparation; with manual screening  Laboratory technical services and rescreening under physician supervision  Manual screening  Professional component indicted by 88141 when physician interpretation required 88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual Conventional Pap test screening under physician supervision  Laboratory technical services  Professional component indicated by 88141 when physician interpretation required 88165 Cytopathology, slides, cervical or vaginal (the Bethesda System); with Conventional Pap test – Rescreening manual screening and rescreening under physician supervision  Laboratory technical services  Professional component indicated by 88141 when physician interpretation required 88174 Cytopathology, cervical or vaginal (any reporting system), collected in Thin Prep Pap test preservative fluid, automated thin layer preparation; screening by automated  Laboratory technical services system, under physician supervision  Automated screening 88175 Cytopathology, cervical or vaginal (any reporting system), collected in Thin Prep Pap test - Rescreening preservative fluid, automated thin layer preparation; with screening by  Laboratory technical services automated system and manual rescreening, under physician supervision  Automated screening with manual rescreening G0123 Screening cytopathology, cervical or vaginal (any reporting system), Thin Prep Pap test collected in preservative fluid, automated thin layer preparation, screening  Laboratory technical services by cytotechnologist under physician supervision.  Automated screening

FY17 2 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) G0124 Screening cytopathology, cervical or vaginal (any reporting system), Thin Prep Pap test collected in preservative fluid, automated thin layer preparation, requiring  Automated screening interpretation by physician.  Professional component indicated by 88141 when physician interpretation required G0145 Screening cytopathology, cervical or vaginal (any reporting system), Thin Prep Pap test collected in preservative fluid, automated thin layer preparation, with  Laboratory technical services screening by automated system and manual rescreening under physician  Automated screening with manual rescreening supervision. 87624 Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, HPV typing of high-risk strain human, amplified probe technique (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) 87625 Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, HPV, types 16 and 18 only, includes type 45, if human, amplified probe technique performed 99201 Office or other outpatient visit for the evaluation and management of a new Partial annual clinical exam patient, which requires these three key components:  Either CBE only OR pelvic/Pap only  a problem focused history;  Symptomatic or diagnosed new patient  a problem focused examination; and  straight forward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problems are self limited or minor. Providers typically spend 10 minutes face-to-face with the patient and/or family.

FY17 3 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 99202 Office or other outpatient visit for the evaluation and management of a new Partial annual clinical exam patient, which requires these three key components:  Either CBE only OR pelvic/Pap only  an expanded problem focused history;  Symptomatic or diagnosed new patient OR  an expanded problem focused examination; and colposcopy office visit  straight forward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Providers typically spend 20 minutes face-to-face with the patient and/or family. 99203 Office or other outpatient visit for the evaluation and management of a new Full annual clinical exam patient, which requires these three key components:  CBE AND pelvic/Pap (if due for Pap test)  a detailed history;  Symptomatic or diagnosed new patient  a detailed examination; and  medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate severity. Providers typically spend 30 minutes face-to-face with the patient and/or family.

FY17 4 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 99204 Breast or Cervical Consultation Full annual clinical exam Office or other outpatient visit for the evaluation and management of a new  CBE AND pelvic/Pap (if due for Pap test) patient, which requires these three key components:  Symptomatic or diagnosed new patient  a comprehensive history;  a comprehensive examination; and  medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Providers typically spend 45 minutes face-to-face with the patient and/or family. 99205 Breast or Cervical Consultation Full annual clinical exam Office or other outpatient visit for the evaluation and management of a new  CBE AND pelvic/Pap (if due for Pap test) patient, which requires these three key components:  Symptomatic or diagnosed new patient  a comprehensive history;  a comprehensive examination; and  medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Providers typically spend 60 minutes face-to-face with the patient and/or family. 99211 Office or other outpatient visit for the evaluation and management of an Partial annual clinical exam established patient that may not require the presence of a physician.  Either CBE only OR pelvic/Pap only Usually, the presenting problem(s) are minimal. Typically, 5 minutes are (including repeat Paps) spent performing or supervising these services.

FY17 5 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 99212 Office or other outpatient visit for the evaluation and management of an Partial annual clinical exam established patient, which requires at least two of these three components:  Either CBE only OR pelvic/pap only (includes  a problem focused history; repeat Paps)  a problem focused examination;  straight forward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Providers typically spend 10 minutes face-to-face with the patient and/or family. 99213 Office or other outpatient visit for the evaluation and management of an Full annual clinical exam established patient, which requires at least two of these three key  CBE AND pelvic/Pap (if due for Pap test) components:  Symptomatic or diagnosed established patient  an expanded problem focused history;  an expanded problem focused examination;  medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Providers typically spend 15 minutes face-to-face with the patient and/or family.

