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Change Change for Routine Gynecological Exams Billing for Neonatal Hearing Screening Should be Directed to Facility Anesthesia Claims Update Gardasil® Approved by the FDA Clarifications to the Intensity Modulated Therapy Radiation Policy Policy Update Policy (CGPU) Update Compendium AmeriHealth Develops Claim and Payment Medical Policies? Assist in Developing Medical Policies ICD-9 CM Diagnosis Codes About the What are the Primary Reasons that Needed to Physician Volunteers d/b/a AmeriHealth Insurance • Company QCC • InsuranceInc. AmeriHealth Company, AmeriHealth Insurance HMO, Company of New Jersey Table of Table Co Introduction Experimental/Investigational Medical Certain Medical Claim 2006

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history, condition, and proposed course course proposed and condition, history, member’s the as well as treatment of should Providers program. benefit review Bulletins Policy with Members as treatment options are discussed, as the Bulletins Policy are designed to be used by our professional staff in making coverage determinations and can be highly technical. Information contained in this document and the actual Policy Bulletin does not constitute an or offermedical of advice, coverage, guarantee of if there is that, a conflict between the Bulletin Policy and a member’s the terms benefit program, of the benefit program will govern. Please note that providers who opted out of the class action settlement may not be entitled to certain claim Therefore, payment policy changes. any payments made pursuant to such policy changes to providers who opted out of the class action settlement are subject to adjustments. retroactive Important Note: The medical policies referenced in this document apply to all and PPO products POS, of HMO, including AmeriHealth, its affiliates, as well as to traditional indemnity products to the extent the applicable covered services are underwritten by AmeriHealth or its affiliates. This document was developed to assist AmeriHealth in administering the and does not constitute medical providers Professional are advice. responsible for providing medical Even advice though and treatment. this document may conclude that a particular service or item is medically such conclusion is NOT necessary, based upon the terms of a particular Members must benefit member’s plan. refer to their specific benefit program limitations for conditions, the terms, and exclusions of coverage. Please note that the Bulletins Policy which are referenced herein describe the status of a specific topic at the time the Bulletin Policy was created. Bulletins Policy are updated biennially and when new medical evidence they are therefore, becomes available, subject to change. Policy actual the that aware be Please Bulletins which are discussed herein Coverage are used as a guide only. a case-by-case on made are decisions basis by applying Bulletin Policy criteria to the medical member’s

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INTRODUCTION

About the Coding Guidelines and What Are the Primary Reasons That Policy Update (CGPU) Compendium AmeriHealth Develops Claim Payment and Medical Policies? Over the past year, AmeriHealth has published four Coding Guidelines and Policy Update (CGPU) newsletters. Some of the primary reasons that AmeriHealth develops claim payment and medical policy are to: This 2006 Coding Guidelines and Policy Update Compendium is a collection of relevant policy summaries that have been • Comply with legislation (e.g., federal, state, and local published in CGPU during the past year. We are not able to legislative mandates). reproduce all of the CGPU summaries in the Compendium • Correspond to national or local Medicare Carrier because some policies have undergone updates and revisions Coverage Policy. since their initial publication in CGPU; however, these updated policies will appear in future issues of CGPU. We • Allow consistent interpretation and application of encourage you to visit www.amerihealth.com/providers for benefits. expanded, up-to-date versions of each policy. • Respond to requests for new, emerging technology or In addition to the descriptions of policies previously changes in existing technology. published in the CGPU, the Compendium has also expanded • Ensure a relevant and timely scheduled review of the normal CGPU parameters to include articles on coding existing policies. and policy, plus a section detailing new, revised, and deleted • CPT®*, HCPCS, and ICD-9 CM codes. Provide claims submission policies and procedures.

ThisCompendium contains information that you can Physician Volunteers Needed to Assist immediately adopt within your practice to simplify your information retrieval and claims submission processes. in Developing Medical Policies

*Current Procedural Terminology (CPT®) is a copyright of the American Medical AmeriHealth is currently recruiting physicians to join our Association (AMA). All Rights Reserved. No fee schedules, basic units, relative Policy Committee Advisory Panel. This panel is responsible values, or related listings are included in the CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to for evaluating the scientific evidence and local standards of government use. CPT® is a trademark of the AMA. care addressed in our medical policies. Medical policies are research-based documents that allow AmeriHealth to evaluate the medical necessity of services, devices, biologics, and procedures for its members. In addition, medical policies provide guidelines for obtaining benefits and reimbursement in accordance with a member’s plan. As a volunteer consultant on the Policy Committee Advisory Panel, you will evaluate proposed medical policies based on your area(s) of expertise. As such, your contributions Visit www.amerihealth.com/medpolicy to get the most current, will significantly impact the care of patients in your region. in-depth and up-to-date information on policies affecting health care in your region. Review and accept the terms & At this time, AmeriHealth is seeking physician consultants in conditions, and you can quickly and easily search all active the following specialties: policies. Bookmark this site and check back regularly for the • Neurosurgery latest information and updates. • Orthopedics • The 2006 CGPU Compendium can be found at Urology • www.amerihealth.com/providers/communications. You Vascular Surgery • can also check the website to find specific billing codes, Physical Medicine and Rehabilitation in-depth descriptions of services, or other policy-related data. • Rheumatology • Cardiology • Gastroenterology www.amerihealth.com/providers/communications • Pain Medicine

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To qualify as a member of the Policy Committee Advisory Panel, you must: • Maintain board certification for each specialty or subspecialty for which you wish to consult. • Maintain an active clinical practice in each specialty or subspecialty for which you wish to consult. • Understand and agree to adhere to our confidentiality statement. • Maintain a high ethical standard, evidenced by the absence of any AmeriHealth investigation into personal or group claims practices. • Complete and sign a Conflict of Interest Statement and Confidentiality Agreement prior to becoming a member of the advisory panel.

If you meet the above criteria and have an interest in sharing your expertise as a member of the Policy Committee Advisory Panel, please submit your curriculum vitae to:

Gerald W. Peden, M.D., M.A. Senior Medical Director Claim Payment Policy Department AmeriHealth 1901 Market Street Philadelphia, PA 19103-1480

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Full descriptions of these policies are available online at: www.amerihealth.com/medpolicy.

View full policies online at www.amerihealth.com/medpolicy 2006 CGPU Compendium

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Medical Policies Covered: according to certain criteria

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Table of Contents

Ambulatory Blood Pressure Monitoring (ABPM) (07.02.09)...... 6 Blepharoplasty with or without a Brow Lift/Repair of Blepharoptosis (11.05.02c)...... 6 Bone Growth Stimulators (05.00.09c)...... 7 High-Frequency Chest Wall Oscillation Devices (05.00.14c)...... 9 Home Phototherapy for Neonatal Jaundice (07.06.02) ...... 9 Hospital Beds and Accessories (05.00.56a) ...... 10 Islet Cell Transplantation (11.04.01) ...... 12 Maze Procedure (11.02.20a) ...... 12 Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder ADHD) (07.03.03b)...... 13 Negative Pressure Wound Therapy (NPWT) Pump (05.00.38a) ...... 13 Outpatient Speech Therapy (10.06.01a) ...... 15 Reduction Mammaplasty (11.08.02c)...... 17 The Boston® Scleral Lens (07.13.11) ...... 18 Trigger Point Injections (11.14.02c) ...... 19

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Medical Policies Covered: According to Certain Criteria Ambulatory Blood Pressure Blepharoplasty with or without a Monitoring (ABPM) (07.02.09) Brow Lift/Repair of Blepharoptosis (11.05.02c) Covered: According to Certain Criteria overed ccording to ertain riteria Ambulatory blood pressure monitoring (ABPM) involves C : A C C the use of a noninvasive device that measures blood Blepharoptosis is the condition of droopiness of the upper pressure in 24-hour cycles. The device consists of a portable eyelid due to underlying eye muscle dysfunction (e.g., sphygmomanometer attached to a recording device. The levator muscle or Muller’s muscle). Surgical repair of this information it provides can help a physician determine condition, including repair of the eye muscle, is performed in whether an individual is truly hypertensive or is exhibiting conjunction with the blepharoplasty procedure. white coat hypertension (WCH). A blepharoplasty procedure includes the removal of The ABPM device is fitted to and removed from the redundant skin of the upper and/or lower eyelids and the individual by a trained technician. The sphygmomanometer removal of protruding periorbital fat. This procedure can be inflates at predetermined times, generally every 30 minutes, performed for either cosmetic or reconstructive purposes. and the blood pressure recorded at each inflation is stored. When performed for cosmetic reasons, the surgery reshapes The individual performs normal activities while wearing the eye-related structures in order to improve appearance and monitor. Automated ABPM is considered more accurate self-esteem; when provided as part of a reconstructive than individual self-monitoring. Therefore, it is generally procedure, the surgery reshapes eye-related structures in thought that readings obtained at frequent intervals order to improve functional ability. Blepharoplasty can be throughout the day and night would help the physician performed alone or in conjunction with other procedures better manage the individual’s care. These stored 24-hour such as a brow lift. measurements are later interpreted at the physician’s office. A clinician is required to interpret the collected data by Under most circumstances, a blepharoplasty with or without uploading it onto a computer where device-specific programs a brow lift and/or repair of blepharoptosis is a cosmetic are used to categorize and analyze the measurements. service and a benefit contract exclusion. However, each of these procedures is medically necessary when performed ABPM is considered medically necessary for individuals who as functional or reconstructive surgeries in certain clinical meet the definition criteria of WCH and have no evidence situations. of end-organ damage. ABPM is covered for individuals requiring 24-hour monitoring of their blood pressure to Blepharoplasty confirm the diagnosis. Blepharoplasty is medically necessary when performed to Physician interpretation is medically necessary and required correct: for reimbursement. Therefore, ABPM utilizing a system such as magnetic tape and/or computer disk, for 24 hours • Prosthetic difficulties in an anophthalmic (without an or longer, with recording only or scanning analysis with eye) socket. report only (no mention of physician interpretation), is not • Disorders of visual impairment caused by redundant eligible for separate reimbursement when billed alone or in skin of the eyelid or eyebrow that include, but are not conjunction with another service. limited to: When a primary care physician (PCP) is contracted to - Visual impairment due to dermatochalasis, provide medically necessary and preventive care services on blepharochalasis, or ptosis of the eyelid. a monthly capitation basis, this service is included in the - Symptomatic, redundant skin that is resting on the monthly capitation payment. upper lashes. Originally published in Winter 2006 CGPU. - Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper eyelid skin.

Lower eyelid blepharoplasty is generally not medically indicated to treat conditions that cause visual field

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obstruction because the lower eyelids are not usually - The upper eyelid skin rests on the eyelashes. associated with visual impairment. In the absence of visual - The upper eyelid indicates the presence of impairment, lower eyelid blepharoplasty is considered a dermatitis. cosmetic service and, therefore, not covered. - The upper eyelid position contributes to difficulty Requests for lower eyelid blepharoplasty are considered tolerating a prosthesis in an anophthalmic socket. on an individual basis when documentation (including the individual’s chief complaint and preoperative photographs) - The brow position is below the superior orbital rim. demonstrates that the procedure is medically necessary for • A written interpretation of the results of both the taped reconstructive reasons. and untaped automated visual field studies must be submitted and must demonstrate one of the following: Blepharoptosis Repair - The upper visual field has improved by at least Blepharoptosis repair is medically necessary when performed eight degrees or 20 percent with the eyelid taped as functional/reconstructive surgery to correct a visual as compared with the visual field obtained without impairment due to drooping or displacement of the upper taping (two sets of visual fields are required). eyelid. - Visual field obstruction by the eyelid limits the upper visual field to within 30 degrees of fixation. Brow Ptosis Repair If both a blepharoplasty and a brow ptosis repair are planned, Brow ptosis repair is medically necessary when performed the need for both must be documented. This requires as functional/reconstructive surgery to correct either of the photographs showing the affect of the drooping, redundant following: skin; the skin resting on the upper eyelid; the presence of • Visual impairment due to droop or displacement of the dermatitis; or the actual presence of blepharoptosis. brow. Originally published in Fall 2006 CGPU. • Brow malposition that would prevent adequate correction of dermatochalasis, blepharochalasis, or Bone Growth Stimulators (05.00.09c) blepharoptosis. Covered: According to Certain Criteria Documentation Requirements Noninvasive bone growth stimulators consist of an external power supply and externally applied coils or a transducer All requests for any of the procedures listed above require a that generate a weak electrical current through the site where letter of medical necessity that describes the individual’s chief bone growth is desired. Noninvasive devices use pulsed complaints and that justifies the need for surgery to correct electromagnetic fields (PEMFs), capacitative coupling, or the functional impairment. Additionally, when blepharoplasty combined magnetic fields technology to generate the current. is to be performed as a functional/reconstructive surgery Ultrasonic bone growth stimulators are noninvasive devices to correct visual impairment, the following additional that accelerate fracture healing by emitting low-intensity, documentation is required: pulsed ultrasound signals on the skin surface over the • Preoperative color photographs that include a view fracture site. Ultrasonic bone growth stimulators are used in of the individual: in forward gaze, looking up, and conjunction with cast immobilization. looking down, and that demonstrate one or more of the Electrical bone growth stimulators are used for nonunion following: fracture(s) of long bone, which is defined by Medicare to - The upper eyelid margin is within 2.5 mm (one- include the following: the clavicle, humerus, radius, ulna, fourth of the diameter of the visible iris) of the metacarpal, femur, tibia, fibula, malleolus, and metatarsal. corneal light reflex (margin-to-reflex distance Studies of bone growth stimulators in the treatment of fresh [MRD] less than 2.5 mm) with the individual in fractures (less than seven days) and in delayed union and primary gaze. nonunion fractures of both long and short bone indicate

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that insufficient scientific evidence exists to demonstrate • Fresh, closed fracture of the distal radius (Colles the effectiveness of electrical bone growth stimulators in fracture [813.41, 813.42]) when used as an adjunct to fresh and delayed union fractures. In addition, the safety closed reduction and cast immobilization. and effectiveness of electrical bone growth stimulators in • Nonunion fractures (733.82) of the clavicle, scapula, individuals under the age of 17 has not been established in humerus, radius, ulna, carpal, metacarpal, phalanges clinical trials. (fingers or toes), femur, patella, tibia, fibula, malleolus, Electrical bone growth stimulators (noninvasive/invasive) talus, calcaneus, cuboid, navicular, cuneiform, tarsal, are considered medically necessary and, therefore, covered metatarsal, rib(s), sternum, and pelvis. for individuals 17 years of age or older when one of the - Nonunion fracture is defined as the point at which following conditions is present: healing has stopped (three months or greater • A fracture secondary to congenital pseudarthrosis from the initial fracture) and further healing (as (755.8). evidenced by serial radiographic documentation) has ceased. • A nonunion fracture (733.82) of a long bone (includes the following: the clavicle, humerus, radius, ulna, If one or more of the following exclusion criteria exist, low- metacarpal, femur, tibia, fibula, malleolus, metatarsal). intensity ultrasonic bone growth stimulators are considered experimental/investigational and, therefore, not covered - Nonunion fracture is defined as the point at which because the safety and/or efficacy of this device for these healing has stopped (three months or greater conditions cannot be established by review of the available from the initial fracture) and further healing (as published literature: evidenced by serial radiographic documentation) has ceased. • For a fracture of the skull or vertebrae. • A failed joint fusion. • For a fracture that is tumor-related. - Post-surgical joint fusion failure is defined as • For concurrent use with any other noninvasive radiologic documentation of nonunion nine months osteogenic stimulator. or more after surgical fixation of the fracture. • In individuals under the age of 17. Electrical bone growth stimulators (noninvasive/invasive) • For a fresh fracture other than one of the tibial are considered medically necessary and, therefore, covered diaphysis or distal radius. following spinal surgery (V45.4) when one of the following criteria is met: • For a delayed union fracture (a recent fracture [three months or less from the initial fracture], where healing • A failed spinal fusion when the surgery was performed a has not advanced at the “average” rate for the location minimum of nine months from the last surgery. and type of fracture). • A multilevel spinal fusion surgery (e.g., L3-L5, L4-S1, For all other indications, electrical bone growth stimulators etc.). and low-intensity ultrasonic bone growth stimulators are • Revisional spinal fusion surgery due to a previously considered experimental/investigational and, therefore, not failed spinal fusion at the same level. covered because the safety and/or efficacy of these devices cannot be established by review of the available published Unless any exclusion criteria exists, low-intensity literature. Examples of other indications include, but are not ultrasonic bone growth stimulators (noninvasive) are limited to: individuals under the age of 17, fresh fractures considered medically necessary and, therefore, covered for (except ultrasonic stimulator use for fractures of the tibial any of the following: diaphysis or distal radius), and delayed union fractures. • Fresh (less than seven days), closed or Grade l open, Originally published in Fall 2006 CGPU. tibial diaphysis fracture (823.20, 823.30) when used as an adjunct to closed reduction and cast immobilization.

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High-Frequency Chest Wall Oscillation High-frequency chest wall oscillation devices for any Devices (05.00.14c) diagnosis other than cystic fibrosis or bronchiectasis are considered not medically necessary and, therefore, not Covered: According to Certain Criteria covered because the available published literature does not A high-frequency chest wall oscillation device is designed support the use of this device for the treatment of any other to enhance the mobilization of bronchial secretions. The diagnosis. device is an inflatable vest that is connected by two tubes to Originally published in Fall 2006 CGPU. a small air-pulse generator. Oscillating positive air pressure causes the vest to inflate and deflate up to 25 times a minute, creating a vibratory motion that aids in the mobilization of Home Phototherapy for Neonatal secretions. The action of the device creates mini-coughs that Jaundice (07.06.02) dislodge mucus from the bronchial walls, thus increasing Covered: According to Certain Criteria mobilization of the mucus toward the central airways. The oscillating action also thins the secretions and makes them Phototherapy is often used to treat neonatal jaundice and easier to remove by coughing or suctioning. High-frequency involves the continuous application of ultraviolet light via chest wall oscillation devices can be used for individuals a lamp or a fiberoptic system to a newborn for a prescribed who have cystic fibrosis or bronchiectasis and require chest period of time. The fiberoptic system consists of a pad of physiotherapy, manual chest percussion, postural drainage, woven fibers that transport light from a light source to the and device-assisted coughing to help them clear their lungs. baby. This covered fiberoptic pad is placed directly against the baby to bathe the skin in light. Phototherapy uses blue A four- to six-week trial of a high-frequency chest wall wavelengths of light to convert the bilirubin to less toxic oscillation device is considered medically necessary and, water-soluble photoisomers, which are then excreted in bile therefore, covered for the treatment of individuals with and urine. Phototherapy can be administered in a hospital a documented history that confirms a failure of standard or home setting (home phototherapy). It is important to treatments (e.g., manual chest percussion, postural drainage) note that the use of phototherapy in the home setting is to adequately mobilize retained bronchial secretions and one contraindicated in the presence of risk factors. of the following diagnoses: Home phototherapy devices do not consistently provide the • Cystic fibrosis. same degree of irradiance as those available in the hospital. • Bronchiectasis, confirmed by computed tomography Due to the questionable efficiency of home phototherapy (CT) scan, and documentation of one of the following: for neonatal jaundice, the American Academy of Pediatrics states that home phototherapy is considered inappropriate for - Daily productive cough for at least six continuous infants with higher bilirubin concentrations. months. - Frequent (i.e., more than two per year) exacerbations Home phototherapy is considered medically necessary of respiratory infection requiring antibiotic therapy. for full-term newborns who are diagnosed with neonatal jaundice and have none of the risk factors, major or minor, Continued coverage of the device after the trial is considered that have been identified by the American Academy of medically necessary and, therefore, covered when the Pediatrics.* effectiveness of the device has been demonstrated by: The following are major risk factors that have been identified • Documentation that the device has been used daily or as by the American Academy of Pediatrics for the development prescribed. of severe hyperbilirubinemia in infants of 35 weeks or more • Documentation of increased expectoration of mucus. gestation: • If the trial of the device is successful and the individual Predischarge total serum bilirubin (TSB) or wishes to continue using the device, continued authorization transcutaneous bilirubin (TcB) level in the high-risk for the device must be obtained. The ordering physician must zone. provide a letter of medical necessity to the Company stating • Jaundice observed within the first 24 hours. compliance with the above requirements.

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• Blood group incompatibility with positive direct relation to the individual’s condition include trapeze bars, bed antiglobulin test, other known hemolytic disease cradles, or side rails. (e.g., glucose-6-phosphate-dehydrogenase [G6PD] deficiency), elevated end tidal carbon monoxide Medically Necessary (ETCOc). Fixed-height Hospital Beds • Gestational age 35-36 weeks. • A fixed-height hospital bed (E0250, E0251, E0290, E0291) Previous sibling received phototherapy. is medically necessary when the individual meets one or more • Cephalohematoma or significant bruising. of the following medical necessity criteria: • Exclusive breastfeeding, particularly if nursing is not • The individual has a medical condition that requires going well and weight loss is excessive. positioning of the body in ways that are not feasible in an ordinary bed. The elevation of the head/upper body • East Asian race. of less than 30 degrees does not usually require the use The following are minor risk factors identified by the of a hospital bed. American Academy of Pediatrics for the development of • The individual requires head elevation of more than 30 severe hyperbilirubinemia in infants of 35 weeks or more degrees most of the time due to congestive heart failure gestation: (CHF), problems with aspiration, or chronic pulmonary • Predischarge TSB or TcB level in the high intermediate- disease. Pillows or wedges must have been considered risk zone and ruled out. • Gestational age 37-38 weeks • The individual requires positioning of the body in ways that are not feasible in an ordinary bed to alleviate pain. • Jaundice observed before discharge • The individual requires traction equipment, which can • Previous sibling with jaundice only be attached to a hospital bed. • Macrosomic infant of a diabetic mother Variable-height Hospital Beds • Maternal age of 25 years or more A variable-height hospital bed (E0255, E0256, E0292, • Male gender E0293) is medically necessary for individuals with severely *Reproduced with permission from Pediatrics, Vol. 114, Pages 297-316, debilitating diseases and conditions (including, but not Copyright © 2004 by the American Academy of Pediatrics (AAP). limited to severe cardiac conditions, spinal cord injuries, amyotrophic lateral sclerosis [ALS], and multiple sclerosis) Originally published in Winter 2006 CGPU. when all of the following apply:

Hospital Beds and Accessories • The individual meets one or more of the medical necessity criteria for a fixed-height hospital bed. (05.00.56a) • The individual requires a bed height that cannot be overed ccording to ertain riteria C : A C C attained with a fixed hospital bed and that allows them A hospital bed is a bed with head and leg elevation and to be transferred to a chair, wheelchair, or standing height adjustment features that are used to assist individuals position. who require adjustment or repositioning to alleviate pain, Semi-Electric Hospital Beds prevent contractures, prevent respiratory infections, and to allow individuals to transfer to and from bed with increased A semi-electric hospital bed (E0260, E0261, E0294, E0295) independence. is medically necessary when the individual meets one or more of the medical necessity criteria for a fixed-height hospital Hospital bed accessories are additions to a bed that are not bed and both of the following criteria: provided as part of the original bed. Accessories that may be • needed for the essential functioning of the hospital bed in The individual’s condition requires that their body position be changed frequently and/or that their body

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position may be changed immediately when necessary necessity requirement for the specified bed and meets the (i.e., no delay can be tolerated). additional criteria as indicated below: • The individual is able to operate the controls and cause • Bed cradle (E0280): When the individual has a medical the adjustments. Exceptions to this requirement can condition that requires the prevention of contact with be made in cases of spinal cord injury (SCI) and brain bed coverings (i.e., burns, diabetic ulcers, gout). injury. • Trapeze equipment (E0910, E0940): When the Heavy-duty Hospital Beds individual requires this device to do any one of the following: A heavy-duty hospital bed (E0301, E0303) is medically necessary when the individual meets one or more of the - Sit up because of a respiratory condition. medical necessity criteria for a fixed-height hospital bed and - Change body position for other medical reasons. when the individual’s weight exceeds 350 pounds but is less than 600 pounds. - Get in or out of bed.

