HEALTH POLICY & ANALYTICS DIVISION Health Evidence Review Commission Kate Brown, Governor
500 Summer St NE, E-65 Salem, OR 97301 Voice (503) 373-1985 FAX (503) 378-5511 August 31, 2020
The Honorable Peter Courtney The Honorable Tina Kotek Senate President Speaker of the House Oregon State Senate Oregon House of Representatives 900 Court St. NE, S-201 900 Court St NE, Rm 269 Salem, OR 97301 Salem, OR 97301
Dear Senator Courtney and Representative Kotek:
The Health Evidence Review Commission of the Oregon Health Authority’s Health Policy & Analytics Division respectfully reports to you, in accordance with ORS 414.690(7), several interim modifications that have been made to the Prioritized List of Health Services appearing in the Health Evidence Review Commission’s May 2019 Report to the Governor and 80th Oregon Legislative Assembly. Therefore, in accordance with ORS 414.690 (8), the Health Evidence Review Commission is reporting these interim modifications.
The coding changes are listed in detail in Attachments A and B. They represent technical changes to the List and other changes made due to new evidence on the effectiveness or ineffectiveness of treatments. Technical changes represented here include the prioritization of new ICD-10-CM diagnosis codes, the addition of previously omitted diagnosis/procedure codes, changes to more appropriately pair diagnosis and treatment codes previously appearing on the List, and codes removed from the List that are obsolete or for which coverage should appropriately be determined by broader Oregon Administrative Rules (e.g., diagnostic, ancillary, excluded and informational codes).
In addition to these changes, the Commission made changes to practice guidelines and coding specifications associated with the Prioritized List. Attachment C shows new practice guidelines. Attachment D shows revised guidelines. Attachment E shows deleted guidelines and Attachment F shows new and deleted coding specifications. Finally, the changes and errata published since the publication of the August 14, 2020 Prioritized List appear in Attachment G. Attachment H contains errata to the 10/1/2020 Prioritized List.
The changes described in this letter are being forwarded to the Health Systems Division (HSD) which, in consultation with the OHA Actuarial Services Unit, will determine if these changes will involve a significant financial impact under the Medicaid Demonstration. If the changes are found to be within the current funding level of the Prioritized List, HSD will determine the effective date for these changes, which will be no earlier than October 1, 2020 pending approval by the Centers for Medicare and Medicaid Services. In the event any of these technical changes are determined to impact the funding level of the List as defined by HSD’s legislatively authorized budget, we will send a separate notice to you prior to requesting direction from the Joint Ways & Means Committee.
Interim Modifications to the Prioritized List of Health Services 8/31/2020 Page 2
The Health Evidence Review Commission thanks you for the opportunity to continue to serve the citizens of Oregon.
Respectfully submitted,
Jason Gingerich Director, Health Evidence Review Commission
cc: Health Evidence Review Commission Patrick Allen, Director, Oregon Health Authority Dawn Jagger, Chief of Staff, Oregon Health Authority Lori Coyner, Medicaid Director, Oregon Health Authority Margie Stanton, Director, Health Systems Division, Oregon Health Authority Jeremy Vandehey, Director, Health Policy & Analytics Division, Oregon Health Authority Trilby de Jung, Deputy Director, Health Policy & Analytics Division, Oregon Health Authority Dana Hargunani, Chief Medical Officer, Oregon Health Authority
ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 1 Condition: PREGNANCY Treatment: MATERNITY CARE Delete: 58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Add: O34.218 Maternal care for other type scar from previous cesarean delivery Add: O34.22 Maternal care for cesarean scar defect (isthmocele) Add: O99.891 Other specified diseases and conditions complicating pregnancy Add: O99.892 Other specified diseases and conditions complicating childbirth Add: O99.893 Other specified diseases and conditions complicating puerperium Add: S2404 Repair, myelomeningocele in the fetus, procedure performed in utero
Line: 6 Condition: REPRODUCTIVE SERVICES Treatment: CONTRACEPTION MANAGEMENT; STERILIZATION Delete: 58340 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography Delete: 58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Delete: 74740 Hysterosalpingography, radiological supervision and interpretation
Line: 9 Condition: ASTHMA Treatment: MEDICAL THERAPY Add: J82.83 Eosinophilic asthma
Line: 23 Condition: INTRACRANIAL HEMORRHAGES; CEREBRAL CONVULSIONS, DEPRESSION, COMA, AND OTHER ABNORMAL CEREBRAL SIGNS OF THE NEWBORN Treatment: MEDICAL THERAPY Add: P91.821 Neonatal cerebral infarction, right side of brain Add: P91.822 Neonatal cerebral infarction, left side of brain Add: P91.823 Neonatal cerebral infarction, bilateral Add: P91.829 Neonatal cerebral infarction, unspecified side
Line: 24 Condition: ENDOCRINE AND METABOLIC DISTURBANCES SPECIFIC TO THE FETUS AND NEWBORN Treatment: MEDICAL THERAPY Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
Line: 30 Condition: EPILEPSY AND FEBRILE CONVULSIONS Treatment: MEDICAL THERAPY Add: G40.42 Cyclin-Dependent Kinase-Like 5 Deficiency Disorder Add: G40.833 Dravet syndrome, intractable, with status epilepticus Add: G40.834 Dravet syndrome, intractable, without status epilepticus
Line: 41 Condition: INTUSSCEPTION, VOLVULUS, INTESTINAL OBSTRUCTION, HAZARDOUS FOREIGN BODY IN GI TRACT WITH RISK OF PERFORATION OR OBSTRUCTION Treatment: MEDICAL AND SURGICAL TREATMENT Add: K59.81 Ogilvie syndrome
Line: 46 Condition: RHEUMATOID ARTHRITIS AND OTHER INFLAMMATORY POLYARTHROPATHIES Treatment: MEDICAL THERAPY, INJECTIONS Add: M05.7A Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement Add: M05.8A Other rheumatoid arthritis with rheumatoid factor of other specified site Add: M06.0A Rheumatoid arthritis without rheumatoid factor, other specified site Add: M06.8A Other specified rheumatoid arthritis, other specified site Add: M08.0A Unspecified juvenile rheumatoid arthritis, other specified site
Page A-1 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Add: M08.2A Juvenile rheumatoid arthritis with systemic onset, other specified site Add: M08.4A Pauciarticular juvenile rheumatoid arthritis, other specified site Add: M08.9A Juvenile arthritis, unspecified, other specified site
Line: 55 Condition: COMPLICATED STONES OF THE GALLBLADDER AND BILE DUCTS; CHOLECYSTITIS Treatment: MEDICAL AND SURGICAL TREATMENT Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
Line: 65 Condition: SUBSTANCE-INDUCED DELIRIUM; SUBSTANCE INTOXICATION AND WITHDRAWAL Treatment: MEDICAL/PSYCHOTHERAPY Add: F10.130 Alcohol abuse with withdrawal, uncomplicated Add: F10.131 Alcohol abuse with withdrawal delirium Add: F10.132 Alcohol abuse with withdrawal with perceptual disturbance Add: F10.139 Alcohol abuse with withdrawal, unspecified Add: F10.930 Alcohol use, unspecified with withdrawal, uncomplicated Add: F10.931 Alcohol use, unspecified with withdrawal delirium Add: F10.932 Alcohol use, unspecified with withdrawal with perceptual disturbance Add: F10.939 Alcohol use, unspecified with withdrawal, unspecified Add: F11.13 Opioid abuse with withdrawal Add: F12.13 Cannabis abuse with withdrawal Add: F13.130 Sedative, hypnotic or anxiolytic abuse with withdrawal, uncomplicated Add: F13.131 Sedative, hypnotic or anxiolytic abuse with withdrawal delirium Add: F13.132 Sedative, hypnotic or anxiolytic abuse with withdrawal with perceptual disturbance Add: F13.139 Sedative, hypnotic or anxiolytic abuse with withdrawal, unspecified Add: F14.13 Cocaine abuse, unspecified with withdrawal Add: F14.93 Cocaine use, unspecified with withdrawal Add: F15.13 Other stimulant abuse with withdrawal Add: F19.130 Other psychoactive substance abuse with withdrawal, uncomplicated Add: F19.131 Other psychoactive substance abuse with withdrawal delirium Add: F19.132 Other psychoactive substance abuse with withdrawal with perceptual disturbance Add: F19.139 Other psychoactive substance abuse with withdrawal, unspecified
Line: 67 Condition: VENTRICULAR SEPTAL DEFECT Treatment: CLOSURE Delete: Z79.01 Long term (current) use of anticoagulants
Line: 71 Condition: NEUROLOGICAL DYSFUNCTION IN BREATHING, EATING, SWALLOWING, BOWEL, OR BLADDER CONTROL CAUSED BY CHRONIC CONDITIONS; ATTENTION TO OSTOMIES Treatment: MEDICAL AND SURGICAL TREATMENT (E.G., G-TUBES, J-TUBES, RESPIRATORS, TRACHEOSTOMY, UROLOGICAL PROCEDURES) Add: E70.81 Aromatic L-amino acid decarboxylase deficiency Add: E70.89 Other disorders of aromatic amino-acid metabolism Add: G11.10 Early-onset cerebellar ataxia, unspecified Add: G11.11 Friedreich ataxia Add: G11.19 Other early-onset cerebellar ataxia Add: G40.42 Cyclin-Dependent Kinase-Like 5 Deficiency Disorder Add: G71.20 Congenital myopathy, unspecifed Add: G71.21 Nemaline myopathy Add: G71.220 X-linked myotubular myopathy Add: G71.228 Other centronuclear myopathy Add: G71.29 Other congenital myopathy Add: G96.810 Intracranial hypotension, unspecified Add: G96.811 Intracranial hypotension, spontaneous Add: G96.819 Other intracranial hypotension Add: G97.83 Intracranial hypotension following lumbar cerebrospinal fluid shunting Add: G97.84 Intracranial hypotension following other procedure Add: P91.821 Neonatal cerebral infarction, right side of brain Add: P91.822 Neonatal cerebral infarction, left side of brain Add: P91.823 Neonatal cerebral infarction, bilateral Add: P91.829 Neonatal cerebral infarction, unspecified side Page A-2 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Add: T40.411A Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), initial encounter Add: T40.411D Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), subsequent encounter Add: T40.412A Poisoning by fentanyl or fentanyl analogs, intentional self-harm, initial encounter Add: T40.412D Poisoning by fentanyl or fentanyl analogs, intentional self-harm, subsequent encounter Add: T40.413A Poisoning by fentanyl or fentanyl analogs, assault, initial encounter Add: T40.413D Poisoning by fentanyl or fentanyl analogs, assault, subsequent encounter Add: T40.414A Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter Add: T40.414D Poisoning by fentanyl or fentanyl analogs, undetermined, subsequent encounter Add: T40.415A Adverse effect of fentanyl or fentanyl analogs, initial encounter Add: T40.415D Adverse effect of fentanyl or fentanyl analogs, subsequent encounter Add: T40.421A Poisoning by tramadol, accidental (unintentional), initial encounter Add: T40.421D Poisoning by tramadol, accidental (unintentional), subsequent encounter Add: T40.422A Poisoning by tramadol, intentional self-harm, initial encounter Add: T40.422D Poisoning by tramadol, intentional self-harm, subsequent encounter Add: T40.423A Poisoning by tramadol, assault, initial encounter Add: T40.423D Poisoning by tramadol, assault, subsequent encounter Add: T40.424A Poisoning by tramadol, undetermined, initial encounter Add: T40.424D Poisoning by tramadol, undetermined, subsequent encounter Add: T40.425A Adverse effect of tramadol, initial encounter Add: T40.425D Adverse effect of tramadol, subsequent encounter Add: T40.491A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter Add: T40.491D Poisoning by other synthetic narcotics, accidental (unintentional), subsequent encounter Add: T40.492A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter Add: T40.492D Poisoning by other synthetic narcotics, intentional self-harm, subsequent encounter Add: T40.493A Poisoning by other synthetic narcotics, assault, initial encounter Add: T40.493D Poisoning by other synthetic narcotics, assault, subsequent encounter Add: T40.494A Poisoning by other synthetic narcotics, undetermined, initial encounter Add: T40.494D Poisoning by other synthetic narcotics, undetermined, subsequent encounter Add: T40.495A Adverse effect of other synthetic narcotics, initial encounter Add: T40.495D Adverse effect of other synthetic narcotics, subsequent encounter
Line: 78 Condition: PHLEBITIS AND THROMBOPHLEBITIS, DEEP Treatment: MEDICAL THERAPY Delete: Z79.01 Long term (current) use of anticoagulants
Line: 89 Condition: CONGENITAL MITRAL VALVE STENOSIS/INSUFFICIENCY Treatment: MITRAL VALVE REPAIR/REPLACEMENT Delete: Z79.01 Long term (current) use of anticoagulants
Line: 97 Condition: HEART FAILURE Treatment: MEDICAL THERAPY Delete: Z79.01 Long term (current) use of anticoagulants
Line: 98 Condition: CARDIOMYOPATHY Treatment: MEDICAL AND SURGICAL TREATMENT Delete: Z79.01 Long term (current) use of anticoagulants
Line: 99 Condition: END STAGE RENAL DISEASE Treatment: RENAL TRANSPLANT Add: N01.A Rapidly progressive nephritic syndrome with C3 glomerulonephritis Add: N02.A Recurrent and persistent hematuria with C3 glomerulonephritis Add: N03.A Chronic nephritic syndrome with C3 glomerulonephritis Add: N04.A Nephrotic syndrome with C3 glomerulonephritis Add: N05.A Unspecified nephritic syndrome with C3 glomerulonephritis Add: N06.A Isolated proteinuria with C3 glomerulonephritis Add: N07.A Hereditary nephropathy, not elsewhere classified with C3 glomerulonephritis
