Codes by Procedure Types Requiring Medical Records Submissions

Effective: December 1, 2015

The following is a list of the Diagnosis, CPT, Revenue and HCPCS codes known to typically require additional information to document medical necessity. When reporting one of the following codes on a claim, only the medical records identified as “Information Required” should be submitted to BCBSNC in advance of the claim being filed.

Please note this code listing is not to be considered all inclusive and is subject to revision by BCBSNC at any time.

CPT, Code Brief Description Information Required • Maternal age 35 years or older at delivery; • Fetal ultrasonographic findings 0009M, indicating increased risk of aneuploidy; 81507, Noninvasive Prenatal Testing • History of previous pregnancy with a CPT 81420, for Fetal Aneuploidies Using trisomy; Codes 81479, Cell-Free Fetal DNA • Standard serum screening test positive 81599 for aneuploidy; or • Parental balanced robertsonian translocation with increased risk of fetal trisomy 13 or trisomy 21. CPT 95044 Dermatology Patch Allergy Testing Information Request Form Code CPT Intraoperative Neurophysiologic 95941 IONM remote/>1 pt or per hr Code Monitoring Information Request Form The physician/nursing/office notes, CPT 15150 Cult skin grft t/arm/leg medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15151 Cult skin grft t/a/l addl medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15152 Cult skin graft t/a/l +% medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15155 Cult skin graft f/n/hf/g medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15156 Cult skin grft f/n/hfg add medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15157 Cult epiderm grft f/n/hfg +% medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15271 Skin sub graft trnk/arm/leg medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15272 Skin sub graft t/a/l add-on medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15273 Skin sub grft t/arm/lg child medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15274 Skn sub grft t/a/l child add medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15275 Skin sub graft face/nk/hf/g medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15276 Skin sub graft f/n/hf/g addl medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15277 Skn sub grft f/n/hf/g child medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15278 Skn sub grft f/n/hf/g ch add medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 15777 Acellular derm matrix implt medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 66174 Translum dil eye canal medication record, operative report, Code invoice and history & physical. The physician/nursing/office notes, CPT 66175 Trnslum dil eye canal w/stnt medication record, operative report, Code invoice and history & physical. CPT 88356 Analysis nerve The Nerve Fiber Density Testing Form Code

Revenue or HCPCS Code Brief Description Information Required 0360 See ICD-10 The itemized invoice, the operative Revenue diagnosis codes 0360 Operating report, the implant log and the circulating Code associated with Room Services nurses’ notes. revenue code 0360 list 0270 Medical/Surgical The itemized invoice, the operative Revenue 0272 Supplies report, the implant log and the circulating Code 0272 Sterile nurses’ notes. supplies 0270 Medical/Surgical The itemized invoice, the operative Revenue 0278 Supplies report, the implant log and the circulating Code 0278 Other nurses’ notes. implants 0920 Other Diagnostic Revenue The itemized invoice and the operative 0922 Services Code report. 0922 Electromyelogram Revenue 0256 0250 Pharmacy Depends somewhat on if it's inpatient or Code 0256 Drugs / outpatient...discharge experimental summary or MD/nursing notes, op note/implant log (especially if it's 0624), medication record (0256), itemized invoice, and other (Please include all information related to revenue code 0256/0624, including clinical trial summary, signed consent, etc). Depends somewhat on if it's inpatient or outpatient...discharge 062X Med—Surg. summary or MD/nursing notes, op Supplies Ext. of note/implant log (especially if it's 0624), Revenue 270 0624 medication record (0256), itemized Code 0624 invoice, and other (Please include all Investigational information related to revenue code device (IDE) 0256/0624, including clinical trial summary, signed consent, etc). The admission and discharge summary, Revenue 017X Newborn MD/nursing progress notes, itemized Code invoice and consults. Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4112, Q4113, Q4114, Q4115, Q4116, Q4117, Q4118, Q4119, Q4120, Q4121, Q4122, Q4123, Q4124, Q4125, Q4126, Q4127, Q4128, Q4129, Q4130, Q4131, Q4132, Q4133, Q4134, Q4135, Q4136, The physician/nursing/office notes, Q4137, Q4138, Specific Skin Graft HCPCS medication record, operative report, Q4139, Q4140, codes invoice and history & physical. Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, Q4150, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, C5271, C5272, C5273, C5274, C5275, C5276, C5277, C5278, C9349, C9354, C9356, C9358, C9360, C9363, C9364 A0430 HCPCS A0431 Ambulance Transport log, Need for transfer if codes A0435 Services hospital to hospital A0436 Insertion of anterior segment aqueous drainage dev ice, without The physician/nursing/office notes, HCPCS extra ocular 0191T medication record, operative report and Code reservoir, internal history & physical. approach, into the trabecular meshwork; initial insertion IONM remote, exclusive to one Intraoperative Neurophysiologic HCPCS G0453 patient, each 15 Monitoring Information Request Form minutes