Extra-heavy-duty Hospital Beds • Heavy-duty trapeze equipment (E0911, E0912): When the individual meets both of the following criteria: An extra-heavy-duty hospital bed (E0302, E0304) is - The individual meets the criteria for regular trapeze medically necessary when the individual meets one or more equipment. of the medical necessity criteria for a fixed-height hospital bed and when the individual’s weight exceeds 600 pounds. - The individual weighs more than 250 pounds.

Pediatric Hospital Beds • Side rails (E0305, E0310): When the individual’s condition requires that they have bed side rails and the A pediatric hospital bed is medically necessary when the rails are a part of or an accessory to the hospital bed. individual meets all of the medical necessity criteria for one of the hospital beds specified above. Not Medically Necessary The following hospital bed accessory is considered not Not Medically Necessary medically necessary: Total Electric Hospital Beds • Trapeze bars (E0910, E0911) will be considered not medically necessary and, therefore, not covered when A total electric hospital bed (E0265, E0266, E0296, E0297) they are used on an ordinary bed. is considered not medically necessary and, therefore, not covered because the electric height adjustment feature does Not Primarily Medical In Nature (Benefit Exclusion) not aid in the treatment of the individual’s condition. • Safety enclosures (E0316) (nylon netting that encloses Institutional Hospital Beds the top and sides of a hospital bed) are considered benefit exclusions and, therefore, not covered as these An institutional hospital bed (E0270) is considered not devices are not primarily medical in nature. Additionally, medically necessary and, therefore, not covered because it these devices have safety concerns associated with them. is deemed inappropriate for home use. These beds include For Medicare members, safety enclosures are considered oscillating beds, circulating beds, and Stryker frame beds. not medically necessary, and, therefore, not covered; these devices have safety concerns associated with them. Hospital Bed Accessories • A bed board (E0273, E0315) (a device placed under a Medically Necessary mattress to make the mattress firmer) is considered a benefit exclusion and, therefore, not covered because its The following hospital bed accessories are considered use is not primarily medical in nature. medically necessary when the individual meets the medical • An over bed table (E0274, E0315) is considered a benefit exclusion and, therefore, not covered because its use is not primarily medical in nature.

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Islet Cell Transplantation (11.04.01) Maze Procedure (11.02.20a) Covered: According to Certain Criteria Covered: According to Certain Criteria Islet cell transplant tissue comes from either the patient The Maze procedure is a surgical procedure intended to (autologous transplant) or from a cadaveric donor restore normal heart rhythm in individuals afflicted with (allogeneic transplant). Islet cell transplantation may benefit atrial fibrillation or atrial flutter that does not respond to an individual who does not have a functioning pancreas. medical therapy. It can be performed alone or in conjunction Currently only individuals with either chronic pancreatitis with other cardiac surgeries for restoring the normal or type 1 diabetes mellitus have been the subject of clinical electrical impulses of the heart. The procedure is done under investigations. general anesthesia while the individual is on cardiopulmonary bypass (a machine that performs the functions of the heart Autologous islet transplantation is a technique to prevent and lungs during the surgery). Access to the heart is obtained the serious morbidity of surgical induced diabetes due to through a sternal incision. The cardiothoracic surgeon then the removal of the individual’s pancreas. Although the makes several incisions in the right and left atria of the heart pancreatectomy and transplant can be performed on two to create a pathway (maze) for the electrical impulses to different days, the transplant is generally performed during flow, thus restoring the normal rhythm of the heart. These the pancreatectomy procedure. During the pancreatectomy, a incisions create a direction for the impulse to flow from the suspension is created by mixing plasma and the isolated islet sinoatrial (SA) node to the atrioventricular (AV) node and cells collected from the individual’s own resected pancreatic block the re-entry of impulses that result in atrial fibrillation specimen. This suspension is then injected into the portal or atrial flutter. vein of the liver, where the cells function as a free graft. There is no risk of rejection because, unlike allogeneic organ/tissue Results may not be evident immediately due to cardiac transplants, the individual’s own islet cells are used in the swelling, and some individuals may experience temporary procedure. fibrillation up to three months following the procedure. The fibrillation normally stops after the heart has had time to heal Autologous islet cell transplantation is considered medically completely. necessary and, therefore, covered as an adjunct to a total or near-total pancreatectomy in individuals with chronic The Maze procedure is considered medically necessary and, pancreatitis. therefore, covered for the treatment of atrial fibrillation or atrial flutter in individuals with any of the following clinical Autologous islet cell transplantation is considered indications: experimental/investigational for all other indications because • the safety and/or efficacy of this service cannot be established Resistance to drug therapy. by review of the available published literature. Therefore, this • Intolerance of drug therapy. service is not covered. • Atrial fibrillation or atrial flutter for more than six Allogeneic islet cell transplantation is considered months with an enlarged left atrium. experimental/investigational for all indications because the • safety and/or efficacy of this service can not be established High risk for thromboembolism (i.e., previous by review of the available published literature. Therefore, this thromboembolism or long-standing atrial fibrillation service is not covered. with mitral valve disease).

Originally published in Winter 2006 CGPU. Originally published in Spring 2006 CGPU.

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Medical Evaluation and Management Experimental/Investigational for Attention-Deficit Hyperactivity Disorder (ADHD) (07.03.03b) Nontraditional treatments for ADHD lack validation and scientific support and are, therefore, considered Covered: According to Certain Criteria experimental/investigational and are not covered. Examples of nontraditional treatments for ADHD include: Evaluation • Sensory integration therapy. All of the following are considered medically necessary and, • therefore, covered for the medical evaluation of attention- Optometric vision training (orthoptic/pleoptic). deficit hyperactivity disorder (ADHD): • Interactive metronome training (a computerized version • A complete physical examination within the last 12 of keeping the beat, which provides auditory feedback). months (including blood tests such as lead levels • Chiropractic therapy. and quantitative plasma amino acid assays to detect phenylketonuria). Originally published in Summer 2006 CGPU. • A comprehensive medical history. Negative Pressure Wound Therapy • Interviews with the parents and child to establish (NPWT) Pump (05.00.38a) problem pattern of behavior and parent-child and child-peer conflicts. Covered: According to Certain Criteria

Neuropsychological testing for the evaluation of a previously Negative pressure wound therapy (NPWT), also known diagnosed ADHD is considered not medically necessary and, as vacuum-assisted closure, is the application of controlled therefore, not covered. It should only be performed if there is negative pressure (vacuum pressure) to a wound using an a suspicion of a neurological deficit that requires additional electrical pump. The NPWT vacuum pressure pump is used evaluation. to apply from 25 mm to greater than 200 mm Hg of pressure to a wound, either continuously or intermittently. Management Pharmacological therapy in the management of ADHD may Medical Necessity be covered under the prescription plan when the member has A NPWT pump and the supplies necessary for its use are a pharmacy benefit. considered medically necessary and, therefore, covered for Not Medically Necessary chronic nonhealing wounds (of at least 30 days duration) as specified below when all of the following applicable Nontraditional treatments for ADHD such as, but not conditions are met: limited to, the following, have not shown positive health • outcomes and are, therefore, considered not medically For chronic nonhealing ulcers or wounds, all of the necessary and are not covered: following program measures should apply or be considered and ruled out by an eligible health care • Elimination diets (e.g., Feingold diet). professional prior to the application of a NPWT pump: • Nutritional supplements (e.g., megadoses of vitamins). - Any wound-specific therapeutic measures. • Antifungal therapy. - Documentation in the individual’s medical record • Electroencephalogram (EEG) biofeedback. of the evaluation, wound measurements (length, depth, and width), and general care performed and • Antimotion sickness medication. documented by a health care professional. • Spinal manipulation. - Wound assessments are performed and documented Physical, occupational, and/or speech therapy is considered at least weekly (e.g., size [length, depth, and width], not medically necessary and, therefore, not covered in the color, exudate type and amount, odor, evidence of treatment of ADHD, unless the individual has a neurological healing, sinus tracking or tunneling, pain, type of or physical deficit that requires such therapy. dressing used). www.amerihealth.com/providers/communications 13

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- Application of dressings to maintain a moist wound cannot be achieved by topical wound treatments and is environment. a medical necessity as demonstrated by documentation of conditions such as, but not limited to, any of the - Debridement of necrotic tissue (if present) by a following: health care professional. - The presence of excessive wound drainage. - Evaluation of and provision for adequate nutritional status. - Large wounds not amenable to primary closure. • The following wound-specific therapeutic measures (if - Conditions that slow healing times (e.g., diabetes). applicable) must be applied or considered and ruled - Infection. out by an eligible health care professional prior to the application of a NPWT pump for the following specific - The wound is a chronic and nonhealing wound of at types of ulcers and wounds: least 30 days duration. - For Stage III or IV pressure ulcers: Initial NPWT pump treatments may begin during an inpatient stay for wounds encountered in the inpatient º The individual has been appropriately turned setting. Treatment with the NPWT pump beyond the and positioned. inpatient stay may continue (upon discharge) in the home º The individual has used a group 2 or 3 setting, subject to meeting the above medical necessity support surface for pressure ulcers on the criteria. posterior trunk or pelvis. (A group 2 or 3 support surface is not required if the ulcer Continued Coverage is not on the trunk or pelvis. For more information on support surfaces, refer to the For continuing coverage of up to four months, an eligible policy addressing this topic.) health care professional must: • º The individual’s moisture and incontinence Directly assess the wound(s) being treated with the have been appropriately managed. NPWT pump device and document findings. • - For neuropathic (e.g., diabetic) ulcers: Supervise or directly perform the NPWT pump dressing changes and document findings. º The individual has been on a comprehensive • diabetic management program. Document changes in the ulcer’s dimensions and characteristics (e.g., size [length, depth, and width], º The individual has experienced reduced color, exudate type and amount, odor, and evidence of pressure on a foot ulcer as a result of using healing) at least weekly. the appropriate modalities (such as, but not limited to, the following: total contact casts; For continued coverage beyond four months, continued removable cast walkers; half shoes; saline wet- documentation demonstrating wound healing is required and to-dry dressings; debridement of all necrotic, will be evaluated by a Company medical director. callus, and fibrous tissue; crutches). - For venous insufficiency ulcers: Not Medically Necessary º The individual has had compression bandages Treatment with an NPWT pump and supplies is considered and/or garments consistently applied. not medically necessary and, therefore, not covered when: º The individual has applied leg elevation. • Adequate wound healing has occurred. º The individual has applied ambulation. • Any measurable degree of wound healing has failed to occur over the prior month. • For complications of surgical, subacute, or traumatic wounds (e.g., postoperative flap, dehiscence, skin graft • Cancer is present in the wound. failure, traumatic amputation, gunshot wounds, or • The equipment or supplies are no longer being used for burns) when accelerated granulation tissue formation

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the individual, regardless of whether it is a result of the Medical Necessity Criteria health care professional’s orders. Speech pathology evaluation and services related to the • The eligible health care professional fails to perform and speech therapy process that are within the scope of the document the following on a weekly basis: member’s benefit contract are considered medically necessary - Direct assessment of the wound(s) being treated and, therefore, are covered when all of the following criteria with the NPWT pump. are met: • - Supervision or directly performing the ulcer/wound The evaluation is prescribed by a physician and dressing changes. performed by a speech/language pathologist who is licensed in the state where the services are being - Changes in the ulcer’s dimensions (length, depth, performed and who is certified by the American and width) at least weekly. Speech-Language-Hearing Association (ASHA). • Necrotic tissue with eschar is present if debridement has • The services must be of such a complex nature that they not been attempted. can only be performed by a speech/language pathologist. • There is a fistula to an organ or body cavity within the • The medical condition must be such that there is a vicinity of the wound. reasonable expectation that the services will bring • Untreated osteomyelitis exists within the vicinity of the about a significant improvement within a reasonable wound. time frame, regardless of whether the individual has a coexisting disorder. Supplies for NPWT • The services are provided in accordance with an ongoing plan of care specific to the diagnosis. An individual is eligible for a maximum of 15 wound care sets (A6550) per wound per month, unless there is - The plan of care should be updated at least weekly, documentation that the wound size requires more than one or more frequently as the treatment progresses, wound care set for each dressing change. An individual is and as goals change or are met. Upon request, eligible for a maximum of 10 canisters (A7000) per month, documentation must be available that shows unless there is documentation evidencing a large volume of measurable progress toward meeting the short- and drainage (90 ml of exudate/day). long-term goals outlined in the plan of care. • An NPWT pump (E2402) must be capable of The therapy is performed for a communication disorder accommodating more than one wound dressing set for that is a result of at least one of the following: multiple wounds on an individual. Therefore, more than one - Disease (e.g., Parkinson’s disease that results in E2402 billed per individual for the same time period will be increased difficulty in swallowing and speaking). denied as not medically necessary. - Surgery (e.g., surgical removal of a malignant Originally published in Fall 2006 CGPU. growth on the head or neck). - Injury (e.g., automobile accident that results in a Outpatient Speech Therapy subdural hematoma influencing the speech center (10.06.01a) and causing neurogenic stuttering or aphasia Covered: According to Certain Criteria following a cerebrovascular accident [CVA]). Speech pathology services are services that are deemed - Congenital anomalies (e.g., inborn defect of the necessary for the diagnosis of speech and language disorders. skull, cleft lip, or cleft palate). Speech therapy is the medically prescribed treatment of - Speech-language delay that is developmental in speech and language disorders due to disease, surgery, nature. injury, congenital anomalies, speech language delay, or previous therapeutic processes that result in communication or disabilities and/or swallowing disorders. • The therapy is performed for a swallowing disorder (dysphagia) that results from a condition such as, www.amerihealth.com/providers/communications 15

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but not limited to, a CVA regardless of whether a • Services that otherwise would not require the skills communication disorder also exists. of a qualified speech/language pathologist, such as treatments that maintain function by using routines and Speech therapy performed for reasons other than those listed repetitions. above is considered not medically necessary and, therefore not covered except as required by law. - Examples of these services include, but are not limited to, word drills for developmental articulation Conditions that do not Meet Medical Necessity errors, computer-based programs (e.g., Fast Criteria Forward), and procedures that may be performed by the individual, family, and/or caregivers. Conditions or situations that do not meet medical necessity criteria for speech pathology evaluation and services related Duplicate Therapy to the speech therapy process include, but are not limited to: When individuals are receiving both occupational and speech • Psychological speech delay. therapy, the therapies must provide different treatments • Behavior problems (e.g., impulsive behavior). with separate treatment plans and goals in order for each to be covered and be separately reimbursed. Otherwise, the • Except as required by law, mental retardation, autism, therapy is considered duplicate therapy and coverage and attention disorders, or pervasive developmental disorders reimbursement is only available for one therapy. (PDDs) in the absence of a documented communication co-morbidity that is amenable to speech therapy with a reasonable expectation of achieving sustainable, Benefit Limitations measurable improvement in a reasonable time frame. Limitations, frequency, and annual maximums may be - Social communication disorder is not considered a applied and vary by product or by group. Individual member medically necessary co-morbidity. benefits must be verified, as speech therapy benefits vary by product and group. • Stammering and stuttering with the following exception: Speech Therapy Services Provided in - Speech therapy is considered medically necessary Conjunction with Speech Generating Devices, and, therefore, covered for neurogenic stuttering Electronic Speech Aids, and Computer-Based caused by acquired brain damage. Programs • Programs that are primarily educational in nature or Speech generating devices including computer-based programs: that support an academic program. Speech therapy provided in association with a speech • Speech therapy for the maintenance of a chronic generating device, including a computer-based program, is condition when the therapeutic goals of a treatment considered medically necessary and, therefore, covered when plan have been achieved, no additional functional the device is considered medically necessary consistent with improvement is apparent or expected to occur, and the the applicable medical policy. provision of services for a condition ceases to be of therapeutic value. Electronic speech aids and other electronic devices for speech:

- Maintenance therapy is defined as a continuation Electronic speech aids/devices are considered medically of care and management of the individual when necessary and, therefore, covered only when an individual has the therapeutic goals of a treatment plan have been had a laryngectomy or has a nonfunctional larynx consistent achieved, no additional functional improvement is with the applicable medical policy. There are several apparent or expected to occur, and the provision of electronic speech aids/devices approved by the U.S. Food and services for a condition ceases to be of therapeutic Drug Administration (FDA) for use with speech therapy. value. This includes maintenance services that seek Speech therapy provided in association with an approved to prevent disease, promote health, and prolong and electronic speech aid/device is considered medically necessary enhance the quality of life. and, therefore, covered in accordance with the terms defined in the applicable medical policy. 16 View full policies online at www.amerihealth.com/medpolicy 2006 CGPU Compendium

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Electronic speech devices that are designed to improve • Any individual 40 years of age or older is required to fluency problems (such as stuttering) rather than aid in have a mammogram which is negative for cancer within communication disabilities are considered experimental/ the year prior to the planned surgery. investigational because the efficacy of these devices cannot When a request is made for reduction mammaplasty, be established by review of the available published literature. photographs documenting breast size are required. Therefore, these devices are not covered. Examples of these types of electronic devices include, but are not limited to: For Medicare Advantage Members only, the following • SpeechEasy ( Janus Development Group, Inc., criteria are applicable: Greenville, N.C.). Reduction mammaplasty is considered reconstructive surgery • FluencyMaster (National Medical Equipment, Inc., and medically necessary for symptomatic individuals with New Hyde Park, N.Y.). macromastia when all of the following criteria are met: • Originally published in Summer 2006 CGPU. The individual has significant symptoms that interfere with normal daily activities, including at least one of the following: Reduction Mammaplasty (11.08.02c) - Symptomatic neck, back, or shoulder pain not overed ccording to ertain riteria C : A C C related to other causes (e.g., poor posture, acute Reduction mammaplasty is a surgical procedure that excises strains, poor lifting techniques). a portion of the breast, including the skin and underlying - Significant breast pain. glandular tissue to reduce the size, shape, and weight of mammary tissue. In some selected cases (e.g., when the - Brachial plexus irritation. breasts are not too large and the skin has good elasticity), - Clinical, nonseasonal submammary intertrigo. liposuction can be utilized. However, in most cases, only fat, º not glandular breast tissue, can be successfully removed by Medicare requires that hypertrophy of breast liposuction. (611.1) be reported as the primary diagnosis, with one of the following clinical conditions For all products except Medicare Advantage, the following reported as a secondary diagnosis: criteria are applicable: □ Other specified erythematous condition Reduction mammaplasty is considered medically necessary (695.89). and, therefore, covered when all of the following medical □ Pain in joint, shoulder region (719.41). necessity criteria are met: □ Cervicalgia (723.1). • An individual has macromastia (enlargement of the breasts) or gigantomastia. □ Unspecified musculoskeletal disorders and symptoms referable to neck • Clinical symptoms of breast, neck, back, or shoulder (723.9). pain, or painful shoulder grooving are present for a minimum six-week period and have not responded to □ Pain in thoracic spine (724.1). conservative measures (e.g., support bra, exercises, heat/ □ Unspecified backache (724.5). cold treatment, non-steroidal anti-inflammatory drugs □ (NSAIDs)/muscle relaxants). Unspecified osteoporosis (733.00). □ • The individual meets the minimum specimen weight Senile osteoporosis (733.01). of breast tissue to be removed based on the individual’s □ Kyphosis (acquired) (postural) (737.10). body surface area (BSA). • The amount of breast tissue anticipated to be removed is - Simplified formula for calculation of body surface at least 350 grams per breast. area: BSA (in m2) = [height (cm)] 0.718 X [weight (kg)] 0.427 X 0.007449

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• Conservative treatment has failed. Examples of The BSL is considered medically necessary and, therefore, conservative treatment include, but are not limited to: covered to alleviate pain and photophobia for PED that have been documented as disabling and that have symptoms that - Appropriate support bra. are not significantly relieved with medical treatment. The - Conservative analgesia (NSAIDs). BSL is also considered medically necessary and, therefore, covered to improve visual acuity in individuals for whom - In individuals where obesity is a documented risk surgery is either undesirable and/or contraindicated due to factor, a legitimate, medically-based attempt to any of the following conditions: reduce and maintain weight (e.g., diet, exercise). • Stevens-Johnson disease (a syndrome of systemic, as - Appropriate medical management of intertrigo. well as more severe, mucocutaneous lesions that results Requests for reduction mammaplasty that do not meet in corneal opacities, perforations, and/or blindness). medical necessity criteria are considered cosmetic, and • Conditions that result from a chemical and/or traumatic therefore are not covered. injury. Originally published in Fall 2006 CGPU. • Postradiotherapy complications. • The Boston® Scleral Lens (07.13.11) Recurrent corneal erosion. • Congenital and/or postsurgical lid defect(s). Covered: According to Certain Criteria • Ocular cicatricial pemphigoid. A contact lens that covers the cornea and the adjacent • portion of the white of the eye (sclera) is called a scleral Exposure keratitis. contact lens and is sometimes referred to as a corneal liquid • Toxic epidermal necrolysis. bandage. • Lacrimal and/or meibomian gland obliteration or ® The BOSTON Scleral Lens (BSL), which is more deficiency. specifically termed the BOSTON® Equalens II, is the only • rigid gas-permeable scleral contact lens that is commercially Superior limbal keratoconjunctivitis. available in the U.S. and that can be post-fabricated for the • Sjögren syndrome. treatment of persistent corneal epithelial defects (PED). • Currently, it is only post-fabricated and distributed by Inflammatory corneal degeneration. the Boston Foundation for Sight in Needham, Mass. The • Neurotrophic corneal disease (e.g., corneal denervation BSL, unlike a traditional rigid gas-permeable contact lens, that is related to acoustic neuroma surgery, trigeminal is a specially designed, fluid-ventilated, gas-permeable ganglion obliteration, diabetes mellitus, herpetic scleral contact lens. It is designed to maintain a bubble- syndrome, congenital dysautonomia [Reily-Day free reservoir of oxygenated aqueous fluid over the corneal syndrome]). surface at a neutral hydrostatic pressure. Due to the fact • Corneal edema. that air bubbles are avoided, the fluid reservoir functions as a liquid corneal bandage that offers unique therapeutic Originally published in Winter 2006 CGPU. benefits for the management of severe ocular surface disease, in addition to its traditional role of masking irregular corneal astigmatism.

Although limited, compelling evidence exists that shows that the BSL is effective in alleviating pain and photophobia and improves the vision of patients with PED. In the majority of studies, the most frequent specific indication for the BSL was Stevens-Johnson syndrome. The BSL has also been shown to be effective in preventing the recurrence of PED in anesthetic corneas.

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Trigger Point Injections (11.14.02c) • Additional reimbursement will not be made for the Covered: According to Certain Criteria injection of water, saline, or local anesthetics. Trigger point injection is one of many modalities utilized in Dry needling of trigger points is considered medically the management of chronic pain. Myofascial trigger points necessary and, therefore, covered. The medical necessity are self-sustaining hyperirritative foci that may occur in any criteria for dry needling of trigger points are the same as skeletal muscle in response to strain produced by acute or those for trigger point injections. chronic overload. Originally published in Fall 2006 CGPU. Trigger point injections are considered medically necessary and, therefore, covered when performed for myofascial pain syndrome (MPS) when at least one of the following situations is present: • Noninvasive medical management (e.g., analgesics, passive physical therapy, ultrasound therapy, range-of- motion, and/or active exercises) is unsuccessful. • Joint movement is mechanically blocked, as when the coccygeus muscle is involved.