Page A-3 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 102 Condition: POISONING BY INGESTION, INJECTION, AND NON-MEDICINAL AGENTS Treatment: MEDICAL THERAPY Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed Add: T40.411A Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), initial encounter Add: T40.411D Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), subsequent encounter Add: T40.412A Poisoning by fentanyl or fentanyl analogs, intentional self-harm, initial encounter Add: T40.412D Poisoning by fentanyl or fentanyl analogs, intentional self-harm, subsequent encounter Add: T40.413A Poisoning by fentanyl or fentanyl analogs, assault, initial encounter Add: T40.413D Poisoning by fentanyl or fentanyl analogs, assault, subsequent encounter Add: T40.414A Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter Add: T40.414D Poisoning by fentanyl or fentanyl analogs, undetermined, subsequent encounter Add: T40.415A Adverse effect of fentanyl or fentanyl analogs, initial encounter Add: T40.415D Adverse effect of fentanyl or fentanyl analogs, subsequent encounter Add: T40.421A Poisoning by tramadol, accidental (unintentional), initial encounter Add: T40.421D Poisoning by tramadol, accidental (unintentional), subsequent encounter Add: T40.422A Poisoning by tramadol, intentional self-harm, initial encounter Add: T40.422D Poisoning by tramadol, intentional self-harm, subsequent encounter Add: T40.423A Poisoning by tramadol, assault, initial encounter Add: T40.423D Poisoning by tramadol, assault, subsequent encounter Add: T40.424A Poisoning by tramadol, undetermined, initial encounter Add: T40.424D Poisoning by tramadol, undetermined, subsequent encounter Add: T40.425A Adverse effect of tramadol, initial encounter Add: T40.425D Adverse effect of tramadol, subsequent encounter Add: T40.491A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter Add: T40.491D Poisoning by other synthetic narcotics, accidental (unintentional), subsequent encounter Add: T40.492A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter Add: T40.492D Poisoning by other synthetic narcotics, intentional self-harm, subsequent encounter Add: T40.493A Poisoning by other synthetic narcotics, assault, initial encounter Add: T40.493D Poisoning by other synthetic narcotics, assault, subsequent encounter Add: T40.494A Poisoning by other synthetic narcotics, undetermined, initial encounter Add: T40.494D Poisoning by other synthetic narcotics, undetermined, subsequent encounter Add: T40.495A Adverse effect of other synthetic narcotics, initial encounter Add: T40.495D Adverse effect of other synthetic narcotics, subsequent encounter
Line: 104 Condition: TETRALOGY OF FALLOT (TOF); CONGENITAL VENOUS ABNORMALITIES Treatment: REPAIR Delete: Z79.01 Long term (current) use of anticoagulants
Line: 108 Condition: SUBACUTE MENINGITIS (E.G., TUBERCULOSIS, CRYPTOCOCCOSIS) Treatment: MEDICAL THERAPY Add: B60.00 Babesiosis, unspecified Add: B60.01 Babesiosis due to Babesia microti Add: B60.02 Babesiosis due to Babesia duncani Add: B60.03 Babesiosis due to Babesia divergens Add: B60.09 Other babesiosis
Line: 110 Condition: CONGENITAL HEART BLOCK; OTHER OBSTRUCTIVE ANOMALIES OF HEART Treatment: MEDICAL THERAPY Delete: Z79.01 Long term (current) use of anticoagulants
Line: 112 Condition: CANCER OF EYE AND ORBIT Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Delete: 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe
Page A-4 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 113 Condition: APLASTIC ANEMIAS; AGRANULOCYTOSIS; SICKLE CELL DISEASE Treatment: BONE MARROW TRANSPLANT Add: D57.00 Hb-SS disease with crisis, unspecified Add: D57.01 Hb-SS disease with acute chest syndrome Add: D57.02 Hb-SS disease with splenic sequestration Add: D57.03 Hb-SS disease with cerebral vascular involvement Add: D57.09 Hb-SS disease with crisis with other specified complication Add: D57.1 Sickle-cell disease without crisis
Line: 117 Condition: NUTRITIONAL DEFICIENCIES Treatment: MEDICAL THERAPY Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
Line: 120 Condition: ABUSE AND NEGLECT Treatment: MEDICAL/PSYCHOTHERAPY Add: 13131 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm Add: 56441 Lysis of labial adhesions Add: N90.810 Female genital mutilation status, unspecified Add: N90.811 Female genital mutilation Type I status Add: N90.812 Female genital mutilation Type II status Add: N90.813 Female genital mutilation Type III status Add: N90.818 Other female genital mutilation status
Line: 126 Condition: ACUTE KIDNEY INJURY Treatment: MEDICAL THERAPY INCLUDING DIALYSIS Add: N00.A Acute nephritic syndrome with C3 glomerulonephritis Add: N01.A Rapidly progressive nephritic syndrome with C3 glomerulonephritis
Line: 131 Condition: CRUSH INJURIES OTHER THAN DIGITS; COMPARTMENT SYNDROME Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal
Line: 139 Condition: GLAUCOMA, OTHER THAN PRIMARY ANGLE-CLOSURE Treatment: MEDICAL, SURGICAL AND LASER TREATMENT Add: 0376T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in addition to code for primary procedure) Add: C1783 Ocular implant, aqueous drainage assist device Add: L8612 Aqueous shunt
Line: 148 Condition: ACQUIRED HEMOLYTIC ANEMIAS Treatment: MEDICAL THERAPY Add: D59.10 Autoimmune hemolytic anemia, unspecified Add: D59.11 Warm autoimmune hemolytic anemia Add: D59.12 Cold autoimmune hemolytic anemia Add: D59.13 Mixed type autoimmune hemolytic anemia Add: D59.19 Other autoimmune hemolytic anemia
Page A-5 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 150 Condition: CERVICAL VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR CLOSED; OTHER VERTEBRAL DISLOCATIONS/FRACTURES, OPEN OR UNSTABLE; SPINAL CORD INJURIES WITH OR WITHOUT EVIDENCE OF VERTEBRAL INJURY Treatment: MEDICAL AND SURGICAL TREATMENT Add: M80.0AXA Age-related osteoporosis with current pathological fracture, other site, initial encounter for fracture Add: M80.0AXD Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing Add: M80.0AXG Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing Add: M80.8AXA Other osteoporosis with current pathological fracture, other site, initial encounter for fracture Add: M80.8AXD Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing Add: M80.8AXG Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing
Line: 151 Condition: DISORDERS OF MINERAL METABOLISM, OTHER THAN CALCIUM Treatment: MEDICAL THERAPY Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed Add: 82652 Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed
Line: 160 Condition: TRAUMATIC AMPUTATION OF ARM(S), HAND(S), THUMB(S), AND FINGER(S) (COMPLETE)(PARTIAL) WITH AND WITHOUT COMPLICATION Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal Delete: 20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space
Line: 161 Condition: GRANULOCYTE DISORDERS Treatment: MEDICAL THERAPY Add: D72.110 Idiopathic hypereosinophilic syndrome [IHES] Add: D72.111 Lymphocytic Variant Hypereosinophilic Syndrome [LHES] Add: D72.118 Other hypereosinophilic syndrome Add: D72.119 Hypereosinophilic syndrome [HES], unspecified Add: D72.12 Drug rash with eosinophilia and systemic symptoms syndrome Add: D72.18 Eosinophilia in diseases classified elsewhere
Line: 177 Condition: DISORDERS OF AMINO-ACID TRANSPORT AND METABOLISM (NON PKU); HEREDITARY FRUCTOSE INTOLERANCE Treatment: MEDICAL THERAPY Add: E70.81 Aromatic L-amino acid decarboxylase deficiency Add: E70.89 Other disorders of aromatic amino-acid metabolism Add: E74.810 Glucose transporter protein type 1 deficiency Add: E74.818 Other disorders of glucose transport Add: E74.819 Disorders of glucose transport, unspecified Add: E74.89 Other specified disorders of carbohydrate metabolism
Line: 184 Condition: ACUTE OSTEOMYELITIS Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 20955 Bone graft with microvascular anastomosis; fibula Delete: 20956 Bone graft with microvascular anastomosis; iliac crest Delete: 20957 Bone graft with microvascular anastomosis; metatarsal Delete: 20962 Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal Delete: 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe Delete: 20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest Delete: 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal Delete: 20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space
Page A-6 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 186 Condition: RHEUMATIC MULTIPLE VALVULAR DISEASE Treatment: SURGICAL TREATMENT Delete: Z79.01 Long term (current) use of anticoagulants
Line: 189 Condition: CHRONIC ISCHEMIC HEART DISEASE Treatment: MEDICAL AND SURGICAL TREATMENT Delete: Z79.01 Long term (current) use of anticoagulants
Line: 194 Condition: HEREDITARY ANEMIAS, HEMOGLOBINOPATHIES, AND DISORDERS OF THE SPLEEN Treatment: MEDICAL THERAPY Add: D57.03 Hb-SS disease with cerebral vascular involvement Add: D57.09 Hb-SS disease with crisis with other specified complication Add: D57.213 Sickle-cell/Hb-C disease with cerebral vascular involvement Add: D57.218 Sickle-cell/Hb-C disease with crisis with other specified complication Add: D57.413 Sickle-cell thalassemia, unspecified, with cerebral vascular involvement Add: D57.418 Sickle-cell thalassemia, unspecified, with crisis with other specified complication Add: D57.42 Sickle-cell thalassemia beta zero without crisis Add: D57.431 Sickle-cell thalassemia beta zero with acute chest syndrome Add: D57.432 Sickle-cell thalassemia beta zero with splenic sequestration Add: D57.433 Sickle-cell thalassemia beta zero with cerebral vascular involvement Add: D57.438 Sickle-cell thalassemia beta zero with crisis with other specified complication Add: D57.439 Sickle-cell thalassemia beta zero with crisis, unspecified Add: D57.44 Sickle-cell thalassemia beta plus without crisis Add: D57.451 Sickle-cell thalassemia beta plus with acute chest syndrome Add: D57.452 Sickle-cell thalassemia beta plus with splenic sequestration Add: D57.453 Sickle-cell thalassemia beta plus with cerebral vascular involvement Add: D57.458 Sickle-cell thalassemia beta plus with crisis with other specified complication Add: D57.459 Sickle-cell thalassemia beta plus with crisis, unspecified Add: D57.813 Other sickle-cell disorders with cerebral vascular involvement Add: D57.818 Other sickle-cell disorders with crisis with other specified complication
Line: 195 Condition: ACUTE PANCREATITIS Treatment: MEDICAL THERAPY Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
Line: 200 Condition: CANCER OF BONES Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Delete: 20955 Bone graft with microvascular anastomosis; fibula Delete: 20956 Bone graft with microvascular anastomosis; iliac crest Delete: 20957 Bone graft with microvascular anastomosis; metatarsal Delete: 20962 Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal Delete: 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe Delete: 20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest Delete: 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal Delete: 20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space
Line: 204 Condition: PNEUMOCOCCAL PNEUMONIA, OTHER BACTERIAL PNEUMONIA, BRONCHOPNEUMONIA Treatment: MEDICAL THERAPY Add: J82.82 Acute eosinophilic pneumonia Add: U07.0 Vaping-related disorder
Line: 205 Condition: SUPERFICIAL ABSCESSES AND CELLULITIS Treatment: MEDICAL AND SURGICAL TREATMENT Add: N61.20 Granulomatous mastitis, unspecified breast
Page A-7 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Add: N61.21 Granulomatous mastitis, right breast Add: N61.22 Granulomatous mastitis, left breast Add: N61.23 Granulomatous mastitis, bilateral breast
Line: 219 Condition: PULMONARY FIBROSIS Treatment: MEDICAL AND SURGICAL TREATMENT Add: J84.170 Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere Add: J84.178 Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere
Line: 223 Condition: DISEASES AND DISORDERS OF AORTIC VALVE Treatment: MEDICAL AND SURGICAL THERAPY Delete: Z79.01 Long term (current) use of anticoagulants
Line: 224 Condition: DISORDERS OF PARATHYROID GLAND; BENIGN NEOPLASM OF PARATHYROID GLAND; DISORDERS OF CALCIUM METABOLISM Treatment: MEDICAL AND SURGICAL TREATMENT Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed Add: 82652 Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed Add: R82.994 Hypercalciuria
Line: 227 Condition: INTESTINAL MALABSORPTION Treatment: MEDICAL THERAPY Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
Line: 228 Condition: FRACTURE OF FACE BONES; INJURY TO OPTIC AND OTHER CRANIAL NERVES Treatment: SURGICAL TREATMENT Delete: S02.2XXD Fracture of nasal bones, subsequent encounter for fracture with routine healing Delete: S02.2XXG Fracture of nasal bones, subsequent encounter for fracture with delayed healing
Line: 239 Condition: SHORT BOWEL SYNDROME Treatment: INTESTINE AND INTESTINE/LIVER TRANSPLANT Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
Line: 241 Condition: ACUTE AND SUBACUTE NECROSIS OF LIVER; SPECIFIED INBORN ERRORS OF METABOLISM (E.G., MAPLE SYRUP URINE DISEASE, TYROSINEMIA) Treatment: LIVER TRANSPLANT Add: E70.81 Aromatic L-amino acid decarboxylase deficiency Add: E70.89 Other disorders of aromatic amino-acid metabolism
Line: 248 Condition: METABOLIC BONE DISEASE Treatment: MEDICAL THERAPY Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed Add: 82652 Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed
Line: 250 Condition: CHRONIC PANCREATITIS Treatment: MEDICAL THERAPY Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
Page A-8 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 254 Condition: CHRONIC OSTEOMYELITIS Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 20955 Bone graft with microvascular anastomosis; fibula Delete: 20956 Bone graft with microvascular anastomosis; iliac crest Delete: 20957 Bone graft with microvascular anastomosis; metatarsal Delete: 20962 Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal Delete: 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe Delete: 20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest Delete: 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal Delete: 20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space
Line: 257 Condition: DISEASES OF MITRAL, TRICUSPID, AND PULMONARY VALVES Treatment: VALVULOPLASTY, VALVE REPLACEMENT, MEDICAL THERAPY Delete: Z79.01 Long term (current) use of anticoagulants
Line: 259 Condition: CANCER OF ENDOCRINE SYSTEM, EXCLUDING THYROID; CARCINOID SYNDROME Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
Line: 268 Condition: RICKETTSIAL AND OTHER ARTHROPOD-BORNE DISEASES Treatment: MEDICAL THERAPY Add: B60.00 Babesiosis, unspecified Add: B60.01 Babesiosis due to Babesia microti Add: B60.02 Babesiosis due to Babesia duncani Add: B60.03 Babesiosis due to Babesia divergens Add: B60.09 Other babesiosis
Line: 280 Condition: BUDD-CHIARI SYNDROME, AND OTHER VENOUS EMBOLISM AND THROMBOSIS Treatment: THROMBECTOMY/LIGATION Delete: Z79.01 Long term (current) use of anticoagulants
Line: 283 Condition: CHRONIC OBSTRUCTIVE PULMONARY DISEASE; CHRONIC RESPIRATORY FAILURE Treatment: MEDICAL THERAPY Add: J82.81 Chronic eosinophilic pneumonia Add: J82.89 Other pulmonary eosinophilia, not elsewhere classified