FY17 6 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 99214 Office or other outpatient visit for the evaluation and management of an Full annual clinical exam established patient, which requires at least two of these three key  CBE AND pelvic/Pap (if due for Pap test) components:  Symptomatic or diagnosed established patient  a detailed history;  a detailed examination;  medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Providers typically spend 25 minutes face-to-face with the patient and/or family. 99215 Office or other outpatient visit for the evaluation and management of an Full annual clinical exam established patient, which requires at least two of these three key  CBE AND pelvic/Pap (if due for Pap test) components:  Symptomatic or diagnosed established patient  a comprehensive history;  a comprehensive examination;  medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Providers typically spend 40 minutes face-to-face with the patient and/or family. 99385 Initial comprehensive preventive medicine evaluation and management of an  Cervical Consult on day of colposcopy individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations(s), laboratory/diagnostic procedures, new patient; 18-39 years

FY17 7 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 99386 Initial comprehensive preventive medicine evaluation and management of an Full annual clinical exam individual including an age and gender appropriate history, examination,  CBE AND pelvic/Pap (if due for Pap test) counseling/anticipatory guidance/risk factor reduction interventions, and the  Asymptomatic new patient between the ages of ordering of appropriate immunizations(s), laboratory/diagnostic procedures, 40 and 64 new patient; 40-64 years 99387 Initial comprehensive preventive medicine evaluation and management of an Full annual clinical exam individual including an age and gender appropriate history, examination,  CBE AND pelvic/Pap (if due for Pap test) counseling/anticipatory guidance/risk factor reduction interventions, and the  Asymptomatic new patient age 65 and older ordering of appropriate immunizations(s), laboratory/diagnostic procedures, new patient; 65 years and over 99395 Periodic comprehensive preventive medicine reevaluation and management  Cervical Consult on day of colposcopy of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 18-39 years 99396 Periodic comprehensive preventive medicine reevaluation and management Full annual clinical exam of an individual including an age and gender appropriate history,  CBE AND pelvic/Pap (if due for Pap test) examination, counseling/anticipatory guidance/risk factor reduction  Asymptomatic established patient between the interventions, and the ordering of appropriate immunization(s), ages of 40 and 64 laboratory/diagnostic procedures, established patient; 40-64 years 99397 Periodic comprehensive preventive medicine reevaluation and management Full annual clinical exam of an individual including an age and gender appropriate history,  CBE AND pelvic/Pap(if due for Pap test) examination, counseling/anticipatory guidance/risk factor reduction  Asymptomatic established patient age 65 and interventions, and the ordering of appropriate immunization(s), older laboratory/diagnostic procedures, established patient; 65 years and over 81025 Urine pregnancy test Urine pregnancy test; with colposcopy 57452 Colposcopy of the cervix including upper/adjacent vagina Colposcopy  Office visit billed separately

FY17 8 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 57454 Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of Colposcopy with biopsy of the cervix and the cervix and endocervical curettage endocervical curettage  Office visit billed separately 57455 Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of Colposcopy with biopsy of the cervix the cervix  Office visit billed separately 57456 Colposcopy of the cervix including upper/adjacent vagina; with endocervical Colposcopy with endocervical curettage curettage  Office visit billed separately 57505 Endocervical curettage (not done as part of a dilation and curettage) ECC – Endocervical curettage  Not part of D & C 10021 Fine needle aspiration; without imaging guidance Fine needle aspiration of superficial breast tissue  Not using imaging guidance 10022 Fine needle aspiration; with imaging guidance Fine needle aspiration of superficial breast tissue  Using imaging guidance 19000 Puncture aspiration of cyst of breast Puncture aspiration, breast cyst

19001 Puncture aspiration of cyst of breast; each additional cyst (List separately in Puncture aspiration, breast cyst addition to code for primary procedure); (Use 19001 in conjunction with  Each additional cyst code 19000) 19081 Biopsy, breast, with placement of breast localization device(s) (eg, clip, Stereotactic localization placement of metallic clip metallic pellet), when performed, and imaging of the biopsy specimen, when during breast biopsy performed, percutaneous; first lesion, including stereotactic guidance 19082 Each additional lesion, including stereotactic guidance (List separately in Stereotactic localization placement of metallic clip addition to code for primary procedure) during breast biopsy (Use 19082 in conjunction with 19081)  Each additional lesion 19083 Biopsy, breast, with placement of breast localization device(s) (eg, clip, Ultrasonic guidance placement of metallic localization metallic pellet), when performed, and imaging of the biopsy specimen, when clip during breast biopsy performed, percutaneous; first lesion, including ultrasound guidance  Imaging supervision and interpretation