Trigger point injections are appropriate when administered to any of the following body regions: • Head. • Cervical spine. • Left upper extremities, including shoulder. • Right upper extremities, including shoulder. • Left lower extremities, including hip. • Right lower extremities, including hip. • Thoracic spine (including the trapezius and scapular areas). • Lumbosacral spine.

When a given region is injected, it is considered one injection service, regardless of the number of injections administered within that region. • It is expected that this procedure would not be performed on more than three body regions on a given date of service. • Trigger point injections for a specific body region should not be performed more frequently than once a month. - Requests for more frequent injections require additional documentation of medical necessity.

Medications listed in the coding table are eligible for separate reimbursement when used for trigger point injections that meet the medical necessity criteria listed in this policy.

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Medical Policies NOT Covered: CONSIDERED EXPERIMENTAL/ INVESTIGATIONAL

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Table of Contents

Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure (11.14.17)...... 22 Cryoablation of Neuromas (11.15.21) ...... 22 Dual-Energy X-ray Absorptiometry (DEXA) Body Composition Study (09.00.20a)...... 22 Infrared Heating Pad Systems (07.00.18a)...... 22 Intraperitoneal Hyperthermic Chemotherapy (IPHC) (11.00.13) ...... 23 Ocular Photoscreening (07.13.12)...... 23 Prolotherapy (11.14.15b)...... 24 Scintimammography (09.00.39)...... 24 Subfascial Endoscopic Perforator Surgery (SEPS) (11.02.23) ...... 24 Surgical Ventricular Restoration (SVR) (11.02.24) ...... 24 Thermography (07.02.13a) ...... 25

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Medical Policies Not Covered: Considered Experimental/Investigational Computer-Assisted Musculoskeletal Dual-Energy X-ray Absorptiometry Surgical Navigational Orthopedic (DEXA) Body Composition Study Procedure (11.14.17) (09.00.20a) Not Covered: Considered Experimental/ Not Covered: Considered Experimental/ Investigational Investigational Computer-assisted navigational orthopedic procedures A full-body DEXA is a noninvasive method for assessing use navigational systems during musculoskeletal surgery body fat and composition. It can also be combined with an to provide additional information and to further integrate additional measurement of total body water and contribute preoperative planning with how the surgery is being to a body composition assessment that is based on a four- performed. Navigational systems are typically used to compartment mode: bone, fat, dry fat-free soft tissue, and improve the placement and positioning of a prosthetic and/or water. surgical instrument during the procedure. Computer-assisted DEXA body composition study is considered experimental/ navigational orthopedic procedures can also be used as an investigational because the safety and/or efficacy of this adjunct to fixation of pelvic, acetabular, or femoral fractures service cannot be established by review of the available and as an adjunct to hip or knee arthroplasty procedures. published literature. Therefore, this service is not covered. A computer-assisted musculoskeletal surgical navigational Originally published in Spring 2006 CGPU. orthopedic procedure is considered experimental/ investigational because the safety and/or efficacy of this service cannot be established by review of the available Infrared Heating Pad Systems published literature. Therefore, this service is not covered. (07.00.18a) Originally published in Summer 2006 CGPU. Not Covered: Considered Experimental/ Investigational Cryoablation of Neuromas (11.15.21) Monochromatic infrared energy (MIRE), applied via an Not Covered: Considered Experimental/ infrared heating pad system, has been used to treat various Investigational conditions related to circulation and pain. An infrared heating pad system consists of a pad or pads containing Cryoanalgesia, also known as cryosurgery, cryolysis, mechanisms that generate infrared, or near-infrared, light cryoneurolysis, and cryoablation, uses extremely low (e.g., luminous gallium aluminum arsenide diodes) and a temperatures to produce a reversible nerve block similar power source. The pads are placed on the skin for 30 to 45 to that delivered by local anesthesia. No randomized or minutes, three times weekly, as a treatment program for controlled studies have tested cryoanalgesia specifically for diabetic neuropathy, ischemic ulcers, and/or musculoskeletal pain control of neuromas. conditions such as back, foot, or myofascial pain. No randomized, controlled studies have been conducted to assess Cryoablation of neuromas is considered experimental/ the efficacy of the technique or its long-term effects. investigational because the safety and/or efficacy of this service cannot be established by review of the available Treatment of wounds, diabetic neuropathy, and/or published literature. Therefore, this service is not covered. musculoskeletal conditions with infrared heating pad systems is considered experimental/investigational because the safety Originally published in Summer 2006 CGPU. and/or efficacy of the service cannot be established by review of the available published literature. Therefore, this service is not covered.

Originally published in Spring 2006 CGPU.

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Intraperitoneal Hyperthermic Ocular Photoscreening (07.13.12) Chemotherapy (IPHC) (11.00.13) Not Covered: Considered Experimental/ Not Covered: Considered Experimental/ Investigational nvestigational I Ocular photoscreening has been investigated as an alternative Intraperitoneal hyperthermic chemotherapy (IPHC) is a screening method to detect the risk factors for amblyopia, procedure that includes a combination of cytoreductive which include strabismus (a misalignment of the eyes in any surgery (debulking or macroscopically removing all direction), media opacities (e.g., cataracts) and refractive visible tumors) with heated chemotherapy delivered errors (e.g., myopia, hyperopia, astigmatism, presbyopia). It intraperitoneally immediately following the surgery. The is based on the principle of photorefraction, in which the extent of this surgery plays a significant role in treatment refractive state of the eye is assessed via the pattern of light because of the limited 1-3 mm penetration of cytostatic that is reflected through the pupil. drugs into the peritoneal tissue. The goal of IPHC is to Ocular photoscreening involves the use of a camera or video eliminate microscopic metastases that are too small to be system that is equipped for photoscreening. By using this identified and removed during cytoreductive surgery. It is equipment, images of the pupillary reflexes (autonomic reflex theorized that heated chemotherapy increases cytotoxicity constrictions caused by light) and red reflex (a circular red and will enhance penetration of chemotherapy into the light reflected from the retina of the eye) are obtained. The tumor. In addition, hyperthermia itself has a cytotoxic effect images can then be analyzed based on the position of the on tumor tissue. corneal light reflex, as well as the overall reflection of light IPHC has been explored in a number of studies over the from the fundus, which provides information on the child’s past 20 years. The majority of research evidence includes fixation pattern and the presence or absence of strabismus. phase II trials and case series. There are few phase III trials. Ocular photoscreening is performed in a darkened room and Also, the populations studied included only a small number requires little cooperation from the child, other than fixating of individuals with various locations of primary cancer, on a target for the duration of the photoscreening process. different stages of peritoneal carcinomatosis and varying The photographs can then be analyzed by the evaluator or degrees of success with cytoreductive surgery. Additional sent to a central laboratory for analysis by an ophthalmologist research is needed to further define the criteria used to or specially-trained personnel. Test results are typically select which individuals should receive hyperthermia, and to graded as pass, fail, or repeat photoscreening. identify the most effective drug combination for peritoneal Ocular photoscreening is considered experimental/ administration. In addition, some of the technical aspects investigational because the safety and/or efficacy of this of the procedure such as the optimal temperature of the service cannot be established by review of the current chemotherapeutic agents, the length of time for the IPHC available published literature. Therefore, this service is not perfusion, and the efficacy and safety of open and closed covered. chemoperfusion need to be determined and standardized. Originally published in Winter 2006 CGPU. IPHC in conjunction with cytoreductive surgery is considered experimental/investigational because the safety and/or efficacy of this service cannot be established by review of the available published literature. Therefore, this service is not covered.

Originally published in Winter 2006 CGPU.

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Prolotherapy (11.14.15b) service cannot be established by review of the available Not Covered: Considered Experimental/ published literature. Therefore, this service is not covered. Investigational Originally published in Summer 2006 CGPU. Prolotherapy consists of a series of intraligamentous and intratendinous injections of sclerosing agents that alleviate Subfascial Endoscopic Perforator chronic pain by inducing the proliferation of new cells. There Surgery (SEPS) (11.02.23) are three classes of proliferant solutions used in prolotherapy: Not Covered: Considered Experimental/ chemical irritants (e.g., phenol), osmotic shock agents (e.g., nvestigational hypertonic dextrose and glycerin), and chemotactic agents I (e.g., morrhuate sodium, a fatty acid derivative of cod liver Subfascial endoscopic perforator surgery (SEPS) is oil). Prolotherapy should not be confused with trigger point performed as a minimally invasive way to treat individuals injections, which relieve pain by infusing anesthetics and/or with chronic venous insufficiency of the lower extremities. anti-inflammatory agents into affected areas. Guided by ultrasound scanning, small incisions are made Prolotherapy is considered experimental/investigational into the skin that is unaffected by severe chronic venous because the safety and/or efficacy of this service cannot be insufficiency. Using endoscopic techniques, the perforating established by review of the available published literature. veins are clipped or divided by endoscopic scissors. Therefore, this service is not covered. SEPS is considered experimental/investigational because the Reporting prolotherapy using the trigger point efficacy of this procedure cannot be established by review of injection CPT® procedure code or any other code is a the available published literature. Therefore, this service is not misrepresentation of the actual service rendered. These covered. services are subject to post-payment review and audit Originally published in Summer 2006 CGPU. procedures. Originally published in Fall 2006 CGPU. Surgical Ventricular Restoration (SVR) (11.02.24) Scintimammography (09.00.39) Not Covered: Considered Experimental/ Not Covered: Considered Experimental/ Investigational Investigational Surgical ventricular restoration (SVR) is a procedure that is Scintimammography, also known as mammoscintigraphy, designed to restore or remodel the left ventricle to its normal has been proposed primarily as an adjunct to standard film spherical shape and size in individuals who have akinetic mammography using radiopharmaceutical agents (radioactive (non-moving) segments of the heart. This condition may be tracer [e.g., technetium-99m sestamibi]) to provide tumor- secondary to either dilated cardiomyopathy or postinfarction specific imaging of the breast. Scintimammography has left ventricular aneurysm. The SVR procedure is most also been proposed for the detection of axillary lymph node commonly performed after coronary artery bypass grafting metastases in individuals with breast carcinoma; however, (CABG) and may also proceed or be followed by procedures it has not been fully investigated for this purpose. There is such as mitral valve repair or replacement, endocardectomy, insufficient data comparing the use of scintimammography and cryoablation for the treatment of ventricular tachycardia. for decision-making regarding nodal dissection versus standard nodal dissection. Although scintimammography is The SVR procedure may also be referred to as ventricular currently being performed, the published medical literature remodeling or surgical anterior ventricular endocardial does not support its efficacy in differentiating malignancies restoration (SAVER). when compared with using surgical biopsy. SVR is considered experimental/investigational because the Scintimammography is considered experimental/ safety and/or efficacy of this service cannot be established by investigational because the safety and/or efficacy of this a review of the available published literature. Therefore, this service is not covered.

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Thermography (07.02.13a) Not Covered: Considered Experimental/ Investigational Thermography is the measurement of self-emanating infrared radiation that reveals temperature variations at the surface of the body. The thermographic device senses body temperature and demonstrates areas of differing heat emission by producing brightly colored patterns on a liquid crystal display. Each color represents a specific temperature level. Interpretation of these color patterns according to designated anatomic distribution is thought to aid in diagnosing a vast array of disease, such as, but not limited to, breast cancer, Raynaud’s phenomenon, headache, and reflex sympathetic dystrophy.

The American College of Radiology, the American Medical Association, and the American Academy of Neurology have all issued documents that do not recommend or endorse thermography as a diagnostic technology.

Thermography is considered experimental/investigational because the safety and/or efficacy of the service cannot be established by review of the available published literature. Therefore, this service is not covered.

Originally published in Spring 2006 CGPU.

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Claim payment Policies www.amerihealth.com

Table of Contents

Associated Services Performed in Conjunction with Dental Services Considered Eligible for Reimbursement When Certain Criteria are Met (00.01.18a)...... 28 Modifiers LT/RT: Left Side/Right Side Procedures (03.00.10)...... 28 Work Hardening and Work Conditioning is Not Covered Under Most of the Company’s Products (10.05.02)...... 29

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Claim Payment Policies

Associated Services Performed in Modifiers LT/RT: Left Side/Right Side Conjunction with Dental Services Procedures (03.00.10) Considered Eligible for Reimbursement When Certain Criteria are Met Modifiers LT/RT are used to indicate the side of the body on which a service or procedure is performed. Modifiers LT/RT (00.01.18a) do not indicate a bilateral service and should not be used to report a service or procedure that is performed bilaterally. Dental services include procedures and/or surgery that relate Modifier 50 should be used to report bilateral services or to the teeth, jaw, and/or mouth (e.g., routine cleanings, procedures. fillings). The Company has established the following guidelines for The Company covers and considers for reimbursement the appropriate reporting of Modifiers LT/RT with the charges that are associated with noncovered dental appropriate procedure codes: procedures or surgery, including anesthesia, when any of the following conditions are met: • Modifiers LT/RT should be used to identify procedures that can be performed on contralateral anatomic sites • The individual has a comorbid condition that would (e.g., bones, joints), paired organs (e.g., ears, eyes, nasal potentially increase the risk of the procedure being passages, kidneys, lungs, ovaries), or extremities (e.g., performed. arms, legs). • The individual is severely disabled. • Modifiers LT/RT should be used to indicate that the • The individual is a child. procedure is performed on only one side of the body.

• The individual’s admission to the Ambulatory Surgery It is inappropriate to use Modifiers LT/RT to identify Center (ASC), Short Procedure Unit (SPU), or hospital bilateral services or procedures because a more appropriate setting is appropriate/necessary to ensure and safeguard modifier exists. the individual’s health. To report a bilateral service or procedure, the appropriate This policy applies to services that are performed in the procedure code and/or modifier should be used. following settings: ASC, SPU, hospital outpatient, or inpatient. Multiple surgery reduction logic will be applied when appropriate. This policy applies whether or not the dental service is eligible under the medical benefits. Additional reporting requirements for Modifiers LT/RT: • For information on dental services that are covered under the The medical records must clearly support the medical benefits, refer to the individual and/or group benefit appropriate use of Modifiers LT/RT. contract. • Medical records, notes, and/or other documentation should not be attached to the claim unless specifically Originally published in Spring 2006 CGPU. required and/or requested by the Company. • Claims submitted with Modifiers LT/RT are subject to post-reimbursement clinical review and potential retractions for inappropriate use.

Originally published in Spring 2006 CGPU.

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Work Hardening and Work Conditioning is Not Covered Under Most of the Company’s Products (10.05.02)

Work hardening services address physical, functional, behavioral and vocational needs of the worker by utilizing real or simulated work activities. Additionally, work hardening includes education (e.g., body mechanics, work pacing, safety and injury prevention). A work hardening program begins at four hours per day and builds to eight hours per day over the course of the program, usually four weeks. Work hardening requires a specific return-to-work goal. Work hardening services relate directly to specific work skills and do not provide any diagnostic or therapeutic rehabilitation benefit for the individual.

Work conditioning (including reconditioning) utilizes physical conditioning and functional activities related to work. These services bridge a gap between acute outpatient therapy and a structured work hardening program or return to work. Work conditioning/re-conditioning may or may not include an education component. Work conditioning/ re-conditioning is typically four hours/day or less and there is no specific return to work goal required.

Work hardening and work conditioning are benefit contract exclusions for some of the Company’s products. If the group benefit contract does not provide a specific exclusion for work hardening, the service is considered not medically necessary as it is considered vocational in nature and does not provide any diagnostic or therapeutic benefit of a medical nature for the individual.

Originally published in Summer 2006 CGPU.

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2006 articles www.amerihealth.com

Table of Contents

ICD-9 CM Diagnosis Codes Change for Routine Gynecological Exams...... 32 Billing for Neonatal Hearing Screening Should be Directed to Facility...... 32 Anesthesia Claims Update...... 32 Gardasil® Approved by the FDA...... 32 Clarifications to the Intensity Modulated Radiation Therapy Policy...... 33

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2006 Articles

ICD-9 CM Diagnosis Codes Change for Please call Provider Services or your Network Coordinator Routine Gynecological Exams with any questions.

Effective January 1, 2006, capitated PCPs who bill for This article originally appeared in the March 2006 Partners in routine gynecological exams should report diagnosis code Health Update. V72.31 with the applicable preventive evaluation and management (E&M) Current Procedural Terminology Anesthesia Claims Update (CPT®) codes 99384-99387 and 99394-99397 or Healthcare Common Procedure Coding System (HCPCS) codes S0610 Effective August 1, 2006, as part of the standard claims and S0612 for reimbursement consideration. adjudication process, ClaimCheck clinical relationship logic will be applied to claims reported with anesthesia Routine gynecological exams that are reported with ICD-9 services. ClaimCheck is the code relationship editing tool CM code V72.32 for CPT codes 99384-99387 and 99394- that is integrated into the claims adjudication process for 99397 are no longer eligible for additional payment outside professional claims processing. of the standard capitation amount. HCPCS codes S0610 and S0612 may still be reported with ICD-9 CM code V72.32 For information regarding ClaimCheck clinical relationship when appropriate. For reference, the diagnosis code narratives logic, please refer to the Clear Claim Connection tool which SM are as follows: is available through the NaviNet Portal. You may also refer to the user guide that was mailed to you in December 2005. • V72.31: Routine gynecological examination. This article originally appeared in the July 2006 Partners in • V72.32: Encounter for Papanicolaou cervical smear to Health Update. confirm findings of a recent normal smear following initial abnormal smear. Gardasil® Approved by the FDA Important reminder: As previously communicated, effective October 1, 2004, we require all practitioners to report In June, the U.S. Food and Drug Administration (FDA) diagnosis codes to the highest degree of specificity, according approved the biologic license application for Gardasil® to the ICD-9 CM Coding Manual. (Quadrivalent Human Papillomavirus [Types 6, 11, 16, 18] Recombinant Vaccine). Gardasil® is a new vaccine indicated If you have questions, please call Provider Services or your for females ages 9 to 26 for the prevention of the following Network Coordinator. conditions caused by HPV types 6, 11, 16, and 18: This article originally appeared in the January 2006 Partners in • Cervical cancer Health Update. • Genital warts

Billing for Neonatal Hearing Screening And the following precancerous or dysplastic lesions: Should be Directed to Facility • Cervical adenocarcinoma in situ (AIS) AmeriHealth has recently received inquiries from members • Cervical intraepithelial neoplasia (CIN) grade 1, who received bills for hearing screenings provided to their grade 2, and grade 3 newborns before discharge from a facility. • Vulvar intraepithelial neoplasia (VIN) grade 2 and Please be advised that newborn hearing screenings are grade 3 covered services and included within the facility’s payment • Vaginal intraepithelial neoplasia (VaIN) grade 2 and for the delivery and are not eligible for separate billing to grade 3 AmeriHealth or to the member. In the event that a provider has a contract or arrangement with a facility to provide these screenings, the provider must look to that facility for payment Coverage Statement and not to AmeriHealth or to our members. Gardasil® (Quadrivalent Human Papillomavirus [Types 6, 11, 16, 18] Recombinant Vaccine) is considered medically necessary and, therefore, covered as a three-dose regimen

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for use in females ages 9 to 26 for the prevention of cervical Coverage Limitations cancer; genital warts; AIS; CIN grade 1, 2, and 3; VIN grade ® 2 and 3; and VaIN grade 2 and 3 for those members who Th e following CPT codes are not to be reported when the have an immunization benefi t. services are performed as part of developing an IMRT plan that is reported using CPT code 77301, even if the services Th is article originally appeared in the October 2006 Partners in are performed on diff erent dates, as reimbursement for the Health Update. following codes is already included in CPT code 77301. Reimbursement for MRI guidance for placement of radiation Clarifications to the Intensity therapy fi elds is already included in CPT code 77301 and should not be separately reported, regardless of the date of Modulated Radiation Therapy service. Policy To review the full version of this policy, go to Eff ective December 6, 2006, we will amend the criteria for www.amerihealth.com/medpolicy. medical policy #09.00.17b – Intensity Modulated Radiation Th erapy (IMRT). Th e annual review of this policy led to the Th is article originally appeared in the November 2006 Partners addition of the following coverage limitations based on the in Health Update. current literature on this topic.

76370 Computerized axial tomographic guidance for placement of radiation therapy fi elds 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image post-processing on an independent workstation 76377 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image post-processing on an independent workstation 77280 Th erapeutic radiology simulation-aided fi eld setting, simple 77285 Th erapeutic radiology simulation-aided fi eld setting; intermediate 77290 Th erapeutic radiology simulation-aided fi eld setting; complex 77295 Th erapeutic radiology simulation-aided fi eld setting; three-dimensional simulation 77305 Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel opposed unmodifi ed ports directed to a single area of interest) 77310 Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more treatment ports directed to a single area of interest) 77315 Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations) 77321 Special teletherapy port plan, particles, hemibody, total body 77331 Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician 77336 Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy 77370 Special medical radiation physics consultation

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class action settlement update www.amerihealth.com

Table of Contents

Enhancements to Claim Payment Policy, Processing and Payment Disclosure, and an Appeals Process for Class Action Settlement Providers...... 36 Assistant Surgery Modifiers 80, 81, 82...... 36 Co-Surgery Modifier 62...... 37

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Class Action Settlement Update:

Enhancements to Claim Payment who actively assists and supports a primary surgeon during Policy, Processing and Payment a surgical procedure. Both primary and assistant surgeons Disclosure, and an Appeals Process should report the same procedure code. The assistant surgeon for Class Action Settlement Providers should append the most appropriate assistant surgery modifier based on the narrative.

The class action settlements involving New Jersey and The table below identifies and describes the intended Delaware providers [of Gregg, et al. v. Independence Blue processing outcome that is associated with each indicator. Cross, et al., Good v. Independence Blue Cross, et al., and However, reimbursement consideration for services that are Pennsylvania Orthopaedic Society v. Independence Blue reported with Modifiers 80, 81, and/or 82 are also contingent Cross, et al.] include the following enhancements for upon eligibility, benefits, exclusions, precertification/referral providers who agreed to the settlement: requirements, provider contracts, and/or applicable policies. • Improving disclosure to Settlement Providers, including Payment for these procedures is based on 20 percent of standard fee schedules, changes to schedules, and the fee schedule allowance for the surgical service. Please medical and payment policies that may affect payment/ note that assistant surgical services that are performed in reimbursement of services, which will be made available conjunction with other surgical services may be subject to online via NaviNetSM, our secure provider portal. multiple surgery reduction guidelines. • Changing claims processing for Settlement Providers CMS utilizes a payment methodology for these types of on the following: selected modifiers (25, 50, 51, 59, 62, services by applying assistant surgery payment indicators to 66, 80, 81, 82, RT, LT), multiple surgical procedures, procedure codes that, when submitted in combination with radiological guidance during a procedure, and certain Modifiers 80, 81, and/or 82, will allow or restrict payment Current Procedural Terminology (CPT®) code-level consideration: designations (e.g., Modifier 51 Exempt, Separate Procedure, Add-on Codes). CMS Indicator and Outcome for the Code/ Description Modifier 80, 81, and/or • Introducing a two-level formal claims appeal process 82 Combination for Settlement Providers in AmeriHealth’s Delaware subsidiary. AmeriHealth New Jersey providers will (0) Assistant surgery payment Ineligible for assistant continue to have access to the existing provider claims is inappropriate unless surgery; additional appeal process. documentation supports consideration determined medical necessity. on an appeal basis only. Certain of these enhancements are currently available. Others will be announced as they become available. (1) Assistant surgery payment Ineligible for assistant This article originally appeared in the January 2006 Partners in is inappropriate. surgery reimbursement Health Update. consideration. (2) Assistant surgery payment Eligible for assistant Assistant Surgery Modifiers 80, 81, 82 is appropriate. surgery reimbursement consideration. AmeriHealth has enhanced its processing system to apply the Centers for Medicare & Medicaid Services (CMS) (9) Concept does not apply. Invalid procedure/ payment methodology for modifiers that represent assistant modifier code surgery [Assistant Surgeon 80; Minimum Assistant Surgeon combination. 81; Assistant Surgeon (when qualified resident surgeon not Medical records, operative reports, and/or other supporting available) 82] as outlined in the Medicare Physician Fee documentation should not be appended to the claim or Schedule Database on the CMS website.* submitted to the Company unless specifically requested by Assistant surgery Modifiers 80, 81, and 82 are used to the Company.

denote surgical procedures that require both a primary and *The following is a link to the Medicare website: www.cms.gov. These sites are an assistant surgeon because of the complexity and/or time maintained by organizations over which AmeriHealth exercises no control and, requirement of the surgery. An assistant surgeon is a surgeon 36 View full policies online at www.amerihealth.com/medpolicy 2006 CGPU Compendium

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accordingly, AmeriHealth expressly disclaims any responsibility for the content, the CMS utilizes a payment methodology for these types of accuracy of the information, and/or quality of the products or services provided by services by applying co-surgery payment indicators to or advertised in these third-party sites. Certain services/treatments referred to in procedure codes that, when submitted in combination with other sites may not be covered under specific benefit plans. Please refer to benefit contracts for complete details of the terms, limitations, and exclusions of coverage. Modifier 62, will allow or restrict payment consideration:

This article originally appeared in the January 2006 Partners in CMS Indicator and Outcome for the Code/ Health Update. Description Modifier 62 Co-Surgery Modifier 62 (0) Co-surgery payment Ineligible for co-surgery is inappropriate. reimbursement consideration. AmeriHealth has enhanced its processing system to apply the (1) Co-surgery payment Ineligible for co-surgery; Centers for Medicare & Medicaid Services (CMS) payment is inappropriate additional consideration methodology for Co-surgery Modifier 62 as outlined in the unless supporting determined on an appeal basis Medicare Physician Fee Schedule Database on the CMS documentation only. website.* establishes medical necessity. Co-surgery Modifier 62 is used to denote when two surgeons act as primary surgeons during the same operative procedure (2) Co-surgery payment Eligible for co-surgery or session for the same individual because of the complexity is appropriate. reimbursement consideration. of the procedure and/or the patient’s condition. The co- (9) Concept does not Invalid procedure/modifier surgeons are typically of different specialties and perform apply. code combination. consecutive or overlapping parts of the same procedure or simultaneous procedures during the same session with one It is inappropriate to report Modifier 62 when one surgeon of the following exceptions for co-surgeons of the same acts as an assistant to the primary surgeon or when more specialty: than two surgeons act as primary surgeons during the same operative session. • Each surgeon must perform a distinct part of the surgical procedure that requires the distinct skills of Medical records, operative reports, and/or other supporting each surgeon. documentation should not be appended to the claim or • Each surgeon performs the same procedure(s) submitted to the Company unless specifically requested by simultaneously for different regions/organs (e.g., the Company. bilateral lung reduction, bilateral knee replacements). In *The following is a link to the Medicare website: www.cms.gov. These sites are such cases, the operative report must reflect the necessity maintained by organizations over which AmeriHealth exercises no control and, of two primary surgeons with the same skills. accordingly, AmeriHealth expressly disclaims any responsibility for the content, the accuracy of the information, and/or quality of the products or services provided by Each of the two surgeons should submit the same procedure or advertised in these third-party sites. Certain services/treatments referred to in code that represents the entire surgical procedure appended other sites may not be covered under specific benefit plans. Please refer to benefit contracts for complete details of the terms, limitations, and exclusions of coverage. with Modifier 62. This article originally appeared in the January 2006 Partners in The table below identifies and describes the final processing Health Update. outcome that is associated with each indicator; however, reimbursement consideration for services that are reported with Modifier 62 are also contingent upon eligibility, benefits, exclusions, precertification/referral requirements, provider contracts, and applicable policies.

Payment for these procedures is based on 62.5 percent of the fee schedule allowance for the service. Please note that co- surgery services that are performed in conjunction with other co-surgery services are subject to multiple surgery reduction guidelines.

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Medical code updates

www.amerihealth.com

Table of Contents

CPT®* Codes...... 40 HCPCS Codes...... 62 ICD-9 CM Codes...... 90

As part of the medical/claim payment policy process, the AmeriHealth Procedure Code Review Unit supports medical code activities. It establishes and maintains the development and documentation of coverage positions for ICD-9 CM, CPT, and HCPCS medical codes across all lines of business and all processing systems.

The following pages detail the new/revised ICD-9 CM, CPT, and HCPCS code updates effective as follows, unless otherwise specified:

ICD-9 CM: Additions and Revisions have an effective date of 10/1/2006. Deletions have a delete date of 10/1/2006.

CPT: Additions and Revisions have an effective date of 1/1/2007. Deletions have a delete date of 1/1/2007.

HCPCS: Additions and Revisions have an effective date of 10/1/2006 or 1/1/2007. Deletions have a delete date of 1/1/2007.

Please note that the listing of a code in this Compendium does not necessarily guarantee coverage or reimbursement for a procedure.

*Current Procedural Terminology (CPT®) is a copyright of the American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in the CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the AMA.

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition A 00625 Anesthesia for procedures on the thoracic spine and cord, 1/1/2007 via an anterior transthoracic approach; not utilizing 1 - lung ventilation A 00626 Anesthesia for procedures on the thoracic spine and cord, 1/1/2007 via an anterior transthoracic approach; utilizing 1 - lung ventilation A 15002 Surgical preparation or creation of recipient site by 1/1/2007 excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children A 15003 Surgical preparation or creation of recipient site by 1/1/2007 excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm or each additional 1% of body area of infants and children (List separately in addition to the code for the primary procedure) A 15004 Surgical preparation or creation of recipient site by 1/1/2007 excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children A 15005 Surgical preparation or creation of recipient site by 1/1/2007 excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm or 1% of body area of infants and children (List separately in addition to code for primary procedure) A 15731 Forehead flap with preservation of vascular pedicle (e.g., 1/1/2007 axial pattern flap, paramedian forehead flap) A 15830 Excision, excessive skin and subcutaneous tissue (includes 1/1/2007 lipectomy); abdomen, infraumbilical panniculectomy A 15847 Excision, excessive skin and subcutaneous tissue (includes 1/1/2007 lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) A 17311 Mohs micrographic technique, including removal of 1/1/2007 all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage up to 5 tissue blocks

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition A 17312 Mohs micrographic technique, including removal of 1/1/2007 all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) A 17313 Mohs micrographic technique, including removal of 1/1/2007 all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks A 17314 Mohs micrographic technique, including removal of 1/1/2007 all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) A 17315 Mohs micrographic technique, including removal of 1/1/2007 all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure) A 19105 Ablation, cryosurgical, of fibroadenoma, including 1/1/2007 ultrasound guidance, each fibroadenoma A 19300 Mastectomy for gynecomastia 1/1/2007 A 19301 Mastectomy, partial (e.g., lumpectomy, tylectomy, 1/1/2007 quadrantectomy, segmentectomy); A 19302 Mastectomy, partial (e.g., lumpectomy, tylectomy, 1/1/2007 quadrantectomy, segmentectomy); with axillary lymphadenectomy A 19303 Mastectomy, simple, complete 1/1/2007 A 19304 Mastectomy, subcutaneous 1/1/2007 A 19305 Mastectomy, radical, including pectoral muscle, axillary 1/1/2007 lymph nodes A 19306 Mastectomy, radical, including pectoral muscles, axillary 1/1/2007 and internal mammary lymph nodes (Urban type operation) A 19307 Mastectomy, modified radical, including axillary lymph 1/1/2007 nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle A 22526 Percutaneous intradiscal electrothermal annuloplasty, 1/1/2007 unilateral or bilateral including fluoroscopic guidance; single level

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition A 22527 Percutaneous intradiscal electrothermal annuloplasty, 1/1/2007 unilateral or bilateral including fluoroscopic guidance; one or more additional levels (List separately in addition to code for primary procedure) A 22857 Total disc arthroplasty (artificial disc), anterior approach, 1/1/2007 including discectomy to prepare interspace (other than for decompression), lumbar, single interspace A 22862 Revision including replacement of total disc arthroplasty 1/1/2007 (artificial disc) anterior approach, lumbar, single interspace A 22865 Removal of total disc arthroplasty (artificial disc), anterior 1/1/2007 approach, lumbar, single interspace A 25109 Excision of tendon, forearm and/or wrist, flexor or 1/1/2007 extensor, each A 25606 Percutaneous skeletal fixation of distal radial fracture or 1/1/2007 epiphyseal separation A 25607 Open treatment of distal radial extra-articular fracture or 1/1/2007 epiphyseal separation, with internal fixation A 25608 Open treatment of distal radial intra-articular fracture or 1/1/2007 epiphyseal separation; with internal fixation of 2 fragments A 25609 Open treatment of distal radial intra-articular fracture or 1/1/2007 epiphyseal separation; with internal fixation of 3 or more fragments A 27325 Neurectomy, hamstring muscle 1/1/2007 A 27326 Neurectomy, popliteal (gastrocnemius) 1/1/2007 A 28055 Neurectomy, intrinsic musculature of feet 1/1/2007 A 32998 Ablation therapy for reduction or eradication of one 1/1/2007 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral A 33202 Insertion of epicardial electrode(s); open incision (e.g., 1/1/2007 thoracotomy, median sternotomy, subxiphoid approach) A 33203 Insertion of epicardial electrode(s); endoscopic approach 1/1/2007 (e.g., thoracoscopy, pericardioscopy) A 33254 Operative tissue ablation and reconstruction of atria, 1/1/2007 limited (e.g., modified maze procedure) A 33255 Operative tissue ablation and reconstruction of atria, 1/1/2007 extensive (e.g., maze procedure); without cardiopulmonary bypass A 33256 Operative tissue ablation and reconstruction of atria, 1/1/2007 extensive (e.g., maze procedure); with cardiopulmonary bypass A 33265 Endoscopy, surgical; operative tissue ablation and 1/1/2007 reconstruction of atria, limited (e.g., modified maze procedure), without cardiopulmonary bypass A 33266 Endoscopy, surgical; operative tissue ablation and 1/1/2007 reconstruction of atria, extensive (e.g., maze procedure), without cardiopulmonary bypass A 33675 Closure of multiple ventricular septal defects; 1/1/2007 A 33676 Closure of multiple ventricular septal defects; with 1/1/2007 pulmonary valvotomy or infundibular resection (acyanotic) A 33677 Closure of multiple ventricular septal defects; with removal 1/1/2007 of pulmonary artery band, with or without gusset

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition A 33724 Repair of isolated partial anomalous pulmonary venous 1/1/2007 return (e.g., Scimitar Syndrome) A 33726 Repair of pulmonary venous stenosis 1/1/2007 A 35302 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; superficial femoral artery A 35303 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; popliteal artery A 35304 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; tibioperoneal trunk artery A 35305 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; tibial or peroneal artery, initial vessel A 35306 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; each additional tibial or peroneal artery (List separately in addition to code for primary procedure) A 35537 Bypass graft, with vein; aortoiliac 1/1/2007 A 35538 Bypass graft, with vein; aortobi-iliac 1/1/2007 A 35539 Bypass graft, with vein; aortofemoral 1/1/2007 A 35540 Bypass graft, with vein; aortobifemoral 1/1/2007 A 35637 Bypass graft, with other than vein; aortoiliac 1/1/2007 A 35638 Bypass graft, with other than vein; aortobi-iliac 1/1/2007 A 35883 Revision, femoral anastomosis of synthetic arterial bypass 1/1/2007 graft in groin, open; with nonautogenous patch graft (e.g., Dacron, ePTFE, bovine pericardium) A 35884 Revision, femoral anastomosis of synthetic arterial bypass 1/1/2007 graft in groin, open; with autogenous vein patch graft A 37210 Uterine fibroid embolization (UFE, embolization of the 1/1/2007 uterine arteries to treat uterine fibroids, leiomyomata), percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging necessary to complete the procedure A 43647 Laparoscopy, surgical; implantation or replacement of 1/1/2007 gastric neurostimulator electrodes, antrum A 43648 Laparoscopy, surgical; revision or removal of gastric 1/1/2007 neurostimulator electrodes, antrum A 43881 Implantation or replacement of gastric neurostimulator 1/1/2007 electrodes, antrum, open A 43882 Revision or removal of gastric neurostimulator electrodes, 1/1/2007 antrum, open A 44157 Colectomy, total, abdominal, with proctectomy; with 1/1/2007 ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, when performed A 44158 Colectomy, total, abdominal, with proctectomy; with 1/1/2007 ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed A 47719 Anastomosis, choledochal cyst, without excision 1/1/2007 A 48105 Resection or debridement of pancreas and peripancreatic 1/1/2007 tissue for acute necrotizing pancreatitis A 48548 Pancreaticojejunostomy, side-to-side anastomosis (Puestow- 1/1/2007 type operation)

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition A 49324 Laparoscopy, surgical; with insertion of intraperitoneal 1/1/2007 cannula or catheter, permanent A 49325 Laparoscopy, surgical; with revision of previously placed 1/1/2007 intraperitoneal cannula or catheter, with removal of intraluminal obstructive material if performed A 49326 Laparoscopy, surgical; with omentopexy (omental tacking 1/1/2007 procedure) (List separately in addition to code for primary procedure) A 49402 Removal of peritoneal foreign body from peritoneal cavity 1/1/2007 A 49435 Insertion of subcutaneous extension to intraperitoneal 1/1/2007 cannula or catheter with remote chest exit site (List separately in addition to code for primary procedure) A 49436 Delayed creation of exit site from embedded subcutaneous 1/1/2007 segment of intraperitoneal cannula or catheter A 54865 Exploration of epididymis, with or without biopsy 1/1/2007 A 55875 Transperineal placement of needles or catheters into 1/1/2007 prostate for interstitial radioelement application, with or without cystoscopy A 55876 Placement of interstitial device(s) for radiation therapy 1/1/2007 guidance (e.g., fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple A 56442 Hymenotomy, simple incision 1/1/2007 A 57296 Revision (including removal) prosthetic vaginal graft; open 1/1/2007 abdominal approach A 57558 Dilation and curettage of cervical stump 1/1/2007 A 58541 Laparoscopy, surgical, supracervical hysterectomy, for 1/1/2007 uterus 250 g or less; A 58542 Laparoscopy, surgical, supracervical hysterectomy, for 1/1/2007 uterus 250 g or less; with removal of tube(s) and/or ovary(s) A 58543 Laparoscopy, surgical, supracervical hysterectomy, for 1/1/2007 uterus greater than 250 g; A 58544 Laparoscopy, surgical, supracervical hysterectomy, for 1/1/2007 uterus greater than 250 g; with removal of tube(s) and/or ovary(s) A 58548 Laparoscopy surgical, with radical hysterectomy, with 1/1/2007 bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed A 58957 Resection (tumor debulking) of recurrent ovarian, tubal, 1/1/2007 primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; A 58958 Resection (tumor debulking) of recurrent ovarian, tubal, 1/1/2007 primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy A 64910 Nerve repair; with synthetic conduit or vein allograft (e.g., 1/1/2007 nerve tube), each nerve A 64911 Nerve repair; with autogenous vein graft (includes harvest 1/1/2007 of vein graft), each nerve A 67346 Biopsy of extraocular muscle 1/1/2007

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition A 70554 Magnetic resonance imaging, brain, functional MRI; 1/1/2007 including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration A 70555 Magnetic resonance imaging, brain, functional MRI; 1/1/2007 requiring physician or psychologist administration of entire neurofunctional testing A 72291 Radiological supervision and interpretation, percutaneous 1/1/2007 vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance A 72292 Radiological supervision and interpretation, percutaneous 1/1/2007 vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance A 76776 Ultrasound, transplanted kidney, real time and duplex 1/1/2007 Doppler with image documentation A 76813 Ultrasound, pregnant uterus, real time with image 1/1/2007 documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation A 76814 Ultrasound, pregnant uterus, real time with image 1/1/2007 documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure) A 76998 Ultrasonic guidance, intraoperative 1/1/2007 A 77001 Fluoroscopic guidance for central venous access device 1/1/2007 placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) A 77002 Fluoroscopic guidance for needle placement (e.g., biopsy, 1/1/2007 aspiration, injection, localization device) A 77003 Fluoroscopic guidance and localization of needle or 1/1/2007 catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction A 77011 Computed tomography guidance for stereotactic 1/1/2007 localization A 77012 Computed tomography guidance for needle placement 1/1/2007 (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation A 77013 Computed tomography guidance for, and monitoring of, 1/1/2007 parenchymal tissue ablation A 77014 Computed tomography guidance for placement of 1/1/2007 radiation therapy fields A 77021 Magnetic resonance guidance for needle placement (e.g., 1/1/2007 for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition A 77022 Magnetic resonance guidance for, and monitoring of, 1/1/2007 parenchymal tissue ablation A 77031 Stereotactic localization guidance for breast biopsy 1/1/2007 or needle placement (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation A 77032 Mammographic guidance for needle placement, breast 1/1/2007 (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation A 77051 Computer-aided detection (computer algorithm analysis 1/1/2007 of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure) A 77052 Computer-aided detection (computer algorithm analysis 1/1/2007 of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure) A 77053 Mammary ductogram or galactogram, single duct, 1/1/2007 radiological supervision and interpretation A 77054 Mammary ductogram or galactogram, multiple ducts, 1/1/2007 radiological supervision and interpretation A 77055 Mammography; unilateral 1/1/2007 A 77056 Mammography; bilateral 1/1/2007 A 77057 Screening mammography, bilateral (2-view film study of 1/1/2007 each breast) A 77058 Magnetic resonance imaging, breast, without and/or with 1/1/2007 contrast material(s); unilateral A 77059 Magnetic resonance imaging, breast, without and/or with 1/1/2007 contrast material(s); bilateral A 77071 Manual application of stress performed by physician for 1/1/2007 joint radiography, including contralateral joint if indicated A 77072 Bone age studies 1/1/2007 A 77073 Bone length studies (orthoroentgenogram, scanogram) 1/1/2007 A 77074 Radiologic examination, osseous survey; limited (e.g., for 1/1/2007 metastases) A 77075 Radiologic examination, osseous survey; complete (axial 1/1/2007 and appendicular skeleton) A 77076 Radiologic examination, osseous survey, infant 1/1/2007 A 77077 Joint survey, single view, 2 or more joints (specify) 1/1/2007 A 77078 Computed tomography, bone mineral density study, 1 or 1/1/2007 more sites; axial skeleton (e.g., hips, pelvis, spine) A 77079 Computed tomography, bone mineral density study, 1 or 1/1/2007 more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) A 77080 Dual-energy X-ray absorptiometry (DXA), bone density 1/1/2007 study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition A 77081 Dual-energy X-ray absorptiometry (DXA), bone density 1/1/2007 study, 1 or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) A 77082 Dual-energy X-ray absorptiometry (DXA), bone density 1/1/2007 study, 1 or more sites; vertebral fracture assessment A 77083 Radiographic absorptiometry (e.g., photodensitometry, 1/1/2007 radiogrammetry), 1 or more sites A 77084 Magnetic resonance (e.g., proton) imaging, bone marrow 1/1/2007 blood supply A 77371 Radiation treatment delivery, stereotactic radiosurgery 1/1/2007 (SRS), complete course of treatment of cerebral lesion(s) consisting of 1 session; multi-source Cobalt 60 based A 77372 Radiation treatment delivery, stereotactic radiosurgery 1/1/2007 (SRS), complete course of treatment of cerebral lesion(s) consisting of 1 session; linear accelerator based A 77373 Stereotactic body radiation therapy, treatment delivery, per 1/1/2007 fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions A 77435 Stereotactic body radiation therapy, treatment 1/1/2007 management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions A 82107 Alfa-fetoprotein (AFP); AFP-L3 fraction isoform and total 1/1/2007 AFP (including ratio) A 83698 Lipoprotein-associated phospholipase A2, (Lp-PLA2) 1/1/2007 A 83913 Molecular diagnostics; RNA stabilization 1/1/2007 A 86788 Antibody; West Nile virus, IgM 1/1/2007 A 86789 Antibody; West Nile virus 1/1/2007 A 87305 Infectious agent antigen detection by enzyme immunoassay 1/1/2007 technique, qualitative or semiquantitative, multiple step method; Aspergillus A 87498 Infectious agent detection by nucleic acid (DNA or RNA); 1/1/2007 enterovirus, amplified probe technique A 87640 Infectious agent detection by nucleic acid (DNA or RNA); 1/1/2007 Staphylococcus aureus, amplified probe technique A 87641 Infectious agent detection by nucleic acid (DNA or RNA); 1/1/2007 Staphylococcus aureus, methicillin resistant, amplified probe technique A 87653 Infectious agent detection by nucleic acid (DNA or RNA); 1/1/2007 Staphylococcus, group B, amplified probe technique A 87808 Infectious agent antigen detection by immunoassay with 1/1/2007 direct optical observation; Trichomonas vaginalis A 91111 Gastrointestinal tract imaging, intraluminal (e.g., capsule 1/1/2007 endoscopy), esophagus with physician interpretation and report A 92025 Computerized corneal topography, unilateral or bilateral, 1/1/2007 with interpretation and report A 92640 Diagnostic analysis with programming of auditory 1/1/2007 brainstem implant, per hour A 94002 Ventilation assist and management, initiation of pressure 1/1/2007 or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition A 94003 Ventilation assist and management, initiation of pressure 1/1/2007 or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day A 94004 Ventilation assist and management, initiation of pressure 1/1/2007 or volume preset ventilators for assisted or controlled breathing; nursing facility, per day A 94005 Home ventilator management care plan oversight of a 1/1/2007 patient (patient not present) in home, domiciliary or rest home (e.g., assisted living) requiring review of status, review of laboratories and other studies and revision of orders and respiratory care plan (as appropriate), within a calendar month, 30 minutes or more. A 94610 Intrapulmonary surfactant administration by a physician 1/1/2007 through endotracheal tube A 94644 Continuous inhalation treatment with aerosol medication 1/1/2007 for acute airway obstruction; first hour A 94645 Continuous inhalation treatment with aerosol medication 1/1/2007 for acute airway obstruction; each additional hour (List separately in addition to code for primary procedure) A 94774 Pediatric home apnea monitoring event recording including 1/1/2007 respiratory rate, pattern and heart rate per 30-day period of time; includes monitor attachment, download of data, physician review, interpretation, and preparation of a report A 94775 Pediatric home apnea monitoring event recording including 1/1/2007 respiratory rate, pattern and heart rate per 30-day period of time; monitor attachment only (includes hook-up, initiation of recording and disconnection) A 94776 Pediatric home apnea monitoring event recording including 1/1/2007 respiratory rate, pattern and heart rate per 30-day period of time; monitoring, download of information, receipt of transmission(s) and analyses by computer only A 94777 Pediatric home apnea monitoring event recording including 1/1/2007 respiratory rate, pattern and heart rate per 30-day period of time; physician review, interpretation and preparation of report only A 95012 Nitric oxide expired gas determination 1/1/2007 A 96020 Neurofunctional testing selection and administration during 1/1/2007 noninvasive imaging functional brain mapping, with test administered entirely by a physician or psychologist, with review of test results and reports A 96040 Medical genetics and genetic counseling services, each 30 1/1/2007 minutes face-to-face with patient/family A 96904 Whole body integumentary photography, for monitoring 1/1/2007 of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma A 99363 Anticoagulant management for an outpatient taking 1/1/2007 warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; initial 90 days of therapy (must include a minimum of 8 INR measurements)

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition A 99364 Anticoagulant management for an outpatient taking 1/1/2007 warfarin, physician review and interpretation of International Normalized Ratio (INR) testing, patient instructions, dosage adjustment (as needed), and ordering of additional tests; each subsequent 90 days of therapy (must include a minimum of 8 INR measurements) A 0162T Electronic analysis and programming, reprogramming of 1/1/2007 gastric neurostimulator (i.e., morbid obesity) A 0163T Total disc arthroplasty (artificial disc), anterior approach, 1/1/2007 including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace A 0164T Removal of total disc arthroplasty, anterior approach, 1/1/2007 lumbar, each additional interspace A 0165T Revision of total disc arthroplasty, anterior approach, 1/1/2007 lumbar, each additional interspace A 0166T Transmyocardial transcatheter closure of ventricular septal 1/1/2007 defect, with implant; without cardiopulmonary bypass A 0167T Transmyocardial transcatheter closure of ventricular septal 1/1/2007 defect, with implant; with cardiopulmonary bypass A 0168T Rhinophototherapy, intranasal application of ultraviolet and 1/1/2007 visible light, bilateral A 0169T Stereotactic placement of infusion catheter(s) in the brain 1/1/2007 for delivery of therapeutic agent(s), including computerized stereotactic planning and burr hole(s) A 0170T Repair of anorectal fistula with plug (e.g., porcine small 1/1/2007 intestine submucosa [SIS]) A 0171T Insertion of posterior spinous process distraction device 1/1/2007 (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single level A 0172T Insertion of posterior spinous process distraction device 1/1/2007 (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; each additional level (List separately in addition to code for primary procedure) A 0173T Monitoring of intraocular pressure during vitrectomy 1/1/2007 surgery (List separately in addition to code for primary procedure) A 0174T Computer aided detection (CAD) (computer algorithm 1/1/2007 analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure) A 0175T Computer aided detection (CAD) (computer algorithm 1/1/2007 analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation A 0176T Transluminal dilation of aqueous outflow canal; without 1/1/2007 retention of device or stent A 0177T Transluminal dilation of aqueous outflow canal; with 1/1/2007 retention of device or stent

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition D 01995 Regional intravenous administration of local anesthetic 1/1/2007 agent or other medication (upper or lower extremity) D 15000 Surgical preparation or creation of recipient site by 1/1/2007 excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture; first 100 sq cm or one percent of body area of infants and children D 15001 Surgical preparation or creation of recipient site by 1/1/2007 excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture; each additional 100 sq cm or each additional one percent of body area of infants and children (List separately in addition to code for primary procedure) D 15831 Excision, excessive skin and subcutaneous tissue (includes 1/1/2007 lipectomy); abdomen, (e.g., abdominoplasty) D 17304 Chemosurgery (Mohs micrographic technique), including 1/1/2007 removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation including the first routine stain (e.g., hematoxylin and eosin, toluidine blue); first stage, fresh tissue technique, up to 5 specimens D 17305 Chemosurgery (Mohs micrographic technique), including 1/1/2007 removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation including the first routine stain (e.g., hematoxylin and eosin, toluidine blue); second stage, fixed or fresh tissue, up to 5 specimens D 17306 Chemosurgery (Mohs micrographic technique), including 1/1/2007 removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation including the first routine stain (e.g., hematoxylin and eosin, toluidine blue); third stage, fixed or fresh tissue, up to 5 specimens D 17307 Chemosurgery (Mohs micrographic technique), including 1/1/2007 removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation including the first routine stain (e.g., hematoxylin and eosin, toluidine blue); additional stage(s), up to 5 specimens, each stage D 17310 Chemosurgery (Mohs micrographic technique), including 1/1/2007 removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and complete histopathologic preparation including the first routine stain (e.g., hematoxylin and eosin, toluidine blue); each additional specimen, after the first 5 specimens; fixed or fresh tissue, any stage (List separately in addition to code for primary procedure) D 19140 Mastectomy for gynecomastia 1/1/2007 D 19160 Mastectomy, partial (e.g., lumpectomy, tylectomy, 1/1/2007 quadrantectomy, segmentectomy);

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition D 19162 Mastectomy, partial (e.g., lumpectomy, tylectomy, 1/1/2007 quadrantectomy, segmentectomy); with axillary lymphadenectomy D 19180 Mastectomy, simple, complete 1/1/2007 D 19182 Mastectomy, subcutaneous 1/1/2007 D 19200 Mastectomy, radical, including pectoral muscle, axillary 1/1/2007 lymph nodes D 19220 Mastectomy, radical, including pectoral muscles, axillary 1/1/2007 and internal mammary lymph nodes (Urban type operation) D 19240 Mastectomy, modified radical, including axillary lymph 1/1/2007 nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle D 21300 Closed treatment of skull fracture without operation 1/1/2007 D 25611 Percutaneous skeletal fixation of distal radial fracture (e.g., 1/1/2007 Colles or Smith type) or epiphyseal separation, with or without fracture of ulnar styloid, requiring manipulation, with or without external fixation D 25620 Open treatment of distal radial fracture (e.g., Colles or 1/1/2007 Smith type) or epiphyseal separation, with or without fracture of ulnar styloid, with or without internal or external fixation D 26504 Reconstruction of tendon pulley, each tendon; with tendon 1/1/2007 prosthesis (separate procedure) D 27315 Neurectomy, hamstring muscle 1/1/2007 D 27320 Neurectomy, popliteal (gastrocnemius) 1/1/2007 D 28030 Neurectomy, intrinsic musculature of feet 1/1/2007 D 31700 Catheterization, transglottic (separate procedure) 1/1/2007 D 31708 Instillation of contrast material for laryngography or 1/1/2007 bronchography, without catheterization D 31710 Catheterization for bronchography, with or without 1/1/2007 instillation of contrast material D 33200 Insertion of permanent pacemaker with epicardial 1/1/2007 electrode(s); by thoracotomy D 33201 Insertion of permanent pacemaker with epicardial 1/1/2007 electrode(s); by xiphoid approach D 33245 Insertion of epicardial single or dual chamber pacing 1/1/2007 cardioverter defibrillator electrodes by thoracotomy; D 33246 Insertion of epicardial single or dual chamber pacing 1/1/2007 cardioverter defibrillator electrodes by thoracotomy; with insertion of pulse generator D 33253 Operative incisions and reconstruction of atria for 1/1/2007 treatment of atrial fibrillation or atrial flutter (e.g., maze procedure) D 35381 Thromboendarterectomy, with or without patch graft; 1/1/2007 femoral and/or popliteal, and/or tibioperoneal D 35507 Bypass graft, with vein; subclavian-carotid 1/1/2007 D 35541 Bypass graft, with vein; aortoiliac or bi iliac 1/1/2007 D 35546 Bypass graft, with vein; aortofemoral or bifemoral 1/1/2007 D 35641 Bypass graft, with other than vein; aortoiliac or bi iliac 1/1/2007

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition D 44152 Colectomy, total, abdominal, without proctectomy; with 1/1/2007 rectal mucosectomy, ileonal anastomosis, with or without loop ileostomy D 44153 Colectomy, total, abdominal, without proctectomy; with 1/1/2007 rectal mucosectomy, ileonal anastomosis, creation of ileal reservoir (S or J), with or without loop ileostomy D 47716 Anastomosis, choledochal cyst, without excision 1/1/2007 D 48005 Resection or debridement of pancreas and peripancreatic 1/1/2007 tissue for acute necrotizing pancreatitis D 48180 Pancreaticojejunostomy, side-to-side anastomosis (Puestow- 1/1/2007 type operation) D 49085 Removal of peritoneal foreign body from peritoneal cavity 1/1/2007 D 54152 Circumcision, using clamp or other device; except 1/1/2007 newborns D 54820 Exploration of epididymis, with or without biopsy 1/1/2007 D 55859 Transperineal placement of needles or catheters into 1/1/2007 prostate for interstitial radioelement application, with or without cystoscopy D 56720 Hymenotomy, simple incision 1/1/2007 D 57820 Dilation and curettage of cervical stump 1/1/2007 D 67350 Biopsy of extraocular muscle 1/1/2007 D 75998 Fluoroscopic guidance for central venous access device 1/1/2007 placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) D 76003 Fluoroscopic guidance for needle placement (e.g., biopsy, 1/1/2007 aspiration, injection, localization device) D 76005 Fluoroscopic guidance and localization of needle or 1/1/2007 catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction D 76006 Manual application of stress performed by physician for 1/1/2007 joint radiography, including contralateral joint if indicated D 76012 Radiological supervision and interpretation, percutaneous 1/1/2007 vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance D 76013 Radiological supervision and interpretation, percutaneous 1/1/2007 vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance D 76020 Bone age studies 1/1/2007 D 76040 Bone length studies (orthoroentgenogram, scanogram) 1/1/2007 D 76061 Radiologic examination, osseous survey; limited (e.g., for 1/1/2007 metastases) D 76062 Radiologic examination, osseous survey; complete (axial 1/1/2007 and appendicular skeleton)

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition D 76065 Radiologic examination, osseous survey; infant 1/1/2007 D 76066 Joint survey, single view, two or more joints (specify) 1/1/2007 D 76070 Computed tomography, bone mineral density study, one or 1/1/2007 more sites; axial skeleton (e.g., hips, pelvis, spine) D 76071 Computed tomography, bone mineral density study, one or 1/1/2007 more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) D 76075 Dual energy x-ray absorptiometry (DXA), bone density 1/1/2007 study, one or more sites; axial skeleton (e.g., hips, pelvis, spine) D 76076 Dual energy x-ray absorptiometry (DXA), bone density 1/1/2007 study, one or more sites; appendicular skeleton (peripheral) (e.g., radius, wrist, heel) D 76077 Dual energy x-ray absorptiometry (DXA), bone density 1/1/2007 study, one or more sites; vertebral fracture assessment D 76078 Radiographic absorptiometry (e.g., photodensitometry, 1/1/2007 radiogrammetry), one or more sites D 76082 Computer aided detection (computer algorithm analysis 1/1/2007 of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure) D 76083 Computer aided detection (computer algorithm analysis 1/1/2007 of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure) D 76086 Mammary ductogram or galactogram, single duct, 1/1/2007 radiological supervision and interpretation D 76088 Mammary ductogram or galactogram, multiple ducts, 1/1/2007 radiological supervision and interpretation D 76090 Mammography, unilateral 1/1/2007 D 76091 Mammography, bilateral 1/1/2007 D 76092 Screening mammography, bilateral (two view film study of 1/1/2007 each breast) D 76093 Magnetic resonance imaging, breast, without and/or with 1/1/2007 contrast material(s); unilateral D 76094 Magnetic resonance imaging, breast, without and/or with 1/1/2007 contrast material(s); bilateral D 76095 Stereotactic localization guidance for breast biopsy 1/1/2007 or needle placement (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation D 76096 Mammographic guidance for needle placement, breast 1/1/2007 (e.g., for wire localization or for injection), each lesion, radiological supervision and interpretation D 76355 Computed tomography guidance for stereotactic 1/1/2007 localization D 76360 Computed tomography guidance for needle placement 1/1/2007 (e.g., biopsy, aspiration, injection, localization device), radiological supervision and interpretation

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition D 76362 Computed tomography guidance for, and monitoring of, 1/1/2007 visceral tissue ablation D 76370 Computed tomography guidance for placement of 1/1/2007 radiation therapy fields D 76393 Magnetic resonance guidance for needle placement (e.g., 1/1/2007 for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation D 76394 Magnetic resonance guidance for, and monitoring of, 1/1/2007 visceral tissue ablation D 76400 Magnetic resonance (e.g., proton) imaging, bone marrow 1/1/2007 blood supply D 76778 Ultrasound, transplanted kidney, B-scan and/or real time 1/1/2007 with image documentation, with or without duplex Doppler study D 76986 Ultrasonic guidance, intraoperative 1/1/2007 D 78704 Kidney imaging; with function study (i.e., imaging 1/1/2007 renogram) D 78715 Kidney vascular flow only 1/1/2007 D 78760 Testicular imaging; 1/1/2007 D 91060 Gastric saline load test 1/1/2007 D 92573 Lombard test 1/1/2007 D 94656 Ventilation assist and management, initiation of pressure 1/1/2007 or volume preset ventilators for assisted or controlled breathing; first day D 94657 Ventilation assist and management, initiation of pressure 1/1/2007 or volume preset ventilators for assisted or controlled breathing; subsequent days D 95078 Provocative testing (e.g., Rankle test) 1/1/2007 D 0044T Whole body integumentary photography, at request of 1/1/2007 a physician, for monitoring of high risk patients; with dysplastic nevus syndrome or familial melanoma D 0045T Whole body integumentary photography, at request of a 1/1/2007 physician, for monitoring of high risk patients; with history of dysplastic nevi or personal history of melanoma D 0082T Stereotactic body radiation therapy, treatment delivery, one 1/1/2007 or more treatment areas, per day D 0083T Stereotactic body radiation therapy, treatment 1/1/2007 management, per day D 0091T Total disc arthroplasty (artificial disc), anterior approach, 1/1/2007 including discectomy to prepare interspace (other than for decompression); single interspace, lumbar D 0094T Removal of total disc arthroplasty, anterior approach; 1/1/2007 single interspace, lumbar D 0097T Revision of total disc arthroplasty, anterior approach; 1/1/2007 single interspace, lumbar D 0120T Ablation, cryosurgical, of fibroadenoma, including 1/1/2007 ultrasound guidance, each fibroadenoma

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition D 0152T Computer aided detection (computer algorithm 1/1/2007 analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; chest radiograph(s) (List separately in addition to code for primary procedure) R 15100 Split-thickness autograft, trunk, arms, legs; first 100 sq cm 1/1/2007 or less, or 1% of body area of infants and children (except 15050) R 15101 Split-thickness autograft, trunk, arms, legs; each additional 1/1/2007 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) R 15110 Epidermal autograft, trunk, arms, legs; first 100 sq cm or 1/1/2007 less, or 1% of body area of infants and children R 15111 Epidermal autograft, trunk, arms, legs; each additional 1/1/2007 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) R 15115 Epidermal autograft, face, scalp, eyelids, mouth, neck, 1/1/2007 ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children R 15116 Epidermal autograft, face, scalp, eyelids, mouth, neck, 1/1/2007 ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) R 15120 Split-thickness autograft, face, scalp, eyelids, mouth, neck, 1/1/2007 ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) R 15121 Split-thickness autograft, face, scalp, eyelids, mouth, neck, 1/1/2007 ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) R 15130 Dermal autograft, trunk, arms, legs; first 100 sq cm or less, 1/1/2007 or 1% of body area of infants and children R 15131 Dermal autograft, trunk, arms, legs; each additional 100 1/1/2007 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) R 15135 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, 1/1/2007 orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children R 15136 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, 1/1/2007 orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants or children or part thereof (List separately in addition to code for primary procedure) R 15152 Tissue cultured epidermal autograft, trunk, arms, legs; each 1/1/2007 additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition R 15157 Tissue cultured epidermal autograft, face, scalp, eyelids, 1/1/2007 mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) R 15170 Acellular dermal replacement, trunk, arms, legs; first 100 1/1/2007 sq cm or less, or 1% of body area of infants and children R 15175 Acellular dermal replacement, face, scalp, eyelids, mouth, 1/1/2007 neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children R 15176 Acellular dermal replacement, face, scalp, eyelids, mouth, 1/1/2007 neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) R 15336 Acellular dermal allograft, face, scalp, eyelids, mouth, 1/1/2007 neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) R 15360 Tissue cultured allogeneic dermal substitute; trunk, arms, 1/1/2007 legs; first 100 sq cm or less, or 1% of body area of infants and children R 15366 Tissue cultured allogeneic dermal substitute, face, scalp, 1/1/2007 eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) R 15400 Xenograft, skin (dermal), for temporary wound closure; 1/1/2007 trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children R 15401 Xenograft, skin (dermal), for temporary wound closure; 1/1/2007 trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children or part thereof (List separately in addition to code for primary procedure) R 17000 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, 1/1/2007 chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion R 17003 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, 1/1/2007 chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) R 17004 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, 1/1/2007 chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions R 17110 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, 1/1/2007 chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition R 17111 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, 1/1/2007 chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; 15 or more lesions R 19361 Breast reconstruction with latissimus dorsi flap without 1/1/2007 prosthetic implant R 25600 Closed treatment of distal radial fracture (e.g., Colles 1/1/2007 or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation R 25605 Closed treatment of distal radial fracture (e.g., Colles 1/1/2007 or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation R 26170 Excision of tendon, palm, flexor or extensor, single, each 1/1/2007 tendon R 26180 Excision of tendon, finger, flexor or extensor, each tendon 1/1/2007 R 33681 Closure of single ventricular septal defect, with or without 1/1/2007 patch; R 33684 Closure of single ventricular septal defect, with or without 1/1/2007 patch; with pulmonary valvotomy or infundibular resection (acyanotic) R 33688 Closure of single ventricular septal defect, with or without 1/1/2007 patch; with removal of pulmonary artery band, with or without gusset R 35301 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; carotid, vertebral, subclavian, by neck incision R 35311 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; subclavian, innominate, by thoracic incision R 35321 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; axillary-brachial R 35331 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; abdominal aorta R 35341 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; mesenteric, celiac, or renal R 35351 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; iliac R 35355 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; iliofemoral R 35361 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; combined aortoiliac R 35363 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; combined aortoiliofemoral R 35371 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; common femoral R 35372 Thromboendarterectomy, including patch graft, if 1/1/2007 performed; deep (profunda) femoral R 35501 Bypass graft, with vein; common carotid-ipsilateral internal 1/1/2007 carotid R 35506 Bypass graft, with vein; carotid-subclavian or subclavian- 1/1/2007 carotid

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition R 35509 Bypass graft, with vein; carotid-contralateral carotid 1/1/2007 R 35601 Bypass graft, with other than vein; common carotid- 1/1/2007 ipsilateral internal carotid R 44211 Laparoscopy, surgical; colectomy, total abdominal, with 1/1/2007 proctectomy, with ileoanal anastomosis, creation of ileal reservoir (S or J), with look ileostomy, includes rectal mucosectomy, when performed R 51720 Bladder instillation of anticarcinogenic agent (including 1/1/2007 retention time) R 52204 Cystourethroscopy, with biopsy(s) 1/1/2007 R 54150 Circumcision, using clamp or other device with regional 1/1/2007 dorsal penile or ring block; neonate (28 days of age or less) R 54160 Circumcision, surgical excision other than clamp, device, 1/1/2007 or dorsal slit; neonate (28 days of age or less) R 54161 Circumcision, surgical excision other than clamp, device, 1/1/2007 or dorsal slit; older than 28 days of age R 58950 Resection (initial) of ovarian, tubal or primary peritoneal 1/1/2007 malignancy with bilateral salpingo-oophorectomy and omentectomy; R 58951 Resection (initial) of ovarian, tubal or primary peritoneal 1/1/2007 malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy R 58952 Resection (initial) of ovarian, tubal or primary peritoneal 1/1/2007 malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (i.e., radical excision or destruction, intra-abdominal or retroperitoneal tumors) R 61107 Twist drill hole(s) for subdural, intracerebral, or ventricular 1/1/2007 puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device R 61210 Burr hole(s); for implanting ventricular catheter, reservoir, 1/1/2007 EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure) R 64590 Insertion or replacement of peripheral or gastric 1/1/2007 neurostimulator pulse generator or receiver, direct or inductive coupling R 64595 Revision or removal of peripheral or gastric neurostimulator 1/1/2007 pulse generator or receiver R 70540 Magnetic resonance (e.g., proton) imaging, orbit, face, 1/1/2007 and/or neck; without contrast material(s) R 70542 Magnetic resonance (e.g., proton) imaging, orbit, face, 1/1/2007 and/or neck; with contrast material(s) R 70543 Magnetic resonance (e.g., proton) imaging, orbit, face, 1/1/2007 and/or neck; without contrast material(s), followed by contrast material(s) and further sequences R 71275 Computed tomographic angiography, chest (noncoronary) 1/1/2007 without contrast material(s), followed by contrast material(s) and further sections, including image postprocessing R 76536 Ultrasound, soft tissues of head and neck (e.g., thyroid, 1/1/2007 parathyroid, parotid), real time with image documentation

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition R 76604 Ultrasound, chest, (includes mediastinum) real time with 1/1/2007 image documentation R 76645 Ultrasound, breast(s) (unilateral or bilateral), real time with 1/1/2007 image documentation R 76700 Ultrasound, abdominal, real time with image 1/1/2007 documentation; complete R 76705 Ultrasound, abdominal, real time with image 1/1/2007 documentation; limited (e.g., single organ, quadrant, follow-up) R 76770 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real 1/1/2007 time with image documentation; complete R 76775 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real 1/1/2007 time with image documentation; limited R 76856 Ultrasound, pelvic (nonobstetric), real time with image 1/1/2007 documentation; complete R 76857 Ultrasound, pelvic (nonobstetric), real time with image 1/1/2007 documentation; limited or follow-up (e.g., for follicles) R 76880 Ultrasound, extremity, nonvascular, real time with image 1/1/2007 documentation R 76940 Ultrasound guidance for, and monitoring of, parenchymal 1/1/2007 tissue ablation R 78700 Kidney imaging morphology; 1/1/2007 R 78707 Kidney imaging morphology; with vascular flow and 1/1/2007 function, single study without pharmacological intervention. R 78708 Kidney imaging morphology; with vascular flow and 1/1/2007 function, single study, with pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic) R 78709 Kidney imaging morphology; with vascular flow 1/1/2007 and function, multiple studies, with and without pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic) R 78710 Kidney imaging morphology; tomographic (SPECT) 1/1/2007 R 78730 Urinary bladder residual study (List separately in addition 1/1/2007 to code for primary procedure) R 78761 Testicular imaging; with vascular flow 1/1/2007 R 87088 Culture, bacterial; with isolation and presumptive 1/1/2007 identification of each isolate, urine R 88106 Cytopathology, fluids, washings or brushings, except 1/1/2007 cervical or vaginal; simple filter method with interpretation R 88107 Cytopathology, fluids, washings or brushings, except 1/1/2007 cervical or vaginal; smears and simple filter preparation with interpretation R 89060 Crystal identification by light microscopy with or without 1/1/2007 polarizing lens analysis, tissue or any body fluid (except urine) R 90655 Influenza virus vaccine, split virus, preservative free, 1/1/2007 when administered to children 6-35 months of age, for intramuscular use R 90656 Influenza virus vaccine, split virus, preservative free, 1/1/2007 when administered to children 3 years and older for intramuscular use

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition R 90657 Influenza virus vaccine, split virus, when administered to 1/1/2007 children 6-35 months of age, for intramuscular use R 90658 Influenza virus vaccine, split virus, when administered to 1/1/2007 children 3 years of age and older, for intramuscular use R 90669 Pneumococcal conjugate vaccine, polyvalent, when 1/1/2007 administered to children younger than 5 years, for intramuscular use R 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine 1/1/2007 (DTaP) when administered to younger than children 7 years, for intramuscular use R 90702 Diphtheria, and tetanus toxoids (DT) adsorbed, 1/1/2007 preservative free, when administered to younger than children 7 years, for intramuscular use R 90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservative 1/1/2007 free when administered to children 7 years or older, for intramuscular use R 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine 1/1/2007 (Tdap), when administered to children 7 years or older, for intramuscular use R 90718 Tetanus and diphtheria toxoids (Td) adsorbed when 1/1/2007 administered to children 7 years or older, for intramuscular use R 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult 1/1/2007 or immunosuppressed patient dosage, when administered to children 2 years or older, for subcutaneous or intramuscular use R 94620 Pulmonary stress testing; simple (e.g., 6 minute walk test, 1/1/2007 prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry) R 99251 Inpatient consultation for a new or established patient 1/1/2007 which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making R 99252 Inpatient consultation for a new or established patient 1/1/2007 which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and a straightforward medical decision making R 99253 Inpatient consultation for a new or established patient 1/1/2007 which requires these three key components: a detailed history; a detailed examination; and medical decision of low complexity R 99254 Inpatient consultation for a new or established 1/1/2007 patient which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity R 99255 Inpatient consultation for a new or established 1/1/2007 patient which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity R 0062T Percutaneous intradiscal annuloplasty, any method except 1/1/2007 electrothermal, unilateral or bilateral including fluoroscopic guidance; single level

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CPT CODES Action A=Addition Effective Date D=Deletion CPT ®* Code Narrative of Revision/ Delete Date R=Revision Addition R 0063T Percutaneous intradiscal annuloplasty, any method except 1/1/2007 electrothermal, unilateral or bilateral including fluoroscopic guidance; one or more additional levels (List separately in addition to 0062T for primary procedure) R 0068T Acoustic heart sound recording and computer analysis; 1/1/2007 with interpretation and report R 0069T Acoustic heart sound recording and computer analysis; 1/1/2007 only R 0070T Acoustic heart sound recording and computer analysis; 1/1/2007 interpretation and report only R 0087T Sperm evaluation, Hyaluronan sperm binding test 1/1/2007 R 0090T Total disc arthroplasty (artificial disc), anterior approach, 1/1/2007 including discectomy to prepare interspace (other than for decompression) cervical; single interspace R 0092T Total disc arthroplasty (artificial disc), anterior approach, 1/1/2007 including discectomy to prepare interspace (other than for decompression) cervical; each additional interspace (List separately in addition to the code for primary procedure) R 0093T Removal of total disc arthroplasty, anterior approach 1/1/2007 cervical; single interspace R 0095T Removal of total disc arthroplasty, anterior approach 1/1/2007 cervical; each additional innerspace (List separately in addition to code for primary procedure) R 0096T Revision of total disc arthroplasty, anterior approach 1/1/2007 cervical; single interspace R 0098T Revision of total disc arthroplasty, anterior approach 1/1/2007 cervical; each additional interspace

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A C9231 Injection, decitabine, per 1 mg 10/1/2006

A C9727 Insertion of implants into the soft palate; minimum of three 10/1/2006 implants A K0738 Portable gaseous oxygen system, rental: home compressor 10/1/2006 used to fill portable oxygen cylinders, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing A K0800 Power operated vehicle, group 1 standard, patient weight 10/1/2006 capacity up to and including 300 pounds A K0801 Power operated vehicle, group 1 heavy duty, patient 10/1/2006 weight capacity, 301 to 450 lbs A K0802 Power operated vehicle, group 1 very heavy duty, patient 10/1/2006 weight capacity 451 to 600 pounds A K0806 Power operated vehicle, group 2 standard, patient weight 10/1/2006 capacity up to and including 300 pounds A K0807 Power operated vehicle, group 2 heavy duty, patient 10/1/2006 weight capacity 301 to 450 pounds A K0808 Power operated vehicle, group 2 very heavy duty, patient 10/1/2006 weight capacity 451 to 600 pounds A K0812 Power operated vehicle, not otherwise classified 10/1/2006

A K0813 Power wheelchair, group 1 standard, portable, sling/ 10/1/2006 solid seat and back, patient weight capacity up to and including 300 pounds A K0814 Power wheelchair, group 1 standard, portable, captain’s 10/1/2006 chair, patient weight capacity up to and including 300 pounds A K0815 Power wheelchair, group 1 standard, sling/solid seat and 10/1/2006 back, patient weight capacity up to and including 300 pounds A K0816 Power wheelchair, group 1 standard, captain’s chair, 10/1/2006 patient weight capacity up to and including 300 pounds A K0820 Power wheelchair, group 2 standard, portable, sling/solid 10/1/2006 seat/back, patient weight capacity up to and including 300 pounds A K0821 Power wheelchair, group 2 standard, portable, captain’s 10/1/2006 chair, patient weight capacity up to and including 300 pounds A K0822 Power wheelchair, group 2 standard, sling/solid seat/ 10/1/2006 back, patient weight capacity up to and including 300 pounds A K0823 Power wheelchair, group 2 standard, captain’s chair, 10/1/2006 patient weight capacity up to and including 300 pounds A K0824 Power wheelchair, group 2 heavy duty, sling/solid seat/ 10/1/2006 back, patient weight capacity 301 to 450 pounds A K0825 Power wheelchair, group 2 heavy duty, captain’s chair, 10/1/2006 patient weight capacity 301 to 450 pounds A K0826 Power wheelchair, group 2 very heavy duty, sling/solid 10/1/2006 seat/back, patient weight capacity 451 to 600 pounds A K0827 Power wheelchair, group 2 very heavy duty, captain’s 10/1/2006 chair, patient weight capacity 451 to 600 pounds

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A K0828 Power wheelchair, group 2 extra heavy duty, sling/solid 10/1/2006 seat/back, patient weight capacity 601 pounds or more A K0829 Power wheelchair, group 2 extra heavy duty, captain’s 10/1/2006 chair, patient weight capacity 601 pounds or more A K0830 Power wheelchair, group 2 standard, seat elevator, 10/1/2006 sling/solid seat/back, patient weight capacity up to and including 300 pounds A K0831 Power wheelchair, group 2 standard, seat elevator, 10/1/2006 captain’s chair, patient weight capacity up to and including 300 pounds A K0835 Power wheelchair, group 2 standard, single power option, 10/1/2006 sling/solid seat/back, patient weight capacity up to and including 300 pounds A K0836 Power wheelchair, group 2 standard, single power 10/1/2006 option, captain’s chair, patient weight capacity up to and including 300 pounds A K0837 Power wheelchair, group 2 heavy duty, single power 10/1/2006 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds A K0838 Power wheelchair, group 2 heavy duty, single power 10/1/2006 option, captain’s chair, patient weight capacity 301 to 450 pounds A K0839 Power wheelchair, group 2 very heavy duty, single power 10/1/2006 option, sling/solid seat/back, patient weight capacity 451 to 600 pounds A K0840 Power wheelchair, group 2 extra heavy duty, single power 10/1/2006 option sling/solid seat/back, patient weight capacity 601 pounds or more A K0841 Power wheelchair, group 2 standard, multiple power 10/1/2006 option, sling/solid seat/back, patient weight capacity up to and including 300 pounds A K0842 Power wheelchair, group 2 standard, multiple power 10/1/2006 option, captain’s chair, patient weight capacity up to and including 300 pounds A K0843 Power wheelchair, group 2 heavy duty, multiple power 10/1/2006 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds A K0848 Power wheelchair, group 3 standard, sling/solid seat/ 10/1/2006 back, patient weight capacity up to and including 300 pounds A K0849 Power wheelchair, group 3 standard, captain’s chair, 10/1/2006 patient weight capacity up to and including 300 pounds A K0850 Power wheelchair, group 3 heavy duty, sling/solid seat/ 10/1/2006 back, patient weight capacity 301 to 450 pounds A K0851 Power wheelchair, group 3 heavy duty, captain’s chair, 10/1/2006 patient weight capacity 301 to 450 pounds A K0852 Power wheelchair, group 3 very heavy duty, sling/solid 10/1/2006 seat/back, patient weight capacity 451 to 600 pounds A K0853 Power wheelchair, group 3 very heavy duty, captain’s 10/1/2006 chair, patient weight capacity, 451 to 600 pounds A K0854 Power wheelchair, group 3 extra heavy duty, sling/solid 10/1/2006 seat/back, patient weight capacity 601 pounds or more

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A K0855 Power wheelchair, group 3 extra heavy duty, captain’s 10/1/2006 chair, patient weight capacity 601 pounds or more A K0856 Power wheelchair, group 3 standard, single power option, 10/1/2006 sling/solid seat/back, patient weight capacity up to and including 300 pounds A K0857 Power wheelchair, group 3 standard, single power 10/1/2006 option, captain’s chair, patient weight capacity up to and including 300 pounds A K0858 Power wheelchair, group 3 heavy duty, single power 10/1/2006 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds A K0859 Power wheelchair, group 3 heavy duty, single power 10/1/2006 option, captain’s chair, patient weight capacity 301 to 450 pounds A K0860 Power wheelchair, group 3 very heavy duty, single power 10/1/2006 option, sling/solid seat/back, patient weight capacity 451 to 600 pounds A K0861 Power wheelchair, group 3 standard, multiple power 10/1/2006 option, sling/solid seat/back, patient weight capacity up to and including 300 pounds A K0862 Power wheelchair, group 3 heavy duty, multiple power 10/1/2006 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds A K0863 Power wheelchair, group 3 very heavy duty, multiple 10/1/2006 power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds A K0864 Power wheelchair, group 3 extra heavy duty, multiple 10/1/2006 power option, sling/solid seat/back, patient weight capacity 601 pounds or more A K0868 Power wheelchair, group 4 standard, sling/solid seat/ 10/1/2006 back, patient weight capacity up to and including 300 pounds A K0869 Power wheelchair, group 4 standard, captains chair, 10/1/2006 patient weight capacity up to and including 300 pounds A K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/ 10/1/2006 back, patient weight capacity 301 to 450 pounds A K0871 Power wheelchair, group 4 very heavy duty, sling/solid 10/1/2006 seat/back, patient weight capacity 451 to 600 pounds A K0877 Power wheelchair, group 4 standard, single power option, 10/1/2006 sling/solid seat/back, patient weight capacity up to and including 300 pounds A K0878 Power wheelchair, group 4 standard, single power 10/1/2006 option, captain’s chair, patient weight capacity up to and including 300 pounds A K0879 Power wheelchair, group 4 heavy duty, single power 10/1/2006 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds A K0880 Power wheelchair, group 4 very heavy duty, single power 10/1/2006 option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A K0884 Power wheelchair, group 4 standard, multiple power 10/1/2006 option, sling/solid seat/back, patient weight capacity up to and including 300 pounds A K0885 Power wheelchair, group 4 standard, multiple power 10/1/2006 option, captain’s chair, weight capacity up to and including 300 pounds A K0886 Power wheelchair, group 4 heavy duty, multiple power 10/1/2006 option, sling/solid seat/back, patient weight capacity 301 to 450 pounds A K0890 Power wheelchair, group 5 pediatric, single power option, 10/1/2006 sling/solid seat/back, patient weight capacity up to and including 125 pounds A K0891 Power wheelchair, group 5 pediatric, multiple power 10/1/2006 option, sling/solid seat/back, patient weight capacity up to and including 125 pounds A K0898 Power wheelchair, not otherwise classified 10/1/2006

A K0899 Power mobility devise, not coded by SADMERC or does 10/1/2006 not meet criteria A S0147 Injection, alglucosidase ALFA, 20 mg 10/1/2006

A S2325 Hip core decompression 10/1/2006

A A4461 Surgical dressing holder, non-reusable, each 1/1/2007

A A4463 Surgical dressing holder, reusable, each 1/1/2007

A A4559 Coupling gel or paste, for use with ultrasound device, per 1/1/2007 oz A A4600 Sleeve for intermittent limb compression device, 1/1/2007 replacement only, each A A4601 Lithium ion battery for non-prosthetic use, replacement 1/1/2007

A A8000 Helmet, protective, soft, prefabricated, includes all 1/1/2007 components and accessories A A8001 Helmet, protective, hard, prefabricated, includes all 1/1/2007 components and accessories A A8002 Helmet, protective, soft, custom fabricated, includes all 1/1/2007 components and accessories A A8003 Helmet, protective, hard, custom fabricated, includes all 1/1/2007 components and accessories A A8004 Hoft interface for helmet, replacement only 1/1/2007

A A9279 Monitoring feature/device, stand-alone or integrated, any 1/1/2007 type, includes all accessories, components and electronics, not otherwise classified A A9527 Iodine I-125, sodium iodide solution, therapeutic, per 1/1/2007 millicurie A A9568 Technetium Tc-99m arcitumomab, diagnostic, per study 1/1/2007 dose, up to 45 millicuries A C1821 Interspinous process distraction device (implantable) 1/1/2007

A C9232 Injection, idursulfase, 1 mg 1/1/2007

A C9233 Injection, ranibizumab, 0.5 mg 1/1/2007

A C9234 Injection, alglucosidase alfa, 10 mg 1/1/2007

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A C9235 Injection, panitumumab, 10 mg 1/1/2007

A C9350 Microporous collagen tube of non-human origin, per 1/1/2007 centimeter length A C9351 Acellular dermal tissue matrix of non-human origin, per 1/1/2007 square centimeter (do not report C9351 in conjunction with J7345) A D0145 Oral evaluation for a patient under three years of age and 1/1/2007 counseling with primary caregiver A D0273 Bitewings - three films 1/1/2007

A D0360 Cone beam CT - craniofacial data capture 1/1/2007

A D0362 Cone beam - two-dimensional image reconstruction using 1/1/2007 existing data, includes multiple images A D0363 Cone beam - three-dimensional image reconstruction using 1/1/2007 existing data, includes multiple images A D0486 Accession of brush biopsy sample, microscopic 1/1/2007 examination, preparation and transmission of written report A D1206 Topical fluoride varnish; therapeutic application for 1/1/2007 moderate to high caries risk patients A D1555 Removal of fixed space maintainer 1/1/2007

A D4230 Anatomical crown exposure - four or more contiguous 1/1/2007 teeth per quadrant A D4231 Anatomical crown exposure - one to three teeth per 1/1/2007 quadrant A D6012 Surgical placement of interim implant body for transitional 1/1/2007 prosthesis: endosteal implant A D6091 Replacement of semi-precision or precision attachment 1/1/2007 (male or female component) of implant/abutment supported prosthesis, per attachment A D6092 Recement implant/abutment supported crown 1/1/2007

A D6093 Recement implant/abutment supported fixed partial 1/1/2007 denture A D7292 Surgical placement: temporary anchorage device [screw 1/1/2007 retained plate] requiring surgical flap A D7293 Surgical placement: temporary anchorage device requiring 1/1/2007 surgical flap A D7294 Surgical placement: temporary anchorage device without 1/1/2007 surgical flap A D7951 Sinus augmentation with bone or bone substitutes 1/1/2007

A D7998 Intraoral placement of a fixation device not in conjunction 1/1/2007 with a fracture A D8693 Rebonding or recementing; and/or repair, as required, of 1/1/2007 fixed retainers A D9120 Fixed partial denture sectioning 1/1/2007

A D9612 Therapeutic parenteral drugs, two or more administrations, 1/1/2007 different medications A E0676 Intermittent limb compression device (includes all 1/1/2007 accessories), not otherwise specified

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A E0936 Continuous passive motion exercise device for use other 1/1/2007 than knee A E2373 Power wheelchair accessory, hand or chin control 1/1/2007 interface, mini-proportional, compact, or short throw remote joystick or touchpad, proportional, including all related electronics and fixed mounting hardware A E2374 Power wheelchair accessory, hand or chin control 1/1/2007 interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only A E2375 Power wheelchair accessory, non-expandable controller, 1/1/2007 including all related electronics and mounting hardware, replacement only A E2376 Power wheelchair accessory, expandable controller, 1/1/2007 including all related electronics and mounting hardware, replacement only A E2377 Power wheelchair accessory, expandable controller, 1/1/2007 including all related electronics and mounting hardware, upgrade provided at initial issue A E2381 Power wheelchair accessory, pneumatic drive wheel tire, 1/1/2007 any size, replacement only, each A E2382 Power wheelchair accessory, tube for pneumatic drive 1/1/2007 wheel tire, any size, replacement only, each A E2383 Power wheelchair accessory, insert for pneumatic drive 1/1/2007 wheel tire (removable), any type, any size, replacement only, each A E2384 Power wheelchair accessory, pneumatic caster tire, any 1/1/2007 size, replacement only, each A E2385 Power wheelchair accessory, tube for pneumatic caster 1/1/2007 tire, any size, replacement only, each A E2386 Power wheelchair accessory, foam filled drive wheel tire, 1/1/2007 any size, replacement only, each A E2387 Power wheelchair accessory, foam filled caster tire, any 1/1/2007 size, replacement only, each A E2388 Power wheelchair accessory, foam drive wheel tire, any 1/1/2007 size, replacement only, each A E2389 Power wheelchair accessory, foam caster tire, any size, 1/1/2007 replacement only, each A E2390 Power wheelchair accessory, solid (rubber/plastic) drive 1/1/2007 wheel tire, any size, replacement only, each A E2391 Power wheelchair accessory, solid (rubber/plastic) caster 1/1/2007 tire (removable), any size, replacement only, each A E2392 Power wheelchair accessory, solid (rubber/plastic) caster 1/1/2007 tire with integrated wheel, any size, replacement only, each A E2393 Power wheelchair accessory, valve for pneumatic tire tube, 1/1/2007 any type, replacement only, each A E2394 Power wheelchair accessory, drive wheel excludes tire, 1/1/2007 any size, replacement only, each A E2395 Power wheelchair accessory, caster wheel excludes tire, 1/1/2007 any size, replacement only, each

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A E2396 Power wheelchair accessory, caster fork, any size, 1/1/2007 replacement only, each A G0377 Administration of vaccine for Part D Drug 1/1/2007

A G0380 Level 1 hospital emergency visit provided in a type B 1/1/2007 department or facility of the hospital: (the department or facility must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) A G0381 Level 2 hospital emergency visit provided in a type B 1/1/2007 department or facility of the hospital: (the department or facility must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) A G0382 Level 3 hospital emergency visit provided in a type B 1/1/2007 department or facility of the hospital: (the department or facility must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment)

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A G0383 Level 4 hospital emergency visit provided in a type B 1/1/2007 department or facility of the hospital: (the department or facility must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) A G0384 Level 5 hospital emergency visit provided in a type B 1/1/2007 department or facility of the hospital: (the department or facility must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) A G0389 Ultrasound b-scan and/or real time with image 1/1/2007 documentation; for abdominal aortic aneurysm (AAA) screening A G0390 Trauma response team associated with hospital critical 1/1/2007 care service A G0392 Transluminal balloon angioplasty, percutaneous; for 1/1/2007 maintenance of hemodialysis access, arteriovenous fistula or graft; arterial A G0393 Transluminal balloon angioplasty, percutaneous; for 1/1/2007 maintenance of hemodialysis access, arteriovenous fistula or graft; venous A G0394 Blood occult test (e.g., guaiac), feces, for single 1/1/2007 determination for colorectal neoplasm (i.e., patient was provided three cards or single triple card for consecutive collection) A G8191 Clinician documented to have given order for prophylactic 1/1/2007 antibiotic to be given within one hour (if Vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required)

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A G8192 Clinician documented to have given the prophylactic 1/1/2007 antibiotic within one hour (if Vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) A G8193 Clinician did not document that an order for prophylactic 1/1/2007 antibiotic to be given within one hour (if Vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required) was given A G8194 Clinician documented that patient was not an eligible 1/1/2007 candidate for prophylactic antibiotic A G8195 Clinician documented to have given the prophylactic 1/1/2007 antibiotic within one hour (if Vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) A G8196 Clinician did not document a prophylactic antibiotic was 1/1/2007 administered within one hour (if Vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required) A G8197 Patient documented to have order for prophylactic 1/1/2007 antibiotic to be given within one hour (if Vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required) A G8198 Patient documented to have order for Cefazolin or 1/1/2007 Cefuroxime for antimicrobial prophylaxis A G8199 Clinician documented to have given Cefazolin or 1/1/2007 Cefuroxime for antimicrobial prophylaxis A G8200 Order for Cefazolin or Cefuroxime for antimicrobial 1/1/2007 prophylaxis not documented A G8201 Patient was not an eligible candidate for Cefazolin or 1/1/2007 Cefuroxime for antimicrobial prophylaxis A G8202 Clinician documented an order was given to discontinue 1/1/2007 prophylactic antibiotics within 24 hours of surgical end time A G8203 Clinician documented that prophylactic antibiotics were 1/1/2007 discontinued within 24 hours of surgical end time A G8204 Clinician did not document an order was given to 1/1/2007 discontinue prophylactic antibiotics within 24 hours of surgical end time A G8205 Clinician documented that patient was not an eligible 1/1/2007 candidate for prophylactic antibiotic discontinuation within 24 hours of surgical end time A G8206 Clinician documented that prophylactic antibiotic was 1/1/2007 given A G8207 Clinician documented an order was given to discontinue 1/1/2007 prophylactic antibiotics within 48 hours of surgical end time A G8208 Clinician documented that prophylactic antibiotics were 1/1/2007 discontinued within 48 hours of surgical end time A G8209 Clinician did not document an order was given to 1/1/2007 discontinue prophylactic antibiotics within 48 hours of surgical end time

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A G8210 Clinician documented patient was not an eligible 1/1/2007 candidate for discontinuation of prophylactic antibiotic discontinuation within 48 hours of surgical end time A G8211 Clinician documented that prophylactic antibiotic was 1/1/2007 given A G8212 Clinician documented an order was given for appropriate 1/1/2007 venous thromboembolism (VTE) prophylaxis to be given within 24 hrs prior to incision time or 24 hours after surgery end time A G8213 Clinician documented to have given VTE prophylaxis 1/1/2007 within 24 hrs prior to incision time or 24 hours after surgery end time A G8214 Clinician did not document an order was given for 1/1/2007 appropriate venous thromboembolism (VTE) prophylaxis to be given within 24 hrs prior to incision time or 24 hours after surgery end time A G8215 Clinician documented that patient was not an eligible 1/1/2007 candidate for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time A G8216 Patient documented to have received DVT prophylaxis by 1/1/2007 end of hospital day two A G8217 Patient not documented to have received DVT prophylaxis 1/1/2007 by end of hospital day 2 A G8218 Patient was not an eligible candidate for DVT prophylaxis 1/1/2007 by end of hospital day 2, including physician documentation that patient is ambulatory A G8219 Patient documented to have received DVT prophylaxis by 1/1/2007 end of hospital day 2 A G8220 Patient not documented to have received DVT prophylaxis 1/1/2007 by end of hospital day 2 A G8221 Clinician documented that patient was not an eligible 1/1/2007 candidate for DVT prophylaxis by the end of hospital day 2, including physician documentation that patient is ambulatory A G8222 Patient documented to have been prescribed antiplatelet 1/1/2007 therapy at discharge A G8223 Patient not documented to have received prescription for 1/1/2007 antiplatelet therapy at discharge A G8224 Clinician documented that patient was not an eligible 1/1/2007 candidate for antiplatelet therapy at discharge, including identification from medical record that patient is on anticoagulation therapy A G8225 Patient documented to have been prescribed an 1/1/2007 anticoagulant at discharge A G8226 Patient not documented to have received prescription for 1/1/2007 anticoagulant therapy at discharge A G8227 Patient not documented to have permanent, persistent, or 1/1/2007 paroxysmal atrial fibrillation A G8228 Clinician documented that patient was not an eligible 1/1/2007 candidate for anticoagulant therapy at discharge A G8229 Patient documented to have been administered or 1/1/2007 considered for T-PA