Line: 285 Condition: COMPLICATIONS OF A PROCEDURE ALWAYS REQUIRING TREATMENT Treatment: MEDICAL AND SURGICAL TREATMENT Add: 61618 Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (eg, pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts) Add: 61619 Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneous flap (including galea, temporalis, frontalis or occipitalis muscle) Add: 62010 Elevation of depressed skull fracture; with repair of dura and/or debridement of brain Add: G96.00 Cerebrospinal fluid leak, unspecified Add: G96.01 Cranial cerebrospinal fluid leak, spontaneous Add: G96.02 Spinal cerebrospinal fluid leak, spontaneous Add: G96.08 Other cranial cerebrospinal fluid leak Add: G96.09 Other spinal cerebrospinal fluid leak Add: G96.810 Intracranial hypotension, unspecified Add: G96.811 Intracranial hypotension, spontaneous Add: G96.819 Other intracranial hypotension Add: G97.83 Intracranial hypotension following lumbar cerebrospinal fluid shunting
Page A-9 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Add: G97.84 Intracranial hypotension following other procedure Add: T86.8401 Corneal transplant rejection, right eye Add: T86.8402 Corneal transplant rejection, left eye Add: T86.8403 Corneal transplant rejection, bilateral Add: T86.8409 Corneal transplant rejection, unspecified eye Add: T86.8411 Corneal transplant failure, right eye Add: T86.8412 Corneal transplant failure, left eye Add: T86.8413 Corneal transplant failure, bilateral Add: T86.8419 Corneal transplant failure, unspecified eye Add: T86.8421 Corneal transplant infection, right eye Add: T86.8422 Corneal transplant infection, left eye Add: T86.8423 Corneal transplant infection, bilateral Add: T86.8429 Corneal transplant infection, unspecified eye Add: T86.8481 Other complications of corneal transplant, right eye Add: T86.8482 Other complications of corneal transplant, left eye Add: T86.8483 Other complications of corneal transplant, bilateral Add: T86.8489 Other complications of corneal transplant, unspecified eye Add: T86.8491 Unspecified complication of corneal transplant, right eye Add: T86.8492 Unspecified complication of corneal transplant, left eye Add: T86.8493 Unspecified complication of corneal transplant, bilateral Add: T86.8499 Unspecified complication of corneal transplant, unspecified eye
Line: 287 Condition: CANCER OF ORAL CAVITY, PHARYNX, NOSE AND LARYNX Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Delete: 20962 Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal
Line: 288 Condition: OSTEOPETROSIS Treatment: BONE MARROW RESCUE AND TRANSPLANT Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
Line: 289 Condition: CRUSH AND OTHER INJURIES OF DIGITS Treatment: MEDICAL AND SURGICAL TREATMENT Delete: 20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space
Line: 292 Condition: NEUROLOGICAL DYSFUNCTION IN POSTURE AND MOVEMENT CAUSED BY CHRONIC CONDITIONS Treatment: MEDICAL AND SURGICAL TREATMENT (E.G., DURABLE MEDICAL EQUIPMENT AND ORTHOPEDIC PROCEDURE) Add: E70.81 Aromatic L-amino acid decarboxylase deficiency Add: E70.89 Other disorders of aromatic amino-acid metabolism Add: G11.10 Early-onset cerebellar ataxia, unspecified Add: G11.11 Friedreich ataxia Add: G11.19 Other early-onset cerebellar ataxia Add: G40.42 Cyclin-Dependent Kinase-Like 5 Deficiency Disorder Add: G71.20 Congenital myopathy, unspecifed Add: G71.21 Nemaline myopathy Add: G71.220 X-linked myotubular myopathy Add: G71.228 Other centronuclear myopathy Add: G71.29 Other congenital myopathy Add: G96.810 Intracranial hypotension, unspecified Add: G96.811 Intracranial hypotension, spontaneous Add: G96.819 Other intracranial hypotension Add: G97.83 Intracranial hypotension following lumbar cerebrospinal fluid shunting Add: G97.84 Intracranial hypotension following other procedure Add: M24.59 Contracture, other specified joint Add: P91.821 Neonatal cerebral infarction, right side of brain Add: P91.822 Neonatal cerebral infarction, left side of brain Add: P91.823 Neonatal cerebral infarction, bilateral Add: P91.829 Neonatal cerebral infarction, unspecified side Add: T40.411A Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), initial encounter Add: T40.411D Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), subsequent encounter Page A-10 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Add: T40.412A Poisoning by fentanyl or fentanyl analogs, intentional self-harm, initial encounter Add: T40.412D Poisoning by fentanyl or fentanyl analogs, intentional self-harm, subsequent encounter Add: T40.413A Poisoning by fentanyl or fentanyl analogs, assault, initial encounter Add: T40.413D Poisoning by fentanyl or fentanyl analogs, assault, subsequent encounter Add: T40.414A Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter Add: T40.414D Poisoning by fentanyl or fentanyl analogs, undetermined, subsequent encounter Add: T40.415A Adverse effect of fentanyl or fentanyl analogs, initial encounter Add: T40.415D Adverse effect of fentanyl or fentanyl analogs, subsequent encounter Add: T40.421A Poisoning by tramadol, accidental (unintentional), initial encounter Add: T40.421D Poisoning by tramadol, accidental (unintentional), subsequent encounter Add: T40.422A Poisoning by tramadol, intentional self-harm, initial encounter Add: T40.422D Poisoning by tramadol, intentional self-harm, subsequent encounter Add: T40.423A Poisoning by tramadol, assault, initial encounter Add: T40.423D Poisoning by tramadol, assault, subsequent encounter Add: T40.424A Poisoning by tramadol, undetermined, initial encounter Add: T40.424D Poisoning by tramadol, undetermined, subsequent encounter Add: T40.425A Adverse effect of tramadol, initial encounter Add: T40.425D Adverse effect of tramadol, subsequent encounter Add: T40.491A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter Add: T40.491D Poisoning by other synthetic narcotics, accidental (unintentional), subsequent encounter Add: T40.492A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter Add: T40.492D Poisoning by other synthetic narcotics, intentional self-harm, subsequent encounter Add: T40.493A Poisoning by other synthetic narcotics, assault, initial encounter Add: T40.493D Poisoning by other synthetic narcotics, assault, subsequent encounter Add: T40.494A Poisoning by other synthetic narcotics, undetermined, initial encounter Add: T40.494D Poisoning by other synthetic narcotics, undetermined, subsequent encounter Add: T40.495A Adverse effect of other synthetic narcotics, initial encounter Add: T40.495D Adverse effect of other synthetic narcotics, subsequent encounter
Line: 293 Condition: ANOMALIES OF GALLBLADDER, BILE DUCTS, AND LIVER Treatment: MEDICAL AND SURGICAL TREATMENT Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
Line: 300 Condition: CLEFT PALATE AND/OR CLEFT LIP Treatment: EXCISION AND REPAIR VESTIBULE OF MOUTH, ORTHODONTICS Add: E70.89 Other disorders of aromatic amino-acid metabolism
Line: 307 Condition: CIRRHOSIS OF LIVER OR BILIARY TRACT; BUDD-CHIARI SYNDROME; HEPATIC VEIN THROMBOSIS; INTRAHEPATIC VASCULAR MALFORMATIONS; CAROLI'S DISEASE Treatment: LIVER TRANSPLANT, LIVER-KIDNEY TRANSPLANT Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed Add: K74.02 Hepatic fibrosis, advanced fibrosis
Line: 310 Condition: CORNEAL OPACITY AND OTHER DISORDERS OF CORNEA Treatment: KERATOPLASTY Add: H18.501 Unspecified hereditary corneal dystrophies, right eye Add: H18.502 Unspecified hereditary corneal dystrophies, left eye Add: H18.503 Unspecified hereditary corneal dystrophies, bilateral Add: H18.509 Unspecified hereditary corneal dystrophies, unspecified eye Add: H18.511 Endothelial corneal dystrophy, right eye Add: H18.512 Endothelial corneal dystrophy, left eye Add: H18.513 Endothelial corneal dystrophy, bilateral Add: H18.519 Endothelial corneal dystrophy, unspecified eye Add: H18.521 Epithelial (juvenile) corneal dystrophy, right eye Add: H18.522 Epithelial (juvenile) corneal dystrophy, left eye Add: H18.523 Epithelial (juvenile) corneal dystrophy, bilateral Add: H18.529 Epithelial (juvenile) corneal dystrophy, unspecified eye Add: H18.531 Granular corneal dystrophy, right eye Add: H18.532 Granular corneal dystrophy, left eye Add: H18.533 Granular corneal dystrophy, bilateral Page A-11 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Add: H18.539 Granular corneal dystrophy, unspecified eye Add: H18.541 Lattice corneal dystrophy, right eye Add: H18.542 Lattice corneal dystrophy, left eye Add: H18.543 Lattice corneal dystrophy, bilateral Add: H18.549 Lattice corneal dystrophy, unspecified eye Add: H18.551 Macular corneal dystrophy, right eye Add: H18.552 Macular corneal dystrophy, left eye Add: H18.553 Macular corneal dystrophy, bilateral Add: H18.559 Macular corneal dystrophy, unspecified eye Add: H18.591 Other hereditary corneal dystrophies, right eye Add: H18.592 Other hereditary corneal dystrophies, left eye Add: H18.593 Other hereditary corneal dystrophies, bilateral Add: H18.599 Other hereditary corneal dystrophies, unspecified eye
Line: 313 Condition: DISORDERS INVOLVING THE IMMUNE SYSTEM Treatment: MEDICAL THERAPY Add: D84.81 Immunodeficiency due to conditions classified elsewhere Add: D84.821 Immunodeficiency due to drugs Add: D84.822 Immunodeficiency due to external causes Add: D84.89 Other immunodeficiencies Add: D89.831 Cytokine release syndrome, grade 1 Add: D89.832 Cytokine release syndrome, grade 2 Add: D89.833 Cytokine release syndrome, grade 3 Add: D89.834 Cytokine release syndrome, grade 4 Add: D89.835 Cytokine release syndrome, grade 5 Add: D89.839 Cytokine release syndrome, grade unspecified
Line: 317 Condition: STROKE Treatment: MEDICAL THERAPY Delete: Z79.01 Long term (current) use of anticoagulants
Line: 333 Condition: BENIGN CEREBRAL CYSTS Treatment: DRAINAGE Add: G96.191 Perineural cyst Add: G96.198 Other disorders of meninges, not elsewhere classified
Line: 334 Condition: ALCOHOLIC FATTY LIVER OR ALCOHOLIC HEPATITIS, CIRRHOSIS OF LIVER Treatment: MEDICAL THERAPY Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed Add: K74.00 Hepatic fibrosis, unspecified Add: K74.01 Hepatic fibrosis, early fibrosis Add: K74.02 Hepatic fibrosis, advanced fibrosis
Line: 339 Condition: CHRONIC KIDNEY DISEASE Treatment: MEDICAL THERAPY INCLUDING DIALYSIS Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed Add: N02.A Recurrent and persistent hematuria with C3 glomerulonephritis Add: N03.A Chronic nephritic syndrome with C3 glomerulonephritis Add: N04.A Nephrotic syndrome with C3 glomerulonephritis Add: N05.A Unspecified nephritic syndrome with C3 glomerulonephritis Add: N06.A Isolated proteinuria with C3 glomerulonephritis Add: N07.A Hereditary nephropathy, not elsewhere classified with C3 glomerulonephritis Add: N18.30 Chronic kidney disease, stage 3 unspecified Add: N18.31 Chronic kidney disease, stage 3a Add: N18.32 Chronic kidney disease, stage 3b
Page A-12 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 345 Condition: NEUROLOGICAL DYSFUNCTION IN COMMUNICATION CAUSED BY CHRONIC CONDITIONS Treatment: MEDICAL THERAPY Add: E70.81 Aromatic L-amino acid decarboxylase deficiency Add: E70.89 Other disorders of aromatic amino-acid metabolism Add: G11.10 Early-onset cerebellar ataxia, unspecified Add: G11.11 Friedreich ataxia Add: G11.19 Other early-onset cerebellar ataxia Add: G71.20 Congenital myopathy, unspecifed Add: G71.21 Nemaline myopathy Add: G71.220 X-linked myotubular myopathy Add: G71.228 Other centronuclear myopathy Add: G71.29 Other congenital myopathy Add: G96.810 Intracranial hypotension, unspecified Add: G96.811 Intracranial hypotension, spontaneous Add: G96.819 Other intracranial hypotension Add: G97.84 Intracranial hypotension following other procedure Add: P91.821 Neonatal cerebral infarction, right side of brain Add: P91.822 Neonatal cerebral infarction, left side of brain Add: P91.823 Neonatal cerebral infarction, bilateral Add: P91.829 Neonatal cerebral infarction, unspecified side Add: T40.411D Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), subsequent encounter Add: T40.412A Poisoning by fentanyl or fentanyl analogs, intentional self-harm, initial encounter Add: T40.412D Poisoning by fentanyl or fentanyl analogs, intentional self-harm, subsequent encounter Add: T40.413A Poisoning by fentanyl or fentanyl analogs, assault, initial encounter Add: T40.413D Poisoning by fentanyl or fentanyl analogs, assault, subsequent encounter Add: T40.414A Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter Add: T40.414D Poisoning by fentanyl or fentanyl analogs, undetermined, subsequent encounter Add: T40.415A Adverse effect of fentanyl or fentanyl analogs, initial encounter Add: T40.415D Adverse effect of fentanyl or fentanyl analogs, subsequent encounter Add: T40.421A Poisoning by tramadol, accidental (unintentional), initial encounter Add: T40.421D Poisoning by tramadol, accidental (unintentional), subsequent encounter Add: T40.422A Poisoning by tramadol, intentional self-harm, initial encounter Add: T40.422D Poisoning by tramadol, intentional self-harm, subsequent encounter Add: T40.423A Poisoning by tramadol, assault, initial encounter Add: T40.423D Poisoning by tramadol, assault, subsequent encounter Add: T40.424A Poisoning by tramadol, undetermined, initial encounter Add: T40.424D Poisoning by tramadol, undetermined, subsequent encounter Add: T40.425A Adverse effect of tramadol, initial encounter Add: T40.425D Adverse effect of tramadol, subsequent encounter Add: T40.491A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter Add: T40.491D Poisoning by other synthetic narcotics, accidental (unintentional), subsequent encounter Add: T40.492A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter Add: T40.492D Poisoning by other synthetic narcotics, intentional self-harm, subsequent encounter Add: T40.493A Poisoning by other synthetic narcotics, assault, initial encounter Add: T40.493D Poisoning by other synthetic narcotics, assault, subsequent encounter Add: T40.494A Poisoning by other synthetic narcotics, undetermined, initial encounter Add: T40.494D Poisoning by other synthetic narcotics, undetermined, subsequent encounter Add: T40.495A Adverse effect of other synthetic narcotics, initial encounter Add: T40.495D Adverse effect of other synthetic narcotics, subsequent encounter
Line: 346 Condition: CONDITIONS OF THE BACK AND SPINE WITH URGENT SURGICAL INDICATIONS Treatment: SURGICAL THERAPY Add: 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored. Add: G2058 Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure). (do not report g2058 for care management services of less than 20 minutes additional to the first 20 minutes of chronic care management services during a calendar month). (use g2058 in conjunction with 99490). (do not report 99490, g2058 in the same calendar month as 99487, 99489, 99491)).