FY17 9 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 19084 Each additional lesion, including ultrasound guidance (List separately in Ultrasonic guidance placement of metallic localization addition to code for primary procedure) clip during breast biopsy (Use 19084 in conjunction with 19083)  Imaging supervision and interpretation  Each additional lesion 19085 Biopsy, breast, with placement of breast localization device(s) (eg, clip, Magnetic resonance guidance placement of metallic metallic pellet), when performed, and imaging of the biopsy specimen, when localization clip during breast biopsy performed, percutaneous; first lesion, including magnetic resonance  Imaging supervision and interpretation guidance 19086 Each additional lesion, including magnetic resonance guidance (List Magnetic resonance guidance placement of metallic separately in addition to code for primary procedure) localization clip during breast biopsy (Use 19086 in conjunction with 19085)  Imaging supervision and interpretation  Each additional lesion 19100 Biopsy of breast; percutaneous, needle core, not using imaging guidance Breast biopsy, needle core  Not using imaging guidance 19101 Biopsy of breast; open, incisional Breast biopsy, incisional 19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant Breast biopsy, excisional breast tissue, duct lesion, nipple or areolar lesion, open, male or female, one or more lesions 19125 Excision of breast lesion identified by preoperative placement of Breast biopsy, excision of single lesion identified by radiological marker, open; single lesion radiological marker 19126 Excision of breast lesion identified by preoperative placement of Breast biopsy, excision of lesion identified by radiological marker, open; each additional lesion separately identified by a radiological marker preoperative radiological marker (List separately in addition to code for  Each additional lesion primary procedure); (Use in conjunction with code 19125) 19281 Placement of breast localization device(s) (eg, clip, metallic pellet, Mammographic localization guidance for needle wire/needle, radioactive seeds), percutaneous; first lesion, including placement mammographic guidance  Radiological supervision/interpretation

FY17 10 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 19282 Each additional lesion, including mammographic guidance (List separately Mammographic localization guidance for needle in addition to code for primary procedure) placement (Use 19282 in conjunction with 19281)  Radiological supervision/interpretation  Each additional lesion 19283 Placement of breast localization device(s) (eg, clip, metallic pellet, Stereotactic localization guidance for needle wire/needle, radioactive seeds), percutaneous; first lesion, including placement stereotactic guidance  Radiological supervision/interpretation 19284 Each additional lesion, including stereotactic guidance (List separately in Stereotactic localization guidance for needle addition to code for primary procedure) placement (Use 19284 in conjunction with 19283)  Radiological supervision/interpretation  Each additional lesion 19285 Placement of breast localization device(s) (eg, clip, metallic pellet, Ultrasonic guidance of breast needle placement wire/needle, radioactive seeds), percutaneous; first lesion, including  Imaging supervision and interpretation ultrasound guidance 19286 Each additional lesion, including ultrasound guidance (List separately in Ultrasonic guidance of breast needle placement addition to code for primary procedure)  Imaging supervision and interpretation (Use 19286 in conjunction with 19285)  Each additional lesion 19287 Placement of breast localization device(s) (eg clip, metallic pellet, Magnetic resonance guidance for needle placement wire/needle, radioactive seeds), percutaneous; first lesion, including  Radiological supervision/interpretation magnetic resonance guidance 19288 Each additional lesion, including magnetic resonance guidance (List Magnetic resonance guidance for needle placement separately in addition to code for primary procedure)  Radiological supervision/interpretation (Use 19288 in conjunction with 19287)  Each additional lesion 76098 Radiological examination, surgical specimen Radiological examination, surgical specimen -TC -Technical/Facility Component -26 -Professional Component

