SETON CHARITY NON-COVERED SERVICES EFF: 01/01/2020 (Updated 05/05/2020)
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SETON CHARITY NON-COVERED SERVICES EFF: 01/01/2020 (updated 05/05/2020) Code Narrative Comments 3051F Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0% (DM) 3052F Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0% (DM) 4185F Histamine therapy - intravenous 4186F Histamine therapy - intravenous 0002M Liver disease, ten biochemical assays (ALT, A2-macro- globulin, apolipoprotein A-1, total bilirubin, GGT, hapto- globin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quanti- tative scores for fibrosis, steatosis and alcoholic/non alco- holic steatohepatitis 0003M Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH) 0004M Scoliosis, DNA analysis of 53 single nucleotide polymor- phisms (SNPs), using saliva, prognostic algorithm reported as a risk score 0006M Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier 0007M Oncology (gastrointestinal neuroendocrine tumors), real- time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index 0008M Oncology (breast), mRNA analysis of 58 genes using hybrid capture, on formalin-fixed paraffin-embedded (FFPE) tissue, prognostic algorithm reported as a risk score 0308T Prosthetic eye or facial quarter 0042T Cerebral perfusion analysis using computed tomography with contrast administration, including postprocessing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time 0051T Implantation of a total replacement heart system heart system (artificial heart) with recipient cardiectomy (i.e., AbioCor, etc.) 0052T Replacement or repair of thoracic unit of a total replacement heart system (artificial heart) (i.e., AbioCor, etc.) 0053T Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit (i.e., AbioCor, etc.) 0054T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure) 0055T Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure) 0058T Cryopreservation; reproductive tissue, ovarian 0071T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue 0072T Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue 0075T Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; initial vessel 0076T Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s), including radiologic supervision and interpretation, percutaneous; each additional vessel 0085T Breath test for heart transplant rejection 0098T Revision of total disc arthroplasty, anterior approach; each additional interspace 0100T Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra- ocular retinal electrode array, with vitrectomy 0101T Extracorporeal shock wave involving musculoskeletal system, not otherwise specified, high energy 0102T Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, involving lateral humeral epicondyle 0106T Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation 0107T Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation 0108T Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia 0109T Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia 0110T Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation 0111T Long-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes 0126T Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor assessment 0133T Upper GI endoscopy, incl esoph, stomach and duod and/ or jejun, w/injection implantable material, lower esophageal sphincter 0163T Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace 0164T Removal of total disc arthroplasty, anterior approach, lumbar, each additional interspace 0165T Revision of total disc arthroplasty, anterior approach, lumbar, each additional interspace 0174T Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation 0175T Computer-aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation 0178T Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; with interpretation and report 0179T Electrocardiogram, 64 leads or greater, tracing and graphics only, without interpretation and report 0180T Electrocardiogram, 64 leads or greater, interpretation and report only 0182T High dose rate electronic brachytherapy per fraction 0198T Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report 0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed 0201T Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed 0202T Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine 0207T Evacuation of Meibomian glands, automated, using heat and intermittent pressure, unilateral 0208T Pure tone audiometry (threshold), automated (includes use of computer-assisted device); air only 0209T Pure tone audiometry (threshold), automated (includes use of computer-assisted device); air and bone 0210T Speech audiometry threshold, automated (includes use of computer- assisted device); 0211T Speech audiometry threshold, automated (includes use of computer- assisted device); with speech recognition 0212T Comprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated (includes use of computer-assisted device) 0213T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level 0214T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) 0215T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary 0216T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level 0217T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) 0218T Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (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) 0219T Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical 0220T Placement of posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement