KAISER PERMANENTE OF OHIO
Appendix B: Authorization Guidelines for Outpatient Services (Auto Auth List) See the following page.
Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 1
KAISER PERMANENTE OF OHIO
KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE ANESTHESIA FOR PROCEDURES IN LUMBAR REGION; NOT 00630 OTHERWISE SPECIFIED anes/rad 1/1/2007 ANESTHESIA FOR UPPER GASTROINTESTINAL ENDOSCOPIC PROCEDURES, ENDOSCOPE INTRODUCED PROXIMAL TO 00740 DUODENUM gastro 1/1/2007 ANESTHESIA FOR LOWER INTESTINAL ENDOSCOPIC PROCEDURES, ENDOSCOPE INTRODUCED DISTAL TO 00810 DUODENUM gastro 1/1/2006 ANESTHESIA FOR MYELOGRAPHY, DISKOGRAPHY, 01905 VERTEBROPLASTY radiology 1/1/2007 01916 ANESTHESIA FOR DIAGNOSTIC ARTERIOGRAPHY/VENOGRAPHY radiology 1/1/2007 ANESTHESIA FOR NON-INVASIVE IMAGING OR RADIATION 01922 THERAPY radiology 1/1/2006 ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC PROCEDURES INVOLVING THE ARTERIAL SYSTEM; NOT 01924 OTHERWISE SPECIFIED radiology 1/1/2006 ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC PROCEDURES INVOLVING THE ARTERIAL SYSTEM; CAROTID OR 01925 CORONARY radiology 1/1/2006 ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC PROCEDURES INVOLVING THE ARTERIAL SYSTEM; 01926 INTRACRANIAL, INTRACARDIAC, OR AORT radiology 1/1/2006 ANESTHESIA FOR THERAPEUTIC INTERVENTIONAL RADIOLOGIC PROCEDURES INVOLVING THE VENOUS/LYMPHATIC SYSTEM 01930 (NOT TO INCLUDE ACCESS TO TH radiology 1/1/2006 REGIONAL INTRAVENOUS ADMINISTRATION OF LOCAL ANESTHETIC AGENT OR OTHER MEDICATION (UPPER OR 01995 LOWER EXTREMITY) general 1/1/2006
10021 FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE general 1/1/2005 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS 10060 ABSCESS, CYST, FURUNCLE, OR P general 1/1/2005 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS 10061 ABSCESS, CYST, FURUNCLE, OR P general 1/1/2005 10080 INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE general 1/1/2006 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS 10120 TISSUES; SIMPLE general 1/1/2005 PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR 10160 CYST general 1/1/2005 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED 11000 SKIN; UP TO 10% OF BODY SURFACE surg 1/1/2005 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH ADDITIONAL 10% OF THE BODY SURFACE (LIST 11001 SEPARATELY IN ADDITION TO CODE surg 1/1/2005 11040 DEBRIDEMENT; SKIN, PARTIAL THICKNESS surg 1/1/2005 11041 DEBRIDEMENT; SKIN, FULL THICKNESS surg 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 2
KAISER PERMANENTE OF OHIO
KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE 11042 DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISSUE surg 1/1/2005 11043 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE surg 1/1/2005 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, MUSCLE, AND 11044 BONE surg 1/1/2005 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS 11100 OTHERWISE LISTED; SINGLE LESION surg 1/1/2005 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS 11101 OTHERWISE LISTED; EACH SEPARATE/ADDI surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, 11300 TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, 11301 TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, 11302 TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, 11303 TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 11305 CM OR LESS surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 11306 TO 1.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 11307 TO 2.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 11308 OVER 2.0 CM surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; 11310 LESION DIAMETER 0.5 CM OR surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; 11311 LESION DIAMETER 0.6 TO 1.0 surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; 11312 LESION DIAMETER 1.1 TO 2.0 surg 1/1/2005 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; 11313 LESION DIAMETER OVER 2.0 C surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; 11400 EXCISED DIAMETER 0.5 CM surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; 11401 EXCISED DIAMETER 0.6 TO surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN 11402 TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; surg 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 3
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE EXCISED DIAMETER 1.1 TO EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; 11403 EXCISED DIAMETER 2.1 TO surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; 11404 EXCISED DIAMETER 3.1 TO surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; 11406 EXCISED DIAMETER OVER 4 surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11420 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11421 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11422 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11423 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11424 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, 11426 FEET, GENITALIA; EXCISED surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11440 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11441 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11442 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11443 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11444 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, 11446 EYELIDS, NOSE, LIPS, MUCOU surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11600 ARMS, OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11601 ARMS, OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM surg 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 4
KAISER PERMANENTE OF OHIO
KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11602 ARMS, OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11603 ARMS, OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11604 ARMS, OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, 11606 ARMS, OR LEGS; EXCISED DIAMETER OVER 4.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR 11620 LESS surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 11621 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 11622 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 11623 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 11624 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 11626 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR 11640 LESS surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, 11641 EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, 11642 EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, 11643 EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, 11644 EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 3.1 TO 4.0 CM surg 1/1/2005 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, 11646 EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM surg 1/1/2005 INJECTION, INTRALESIONAL; UP TO AND INCLUDING SEVEN 11900 LESIONS surg 1/1/2005 11901 INJECTION, INTRALESIONAL; MORE THAN SEVEN LESIONS surg 1/1/2005 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM 12032 TO 7.5 CM surg 9/1/2008 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR 12041 EXTERNAL GENITALIA; 2.5 CM OR LESS surg 4/1/2008 INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE 16000 THAN LOCAL TREATMENT IS REQUIRED surg 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 5
KAISER PERMANENTE OF OHIO
KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL 16020 BODY SURFACE AREA) surg 1/1/2005 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE 16025 OR WHOLE EXTREMITY, OR 5% T surg 1/1/2005 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN ONE 16030 EXTREMITY, OR GREATER THA surg 1/1/2005 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), 17000 ALL BENIGN OR PREMALIGNANT LESIO surg 1/1/2005 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), 17003 ALL BENIGN OR PREMALIGNANT LESIO surg 1/1/2005 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), 17004 ALL BENIGN OR PREMALIGNANT LESIO surg 1/1/2005 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), 17110 OF FLAT WARTS, MOLLUSCUM CONTAGI surg 1/1/2005 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), 17111 OF FLAT WARTS, MOLLUSCUM CONTAGI surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17260 SURGICAL CURETTEMENT), TRUNK, ARMS OR surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17261 SURGICAL CURETTEMENT), TRUNK, ARMS OR surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17262 SURGICAL CURETTEMENT), TRUNK, ARMS OR surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17263 SURGICAL CURETTEMENT), TRUNK, ARMS OR surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17264 SURGICAL CURETTEMENT), TRUNK, ARMS OR surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17266 SURGICAL CURETTEMENT), TRUNK, ARMS OR surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17270 SURGICAL CURETTEMENT), SCALP, NECK, H surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17271 SURGICAL CURETTEMENT), SCALP, NECK, H surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 17272 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, surg 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 6
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE SURGICAL CURETTEMENT), SCALP, NECK, H DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17273 SURGICAL CURETTEMENT), SCALP, NECK, H surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17274 SURGICAL CURETTEMENT), SCALP, NECK, H surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17276 SURGICAL CURETTEMENT), SCALP, NECK, H surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17280 SURGICAL CURETTEMENT), FACE, EARS, EY surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17281 SURGICAL CURETTEMENT), FACE, EARS, EY surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17282 SURGICAL CURETTEMENT), FACE, EARS, EY surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17283 SURGICAL CURETTEMENT), FACE, EARS, EY surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17284 SURGICAL CURETTEMENT), FACE, EARS, EY surg 1/1/2005 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, 17286 SURGICAL CURETTEMENT), FACE, EARS, EY surg 1/1/2005 19000 PUNCTURE ASPIRATION OF CYST OF BREAST; surg 8/1/2010 PUNCTURE ASPIRATION OF CYST OF BREAST; EACH ADDITIONAL CYST (LIST SEPARATELY IN ADDITION TO CODE 19001 FOR PRIMARY PROCEDURE) surg 8/1/2010 INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, 20526 CORTICOSTEROID), CARPAL TUNNEL general 1/1/2005 INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, 20550 APONEUROSIS (EG, PLANTAR 'FASCIA') pod 1/1/2005 20551 INJECTION(S); SINGLE TENDON ORIGIN/INSERTION ortho/pod 1/1/2005 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), ONE 20552 OR TWO MUSCLE(S) ortho/pod 1/1/2005 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), THREE 20553 OR MORE MUSCLE(S) ortho/pod 1/1/2005 PLACEMENT OF NEEDLES OR CATHETERS INTO MUSCLE AND/OR SOFT TISSUE FOR SUBSEQUENT INTERSTITIAL 20555 RADIOELEMENT APPLICATION (AT THE TIME ortho/pod 1/1/2008 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; SMALL 20600 JOINT OR BURSA (EG, FINGERS, TOES) ortho/pod 1/1/2005 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, 20605 ACROMIOCLAVICULAR, WRIST, ELBOW O ortho/pod 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; MAJOR JOINT OR BURSA (EG, SHOULDER, HIP, KNEE JOINT, 20610 SUBACROMIAL BURSA) ortho/pod 1/1/2005 ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY 20612 LOCATION ortho/pod 1/1/2005 20615 ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYST ortho/pod 1/1/2005 CLOSED TREATMENT OF SKULL FRACTURE WITHOUT 21300 OPERATION ortho/pod 1/1/2005 CLOSED TREATMENT OF NASAL BONE FRACTURE WITHOUT 21310 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF NASAL BONE FRACTURE; WITHOUT 21315 STABILIZATION ortho/pod 1/1/2005 CLOSED TREATMENT OF NASAL BONE FRACTURE; WITH 21320 STABILIZATION ortho/pod 1/1/2005 CLOSED TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR 21337 WITHOUT STABILIZATION ortho/pod 1/1/2005 CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT 21400 BLOWOUT; WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT 21401 BLOWOUT; WITH MANIPULATION ortho/pod 1/1/2005 21550 BIOPSY, SOFT TISSUE OF NECK OR THORAX general 1/1/2005 CLOSED TREATMENT OF RIB FRACTURE, UNCOMPLICATED, 21800 EACH ortho/pod 1/1/2005 21820 CLOSED TREATMENT OF STERNUM FRACTURE ortho/pod 1/1/2005 CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITHOUT 23500 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITH 23505 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH 23650 MANIPULATION; WITHOUT ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH FRACTURE OF GREATER HUMERAL TUBEROSITY, WITH 23665 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH SURGICAL OR ANATOMICAL NECK FRACTURE, WITH 23675 MANIPULATION ortho/pod 1/1/2005 ARTHROTOMY, ELBOW, INCLUDING EXPLORATION, DRAINAGE, 24000 OR REMOVAL OF FOREIGN BODY ortho/pod 1/1/2005 24220 INJECTION PROCEDURE FOR ELBOW ARTHROGRAPHY ortho/pod 1/1/2005 CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; 24500 WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITH 24505 MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION ortho/pod 1/1/2005 CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE, WITH OR WITHOUT 24530 INTERCONDYLAR EXTENSION; WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE, WITH OR WITHOUT 24535 INTERCONDYLAR EXTENSION; WITH MANIPULATION, W ortho/pod 1/1/2005
Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 8
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, 24560 MEDIAL OR LATERAL; WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, 24565 MEDIAL OR LATERAL; WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, 24576 MEDIAL OR LATERAL; WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, 24577 MEDIAL OR LATERAL; WITH MANIPULATION ortho/pod 1/1/2005 TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT 24600 ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA 24620 WITH DISLOCATION OF RADIAL HEAD ortho/pod 1/1/2005 CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, 24640 NURSEMAID ELBOW, WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; 24650 WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; 24655 WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END 24670 (OLECRANON PROCESS); WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END 24675 (OLECRANON PROCESS); WITH MANIPULATION ortho/pod 1/1/2005 25246 INJECTION PROCEDURE FOR WRIST ARTHROGRAPHY ortho/pod 1/1/2005 CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITHOUT 25500 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH 25505 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF RADIAL SHAFT FRACTURE AND CLOSED TREATMENT OF DISLOCATION OF DISTAL RADIOULNAR 25520 JOINT (GALEAZZI FRACTURE/DISLOC ortho/pod 1/1/2005 CLOSED TREATMENT OF ULNAR SHAFT FRACTURE; WITHOUT 25530 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF ULNAR SHAFT FRACTURE; WITH 25535 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT 25560 FRACTURES; WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT 25565 FRACTURES; WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, WITH 25600 OR WITHOUT FRACTURE OF ULNAR ortho/pod 1/1/2005 CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, WITH 25605 OR WITHOUT FRACTURE OF ULNAR ortho/pod 1/1/2005 CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) 25622 FRACTURE; WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) 25624 FRACTURE; WITH MANIPULATION ortho/pod 1/1/2005
Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 9
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL SCAPHOID (NAVICULAR)); WITHOUT MANIPULATION, 25630 EACH BONE ortho/pod 1/1/2005 CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL SCAPHOID (NAVICULAR)); WITH MANIPULATION, EACH 25635 BONE ortho/pod 1/1/2005 25650 CLOSED TREATMENT OF ULNAR STYLOID FRACTURE ortho/pod 1/1/2005 CLOSED TREATMENT OF RADIOCARPAL OR INTERCARPAL 25660 DISLOCATION, ONE OR MORE BONES, WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF DISTAL RADIOULNAR DISLOCATION 25675 WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF 25680 FRACTURE DISLOCATION, WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF LUNATE DISLOCATION, WITH 25690 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; 26600 WITHOUT MANIPULATION, EACH BONE ortho/pod 1/1/2005 CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; 26605 WITH MANIPULATION, EACH BONE ortho/pod 1/1/2005 CLOSED TREATMENT OF METACARPAL FRACTURE, WITH 26607 MANIPULATION, WITH EXTERNAL FIXATION, EACH BONE ortho/pod 1/1/2005 CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, 26641 THUMB, WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH 26645 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT; 26670 WITHOUT ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT 26700 ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITHOUT 26720 MANIPULATION, EACH ortho/pod 1/1/2005 CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB; WITH 26725 MANIPULATION, WITH OR WITHOUT SKI ortho/pod 1/1/2005 CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT; 26740 WITHOUT MANIPULATION, EACH ortho/pod 1/1/2005 CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT; WITH 26742 MANIPULATION, EACH ortho/pod 1/1/2005 CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, 26750 FINGER OR THUMB; WITHOUT MANIPULATION, EACH ortho/pod 1/1/2005 CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, 26755 FINGER OR THUMB; WITH MANIPULATION, EACH ortho/pod 1/1/2005
Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 10
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH MANIPULATION; WITHOUT 26770 ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, DIASTASIS OR SUBLUXATION; WITHOUT 27193 MANIPULATION ortho/pod 1/1/2005 27200 CLOSED TREATMENT OF COCCYGEAL FRACTURE ortho/pod 1/1/2005 CLOSED TREATMENT OF ACETABULUM (HIP SOCKET) 27220 FRACTURE(S); WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, 27230 NECK; WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK; WITH MANIPULATION, WITH OR WITHOUT SKELETAL 27232 TRACTION ortho/pod 1/1/2005 CLOSED TREATMENT OF INTERTROCHANTERIC, PERTROCHANTERIC, OR SUBTROCHANTERIC FEMORAL 27238 FRACTURE; WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF INTERTROCHANTERIC, PERTROCHANTERIC, OR SUBTROCHANTERIC FEMORAL 27240 FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SK ortho/pod 1/1/2005 CLOSED TREATMENT OF GREATER TROCHANTERIC FRACTURE, 27246 WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; 27250 WITHOUT ANESTHESIA ortho/pod 1/1/2005 TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, INCLUDING CONGENITAL OR 27256 PATHOLOGICAL), BY ABDUCTION, SPLINT OR TRACTION; ortho/pod 1/1/2005 CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, 27267 HEAD; WITHOUT MANIPULATION ortho/pod 1/1/2008 CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, 27268 HEAD; WITH MANIPULATION ortho/pod 1/1/2008 27370 INJECTION PROCEDURE FOR KNEE ARTHROGRAPHY ortho/pod 1/1/2005 CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE, 27500 WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR FEMORAL FRACTURE WITH OR WITHOUT 27501 INTERCONDYLAR EXTENSION, WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE, WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL 27502 TRACTION ortho/pod 1/1/2005 CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR FEMORAL FRACTURE WITH OR WITHOUT 27503 INTERCONDYLAR EXTENSION, WITH MANIPULATION, WI ortho/pod 1/1/2005 CLOSED TREATMENT OF FEMORAL FRACTURE, DISTAL END, 27508 MEDIAL OR LATERAL CONDYLE, WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF FEMORAL FRACTURE, DISTAL END, 27510 MEDIAL OR LATERAL CONDYLE, WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL 27516 SEPARATION; WITHOUT MANIPULATION ortho/pod 1/1/2005
Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 11
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION; WITH MANIPULATION, WITH OR WITHOUT SKIN OR 27517 SKELETAL TRACTION ortho/pod 1/1/2005 CLOSED TREATMENT OF PATELLAR FRACTURE, WITHOUT 27520 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL 27530 (PLATEAU); WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF KNEE, WITH OR WITHOUT 27538 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF KNEE DISLOCATION; WITHOUT 27550 ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT 27560 ANESTHESIA ortho/pod 1/1/2005 27648 INJECTION PROCEDURE FOR ANKLE ARTHROGRAPHY ortho/pod 1/1/2005 CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR 27750 WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR 27752 WITHOUT SKELETAL TRACTION ortho/pod 1/1/2005 CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; 27760 WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL 27762 TRACTION ortho/pod 1/1/2005 CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; 27767 WITHOUT MANIPULATION ortho/pod 1/1/2008 CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; 27768 WITH MANIPULATION ortho/pod 1/1/2008 CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT 27780 FRACTURE; WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT 27781 FRACTURE; WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL 27786 MALLEOLUS); WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL 27788 MALLEOLUS); WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE, 27808 (INCLUDING POTTS); WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE, 27810 (INCLUDING POTTS); WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; 27816 WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; 27818 WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL 27824 PLAFOND), WITH OR WITHOUT AN ortho/pod 1/1/2005 27825 CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ortho/pod 1/1/2005
Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 12
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT AN CLOSED TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT 27830 DISLOCATION; WITHOUT ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF ANKLE DISLOCATION; WITHOUT 27840 ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT 28400 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF CALCANEAL FRACTURE; WITH 28405 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT 28430 MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF TALUS FRACTURE; WITH 28435 MANIPULATION ortho/pod 1/1/2005 TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND 28450 CALCANEUS); WITHOUT MANIPULATION, EACH ortho/pod 1/1/2005 TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND 28455 CALCANEUS); WITH MANIPULATION, EACH ortho/pod 1/1/2005 CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT 28470 MANIPULATION, EACH ortho/pod 1/1/2005 CLOSED TREATMENT OF METATARSAL FRACTURE; WITH 28475 MANIPULATION, EACH ortho/pod 1/1/2005 CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR 28490 PHALANGES; WITHOUT MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR 28495 PHALANGES; WITH MANIPULATION ortho/pod 1/1/2005 CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, 28510 OTHER THAN GREAT TOE; WITHOUT MANIPULATION, EACH ortho/pod 1/1/2005 CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, 28515 OTHER THAN GREAT TOE; WITH MANIPULATION, EACH ortho/pod 1/1/2005 28530 CLOSED TREATMENT OF SESAMOID FRACTURE ortho/pod 1/1/2005 CLOSED TREATMENT OF TARSAL BONE DISLOCATION, OTHER 28540 THAN TALOTARSAL; WITHOUT ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION; 28570 WITHOUT ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF TARSOMETATARSAL JOINT 28600 DISLOCATION; WITHOUT ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF METATARSOPHALANGEAL JOINT 28630 DISLOCATION; WITHOUT ANESTHESIA ortho/pod 1/1/2005 CLOSED TREATMENT OF INTERPHALANGEAL JOINT 28660 DISLOCATION; WITHOUT ANESTHESIA ortho/pod 1/1/2005 APPLICATION OF HALO TYPE BODY CAST (SEE 20661-20663 FOR 29000 INSERTION) ortho/pod 1/1/2005 29010 APPLICATION OF RISSER JACKET, LOCALIZER, BODY; ONLY ortho/pod 1/1/2005 APPLICATION OF RISSER JACKET, LOCALIZER, BODY; 29015 INCLUDING HEAD ortho/pod 1/1/2005 29020 APPLICATION OF TURNBUCKLE JACKET, BODY; ONLY ortho/pod 1/1/2005 APPLICATION OF TURNBUCKLE JACKET, BODY; INCLUDING 29025 HEAD ortho/pod 1/1/2005
Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 13
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE 29035 APPLICATION OF BODY CAST, SHOULDER TO HIPS; ortho/pod 1/1/2005 APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING 29040 HEAD, MINERVA TYPE ortho/pod 1/1/2005 APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING 29044 ONE THIGH ortho/pod 1/1/2005 APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING 29046 BOTH THIGHS ortho/pod 1/1/2005 29049 APPLICATION, CAST; FIGURE-OF-EIGHT ortho/pod 1/1/2005 29055 APPLICATION, CAST; SHOULDER SPICA ortho/pod 1/1/2005 29058 APPLICATION, CAST; PLASTER VELPEAU ortho/pod 1/1/2005 29065 APPLICATION, CAST; SHOULDER TO HAND (LONG ARM) ortho/pod 1/1/2005 29075 APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM) ortho/pod 1/1/2005 29085 APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET) ortho/pod 1/1/2005 29086 APPLICATION, CAST; FINGER (EG, CONTRACTURE) ortho/pod 1/1/2005 29105 APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) ortho/pod 1/1/2005 APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); 29125 STATIC ortho/pod 1/1/2005 APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); 29126 DYNAMIC ortho/pod 1/1/2005 29130 APPLICATION OF FINGER SPLINT; STATIC ortho/pod 1/1/2005 29131 APPLICATION OF FINGER SPLINT; DYNAMIC ortho/pod 1/1/2005 29200 STRAPPING; THORAX ortho/pod 1/1/2005 29220 STRAPPING; LOW BACK ortho/pod 1/1/2005 29240 STRAPPING; SHOULDER (EG, VELPEAU) ortho/pod 1/1/2005 29260 STRAPPING; ELBOW OR WRIST ortho/pod 1/1/2005 29280 STRAPPING; HAND OR FINGER ortho/pod 1/1/2005 29305 APPLICATION OF HIP SPICA CAST; ONE LEG ortho/pod 1/1/2005 APPLICATION OF HIP SPICA CAST; ONE AND ONE-HALF SPICA 29325 OR BOTH LEGS ortho/pod 1/1/2005 29345 APPLICATION OF LONG LEG CAST (THIGH TO TOES); ortho/pod 1/1/2005 APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER 29355 OR AMBULATORY TYPE ortho/pod 1/1/2005 29358 APPLICATION OF LONG LEG CAST BRACE ortho/pod 1/1/2005 29365 APPLICATION OF CYLINDER CAST (THIGH TO ANKLE) ortho/pod 1/1/2005 29405 APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); ortho/pod 1/1/2005 APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); 29425 WALKING OR AMBULATORY TYPE ortho/pod 1/1/2005 29435 APPLICATION OF PATELLAR TENDON BEARING (PTB) CAST ortho/pod 1/1/2005 29440 ADDING WALKER TO PREVIOUSLY APPLIED CAST ortho/pod 1/1/2005 29445 APPLICATION OF RIGID TOTAL CONTACT LEG CAST ortho/pod 1/1/2005 APPLICATION OF CLUBFOOT CAST WITH MOLDING OR 29450 MANIPULATION, LONG OR SHORT LEG ortho/pod 1/1/2005 29505 APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) ortho/pod 1/1/2005 29515 APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) ortho/pod 1/1/2005 29520 STRAPPING; HIP ortho/pod 1/1/2005 29530 STRAPPING; KNEE ortho/pod 1/1/2005 29540 STRAPPING; ANKLE AND/OR FOOT ortho/pod 1/1/2005 29550 STRAPPING; TOES ortho/pod 1/1/2005 29580 STRAPPING; UNNA BOOT ortho/pod 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 14
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE 29590 DENIS-BROWNE SPLINT STRAPPING ortho/pod 1/1/2005 29700 REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST ortho/pod 1/1/2005 29705 REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST ortho/pod 1/1/2005 REMOVAL OR BIVALVING; SHOULDER OR HIP SPICA, MINERVA, 29710 OR RISSER JACKET, ETC. ortho/pod 1/1/2005 29715 REMOVAL OR BIVALVING; TURNBUCKLE JACKET ortho/pod 1/1/2005 29720 REPAIR OF SPICA, BODY CAST OR JACKET ortho/pod 1/1/2005 29730 WINDOWING OF CAST ortho/pod 1/1/2005 29740 WEDGING OF CAST (EXCEPT CLUBFOOT CASTS) ortho/pod 1/1/2005 29750 WEDGING OF CLUBFOOT CAST ortho/pod 1/1/2005 30100 BIOPSY, INTRANASAL ent 1/1/2005 30110 EXCISION, NASAL POLYP(S), SIMPLE ent 1/1/2005 EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; 30117 INTERNAL APPROACH ent 1/1/2005 EXCISION DERMOID CYST, NOSE; SIMPLE, SKIN, 30124 SUBCUTANEOUS ent 1/1/2005 30200 INJECTION INTO TURBINATE(S), THERAPEUTIC ent 1/1/2005 REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE 30300 PROCEDURE ent 1/1/2005 CAUTERY AND/OR ABLATION, MUCOSA OF INFERIOR TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD; 30801 SUPERFICIAL ent 1/1/2005 CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED 30901 CAUTERY AND/OR PACKING) ANY METHOD general 1/1/2005 CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX 30903 (EXTENSIVE CAUTERY AND/OR PACKING) ANY METHOD general 1/1/2005 CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR 30905 NASAL PACKS AND/OR CAUTERY, ANY METHOD; INITIAL general 1/1/2005 CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR 30906 NASAL PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT general 1/1/2005 NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL 31231 (SEPARATE PROCEDURE) ent 1/1/2005 NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH MAXILLARY SINUSOSCOPY (VIA INFERIOR MEATUS OR CANINE FOSSA 31233 PUNCTURE) ent 1/1/2005 NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH SPHENOID SINUSOSCOPY (VIA PUNCTURE OF SPHENOIDAL FACE OR 31235 CANNULATION OF OSTIUM) ent 1/1/2005 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, 31237 POLYPECTOMY OR DEBRIDEMENT (SEPARATE PROCEDURE) ent 1/1/2008 LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE 31505 PROCEDURE) ent 1/1/2005 31510 LARYNGOSCOPY, INDIRECT; WITH BIOPSY ent 1/1/2005 31511 LARYNGOSCOPY, INDIRECT; WITH REMOVAL OF FOREIGN BODY ent 1/1/2005 31512 LARYNGOSCOPY, INDIRECT; WITH REMOVAL OF LESION ent 1/1/2005 31513 LARYNGOSCOPY, INDIRECT; WITH VOCAL CORD INJECTION ent 1/1/2005 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; 31515 FOR ASPIRATION ent 1/1/2005 31520 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; ent 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 15
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE DIAGNOSTIC, NEWBORN LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; 31525 DIAGNOSTIC, EXCEPT NEWBORN ent 1/1/2005 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; 31528 WITH DILATION, INITIAL ent 1/1/2005 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; 31529 WITH DILATION, SUBSEQUENT ent 1/1/2005 31575 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC ent 1/1/2005 31576 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH BIOPSY ent 1/1/2005 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF 31577 FOREIGN BODY ent 1/1/2005 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF 31578 LESION ent 1/1/2005 LARYNGOSCOPY, FLEXIBLE OR RIGID FIBEROPTIC, WITH 31579 STROBOSCOPY ent 1/1/2005 TRACHEOBRONCHOSCOPY THROUGH ESTABLISHED 31615 TRACHEOSTOMY INCISION ent 1/1/2005 ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC 31620 INTERVENTION(S) (LIST SEPARATELY IN ADDITION TO COD ent 1/1/2005 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; DIAGNOSTIC, WITH OR WITHOUT 31622 CELL WASHING (SEPARATE PROCEDU ent/pulm 1/1/2005 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRUSHING OR PROTECTED 31623 BRUSHINGS ent 1/1/2005 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRONCHIAL ALVEOLAR 31624 LAVAGE ent/pulm 1/1/2005 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRONCHIAL OR 31625 ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTI ent/pulm 1/1/2005 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH TRANSBRONCHIAL LUNG 31628 BIOPSY(S), SINGLE LOBE ent/pulm 1/1/2005 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH TRANSBRONCHIAL NEEDLE 31629 ASPIRATION BIOPSY(S), TRACHEA, ent/pulm 1/1/2005 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH PLACEMENT OF BRONCHIAL 31636 STENT(S) (INCLUDES TRACHEAL/BR ent/pulm 1/1/2005 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; EACH ADDITIONAL MAJOR 31637 BRONCHUS STENTED (LIST SEPARATELY IN ent/pulm 1/1/2005 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH REVISION OF TRACHEAL OR 31638 BRONCHIAL STENT INSERTED AT P ent/pulm 1/1/2005 BRONCHOSCOPY, (RIGID OR FLEXIBLE); WITH INJECTION OF 31656 CONTRAST MATERIAL FOR SEGMENTAL BRONCHOGRAPHY ent/pulm 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE (FIBERSCOPE ONLY) INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER 32019 WITH CUFF interventional 1/1/2005 36000 INTRODUCTION OF NEEDLE OR INTRACATHETER, VEIN interventional 1/1/2005 INJECTION PROCEDURES (EG, THROMBIN) FOR PERCUTANEOUS TREATMENT OF EXTREMITY 36002 PSEUDOANEURYSM interventional 1/1/2005 INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY 36005 (INCLUDING INTRODUCTION OF NEEDLE OR INTRACATHETER) interventional 1/1/2005 INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA 36010 CAVA interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST 36011 ORDER BRANCH (EG, RENAL VEIN, JUGULAR VEIN) interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR MORE SELECTIVE, BRANCH (EG, LEFT ADRENAL 36012 VEIN, PETROSAL SINUS) interventional 1/1/2005 INTRODUCTION OF CATHETER, RIGHT HEART OR MAIN 36013 PULMONARY ARTERY interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, LEFT OR RIGHT 36014 PULMONARY ARTERY interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, SEGMENTAL OR 36015 SUBSEGMENTAL PULMONARY ARTERY interventional 1/1/2005 INTRODUCTION OF NEEDLE OR INTRACATHETER, CAROTID OR 36100 VERTEBRAL ARTERY interventional 1/1/2005 INTRODUCTION OF NEEDLE OR INTRACATHETER; RETROGRADE 36120 BRACHIAL ARTERY interventional 1/1/2005 INTRODUCTION OF NEEDLE OR INTRACATHETER; EXTREMITY 36140 ARTERY interventional 1/1/2005 INTRODUCTION OF NEEDLE OR INTRACATHETER; ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS (CANNULA, 36145 FISTULA, OR GRAFT) interventional 1/1/2005 INTRODUCTION OF NEEDLE OR INTRACATHETER, AORTIC, 36160 TRANSLUMBAR interventional 1/1/2005 36200 INTRODUCTION OF CATHETER, AORTA interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, 36215 WITHIN A VASCULAR FAMILY interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, 36216 WITHIN A VASCULAR FAMILY interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE THORACIC OR 36217 BRACHIOCEPHALIC BRANCH, WITHIN A interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, 36218 THORACIC OR BRACHIOCEPHALIC BRANC interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY 36245 ARTERY BRANCH, WITHIN A VASC interventional 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY 36246 ARTERY BRANCH, WITHIN A interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR 36247 LOWER EXTREMITY ARTERY interventional 1/1/2005 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, 36248 ABDOMINAL, PELVIC, OR LOWER EXTRE interventional 1/1/2005 PERCUTANEOUS PORTAL VEIN CATHETERIZATION BY ANY 36481 METHOD interventional 1/1/2005 VENOUS CATHETERIZATION FOR SELECTIVE ORGAN BLOOD 36500 SAMPLING interventional 1/1/2007 CATHETERIZATION OF UMBILICAL VEIN FOR DIAGNOSIS OR 36510 THERAPY, NEWBORN interventional 1/1/2007 36522 PHOTOPHERESIS, EXTRACORPOREAL interventional 1/1/2007 COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY 36540 IMPLANTABLE VENOUS ACCESS DEVICE interventional 1/1/2007 DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED 36550 VASCULAR ACCESS DEVICE OR CATHETER interventional 1/1/2007 INSERTION OF NON-TUNNELED CENTRALLY INSERTED 36555 CENTRAL VENOUS CATHETER; UNDER 5 YEARS OF AGE interventional 1/1/2005 INSERTION OF NON-TUNNELED CENTRALLY INSERTED 36556 CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER interventional 1/1/2005 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR 36557 PUMP; UNDER 5 YEARS OF AGE interventional 1/1/2005 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR 36558 PUMP; AGE 5 YEARS OR OLDER interventional 1/1/2005 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; UNDER 36560 5 YEARS OF AGE interventional 1/1/2005 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 36561 YEARS OR OLDER interventional 1/1/2005 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL 36563 VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PUMP interventional 1/1/2005 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING TWO CATHETERS VIA 36565 TWO SEPARATE VENOUS ACCESS SITE interventional 1/1/2005 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING TWO CATHETERS VIA 36566 TWO SEPARATE VENOUS ACCESS SITE interventional 1/1/2005 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP; 36568 UNDER 5 YEARS OF AGE interventional 1/1/2005 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS 36569 CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP; interventional 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE AGE 5 YEARS OR OLDER INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; UNDER 5 YEARS 36570 OF AGE interventional 1/1/2005 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS 36571 OR OLDER interventional 1/1/2005 REPAIR OF TUNNELED OR NON-TUNNELED CENTRAL VENOUS ACCESS CATHETER, WITHOUT SUBCUTANEOUS PORT OR 36575 PUMP, CENTRAL OR PERIPHERAL INSERT interventional 1/1/2005 REPAIR OF CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL 36576 INSERTION SITE interventional 1/1/2005 REPLACEMENT, CATHETER ONLY, OF CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, 36578 CENTRAL OR PERIPHERAL INSERTION SITE interventional 1/1/2005 REPLACEMENT, COMPLETE, OF A NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT 36580 SUBCUTANEOUS PORT OR PUMP, THROUGH SA interventional 1/1/2005 REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT 36581 SUBCUTANEOUS PORT OR PUMP, THROUGH SAME V interventional 1/1/2005 REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH 36582 SUBCUTANEOUS PORT, THROUGH SAME VENOUS interventional 1/1/2005 REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH 36583 SUBCUTANEOUS PUMP, THROUGH SAME VENOUS interventional 1/1/2005 REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT 36584 SUBCUTANEOUS PORT OR PUMP, THROUGH SAME interventional 1/1/2005 REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS 36585 PORT, THROUGH SAME VENOUS ACCESS interventional 1/1/2005 REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, 36589 WITHOUT SUBCUTANEOUS PORT OR PUMP interventional 1/1/2005 REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR 36590 PERIPHERAL INSERTION interventional 1/1/2005 DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED 36593 VASCULAR ACCESS DEVICE OR CATHETER interventional 1/1/2008 MECHANICAL REMOVAL OF PERICATHETER OBSTRUCTIVE MATERIAL (EG, FIBRIN SHEATH) FROM CENTRAL VENOUS 36595 DEVICE VIA SEPARATE VENOUS ACCESS interventional 1/1/2005 MECHANICAL REMOVAL OF INTRALUMINAL (INTRACATHETER) OBSTRUCTIVE MATERIAL FROM CENTRAL VENOUS DEVICE 36596 THROUGH DEVICE LUMEN interventional 1/1/2005 REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS 36597 CATHETER UNDER FLUOROSCOPIC GUIDANCE interventional 1/1/2005 36600 ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR interventional 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 19
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE DIAGNOSIS ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE 36620 PROCEDURE); PERCUTANEOUS interventional 1/1/2005 ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE 36625 PROCEDURE); CUTDOWN interventional 1/1/2005 ARTERIAL CATHETERIZATION FOR PROLONGED INFUSION 36640 THERAPY (CHEMOTHERAPY), CUTDOWN interventional 1/1/2005 CATHETERIZATION, UMBILICAL ARTERY, NEWBORN, FOR 36660 DIAGNOSIS OR THERAPY interventional 1/1/2005 36680 PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION interventional 1/1/2005 INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC 37250 INTERVENTION; INITIAL VESSEL (LIST interventional 1/1/2005 INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC 37251 INTERVENTION; EACH ADDITIONAL VESSE interventional 1/1/2005 38200 INJECTION PROCEDURE FOR SPLENOPORTOGRAPHY interventional 1/1/2005 38790 INJECTION PROCEDURE; LYMPHANGIOGRAPHY interventional 1/1/2005 INJECTION PROCEDURE; FOR IDENTIFICATION OF SENTINEL 38792 NODE interventional 1/1/2005 38794 CANNULATION, THORACIC DUCT interventional 1/1/2005 40490 BIOPSY OF LIP general 1/1/2005 41100 BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS general 1/1/2006 41105 BIOPSY OF TONGUE; POSTERIOR ONE-THIRD general 1/1/2006 41108 BIOPSY OF FLOOR OF MOUTH general 1/1/2006 41110 EXCISION OF LESION OF TONGUE WITHOUT CLOSURE general 1/1/2006 EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR 41112 TWO-THIRDS general 1/1/2006 EXCISION OF LESION OF TONGUE WITH CLOSURE; POSTERIOR 41113 ONE-THIRD general 1/1/2006 42800 BIOPSY; OROPHARYNX general 1/1/2006 42802 BIOPSY; HYPOPHARYNX general 1/1/2006 42804 BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE general 1/1/2006 BIOPSY; NASOPHARYNX, SURVEY FOR UNKNOWN PRIMARY 42806 LESION general 1/1/2006 CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR 42960 SECONDARY (EG, POST-TONSILLECTOMY); SIMPLE general 1/1/2005 CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH 42970 POSTERIOR NASAL PACKS, WITH OR WI general 1/1/2005 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR 43200 WASHING (SEPARATE PROCEDURE gastro 1/1/2005 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH DIRECTED 43201 SUBMUCOSAL INJECTION(S), ANY SUBSTANCE gastro 1/1/2005 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BIOPSY, SINGLE 43202 OR MULTIPLE gastro 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INJECTION 43204 SCLEROSIS OF ESOPHAGEAL VARICES gastro 1/1/2006 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BAND LIGATION 43205 OF ESOPHAGEAL VARICES gastro 1/1/2006 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF 43215 FOREIGN BODY gastro 1/1/2007 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY 43216 FORCEPS OR BIPOLAR CAUTERY gastro 1/1/2007 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE 43217 TECHNIQUE gastro 1/1/2007 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INSERTION OF 43219 PLASTIC TUBE OR STENT gastro 1/1/2007 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BALLOON 43220 DILATION (LESS THAN 30 MM DIAMETER) gastro 1/1/2005 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INSERTION OF 43226 GUIDE WIRE FOLLOWED BY DILATION OVER GUIDE WIRE gastro 1/1/2007 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR 43227 CAUTERY, LASER, HEATER PROBE, gastro 1/1/2007 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), NOT AMENABLE TO 43228 REMOVAL BY HOT BIOPSY F gastro 1/1/2007 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH ENDOSCOPIC 43231 ULTRASOUND EXAMINATION gastro 1/1/2007 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR 43232 TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY, SIMPLE PRIMARY EXAMINATION (EG, WITH SMALL DIAMETER FLEXIBLE 43234 ENDOSCOPE) (SEPARATE PROCEDURE) gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43235 JEJUNUM AS APPROPRIATE; DIAGNOSTIC, gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43236 JEJUNUM AS APPROPRIATE; WITH DIRECTE gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43237 JEJUNUM AS APPROPRIATE; WITH ENDOSCO gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43238 JEJUNUM AS APPROPRIATE; WITH TRANSEN gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43239 JEJUNUM AS APPROPRIATE; WITH BIOPSY, gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43240 JEJUNUM AS APPROPRIATE; WITH TRANSMU gastro 1/1/2007 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 21
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43241 JEJUNUM AS APPROPRIATE; WITH TRANSEN gastro 1/1/2007 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43242 JEJUNUM AS APPROPRIATE; WITH TRANSEN gastro 1/1/2007 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43243 JEJUNUM AS APPROPRIATE; WITH INJECTI gastro 1/1/2007 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43244 JEJUNUM AS APPROPRIATE; WITH BAND LI gastro 1/1/2007 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43245 JEJUNUM AS APPROPRIATE; WITH DILATIO gastro 1/1/2007 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43246 JEJUNUM AS APPROPRIATE; WITH DIRECTE gastro 1/1/2007 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43247 JEJUNUM AS APPROPRIATE; WITH REMOVAL gastro 1/1/2007 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43248 JEJUNUM AS APPROPRIATE; WITH INSERTI gastro 1/1/2007 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43249 JEJUNUM AS APPROPRIATE; WITH BALLOON gastro 1/1/2007 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43250 JEJUNUM AS APPROPRIATE; WITH REMOVAL gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43251 JEJUNUM AS APPROPRIATE; WITH REMOVAL gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43255 JEJUNUM AS APPROPRIATE; WITH CONTROL gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43256 JEJUNUM AS APPROPRIATE; WITH TRANSEN gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43257 JEJUNUM AS APPROPRIATE; WITH DELIVER gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43258 JEJUNUM AS APPROPRIATE; WITH ABLATIO gastro 1/1/2005 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR 43259 JEJUNUM AS APPROPRIATE; WITH ENDOSCO gastro 1/1/2005 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY 43260 (ERCP); DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF gastro 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 22
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE SPECIMEN(S) BY BRUSHING OR WASHIN ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY 43261 (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE gastro 1/1/2005 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY 43262 (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY gastro 1/1/2005 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PRESSURE MEASUREMENT OF SPHINCTER OF 43263 ODDI (PANCREATIC DUCT OR COMMON B gastro 1/1/2005 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE REMOVAL OF 43264 CALCULUS/CALCULI FROM BILIARY AND/OR gastro 1/1/2005 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE DESTRUCTION, 43265 LITHOTRIPSY OF CALCULUS/CALCULI, AN gastro 1/1/2005 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE INSERTION OF 43267 NASOBILIARY OR NASOPANCREATIC DRAIN gastro 1/1/2005 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE INSERTION OF TUBE 43268 OR STENT INTO BILE OR PANCREAT gastro 1/1/2005 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE REMOVAL OF 43269 FOREIGN BODY AND/OR CHANGE OF TUBE OR gastro 1/1/2005 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE BALLOON DILATION 43271 OF AMPULLA, BILIARY AND/OR PANC gastro 1/1/2005 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER 43272 LESION(S) NOT AMENABLE TO REM gastro 1/1/2005 DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, 43450 SINGLE OR MULTIPLE PASSES gastro 1/1/2005 43453 DILATION OF ESOPHAGUS, OVER GUIDE WIRE gastro 1/1/2005 DILATION OF ESOPHAGUS, BY BALLOON OR DILATOR, 43456 RETROGRADE gastro 1/1/2005 DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR 43458 LARGER) FOR ACHALASIA gastro 1/1/2005 ESOPHAGOGASTRIC TAMPONADE, WITH BALLOON 43460 (SENGSTAAKEN TYPE) gastro 1/1/2005 ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR 44380 WASHING (SEPARATE PROCEDURE) gastro 1/1/2005 ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR 44382 MULTIPLE gastro 1/1/2005 ILEOSCOPY, THROUGH STOMA; WITH TRANSENDOSCOPIC 44383 STENT PLACEMENT (INCLUDES PREDILATION) gastro 1/1/2007 ENDOSCOPIC EVALUATION OF SMALL INTESTINAL (ABDOMINAL OR PELVIC) POUCH; DIAGNOSTIC, WITH OR WITHOUT 44385 COLLECTION OF SPECIMEN(S) BY BR gastro 1/1/2005 44386 ENDOSCOPIC EVALUATION OF SMALL INTESTINAL (ABDOMINAL gastro 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE OR PELVIC) POUCH; WITH BIOPSY, SINGLE OR MULTIPLE COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR 44388 WASHING (SEPARATE PROCEDURE) gastro 1/1/2005 COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR 44389 MULTIPLE gastro 1/1/2005 COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF 44390 FOREIGN BODY gastro 1/1/2007 COLONOSCOPY THROUGH STOMA; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR 44391 CAUTERY, LASER, HEATER PROBE, STAPLE gastro 1/1/2007 COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY 44392 FORCEPS OR BIPOLAR CAUTERY gastro 1/1/2007 COLONOSCOPY THROUGH STOMA; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO 44393 REMOVAL BY HOT BIOPSY FORCEPS, gastro 1/1/2007 COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE 44394 TECHNIQUE gastro 1/1/2007 COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC 44397 STENT PLACEMENT (INCLUDES PREDILATION) gastro 1/1/2007 PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR 45300 WASHING (SEPARATE PROCEDURE) gastro 1/1/2005 PROCTOSIGMOIDOSCOPY, RIGID; WITH DILATION (EG, 45303 BALLOON, GUIDE WIRE, BOUGIE) gastro 1/1/2005 PROCTOSIGMOIDOSCOPY, RIGID; WITH BIOPSY, SINGLE OR 45305 MULTIPLE gastro 1/1/2005 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF FOREIGN 45307 BODY gastro 1/1/2005 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS 45308 OR BIPOLAR CAUTERY gastro 1/1/2005 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE 45309 TUMOR, POLYP, OR OTHER LESION BY SNARE TECHNIQUE gastro 1/1/2005 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF MULTIPLE TUMORS, POLYPS, OR OTHER LESIONS BY HOT BIOPSY 45315 FORCEPS, BIPOLAR CAUTERY OR SN gastro 1/1/2005 PROCTOSIGMOIDOSCOPY, RIGID; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, 45317 LASER, HEATER PROBE, STAPL gastro 1/1/2007 PROCTOSIGMOIDOSCOPY, RIGID; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO 45320 REMOVAL BY HOT BIOPSY FORCEPS, gastro 1/1/2007 PROCTOSIGMOIDOSCOPY, RIGID; WITH DECOMPRESSION OF 45321 VOLVULUS gastro 1/1/2007 PROCTOSIGMOIDOSCOPY, RIGID; WITH TRANSENDOSCOPIC 45327 STENT PLACEMENT (INCLUDES PREDILATION) gastro 1/1/2007
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 45330 (SEPARATE PROCEDURE) gastro 1/1/2005 SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR 45331 MULTIPLE gastro 1/1/2005 45332 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY gastro 1/1/2005 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR 45333 BIPOLAR CAUTERY gastro 1/1/2005 SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, 45334 HEATER PROBE, STAPLER, gastro 1/1/2007 SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL 45335 INJECTION(S), ANY SUBSTANCE gastro 1/1/2007 SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION OF 45337 VOLVULUS, ANY METHOD gastro 1/1/2007 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), 45338 POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE gastro 1/1/2007 SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL 45339 BY HOT BIOPSY FORCEPS, BI gastro 1/1/2007 SIGMOIDOSCOPY, FLEXIBLE; WITH DILATION BY BALLOON, 1 OR 45340 MORE STRICTURES gastro 1/1/2007 SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND 45341 EXAMINATION gastro 1/1/2005 SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE 45342 NEEDLE ASPIRATION/BIOPSY(S) gastro 1/1/2007 SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC STENT 45345 PLACEMENT (INCLUDES PREDILATION) gastro 1/1/2007 COLONOSCOPY, RIGID OR FLEXIBLE, TRANSABDOMINAL VIA 45355 COLOTOMY, SINGLE OR MULTIPLE gastro 1/1/2007 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) 45378 BY BRUSHING OR WASHING, gastro 1/1/2005 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; 45379 WITH REMOVAL OF FOREIGN BODY gastro 1/1/2005 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; 45380 WITH BIOPSY, SINGLE OR MULTIPLE gastro 1/1/2005 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; 45381 WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE gastro 1/1/2005 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR 45382 CAUTERY, UNIPOLAR CAUTERY, LA gastro 1/1/2005 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) 45383 NOT AMENABLE TO REMOVA gastro 1/1/2005 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; 45384 WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) gastro 1/1/2005
Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 25
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE BY HOT BIOPSY FORCEPS O COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) 45385 BY SNARE TECHNIQUE gastro 1/1/2005 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; 45386 WITH DILATION BY BALLOON, 1 OR MORE STRICTURES gastro 1/1/2005 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES 45387 PREDILATION) gastro 1/1/2005 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; 45391 WITH ENDOSCOPIC ULTRASOUND EXAMINATION gastro 1/1/2005 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL 45392 OR TRANSMURAL FINE NEEDLE AS gastro 1/1/2005 46200 FISSURECTOMY, WITH OR WITHOUT SPHINCTEROTOMY gastro 1/1/2006 46210 CRYPTECTOMY; SINGLE gastro 1/1/2006 46211 CRYPTECTOMY; MULTIPLE (SEPARATE PROCEDURE) gastro 1/1/2006 PAPILLECTOMY OR EXCISION OF SINGLE TAG, ANUS (SEPARATE 46220 PROCEDURE) gastro 1/1/2006 HEMORRHOIDECTOMY, BY SIMPLE LIGATURE (EG, RUBBER 46221 BAND) gastro 1/1/2006 EXCISION OF EXTERNAL HEMORRHOID TAGS AND/OR MULTIPLE 46230 PAPILLAE gastro 1/1/2006 46250 HEMORRHOIDECTOMY, EXTERNAL, COMPLETE gastro 1/1/2006 46255 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; gastro 1/1/2006 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; 46257 WITH FISSURECTOMY gastro 1/1/2006 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; 46258 WITH FISTULECTOMY, WITH OR WITHOUT FISSURECTOMY gastro 1/1/2006 46500 INJECTION OF SCLEROSING SOLUTION, HEMORRHOIDS gastro 1/1/2007 46505 CHEMODENERVATION OF INTERNAL ANAL SPHINCTER gastro 1/1/2006 ANOSCOPY; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE 46600 PROCEDURE) gastro 1/1/2009 DESTRUCTION OF INTERNAL HEMORRHOID(S) BY THERMAL ENERGY (EG, INFRARED COAGULATION, CAUTERY, 46930 RADIOFREQUENCY) gastro 1/1/2009 INSERTION OF GASTROSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST 49440 INJECTION(S), IMAGE DOCUMENTATION AND gastro 1/1/2008 INSERTION OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE 49441 INCLUDING CONTRAST INJECTION(S), IMAGE DO gastro 1/1/2008 INSERTION OF CECOSTOMY OR OTHER COLONIC TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE 49442 INCLUDING CONTRAST INJECTION(S), IMAGE DOC gastro 1/1/2008 CONVERSION OF GASTROSTOMY TUBE TO GASTRO- JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC 49446 GUIDANCE INCLUDING CONTRAST INJECTION( gastro 1/1/2008
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC 49450 GUIDANCE INCLUDING CONTRAST INJE gastro 1/1/2008 REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE 49451 INCLUDING CONTRAST INJECTION(S), IMAGE gastro 1/1/2008 REPLACEMENT OF GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE 49452 INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTA gastro 1/1/2008 MECHANICAL REMOVAL OF OBSTRUCTIVE MATERIAL FROM GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO- 49460 JEJUNOSTOMY, OR CECOSTOMY (OR OTHER gastro 1/1/2008 CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTING GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, 49465 GASTRO-JEJUNOSTOMY, OR CECOS gastro 1/1/2008 INSTILLATION(S) OF THERAPEUTIC AGENT INTO RENAL PELVIS AND/OR URETER THROUGH ESTABLISHED NEPHROSTOMY, 50391 PYELOSTOMY OR URETEROSTOMY T urol/neph 1/1/2005 INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL 50392 PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS urol/neph 1/1/2007 51100 ASPIRATION OF BLADDER; BY NEEDLE urol/neph 1/1/2008 51101 ASPIRATION OF BLADDER; BY TROCAR OR INTRACATHETER urol/neph 1/1/2008 ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC 51102 CATHETER urol/neph 1/1/2008 INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING 51600 URETHROCYSTOGRAPHY urol/neph 1/1/2005 INJECTION PROCEDURE AND PLACEMENT OF CHAIN FOR 51605 CONTRAST AND/OR CHAIN URETHROCYSTOGRAPHY urol/neph 1/1/2005 INJECTION PROCEDURE FOR RETROGRADE 51610 URETHROCYSTOGRAPHY urol/neph 1/1/2005 51700 BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION general 1/1/2005 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, 51701 STRAIGHT CATHETERIZATION FOR RESIDUAL URINE) general 1/1/2005 INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; 51702 SIMPLE (EG, FOLEY) general 1/1/2005 51705 CHANGE OF CYSTOSTOMY TUBE; SIMPLE general 1/1/2005 BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT 51720 (INCLUDING DETENTION TIME) heme/onc 1/1/2005 51725 SIMPLE CYSTOMETROGRAM (CMG) (EG, SPINAL MANOMETER) urol/neph 1/1/2005 COMPLEX CYSTOMETROGRAM (EG, CALIBRATED ELECTRONIC 51726 EQUIPMENT) urol/neph 1/1/2005 SIMPLE UROFLOWMETRY (UFR) (EG, STOP-WATCH FLOW RATE, 51736 MECHANICAL UROFLOWMETER) urol/neph 1/1/2005 COMPLEX UROFLOWMETRY (EG, CALIBRATED ELECTRONIC 51741 EQUIPMENT) urol/neph 1/1/2005 URETHRAL PRESSURE PROFILE STUDIES (UPP) (URETHRAL 51772 CLOSURE PRESSURE PROFILE), ANY TECHNIQUE urol/neph 1/1/2006 ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL 51784 SPHINCTER, OTHER THAN NEEDLE, ANY TECHNIQUE urol/neph 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR 51785 URETHRAL SPHINCTER, ANY TECHNIQUE urol/neph 1/1/2005 STIMULUS EVOKED RESPONSE (EG, MEASUREMENT OF 51792 BULBOCAVERNOSUS REFLEX LATENCY TIME) urol/neph 1/1/2005 VOIDING PRESSURE STUDIES (VP); INTRA-ABDOMINAL VOIDING 51797 PRESSURE (AP) (RECTAL, GASTRIC, INTRAPERITONEAL) urol/neph 1/1/2006 52000 CYSTOURETHROSCOPY (SEPARATE PROCEDURE) urol/neph 1/1/2005 CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF 52001 MULTIPLE OBSTRUCTING CLOTS urol/neph 1/1/2005 CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 52005 URETEROPYELOGRAPHY, EXCLUSIVE OF RA urol/neph 1/1/2005 CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 52007 URETEROPYELOGRAPHY, EXCLUSIVE OF RA urol/neph 1/1/2005 CYSTOURETHROSCOPY, WITH EJACULATORY DUCT CATHETERIZATION, WITH OR WITHOUT IRRIGATION, 52010 INSTILLATION, OR DUCT RADIOGRAPHY, EXCLUSIVE urol/neph 1/1/2005 52204 CYSTOURETHROSCOPY, WITH BIOPSY urol/neph 1/1/2005 CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR 52351 PYELOSCOPY; DIAGNOSTIC urol/neph 1/1/2007 DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND 53600 OR URETHRAL DILATOR, MALE; INITIAL urol/neph 1/1/2005 DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND 53601 OR URETHRAL DILATOR, MALE; SUBSEQUENT urol/neph 1/1/2005 DILATION OF URETHRAL STRICTURE OR VESICAL NECK BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE, GENERAL 53605 OR CONDUCTION (SPINAL) ANEST urol/neph 1/1/2005 DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM 53620 AND FOLLOWER, MALE; INITIAL urol/neph 1/1/2005 DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM 53621 AND FOLLOWER, MALE; SUBSEQUENT urol/neph 1/1/2005 DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY 53660 AND/OR INSTILLATION; INITIAL urol/neph 1/1/2005 DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY 53661 AND/OR INSTILLATION; SUBSEQUENT urol/neph 1/1/2006 54100 BIOPSY OF PENIS; (SEPARATE PROCEDURE) general 1/1/2005 54800 BIOPSY OF EPIDIDYMIS, NEEDLE general 1/1/2005 62270 SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC general 1/1/2005 INJECTION PROCEDURE FOR MYELOGRAPHY AND/OR COMPUTED TOMOGRAPHY, SPINAL (OTHER THAN C1-C2 AND 62284 POSTERIOR FOSSA) radiology 1/1/2005 INJECTION PROCEDURE FOR DISKOGRAPHY, EACH LEVEL; 62290 LUMBAR radiology 1/1/2005 INJECTION PROCEDURE FOR DISKOGRAPHY, EACH LEVEL; 62291 CERVICAL OR THORACIC radiology 1/1/2005 PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE, ONE OR MORE 67141 SESSIONS; CRYOTHERAPY, D pain mgt 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE, ONE OR MORE 67145 SESSIONS; PHOTOCOAGULATI pain mgt 1/1/2005 DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE OR MORE SESSIONS; 67208 CRYOTHERAPY, DIATHERMY pain mgt 1/1/2005 DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE OR MORE SESSIONS; 67210 PHOTOCOAGULATION pain mgt 1/1/2005 DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE OR MORE SESSIONS; 67218 RADIATION BY IMPLANTATION OF SOURCE pain mgt 1/1/2005 DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL NEOVASCULARIZATION); PHOTOCOAGULATION 67220 (EG, LASER), ONE OR MORE SESSIONS pain mgt 1/1/2005 DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL NEOVASCULARIZATION); PHOTODYNAMIC 67221 THERAPY (INCLUDES INTRAVENOUS INFUSION pain mgt 1/1/2005 DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL NEOVASCULARIZATION); PHOTODYNAMIC 67225 THERAPY, SECOND EYE, AT SINGLE SESSION pain mgt 1/1/2005 DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), ONE OR MORE SESSIONS; 67227 CRYOTHERAPY, DIATHERMY pain mgt 1/1/2005 DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), ONE OR MORE SESSIONS; 67228 PHOTOCOAGULATION (LASER OR X pain mgt 1/1/2005 67810 BIOPSY OF EYELID opthamol 1/1/2005 DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT 68801 IRRIGATION opthamol 1/1/2005 PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT 68810 IRRIGATION; ent 1/1/2005 PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH TRANSLUMINAL BALLOON CATHETER 68816 DILATION ent 1/1/2008 69000 DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; SIMPLE ent 1/1/2005 DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; 69005 COMPLICATED ent 1/1/2005 69020 DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS ent 1/1/2005 69100 BIOPSY EXTERNAL EAR ent 1/1/2005 69105 BIOPSY EXTERNAL AUDITORY CANAL ent 1/1/2005 69140 EXCISION EXOSTOSIS(ES), EXTERNAL AUDITORY CANAL ent 1/1/2005 69145 EXCISION SOFT TISSUE LESION, EXTERNAL AUDITORY CANAL ent 1/1/2005 REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; 69200 WITHOUT GENERAL ANESTHESIA ent 1/1/2005 DEBRIDEMENT, MASTOIDECTOMY CAVITY, SIMPLE (EG, 69220 ROUTINE CLEANING) ent 7/1/2008 DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPLEX (EG, WITH 69222 ANESTHESIA OR MORE THAN ROUTINE CLEANING) ent 7/1/2008
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE 70300 RADIOLOGIC EXAMINATION, TEETH; SINGLE VIEW radiology 8/1/2009 RADIOLOGIC EXAMINATION, TEETH; PARTIAL EXAMINATION, 70310 LESS THAN FULL MOUTH radiology 8/1/2009 70320 RADIOLOGIC EXAMINATION, TEETH; COMPLETE, FULL MOUTH radiology 8/1/2009 70355 ORTHOPANTOGRAM radiology 8/1/2009 MYELOGRAPHY, CERVICAL, RADIOLOGICAL SUPERVISION AND 72240 INTERPRETATION radiology 1/1/2005 MYELOGRAPHY, THORACIC, RADIOLOGICAL SUPERVISION AND 72255 INTERPRETATION radiology 1/1/2005 MYELOGRAPHY, LUMBOSACRAL, RADIOLOGICAL SUPERVISION 72265 AND INTERPRETATION radiology 1/1/2005 MYELOGRAPHY, TWO OR MORE REGIONS (EG, LUMBAR/THORACIC, CERVICAL/THORACIC, LUMBAR/CERVICAL, 72270 LUMBAR/THORACIC/CERVICAL), RADIOLOGICAL radiology 1/1/2005 EPIDUROGRAPHY, RADIOLOGICAL SUPERVISION AND 72275 INTERPRETATION radiology 1/1/2005 DISKOGRAPHY, CERVICAL OR THORACIC, RADIOLOGICAL 72285 SUPERVISION AND INTERPRETATION radiology 1/1/2005 DISKOGRAPHY, LUMBAR, RADIOLOGICAL SUPERVISION AND 72295 INTERPRETATION radiology 1/1/2005 PERITONEOGRAM (EG, AFTER INJECTION OF AIR OR CONTRAST), RADIOLOGICAL SUPERVISION AND 74190 INTERPRETATION radiology 1/1/2005 REMOVAL OF FOREIGN BODY(S), ESOPHAGEAL, WITH USE OF BALLOON CATHETER, RADIOLOGICAL SUPERVISION AND 74235 INTERPRETATION radiology 1/1/2005 THERAPEUTIC ENEMA, CONTRAST OR AIR, FOR REDUCTION OF INTUSSUSCEPTION OR OTHER INTRALUMINAL OBSTRUCTION 74283 (EG, MECONIUM ILEUS) radiology 1/1/2005 CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; THROUGH EXISTING CATHETER, RADIOLOGICAL SUPERVISION AND 74305 INTERPRETATION radiology 1/1/2006 CHOLANGIOGRAPHY, PERCUTANEOUS, TRANSHEPATIC, 74320 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL 74328 SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ENDOSCOPIC CATHETERIZATION OF THE PANCREATIC DUCTAL 74329 SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 RADIOLOGIC EXAMINATION, RENAL CYST STUDY, TRANSLUMBAR, CONTRAST VISUALIZATION, RADIOLOGICAL 74470 SUPERVISION AND INTERPRETATION radiology 1/1/2007 INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE ,/OR INJECTION, PERCUTANEOUS, 74475 RADIOLOGICAL SUPERVISION radiology 8/1/2008 74710 PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION radiology 1/1/2005 HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND 74740 INTERPRETATION radiology 1/1/2007 AORTOGRAPHY, THORACIC, WITHOUT SERIALOGRAPHY, 75600 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE AORTOGRAPHY, THORACIC, BY SERIALOGRAPHY, 75605 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, 75625 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER EXTREMITY, CATHETER, BY SERIALOGRAPHY, 75630 RADIOLOGICAL SUPERVISION AND INTERP radiology 1/1/2005 ANGIOGRAPHY, CERVICOCEREBRAL, CATHETER, INCLUDING VESSEL ORIGIN, RADIOLOGICAL SUPERVISION AND 75650 INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, BRACHIAL, RETROGRADE, RADIOLOGICAL 75658 SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, EXTERNAL CAROTID, UNILATERAL, SELECTIVE, 75660 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, EXTERNAL CAROTID, BILATERAL, SELECTIVE, 75662 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, CAROTID, CEREBRAL, UNILATERAL, 75665 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, CAROTID, CEREBRAL, BILATERAL, 75671 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, CAROTID, CERVICAL, UNILATERAL, 75676 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, CAROTID, CERVICAL, BILATERAL, 75680 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, VERTEBRAL, CERVICAL, AND/OR INTRACRANIAL, RADIOLOGICAL SUPERVISION AND 75685 INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, SPINAL, SELECTIVE, RADIOLOGICAL 75705 SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL 75710 SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL 75716 SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, RENAL, UNILATERAL, SELECTIVE (INCLUDING FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND 75722 INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, RENAL, BILATERAL, SELECTIVE (INCLUDING FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND 75724 INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE, (WITH OR WITHOUT FLUSH AORTOGRAM), RADIOLOGICAL 75726 SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, 75731 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, 75733 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, PELVIC, SELECTIVE OR SUPRASELECTIVE, 75736 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 75741 ANGIOGRAPHY, PULMONARY, UNILATERAL, SELECTIVE, radiology 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PULMONARY, BILATERAL, SELECTIVE, 75743 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, PULMONARY, BY NONSELECTIVE CATHETER OR VENOUS INJECTION, RADIOLOGICAL SUPERVISION AND 75746 INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, INTERNAL MAMMARY, RADIOLOGICAL 75756 SUPERVISION AND INTERPRETATION radiology 1/1/2005 ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL VESSEL STUDIED AFTER BASIC EXAMINATION, RADIOLOGICAL 75774 SUPERVISION AND INTERPRETATION (LIST radiology 1/1/2005 ANGIOGRAPHY, ARTERIOVENOUS SHUNT (EG, DIALYSIS 75790 PATIENT), RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 LYMPHANGIOGRAPHY, EXTREMITY ONLY, UNILATERAL, 75801 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 LYMPHANGIOGRAPHY, EXTREMITY ONLY, BILATERAL, 75803 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, UNILATERAL, 75805 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, BILATERAL, 75807 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING NONVASCULAR SHUNT (EG, LEVEEN SHUNT, 75809 VENTRICULOPERITONEAL SHUNT, INDW radiology 1/1/2005 SPLENOPORTOGRAPHY, RADIOLOGICAL SUPERVISION AND 75810 INTERPRETATION radiology 1/1/2005 VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, 75825 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, 75827 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 VENOGRAPHY, RENAL, UNILATERAL, SELECTIVE, 75831 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 VENOGRAPHY, RENAL, BILATERAL, SELECTIVE, RADIOLOGICAL 75833 SUPERVISION AND INTERPRETATION radiology 1/1/2005 VENOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, 75840 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 VENOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, 75842 RADIOLOGICAL SUPERVISION AND INTERPRETATION radiology 1/1/2005 VENOGRAPHY, VENOUS SINUS (EG, PETROSAL AND INFERIOR SAGITTAL) OR JUGULAR, CATHETER, RADIOLOGICAL 75860 SUPERVISION AND INTERPRETATION radiology 1/1/2005 VENOGRAPHY, SUPERIOR SAGITTAL SINUS, RADIOLOGICAL 75870 SUPERVISION AND INTERPRETATION radiology 1/1/2005 VENOGRAPHY, EPIDURAL, RADIOLOGICAL SUPERVISION AND 75872 INTERPRETATION radiology 1/1/2005 VENOGRAPHY, ORBITAL, RADIOLOGICAL SUPERVISION AND 75880 INTERPRETATION radiology 1/1/2005 PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITH 75885 HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION radiology 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE AND INTERPRETATION PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITHOUT HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION 75887 AND INTERPRETATION radiology 1/1/2005 HEPATIC VENOGRAPHY, WEDGED OR FREE, WITH HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION 75889 AND INTERPRETATION radiology 1/1/2005 HEPATIC VENOGRAPHY, WEDGED OR FREE, WITHOUT HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION 75891 AND INTERPRETATION radiology 1/1/2005 VENOUS SAMPLING THROUGH CATHETER, WITH OR WITHOUT ANGIOGRAPHY (EG, FOR PARATHYROID HORMONE, RENIN), 75893 RADIOLOGICAL SUPERVISION AND I radiology 1/1/2005 ANGIOGRAPHY THROUGH EXISTING CATHETER FOR FOLLOW- UP STUDY FOR TRANSCATHETER THERAPY, EMBOLIZATION OR 75898 INFUSION radiology 1/1/2005 MECHANICAL REMOVAL OF PERICATHETER OBSTRUCTIVE MATERIAL (EG, FIBRIN SHEATH) FROM CENTRAL VENOUS DEVICE VIA SEPARATE VENOUS ACCESS,RADIOLOGICAL 75901 SUPERVISION AND INTERPRETATION radiology 1/1/2005 MECHANICAL REMOVAL OF INTRALUMINAL (INTRACATHETER) OBSTRUCTIVE MATERIAL FROM CENTRAL VENOUS DEVICE 75902 THROUGH DEVICE LUMEN, RADIOLOGI radiology 1/1/2005 INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL), RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL 75945 VESSEL radiology 1/1/2005 INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL), RADIOLOGICAL SUPERVISION AND INTERPRETATION; EACH 75946 ADDITIONAL NON-CORONARY VESSEL ( radiology 1/1/2005 FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR 75998 COMPLETE), OR REMOVAL (INCLUDES FL radiology 1/1/2005 FLUOROSCOPY (SEPARATE PROCEDURE), UP TO ONE HOUR PHYSICIAN TIME, OTHER THAN 71023 OR 71034 (EG, CARDIAC 76000 FLUOROSCOPY) radiology 1/1/2005 FLUOROSCOPY, PHYSICIAN TIME MORE THAN ONE HOUR, ASSISTING A NON-RADIOLOGIC PHYSICIAN (EG, 76001 NEPHROSTOLITHOTOMY, ERCP, BRONCHOSCOPY, radiology 1/1/2005 FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, 76003 BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) radiology 1/1/2005 FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR 76005 THERAPEUTIC INJECTION PROC radiology 1/1/2005 ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND 76776 DUPLEX DOPPLER WITH IMAGE DOCUMENTATION radiology 1/1/2007 ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ACCESS SITES, 76937 DOCUMENTATION OF SELECTED VESSE radiology 1/1/2005 ULTRASONIC GUIDANCE FOR INTERSTITIAL RADIOELEMENT 76965 APPLICATION radiology 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 33
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR 77001 COMPLETE), OR REMOVAL (INCLUDES FL radiology 1/1/2007 FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, 77002 BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) radiology 1/1/2007 FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR 77003 THERAPEUTIC INJECTION PROC radiology 1/1/2007 STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR NEEDLE PLACEMENT (EG, FOR WIRE LOCALIZATION OR FOR 77031 INJECTION), EACH LESION radiology 1/1/2007 MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST (EG, FOR WIRE LOCALIZATION OR FOR INJECTION), EACH 77032 LESION, RADIOLOGICAL SUPERVI radiology 1/1/2007 77072 BONE AGE STUDIES radiology 1/1/2007 BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, 77073 SCANOGRAM) radiology 1/1/2007 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE 77075 (AXIAL AND APPENDICULAR SKELETON) radiology 1/1/2007 77076 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT radiology 1/1/2007 77077 JOINT SURVEY, SINGLE VIEW, 2 OR MORE JOINTS (SPECIFY) radiology 1/1/2007 UREA BREATH TEST, C-14 (ISOTOPIC); ACQUISITION FOR 78267 ANALYSIS radiology 1/1/2005 78268 UREA BREATH TEST, C-14 (ISOTOPIC); ANALYSIS radiology 1/1/2005 DETERMINATION OF CENTRAL C-V HEMODYNAMICS (NON- IMAGING) (EG, EJECTION FRACTION WITH PROBE TECHNIQUE) 78414 WITH OR WITHOUT PHARMACOLOGIC radiology 1/1/2005 78428 CARDIAC SHUNT DETECTION radiology 1/1/2005 78455 VENOUS THROMBOSIS STUDY (EG, RADIOACTIVE FIBRINOGEN) radiology 1/1/2005 78456 ACUTE VENOUS THROMBOSIS IMAGING, PEPTIDE radiology 1/1/2005 78457 VENOUS THROMBOSIS IMAGING, VENOGRAM; UNILATERAL radiology 1/1/2005 78458 VENOUS THROMBOSIS IMAGING, VENOGRAM; BILATERAL radiology 1/1/2005 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING 78630 INTRODUCTION OF MATERIAL); CISTERNOGRAPHY radiology 1/1/2005 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING 78635 INTRODUCTION OF MATERIAL); VENTRICULOGRAPHY radiology 1/1/2005 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING 78645 INTRODUCTION OF MATERIAL); SHUNT EVALUATION radiology 1/1/2005 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING 78647 INTRODUCTION OF MATERIAL); TOMOGRAPHIC (SPECT) radiology 1/1/2005 CEREBROSPINAL FLUID LEAKAGE DETECTION AND 78650 LOCALIZATION radiology 1/1/2005 78660 RADIOPHARMACEUTICAL DACRYOCYSTOGRAPHY radiology 1/1/2005 79005 RADIOPHARMACEUTICAL THERAPY, BY ORAL ADMINISTRATION radiology 1/1/2005 RADIOPHARMACEUTICAL THERAPY, BY INTRAVENOUS 79101 ADMINISTRATION radiology 1/1/2007 RADIOPHARMACEUTICAL THERAPY, BY INTRACAVITARY 79200 ADMINISTRATION radiology 1/1/2007 79300 RADIOPHARMACEUTICAL THERAPY, BY INTERSTITIAL radiology 1/1/2007
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE RADIOACTIVE COLLOID ADMINISTRATION RADIOPHARMACEUTICAL THERAPY, RADIOLABELED 79403 MONOCLONAL ANTIBODY BY INTRAVENOUS INFUSION radiology 1/1/2007 RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTICULAR 79440 ADMINISTRATION radiology 1/1/2007 RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTERIAL 79445 PARTICULATE ADMINISTRATION radiology 1/1/2007 83987 PH; EXHALED BREATH CONDENSATE Pulm 1/1/2010 THROMBOXANE METABOLITE(S), INCLUDING THROMBOXANE IF 84431 PERFORMED, URINE general 1/1/2010 LEVEL II - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION APPENDIX, INCIDENTAL FALLOPIAN TUBE, 88302 STERILIZATION FINGERS/TOES, lab/pathol 1/1/2006 LEVEL III - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION ABORTION, INDUCED ABSCESS ANEURYSM - 88304 ARTERIAL/VENTRICULAR ANUS, lab/pathol 1/1/2006 LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION ABORTION - SPONTANEOUS/MISSED ARTERY, 88305 BIOPSY BONE MARROW, BIOPSY lab/pathol 1/1/2006 LEVEL V - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE - 88307 BIOPSY/CURETTINGS BONE FRAGMENT(S), PATH lab/pathol 1/1/2006 LEVEL VI - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION BONE RESECTION BREAST, MASTECTOMY - WITH 88309 REGIONAL LYMPH NODES COL lab/pathol 1/1/2006 MICRODISSECTION (IE, SAMPLE PREPARATION OF 88381 MICROSCOPICALLY IDENTIFIED TARGET); MANUAL lab/pathol 1/1/2008 DUODENAL INTUBATION AND ASPIRATION; SINGLE SPECIMEN (EG, SIMPLE BILE STUDY OR AFFERENT LOOP CULTURE) PLUS 89100 APPROPRIATE TEST PROCEDU lab/pathol 1/1/2005 DUODENAL INTUBATION AND ASPIRATION; COLLECTION OF MULTIPLE FRACTIONAL SPECIMENS WITH PANCREATIC OR 89105 GALLBLADDER STIMULATION, SINGLE lab/pathol 1/1/2005 GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH 89130 SPECIMEN, FOR CHEMICAL ANALYSES OR CYTOPATHOLOGY; lab/pathol 1/1/2005 GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH SPECIMEN, FOR CHEMICAL ANALYSES OR CYTOPATHOLOGY; 89132 AFTER STIMULATION lab/pathol 1/1/2005 GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL 89135 COLLECTIONS (EG, GASTRIC SECRETORY STUDY); ONE HOUR lab/pathol 1/1/2005 GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL 89136 COLLECTIONS (EG, GASTRIC SECRETORY STUDY); TWO HOURS lab/pathol 1/1/2005 GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, GASTRIC SECRETORY STUDY); TWO HOURS 89140 INCLUDING GASTRIC STIMULATION lab/pathol 1/1/2005 GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, GASTRIC SECRETORY STUDY); THREE 89141 HOURS, INCLUDING GASTRIC STIMULATI lab/pathol 1/1/2005 90769 SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS general 1/1/2008
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO ONE HOUR, INCLUDING PUMP SET-UP AND E SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR 90770 (LIST SEPARATELY IN ADDITION TO general 1/1/2008 SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL PUMP SET-UP 90771 WITH ESTABLISHMENT OF NEW SUB general 1/1/2008 ESOPHAGEAL INTUBATION AND COLLECTION OF WASHINGS FOR CYTOLOGY, INCLUDING PREPARATION OF SPECIMENS 91000 (SEPARATE PROCEDURE) gastro 1/1/2005 91020 GASTRIC MOTILITY (MANOMETRIC) STUDIES gastro 1/1/2005 91022 DUODENAL MOTILITY (MANOMETRIC) STUDY gastro 1/1/2006 ESOPHAGUS, ACID PERFUSION (BERNSTEIN) TEST FOR 91030 ESOPHAGITIS gastro 1/1/2005 ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH NASAL CATHETER PH ELECTRODE(S) PLACEMENT, RECORDING, 91034 ANALYSIS AND INTERPRETATION gastro 1/1/2005 ESOPHAGEAL FUNCTION TEST, GASTROESOPHAGEAL REFLUX TEST WITH NASAL CATHETER INTRALUMINAL IMPEDANCE 91037 ELECTRODE(S) PLACEMENT, RECORDIN gastro 1/1/2005 ESOPHAGEAL FUNCTION TEST, GASTROESOPHAGEAL REFLUX TEST WITH NASAL CATHETER INTRALUMINAL IMPEDANCE 91038 ELECTRODE(S) PLACEMENT, RECORDIN gastro 1/1/2005 91040 ESOPHAGEAL BALLOON DISTENSION PROVOCATION STUDY gastro 1/1/2005 GASTRIC ANALYSIS TEST WITH INJECTION OF STIMULANT OF GASTRIC SECRETION (EG, HISTAMINE, INSULIN, PENTAGASTRIN, 91052 CALCIUM AND SECRETIN gastro 1/1/2005 GASTRIC INTUBATION, WASHINGS, AND PREPARING SLIDES 91055 FOR CYTOLOGY (SEPARATE PROCEDURE) gastro 1/1/2005 91060 GASTRIC SALINE LOAD TEST gastro 1/1/2005 BREATH HYDROGEN TEST (EG, FOR DETECTION OF LACTASE DEFICIENCY, FRUCTOSE INTOLERANCE, BACTERIAL 91065 OVERGROWTH, OR ORO-CECAL GASTROINTE gastro 1/1/2005 INTESTINAL BLEEDING TUBE, PASSAGE, POSITIONING AND 91100 MONITORING gastro 1/1/2005 GASTRIC INTUBATION, AND ASPIRATION OR LAVAGE FOR 91105 TREATMENT (EG, FOR INGESTED POISONS) gastro 1/1/2005 RECTAL SENSATION, TONE, AND COMPLIANCE TEST (IE, 91120 RESPONSE TO GRADED BALLOON DISTENTION) gastro 1/1/2005 91122 ANORECTAL MANOMETRY gastro 1/1/2005 91132 ELECTROGASTROGRAPHY, DIAGNOSTIC, TRANSCUTANEOUS; gastro 1/1/2005 ELECTROGASTROGRAPHY, DIAGNOSTIC, TRANSCUTANEOUS; 91133 WITH PROVOCATIVE TESTING gastro 1/1/2005 92015 DETERMINATION OF REFRACTIVE STATE opthamol 1/1/2005 92020 GONIOSCOPY (SEPARATE PROCEDURE) opthamol 1/1/2005 COMPUTERIZED CORNEAL TOPOGRAPHY, UNILATERAL OR 92025 BILATERAL, WITH INTERPRETATION AND REPORT opthamol 1/1/2007 92060 SENSORIMOTOR EXAMINATION WITH MULTIPLE opthamol 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE MEASUREMENTS OF OCULAR DEVIATION (EG, RESTRICTIVE OR PARETIC MUSCLE WITH DIPLOPIA) WITH INT VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; LIMITED EXAMINATION (EG, 92081 TANGENT SCREEN, AUTOPL opthamol 1/1/2005 VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; INTERMEDIATE EXAMINATION 92082 (EG, AT LEAST 2 ISOPTE opthamol 1/1/2005 VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; EXTENDED EXAMINATION (EG, 92083 GOLDMANN VISUAL FIELD opthamol 1/1/2005 SERIAL TONOMETRY (SEPARATE PROCEDURE) WITH MULTIPLE MEASUREMENTS OF INTRAOCULAR PRESSURE OVER AN 92100 EXTENDED TIME PERIOD WITH INTERPR opthamol 1/1/2005 TONOGRAPHY WITH INTERPRETATION AND REPORT, RECORDING INDENTATION TONOMETER METHOD OR 92120 PERILIMBAL SUCTION METHOD opthamol 1/1/2005 92130 TONOGRAPHY WITH WATER PROVOCATION opthamol 1/1/2005 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING (EG, SCANNING LASER) WITH INTERPRETATION AND REPORT, 92135 UNILATERAL opthamol 1/1/2005 OPHTHALMIC BIOMETRY BY PARTIAL COHERENCE INTERFEROMETRY WITH INTRAOCULAR LENS POWER 92136 CALCULATION opthamol 1/1/2005 PROVOCATIVE TESTS FOR GLAUCOMA, WITH INTERPRETATION 92140 AND REPORT, WITHOUT TONOGRAPHY opthamol 1/1/2005 OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH 92225 INTERPRETATION AND REPORT; INITIAL opthamol 1/1/2005 OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH 92226 INTERPRETATION AND REPORT; SUBSEQUENT opthamol 1/1/2005 FLUORESCEIN ANGIOSCOPY WITH INTERPRETATION AND 92230 REPORT opthamol 1/1/2005 FLUORESCEIN ANGIOGRAPHY (INCLUDES MULTIFRAME 92235 IMAGING) WITH INTERPRETATION AND REPORT opthamol 1/1/2005 INDOCYANINE-GREEN ANGIOGRAPHY (INCLUDES MULTIFRAME 92240 IMAGING) WITH INTERPRETATION AND REPORT opthamol 1/1/2005 92250 FUNDUS PHOTOGRAPHY WITH INTERPRETATION AND REPORT opthamol 1/1/2005 92260 OPHTHALMODYNAMOMETRY opthamol 1/1/2005 NEEDLE OCULOELECTROMYOGRAPHY, ONE OR MORE EXTRAOCULAR MUSCLES, ONE OR BOTH EYES, WITH 92265 INTERPRETATION AND REPORT opthamol 1/1/2005 92270 ELECTRO-OCULOGRAPHY WITH INTERPRETATION AND REPORT opthamol 1/1/2005 92275 ELECTRORETINOGRAPHY WITH INTERPRETATION AND REPORT opthamol 1/1/2005 COLOR VISION EXAMINATION, EXTENDED, EG, ANOMALOSCOPE 92283 OR EQUIVALENT opthamol 1/1/2005 DARK ADAPTATION EXAMINATION WITH INTERPRETATION AND 92284 REPORT opthamol 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE EXTERNAL OCULAR PHOTOGRAPHY WITH INTERPRETATION AND REPORT FOR DOCUMENTATION OF MEDICAL PROGRESS 92285 (EG, CLOSE-UP PHOTOGRAPHY, SLIT opthamol 1/1/2005 SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY WITH INTERPRETATION AND REPORT; WITH SPECULAR ENDOTHELIAL 92286 MICROSCOPY AND CELL COUNT opthamol 1/1/2005 SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY WITH INTERPRETATION AND REPORT; WITH FLUORESCEIN 92287 ANGIOGRAPHY opthamol 1/1/2005 NASOPHARYNGOSCOPY WITH ENDOSCOPE (SEPARATE 92511 PROCEDURE) ent 1/1/2005 92512 NASAL FUNCTION STUDIES (EG, RHINOMANOMETRY) ent 1/1/2005 FACIAL NERVE FUNCTION STUDIES (EG, 92516 ELECTRONEURONOGRAPHY) ent 1/1/2005 LARYNGEAL FUNCTION STUDIES (IE, AERODYNAMIC TESTING 92520 AND ACOUSTIC TESTING) ent 1/1/2005 TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL 92526 FUNCTION FOR FEEDING ent 1/1/2005 92531 SPONTANEOUS NYSTAGMUS, INCLUDING GAZE ent 1/1/2005 92532 POSITIONAL NYSTAGMUS TEST ent 1/1/2005 CALORIC VESTIBULAR TEST, EACH IRRIGATION (BINAURAL, 92533 BITHERMAL STIMULATION CONSTITUTES FOUR TESTS) ent 1/1/2005 92534 OPTOKINETIC NYSTAGMUS TEST ent 1/1/2005 SPONTANEOUS NYSTAGMUS TEST, INCLUDING GAZE AND 92541 FIXATION NYSTAGMUS, WITH RECORDING ent 1/1/2005 POSITIONAL NYSTAGMUS TEST, MINIMUM OF 4 POSITIONS, 92542 WITH RECORDING ent 1/1/2005 CALORIC VESTIBULAR TEST, EACH IRRIGATION (BINAURAL, BITHERMAL STIMULATION CONSTITUTES FOUR TESTS), WITH 92543 RECORDING ent 1/1/2005 OPTOKINETIC NYSTAGMUS TEST, BIDIRECTIONAL, FOVEAL OR 92544 PERIPHERAL STIMULATION, WITH RECORDING ent 1/1/2005 92545 OSCILLATING TRACKING TEST, WITH RECORDING ent 1/1/2005 92546 SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING ent 1/1/2005 USE OF VERTICAL ELECTRODES (LIST SEPARATELY IN 92547 ADDITION TO CODE FOR PRIMARY PROCEDURE) ent 1/1/2005 92548 COMPUTERIZED DYNAMIC POSTUROGRAPHY ent 1/1/2005 92550 TYMPANOMETRY AND REFLEX THRESHOLD MEASUREMENTS ent 1/1/2010 92551 SCREENING TEST, PURE TONE, AIR ONLY audiol 1/1/2005 92552 PURE TONE AUDIOMETRY (THRESHOLD); AIR ONLY audiol 1/1/2005 92553 PURE TONE AUDIOMETRY (THRESHOLD); AIR AND BONE audiol 1/1/2005 92555 SPEECH AUDIOMETRY THRESHOLD; audiol 1/1/2005 SPEECH AUDIOMETRY THRESHOLD; WITH SPEECH 92556 RECOGNITION audiol 1/1/2005 COMPREHENSIVE AUDIOMETRY THRESHOLD EVALUATION AND 92557 SPEECH RECOGNITION (92553 AND 92556 COMBINED) audiol 1/1/2005 92560 BEKESY AUDIOMETRY; SCREENING audiol 1/1/2005 92561 BEKESY AUDIOMETRY; DIAGNOSTIC audiol 1/1/2005 92562 LOUDNESS BALANCE TEST, ALTERNATE BINAURAL OR audiol 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE MONAURAL 92563 TONE DECAY TEST audiol 1/1/2005 92564 SHORT INCREMENT SENSITIVITY INDEX (SISI) audiol 1/1/2005 92565 STENGER TEST, PURE TONE audiol 1/1/2005 92567 TYMPANOMETRY (IMPEDANCE TESTING) audiol 1/1/2005 92568 ACOUSTIC REFLEX TESTING; THRESHOLD audiol 1/1/2005 92569 ACOUSTIC REFLEX TESTING; DECAY audiol 1/1/2005 ACOUSTIC IMMITTANCE TESTING, INCLUDES TYMPANOMETRY (IMPEDANCE TESTING), ACOUSTIC REFLEX THRESHOLD 92570 TESTING, AND ACOUSTIC REFLEX DEC audiol 1/1/2010 92571 FILTERED SPEECH TEST audiol 1/1/2005 92572 STAGGERED SPONDAIC WORD TEST audiol 1/1/2005 92573 LOMBARD TEST audiol 1/1/2005 92575 SENSORINEURAL ACUITY LEVEL TEST audiol 1/1/2005 92576 SYNTHETIC SENTENCE IDENTIFICATION TEST audiol 1/1/2005 92577 STENGER TEST, SPEECH audiol 1/1/2005 92579 VISUAL REINFORCEMENT AUDIOMETRY (VRA) audiol 1/1/2005 92582 CONDITIONING PLAY AUDIOMETRY audiol 1/1/2005 92583 SELECT PICTURE AUDIOMETRY audiol 1/1/2005 92584 ELECTROCOCHLEOGRAPHY audiol 1/1/2005 AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY AND/OR TESTING OF THE CENTRAL NERVOUS 92585 SYSTEM; COMPREHENSIVE audiol 1/1/2005 AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY AND/OR TESTING OF THE CENTRAL NERVOUS 92586 SYSTEM; LIMITED audiol 1/1/2005 EVOKED OTOACOUSTIC EMISSIONS; LIMITED (SINGLE STIMULUS 92587 LEVEL, EITHER TRANSIENT OR DISTORTION PRODUCTS) audiol 1/1/2005 EVOKED OTOACOUSTIC EMISSIONS; COMPREHENSIVE OR DIAGNOSTIC EVALUATION (COMPARISON OF TRANSIENT 92588 AND/OR DISTORTION PRODUCT OTOACOUSTI audiol 1/1/2005 MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING 92611 FUNCTION BY CINE OR VIDEO RECORDING general 1/1/2005 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF 92612 SWALLOWING BY CINE OR VIDEO RECORDING; general 1/1/2005 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING BY CINE OR VIDEO RECORDING; PHYSICIAN 92613 INTERPRETATION AND REPORT ONLY general 1/1/2005 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL 92614 SENSORY TESTING BY CINE OR VIDEO RECORDING; general 1/1/2005 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING; PHYSICIAN 92615 INTERPRETATION AND REPO general 1/1/2005 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING AND LARYNGEAL SENSORY TESTING BY CINE OR 92616 VIDEO RECORDING; general 1/1/2005 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING AND LARYNGEAL SENSORY TESTING BY CINE OR 92617 VIDEO RECORDING; PHYSICIAN INTERP general 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE EVALUATION OF CENTRAL AUDITORY FUNCTION, WITH REPORT; 92620 INITIAL 60 MINUTES audiol 1/1/2005 EVALUATION OF CENTRAL AUDITORY FUNCTION, WITH REPORT; 92621 EACH ADDITIONAL 15 MINUTES audiol 1/1/2005 ASSESSMENT OF TINNITUS (INCLUDES PITCH, LOUDNESS 92625 MATCHING, AND MASKING) audiol 1/1/2005 EVALUATION OF AUDITORY REHABILITATION STATUS; FIRST 92626 HOUR audiol 1/1/2006 EVALUATION OF AUDITORY REHABILITATION STATUS; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO 92627 CODE FOR PRIMARY PROCEDUR audiol 1/1/2006 DIAGNOSTIC ANALYSIS WITH PROGRAMMING OF AUDITORY 92640 BRAINSTEM IMPLANT, PER HOUR ent 1/1/2007 93024 ERGONOVINE PROVOCATION TEST cardiol 1/1/2005 MICROVOLT T-WAVE ALTERNANS FOR ASSESSMENT OF 93025 VENTRICULAR ARRHYTHMIAS cardiol 1/1/2005 PROGRAMMING DEVICE EVALUATION WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE 93282 FUNCTION OF THE DEVICE AND SELECT OP cardiol 1/1/2009 PROGRAMMING DEVICE EVALUATION WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE 93283 FUNCTION OF THE DEVICE AND SELECT OP cardiol 1/1/2009 PROGRAMMING DEVICE EVALUATION WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE 93284 FUNCTION OF THE DEVICE AND SELECT OP cardiol 1/1/2009 PERI-PROCEDURAL DEVICE EVALUATION AND PROGRAMMING OF DEVICE SYSTEM PARAMETERS BEFORE OR AFTER A 93286 SURGERY, PROCEDURE, OR TEST WITH P cardiol 1/1/2009 PERI-PROCEDURAL DEVICE EVALUATION AND PROGRAMMING OF DEVICE SYSTEM PARAMETERS BEFORE OR AFTER A 93287 SURGERY, PROCEDURE, OR TEST WITH P cardiol 1/1/2009 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH PHYSICIAN ANALYSIS, REVIEW AND REPORT, INCLUDES 93289 CONNECTION, RECORDING AND DISCONN cardiol 1/1/2009 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH PHYSICIAN ANALYSIS, REVIEW AND REPORT, INCLUDES 93290 CONNECTION, RECORDING AND DISCONN cardiol 1/1/2009 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH PHYSICIAN ANALYSIS, REVIEW AND REPORT, INCLUDES 93292 CONNECTION, RECORDING AND DISCONN cardiol 1/1/2009 INTERROGATION DEVICE EVALUATION(S) (REMOTE), UP TO 90 DAYS; SINGLE, DUAL, OR MULTIPLE LEAD IMPLANTABLE 93295 CARDIOVERTER-DEFIBRILLATOR cardiol 1/1/2009 INTERROGATION DEVICE EVALUATION(S) (REMOTE), UP TO 90 DAYS; SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM 93296 OR IMPLANTABLE CARDIOV cardiol 1/1/2009 INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR MONITOR SYSTEM, 93297 INCLUDING ANALYSIS OF 1 OR cardiol 1/1/2009
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR MONITOR SYSTEM OR 93299 IMPLANTABLE LOOP RECORDER cardiol 1/1/2009 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE 93312 RECORDING); INCLUDING PROBE PLA cardiol 1/1/2005 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE 93313 RECORDING); PLACEMENT OF TRANSE cardiol 1/1/2005 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE 93314 RECORDING); IMAGE ACQUISITION, cardiol 1/1/2005 TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE 93315 ACQUISITION, INTERPRETATION AN cardiol 1/1/2005 TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; PLACEMENT OF TRANSESOPHAGEAL 93316 PROBE ONLY cardiol 1/1/2005 TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; IMAGE ACQUISITION, INTERPRETATION 93317 AND REPORT ONLY cardiol 1/1/2005 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL (TEE) FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL 93318 TIME 2-DIMENSIONAL IMAGE ACQUISIT cardiol 1/1/2005 EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND 93660 INTERMITTENT BLOOD PRESSURE M cardiol 1/1/2011 93701 BIOIMPEDANCE, THORACIC, ELECTRICAL cardiol 1/1/2005 PLETHYSMOGRAPHY, TOTAL BODY; WITH INTERPRETATION 93720 AND REPORT cardiol 1/1/2005 PLETHYSMOGRAPHY, TOTAL BODY; TRACING ONLY, WITHOUT 93721 INTERPRETATION AND REPORT cardiol 1/1/2005 PLETHYSMOGRAPHY, TOTAL BODY; INTERPRETATION AND 93722 REPORT ONLY cardiol 1/1/2005 ELECTRONIC ANALYSIS OF ANTITACHYCARDIA PACEMAKER SYSTEM (INCLUDES ELECTROCARDIOGRAPHIC RECORDING, 93724 PROGRAMMING OF DEVICE, INDUCTION cardiol 1/1/2005 ELECTRONIC ANALYSIS OF IMPLANTABLE LOOP RECORDER (ILR) SYSTEM (INCLUDES RETRIEVAL OF RECORDED AND 93727 STORED ECG DATA, PHYSICIAN REVIE cardiol 1/1/2005 ELECTRONIC ANALYSIS OF DUAL-CHAMBER PACEMAKER SYSTEM (INCLUDES EVALUATION OF PROGRAMMABLE 93731 PARAMETERS AT REST AND DURING ACTIVITY W cardiol 1/1/2005 ELECTRONIC ANALYSIS OF DUAL-CHAMBER PACEMAKER SYSTEM (INCLUDES EVALUATION OF PROGRAMMABLE 93732 PARAMETERS AT REST AND DURING ACTIVITY W cardiol 1/1/2005 ELECTRONIC ANALYSIS OF DUAL CHAMBER INTERNAL PACEMAKER SYSTEM (MAY INCLUDE RATE, PULSE AMPLITUDE 93733 AND DURATION, CONFIGURATION OF WA cardiol 1/1/2005 93734 ELECTRONIC ANALYSIS OF SINGLE CHAMBER PACEMAKER cardiol 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 41
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE SYSTEM (INCLUDES EVALUATION OF PROGRAMMABLE PARAMETERS AT REST AND DURING ACTIVITY ELECTRONIC ANALYSIS OF SINGLE CHAMBER PACEMAKER SYSTEM (INCLUDES EVALUATION OF PROGRAMMABLE 93735 PARAMETERS AT REST AND DURING ACTIVITY cardiol 1/1/2005 ELECTRONIC ANALYSIS OF SINGLE CHAMBER INTERNAL PACEMAKER SYSTEM (MAY INCLUDE RATE, PULSE AMPLITUDE 93736 AND DURATION, CONFIGURATION OF cardiol 1/1/2005 93740 TEMPERATURE GRADIENT STUDIES cardiol 1/1/2005 ELECTRONIC ANALYSIS OF PACING CARDIOVERTER- DEFIBRILLATOR (INCLUDES INTERROGATION, EVALUATION OF 93741 PULSE GENERATOR STATUS, EVALUATION cardiol 1/1/2005 ELECTRONIC ANALYSIS OF PACING CARDIOVERTER- DEFIBRILLATOR (INCLUDES INTERROGATION, EVALUATION OF 93742 PULSE GENERATOR STATUS, EVALUATION cardiol 1/1/2005 ELECTRONIC ANALYSIS OF PACING CARDIOVERTER- DEFIBRILLATOR (INCLUDES INTERROGATION, EVALUATION OF 93743 PULSE GENERATOR STATUS, EVALUATION cardiol 1/1/2005 ELECTRONIC ANALYSIS OF PACING CARDIOVERTER- DEFIBRILLATOR (INCLUDES INTERROGATION, EVALUATION OF 93744 PULSE GENERATOR STATUS, EVALUATION cardiol 1/1/2005 INITIAL SET-UP AND PROGRAMMING BY A PHYSICIAN OF WEARABLE CARDIOVERTER-DEFIBRILLATOR INCLUDES INITIAL 93745 PROGRAMMING OF SYSTEM, ESTAB cardiol 1/1/2005 93760 THERMOGRAM; CEPHALIC radiology 1/1/2005 93762 THERMOGRAM; PERIPHERAL radiology 1/1/2005 93770 DETERMINATION OF VENOUS PRESSURE radiology 1/1/2005 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL 93890 ARTERIES; VASOREACTIVITY STUDY radiology 1/1/2005 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; EMBOLI DETECTION WITHOUT INTRAVENOUS 93892 MICROBUBBLE INJECTION radiology 1/1/2005 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; EMBOLI DETECTION WITH INTRAVENOUS 93893 MICROBUBBLE INJECTION radiology 1/1/2005 NONINVASIVE PHYSIOLOGIC STUDY OF IMPLANTED WIRELESS PRESSURE SENSOR IN ANEURYSMAL SAC FOLLOWING 93982 ENDOVASCULAR REPAIR, COMPLETE STUD radiology 1/1/2008 MEASUREMENT OF SPIROMETRIC FORCED EXPIRATORY FLOWS 94011 IN AN INFANT OR CHILD THROUGH 2 YEARS OF AGE pulm 1/1/2010 MEASUREMENT OF SPIROMETRIC FORCED EXPIRATORY FLOWS, BEFORE AND AFTER BRONCHODILATOR, IN AN INFANT 94012 OR CHILD THROUGH 2 YEARS OF AGE pulm 1/1/2010 MEASUREMENT OF LUNG VOLUMES (IE, FUNCTIONAL RESIDUAL CAPACITY [FRC], FORCED VITAL CAPACITY [FVC], AND 94013 EXPIRATORY RESERVE VOLUME [E pulm 1/1/2010 HIGH ALTITUDE SIMULATION TEST (HAST), WITH PHYSICIAN 94452 INTERPRETATION AND REPORT; pulm 1/1/2005 94453 HIGH ALTITUDE SIMULATION TEST (HAST), WITH PHYSICIAN pulm 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE INTERPRETATION AND REPORT; WITH SUPPLEMENTAL OXYGEN TITRATION CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION 94660 (CPAP), INITIATION AND MANAGEMENT pulm 1/1/2005 CONTINUOUS NEGATIVE PRESSURE VENTILATION (CNP), 94662 INITIATION AND MANAGEMENT pulm 1/1/2005 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND VIBRATION TO FACILITATE LUNG FUNCTION; INITIAL 94667 DEMONSTRATION AND/OR EVAL pulm 1/1/2005 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, 94668 AND VIBRATION TO FACILITATE LUNG FUNCTION; SUBSEQUENT pulm 1/1/2005 94725 MEMBRANE DIFFUSION CAPACITY pulm 1/1/2005 PULMONARY COMPLIANCE STUDY (EG, PLETHYSMOGRAPHY, 94750 VOLUME AND PRESSURE MEASUREMENTS) pulm 1/1/2005 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; BY CONTINUOUS OVERNIGHT MONITORING 94762 (SEPARATE PROCEDURE) pulm 1/1/2005 CIRCADIAN RESPIRATORY PATTERN RECORDING (PEDIATRIC PNEUMOGRAM), 12 TO 24 HOUR CONTINUOUS RECORDING, 94772 INFANT pulm 1/1/2006 PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) WITH ALLERGENIC EXTRACTS, IMMEDIATE TYPE REACTION, SPECIFY 95004 NUMBER OF TESTS allergy 1/1/2005 PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) SEQUENTIAL AND INCREMENTAL, WITH DRUGS, BIOLOGICALS 95010 OR VENOMS, IMMEDIATE TYPE REACTI allergy 1/1/2005 95012 NITRIC OXIDE EXPIRED GAS DETERMINATION allergy 1/1/2007 INTRACUTANEOUS (INTRADERMAL) TESTS, SEQUENTIAL AND INCREMENTAL, WITH DRUGS, BIOLOGICALS, OR VENOMS, 95015 IMMEDIATE TYPE REACTION, SPECI allergy 1/1/2005 INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, IMMEDIATE TYPE REACTION, SPECIFY NUMBER OF 95024 TESTS allergy 1/1/2005 INTRACUTANEOUS (INTRADERMAL) TESTS, SEQUENTIAL AND INCREMENTAL, WITH ALLERGENIC EXTRACTS FOR AIRBORNE 95027 ALLERGENS, IMMEDIATE TYPE RE allergy 1/1/2005 INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, DELAYED TYPE REACTION, INCLUDING READING, 95028 SPECIFY NUMBER OF TESTS allergy 1/1/2005 95044 PATCH OR APPLICATION TEST(S) (SPECIFY NUMBER OF TESTS) allergy 1/1/2005 95052 PHOTO PATCH TEST(S) (SPECIFY NUMBER OF TESTS) allergy 1/1/2005 95056 PHOTO TESTS allergy 1/1/2005 95060 OPHTHALMIC MUCOUS MEMBRANE TESTS allergy 1/1/2005 95065 DIRECT NASAL MUCOUS MEMBRANE TEST allergy 1/1/2005 INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING NECESSARY PULMONARY FUNCTION TESTS); WITH HISTAMINE, 95070 METHACHOLINE, OR SIMILA allergy 1/1/2005 INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING 95071 NECESSARY PULMONARY FUNCTION TESTS); WITH ANTIGENS allergy 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE OR GASES, SPECIFY INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTION OF TEST ITEMS, EG, FOOD, DRUG OR OTHER 95075 SUBSTANCE SUCH AS METABISULF allergy 1/1/2005 95078 PROVOCATIVE TESTING (EG, RINKEL TEST) allergy 1/1/2005 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; 95115 SINGLE INJECTION allergy 1/1/2005 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; TWO 95117 OR MORE INJECTIONS allergy 1/1/2005 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING 95120 PROVISION OF ALLERGENI allergy 1/1/2005 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING 95125 PROVISION OF ALLERGENI allergy 1/1/2005 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING 95130 PROVISION OF ALLERGENI allergy 1/1/2005 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING 95131 PROVISION OF ALLERGENI allergy 1/1/2005 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING 95132 PROVISION OF ALLERGENI allergy 1/1/2005 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING 95133 PROVISION OF ALLERGENI allergy 1/1/2005 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING 95134 PROVISION OF ALLERGENI allergy 1/1/2005 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN 95144 IMMUNOTHERAPY, SINGLE DOSE VIAL(S) allergy 1/1/2005 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN 95145 IMMUNOTHERAPY (SPECIFY NUMBER OF D allergy 1/1/2005 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN 95146 IMMUNOTHERAPY (SPECIFY NUMBER OF D allergy 1/1/2005 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN 95147 IMMUNOTHERAPY (SPECIFY NUMBER OF D allergy 1/1/2005 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN 95148 IMMUNOTHERAPY (SPECIFY NUMBER OF D allergy 1/1/2005 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN 95149 IMMUNOTHERAPY (SPECIFY NUMBER OF D allergy 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 44
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN 95165 IMMUNOTHERAPY; SINGLE OR MULTIPLE allergy 1/1/2005 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN 95170 IMMUNOTHERAPY; WHOLE BODY EXTRACT allergy 1/1/2005 RAPID DESENSITIZATION PROCEDURE, EACH HOUR (EG, 95180 INSULIN, PENICILLIN, EQUINE SERUM) allergy 1/1/2005 AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TISSUE FLUID VIA A SUBCUTANEOUS SENSOR 95250 FOR UP TO 72 HOURS; SENSOR PLACEME endocrin 1/1/2005 AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL TISSUE FLUID VIA A SUBCUTANEOUS SENSOR 95251 FOR UP TO 72 HOURS; PHYSICIAN INTE endocrin 1/1/2006 ELECTROENCEPHALOGRAM (EEG) EXTENDED MONITORING; 41- 95812 60 MINUTES neurol 1/1/2005 ELECTROENCEPHALOGRAM (EEG) EXTENDED MONITORING; 95813 GREATER THAN ONE HOUR neurol 1/1/2005 ELECTROENCEPHALOGRAM (EEG); INCLUDING RECORDING 95816 AWAKE AND DROWSY neurol 1/1/2005 ELECTROENCEPHALOGRAM (EEG); INCLUDING RECORDING 95819 AWAKE AND ASLEEP neurol 1/1/2005 ELECTROENCEPHALOGRAM (EEG); RECORDING IN COMA OR 95822 SLEEP ONLY neurol 1/1/2005 ELECTROENCEPHALOGRAM (EEG); CEREBRAL DEATH 95824 EVALUATION ONLY neurol 1/1/2005 95827 ELECTROENCEPHALOGRAM (EEG); ALL NIGHT RECORDING neurol 1/1/2005 MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH 95831 REPORT; EXTREMITY (EXCLUDING HAND) OR TRUNK neurol 1/1/2005 MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH REPORT; HAND, WITH OR WITHOUT COMPARISON WITH 95832 NORMAL SIDE neurol 1/1/2005 MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH 95833 REPORT; TOTAL EVALUATION OF BODY, EXCLUDING HANDS neurol 1/1/2005 MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH 95834 REPORT; TOTAL EVALUATION OF BODY, INCLUDING HANDS neurol 1/1/2005 RANGE OF MOTION MEASUREMENTS AND REPORT (SEPARATE PROCEDURE); EACH EXTREMITY (EXCLUDING HAND) OR EACH 95851 TRUNK SECTION (SPINE) neurol 1/1/2005 RANGE OF MOTION MEASUREMENTS AND REPORT (SEPARATE PROCEDURE); HAND, WITH OR WITHOUT COMPARISON WITH 95852 NORMAL SIDE neurol 1/1/2005 95857 TENSILON TEST FOR MYASTHENIA GRAVIS neurol 1/1/2005 TENSILON TEST FOR MYASTHENIA GRAVIS; WITH 95858 ELECTROMYOGRAPHIC RECORDING neurol 1/1/2005 NEEDLE ELECTROMYOGRAPHY; ONE EXTREMITY WITH OR 95860 WITHOUT RELATED PARASPINAL AREAS neurol 1/1/2005 NEEDLE ELECTROMYOGRAPHY; TWO EXTREMITIES WITH OR 95861 WITHOUT RELATED PARASPINAL AREAS neurol 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE NEEDLE ELECTROMYOGRAPHY; THREE EXTREMITIES WITH OR 95863 WITHOUT RELATED PARASPINAL AREAS neurol 1/1/2005 NEEDLE ELECTROMYOGRAPHY; FOUR EXTREMITIES WITH OR 95864 WITHOUT RELATED PARASPINAL AREAS neurol 1/1/2005 95865 NEEDLE ELECTROMYOGRAPHY; LARYNX neurol 1/1/2006 95866 NEEDLE ELECTROMYOGRAPHY; HEMIDIAPHRAGM neurol 1/1/2006 NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED 95867 MUSCLE(S), UNILATERAL neurol 1/1/2005 NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED 95868 MUSCLES, BILATERAL neurol 1/1/2005 NEEDLE ELECTROMYOGRAPHY; THORACIC PARASPINAL 95869 MUSCLES (EXCLUDING T1 OR T12) neurol 1/1/2005 NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY OF MUSCLES IN ONE EXTREMITY OR NON-LIMB (AXIAL) MUSCLES (UNILATERAL 95870 OR BILATERAL), OTHER TH neurol 1/1/2005 NEEDLE ELECTROMYOGRAPHY USING SINGLE FIBER ELECTRODE, WITH QUANTITATIVE MEASUREMENT OF JITTER, 95872 BLOCKING AND/OR FIBER DENSITY, ANY/ neurol 1/1/2005 ELECTRICAL STIMULATION FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO 95873 CODE FOR PRIMARY PROCEDUR neurol 1/1/2006 NEEDLE ELECTROMYOGRAPHY FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY 95874 IN ADDITION TO CODE FOR PRIMARY PROCEDU neurol 1/1/2006 ISCHEMIC LIMB EXERCISE TEST WITH SERIAL SPECIMEN(S) 95875 ACQUISITION FOR MUSCLE(S) METABOLITE(S) neurol 1/1/2005 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY 95900 STUDY, EACH NERVE; MOTOR, WITHOUT F-WAVE STUDY neurol 1/1/2005 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY 95903 STUDY, EACH NERVE; MOTOR, WITH F-WAVE STUDY neurol 1/1/2005 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY 95904 STUDY, EACH NERVE; SENSORY neurol 1/1/2005 TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; CARDIOVAGAL INNERVATION (PARASYMPATHETIC FUNCTION), 95921 INCLUDING TWO OR MORE OF THE FOL neurol 1/1/2005 TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; VASOMOTOR ADRENERGIC INNERVATION (SYMPATHETIC 95922 ADRENERGIC FUNCTION), INCLUDING BEAT-T neurol 1/1/2005 TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; SUDOMOTOR, INCLUDING ONE OR MORE OF THE FOLLOWING: 95923 QUANTITATIVE SUDOMOTOR AXON REFLE neurol 1/1/2005 SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR 95925 SKIN SITES, RECORDING FROM THE CEN neurol 1/1/2005 SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR 95926 SKIN SITES, RECORDING FROM THE CEN neurol 1/1/2005 SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL 95927 STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR neurol 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE SKIN SITES, RECORDING FROM THE CEN CENTRAL MOTOR EVOKED POTENTIAL STUDY (TRANSCRANIAL 95928 MOTOR STIMULATION); UPPER LIMBS neurol 1/1/2005 CENTRAL MOTOR EVOKED POTENTIAL STUDY (TRANSCRANIAL 95929 MOTOR STIMULATION); LOWER LIMBS neurol 1/1/2005 VISUAL EVOKED POTENTIAL (VEP) TESTING CENTRAL NERVOUS 95930 SYSTEM, CHECKERBOARD OR FLASH neurol 1/1/2005 ORBICULARIS OCULI (BLINK) REFLEX, BY ELECTRODIAGNOSTIC 95933 TESTING neurol 1/1/2005 H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD 95934 GASTROCNEMIUS/SOLEUS MUSCLE neurol 1/1/2005 H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD MUSCLE 95936 OTHER THAN GASTROCNEMIUS/SOLEUS MUSCLE neurol 1/1/2005 NEUROMUSCULAR JUNCTION TESTING (REPETITIVE STIMULATION, PAIRED STIMULI), EACH NERVE, ANY ONE 95937 METHOD neurol 1/1/2005 MONITORING FOR IDENTIFICATION AND LATERALIZATION OF CEREBRAL SEIZURE FOCUS, ELECTROENCEPHALOGRAPHIC 95950 (EG, 8 CHANNEL EEG) RECORDING neurol 1/1/2005 MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS BY CABLE OR RADIO, 16 OR MORE CHANNEL 95951 TELEMETRY, COMBINED ELECTROENCEPHALOGR neurol 1/1/2005 MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS BY COMPUTERIZED PORTABLE 16 OR MORE CHANNEL 95953 EEG, ELECTROENCEPHALOGRAPHIC (EE neurol 1/1/2005 PHARMACOLOGICAL OR PHYSICAL ACTIVATION REQUIRING PHYSICIAN ATTENDANCE DURING EEG RECORDING OF 95954 ACTIVATION PHASE (EG, THIOPENTAL ACT neurol 1/1/2005 MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS BY