FY17 11 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle Magnetic resonance guidance for needle placement aspiration, injection, or placement of localization device) radiological  Radiological supervision/interpretation supervision and interpretation -TC -Technical/Facility Component -26 -Professional Component 76641 Ultrasound, breast(s) (unilateral or bilateral), Complete exam, including Breast ultrasound -TC axilla  Radiological supervision/interpretation -26 -Technical Component -Professional Component 76642 Ultrasound, breast(s) (unilateral or bilateral), Limited exam, including axilla Breast ultrasound -TC -Technical Component  Radiological supervision/interpretation -26 -Professional Component 76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, Ultrasonic guidance of breast needle placement localization device), imaging supervision and interpretation  Imaging supervision and interpretation -TC -Technical/Facility Component -26 -Professional Component 88305 Level IV – Surgical pathology, gross and microscopic examination; Breast, Breast or cervical biopsy, laboratory evaluation of biopsy, not requiring microscopic evaluation of surgical margins; Cervix, tissue sample biopsy  Level IV -TC -Technical/Facility Component -26 -Professional Component 88307 Level V – Surgical pathology; gross and microscopic examination; Breast, Breast or cervical biopsy, laboratory evaluation of excision of lesion, requiring microscopic evaluation of surgical margins; tissue sample Cervix, conization  Level V -TC -Technical/Facility Component -26 -Professional Component 88331 Pathology consultation during surgery; first tissue block, with frozen Pathology consultation during surgery, single section(s), single specimen specimen -TC - Technical/Facility Component -26 - Professional Component FY17 12 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 88332 Pathology consultation during surgery; each additional tissue block, with Pathology consultation during surgery, each additional frozen section(s). (List separately in addition to code for primary procedure) specimen (use with 88331) -TC - Technical/Facility Component -26 - Professional Component 88341 Immunohistochemistry or immunocytochemistry, per specimen; first single Immunohistochemistry or immunocytochemistry or multiplex antibody stain -TC -Technical component -26 -Professional Component 88342 Immunohistochemistry or immunocytochemistry, per specimen; each Immunohistochemistry or immunocytochemistry additional single or multiplex antibody stain (list separately in addition to  Each additional specimen or stain code for primary procedure) -TC -Technical component -26 -Professional Component 88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic Cytopathology, evaluation of fine needle aspirate to study to determine adequacy of specimen(s) determine specimen adequacy -TC -Technical/Facility Component -26 -Professional Component 88173 Cytopathology, evaluation of fine needle aspirate; interpretation and report Cytopathology, evaluation of fine needle aspirate -TC -Technical/Facility Component  Interpretation and report -26 -Professional Component 88112 Cytopathology, Selective Cellular Enhancement Technique with Cytopathology, Selective Cellular Enhancement Interpretation (e.g. Liquid Based Slide Preparation Method), except Cervical Technique with Interpretation or Vaginal **Cannot bill in conjunction with 88173**  Interpretation and reports -TC -Technical component -26 -Professional Component G9012 Unlisted evaluation and management Patient Navigation

FY17 13 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 00400 Anesthesia for procedures on the integumentary system on the extremities, Anesthesia CPT code used when billing for Breast anterior trunk and perineum; not otherwise specified biopsy, excisional (19120 or 19125) -AA -Anesthesia service performed personally by anesthesiologist  Anesthesia service performed personally by anesthesiologist -AD -Medical supervision by a physician: more than four concurrent  Medical supervision by a physician: more than anesthesia procedures four concurrent anesthesia procedures -QK -Medical direction of 2, 3, or 4 concurrent anesthesia procedures  Medical direction of 2, 3, or 4 concurrent involving qualified individuals anesthesia procedures involving qualified -QX -CRNA service: with medical direction by a physician individuals -QY -Anesthesiologist medically directs one CRNA  CRNA service: with medical direction by a -QZ -CRNA service: (supervised) without medical direction by a physician physician  Anesthesiologist medically directs one CRNA  CRNA service: (supervised) without medical direction by a physician 57520 Cone - Conization of cervix, with or without fulguration, with or without Cone - Conization of cervix, with or without dilation and curettage, with or without repair; cold knife or laser fulguration, with or without dilation and curettage, **Cannot bill in conjunction with 57522 with or without repair; cold knife or laser  Cannot bill in conjunction with 57522  MDHHS Nurse-Approved ONLY 57522 Cone - Conization of cervix, with or without fulguration, with or without Cone - Conization of cervix, with or without dilation and curettage, with or without repair; cold knife or laser; loop fulguration, with or without dilation and curettage, electrode excision with or without repair; cold knife or laser; loop **Cannot bill in conjunction with 57520 electrode excision  Cannot bill in conjunction with 57520  MDHHS Nurse-Approved ONLY