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A G8230 Patient not eligible for T-PA administration, ischemic stroke 1/1/2007 symptom onset of more than 3 hours A G8231 Patient not documented to have received T-PA or not 1/1/2007 documented to have been considered a candidate for T-PA administration A G8232 Patient documented to have received dysphagia screening 1/1/2007 prior to taking any foods, fluids or medication by mouth A G8234 Patient not documented to have received dysphagia 1/1/2007 screening A G8235 Patient not receiving or ineligible to receive food, fluids or 1/1/2007 medication by mouth, or documentation of NPO (nothing by mouth) order A G8236 Clinician documented that patient was not an eligible 1/1/2007 candidate for dysphagia screening prior to taking any foods, fluids or medication by mouth A G8237 Patient documented to have received order for 1/1/2007 rehabilitation services or documentation of consideration for rehabilitation services A G8238 Patient not documented to have received order for or 1/1/2007 consideration for rehabilitation services A G8239 Internal carotid stenosis patient below 30%, reference to 1/1/2007 measurements of distal internal carotid diameter as the denominator for stenosis measurement not necessary A G8240 Internal carotid stenosis patient in the 30-99% range, and 1/1/2007 no documentation of reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement A G8241 Clinician documented that patient whose final report of 1/1/2007 the carotid imaging study performed (neck MRA, neck CTA, neck duplex ultrasound, carotid angiogram), with characterization of an internal carotid stenosis in the 30- 99% range, was not an eligible candidate for reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement A G8242 Patient documented to have received CT or MRI with 1/1/2007 presence or absence of hemorrhage, mass lesion and acute infarction documented in the final report A G8243 Patient not documented to have received CT or MRI and 1/1/2007 the presence or absence of hemorrhage, mass lesion and acute infarction not documented in the final report A G8245 Clinician documented presence or absence alarm 1/1/2007 symptoms A G8246 Patient was not an eligible candidate for medical history 1/1/2007 review with assessment of new or changing moles A G8247 Patient with alarm symptom(s) documented to have 1/1/2007 had upper endoscopy performed or referral for upper endoscopy A G8248 Patient with at least one alarm symptom not documented 1/1/2007 to have had upper endoscopy or referral for upper endoscopy A G8249 Clinician documented that patient was not an eligible 1/1/2007 candidate for upper endoscopy

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A G8250 Patient with suspicion of Barrett’s esophagus in endoscopy 1/1/2007 report and documented to have received an esophageal biopsy A G8251 Patient not documented to have received an esophageal 1/1/2007 biopsy when suspicion of Barrett’s esophagus is indicated in the endoscopy report A G8252 Clinician documented that patient was not an eligible 1/1/2007 candidate for esophageal biopsy A G8253 Patient documented to have received an order for a 1/1/2007 barium swallow test A G8254 Patient with no documentation order for barium swallow 1/1/2007 test A G8255 Clinician documentation that patient was an eligible 1/1/2007 candidate for barium swallow test A G8256 Clinician documented reconciliation of discharge 1/1/2007 medications with current medication list in medical record A G8257 Clinician has not documented reconciliation of discharge 1/1/2007 medications with current medication list in medical record A G8258 Patient was not an eligible candidate for discharge 1/1/2007 medications review A G8259 Patient documented to have surrogate decision maker or 1/1/2007 advance care plan in medical record A G8260 Patient not documented to have surrogate decision maker 1/1/2007 or advance care plan in medical record A G8261 Clinician documented that patient was not an eligible 1/1/2007 candidate for surrogate decision maker or advance care plan A G8262 Patient documented to have been assessed for presence or 1/1/2007 absence of urinary incontinence A G8263 Patient not documented to have been assessed for 1/1/2007 presence or absence of urinary incontinence A G8264 Clinician documented that patient was not an eligible 1/1/2007 candidate for an assessment of the presence or absence of urinary incontinence A G8265 Patient documented to have received characterization of 1/1/2007 urinary incontinence A G8266 Patient not documented to have received characterization 1/1/2007 of urinary incontinence A G8267 Patient documented to have received a plan of care for 1/1/2007 urinary incontinence A G8268 Patient not documented to have received plan of care for 1/1/2007 urinary incontinence A G8269 Clinician has not provided care for the patient for 1/1/2007 the required time to develop plan of care for urinary incontinence A G8270 Patient documented to have received screening for fall risk 1/1/2007 (2 or more falls in the past year or any fall with injury in the past year) A G8271 Patient with no documentation of screening for fall risks (2 1/1/2007 or more falls in the past year or any fall with injury in the past year)

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A G8272 Clinician documentation that patient was not an eligible 1/1/2007 candidate for fall risk screening A G8273 Clinician has not provided care for the patient for the 1/1/2007 required time to screen for fall risk A G8274 Clinician has not documented presence or absence of 1/1/2007 alarm symptoms A G8275 Patient documented to have medical history taken which 1/1/2007 included assessment of new or changing moles A G8276 Patient not documented to have received medical history 1/1/2007 with assessment of new or changing moles A G8277 Patient was not an eligible candidate for medical history 1/1/2007 review with assessment of new or changing moles A G8278 Patient documented to have received complete physical 1/1/2007 skin exam A G8279 Patient not documented to have received a complete 1/1/2007 physical skin exam A G8280 Patient was not an eligible candidate for complete physical 1/1/2007 skin exam during the reporting year A G8281 Patient documented to have received counseling to 1/1/2007 perform a self-examination A G8282 Patient not documented to have received counseling to 1/1/2007 perform a self-examination A G8283 Patient was not an eligible candidate for counseling to 1/1/2007 perform self-examination A G8284 Patient documented to have received a prescription for 1/1/2007 pharmacologic therapy for osteoporosis A G8285 Patient not documented to have received pharmacologic 1/1/2007 therapy A G8286 Clinician documented that patient was not an eligible 1/1/2007 candidate for pharmacologic therapy A G8287 Clinician has not provided care for the patient for the 1/1/2007 required time for the pharmacologic therapy measure A G8288 Patient documented to have received calcium and vitamin 1/1/2007 D or counseling on both calcium and vitamin D use, and exercise A G8289 Patient with no documentation of calcium and vitamin D 1/1/2007 use or counseling regarding both calcium and vitamin D use, or exercise A G8290 Clinician documentation that patient was not an eligible 1/1/2007 candidate for calcium and vitamin D, and exercise during the reporting year A G8291 Clinician has not provided care for the patient for the 1/1/2007 required time for the calcium, vitamin D, and exercise measure A G8292 COPD patient with spirometry results documented 1/1/2007

A G8293 COPD patient without spirometry results documented 1/1/2007

A G8294 COPD patient was not eligible for spirometry results 1/1/2007

A G8295 COPD patient documented to have received inhaled 1/1/2007 bronchodilator therapy

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A G8296 COPD patient not documented to have inhaled 1/1/2007 bronchodilator therapy prescribed A G8297 COPD patient was not eligible for inhaled bronchodilator 1/1/2007 therapy A G8298 Patient documented to have received optic nerve head 1/1/2007 evaluation A G8299 Patient not documented to have received optic nerve head 1/1/2007 evaluation A G8300 Clinician documented that patient was not an eligible 1/1/2007 candidate for optic nerve head evaluation during the reporting year A G8301 Clinician has not provided care for the primary open-angle 1/1/2007 glaucoma patient for the required time for optic nerve head evaluation measure A G8302 Patient documented to have a specific target intraocular 1/1/2007 pressure range goal A G8303 Patient not documented to have a specific target 1/1/2007 intraocular pressure range goal A G8304 Clinician documented that patient was not an eligible 1/1/2007 candidate for a specific target intraocular pressure range goal A G8305 Clinician has not provided care for the primary open-angle 1/1/2007 glaucoma patient for the required time for treatment range goal documentation measurement A G8306 Primary open-angle glaucoma patient with intraocular 1/1/2007 pressure above the target range goal documented to have received plan of care A G8307 Primary open-angle glaucoma patient with intraocular 1/1/2007 pressure at or below goal, no plan of care necessary A G8308 Primary open-angle glaucoma patient with intraocular 1/1/2007 pressure above the target range goal, and not documented to have received plan of care during the reporting year A G8309 Patient documented to have been prescribed/ 1/1/2007 recommended antioxidant vitamin or mineral supplement A G8310 Patient not documented to have been prescribed/ 1/1/2007 recommended at least one antioxidant vitamin or mineral supplement during the reporting year A G8311 Clinician documentation that patient was not an eligible 1/1/2007 candidate for antioxidant vitamin or mineral supplement during the reporting year A G8312 Clinician has not provided care for the age-related 1/1/2007 macular degeneration patient for the required time for antioxidant supplement prescription/recommended measure A G8313 Patient documented to have received macular exam, 1/1/2007 including documentation of the presence or absence of macular thickening or hemorrhage and the level of macular degeneration severity A G8314 Patient not documented to have received macular exam 1/1/2007 with documentation of presence or absence of macular thickening or hemorrhage and no documentation of level of macular degeneration severity

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A G8315 Clinician documentation that patient was not an eligible 1/1/2007 candidate for macular examination during the reporting year A G8316 Clinician has not provided care for the age-related 1/1/2007 macular degeneration patient for the required time for macular examination measurement A G8317 Patient documented to have visual functional status 1/1/2007 assessed A G8318 Patient documented not to have visual functional status 1/1/2007 assessed A G8319 Clinician documented that patient was not an eligible 1/1/2007 candidate for assessment of visual functional status A G8320 Clinician has not provided care for the cataract patient for 1/1/2007 the required time for assessment of visual functional status measurement A G8321 Patient documented to have had pre-surgical axial length, 1/1/2007 corneal power measurement and method of intraocular lens power calculation A G8322 Patient not documented to have had pre-surgical axial 1/1/2007 length, corneal power measurement and method of intraocular lens power calculation A G8323 Clinician documentation that patient was not an eligible 1/1/2007 candidate for pre-surgical axial length, corneal power measurement and method of intraocular lens power calculation A G8324 Clinician has not provided care for the cataract patient 1/1/2007 for the required time for pre-surgical measurement and intraocular lens power calculation measure A G8325 Patient documented to have received fundus evaluation 1/1/2007 within six months prior to cataract surgery A G8326 Patient not documented to have received fundus evaluation 1/1/2007 within six months prior to cataract surgery A G8327 Patient was not an eligible candidate for pre-surgical 1/1/2007 fundus evaluation A G8328 Clinician has not provided care for the cataract patient for 1/1/2007 the required time for fundus evaluation measurement A G8329 Patient documented to have received dilated macular or 1/1/2007 fundus exam with level of severity of retinopathy and the presence or absence of macular edema documented A G8330 Patient not documented to have received dilated macular 1/1/2007 or fundus exam with level of severity of retinopathy and the presence or absence of macular edema not documented A G8331 Clinician documentation that patient was not an eligible 1/1/2007 candidate for dilated macular or fundus exam during the reporting year A G8332 Clinician has not provided care for the diabetic 1/1/2007 retinopathy patient for the required time for macular edema and retinopathy measurement A G8333 Patient documented to have had findings of macular or 1/1/2007 fundus exam communicated to the physician managing the diabetes care

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A G8334 Documentation of findings of macular or fundus exam not 1/1/2007 communicated to the physician managing the patient’s ongoing diabetes care A G8335 Clinician documentation that patient was not an eligible 1/1/2007 candidate for the findings of their macular or fundus exam being communicated to the physician managing their diabetes care during the reporting year A G8336 Clinician has not provided care for the diabetic 1/1/2007 retinopathy patient for the required time for physician communication measurement A G8337 Clinician documented that communication was sent to 1/1/2007 the physician managing ongoing care of patient that a fracture occurred and that the patient was or should be tested or treated for osteoporosis A G8338 Clinician has not documented that communication was 1/1/2007 sent to the physician managing ongoing care of patient that a fracture occurred and that the patient was or should be tested or treated for osteoporosis A G8339 Patient was not an eligible candidate for communication 1/1/2007 with the physician managing the patient’s ongoing care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis A G8340 Patient documented to have had central DEXA performed 1/1/2007 and results documented or central DEXA ordered or pharmacologic therapy prescribed A G8341 Patient not documented to have had central DEXA 1/1/2007 measurement or pharmacologic therapy A G8342 Clinician documented that patient was not an eligible 1/1/2007 candidate for central DEXA measurement or prescribing pharmacologic A G8343 Clinician has not provided care for the patient for 1/1/2007 the required time for central DEXA measurement or pharmacological therapy measure A G8344 Patient documented to have had central DEXA ordered or 1/1/2007 performed and results documented or pharmacological therapy prescribed A G8345 Patient not documented to have had central DEXA 1/1/2007 measurement ordered or performed or pharmacologic therapy A G8346 Clinician documented that patient was not an 1/1/2007 eligible candidate for central DEXA measurement or pharmacologic therapy A G8347 Clinician has not provided care for the patient for 1/1/2007 the required time for central DEXA measurement or pharmacological therapy measure A G9131 Oncology; disease status; invasive female breast 1/1/2007 cancer (does not include ductal carcinoma in situ); adenocarcinoma as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) A G9132 Oncology; disease status; prostate cancer, limited 1/1/2007 to adenocarcinoma; hormone-refractory/androgen- independent (e.g., rising PSA on anti-androgen therapy or post-orchiectomy); clinical metastases (for use in a Medicare-approved demonstration project)

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A G9133 Oncology; disease status; prostate cancer, limited to 1/1/2007 adenocarcinoma; hormone-responsive; clinical metastases or M1 at diagnosis (for use in a Medicare-approved demonstration project) A G9134 Oncology; disease status; non-Hodgkin’s lymphoma, 1/1/2007 any cellular classification; stage I, II at diagnosis, not relapsed, not refractory (for use in a Medicare-approved demonstration project) A G9135 Oncology; disease status; non-Hodgkin’s lymphoma, 1/1/2007 any cellular classification; stage III, IV, not relapsed, not refractory (for use in a Medicare-approved demonstration project) A G9136 Oncology; disease status; non-Hodgkin’s lymphoma, 1/1/2007 transformed from original cellular diagnosis to a second cellular classification (for use in a Medicare-approved demonstration project) A G9137 Oncology; disease status; non-Hodgkin’s lymphoma, any 1/1/2007 cellular classification; relapsed/refractory (for use in a Medicare-approved demonstration project) A G9138 Oncology; disease status; non-Hodgkin’s lymphoma, any 1/1/2007 cellular classification; diagnostic evaluation, stage not determined, evaluation of possible relapse or non-response to therapy, or not listed (for use in a Medicare-approved demonstration project) A G9139 Oncology; disease status; chronic myelogenous leukemia, 1/1/2007 limited to Philadelphia chromosome positive and/or BCR-ABL positive; extent of disease unknown, staging in progress, not listed (for use in a Medicare-approved demonstration project) A H0049 Alcohol and/or drug screening 1/1/2007

A H0050 Alcohol and/or drug services, brief intervention, per 15 1/1/2007 minutes A J0129 Injection, abatacept, 10 mg 1/1/2007

A J0348 Injection, anadulafungin, 1 mg 1/1/2007

A J0364 Injection, apomorphine hydrochloride, 1 mg 1/1/2007

A J0594 Injection, busulfan, 1 mg 1/1/2007

A J0894 Injection, decitabine, 1 mg 1/1/2007

A J1324 Injection, enfuvirtide, 1 mg 1/1/2007

A J1458 Injection, galsulfase, 1 mg 1/1/2007

A J1562 Injection, immune globulin, subcutaneous, 100 mg 1/1/2007

A J1740 Injection, ibandronate sodium, 1 mg 1/1/2007

A J2170 Injection, mecasermin, 1 mg 1/1/2007

A J2248 Injection, micafungin sodium, 1 mg 1/1/2007

A J2315 Injection, naltrexone, depot form, 1 mg 1/1/2007

A J3243 Injection, tigecycline, 1 mg 1/1/2007

A J3473 Injection, hyaluronidase, recombinant, 1 usp unit 1/1/2007

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A J7187 Injection, Von Willebrand factor complex, human, 1/1/2007 ristocetin cofactor, per IU A J7311 Fluocinolone acetonide, intravitreal implant 1/1/2007

A J7319 Hyaluronan (sodium hyaluronate) or derivative, intra- 1/1/2007 articular injection, per injection A J7345 Dermal (substitute) tissue of non-human origin, with or 1/1/2007 without other bioengineered or processed elements, without metabolically active elements, per square centimeter A J7346 Dermal (substitute) tissue of human origin, injectable, with 1/1/2007 or without other bioengineered or processed elements, but without metabolically active elements, 1 cc A J7607 Levalbuterol, inhalation solution, compounded product, 1/1/2007 administered through DME, concentrated form, 0.5 mg A J7609 Albuterol, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose, 1 mg concentrated form, 1 mg A J7610 Albuterol, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose, 1 mg concentrated form, 1 mg A J7615 Levalbuterol, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose, 0.5 mg A J7634 Budesonide, inhalation solution, compounded product, 1/1/2007 administered through DME, concentrated form, per 0.25 milligram A J7645 Ipratropium bromide, inhalation solution, compounded 1/1/2007 product, administered through DME, unit dose form, per milligram A J7647 Soetharine HCL, inhalation solution, compounded product, 1/1/2007 administered through DME, concentrated form, per milligram A J7650 Isoetharine HCL, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose form, per milligram A J7657 Isoproterenol HCL, inhalation solution, compounded 1/1/2007 product, administered through DME, concentrated form, per milligram A J7660 Isoproterenol HCL, inhalation solution, compounded 1/1/2007 product, administered through DME, unit dose form, per milligram A J7667 Metaproterenol sulfate, inhalation solution, compounded 1/1/2007 product, concentrated form, per 10 milligrams A J7670 Metaproterenol sulfate, inhalation solution, compounded 1/1/2007 product, administered through DME, unit dose form, per 10 milligrams A J7685 Tobramycin, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose form, per 300 milligrams A J8650 Nabilone, oral, 1 mg 1/1/2007

A J9261 Injection, nelarabine, 50 mg 1/1/2007

A L1001 Cervical thoracic lumbar sacral orthosis, immobilizer, 1/1/2007 infant size, each

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A L3806 Wrist hand finger orthosis, includes one or more 1/1/2007 nontorsion joint(s), elastic bands, turnbuckles, may include soft interface material, straps, custom fabricated, includes fitting and adjustment A L3808 Wrist hand finger orthosis, rigid without joints, may 1/1/2007 include soft interface material; straps, custom fabricated, includes fitting and adjustment A L3915 Wrist hand orthosis, includes one or more nontorsion 1/1/2007 joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment A L5993 Addition to lower extremity prosthesis, heavy duty feature, 1/1/2007 foot only, (for patient weight greater than 300 lbs) A L5994 Addition to lower extremity prosthesis, heavy duty feature, 1/1/2007 knee only, (for patient weight greater than 300 lbs) A L6611 Addition to upper extremity prosthesis, external powered, 1/1/2007 additional switch, any type A L6624 Upper extremity addition, flexion/extension and rotation 1/1/2007 wrist unit A L6639 Upper extremity addition, heavy duty feature, any elbow 1/1/2007

A L6703 Terminal device, passive hand/mitt, any material, any size 1/1/2007

A L6704 Terminal device, sport/recreational/work attachment, any 1/1/2007 material, any size A L6706 Terminal device, hook, mechanical, voluntary opening, 1/1/2007 any material, any size, lined or unlined A L6707 Terminal device, hook, mechanical, voluntary closing, any 1/1/2007 material, any size, lined or unlined A L6708 Terminal device, hand, mechanical, voluntary opening, 1/1/2007 any material, any size A L6709 Terminal device, hand, mechanical, voluntary closing, any 1/1/2007 material, any size A L7007 Electric hand, switch or myoelectric controlled, adult 1/1/2007

A L7008 Electric hand, switch or myoelectric, controlled, pediatric 1/1/2007

A L7009 Electric hook, switch or myoelectric controlled, adult 1/1/2007

A L8690 Auditory osseointegrated device, includes all internal and 1/1/2007 external components A L8691 Auditory osseointegrated device, external sound processor, 1/1/2007 replacement A L8695 External recharging system for battery (external) for use 1/1/2007 with implantable neurostimulator A Q4081 Injection, epoetin alfa, 100 units (for ESRD on dialysis) 1/1/2007

A Q4082 Drug or biological, not otherwise classified, part B drug 1/1/2007 competitive acquisition program (cap) A Q4083 Hyaluronan or derivative, Hyalgan or Supartz, for intra- 1/1/2007 articular injection, per dose A Q4084 Hyaluronan or derivative, Synvisc, for intra-articular 1/1/2007 injection, per dose A Q4085 Hyaluronan or derivative, Euflexxa, for intra-articular 1/1/2007 injection, per dose

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition A Q4086 Hyaluronan or derivative, Orthovisc, for intra-articular 1/1/2007 injection per dose A Q5001 Hospice care provided in patient’s home/residence 1/1/2007

A Q5002 Hospice care provided in assisted living facility 1/1/2007

A Q5003 Hospice care provided in nursing long term care facility 1/1/2007 (LTC) or non-skilled nursing facility (NF) A Q5004 Hospice care provided in skilled nursing facility (SNF) 1/1/2007

A Q5005 Hospice care provided in inpatient hospital 1/1/2007

A Q5006 Hospice care provided in inpatient hospice facility 1/1/2007

A Q5007 Hospice care provided in long term care facility 1/1/2007

A Q5008 Hospice care provided in inpatient psychiatric facility 1/1/2007

A Q5009 Hospice care provided in place not otherwise specified 1/1/2007 (NOS) A S0180 Etonogestrel (contraceptive) implant system, including 1/1/2007 implant and supplies A S2344 Nasal/sinus endoscopy, surgical; with enlargement of 1/1/2007 sinus ostium opening using inflatable device (i.e., balloon sinuplasty) A S3855 Genetic testing for detection of mutations in the presenilin, 1/1/2007 1 gene A T4543 Disposable incontinence product, brief/diaper, bariatric, 1/1/2007 each D A0800 Ambulance transport provided between the hours of 7pm 1/1/2007 and 7am D A4348 Male external catheter with integral collection 1/1/2007 compartment, extended wear, each (e.g., 2 per month) D A4359 Urinary suspensory without leg bag, each 1/1/2007 D A4462 Abdominal dressing holder, each 1/1/2007 D A4632 Replacement battery for external infusion pump, any type, 1/1/2007 each D A9549 Technetium Tc-99m arcitumomab, diagnostic, per study 1/1/2007 dose, up to 25 millicuries D C1178 Injection, busulfan, per 6 mg 1/1/2007 D C2632 Brachytherapy solution, iodine-125, per mci 1/1/2007 D C8950 Intravenous infusion for therapy/diagnosis; up to 1 hour 1/1/2007 D C8951 Intravenous infusion for therapy/diagnosis; each 1/1/2007 additional hour (list separately in addition to C8950) D C8952 Therapeutic, prophylactic or diagnostic injection; 1/1/2007 intravenous push of each new substance/drug D C8953 Chemotherapy administration, intravenous; push technique 1/1/2007 D C8954 Chemotherapy administration, intravenous; infusion 1/1/2007 technique, up to one hour D C8955 Chemotherapy administration, intravenous; infusion 1/1/2007 technique, each additional hour (list separately in addition to C8954) D C9220 Sodium hyaluronate per 30 mg dose, for intra-articular 1/1/2007 injection