Page A-13 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 347 Condition: CARDIAC ARRHYTHMIAS Treatment: MEDICAL THERAPY, PACEMAKER Delete: Z79.01 Long term (current) use of anticoagulants
Line: 352 Condition: URINARY SYSTEM CALCULUS Treatment: MEDICAL AND SURGICAL TREATMENT Add: 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed Add: 82652 Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed Add: R82.994 Hypercalciuria
Line: 355 Condition: CLOSED FRACTURE OF EXTREMITIES (EXCEPT MINOR TOES) Treatment: OPEN OR CLOSED REDUCTION Add: M80.0AXA Age-related osteoporosis with current pathological fracture, other site, initial encounter for fracture Add: M80.0AXD Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing Add: M80.0AXG Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing Add: M80.8AXA Other osteoporosis with current pathological fracture, other site, initial encounter for fracture Add: M80.8AXD Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing Add: M80.8AXG Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing
Line: 356 Condition: RHEUMATOID ARTHRITIS, OSTEOARTHRITIS, OSTEOCHONDRITIS DISSECANS, AND ASEPTIC NECROSIS OF BONE Treatment: ARTHROPLASTY/RECONSTRUCTION Add: M05.7A Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvement Add: M05.8A Other rheumatoid arthritis with rheumatoid factor of other specified site Add: M06.0A Rheumatoid arthritis without rheumatoid factor, other specified site Add: M06.8A Other specified rheumatoid arthritis, other specified site Add: M08.0A Unspecified juvenile rheumatoid arthritis, other specified site Add: M08.2A Juvenile rheumatoid arthritis with systemic onset, other specified site Add: M08.4A Pauciarticular juvenile rheumatoid arthritis, other specified site Add: M08.9A Juvenile arthritis, unspecified, other specified site Add: M19.09 Primary osteoarthritis, other specified site Add: M19.19 Post-traumatic osteoarthritis, other specified site Add: M19.29 Secondary osteoarthritis, other specified site
Line: 359 Condition: DEFORMITY/CLOSED DISLOCATION OF JOINT AND RECURRENT JOINT DISLOCATIONS Treatment: SURGICAL TREATMENT Add: 27709 Osteotomy; tibia and fibula Add: M92.501 Unspecified juvenile osteochondrosis, right leg Add: M92.502 Unspecified juvenile osteochondrosis, left leg Add: M92.503 Unspecified juvenile osteochondrosis, bilateral leg Add: M92.509 Unspecified juvenile osteochondrosis, unspecified leg Add: M92.511 Juvenile osteochondrosis of proximal tibia, right leg Add: M92.512 Juvenile osteochondrosis of proximal tibia, left leg Add: M92.513 Juvenile osteochondrosis of proximal tibia, bilateral Add: M92.519 Juvenile osteochondrosis of proximal tibia, unspecified leg Add: M92.521 Juvenile osteochondrosis of tibia tubercle, right leg Add: M92.522 Juvenile osteochondrosis of tibia tubercle, left leg Add: M92.523 Juvenile osteochondrosis of tibia tubercle, bilateral Add: M92.529 Juvenile osteochondrosis of tibia tubercle, unspecified leg Add: M92.591 Other juvenile osteochondrosis of tibia and fibula, right leg Add: M92.592 Other juvenile osteochondrosis of tibia and fibula, left leg Add: M92.593 Other juvenile osteochondrosis of tibia and fibula, bilateral Add: M92.599 Other juvenile osteochondrosis of tibia and fibula, unspecified leg
Page A-14 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 361 Condition: SCOLIOSIS Treatment: MEDICAL AND SURGICAL THERAPY Delete: 63650 Percutaneous implantation of neurostimulator electrode array, epidural Delete: 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural Delete: 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling Add: 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored. Delete: C1767 Generator, neurostimulator (implantable), non-rechargeable Delete: C1778 Lead, neurostimulator (implantable) Delete: C1816 Receiver and/or transmitter, neurostimulator (implantable) Delete: C1820 Generator, neurostimulator (implantable), with rechargeable battery and charging system Delete: C1822 Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system Delete: C1823 Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads Delete: C1897 Lead, neurostimulator test kit (implantable) Add: G2058 Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure). (do not report g2058 for care management services of less than 20 minutes additional to the first 20 minutes of chronic care management services during a calendar month). (use g2058 in conjunction with 99490). (do not report 99490, g2058 in the same calendar month as 99487, 99489, 99491)).
Line: 364 Condition: ACUTE SINUSITIS Treatment: MEDICAL TREATMENT Delete: 31090 Sinusotomy, unilateral, 3 or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid)
Line: 377 Condition: DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVEL OF INDEPENDENCE IN SELF- DIRECTED CARE CAUSED BY CHRONIC CONDITIONS THAT CAUSE NEUROLOGICAL DYSFUNCTION Treatment: MEDICAL THERAPY (SHORT-TERM REHABILITATION WITH DEFINED GOALS) Add: E70.81 Aromatic L-amino acid decarboxylase deficiency Add: E70.89 Other disorders of aromatic amino-acid metabolism Add: G11.11 Friedreich ataxia Add: G11.19 Other early-onset cerebellar ataxia Add: G40.42 Cyclin-Dependent Kinase-Like 5 Deficiency Disorder Add: G71.20 Congenital myopathy, unspecifed Add: G71.21 Nemaline myopathy Add: G71.220 X-linked myotubular myopathy Add: G71.228 Other centronuclear myopathy Add: G71.29 Other congenital myopathy Add: G96.810 Intracranial hypotension, unspecified Add: G96.811 Intracranial hypotension, spontaneous Add: G96.819 Other intracranial hypotension Add: G97.83 Intracranial hypotension following lumbar cerebrospinal fluid shunting Add: G97.84 Intracranial hypotension following other procedure Add: P91.821 Neonatal cerebral infarction, right side of brain Add: P91.822 Neonatal cerebral infarction, left side of brain Add: P91.823 Neonatal cerebral infarction, bilateral Add: P91.829 Neonatal cerebral infarction, unspecified side Add: T40.411D Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), subsequent encounter Add: T40.412A Poisoning by fentanyl or fentanyl analogs, intentional self-harm, initial encounter Add: T40.412D Poisoning by fentanyl or fentanyl analogs, intentional self-harm, subsequent encounter Add: T40.413A Poisoning by fentanyl or fentanyl analogs, assault, initial encounter Add: T40.413D Poisoning by fentanyl or fentanyl analogs, assault, subsequent encounter Add: T40.414A Poisoning by fentanyl or fentanyl analogs, undetermined, initial encounter Add: T40.414D Poisoning by fentanyl or fentanyl analogs, undetermined, subsequent encounter Add: T40.415A Adverse effect of fentanyl or fentanyl analogs, initial encounter Add: T40.415D Adverse effect of fentanyl or fentanyl analogs, subsequent encounter Add: T40.421A Poisoning by tramadol, accidental (unintentional), initial encounter Add: T40.421D Poisoning by tramadol, accidental (unintentional), subsequent encounter Add: T40.422A Poisoning by tramadol, intentional self-harm, initial encounter
Page A-15 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Add: T40.422D Poisoning by tramadol, intentional self-harm, subsequent encounter Add: T40.423A Poisoning by tramadol, assault, initial encounter Add: T40.423D Poisoning by tramadol, assault, subsequent encounter Add: T40.424A Poisoning by tramadol, undetermined, initial encounter Add: T40.424D Poisoning by tramadol, undetermined, subsequent encounter Add: T40.425A Adverse effect of tramadol, initial encounter Add: T40.425D Adverse effect of tramadol, subsequent encounter Add: T40.491A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter Add: T40.491D Poisoning by other synthetic narcotics, accidental (unintentional), subsequent encounter Add: T40.492A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter Add: T40.492D Poisoning by other synthetic narcotics, intentional self-harm, subsequent encounter Add: T40.493A Poisoning by other synthetic narcotics, assault, initial encounter Add: T40.493D Poisoning by other synthetic narcotics, assault, subsequent encounter Add: T40.494A Poisoning by other synthetic narcotics, undetermined, initial encounter Add: T40.494D Poisoning by other synthetic narcotics, undetermined, subsequent encounter Add: T40.495A Adverse effect of other synthetic narcotics, initial encounter Add: T40.495D Adverse effect of other synthetic narcotics, subsequent encounter
Line: 379 Condition: CHRONIC ULCER OF SKIN; VARICOSE VEINS WITH MAJOR COMPLICATIONS Treatment: MEDICAL AND SURGICAL TREATMENT Add: I83.891 Varicose veins of right lower extremity with other complications Add: I83.892 Varicose veins of left lower extremity with other complications Add: I83.893 Varicose veins of bilateral lower extremities with other complications Add: I83.899 Varicose veins of unspecified lower extremity with other complications Add: I87.091 Postthrombotic syndrome with other complications of right lower extremity Add: I87.092 Postthrombotic syndrome with other complications of left lower extremity Add: I87.093 Postthrombotic syndrome with other complications of bilateral lower extremity Add: I87.099 Postthrombotic syndrome with other complications of unspecified lower extremity
Line: 380 Condition: ESOPHAGITIS; GERD Treatment: SHORT-TERM MEDICAL THERAPY; SURGICAL TREATMENT Add: K20.80 Other esophagitis without bleeding Add: K20.81 Other esophagitis with bleeding Add: K20.90 Esophagitis, unspecified without bleeding Add: K20.91 Esophagitis, unspecified with bleeding Add: K21.00 Gastro-esophageal reflux disease with esophagitis, without bleeding Add: K21.01 Gastro-esophageal reflux disease with esophagitis, with bleeding
Line: 401 Condition: BENIGN CONDITIONS OF BONE AND JOINTS AT HIGH RISK FOR COMPLICATIONS Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Delete: 20955 Bone graft with microvascular anastomosis; fibula Delete: 20956 Bone graft with microvascular anastomosis; iliac crest Delete: 20957 Bone graft with microvascular anastomosis; metatarsal Delete: 20962 Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal Delete: 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe Delete: 20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest Delete: 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal Delete: 20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space
Line: 402 Condition: CONDITIONS OF THE BACK AND SPINE Treatment: RISK ASSESSMENT, PHYSICAL MODALITIES, COGNITIVE BEHAVIORAL THERAPY, MEDICAL THERAPY Delete: M40.00 Postural kyphosis, site unspecified Delete: M40.03 Postural kyphosis, cervicothoracic region Delete: M40.04 Postural kyphosis, thoracic region Delete: M40.05 Postural kyphosis, thoracolumbar region Delete: M40.40 Postural lordosis, site unspecified Delete: M40.45 Postural lordosis, thoracolumbar region Delete: M40.46 Postural lordosis, lumbar region Delete: M40.47 Postural lordosis, lumbosacral region Delete: M40.50 Lordosis, unspecified, site unspecified Page A-16 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Delete: M40.55 Lordosis, unspecified, thoracolumbar region Delete: M40.56 Lordosis, unspecified, lumbar region Delete: M40.57 Lordosis, unspecified, lumbosacral region
Line: 442 Condition: MALUNION AND NONUNION OF FRACTURE Treatment: SURGICAL TREATMENT Delete: 20955 Bone graft with microvascular anastomosis; fibula Delete: 20956 Bone graft with microvascular anastomosis; iliac crest Delete: 20957 Bone graft with microvascular anastomosis; metatarsal Delete: 20962 Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal Delete: 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe Delete: 20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest Delete: 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal Delete: 20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space Add: M80.0AXK Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with nonunion Add: M80.0AXP Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with malunion Add: M80.8AXK Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with nonunion Add: M80.8AXP Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with malunion
Line: 463 Condition: OSTEOARTHRITIS AND ALLIED DISORDERS Treatment: MEDICAL THERAPY, INJECTIONS Add: M19.09 Primary osteoarthritis, other specified site Add: M19.19 Post-traumatic osteoarthritis, other specified site Add: M19.29 Secondary osteoarthritis, other specified site
Line: 478 Condition: CLOSED DISLOCATIONS/FRACTURES OF NON-CERVICAL VERTEBRAL COLUMN WITHOUT NEUROLOGIC INJURY OR STRUCTURAL INSTABILITY Treatment: MEDICAL AND SURGICAL TREATMENT Add: M80.0AXA Age-related osteoporosis with current pathological fracture, other site, initial encounter for fracture Add: M80.0AXD Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing Add: M80.0AXG Age-related osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing Add: M80.8AXA Other osteoporosis with current pathological fracture, other site, initial encounter for fracture Add: M80.8AXD Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with routine healing Add: M80.8AXG Other osteoporosis with current pathological fracture, other site, subsequent encounter for fracture with delayed healing
Line: 513 Condition: ESOPHAGITIS AND GERD; ESOPHAGEAL SPASM; ASYMPTOMATIC DIAPHRAGMATIC HERNIA Treatment: MEDICAL THERAPY Add: K20.80 Other esophagitis without bleeding Add: K20.81 Other esophagitis with bleeding Add: K20.90 Esophagitis, unspecified without bleeding Add: K20.91 Esophagitis, unspecified with bleeding Add: K21.00 Gastro-esophageal reflux disease with esophagitis, without bleeding Add: K21.01 Gastro-esophageal reflux disease with esophagitis, with bleeding
Line: 516 Condition: PHLEBITIS AND THROMBOPHLEBITIS, SUPERFICIAL Treatment: MEDICAL THERAPY Delete: Z79.01 Long term (current) use of anticoagulants
Page A-17 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 527 Condition: DEFORMITIES OF UPPER BODY AND ALL LIMBS Treatment: REPAIR/REVISION/RECONSTRUCTION/RELOCATION/MEDICAL THERAPY Add: M24.69 Ankylosis, other specified joint
Line: 528 Condition: DISORDERS OF FUNCTION OF STOMACH AND OTHER FUNCTIONAL DIGESTIVE DISORDERS Treatment: MEDICAL AND SURGICAL THERAPY Add: K59.89 Other specified functional intestinal disorders
Line: 529 Condition: CONDITIONS OF THE BACK AND SPINE WITHOUT URGENT SURGICAL INDICATIONS Treatment: SURGICAL THERAPY Add: 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored. Delete: M40.00 Postural kyphosis, site unspecified Delete: M40.03 Postural kyphosis, cervicothoracic region Delete: M40.04 Postural kyphosis, thoracic region Delete: M40.05 Postural kyphosis, thoracolumbar region Delete: M40.40 Postural lordosis, site unspecified Delete: M40.45 Postural lordosis, thoracolumbar region Delete: M40.46 Postural lordosis, lumbar region Delete: M40.47 Postural lordosis, lumbosacral region Delete: M40.50 Lordosis, unspecified, site unspecified Delete: M40.55 Lordosis, unspecified, thoracolumbar region Delete: M40.56 Lordosis, unspecified, lumbar region Delete: M40.57 Lordosis, unspecified, lumbosacral region Add: G2058 Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure). (do not report g2058 for care management services of less than 20 minutes additional to the first 20 minutes of chronic care management services during a calendar month). (use g2058 in conjunction with 99490). (do not report 99490, g2058 in the same calendar month as 99487, 99489, 99491)).