FY17 14 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 58100 EMB - Endometrial sampling (biopsy) with or without endocervical EMB - Endometrial sampling (biopsy) with or without sampling (biopsy), without cervical dilation, any method endocervical sampling (biopsy), without cervical **Cannot bill in conjunction with 58110 dilation, any method  Cannot bill in conjunction with 58110  MDHHS Nurse-Approved ONLY 58110 EMB - Endometrial sampling (biopsy) performed in conjunction with a EMB - Endometrial sampling (biopsy) performed in colposcopy (List separately in addition to code for primary procedure ~ conjunction with a colposcopy (Colposcopy 57452, 57454, 57455, 57456))  (List separately in addition to code for primary **Cannot bill in conjunction with 58100 procedure ~ Colposcopy 57452, 57454, 57455, 57456))  Cannot bill in conjunction with 58100  MDHHS Nurse-Approved ONLY 57460 LEEP - Colposcopy of the cervix including upper/adjacent vagina; with loop LEEP - Colposcopy of the cervix including electrode conization of the cervix upper/adjacent vagina; with loop electrode conization **Cannot bill in conjunction with 57460 of the cervix  Cannot bill in conjunction with 57460  MDHHS Nurse-Approved ONLY 57461 LEEP - Colposcopy of the cervix including upper/adjacent vagina; with loop LEEP - Colposcopy of the cervix including electrode biopsy(s) of the cervix upper/adjacent vagina; with loop electrode biopsy(s) **Cannot bill in conjunction with 57461 of the cervix  Cannot bill in conjunction with 57461  MDHHS Nurse-Approved ONLY

FY17 15 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 00940 Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix Anesthesia CPT code used when billing for cervical or endometrium); not otherwise specified diagnostic procedures (Cone, LEEP or EMB) -AA -Anesthesia service performed personally by anesthesiologist  Anesthesia service performed personally by anesthesiologist -AD -Medical supervision by a physician: more than four concurrent  Medical supervision by a physician: more than anesthesia procedures four concurrent anesthesia procedures -QK -Medical direction of 2, 3, or 4 concurrent anesthesia procedures  Medical direction of 2, 3, or 4 concurrent involving qualified individuals anesthesia procedures involving qualified individuals -QX -CRNA service: with medical direction by a physician  CRNA service: with medical direction by a physician -QY -Anesthesiologist medically directs one CRNA  Anesthesiologist medically directs one CRNA -QZ -CRNA service: (supervised) without medical direction by a physician  CRNA service: (supervised) without medical direction by a physician  MDHHS Nurse-Approved ONLY 77058 MRI – Breast, with and/or without contrast, Unilateral MRI – Breast, with and/or without contrast -TC -Technical component  Unilateral -26 -Professional Component  MDHHS Nurse-Approved ONLY 77059 MRI – Breast, with and/or without contrast, Bilateral MRI – Breast, with and/or without contrast -TC -Technical component  Bilateral -26 -Professional Component  MDHHS Nurse-Approved ONLY 11100 Biopsy of Skin, Subcutaneous tissue and/or mucous membrane Biopsy of Skin, Subcutaneous tissue and/or mucous membrane  MDHHS Nurse-Approved ONLY 19110 Excisional procedure: Breast nipple exploration, with or without excision of Excisional procedure: Breast nipple exploration, with a solitary lactiferous duct or a papilloma lactiferous duct or without excision of a solitary lactiferous duct or a papilloma lactiferous duct  MDHHS Nurse-Approved ONLY

FY17 16 08/10/2016 FY 2017 BCCCNP Procedure Code Reference Chart

CPT / Procedure Description BCCCNP Service Billable with CPT / HCPCS HCPCS Code Code (BCCCNP Definition) 76882 Ultrasound; Axilla Ultrasound; Axilla -TC -Technical component  MDHHS Nurse-Approved ONLY -26 -Professional Component 77053 Mammary Ductogram or Galactogram, Single Duct, Radiological Mammary Ductogram or Galactogram, Single Duct, Supervision and Interpretation  Radiological Supervision and Interpretation -TC -Technical component  MDHHS Nurse-Approved ONLY -26 -Professional Component 77054 Mammary Ductogram or Galactogram, Multiple Ducts, Radiological Mammary Ductogram or Galactogram, Multiple Supervision and Interpretation Ducts, -TC -Technical component  Radiological Supervision and Interpretation -26 -Professional Component  MDHHS Nurse-Approved ONLY

FY17 17 08/10/2016