CABLE OR RADIO, 16 OR MORE CHANNEL 95956 TELEMETRY, ELECTROENCEPHALOGRAPHIC (EE neurol 1/1/2005 DIGITAL ANALYSIS OF ELECTROENCEPHALOGRAM (EEG) (EG, 95957 FOR EPILEPTIC SPIKE ANALYSIS) neurol 1/1/2005 WADA ACTIVATION TEST FOR HEMISPHERIC FUNCTION, 95958 INCLUDING ELECTROENCEPHALOGRAPHIC (EEG) MONITORING neurol 1/1/2005 MAGNETOENCEPHALOGRAPHY (MEG), RECORDING AND ANALYSIS; FOR SPONTANEOUS BRAIN MAGNETIC ACTIVITY (EG, 95965 EPILEPTIC CEREBRAL CORTEX LOCAL neurol 1/1/2005 MAGNETOENCEPHALOGRAPHY (MEG), RECORDING AND ANALYSIS; FOR EVOKED MAGNETIC FIELDS, SINGLE MODALITY 95966 (EG, SENSORY, MOTOR, LANGUAGE, O neurol 1/1/2005 MAGNETOENCEPHALOGRAPHY (MEG), RECORDING AND ANALYSIS; FOR EVOKED MAGNETIC FIELDS, EACH ADDITIONAL 95967 MODALITY (EG, SENSORY, MOTOR, LA neurol 1/1/2005 ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE 95970 AND DURATION, CONFIGURATION OF neurol 1/1/2005 ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR 95978 PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE neurol 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE AND DURATION, BATTERY STATUS, E ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE 95979 AND DURATION, BATTERY STATUS, E neurol 1/1/2005 REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR FOR DRUG DELIVERY, SPINAL (INTRATHECAL, 95990 EPIDURAL) OR BRAIN (INTRAVENTRI general 1/1/2005 REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR FOR DRUG DELIVERY, SPINAL (INTRATHECAL, 95991 EPIDURAL) OR BRAIN (INTRAVENTRI general 1/1/2005 NEUROFUNCTIONAL TESTING SELECTION AND ADMINISTRATION DURING NONINVASIVE IMAGING FUNCTIONAL 96020 BRAIN MAPPING, WITH TEST ADMINISTERED E general 1/1/2007 MEDICAL GENETICS AND GENETIC COUNSELING SERVICES, 96040 EACH 30 MINUTES FACE-TO-FACE WITH PATIENT/FAMILY general 1/1/2007 INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 96360 HOUR general 1/1/2009 INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 96361 PROCEDURE) general 1/1/2009 SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR, 96369 INCLUDING PUMP SET-UP AND EST general 1/1/2009 SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR 96370 (LIST SEPARATELY IN ADDITION TO general 1/1/2009 SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL PUMP SET-UP 96371 WITH ESTABLISHMENT OF NEW SUB general 1/1/2009 96520 REFILLING AND MAINTENANCE OF PORTABLE PUMP heme/onc 1/1/2006 96521 REFILLING AND MAINTENANCE OF PORTABLE PUMP heme/onc 1/1/2006 REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR FOR DRUG DELIVERY, SYSTEMIC (EG, 96522 INTRAVENOUS, INTRA-ARTERIAL) heme/onc 1/1/2006 IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR 96523 DRUG DELIVERY SYSTEMS heme/onc 1/1/2006 REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR FOR DRUG DELIVERY, SYSTEMIC (EG, 96530 INTRAVENOUS, INTRA-ARTERIAL) heme/onc 1/1/2006 ORTHOTIC(S) MANAGEMENT AND TRAINING (INCLUDING ASSESSMENT AND FITTING WHEN NOT OTHERWISE Therapy/PTO 97760 REPORTED), UPPER EXTREMITY(S), LOWER EXTR T 1/1/2011 CHECKOUT FOR ORTHOTIC/PROSTHETIC USE, ESTABLISHED Therapy/PTO 97762 PATIENT, EACH 15 MINUTES T 1/1/2011 MODERATE SEDATION SERVICES (OTHER THAN THOSE SERVICES DESCRIBED BY CODES 00100-01999) PROVIDED BY 99143 THE SAME PHYSICIAN PERFORMING TH general 1/1/2006 MODERATE SEDATION SERVICES (OTHER THAN THOSE SERVICES DESCRIBED BY CODES 00100-01999) PROVIDED BY 99144 THE SAME PHYSICIAN PERFORMING TH general 1/1/2006 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 48
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE MODERATE SEDATION SERVICES (OTHER THAN THOSE SERVICES DESCRIBED BY CODES 00100-01999) PROVIDED BY 99145 THE SAME PHYSICIAN PERFORMING TH general 1/1/2006 MODERATE SEDATION SERVICES (OTHER THAN THOSE SERVICES DESCRIBED BY CODES 00100-01999), PROVIDED BY A 99148 PHYSICIAN OTHER THAN THE HEAL general 1/1/2006 MODERATE SEDATION SERVICES (OTHER THAN THOSE SERVICES DESCRIBED BY CODES 00100-01999), PROVIDED BY A 99149 PHYSICIAN OTHER THAN THE HEAL general 1/1/2006 MODERATE SEDATION SERVICES (OTHER THAN THOSE SERVICES DESCRIBED BY CODES 00100-01999), PROVIDED BY A 99150 PHYSICIAN OTHER THAN THE HEAL general 1/1/2006 OCULAR PHOTOSCREENING WITH INTERPRETATION AND 99174 REPORT, BILATERAL opthamol 1/1/2008 PROLONGED PHYSICIAN SERVICE IN THE OFFICE OR OTHER OUTPATIENT SETTING REQUIRING DIRECT (FACE-TO-FACE) 99354 PATIENT CONTACT BEYOND THE U general 1/1/2005 A4580 CAST SUPPLIES (E.G., PLASTER) ortho/pod 1/1/2005 A4590 SPECIAL CASTING MATERIAL (E.G., FIBERGLASS) ortho/pod 1/1/2005 TECHNETIUM TC-99M TEBOROXIME, DIAGNOSTIC, PER STUDY A9501 DOSE radiology 1/1/2008 A9509 IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER MILLICURIE radiology 1/1/2008 TECHNETIUM TC-99M ARCITUMOMAB, DIAGNOSTIC, PER STUDY A9568 DOSE, UP TO 45 MILLICURIES radiology 1/1/2007 TECHNETIUM TC-99M EXAMETAZIME LABELED AUTOLOGOUS A9569 WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE radiology 1/1/2008 INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, A9570 DIAGNOSTIC, PER STUDY DOSE radiology 1/1/2008 INDIUM IN-111 LABELED AUTOLOGOUS PLATELETS, A9571 DIAGNOSTIC, PER STUDY DOSE radiology 1/1/2008 INDIUM IN-111 PENTETREOTIDE, DIAGNOSTIC, PER STUDY A9572 DOSE, UP TO 6 MILLICURIES radiology 1/1/2008 A9576 INJECTION, GADOTERIDOL, (PROHANCE MULTIPACK), PER ML radiology 1/1/2008 INJECTION, GADOBENATE DIMEGLUMINE (MULTIHANCE), PER A9577 ML radiology 1/1/2008 INJECTION, GADOBENATE DIMEGLUMINE (MULTIHANCE A9578 MULTIPACK), PER ML radiology 1/1/2008 INJECTION, GADOLINIUM BASED MAGNETIC RESONANCE A9579 CONTRAST AGENT, NOT OTHERWISE SPECIFIED, PER ML radiology 1/1/2008 SODIUM FLUORIDE F-18, DIAGNOSTIC, PER STUDY DOSE, UP TO A9580 30 MILLICURIES radiology 1/1/2009 C1724 CATHETER, TRANSLUMINAL ATHERECTOMY, ROTATIONAL radiology 1/1/2006 C1729 CATHETER, DRAINAGE general 1/1/2006 CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY C1751 OR MIDLINE (OTHER THAN HEMODIALYSIS) general 1/1/2006 C1753 CATHETER, INTRAVASCULAR ULTRASOUND vasc 1/1/2006 C1754 CATHETER, INTRADISCAL vasc 1/1/2006 C1755 CATHETER, INTRASPINAL vasc 1/1/2006 C1756 CATHETER, PACING, TRANSESOPHAGEAL cardiol 1/1/2006
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE C1757 CATHETER, THROMBECTOMY/EMBOLECTOMY cardiol 1/1/2006 C1758 CATHETER, URETERAL urol 1/1/2006 C1759 CATHETER, INTRACARDIAC ECHOCARDIOGRAPHY cardiol 1/1/2006 C1765 ADHESION BARRIER general 1/1/2006 C1769 GUIDE WIRE interventional 1/1/2006 C1770 IMAGING COIL, MAGNETIC RESONANCE (INSERTABLE) radiology 1/1/2007 C1788 PORT, INDWELLING (IMPLANTABLE) general 11/1/2008 C2618 PROBE, CRYOABLATION interventional 1/1/2006 C2627 CATHETER, SUPRAPUBIC/CYSTOSCOPIC urol 1/1/2006 C2628 CATHETER, OCCLUSION radiology 1/1/2006 SODIUM HYALURONATE PER 30 MG DOSE, FOR INTRA- C9220 ARTICULAR INJECTION ortho/pod 1/1/2005 C9235 INJECTION, PANITUMUMAB, 10 MG heme/onc 1/1/2007 C9237 INJECTION, LANREOTIDE ACETATE, 1 MG heme/onc 1/1/2008 C9238 INJECTION, LEVETIRACETAM, 10 MG heme/onc 1/1/2008 C9239 INJECTION, TEMSIROLIMUS, 1 MG heme/onc 1/1/2008 C9240 INJECTION, IXABEPILONE, 1 MG heme/onc 1/1/2008 C9241 INJECTION, DORIPENEM, 10 MG heme/onc 4/1/2008 C9243 INJECTION, BENDAMUSTINE HCL, 1 MG heme/onc 9/1/2008 C9244 INJECTION, REGADENOSON, 0.4 MG heme/onc 9/1/2008 C9246 INJECTION, GADOXETATE DISODIUM, PER ML heme/onc 1/1/2009 C9248 INJECTION, CLEVIDIPINE BUTYRATE, 1 MG heme/onc 1/1/2009 C9723 DYNAMIC INFRARED BLOOD PERFUSION IMAGING radiology 1/1/2005 G0104 COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY gastro 1/1/2005 COLORECTAL CANCER SCREENING; COLONOSCOPY ON G0105 INDIVIDUAL AT HIGH RISK gastro 1/1/2005 GLAUCOMA SCREENING FOR HIGH RISK PATIENTS FURNISHED G0117 BY AN OPTOMETRIST OR OPHTHALMOLOGIST opthamol 1/1/2005 GLAUCOMA SCREENING FOR HIGH RISK PATIENT FURNISHED UNDER THE DIRECT SUPERVISION OF AN OPTOMETRIST OR G0118 OPHTHALMOLOGIST opthamol 1/1/2005 COLORECTAL CANCER SCREENING; COLONOSCOPY ON G0121 INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK gastro 1/1/2005 DESTRUCTION OF LOCALIZED LESION OF CHOROID (FOR EXAMPLE, CHOROIDAL NEOVASCULARIZATION); G0186 PHOTOCOAGULATION, FEEDER VESSEL TECHNIQUE opthamol 1/1/2005 INITIAL PHYSICIAN EVALUATION AND MANAGEMENT OF A DIABETIC PATIENT WITH DIABETIC SENSORY NEUROPATHY G0245 RESULTING IN A LOSS OF PROTECTI endocrin 1/1/2005 FOLLOW-UP PHYSICIAN EVALUATION AND MANAGEMENT OF A DIABETIC PATIENT WITH DIABETIC SENSORY NEUROPATHY G0246 RESULTING IN A LOSS OF PROTEC endocrin 1/1/2005 ROUTINE FOOT CARE BY A PHYSICIAN OF A DIABETIC PATIENT WITH DIABETIC SENSORY NEUROPATHY RESULTING IN A LOSS G0247 OF PROTECTIVE SENSATIO pod 1/1/2005 INJECTION PROCEDURE FOR SACROILIAC JOINT; G0259 ARTHROGRAPHY radiology 1/1/2005 INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF G0260 ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, radiology 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 50
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE WITH OR WITHOUT ARTHROG PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL G0269 PROCEDURE (E.G., ANGIO interventional 1/1/2005 RENAL ARTERY ANGIOGRAPHY (UNILATERAL OR BILATERAL) PERFORMED AT THE TIME OF CARDIAC CATHETERIZATION, G0275 INCLUDES CATHETER PLACEMENT, radiology 1/1/2005 ILIAC ARTERY ANGIOGRAPHY PERFORMED AT THE SAME TIME OF CARDIAC CATHETERIZATION, INCLUDES CATHETER G0278 PLACEMENT, INJECTION OF DYE, RAD radiology 1/1/2005 RECONSTRUCTION, COMPUTED TOMOGRAPHIC ANGIOGRAPHY G0288 OF AORTA FOR SURGICAL PLANNING FOR VASCULAR SURGERY radiology 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS UNDER 2 G0308 YEARS OF AGE TO INCLUDE MONIT nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS UNDER 2 G0309 YEARS OF AGE TO INCLUDE MONIT nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS UNDER 2 G0310 YEARS OF AGE TO INCLUDE MONIT nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS G0311 BETWEEN 2 AND 11 YEARS OF AGE TO INCL nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS G0312 BETWEEN 2 AND 11 YEARS OF AGE TO INCL nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS G0313 BETWEEN 2 AND 11 YEARS OF AGE TO INCL nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS G0314 BETWEEN 12 AND 19 YEARS OF AGE TO INC nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS G0315 BETWEEN 12 AND 19 YEARS OF AGE TO INC nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS G0316 BETWEEN 12 AND 19 YEARS OF AGE TO INC nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS 20 YEARS G0317 OF AGE AND OVER; WITH 4 OR M nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS 20 YEARS G0318 OF AGE AND OVER; WITH 2 OR 3 nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES DURING THE COURSE OF TREATMENT, FOR PATIENTS 20 YEARS G0319 OF AGE AND OVER; WITH 1 FACE nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR G0320 HOME DIALYSIS PATIENTS PER FULL MONTH; FOR PATIENTS nephrol. 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 51
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE UNDER TWO YEARS OF AGE TO END STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PER FULL MONTH; FOR PATIENTS G0321 TWO TO ELEVEN YEARS OF AGE nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PER FULL MONTH; FOR PATIENTS G0322 TWELVE TO NINETEEN YEARS O nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES FOR HOME DIALYSIS PATIENTS PER FULL MONTH; FOR PATIENTS G0323 TWENTY YEARS OF AGE AND OL nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY; FOR PATIENTS UNDER TWO G0324 YEARS OF AGE nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY; FOR PATIENTS BETWEEN TWO G0325 AND ELEVEN YEARS OF AGE nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY; FOR PATIENTS BETWEEN G0326 TWELVE AND NINETEEN YEARS OF A nephrol. 1/1/2005 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES LESS THAN FULL MONTH, PER DAY; FOR PATIENTS TWENTY YEARS G0327 OF AGE AND OVER nephrol. 1/1/2005 ULTRASOUND B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; FOR ABDOMINAL AORTIC ANEURYSM (AAA) G0389 SCREENING radiology 1/1/2011 INFECTIOUS AGENT ANTIBODY DETECTION BY ENZYME IMMUNOASSAY (EIA) TECHNIQUE, HIV-1 AND/OR HIV-2, G0432 SCREENING lab 1/1/2011 INFECTIOUS AGENT ANTIBODY DETECTION BY ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA) TECHNIQUE, HIV-1 AND/OR G0433 HIV-2, SCREENING lab 1/1/2011 INFECTIOUS AGENT ANTIBODY DETECTION BY RAPID ANTIBODY G0435 TEST, HIV-1 AND/OR HIV-2, SCREENING lab 1/1/2011 G3001 ADMINISTRATION AND SUPPLY OF TOSITUMOMAB, 450 MG heme/onc 1/1/2005 LEFT VENTRICULAR EJECTION FRACTION (LVEF) >= 40% OR DOCUMENTATION AS NORMAL OR MILDLY DEPRESSED LEFT G8395 VENTRICULAR SYSTOLIC FUNCTION cardiol 1/1/2008 DILATED MACULAR OR FUNDUS EXAM PERFORMED, INCLUDING DOCUMENTATION OF THE PRESENCE OR ABSENCE OF G8397 MACULAR EDEMA AND LEVEL OF SEVERIT opthamol 1/1/2008 LOWER EXTREMITY NEUROLOGICAL EXAM PERFORMED AND G8404 DOCUMENTED neurol 1/1/2008 G8407 ABI MEASURED AND DOCUMENTED general 1/1/2008 J0128 INJECTION, ABARELIX, 10 MG heme/onc 1/1/2005 J0130 INJECTION ABCIXIMAB, 10 MG cardiol 1/1/2005 J0132 INJECTION, ACETYLCYSTEINE, 100 MG general 1/1/2006 J0133 INJECTION, ACYCLOVIR, 5 MG general 1/1/2006 J0135 INJECTION, ADALIMUMAB, 20 MG general 1/1/2005 J0150 INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO cardiol 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS, INSTEAD USE A9270) J0190 INJECTION, BIPERIDEN LACTATE, PER 5 MG general 1/1/2005 INJECTION, ALPROSTADIL, 1.25 MCG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER DIRECT J0270 SUPERVISION OF A PHYSICIAN, NO urol 1/1/2005 J0300 INJECTION, AMOBARBITAL, UP TO 125 MG ortho/pod 1/1/2005 J0330 INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG general 1/1/2005 J0348 INJECTION, ANIDULAFUNGIN, 1 MG general 1/1/2007 J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG general 1/1/2005 J0380 INJECTION, METARAMINOL BITARTRATE, PER 10 MG general 1/1/2005 J0460 INJECTION, ATROPINE SULFATE, UP TO 0.3 MG heme/onc 1/1/2005 J0480 INJECTION, BASILIXIMAB, 20 MG TRN 1/1/2006 J0592 INJECTION, BUPRENORPHINE HYDROCHLORIDE, 0.1 MG cardiol 1/1/2005 J0594 INJECTION, BUSULFAN, 1 MG heme/onc 1/1/2007 J0595 INJECTION, BUTORPHANOL TARTRATE, 1 MG general 1/1/2005 J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML heme/onc 1/1/2005 J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG heme/onc 1/1/2005 J0641 INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MG heme/onc 1/1/2009 J0670 INJECTION, MEPIVACAINE HCL, PER 10 ML ortho/pod 1/1/2005 INJECTION, BETAMETHASONE ACETATE AND BETAMETHASONE J0702 SODIUM PHOSPHATE, PER 3 MG ortho/pod 1/1/2005 J0704 INJECTION, BETAMETHASONE SODIUM PHOSPHATE, PER 4 MG general 1/1/2005 J0710 INJECTION, CEPHAPIRIN SODIUM, UP TO 1 G general 1/1/2005 J0713 INJECTION, CEFTAZIDIME, PER 500 MG general 1/1/2005 J0715 INJECTION, CEFTIZOXIME SODIUM, PER 500 MG general 1/1/2005 J0743 INJECTION, CILASTATIN SODIUM IMIPENEM, PER 250 MG general 1/1/2005 J0795 INJECTION, CORTICORELIN OVINE TRIFLUTATE, 1 MCG general 1/1/2006 J0835 INJECTION, COSYNTROPIN, PER 0.25 MG endocrin 1/1/2005 J0894 INJECTION, DECITABINE, 1 MG heme/onc 1/1/2007 J0895 INJECTION, DEFEROXAMINE MESYLATE, 500 MG heme/onc 1/1/2005 INJECTION, TESTOSTERONE ENANTHATE AND ESTRADIOL J0900 VALERATE, UP TO 1 CC general 1/1/2005 J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG general 1/1/2005 J1230 INJECTION, METHADONE HCL, UP TO 10 MG general 1/1/2007 J1245 INJECTION, DIPYRIDAMOLE, PER 10 MG cardiol 1/1/2005 J1267 INJECTION, DORIPENEM, 10 MG general 1/1/2009 J1324 INJECTION, ENFUVIRTIDE, 1 MG general 1/1/2007 J1330 INJECTION, ERGONOVINE MALEATE, UP TO 0.2 MG general 1/1/2005 J1335 INJECTION, ERTAPENEM SODIUM, 500 MG general 1/1/2005 J1430 INJECTION, ETHANOLAMINE OLEATE, 100 MG general 1/1/2006 J1450 INJECTION, FLUCONAZOLE, 200 MG general 1/1/2005 J1453 INJECTION, FOSAPREPITANT, 1 MG general 1/1/2009 J1458 INJECTION, GALSULFASE, 1 MG general 1/1/2007 J1610 INJECTION, GLUCAGON HCL, PER 1 MG general 1/1/2005 J1953 INJECTION, LEVETIRACETAM, 10 MG general 1/1/2009 J2150 INJECTION, MANNITOL, 25% IN 50 ML general 1/1/2007 J2185 INJECTION, MEROPENEM, 100 MG general 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE J2260 INJECTION, MILRINONE LACTATE, 5 MG general 1/1/2005 J2405 INJECTION, ONDANSETRON HCL, PER 1 MG heme/onc 1/1/2005 J2410 INJECTION, OXYMORPHONE HCL, UP TO 1 MG general 1/1/2005 J2425 INJECTION, PALIFERMIN, 50 MCG general 1/1/2006 J2430 INJECTION, PAMIDRONATE DISODIUM, PER 30 MG heme/onc 1/1/2005 J2469 INJECTION, PALONOSETRON HCL, 25 MCG heme/onc 1/1/2005 J2503 INJECTION, PEGAPTANIB SODIUM, 0.3 MG opthamol 1/1/2006 J2515 INJECTION, PENTOBARBITAL SODIUM, PER 50 MG general 1/1/2007 J2675 INJECTION, PROGESTERONE, PER 50 MG general 1/1/2011 INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, J2724 10 IU general 1/1/2008 J2783 INJECTION, RASBURICASE, 0.5 MG general 1/1/2005 INJECTION, RHO D IMMUNE GLOBULIN, INTRAVENOUS, HUMAN, J2792 SOLVENT DETERGENT, 100 IU heme/onc 1/1/2005 J2910 INJECTION, AUROTHIOGLUCOSE, UP TO 50 MG general 1/1/2005 INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN J2916 SUCROSE INJECTION, 12.5 MG heme/onc 1/1/2005 J2950 INJECTION, PROMAZINE HCL, UP TO 25 MG general 1/1/2005 J2993 INJECTION, RETEPLASE, 18.1 MG general 1/1/2005 J2995 INJECTION, STREPTOKINASE, PER 250,000 IU general 1/1/2005 J2997 INJECTION, ALTEPLASE RECOMBINANT, 1 MG heme/onc 1/1/2005 J3010 INJECTION, FENTANYL CITRATE, 0.1 MG general 1/1/2005 INJECTION, THYROTROPIN ALPHA, 0.9 MG, PROVIDED IN 1.1 MG J3240 VIAL endocrin 1/1/2005 J3243 INJECTION, TIGECYCLINE, 1 MG general 1/1/2007 J3303 INJECTION, TRIAMCINOLONE HEXACETONIDE, PER 5 MG general 1/1/2005 J3315 INJECTION, TRIPTORELIN PAMOATE, 3.75 MG urol 1/1/2005 J3364 INJECTION, UROKINASE, 5,000 IU VIAL general 1/1/2005 J3365 INJECTION, IV, UROKINASE, 250,000 IU VIAL general 1/1/2005 J3473 INJECTION, HYALURONIDASE, RECOMBINANT, 1 USP UNIT general 1/1/2007 J3487 INJECTION, ZOLEDRONIC ACID, 1 MG heme/onc 1/1/2005 SODIUM HYALURONATE, PER 20 TO 25 MG DOSE FOR INTRA- J7317 ARTICULAR INJECTION general 1/1/2005 DERMAL (SUBSTITUTE) TISSUE OF NONHUMAN ORIGIN, WITH OR WITHOUT OTHER BIOENGINEERED OR PROCESSED J7345 ELEMENTS, WITHOUT METABOLICALLY AC general 1/1/2007 DERMAL (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, INJECTABLE, WITH OR WITHOUT OTHER BIOENGINEERED OR PROCESSED J7346 ELEMENTS, BUT WITHOUT MET general 1/1/2007 BUDESONIDE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMINISTERED THROUGH DME, CONCENTRATED J7634 FORM, PER 0.25 MILLIGRAM general 1/1/2007 FORMOTEROL, INHALATION SOLUTION ADMINISTERED J7640 THROUGH DME, UNIT DOSE FORM, 12 MCG general 1/1/2006 J8650 NABILONE, ORAL, 1 MG heme/onc 1/1/2007 J9000 DOXORUBICIN HCL, 10 MG heme/onc 1/1/2005 J9001 DOXORUBICIN HCL, ALL LIPID FORMULATIONS, 10 MG heme/onc 1/1/2005 J9010 ALEMTUZUMAB, 10 MG heme/onc 1/1/2005 J9025 INJECTION, AZACITIDINE, 1 MG heme/onc 1/1/2006 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 54