Line: 535 Condition: VIRAL, SELF-LIMITING ENCEPHALITIS, MYELITIS AND ENCEPHALOMYELITIS Treatment: MEDICAL THERAPY Add: A84.81 Powassan virus disease Add: A84.89 Other tick-borne viral encephalitis
Line: 539 Condition: LESION OF PLANTAR NERVE; PLANTAR FASCIAL FIBROMATOSIS Treatment: MEDICAL THERAPY, EXCISION Delete: 64632 Destruction by neurolytic agent; plantar common digital nerve
Line: 540 Condition: TENSION HEADACHES Treatment: MEDICAL THERAPY Add: R51.0 Headache with orthostatic component, not elsewhere classified Add: R51.9 Headache, unspecified
Line: 549 Condition: TMJ DISORDER Treatment: TMJ SPLINTS Add: M26.641 Arthritis of right temporomandibular joint Add: M26.642 Arthritis of left temporomandibular joint Add: M26.643 Arthritis of bilateral temporomandibular joint Add: M26.649 Arthritis of unspecified temporomandibular joint Add: M26.651 Arthropathy of right temporomandibular joint
Page A-18 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Add: M26.652 Arthropathy of left temporomandibular joint Add: M26.653 Arthropathy of bilateral temporomandibular joint Add: M26.659 Arthropathy of unspecified temporomandibular joint
Line: 558 Condition: BENIGN NEOPLASM OF BONE AND ARTICULAR CARTILAGE INCLUDING OSTEOID OSTEOMAS; BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE Treatment: MEDICAL AND SURGICAL TREATMENT, WHICH INCLUDES CHEMOTHERAPY AND RADIATION THERAPY Delete: 20955 Bone graft with microvascular anastomosis; fibula Delete: 20956 Bone graft with microvascular anastomosis; iliac crest Delete: 20957 Bone graft with microvascular anastomosis; metatarsal Delete: 20962 Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal Delete: 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe Delete: 20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest Delete: 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal Delete: 20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space
Line: 608 Condition: SPRAINS AND STRAINS OF ADJACENT MUSCLES AND JOINTS, MINOR Treatment: MEDICAL THERAPY Add: M24.29 Disorder of ligament, other specified site
Line: 634 Condition: SUPERFICIAL WOUNDS WITHOUT INFECTION AND CONTUSIONS Treatment: MEDICAL THERAPY Add: S20.213A Contusion of bilateral front wall of thorax, initial encounter Add: S20.213D Contusion of bilateral front wall of thorax, subsequent encounter Add: S20.214A Contusion of middle front wall of thorax, initial encounter Add: S20.214D Contusion of middle front wall of thorax, subsequent encounter Add: S20.223A Contusion of bilateral back wall of thorax, initial encounter Add: S20.223D Contusion of bilateral back wall of thorax, subsequent encounter Add: S20.224A Contusion of middle back wall of thorax, initial encounter Add: S20.224D Contusion of middle back wall of thorax, subsequent encounter Add: S20.303A Unspecified superficial injuries of bilateral front wall of thorax, initial encounter Add: S20.303D Unspecified superficial injuries of bilateral front wall of thorax, subsequent encounter Add: S20.304A Unspecified superficial injuries of middle front wall of thorax, initial encounter Add: S20.304D Unspecified superficial injuries of middle front wall of thorax, subsequent encounter Add: S20.313A Abrasion of bilateral front wall of thorax, initial encounter Add: S20.313D Abrasion of bilateral front wall of thorax, subsequent encounter Add: S20.314A Abrasion of middle front wall of thorax, initial encounter Add: S20.314D Abrasion of middle front wall of thorax, subsequent encounter Add: S20.323A Blister (nonthermal) of bilateral front wall of thorax, initial encounter Add: S20.323D Blister (nonthermal) of bilateral front wall of thorax, subsequent encounter Add: S20.324A Blister (nonthermal) of middle front wall of thorax, initial encounter Add: S20.324D Blister (nonthermal) of middle front wall of thorax, subsequent encounter Add: S20.343A External constriction of bilateral front wall of thorax, initial encounter Add: S20.343D External constriction of bilateral front wall of thorax, subsequent encounter Add: S20.344A External constriction of middle front wall of thorax, initial encounter Add: S20.344D External constriction of middle front wall of thorax, subsequent encounter Add: S20.353A Superficial foreign body of bilateral front wall of thorax, initial encounter Add: S20.353D Superficial foreign body of bilateral front wall of thorax, subsequent encounter Add: S20.354A Superficial foreign body of middle front wall of thorax, initial encounter Add: S20.354D Superficial foreign body of middle front wall of thorax, subsequent encounter Add: S20.363A Insect bite (nonvenomous) of bilateral front wall of thorax, initial encounter Add: S20.363D Insect bite (nonvenomous) of bilateral front wall of thorax, subsequent encounter Add: S20.364A Insect bite (nonvenomous) of middle front wall of thorax, initial encounter Add: S20.364D Insect bite (nonvenomous) of middle front wall of thorax, subsequent encounter Add: S20.373A Other superficial bite of bilateral front wall of thorax, initial encounter Add: S20.373D Other superficial bite of bilateral front wall of thorax, subsequent encounter Add: S20.374A Other superficial bite of middle front wall of thorax, initial encounter Add: S20.374D Other superficial bite of middle front wall of thorax, subsequent encounter
Page A-19 ATTACHMENT A
Coding Changes to Condition-Treatment Pairs for the October 1, 2020 Prioritized List of Health Services
Line: 643 Condition: TMJ DISORDERS Treatment: TMJ SURGERY Add: M26.641 Arthritis of right temporomandibular joint Add: M26.642 Arthritis of left temporomandibular joint Add: M26.643 Arthritis of bilateral temporomandibular joint Add: M26.649 Arthritis of unspecified temporomandibular joint Add: M26.651 Arthropathy of right temporomandibular joint Add: M26.652 Arthropathy of left temporomandibular joint Add: M26.653 Arthropathy of bilateral temporomandibular joint Add: M26.659 Arthropathy of unspecified temporomandibular joint
Line: 658 Condition: GENITOURINARY CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Delete: N90.810 Female genital mutilation status, unspecified Delete: N90.811 Female genital mutilation Type I status Delete: N90.812 Female genital mutilation Type II status Delete: N90.813 Female genital mutilation Type III status Delete: N90.818 Other female genital mutilation status
Line: 659 Condition: MUSCULOSKELETAL CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Add: M24.19 Other articular cartilage disorders, other specified site Add: M24.39 Pathological dislocation of other specified joint, not elsewhere classified Add: M24.49 Recurrent dislocation, other specified joint Add: M24.89 Other specific joint derangement of other specified joint, not elsewhere classified Add: M25.39 Other instability, other specified joint Add: M40.00 Postural kyphosis, site unspecified Add: M40.03 Postural kyphosis, cervicothoracic region Add: M40.04 Postural kyphosis, thoracic region Add: M40.05 Postural kyphosis, thoracolumbar region Add: M40.40 Postural lordosis, site unspecified Add: M40.45 Postural lordosis, thoracolumbar region Add: M40.46 Postural lordosis, lumbar region Add: M40.47 Postural lordosis, lumbosacral region Add: M40.50 Lordosis, unspecified, site unspecified Add: M40.55 Lordosis, unspecified, thoracolumbar region Add: M40.56 Lordosis, unspecified, lumbar region Add: M40.57 Lordosis, unspecified, lumbosacral region
Line: 661 Condition: MISCELLANEOUS CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY Treatment: EVALUATION Add: 58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants Add: 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored. Add: F88. Other disorders of psychological development Add: G2058 Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (list separately in addition to code for primary procedure). (do not report g2058 for care management services of less than 20 minutes additional to the first 20 minutes of chronic care management services during a calendar month). (use g2058 in conjunction with 99490). (do not report 99490, g2058 in the same calendar month as 99487, 99489, 99491)).
Page A-20 ATTACHMENT B
Coding Changes to Condition-Treatment Pairs Affecting Numerous Lines for the October 1, 2020 Prioritized List of Health Services
Add code G2010 (Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment) to the following lines:
Remove code G2010 (Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment) from the following lines: 1-4,6,8-21,23-25,27-53,55-61,63-95,97-120,122-148,150-172,174-192,194-200,202,204-210,212-217,219-251,253-276,278-281, 283-289,291-342,345-380,382,383,385-387,389,390,392-397,399-406,408-410,413,415-420,422-431,433-436,438-442,445,447, 448,450-452,454-456,459-461,463-467,469,471,472,474-478,480-491,493,495-501,503-506,508-536,538-545,547-550,552-573, 575-590,592-600,602-610,612-617,620-630,632-644,647,648,650-661
Remove code 93792 (Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results) from the following lines: 1-53,55-217,219-342,345-383,385-397,399-410,412-442,444-452,454-456,458-467,469-491,493-501,503-506,508-536,538-590, 592-600,602-617,620-644,647-661
Remove code 93793 (Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed) from the following lines: 1-53,55-217,219-342,345-383,385-397,399-410,412-442,444-452,454-456,458-467,469-491,493-501,503-506,508-536,538-590, 592-600,602-617,620-644,647-661
Add code 97810 (Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient) to the following lines: 92,111,112,114,125,129,133,135,157,158,191,199,200,208,210,214,215,229,234,237,238,258,259,262,271,276,287,294,314-316, 329,342,396,397,420,434,558
Add code 97811 (Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)) to the following lines: 92,111,112,114,125,129,133,135,157,158,191,199,200,208,210,214,215,229,234,237,238,258,259,262,271,276,286,287,294,314- 316,329,342,396,397,420,434,558
Add code 97813 (Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient) to the following lines: 92,111,112,114,125,129,133,135,157,158,191,199,200,208,210,214,215,229,234,237,238,258,259,262,271,276,286,287,294,314- 316,329,342,396,397,420,434,558
Add code 97814 (Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)) to the following lines: 92,111,112,114,125,129,133,135,157,158,191,199,200,208,210,214,215,229,234,237,238,258,259,262,271,276,286,287,294,314- 316,329,342,396,397,420,434,558
Page B-1 ATTACHMENT C
New Guidelines for the October 1, 2020 Prioritized List of Health Services
GUIDELINE NOTE 64, BONE MARROW TRANSPLANT FOR SICKLE CELL DISEASE Line 113 Allogeneic hematopoietic cell transplantation for sickle cell disease is included on this line only when: A) Patient has a related human leukocyte antigen (HLA) matched donor; or B) Patient has an unrelated or HLA mismatched related donor AND severe sickle cell disease (e.g. recurrent chest syndrome, recurrent vaso-occlusive crises, red blood cell alloimmunization on chronic transfusion therapy).
GUIDELINE NOTE 68, TREATMENT OF CHRONIC LOWER EXTREMITY VENOUS DISEASE Lines 379,519,639 Medical treatment of chronic lower extremity venous disease with major complications (skin ulceration, recurrent cellulitis or clinically significant bleeding) is included on Line 379, including medical compression garments.
Surgical treatment of chronic lower extremity venous disease is only included on Line 379 when A) The patient has had an adequate 3-month trial of conservative therapy and failed; AND B) Ultrasound findings of severe axial venous reflux (>1 second in the greater or small saphenous vein or accessory saphenous vein; AND C) The patient has one of the following: 1) Non-healing skin ulceration in the area of the varicose vein(s), OR 2) Recurrent episodes of cellulitis associated with chronic venous disease OR 3) Clinically significant bleeding from varicose vein(s).
Otherwise, these diagnoses are included on Lines 519 and 639.
GUIDELINE NOTE 178, SPINAL CORD STIMULATOR THERAPY Lines 292,346,529 A spinal cord stimulator trial is included on Lines 292 and 346 only when a patient meets all of the following criteria: A) The patient has moderate to severe (>5 on the VAS pain scale) neuropathic pain and objective neurologic impairment with documented pathology related to pain complaint (i.e. abnormal MRI). Neurologic impairment is defined as objective evidence of one or more of the following: 1) Markedly abnormal reflexes 2) Segmental muscle weakness 3) Segmental sensory loss 4) EMG or NCV evidence of nerve root impingement 5) Cauda equina syndrome 6) Neurogenic bowel or bladder 7) Long tract abnormalities; AND B) The patient has failed 12 or more months of other treatment modalities (e.g. pharmacological, surgical, physical therapy, cognitive therapy, and activity lifestyle modification); AND C) The patient has had an evaluation by a mental health provider (e.g., a face-to-face assessment with or without psychological questionnaires and/or psychological testing) which revealed no evidence of an inadequately controlled mental health problem (e.g., alcohol or drug dependence, depression, psychosis) and the patient receives written clearance from the mental health provider for device placement.
Implantation of a spinal cord stimulator is included on Lines 292 and 346 when the trial criteria above are met and the patient experienced significant pain reduction (50% or more) with a 3 to 7 day trial of percutaneous spinal stimulation.
Spinal cord stimulation (CPT 63650-63688) is not included on Line 292 when paired with ICD-10-CM category G90.5 Complex regional pain syndrome/reflex sympathetic dystrophy.
Otherwise, spinal cord stimulation therapy is included on Line 529.
GUIDELINE NOTE 200, SURGERIES RELATED TO FEMALE GENITAL MUTILATION Line 120 Female genital mutilation of children or adults is not included on any line on the Prioritized List, including returning a woman to her former status after delivery.
C-1
ATTACHMENT C
New Guidelines for the October 1, 2020 Prioritized List of Health Services
Repair of female genital mutilation (e.g. Type II or III) with defibulation or lysis of adhesions is included on this line when causing interference in function (i.e. urinary, menstrual, or potential future vaginal childbirth) or causing recurrent complications including chronic pain related to the mutilation. Clitoral reconstruction is not included on this line due to an unclear risk/benefit ratio.
C-2
ATTACHMENT E
Deleted Guideline Note for the October 1, 2020 Prioritized List of Health Services
ANCILLARY GUIDELINE A5, TELEHEALTH, TELECONSULTATIONS AND ONLINE/TELEPHONIC SERVICES As referred to in this guideline note, the COVID-19 emergency is defined as per Oregon Governor Kate Brown’s executive order 20- 03 and any subsequent executive order extending or reinstating a state of emergency related to COVID-19. Italicized portions of this guideline note apply only during the COVID-19 emergency.
Telehealth (Synchronous visits including audio and video. Audio-only telephone services can be provided using these codes only during the COVID-19 emergency and if providing the service via synchronous audio and video is not available or feasible)
Telehealth services described in this section are defined as synchronous services with both audio and video capability, when billed with the same codes that would be billed for in-person services, and when mode of delivery is indicated by the use of specific modifiers and/or place of service codes specified by the plan. The patient may be in the community or in a health care setting. The provider may be in any location in which appropriate privacy can be ensured. The clinical value of the telehealth service delivered must reasonably approximate the clinical value of services delivered in-person.
During the COVID-19 emergency, telephone (audio-only) visits are an acceptable replacement for the equivalent service provided by synchronous audio and video, if synchronous audio and video capabilities are not available or feasible.
Certain requirements for encryption will not be enforced by federal authorities (or required by OHP) during the COVID-19 emergency. This means services such as Facetime, Skype or Google Hangouts can be used for service delivery. HIPAA-compliant platforms are preferred when available. See https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency- preparedness/notification-enforcement-discretion-telehealth/index.html for details.
When a COVID-19 emergency declaration is not in effect, codes eligible for telehealth delivery include 90785, 90791, 90792, 90832- 90834, 90836, 90837-90840, 90846, 90847, 90951, 90952, 90954, 90955, 90957, 90958, 90960, 90961, 90963, 90964-90970, 96116, 96156-96171, 96160, 96161, 97802-97804, 99201-99205, 99211-99215, 99231-99233, 99307-99310, 99354-99357, 99406- 99407, 99495-99498, G0108-G0109, G0270, G0296, G0396, G0397, G0406-G0408, G0420, G0421, G0425-G0427, G0438-G0439, G0442-G0447, G0459, G0506, G0508, G0509, G0513, G0514, G2086-G2088. During a COVID-19 emergency, additional codes are covered when otherwise appropriate according to this guideline note and other applicable coverage criteria.
The originating site code Q3014 can be billed only when the patient is present in an appropriate health care setting and receiving services from a provider in another location.
Telehealth visits are covered for inpatient and outpatient services for new or established patients.
Telehealth consultations are covered for emergency and inpatient services.
Billing for telehealth services requires the same level of documentation, medical necessity, and coverage determinations as in- person visits.
Patient to Clinician Services billed using specified codes indicating telephone or online service delivery Telephonic and online services, including services related to diagnostic workup (CPT 98966-98968, 99441-99443, 99421-99423, 98970-98972, G2010, G2012, G2061-G2063) between a patient and clinician must: A) Be provided only for established patients (This requirement does not apply during a COVID-19 emergency) B) Be documented as follows: 1) using model SOAP charting, or as described in program’s OAR; 2) include patient history, provider assessment, treatment plan and follow-up instructions; 3) support the assessment and plan; 4) be retained in the patient’s medical record and be retrievable. C) Include medical decision making or service delivery (e.g. behavioral health intervention/psychotherapy, other forms of therapy). D) Include permanent storage (online or hard copy) of the encounter. E) Meet applicable HIPAA standards for privacy. F) Include patient-clinician agreement of informed consent, discussed with and agreed to by the patient and documented in the medical record. (During the COVID-19 emergency, verbal consent is sufficient.) G) Not include any of the following: 1) Services which are part of care plan oversight or anticoagulation management (CPT codes 99339-99340, 99374- 99380 or 99363-99364). 2) Services related to a service performed and billed by the physician or qualified health professional within the previous seven days, regardless of whether it is the result of patient-initiated or physician-requested follow-up. 3) Services which result in the patient being seen within 24 hours or the next available appointment. 4) Services which relate to or take place within the postoperative period of a procedure provided by the physician. (Such a service is considered part of the procedure and is not be billed separately.)
Examples of reimbursable telephone or online services include but are not limited to: E-1
ATTACHMENT E
Deleted Guideline Note for the October 1, 2020 Prioritized List of Health Services
A) Extended counseling when person-to-person contact would involve an unwise delay or exposure to COVID-19. B) Treatment of relapses that require significant investment of provider time and judgment. C) Counseling and education for patients with complex chronic conditions.
Examples of non-reimbursable telephone/online consultations include but are not limited to: A) Prescription renewal. B) Scheduling a test. C) Reporting normal test results. D) Requesting a referral. E) Follow up of medical procedure to confirm stable condition, without indication of complication or new condition. F) Brief discussion to confirm stability of chronic problem and continuity of present management.
Clinician-to-Clinician Consultations (telephonic and online or using electronic health record)
Coverage of interprofessional consultations delivered online, through electronic health records or by telephone is included as follows:
Consulting Providers (CPT 99451, 99446-99449) • For new or established patients • Consult must be requested by another provider. • Can be for a new or an exacerbated condition. • Cannot be reported more than 1 time per 7 days for the same patient. • Must report cumulative time spent, even if time occurs over multiple days. • Cannot be reported if a transfer of care or request for face-to-face visit occurs as a result of the consultation within the following 14 days. • Cannot be reported if the patient was seen by the consultant within the past 14 days. • The request and reason for consultation is documented in the patient’s medical record. • Requires a minimum of 5 minutes of medical consultation, discussion and/or review
Requesting Providers (CPT 99452) • Consult must be reported by requesting provider (not for the transfer of a patient or request for face-to-face consult) • Reported only when the patient is not on-site with the requesting provider at the time of consultation • Cannot be reported more than 1 time per 14 days per patient. • Requires a minimum of 16 minutes. Includes time for referral prep and/or communicating with the consultant. • Can be reported with prolonged services, non-direct
Limited information provided by one clinician to another that does not contribute to collaboration (e.g., interpretation of an electroencephalogram, report on an x-ray or scan, or reporting the results of a diagnostic test) is not considered a consultation..
DIAGNOSTIC GUIDELINE D26, NEUROBEHAVIORAL STATUS EXAMS AND NEUROPSYCHOLOGICAL TESTING Neurobehavioral status exams (CPT 96116 and 96121) and neuropsychological testing services (CPT 96132 and 96133) are only covered when all of the following are met: A) Symptoms are not explained by an existing diagnosis; AND B) When the results of such testing will be used to develop a care plan.
OR when neuropsychological testing is done as part of the pre-operative evaluation prior to epilepsy surgery.
GUIDELINE NOTE 1, ROUTINE CERVICAL CANCER SCREENING Line 3 Cervical cancer screening is covered on Line 3 for women:
Age group in years Type of screening covered Frequency <21 None Never 21-29 Cytology alone Every 3 years Mandatory HPV testing (87620-87621) is not covered for women age 21-29 30-65 High-risk human papillomavirus (hrHPV) testing alone, co- Co-testing every 5 years testing (hrHPV and cytology) or cytology alone hrHPV testing alone every 5 years Cytology alone every 3 years E-2
ATTACHMENT E
Deleted Guideline Note for the October 1, 2020 Prioritized List of Health Services
>65 None Never Unless adequate screening* has not been achieved, or it is <20 years after regression or appropriate management of a high-grade precancerous lesion Women who have had a None Never hysterectomy with removal of cervix for non cervical cancer related reasons (i.e. other than high grade precancerous lesion, CIN 2 or 3, or cervical cancer) Women who have Per ASCCP** Guideline, until indicated to resume routine Per ASCCP Guideline, until abnormal testing screening indicated to resume routine screening * Adequate screening is defined as 3 consecutive negative cytology results or 2 consecutive negative HPV results within 10 years of the cessation of screening, with the most recent test occurring within 5 years. ** American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology guideline (Perkins, 2020)
Women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive) are intended to have screening more frequently than delineated in this guideline.
GUIDELINE NOTE 2, FETAL SURGERY Line 1 Fetal surgery is only covered for the following conditions: repair of urinary tract obstructions via placement of a urethral shunt, repair of congenital cystic adenomatoid malformation, repair of extralobal pulmonary sequestration, repair of sacrococcygeal teratoma, therapy for twin-twin transfusion syndrome, and repair of myelomeningocele.
Fetoscopic repair of urinary tract obstruction (S2401) is only covered for placement of a urethral shunt. Fetal surgery for cystic adenomatoid malformation of the lung, extralobal pulmonary sequestration and sacrococcygeal teratoma must show evidence of developing hydrops fetalis.
Certification of laboratory required (76813-76814).
GUIDELINE NOTE 6, REHABILITATIVE AND HABILITATIVE THERAPIES Lines 31,46,57,68,71,73,80,90,91,127,131,132,136,150,153,160,178,183,184,196,200,201,207,254,256,272,285,287,292,300, 301,309,317,341,345,348,355,356,359,376,377,398,401,402,408,416,418,423,424,431,442,455,463,466,467,478,486,497, 509,555,558,571,589,608 The quantitative limits in this guideline note do not apply to mental health or substance abuse conditions.
A total of 30 visits per year of rehabilitative therapy and a total of 30 visits per year of habilitative therapy (physical, occupational and speech therapy) are included on these lines when medically appropriate. Additional visits, not to exceed 30 visits per year of rehabilitative therapy and 30 visits per year of habilitative therapy, may be authorized in cases of a new acute injury, surgery, or other significant change in functional status. Children under age 21 may have additional visits authorized beyond these limits if medically appropriate. Massage therapy (CPT 97124) is included in these service limits. When billing CPT 97124, there must be a minimum of 8 minutes of massage provided. Massage is limited to no more than one session per week.
Physical, occupational and speech therapy are only included on these lines when the following criteria are met:
A) therapy is provided by a licensed physical therapist, occupational therapist, speech language pathologist, physician, or other practitioner licensed to provide the therapy, B) there is objective, measurable documentation of clinically significant progress toward the therapy plan of care goals and objectives, C) the therapy plan of care requires the skills of a medical provider, and D) the client and/or caregiver cannot be taught to carry out the therapy regimen independently.
No limits apply while in a skilled nursing facility for the primary purpose of rehabilitation, an inpatient hospital or an inpatient rehabilitation unit.
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Spinal cord injuries, traumatic brain injuries, or cerebral vascular accidents are not subject to the visit limitations during the first year after an acute injury.
GUIDELINE NOTE 21, SEVERE INFLAMMATORY SKIN DISEASE Lines 426,482,504,532,541,656 Inflammatory skin conditions included in this guideline are: A) Psoriasis B) Atopic dermatitis C) Lichen planus D) Darier disease E) Pityriasis rubra pilaris F) Discoid lupus
The conditions above are included on Line 426 if severe, defined as having functional impairment as indicated by Dermatology Life Quality Index (DLQI) ≥ 11 or Children's Dermatology Life Quality Index (CDLQI) ≥ 13 (or severe score on other validated tool) AND one or more of the following: A) At least 10% of body surface area involved B) Hand, foot or mucous membrane involvement.
Otherwise, these conditions above are included on Lines 482, 504, 532, 541 and 656.
For severe psoriasis, first line agents include topical agents, phototherapy and methotrexate. Second line agents include other systemic agents and oral retinoids and should be limited to those who fail, or have contraindications to, or do not have access to first line agents. Biologics are included on this line only for the indication of severe plaque psoriasis; after documented failure of first line agents and failure of (or contraindications to) a second line agent.
For severe atopic dermatitis/eczema, first-line agents include topical moderate- to high- potency corticosteroids and narrowband UVB. Second line agents include topical calcineurin inhibitors (e.g. pimecrolimus, tacrolimus), topical phosphodiesterase (PDE)-4 inhibitors (e.g. crisaborole), and oral immunomodulatory therapy (e.g. cyclosporine, methotrexate, azathioprine, mycophenolate mofetil, or oral corticosteroids). Use of the topical second line agents (e.g. calcineurin inhibitors and phosphodiesterase (PDE)-4 inhibitors) should be limited to those who fail or have contraindications to first line agents. Biologic agents are included on this line for atopic dermatitis only after failure of or contraindications to at least one agent from each of the following three classes: 1) moderate to high potency topical corticosteroids, 2) topical calcineurin inhibitors or topical phosphodiesterase (PDE)-4 inhibitors, and 3) oral immunomodulator therapy.
GUIDELINE NOTE 37, SURGICAL INTERVENTIONS FOR CONDITIONS OF THE BACK AND SPINE OTHER THAN SCOLIOSIS Lines 346,529 Spine surgery is included on Line 346 only in the following circumstances: A) Decompressive surgery is included on Line 346 to treat debilitating symptoms due to central or foraminal spinal stenosis, and only when the patient meets the following criteria: 1) Has MRI evidence of moderate or severe central or foraminal spinal stenosis AND 2) Has neurogenic claudication OR 3) Has objective neurologic impairment consistent with the MRI findings. Neurologic impairment is defined as objective evidence of one or more of the following: a) Markedly abnormal reflexes b) Segmental muscle weakness c) Segmental sensory loss d) EMG or NCV evidence of nerve root impingement e) Cauda equina syndrome f) Neurogenic bowel or bladder g) Long tract abnormalities Foraminal or central spinal stenosis causing only radiating pain (e.g. radiculopathic pain) is included only on Line 529.
B) Spinal fusion procedures are included on Line 346 for patients with MRI evidence of moderate or severe central spinal stenosis only when one of the following conditions are met: 1) spinal stenosis in the cervical spine (with or without spondylolisthesis) which results in objective neurologic impairment as defined above OR 2) spinal stenosis in the thoracic or lumbar spine caused by spondylolisthesis resulting in signs and symptoms of neurogenic claudication and which correlate with xray flexion/extension films showing at least a 5 mm translation OR
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3) pre-existing or expected post-surgical spinal instability (e.g. degenerative scoliosis >10 deg, >50% of facet joints per level expected to be resected)
For all other indications, spine surgery is included on Line 529.
The following interventions are not included on these lines due to lack of evidence of effectiveness for the treatment of conditions on these lines, including cervical, thoracic, lumbar, and sacral conditions: • local injections (including ozone therapy injections) • botulinum toxin injection • intradiscal electrothermal therapy • therapeutic medial branch block • coblation nucleoplasty • percutaneous intradiscal radiofrequency thermocoagulation • percutaneous laser disc decompression • radiofrequency denervation • corticosteroid injections for cervical pain
Corticosteroid injections for low back pain with or without radiculopathy are only included on Line 529. Diagnostic anesthetic injections for selective nerve root blocks are included on line 529 for lumbar or sacral symptoms.
The development of this guideline note was informed by HERC coverage guidances on Percutaneous Interventions for Low Back Pain, Percutaneous Interventions for Cervical Spine Pain, Low Back Pain: Corticosteroid Injections and Low Back Pain: Minimally Invasive and Non-Cordicosteroid Percutaneous Interventions. See https://www.oregon.gov/oha/HPA/DSI-HERC/Pages/Evidence- based-Reports.aspx
GUIDELINE NOTE 44, MENSTRUAL BLEEDING DISORDERS Line 422 Endometrial ablation or hysterectomy for abnormal uterine bleeding in Premenopausal women may be indicated when all of the following are documented (A-C): A) Patient history of (1, 2, 3, 4, and 5): 1) Excessive uterine bleeding evidence by (a, b and c): a) Profuse bleeding lasting more than 7 days or repetitive periods at less than 21-day intervals b) Anemia due to acute or chronic blood loss (hemoglobin less than 10 g/dL or hemoglobin less than 11 g/dL if use of iron is documented) for hysterectomy. No documented hemoglobin level is required for endometrial ablation procedures. c) Bleeding causes major impairment or interferes with quality of life 2) Failure of hormonal treatment for a six-month trial period or contraindication to hormone use (oral contraceptive pills or patches, progesterone-containing IUDs, injectable hormone therapy, or similar) 3) No current medication use that may cause bleeding, or contraindication to stopping those medications 4) Endometrial sampling performed 5) For hysterectormy, no evidence of treatable intrauterine conditions or lesions by (a, b or c): a) Sonohysterography b) Hysteroscopy c) Transvaginal ultrasound For endometrial ablation, a pre-operative ultrasound should be performed. B) Negative preoperative pregnancy test result unless patient has been previously sterilized C) Nonmalignant cervical cytology, if cervix is present
GUIDELINE NOTE 56, NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE Lines 361,402 Patients seeking care for back pain should be assessed for potentially serious conditions (“red flag” symptoms requiring immediate diagnostic testing), as defined in Diagnostic Guideline D4. Patients lacking red flag symptoms should be assessed using a validated assessment tool (e.g. STarT Back Assessment Tool) in order to determine their risk level for poor functional prognosis based on psychosocial indicators. For patients who are determined to be low risk on the assessment tool, the following services are included on these lines: • Office evaluation and education, • Up to four total visits, consisting of the following treatments: OMT/CMT, acupuncture, and PT/OT. Massage, if available, may be provided as part of these four total visits.