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE J9031 BCG LIVE (INTRAVESICAL), PER INSTILLATION urol 1/1/2005 J9040 BLEOMYCIN SULFATE, 15 UNITS heme/onc 1/1/2005 J9045 CARBOPLATIN, 50 MG heme/onc 1/1/2005 J9060 CISPLATIN, POWDER OR SOLUTION, PER 10 MG heme/onc 1/1/2005 J9062 CISPLATIN, 50 MG heme/onc 1/1/2005 J9065 INJECTION, CLADRIBINE, PER 1 MG heme/onc 1/1/2005 J9070 CYCLOPHOSPHAMIDE, 100 MG heme/onc 1/1/2005 J9080 CYCLOPHOSPHAMIDE, 200 MG heme/onc 1/1/2005 J9090 CYCLOPHOSPHAMIDE, 500 MG heme/onc 1/1/2005 J9091 CYCLOPHOSPHAMIDE, 1 G heme/onc 1/1/2005 J9092 CYCLOPHOSPHAMIDE, 2 G heme/onc 1/1/2005 J9095 CYCLOPHOSPHAMIDE, LYOPHILIZED, 500 MG heme/onc 1/1/2005 J9096 CYCLOPHOSPHAMIDE, LYOPHILIZED, 1 G heme/onc 1/1/2005 J9097 CYCLOPHOSPHAMIDE, LYOPHILIZED, 2 G heme/onc 1/1/2005 J9100 CYTARABINE, 100 MG heme/onc 1/1/2005 J9120 DACTINOMYCIN, 0.5 MG heme/onc 1/1/2005 J9130 DACARBAZINE, 100 MG heme/onc 1/1/2005 J9140 DACARBAZINE, 200 MG heme/onc 1/1/2005 J9150 DAUNORUBICIN HCL, 10 MG heme/onc 1/1/2005 J9175 INJECTION, ELIOTTS' B SOLUTION, 1 ML general 1/1/2006 J9178 INJECTION, EPIRUBICIN HCL, 2 MG heme/onc 1/1/2005 J9181 ETOPOSIDE, 10 MG heme/onc 1/1/2005 J9182 ETOPOSIDE, 100 MG heme/onc 1/1/2005 J9185 FLUDARABINE PHOSPHATE, 50 MG heme/onc 1/1/2005 J9190 FLUOROURACIL, 500 MG heme/onc 1/1/2005 J9201 GEMCITABINE HCL, 200 MG heme/onc 1/1/2005 J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 MG urol 1/1/2005 J9206 IRINOTECAN, 20 MG heme/onc 1/1/2005 J9208 IFOSFAMIDE, PER 1 G heme/onc 1/1/2005 J9209 MESNA, 200 MG nephrol. 1/1/2005 J9213 INTERFERON ALFA-2A, RECOMBINANT, 3 MILLION UNITS heme/onc 1/1/2005 J9214 INTERFERON ALFA-2B, RECOMBINANT, 1 MILLION UNITS heme/onc 1/1/2005 J9261 INJECTION, NELARABINE, 50 MG heme/onc 1/1/2007 J9264 INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG heme/onc 1/1/2006 J9270 PLICAMYCIN, 2.5 MG heme/onc 1/1/2005 J9280 MITOMYCIN, 5 MG general 1/1/2005 J9290 MITOMYCIN, 20 MG urol 1/1/2005 J9291 MITOMYCIN, 40 MG urol 1/1/2005 J9293 INJECTION, MITOXANTRONE HCL, PER 5 MG heme/onc 1/1/2005 J9303 INJECTION, PANITUMUMAB, 10 MG heme/onc 1/1/2008 J9305 INJECTION, PEMETREXED, 10 MG heme/onc 1/1/2005 J9350 TOPOTECAN, 4 MG heme/onc 1/1/2005 J9355 TRASTUZUMAB, 10 MG heme/onc 1/1/2005 J9360 VINBLASTINE SULFATE, 1 MG heme/onc 1/1/2005 J9370 VINCRISTINE SULFATE, 1 MG heme/onc 1/1/2005 J9375 VINCRISTINE SULFATE, 2 MG heme/onc 1/1/2005 J9390 VINORELBINE TARTRATE, PER 10 MG heme/onc 1/1/2005 J9395 INJECTION, FULVESTRANT, 25 MG heme/onc 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE L0120 CERVICAL, FLEXIBLE, NONADJUSTABLE (FOAM COLLAR) general 11/1/2009 L0140 CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC COLLAR) general 11/1/2009 CERVICAL, SEMI-RIGID, ADJUSTABLE MOLDED CHIN CUP L0150 (PLASTIC COLLAR WITH MANDIBULAR/OCCIPITAL PIECE) general 11/1/2009 LUMBAR-SACRAL ORTHOTIC, FLEXIBLE, PROVIDES LUMBO- SACRAL SUPPORT, POSTERIOR EXTENDS FROM L0628 SACROCOCCYGEAL JUNCTION TO T-9 VERTEBRA, P general 11/1/2009 KNEE ORTHOTIC (KO), ELASTIC WITH STAYS, PREFABRICATED, L1800 INCLUDES FITTING AND ADJUSTMENT general 11/1/2009 KNEE ORTHOTIC (KO), ELASTIC WITH JOINTS, PREFABRICATED, L1810 INCLUDES FITTING AND ADJUSTMENT general 11/1/2009 KNEE ORTHOTIC (KO), ELASTIC OR OTHER ELASTIC TYPE MATERIAL WITH CONDYLAR PAD(S), PREFABRICATED, L1815 INCLUDES FITTING AND ADJUSTMENT general 11/1/2009 KNEE ORTHOTIC (KO), ELASTIC KNEE CAP, PREFABRICATED, L1825 INCLUDES FITTING AND ADJUSTMENT general 11/1/2009 KNEE ORTHOTIC (KO), IMMOBILIZER, CANVAS LONGITUDINAL, L1830 PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT general 11/1/2009 ANKLE ORTHOTIC, ELASTIC, PREFABRICATED, INCLUDES L1901 FITTING AND ADJUSTMENT (E.G., NEOPRENE, LYCRA) general 11/1/2009 ANKLE-FOOT ORTHOTIC (AFO), ANKLE GAUNTLET, L1902 PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT general 11/1/2009 ANKLE-FOOT ORTHOSIS (AFO), MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND L1906 ADJUSTMENT general 11/1/2009 SHOULDER ORTHOTIC (SO), FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, CANVAS AND WEBBING, L3660 PREFABRICATED, INCLUDES FITTING AND ADJUS general 11/1/2009 SHOULDER ORTHOTIC (SO), ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE), PREFABRICATED, INCLUDES FITTING AND L3670 ADJUSTMENT general 11/1/2009 ELBOW ORTHOTIC (EO), ELASTIC WITH STAYS, L3700 PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT general 11/1/2009 ELBOW ORTHOTIC (EO), ELASTIC, PREFABRICATED, INCLUDES L3701 FITTING AND ADJUSTMENT (E.G., NEOPRENE, LYCRA) general 11/1/2009 ELBOW ORTHOTIC (EO), RIGID, WITHOUT JOINTS, INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, INCLUDES L3762 FITTING AND ADJUSTMENT general 11/1/2009 WRIST-HAND ORTHOTIC (WHO), WRIST EXTENSION CONTROL COCK-UP, NONMOLDED, PREFABRICATED, INCLUDES FITTING L3908 AND ADJUSTMENT general 11/1/2009 WRIST ORTHOTIC (WO), ELASTIC, PREFABRICATED, INCLUDES L3909 FITTING AND ADJUSTMENT (E.G., NEOPRENE, LYCRA) general 11/1/2009 WRIST HAND FINGER ORTHOTIC (WHFO), ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G., L3911 NEOPRENE, LYCRA) general 11/1/2009 HAND-FINGER ORTHOTIC (HFO), FLEXION GLOVE WITH ELASTIC FINGER CONTROL, PREFABRICATED, INCLUDES FITTING AND L3912 ADJUSTMENT general 11/1/2009
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE HAND ORTHOTIC (HO), METACARPAL FRACTURE ORTHOTIC, L3917 PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT general 11/1/2009 HAND FINGER ORTHOTIC (HFO), WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, L3923 INCLUDES FITTING AND ADJUSTMENT general 11/1/2009 FINGER ORTHOTIC (FO), PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP), NONTORSION L3925 JOINT/SPRING, EXTENSION/FLEXION, MAY general 11/1/2009 FINGER ORTHOTIC (FO), PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP), WITHOUT JOINT/SPRING, L3927 EXTENSION/FLEXION (E.G., general 11/1/2009 HAND-FINGER ORTHOTIC (HFO), INCLUDES ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES, ELASTIC L3929 BANDS/SPRINGS, MAY INCLUDE SOFT INTERFA general 11/1/2009 ANKLE CONTROL ORTHOTIC, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G., PNEUMATIC, GEL), L4350 PREFABRICATED, INCLUDES FITTING general 11/1/2009 WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, L4360 PREFABRICATED, INCLUDES FITTING general 11/1/2009 P9016 RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT general 1/1/2005 RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, P9040 EACH UNIT general 4/1/2008 INFUSION THERAPY, USING OTHER THAN CHEMOTHERAPEUTIC Q0081 DRUGS, PER VISIT general 1/1/2005 CHEMOTHERAPY ADMINISTRATION BY OTHER THAN INFUSION TECHNIQUE ONLY (E.G., SUBCUTANEOUS, INTRAMUSCULAR, Q0083 PUSH), PER VISIT heme/onc 1/1/2005 CHEMOTHERAPY ADMINISTRATION BY INFUSION TECHNIQUE Q0084 ONLY, PER VISIT heme/onc 1/1/2005 CHEMOTHERAPY ADMINISTRATION BY BOTH INFUSION TECHNIQUE AND OTHER TECHNIQUE(S) (E.G., SUBCUTANEOUS, Q0085 INTRAMUSCULAR, PUSH), PER VISIT heme/onc 1/1/2005 DIPHENHYDRAMINE HCL, 50 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0163 THERAPEUTIC SUBSTITUTE FOR AN IV AN general 1/1/2005 PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0164 THERAPEUTIC SUBSTITUTE FOR AN I general 1/1/2005 PROCHLORPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0165 THERAPEUTIC SUBSTITUTE FOR AN general 1/1/2005 GRANISETRON HCL, 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0166 THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EM general 1/1/2005 DRONABINOL, 2.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC Q0167 SUBSTITUTE FOR AN IV ANTI-EMETI general 1/1/2005 DRONABINOL, 5 MG, ORAL, FDA APPROVED PRESCRIPTION Q0168 ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC general 1/1/2005 Kaiser Permanente Provider Manual APPENDIX B Revised June 2011 57
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE SUBSTITUTE FOR AN IV ANTI-EMETIC PROMETHAZINE HCL, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0169 THERAPEUTIC SUBSTITUTE FOR AN IV ANT general 1/1/2005 PROMETHAZINE HCL, 25 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0170 THERAPEUTIC SUBSTITUTE FOR AN IV ANTI- general 1/1/2005 CHLORPROMAZINE HCL, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0171 THERAPEUTIC SUBSTITUTE FOR AN IV ANT general 1/1/2005 CHLORPROMAZINE HCL, 25 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0172 THERAPEUTIC SUBSTITUTE FOR AN IV ANT general 1/1/2005 TRIMETHOBENZAMIDE HCL, 250 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0173 THERAPEUTIC SUBSTITUTE FOR AN IV general 1/1/2005 THIETHYLPERAZINE MALEATE, 10 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0174 THERAPEUTIC SUBSTITUTE FOR AN general 1/1/2005 PERPHENZAINE, 4 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC Q0175 SUBSTITUTE FOR AN IV ANTI-EMETI general 1/1/2005 PERPHENZAINE, 8MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC Q0176 SUBSTITUTE FOR AN IV ANTI-EMETIC general 1/1/2005 HYDROXYZINE PAMOATE, 25 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0177 THERAPEUTIC SUBSTITUTE FOR AN IV AN general 1/1/2005 HYDROXYZINE PAMOATE, 50 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0178 THERAPEUTIC SUBSTITUTE FOR AN IV AN general 1/1/2005 ONDANSETRON HCL 8 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0179 THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EME general 1/1/2005 DOLASETRON MESYLATE, 100 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0180 THERAPEUTIC SUBSTITUTE FOR AN IV A general 1/1/2005 UNSPECIFIED ORAL DOSAGE FORM, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE Q0181 THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-E general 1/1/2005 IRRIGATION SOLUTION FOR TREATMENT OF BLADDER CALCULI, Q2004 FOR EXAMPLE RENACIDIN, PER 500 ML general 1/1/2007 Q2009 INJECTION, FOSPHENYTOIN, 50 MG general 1/1/2007 Q2017 INJECTION, TENIPOSIDE, 50 MG general 1/1/2007 INJECTION, INTERFERON BETA-1A, 11 MCG FOR Q3025 INTRAMUSCULAR USE general 1/1/2005 INJECTION, INTERFERON BETA-1A, 11 MCG FOR Q3026 SUBCUTANEOUS USE general 1/1/2005 Q3031 COLLAGEN SKIN TEST general 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE CASTING SUPPLIES, BODY CAST ADULT, WITH OR WITHOUT Q4001 HEAD, PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, BODY CAST ADULT, WITH OR WITHOUT HEAD, Q4002 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, SHOULDER CAST, ADULT (11 YEARS +), Q4003 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, SHOULDER CAST, ADULT (11 YEARS +), Q4004 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, LONG ARM CAST, ADULT (11 YEARS +), Q4005 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, LONG ARM CAST, ADULT (11 YEARS +), Q4006 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, LONG ARM CAST, PEDIATRIC (0-10 YEARS), Q4007 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, LONG ARM CAST, PEDIATRIC (0-10 YEARS), Q4008 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), Q4009 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, SHORT ARM CAST, ADULT (11 YEARS +), Q4010 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, SHORT ARM CAST, PEDIATRIC (0-10 YEARS), Q4011 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, SHORT ARM CAST, PEDIATRIC (0-10 YEARS), Q4012 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM Q4013 AND HAND), ADULT (11 YEARS +), PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM Q4014 AND HAND), ADULT (11 YEARS +), FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM Q4015 AND HAND), PEDIATRIC (0-10 YEARS), PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, GAUNTLET CAST (INCLUDES LOWER FOREARM Q4016 AND HAND), PEDIATRIC (0-10 YEARS), FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), Q4017 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, LONG ARM SPLINT, ADULT (11 YEARS +), Q4018 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, LONG ARM SPLINT, PEDIATRIC (0-10 YEARS), Q4019 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, LONG ARM SPLINT, PEDIATRIC (0-10 YEARS), Q4020 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), Q4021 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, SHORT ARM SPLINT, ADULT (11 YEARS +), Q4022 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, SHORT ARM SPLINT, PEDIATRIC (0-10 YEARS), Q4023 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, SHORT ARM SPLINT, PEDIATRIC (0-10 YEARS), Q4024 FIBERGLASS ortho/pod 1/1/2005 Q4025 CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), ADULT (11 ortho/pod 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE YEARS +), PLASTER CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), ADULT (11 Q4026 YEARS +), FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), PEDIATRIC (0- Q4027 10 YEARS), PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, HIP SPICA (ONE OR BOTH LEGS), PEDIATRIC (0- Q4028 10 YEARS), FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG CAST, ADULT (11 YEARS +), Q4029 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG CAST, ADULT (11 YEARS +), Q4030 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG CAST, PEDIATRIC (0-10 YEARS), Q4031 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG CAST, PEDIATRIC (0-10 YEARS), Q4032 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG CYLINDER CAST, ADULT (11 YEARS Q4033 +), PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG CYLINDER CAST, ADULT (11 YEARS Q4034 +), FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG CYLINDER CAST, PEDIATRIC (0-10 Q4035 YEARS), PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG CYLINDER CAST, PEDIATRIC (0-10 Q4036 YEARS), FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), Q4037 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, SHORT LEG CAST, ADULT (11 YEARS +), Q4038 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, SHORT LEG CAST, PEDIATRIC (0-10 YEARS), Q4039 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, SHORT LEG CAST, PEDIATRIC (0-10 YEARS), Q4040 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG SPLINT, ADULT (11 YEARS +), Q4041 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG SPLINT, ADULT (11 YEARS +), Q4042 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG SPLINT, PEDIATRIC (0-10 YEARS), Q4043 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, LONG LEG SPLINT, PEDIATRIC (0-10 YEARS), Q4044 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), Q4045 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, SHORT LEG SPLINT, ADULT (11 YEARS +), Q4046 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, SHORT LEG SPLINT, PEDIATRIC (0-10 YEARS), Q4047 PLASTER ortho/pod 1/1/2005 CAST SUPPLIES, SHORT LEG SPLINT, PEDIATRIC (0-10 YEARS), Q4048 FIBERGLASS ortho/pod 1/1/2005 CAST SUPPLIES, FOR UNLISTED TYPES AND MATERIALS OF Q4050 CASTS ortho/pod 1/1/2005
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KAISER PERMANENTE AUTO AUTH LIST HCPCS PRIMARY EFFECTIVE Code PROCEDURE DESCRIPTION SPECIALTY DATE SPLINT SUPPLIES, MISCELLANEOUS (INCLUDES THERMOPLASTICS, STRAPPING, FASTENERS, PADDING AND Q4051 OTHER SUPPLIES) ortho/pod 1/1/2005 Q4079 INJECTION, NATALIZUMAB, PER 1 MG neuro only 1/1/2005 Q4081 INJECTION, EPOETIN ALFA, 100 UNITS (FOR ESRD ON DIALYSIS) nephrol. 1/1/2007 HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR Q4083 INTRA-ARTICULAR INJECTION, PER DOSE ortho 1/1/2007 Q4098 INJECTION, IRON DEXTRAN, 50 MG general 4/1/2008 INJECTION, IRON-BASED MAGNETIC RESONANCE CONTRAST Q9953 AGENT, PER ML radiology 1/1/2006 Q9954 ORAL MAGNETIC RESONANCE CONTRAST AGENT, PER ML radiology 1/1/2006 HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE Q9958 CONCENTRATION, PER ML radiology 1/1/2005 LOW OSMOLAR CONTRAST MATERIAL, 100-199 MG/ML IODINE Q9965 CONCENTRATION, PER ML radiology 1/1/2008 LOW OSMOLAR CONTRAST MATERIAL, 200-299 MG/ML IODINE Q9966 CONCENTRATION, PER ML radiology 1/1/2008 LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE Q9967 CONCENTRATION, PER ML radiology 1/1/2008 NEWBORN METABOLIC SCREENING PANEL, INCLUDES TEST KIT, POSTAGE AND THE LABORATORY TESTS SPECIFIED BY THE S3620 STATE FOR INCLUSION IN THI lab 1/1/2011 S3645 HIV-1 ANTIBODY TESTING OF ORAL MUCOSAL TRANSUDATE lab 1/1/2011
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