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• First line medications: NSAIDs, acetaminophen, and/or muscle relaxers. Opioids may be considered as a second line treatment, subject to the limitations on coverage of opioids in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE.
For patients who are determined to be medium- or high risk on the validated assessment tool, as well as patients undergoing opioid tapers as in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE, the following treatments are included on these lines: • Office evaluation, consultation and education • Cognitive behavioral therapy. The necessity for cognitive behavioral therapy should be re-evaluated every 90 days and coverage will only be continued if there is documented evidence of decreasing depression or anxiety symptomatology, improved ability to work/function, increased self-efficacy, or other clinically significant, objective improvement. • Prescription and over-the-counter medications; opioid medications subject to the limitations on coverage of opioids in Guideline Note 60 OPIOIDS FOR CONDITIONS OF THE BACK AND SPINE. • The following evidence-based therapies, when available, may be provided: yoga, massage when not billed under 97124 and limited to one session per week, Pilates, supervised exercise therapy, intensive interdisciplinary rehabilitation. HCPCS S9451 is only included on Line 402 for the provision of yoga or supervised exercise therapy. • A total of 30 visits per year of any combination of the following evidence-based therapies when available and medically appropriate. These therapies are only included on these lines if provided by a provider licensed to provide the therapy and when there is documentation of measurable clinically significant progress toward the therapy plan of care goals and objectives using evidence based objective tools (e.g. Oswestry, Neck Disability Index, SF-MPQ, and MSPQ). 1) Rehabilitative therapy (physical and/or occupational therapy), if provided according to Guideline Note 6 REHABILITATIVE AND HABILITATIVE THERAPIES. Rehabilitation services provided under this guideline also count towards visit totals in Guideline Note 6. Massage billed under CPT 97124 is included in this category and is subject to the restrictions on massage in Guideline Note 6. 2) Chiropractic or osteopathic manipulation 3) Acupuncture
Mechanical traction (CPT 97012) is not included on these lines, due to evidence of lack of effectiveness for treatment of back and neck conditions.
The development of this guideline note was informed by HERC coverage guidances on Low Back Pain Non-Pharmacologic, Non- Invasive Intervention, Low Back Pain, Pharmacological and Herbal Therapies. See https://www.oregon.gov/oha/HPA/DSI- HERC/Pages/Evidence-based-Reports.aspx
GUIDELINE NOTE 92, ACUPUNCTURE Lines 1,5,92,111,112,114,125,129,133,135,157,158,191,199-202,208,210,214,215,229,234,237,238,258,259,261,262,271, 276,286,287,294,314-316,329,342,361,372,396,397,401,402,409,410,420,434,461,463,538,540,558 Inclusion of acupuncture (CPT 97810-97814) on the Prioritized List has the following limitations:
Line 1 PREGNANCY Acupuncture pairs on Line 1 for the following conditions and codes. Hyperemesis gravidarum ICD-10-CM: O21.0, O21.1 Acupuncture pairs with hyperemesis gravidarum when a diagnosis is made by the maternity care provider and referred for acupuncture treatment for up to 12 sessions of acupressure/acupuncture per pregnancy. Breech presentation ICD-10-CM: O32.1 Acupuncture (and moxibustion) is paired with breech presentation when a referral with a diagnosis of breech presentation is made by the maternity care provider, the patient is between 33 and 38 weeks gestation, for up to 6 session per pregnancy. Back and pelvic pain of pregnancy ICD-10-CM: O99.89 Acupuncture is paired with back and pelvic pain of pregnancy when referred by maternity care provider/primary care provider for up to 12 sessions per pregnancy. Line 5 TOBACCO DEPENDENCE Acupuncture is included on this line for a maximum of 12 sessions per quit attempt up to two quit attempts per year; additional sessions may be authorized if medically appropriate. Lines 92, 111, 112, 114, 125, 129, 133, 135, 157, 158, 191, 199, 200, 208, 210, 214, 215, 229, 234, 237, 238, 258, 259, 261, 262, 271, 276, 286, 287, 294, 314, 315, 316, 329, 342, 372, 396, 397, 420, 434 and 558 Acupuncture is paired only with the ICD-10 code G89.3 (Neoplasm related pain (acute) (chronic)) when there is active cancer and limited to 12 total sessions per year; patients may have additional visits authorized beyond these limits if medically appropriate. Line 201 CHRONIC ORGANIC MENTAL DISORDERS INCLUDING DEMENTIAS E-6
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Acupuncture is paired with the treatment of post-stroke depression only. Treatments may be billed to a maximum of 30 minutes face-to-face time and limited to 12 total sessions per year, with documentation of meaningful improvement; patients may have additional visits authorized beyond these limits if medically appropriate. Line 361 SCOLIOSIS Acupuncture is included on this line with visit limitations as in Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE. Line 402 CONDITIONS OF THE BACK AND SPINE Acupuncture is included on this line with visit limitations as in Guideline Note 56 NON-INTERVENTIONAL TREATMENTS FOR CONDITIONS OF THE BACK AND SPINE. Line 410 MIGRAINE HEADACHES Acupuncture pairs on Line 410 for migraine (ICD-10-CM G43.0, G43.1, G43.5, G43.7, G43.8, G43.9), for up to 12 sessions per year. Line 463 OSTEOARTHRITIS AND ALLIED DISORDERS Acupuncture pairs on Line 463 for osteoarthritis of the knee only (ICD-10-CM M17), for up to 12 sessions per year. *Line 540 TENSION HEADACHES Acupuncture is included on Line 540 for treatment of tension headaches (ICD-10-CM G44.2), for up to 12 sessions per year.
The development of this guideline note was informed by a HERC coverage guidance. See https://www.oregon.gov/oha/HPA/DSI- HERC/Pages/Evidence-based-Reports.aspx
*Below the current funding line.
GUIDELINE NOTE 153, PLANNED OUT-OF-HOSPITAL BIRTH Lines 1,2 Planned out-of-hospital birth is included on this line for pregnant women who are at low risk for adverse obstetric or birth outcomes. The high-risk conditions outlined below would either preclude coverage of planned out-of-hospital birth, necessitate a consultation, or require transfer of the mother or infant to a hospital setting. When a condition requiring transfer arises during labor, an attempt should be made to transer the mother and/or her newborn; however, imminent fetal delivery may delay or preclude actual transfer prior to birth.
Coverage of prenatal, intrapartum, and postpartum care is recommended with the performance of appropriate risk assessments (at initiation of care and throughout pregnancy and delivery) and the out-of-hospital birth attendant’s adherence to the consultation and transfer criteria as outlined below.
When a high-risk condition develops that requires transfer or planned hospital birth, coverage is recommended when appropriate care is provided until the point the high-risk condition is identified. For women who have a high-risk condition requiring consultation, ongoing coverage of planned out-of-hospital birth care is recommended as long as the consulting provider’s recommendations are then appropriately managed by the out-of-hospital birth attendant in a planned out-of-hospital birth setting.
HIGH-RISK CONDITIONS Conditions in the red (darker) boxes indicate high-risk conditions that require planned hospital birth (when present on intake) or transfer of the mother or infant to hospital-based care (when condition develops).
Conditions in the yellow (lighter) boxes indicate potentially risky conditions that require consultation. Consultations may be with 1) a provider (MD/DO or CNM) who has active admitting privileges to manage pregnancy in a hospital and/or 2) appropriate specialty consultation (e.g., maternal-fetal medicine, hepatologist, hematologist, psychiatrist).
This list of high-risk conditions is not exhaustive, and other, physical health, behavioral health, obstetric, or fetal high-risk conditions may arise that require consultation and/or transfer to hospital-based care. Having multiple risk conditions requiring consultation may increase the risk sufficiently to indicate the need for transfer of care.
MEDICAL HISTORY OR OBSTETRIC HISTORY ^ indicates transfer; ~ indicates consultation Cancer • Active gynecologic cancer^ Cardiovascular Disease • Cardiovascular disease causing functional impairment^ Connective Tissue Disorders • Systemic lupus erythematous~ • Scleroderma~ • Rheumatoid arthritis~ • Any collagen-vascular disease~ Delivery History • Prior cesarean section^
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MEDICAL HISTORY OR OBSTETRIC HISTORY ^ indicates transfer; ~ indicates consultation Diabetes Mellitus • Type 1 diabetes^ • Type 2 diabetes^ Endocrine Conditions • Significant endocrine conditions other than diabetes (e.g. hyperthyroidism)~ Fetal Demise or Stillbirth • Prior stillbirth/neonatal death~ Hematologic Disorders • Maternal bleeding disorder^ • Hemoglobinopathies~ • History of thrombosis or thromboembolism~ • History of postpartum hemorrhage requiring transfusion or other advanced treatment (e.g. Bakri balloon)~ Hypertensive Disorders • Eclampsia^ • Pre-eclampsia requiring preterm birth^ • HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)^ • Pre-existing or chronic hypertension^ Infectious Diseases • HIV positive^ Isoimmunization • Blood group incompatibility and/or Rh sensitization in a prior pregnancy~ Neonatal Encephalopathy in prior • Neonatal encephalopathy in prior pregnancy~ pregnancy Neurological disorders • Neurological disorders or active seizure disorders that would impact maternal or neonatal health (e.g. epilepsy, myasthenia gravis, previous cerebrovascular accident)^ Placental Conditions • History of retained placenta requiring surgical removal^ Psychiatric Conditions • History of postpartum mood disorder with high risk to the infant (e.g. psychosis)~ • Schizophrenia, other psychotic disorders, bipolar I disorder or schizotypal disorders~ Pulmonary Disease • Chronic pulmonary disease (e.g. cystic fibrosis)~ Renal Disease • Renal disease requiring supervision by a renal specialist^ • Renal failure^ (Preeclampsia and related conditions are listed separately) Shoulder Dystocia • History of, with or without fetal clavicular fracture~ Uterine Conditions • Prior myomectomy~ • Prior hysterotomy^
CONDITIONS OF CURRENT PREGNANCY • Antepartum hemorrhage, recurrent^ Abnormal Bleeding in pregnancy • Hemorrhage (hypovolemia, shock, need for transfusion, vital sign instability)^ Amniotic Membrane Rupture • Before 37 weeks 0 days^ • Pre-labor rupture > 24 hours~ Congenital or Hereditary Anomaly of the • Evidence of congenital anomalies requiring immediate assessment fetus and/or management by a neonatal specialist~ Diabetes, Gestational • Requiring medication or uncontrolled^ Fetal Growth • Uteroplacental insufficiency^ • IUGR (defined as fetal weight less than fifth percentile using ethnically- appropriate growth tables, or concerning reduced growth velocity on ultrasound)^ • Inappropriate uterine growth (size-date discrepancy). (An ultrasound read by a qualified physician constitutes a consultation)~ Fetal presentation • Breech or noncephalic presentation^ Gestational age • < 37 weeks 0 days^ • ≥42 weeks 0 days (unless already in active labor at 41 weeks 6 days)^ • Expected date of delivery (EDD) uncertain~ Hematologic conditions • Anemia with hemoglobin < 8.5 g/dL (current pregnancy)^ • Suspected or diagnosed thrombosis or thromboembolism^ • Thrombocytopenia (platelets < 100,000)^
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CONDITIONS OF CURRENT PREGNANCY • Hemoglobin < 10 g/dL, unresponsive to treatment~
Hepatic disorders • Disorders including uncontrolled intrahepatic cholestasis of pregnancy and/or abnormal liver function tests~ Hyperemesis gravidarum • Refractory~ Hypertensive disorders • Elevated blood pressure on two occasions 30 minutes apart (e.g. gestational hypertension or pregnancy-induced hypertension)^ o Systolic ≥ 140 or diastolic ≥ 90 • Elevated blood pressure on one occasion^ o Systolic ≥ 160 or diastolic ≥ 110, or o Systolic ≥ 140 or diastolic ≥ 90, with severe pre-eclampsia features • Pre-eclampsia^ • Eclampsia^ • HELLP syndrome^ Infectious conditions • HIV, Hepatitis B or syphilis positive^ • Chorioamnionitis^ • Maternal temperature ≥ 38.0 C in labor/postpartum • Genital herpes at time of labor^ • Maternal infection postpartum (e.g., endometritis, sepsis, wound) requiring hospital treatment^ • Rubella^ • Tuberculosis (other than latent)^ • Toxoplasmosis^ • Varicella (active at labor)^ Isoimmunization • Blood group incompatibility and/or Rh sensitization in current pregnancy^ Labor management • Induction^ • Failure to progress/failure of head to engage in active labor^ • Lack of adequate progress in 2nd stage with cephalic presentation^ Miscarriage/non-viable pregnancy • Molar^ Multiple gestations • Multiple gestations^ Oligohydramnios or polyhydramnios • Oligohydramnios^ • Polyhydramnios^ Perineal laceration or obstetric anal • 3rd degree requiring hospital repair or beyond expertise of attendant^ sphincter injury • 4th degree^ • Enlarging hematoma^ Placental conditions • Low lying placenta within 2 cm or less of cervical os at 38 weeks 0 days or later^ • Placenta previa^ • Vasa previa^ • Abruption^ • Retained placenta > 60 minutes^ Psychiatric conditions • Maternal mental illness requiring psychological or psychiatric intervention~ • Patient currently taking psychotropic medications~ Renal • Acute pyelonephritis~ Substance Use • Drug or alcohol misuse with high risk for adverse effects to fetal or maternal health^ Umbilical cord • Prolapse^ Uterine condition • Anatomic anomaly (e.g. bicornuate, large fibroid impacting delivery)~ • Uterine prolapse~ • Uterine rupture, inversion^
The development of this guideline note was informed by a HERC Coverage Guidance. See https://www.oregon.gov/oha/HPA/DSI- HERC/Pages/Evidence-based-Reports.aspx.
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GUIDELINE NOTE 172, INTERVENTIONS WITH MARGINAL CLINICAL BENEFIT OR LOW COST-EFFECTIVENESS FOR CERTAIN CONDITIONS Line 502 The following interventions are prioritized on Line 502 CONDITIONS
[Note: Only new or revised entries to the table are shown here]
Procedure Code Intervention Description Rationale Last Review 45391-45392 Colonoscopy, flexible; with endoscopic More costly than equally effective tests January 2005 ultrasound examination
74263, 81528, Screening CT Colonography, Insufficient evidence for use in September, 2017 81327 FIT-DNA (Cologuard), population screening mSEPT9, Chromoscopy August 2020
99174, 99177 Photoscreening More costly than equally effective May 2019 methods of screening
GUIDELINE NOTE 173, INTERVENTIONS THAT ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS FOR CERTAIN CONDITIONS Line 662 The following Interventions are prioritized on Line 662 CONDITIONS FOR WHICH CERTAIN INTERVENTIONS ARE UNPROVEN, HAVE NO CLINICALLY IMPORTANT BENEFIT OR HAVE HARMS THAT OUTWEIGH BENEFITS:
[Note: Only new or revised entries to the table are shown here]
Procedure Code Intervention Description Rationale Last Review K1002 Cranial electrotherapy stimulation system No clinically important benefit (CES) March 2020 (CES) for chronic pain; insufficient evidence of effectiveness for all othe indications
S8948 Low level laser therapy and all similar Insufficient evidence of effectiveness August 2020 therapies
20696-20697 Application of multiplane (pins or wires in Insufficient evidence of effectiveness January 2009 more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame)
20979 Low intensity ultrasound stimulation to aid Insufficient evidence of effectiveness February 2000 bone healing, noninvasive (nonoperative)
21685 Hyoid myotomy and suspension Insufficient evidence of effectiveness December 2003
27080 Coccygectomy, primary No evidence of effectiveness November 2000
28890 Extracorporeal shock wave, high energy Insufficient evidence of effectiveness December 2005 involving the plantar fascia
29866-29867 Arthroscopy, knee, surgical; osteochondral Insufficient evidence of effectiveness November 2007 autograft(s)/allograft(s) (eg, mosaicplasty)
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Procedure Code Intervention Description Rationale Last Review 29868 Arthroscopy, knee, surgical; meniscal Insufficient evidence of effectiveness November 2007 transplantation
33140-33141 Transmyocardial laser revascularization, by Insufficient evidence of effectiveness February 2000 thoracotomy
33548 Surgical ventricular restoration procedure, Insufficient evidence of effectiveness December 2005 includes prosthetic patch, when performed (eg, ventricular remodeling, SVR, SAVER, Dor procedures)
36455 Exchange transfusion, blood; other than Insufficient evidence of effectiveness November 2016 newborn
36456 Partial exchange transfusion, blood, plasma Added to services recommended for November, 2016 or crystalloid necessitating the skill of a Non Coverage file physician or other qualified health care professional, newborn
41530 Submucosal ablation of the tongue base, Insufficient evidence of effectiveness December 2008 radiofrequency
50380 Renal autotransplantation, reimplantation of Insufficient evidence of effectiveness November 2000 kidney
50592 Radiofrequency ablation, 1 or more renal Insufficient evidence of effectiveness December 2005 tumor(s)
58565 Hysteroscopy, surgical; with bilateral Risk outweighs benefits August 2020 fallopian tube cannulation to induce occlusion by placement of permanent implants
62263 Percutaneous lysis of epidural adhesions Insufficient evidence of effectiveness February 2000 using solution injection (eg, hypertonic saline, enzyme) or mechanical means
62290-62292 Discography Insufficient evidence of effectiveness August 2007
72285, 72295
64479-64480 Transforaminal epidural steroid injections, Insufficient evidence of benefit March, 2015 or diagnostic anesthetic injections, cervical and thoracic spine Coverage guidance; August 2020
64632 Destruction by neurolytic agent; plantar Insufficient evidence of effectiveness March 2020 common digital nerve
64640 Destruction by neurolytic agent; other Insufficient evidence of effectiveness March 2020 peripheral nerve or branch
70554 Functional MRI Insufficient evidence of effectiveness May 2019
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Procedure Code Intervention Description Rationale Last Review 74263, 81528, Screening CT colonography, FIT-DNA Insufficient evidence for use in September 2017; 81327 (Cologard), mSEPT9, Chromoscopy population screening August 2020 (Cologard)
77061-77063 Digital breast tomosynthesis No evidence of effectiveness March 2017 Coverage Guidance
83037 Hemoglobin; glycosylated (A1C) by device Insufficient evidence of effectiveness January 2006 cleared by FDA for home us3
83631 Lactoferrin, fecal; quantitative Insufficient evidence of effectiveness January 2006
83695 Lipoprotein (a) Insufficient evidence of effectiveness January, 2014
83698 Lipoprotein-associated phospholipase A2 Insufficient evidence of effectiveness October 2013 (Lp-PLA2)
83700-87004 Lipoprotein, blood Insufficient evidence of effectiveness October 2006
83861 Tear osmolarity Insufficient evidence of effectiveness December 2010
83951 Oncoprotein; des-gamma-carboxy- Insufficient evidence of effectiveness August 2008 prothrombin (DCP)
86356 Mononuclear cell antigen, quantitative (eg, Insufficient evidence of effectiveness December 2007 flow cytometry
87905 Infectious agent enzymatic activity other Insufficient evidence of effectiveness August 2008 than virus (eg, sialidase activity in vaginal fluid)
88740 Hemoglobin, quantitative, transcutaneous, Insufficient evidence of effectiveness August 2008 per day; carboxyhemoglobin
88741 Hemoglobin, quantitative, transcutaneous, Insufficient evidence of effectiveness August 2008 per day; methemoglobin
90845 Psychoanalysis No longer used in clinical practice November 2017
91040 Esophageal balloon distension study Evidence of ineffectiveness December 2004
91117 Colon motility (manometric) study Insufficient evidence of effectiveness December 2010
91120 Rectal sensation, tone, and compliance test Insufficient evidence of effectiveness December 2004
93571-93572 Intravascular Doppler velocity and/or Insufficient evidence of effectiveness January 2008 pressure derived coronary flow reserve measurement
93890-93893 Transcranial Doppler study of the Insufficient evidence of effectiveness December 2004 intracranial arteries
95928-95929 Central motor evoked potential study Insufficient evidence of effectiveness December 2004
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Procedure Code Intervention Description Rationale Last Review
97014, 97032, Transcutaneous electrical nerve stimulation Insufficient evidence of effectiveness January 2020 0278T, (TENS), frequency specific microcurrent for chronic pain and all other therapy, microcurrent electrical stimulation, indications E0720, E0730, and all similar therapies; Scrambler therapy; G0283 all similar transcutaneous electrical neurostimulation therapies
97035 Application of a modality to 1 or more areas; Insufficient evidence of effectiveness June 2011 ultrasound
97533 Sensory integrative techniques to enhance Insufficient evidence of effectiveness August 2010 sensory processing and promote adaptive responses to environmental demands
GUIDELINE NOTE 185, YTTRIUM-90 THERAPY Line 315 Yttrium 90 therapy is only included on this line for treatment of hepatocellular carcinoma (HCC) and only when recommended by a multidisciplinary tumor board or team in the following circumstances: A) Downsizing tumors in patients who could become eligible for curative treatment (transplant, ablation, or resection), OR B) Palliative treatment of incurable patients with unresectable or inoperable tumors that are not amenable to ablation therapy and 1) who have good liver function (Child-Pugh class A or B) and 2) good performance status (ECOG performance status 0-2), and 3) who have intermediate stage disease with tumors > 5 cm OR advanced stage HCC with unilateral (not main) portal vein tumor thrombus
Pretreatment mapping is included on this line, however, pre-treatment embolization is not included on this line due to insufficient evidence of effectiveness.
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New and Deleted Coding Specifications for the October 1, 2020 Prioritized List of Health Services
Line: 292 Condition: NEUROLOGICAL DYSFUNCTION IN POSTURE AND MOVEMENT CAUSED BY CHRONIC CONDITIONS (See Coding Specification Below) (See Guideline Notes 6,170,178)
Chemodenervation with botulinum toxin injection (CPT 64642-64647) is included on this line for treatment of upper and lower limb spasticity (ICD-10-CM codes G24.02, G24.1, G35, G36.0, I69.03- I69.06 and categories G71, and G80-G83.) CPT codes 62320-3 are only included on Lines 71 and 292 for trials of antispasmodics in preparation for placement of a baclofen pump. ICD-10-CM R62.0 is included on Lines 292, 345 and 377 for children 8 and under. ICD-10-CM F88 is included on these lines for developmental delay. When it is used to indicate sensory integration disorder or sensory processing disorder, it is included on Line 661.
Line: 661 Condition: MISCELLANEOUS CONDITIONS WITH NO OR MINIMALLY EFFECTIVE TREATMENTS OR NO TREATMENT NECESSARY (See Coding Specification Below)
F88 is included on Line 661 when it is used to indicate sensory integration disorder or sensory processing disorder. When F88 is used for developmental delay, it is included on Lines 292, 345 and 377].
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ATTACHMENT G Errata & Revisions to the August 14, 2020 Prioritized List
1) On 8/26/20, the following change was made: a. The coding specification for F88 discussed in the 8/13/20 HERC meeting was amended to read:
“F88 is included on line 661 when used to indicate sensory integration disorder or sensory processing disorder. When F88 is used for developmental delay, it is included on lines 292, 345, and 377.”
2) On 8/20/2020, the following change was made: a. Guideline note D27 SARS-COV-2 (COVID-19) TESTING was amended to include CPT codes 86408 and 86409 to the list of covered diagnostic antibody testing procedures.
DIAGNOSTIC GUIDELINE D27, SARS-COV-2 (COVID-19) TESTING Testing for SARS-CoV-2 (COVID-19) virus RNA or viral antigen is a covered diagnostic service.
Antibody testing for SARS-CoV-2 (COVID-19; CPT 86408, 86409, 86328 or 86769) is covered as diagnostic only when such testing meets the following criteria: A) Testing is done using tests that have FDA Emergency Use Authorization (EUA) or FDA approval; AND B) Testing is used as part of the diagnostic work up of multisystem inflammatory syndrome in children (MIS-C) for hospitalized persons under the age of 21.
3) On 8/19/2020, the following change was made: a. Correct the line numbers in guideline note 67 BROW PTOSIS, removing it from line 455 URINARY INCONTINENCE and placing it on line 471 ACQUIRED PTOSIS AND OTHER EYELID DISORDERS WITH VISION IMPAIRMENT.
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ATTACHMENT H October 2020 -Errata
1) 38 ICD-10-CM sequela codes (ending in S) were removed from lines and recommended for placement Informational file (these codes are not eligible for payment when billed as a primary diagnosis). See Table 1 below. 2) ICD-10-CM code E70.89 (Other disorders of aromatic amino-acid metabolism) was removed from Line 300 CLEFT PALATE AND/OR CLEFT LIP and added to line 377 DYSFUNCTION RESULTING IN LOSS OF ABILITY TO MAXIMIZE LEVEL OF INDEPENDENCE IN SELF-DIRECTED CARE CAUSED BY CHRONIC CONDITIONS THAT CAUSE NEUROLOGICAL DYSFUNCTION to correct a typographical error. 3) The coding specification for F88 (Other disorders of psychological development) discussed in the 8/13/20 HERC meeting was amended to read:
“F88 is included on line 661 when used to indicate sensory integration disorder or sensory processing disorder. When F88 is used for developmental delay, it is included on lines 292, 345, and 377.”
4) Guideline note D27 SARS-COV-2 (COVID-19) TESTING was amended to include CPT codes 86408 and 86409 to the list of covered diagnostic antibody testing procedures:
DIAGNOSTIC GUIDELINE D27, SARS-COV-2 (COVID-19) TESTING Testing for SARS-CoV-2 (COVID-19) virus RNA or viral antigen is a covered diagnostic service.
Antibody testing for SARS-CoV-2 (COVID-19; CPT 86408, 86409, 86328 or 86769) is covered as diagnostic only when such testing meets the following criteria: A) Testing is done using tests that have FDA Emergency Use Authorization (EUA) or FDA approval; AND B) Testing is used as part of the diagnostic work up of multisystem inflammatory syndrome in children (MIS-C) for hospitalized persons under the age of 21.
5) Additional corrections: a. Guideline Note 67 BROW PTOSIS erroneously linked with line 455 URINARY INCONTINENCE instead of line 471 ACQUIRED PTOSIS AND OTHER EYELID DISORDERS WITH VISION IMPAIRMENT. This was corrected.
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ATTACHMENT H October 2020 -Errata
Table 1 Codes moved to informational file
Code Description M80.0AXS Age-related osteoporosis with current pathological fracture, other site, sequela M80.8AXS Other osteoporosis with current pathological fracture, other site, sequela S20.213S Contusion of bilateral front wall of thorax, sequela S20.214S Contusion of middle front wall of thorax, sequela S20.223S Contusion of bilateral back wall of thorax, sequela S20.224S Contusion of middle back wall of thorax, sequela S20.303S Unspecified superficial injuries of bilateral front wall of thorax, sequela S20.304S Unspecified superficial injuries of middle front wall of thorax, sequela S20.313S Abrasion of bilateral front wall of thorax, sequela S20.314S Abrasion of middle front wall of thorax, sequela S20.323S Blister (nonthermal) of bilateral front wall of thorax, sequela S20.324S Blister (nonthermal) of middle front wall of thorax, sequela S20.343S External constriction of bilateral front wall of thorax, sequela S20.344S External constriction of middle front wall of thorax, sequela S20.353S Superficial foreign body of bilateral front wall of thorax, sequela S20.354S Superficial foreign body of middle front wall of thorax, sequela S20.363S Insect bite (nonvenomous) of bilateral front wall of thorax, sequela S20.364S Insect bite (nonvenomous) of middle front wall of thorax, sequela S20.373S Other superficial bite of bilateral front wall of thorax, sequela S20.374S Other superficial bite of middle front wall of thorax, sequela T40.411S Poisoning by fentanyl or fentanyl analogs, accidental (unintentional), sequela T40.412S Poisoning by fentanyl or fentanyl analogs, intentional self-harm, sequela T40.413S Poisoning by fentanyl or fentanyl analogs, assault, sequela T40.414S Poisoning by fentanyl or fentanyl analogs, undetermined, sequela T40.415S Adverse effect of fentanyl or fentanyl analogs, sequela T40.416S Underdosing of fentanyl or fentanyl analogs, sequela T40.421S Poisoning by tramadol, accidental (unintentional), sequela T40.422S Poisoning by tramadol, intentional self-harm, sequela T40.423S Poisoning by tramadol, assault, sequela T40.424S Poisoning by tramadol, undetermined, sequela T40.425S Adverse effect of tramadol, sequela T40.426S Underdosing of tramadol, sequela T40.491S Poisoning by other synthetic narcotics, accidental (unintentional), sequela T40.492S Poisoning by other synthetic narcotics, intentional self-harm, sequela T40.493S Poisoning by other synthetic narcotics, assault, sequela T40.494S Poisoning by other synthetic narcotics, undetermined, sequela T40.495S Adverse effect of other synthetic narcotics, sequela T40.496S Underdosing of other synthetic narcotics, sequela
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