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition D C9221 Acellular dermal tissue matrix, per 16 sq. cm. 1/1/2007 D C9222 Decellularized soft tissue scaffold, per 1 cc 1/1/2007 D C9224 Injection, galsulfase, per 5 mg 1/1/2007 D C9225 Injection, fluocinolone acetonide intravitreal implant, per 1/1/2007 0.59 mg D C9227 Injection, micafungin sodium, per 1 mg 1/1/2007 D C9228 Injection, tigecycline, per 1 mg 1/1/2007 D C9229 Injection, ibandronate sodium, per 1 mg 1/1/2007 D C9230 Injection, abatacept, per 10 mg 1/1/2007 D C9231 Injection, decitabine, per 1 mg 1/1/2007 D D1201 Topical application of fluoride (including prophylaxis)-child 1/1/2007 D D1205 Topical application of fluoride (including prophylaxis)-adult 1/1/2007 D D6971 Cast post as part of bridge retainer 1/1/2007 D E0164 Commode chair, mobile, with fixed arms 1/1/2007 D E0166 Commode chair, mobile, with detachable arms 1/1/2007 D E0180 Pressure pad, alternating with pump 1/1/2007 D E0701 Helmet with face guard and soft interface material, 1/1/2007 prefabricated D E0977 Wedge cushion, wheelchair 1/1/2007 D E0997 Caster with a fork 1/1/2007 D E0998 Caster without fork 1/1/2007 D E0999 Pneumatic tire with wheel 1/1/2007 D E2320 Power wheelchair accessory, hand or chin control 1/1/2007 interface, remote joystick or touchpad, proportional, including all related electronics, and fixed mounting hardware D G0107 Colorectal cancer screening; fecal-occult blood test, 1-3 1/1/2007 simultaneous determinations D G0243 Multi-source photon stereotactic radiosurgery, delivery 1/1/2007 including collimator changes and custom plugging, complete course of treatment, all lesions D G9127 Oncology; disease status; limited to multiple myeloma, 1/1/2007 systemic disease; smoldering, stage I (for use in a Medicare-approved demonstration project) D J2912 Injection, sodium chloride, 0.9%, per 2 ml 1/1/2007 D J7188 Injection, Von Willebrand factor complex, human, IU 1/1/2007 D J7317 Sodium hyaluronate, per 20 to 25 mg dose for intra- 1/1/2007 articular injection D J7320 Hylan G-F 20, 16 mg, for intra-articular injection 1/1/2007 D J7350 Dermal (substitute) tissue of human origin, injectable, with 1/1/2007 or without other bioengineered or processed elements, but without metabolized active elements, per 10 mg D K0090 Rear wheel tire for power wheelchair, any size, each 1/1/2007 D K0091 Rear wheel tire tube other than zero pressure for power 1/1/2007 wheelchair, any size, each D K0092 Rear wheel assembly for power wheelchair, complete, 1/1/2007 each

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition D K0093 Rear wheel, zero pressure tire tube (flat free insert) for 1/1/2007 power wheelchair, any size, each D K0094 Wheel tire for power base, any size, each 1/1/2007 D K0095 Wheel tire tube other than zero pressure for each base, 1/1/2007 any size, each D K0096 Wheel assembly for power base, complete, each 1/1/2007 D K0097 Wheel zero pressure tire tube (flat free insert) for power 1/1/2007 base, any size, each D K0099 Front caster for power wheelchair 1/1/2007 D L0100 Cranial orthosis (helmet), with or without soft interface, 1/1/2007 molded to patient model D L0110 Cranial orthosis (helmet), with or without soft-interface, 1/1/2007 non-molded D L3902 Wrist hand finger orthosis, external powered, compressed 1/1/2007 gas, custom-fabricated D L3914 Wrist hand orthosis, wrist extension cock-up, 1/1/2007 prefabricated, includes fitting/adjustment D L6700 Terminal device, hook, Dorrance, or equal, model #3 1/1/2007 D L6705 Terminal device, hook, Dorrance, or equal, model #5 1/1/2007 D L6710 Terminal device, hook, Dorrance, or equal, model #5X 1/1/2007 D L6715 Terminal device, hook, Dorrance, or equal, model #5XA 1/1/2007 D L6720 Terminal device, hook, Dorrance, or equal, model #6 1/1/2007 D L6725 Terminal device, hook, Dorrance, or equal, model #7 1/1/2007 D L6730 Terminal device, hook, Dorrance, or equal, model #7LO 1/1/2007 D L6735 Terminal device, hook, Dorrance, or equal, model #8 1/1/2007 D L6740 Terminal device, hook, Dorrance, or equal, model #8X 1/1/2007 D L6745 Terminal device, hook, Dorrance, or equal, model #88X 1/1/2007 D L6750 Terminal device, hook, Dorrance, or equal, model #10P 1/1/2007 D L6755 Terminal device, hook, Dorrance, or equal, model #10X 1/1/2007 D L6765 Terminal device, hook, Dorrance, or equal, model #12P 1/1/2007 D L6770 Terminal device, hook, Dorrance, or equal, model #99X 1/1/2007 D L6775 Terminal device, hook, Dorrance, or equal, model #555 1/1/2007 D L6780 Terminal device, hook, Dorrance, or equal, model #ss555 1/1/2007 D L6790 Terminal device, hook, Accu hook, or equal 1/1/2007 D L6795 Terminal device, hook, 2 load, or equal 1/1/2007 D L6800 Terminal device, hook, APRL VC, or equal 1/1/2007 D L6806 Terminal device, hook, TRS Grip, Grip III, VC, or equal 1/1/2007 D L6807 Terminal device, hook, Grip I, Grip II, VC, or equal 1/1/2007 D L6808 Terminal device, hook, TRS Adept, infant or child, VC, or 1/1/2007 equal D L6809 Terminal device, hook, TRS Super Sport, passive 1/1/2007 D L6825 Terminal device, hand, Dorrance, VO 1/1/2007 D L6830 Terminal device, hand, APRL, VC 1/1/2007 D L6835 Terminal device, hand, Sierra, VO 1/1/2007 D L6840 Terminal device, hand, Becker Imperial 1/1/2007

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition D L6845 Terminal device, hand, Becker Lock Grip 1/1/2007 D L6850 Terminal device, hand, Becker Plylite 1/1/2007 D L6855 Terminal device, hand, Robin-Aids, VO 1/1/2007 D L6860 Terminal device, hand, Robin-Aids, VO soft 1/1/2007 D L6865 Terminal device, hand, passive hand 1/1/2007 D L6867 Terminal device, hand, Detroit infant hand (mechanical) 1/1/2007 D L6868 Terminal device, hand, passive infant hand, (Steeper, 1/1/2007 Hosmer or equal) D L6870 Terminal device, hand, child mitt 1/1/2007 D L6872 Terminal device, hand, NYU child hand 1/1/2007 D L6873 Terminal device, hand, mechanical infant hand, steeper or 1/1/2007 equal D L6875 Terminal device, hand, Bock, VC 1/1/2007 D L6880 Terminal device, hand, Bock, VO 1/1/2007 D L7010 Electronic hand, Otto Bock, Steeper or equal, switch 1/1/2007 controlled D L7015 Electronic hand, System Teknik, Variety Village or equal, 1/1/2007 switch controlled D L7020 Electronic greifer, Otto Bock or equal, switch controlled 1/1/2007 D L7025 Electronic hand, Otto Bock or equal, myoelectronically 1/1/2007 controlled D L7030 Electronic hand, System Teknik, Variety Village or equal, 1/1/2007 myoelectronically controlled D L7035 Electronic Greifer, Otto Bock or equal, myoelectronically 1/1/2007 controlled D S2262 Abortion for maternal indication, 25 weeks or greater 1/1/2007 D S4036 Intravaginal culture (IVC), case rate 1/1/2007 R S0316 Disease Management Program, follow-up/reassessment 10/1/2006

R A4216 Sterile water, saline and/or dextrose, diluent/flush, 10 ml 1/1/2007

R A4306 Disposable drug delivery system, flow rate of less than 50 1/1/2007 ml per hour R A4326 Male external catheter with integral collection chamber, 1/1/2007 any type, each R A4394 Ostomy deodorant, with or without lubricant, for use in 1/1/2007 ostomy pouch, per fluid ounce R A4558 Conductive gel or paste, for use with electrical device 1/1/2007 (e.g., TENS, NMES), per oz R A5105 Urinary suspensory; with or without leg bag, with or 1/1/2007 without tube, each R D0120 Periodic oral evaluation - established patient 1/1/2007

R D0480 Accession of exfoliative cytologic smears, microscopic 1/1/2007 examination, the preparation and transmission of written report R D2952 Post and core in addition to crown, indirectly fabricated 1/1/2007

R D2953 Each additional indirectly fabricated post - same tooth 1/1/2007

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition R D6970 Post and core in addition to fixed partial denture retainer, 1/1/2007 indirectly fabricated R D6976 Each additional indirectly fabricated post - same tooth 1/1/2007

R D7310 Alveoloplasty in conjunction with extractions - four or more 1/1/2007 teeth or tooth spaces, per quadrant R D7320 Alveoloplasty not in conjunction with extractions - four or 1/1/2007 more teeth or tooth spaces, per quadrant R D7944 Osteotomy-segmented or subapical 1/1/2007

R D7950 Osseous, osteoperiosteal, or cartilage graft of the 1/1/2007 mandible or maxilla - autogenous or nonautogenous, by report R D9310 Consultation - diagnostic service provided by dentist or 1/1/2007 physician other than requesting dentist or physician R D9610 Therapeutic parenteral drug, single administration 1/1/2007

R E0163 Commode chair, mobile or stationary, with fixed arms 1/1/2007

R E0165 Commode chair, mobile or stationary, with detachable 1/1/2007 arms R E0167 Pail or pan for use with commode chair, replacement only 1/1/2007

R E0181 Powered pressure reducing mattress overlay/pad, 1/1/2007 alternating, with pump, includes heavy duty R E0182 Pump for alternating pressure pad, for replacement only 1/1/2007

R E0190 Positioning cushion/pillow/wedge, any shape or size, 1/1/2007 includes all components and accessories R E0720 Transcutaneous electrical nerve stimulation (TENS) device, 1/1/2007 two lead, localized stimulation R E0730 Transcutaneous electrical nerve stimulation (TENS) device, 1/1/2007 four or more leads, for multiple nerve stimulation R E0967 Manual wheelchair accessory, hand rim with projections, 1/1/2007 any type, each R E2209 Arm trough, with or without hand support, each 1/1/2007

R G0103 Prostate cancer screening; prostate specific antigen test 1/1/2007 (PSA) R G0332 Services for intravenous infusion of immunoglobulin prior 1/1/2007 to administration (this service is to be billed in conjunction with administration of immunoglobulin) R G9067 Oncology; disease status; limited to non-small cell lung 1/1/2007 cancer; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) R G9070 Oncology; disease status; small cell lung cancer, limited 1/1/2007 to small cell and combined small cell/non-small; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) R G9083 Oncology; disease status; prostate cancer, limited to 1/1/2007 adenocarcinoma; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project)

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition R G9089 Oncology; disease status; colon cancer, limited to invasive 1/1/2007 cancer; adenocarcinoma as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) R G9095 Oncology; disease status; rectal cancer, limited to invasive 1/1/2007 cancer; adenocarcinoma as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) R G9099 Oncology; disease status; esophageal cancer, limited 1/1/2007 to adenocarcinoma or squamous cell carcinoma as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) R G9104 Oncology; disease status; gastric cancer, limited to 1/1/2007 adenocarcinoma as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) R G9108 Oncology; disease status; pancreatic cancer, limited to 1/1/2007 adenocarcinoma; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) R G9112 Oncology; disease status; head and neck cancer, limited 1/1/2007 to cancers of oral cavity, pharynx and larynx with squamous cell as predominant cell type; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) R G9117 Oncology; disease status; ovarian cancer, limited to 1/1/2007 epithelial cancer; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) R G9130 Oncology; disease status; limited to multiple myeloma, 1/1/2007 systemic disease; extent of disease unknown, staging in progress, or not listed (for use in a Medicare-approved demonstration project) R J7611 Albuterol, inhalation solution, FDA-approved final 1/1/2007 product, non-compounded, administered through DME, concentrated form, 1 mg R J7612 Levalbuterol, inhalation solution, FDA-approved final 1/1/2007 product, non-compounded, administered through DME, concentrated form, 0.5 mg R J7613 Albuterol, inhalation solution, FDA-approved final product, 1/1/2007 non-compounded, administered through DME, unit dose, 1 mg R J7614 Levalbuterol, inhalation solution, FDA-approved final 1/1/2007 product, non-compounded, administered through DME, unit dose, 0.5 mg R J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 1/1/2007 0.5 mg, FDA-approved final product, non-compounded, administered through DME R J7622 Beclomethasone, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose form, per milligram R J7624 Betamethasone, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose form, per milligram

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition R J7626 Budesonide, inhalation solution, FDA-approved final 1/1/2007 product, non-compounded, administered through DME, unit dose form, up to 0.5 mg R J7627 Budesonide, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose form, up to 0.5 mg R J7628 Bitolterol mesylate, inhalation solution, compounded 1/1/2007 product, administered through DME, concentrated form, per milligram R J7629 Bitolterol mesylate, inhalation solution, compounded 1/1/2007 product, administered through DME, unit dose form, per milligram R J7633 Budesonide, inhalation solution, FDA-approved final 1/1/2007 product, non-compounded, administered through DME, concentrated form, per 0.25 milligram R J7635 Atropine, inhalation solution, compounded product, 1/1/2007 administered through DME, concentrated form, per milligram R J7636 Atropine, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose form, per milligram R J7637 Dexamethasone, inhalation solution, compounded product, 1/1/2007 administered through DME, concentrated form, per milligram R J7638 Dexamethasone, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose form, per milligram R J7640 Formoterol, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose form, 12 micrograms R J7641 Flunisolide, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose, per milligram R J7642 Glycopyrrolate, inhalation solution, compounded product, 1/1/2007 administered through DME, concentrated form, per milligram R J7643 Glycopyrrolate, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose form, per milligram R J7644 Ipratropium bromide, inhalation solution, FDA-approved 1/1/2007 final product, non-compounded, administered through DME, unit dose form, per milligram R J7648 Isoetharine HCL, inhalation solution, FDA-approved final 1/1/2007 product, non-compounded, administered through DME, concentrated form, per milligram R J7649 Isoetharine HCL, inhalation solution, FDA-approved final 1/1/2007 product, non-compounded, administered through DME, unit dose form, per milligram R J7658 Isoproterenol HCL, inhalation solution, FDA-approved final 1/1/2007 product, non-compounded, administered through DME, concentrated form, per milligram R J7659 Isoproterenol HCL, inhalation solution, FDA-approved final 1/1/2007 product, non-compounded, administered through DME, unit dose form, per milligram R J7668 Metaproterenol sulfate, inhalation solution, FDA-approved 1/1/2007 final product, non-compounded, administered through DME, concentrated form, per 10 milligrams

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition R J7669 Metaproterenol sulfate, inhalation solution, FDA-approved 1/1/2007 final product, non-compounded, administered through DME, unit dose form, per 10 milligrams R J7680 Terbutaline sulfate, inhalation solution, compounded 1/1/2007 product, administered through DME, concentrated form, per milligram R J7681 Terbutaline sulfate, inhalation solution, compounded 1/1/2007 product, administered through DME, unit dose form, per milligram R J7682 Tobramycin, inhalation solution, FDA-approved final 1/1/2007 product, non-compounded, unit dose form, administered through DME, per 300 milligrams R J7683 Triamcinolone, inhalation solution, compounded product, 1/1/2007 administered through DME, concentrated form, per milligram R J7684 Triamcinolone, inhalation solution, compounded product, 1/1/2007 administered through DME, unit dose form, per milligram R L0631 Lumbar-sacral orthosis, sagittal control, with rigid 1/1/2007 anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, pendulous abdomen design, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment R L5848 Addition to endoskeletal knee-shin system, hydraulic fluid 1/1/2007 stance extension, dampening feature, with or without adjustability R L5995 Addition to lower extremity prosthesis, heavy duty feature, 1/1/2007 other than foot or knee, (for patient weight greater than 300 lbs) R L6805 Addition to terminal device, modifier wrist unit 1/1/2007

R L6810 Addition to terminal device, Pincher tool, Otto Bock or 1/1/2007 equal precision pinch device R L6881 Automatic grasp feature, addition to upper limb electric 1/1/2007 prosthetic terminal device R L6884 Replacement socket, above elbow/elbow disarticulation, 1/1/2007 molded to patient model, for use with or without external power R L7040 Prehensile actuator, Hosmer or equal switch controlled 1/1/2007

R L7045 Electric hook, child, Michigan or equal switch or 1/1/2007 myoelectric controlled, pediatric R L8614 Cochlear device/system, includes all internal and external 1/1/2007 components R L8689 External recharging system for implanted battery (internal) 1/1/2007 for use with implantable neurostimulator, replacement only R P9011 Blood, split unit 1/1/2007

R S1040 Cranial remolding orthosis, pediatric, rigid, with soft 1/1/2007 interface material, custom fabricated, includes fitting and adjustment(s) R S2260 Induced abortion, 17 to 24 weeks, any surgical method 1/1/2007

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HCPCS CODES Action A=Addition Effective Date D=Deletion HCPCS Code Narrative of Revision/ Delete Date R=Revision Addition R S2265 Induced abortion for fetal indication, 25 to 28 weeks 1/1/2007

R S2266 Induced abortion for fetal indication, 29 to 31 weeks 1/1/2007

R S2267 Induced abortion for fetal indication, 32 weeks or greater 1/1/2007

R T5001 Positioning seat for persons with special orthopedic needs, 1/1/2007 for use in vehicles

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ICD-9 CM CODES Action Effective A=Addition Date of ICD-9 CM Delete Date D=Deletion Narrative Revision / Code R-Revision Addition A V18.51 Family history, colonic polyps 10/1/2006 A V18.59 Family history, other digestive disorders 10/1/2006 A V26.34 Testing of male for genetic disease carrier status 10/1/2006 A V26.35 Encounter for testing of male partner of habitual aborter 10/1/2006 A V26.39 Other genetic testing of male 10/1/2006 A V45.86 Bariatric surgery status 10/1/2006 Encounter for change or removal of nonsurgical wound A V58.30 10/1/2006 dressing Encounter for change or removal of surgical wound A V58.31 10/1/2006 dressing A V58.32 Encounter for removal of sutures 10/1/2006 Encounter for hearing examination following failed hearing A V72.11 10/1/2006 screening A V72.19 Other examination of ears and hearing 10/1/2006 A V82.71 Screening for genetic disease carrier status 10/1/2006 A V82.79 Other genetic screening 10/1/2006 Body mass index, pediatric, less than 5th percentile for A V85.51 10/1/2006 age Body mass index, pediatric, 5th percentile to less than A V85.52 10/1/2006 85th percentile for age Body mass index, pediatric, 85th percentile to less than A V85.53 10/1/2006 95th percentile for age Body mass index, pediatric, greater than or equal to 95th A V85.54 10/1/2006 percentile for age A V86.0 Estrogen receptor positive status [ER+] 10/1/2006 A V86.1 Estrogen receptor negative status [ER-] 10/1/2006 A 052.2 Postvaricella myelitis 10/1/2006 A 053.14 Herpes zoster myelitis 10/1/2006 A 054.74 Herpes simplex myelitis 10/1/2006 A 238.71 Essential thrombocythemia 10/1/2006 A 238.72 Low grade myelodysplastic syndrome lesions 10/1/2006 A 238.73 High grade myelodysplastic syndrome lesions 10/1/2006 A 238.74 Myelodysplastic syndrome with 5q deletion 10/1/2006 A 238.75 Myelodysplastic syndrome, unspecified 10/1/2006 A 238.76 Myelofibrosis with myeloid metaplasia 10/1/2006 A 238.79 Other lymphatic and hematopoietic tissues 10/1/2006 A 277.30 Amyloidosis, unspecified 10/1/2006 A 277.31 Familial Mediterranean fever 10/1/2006 A 277.39 Other amyloidosis 10/1/2006 A 284.01 Constitutional red blood cell aplasia 10/1/2006 A 284.09 Other constitutional aplastic anemia 10/1/2006 A 284.1 Pancytopenia 10/1/2006 A 284.2 Myelophthisis 10/1/2006 A 288.00 Neutropenia, unspecified 10/1/2006

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ICD-9 CM CODES Action Effective A=Addition Date of ICD-9 CM Delete Date D=Deletion Narrative Revision / Code R-Revision Addition A 288.01 Congenital neutropenia 10/1/2006 A 288.02 Cyclic neutropenia 10/1/2006 A 288.03 Drug induced neutropenia 10/1/2006 A 288.04 Neutropenia due to infection 10/1/2006 A 288.09 Other neutropenia 10/1/2006 A 288.4 Hemophagocytic syndromes 10/1/2006 A 288.50 Leukocytopenia, unspecified 10/1/2006 A 288.51 Lymphocytopenia 10/1/2006 A 288.59 Other decreased white blood cell count 10/1/2006 A 288.60 Leukocytosis, unspecified 10/1/2006 A 288.61 Lymphocytosis (symptomatic) 10/1/2006 A 288.62 Leukemoid reaction 10/1/2006 A 288.63 Monocytosis (symptomatic) 10/1/2006 A 288.64 Plasmacytosis 10/1/2006 A 288.65 Basophilia 10/1/2006 A 288.69 Other elevated white blood cell count 10/1/2006 A 289.53 Neutropenic splenomegaly 10/1/2006 A 289.83 Myelofibrosis 10/1/2006 Encephalitis and encephalomyelitis in viral diseases A 323.01 10/1/2006 classified elsewhere A 323.02 Myelitis in viral diseases classified elsewhere 10/1/2006 Other encephalitis and encephalomyelitis due to infection A 323.41 10/1/2006 classified elsewhere A 323.42 Other myelitis due to infection classified elsewhere 10/1/2006 Encephalitis and encephalomyelitis following immunization A 323.51 10/1/2006 procedures A 323.52 Myelitis following immunization procedures 10/1/2006 A 323.61 Infectious acute disseminated encephalomyelitis (ADEM) 10/1/2006 A 323.62 Other postinfectious encephalitis and encephalomyelitis 10/1/2006 A 323.63 Postinfectious myelitis 10/1/2006 A 323.71 Toxic encephalitis and encephalomyelitis 10/1/2006 A 323.72 Toxic myelitis 10/1/2006 A 323.81 Other causes of encephalitis and encephalomyelitis 10/1/2006 A 323.82 Other causes of myelitis 10/1/2006 A 331.83 Mild cognitive impairment, so stated 10/1/2006 A 333.71 Athetoid cerebral palsy 10/1/2006 A 333.72 Acute dystonia due to drugs 10/1/2006 A 333.79 Other acquired torsion dystonia 10/1/2006 A 333.85 Subacute dyskinesia due to drugs 10/1/2006 A 333.94 Restless legs syndrome (RLS) 10/1/2006 A 338.0 Central pain syndrome 10/1/2006 A 338.11 Acute pain due to trauma 10/1/2006 A 338.12 Acute post-thoracotomy pain 10/1/2006

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ICD-9 CM CODES Action Effective A=Addition Date of ICD-9 CM Delete Date D=Deletion Narrative Revision / Code R-Revision Addition A 338.18 Other acute postoperative pain 10/1/2006 A 338.19 Other acute pain 10/1/2006 A 338.21 Chronic pain due to trauma 10/1/2006 A 338.22 Chronic post-thoracotomy pain 10/1/2006 A 338.28 Other chronic postoperative pain 10/1/2006 A 338.29 Other chronic pain 10/1/2006 A 338.3 Neoplasm related pain (acute) (chronic) 10/1/2006 A 338.4 Chronic pain syndrome 10/1/2006 A 341.20 Acute (transverse) myelitis nos 10/1/2006 Acute (transverse) myelitis in conditions classified A 341.21 10/1/2006 elsewhere A 341.22 Idiopathic transverse myelitis 10/1/2006 A 377.43 Optic nerve hypoplasia 10/1/2006 A 379.60 Inflammation (infection) of postprocedural bleb, unspecified 10/1/2006 A 379.61 Inflammation (infection) of postprocedural bleb, stage 1 10/1/2006 A 379.62 Inflammation (infection) of postprocedural bleb, stage 2 10/1/2006 A 379.63 Inflammation (infection) of postprocedural bleb, stage 3 10/1/2006 A 389.15 Sensorineural hearing loss, unilateral 10/1/2006 A 389.16 Sensorineural hearing loss, asymmetrical 10/1/2006 A 429.83 Takotsubo syndrome 10/1/2006 A 478.11 Nasal mucositis (ulcerative) 10/1/2006 A 478.19 Other disease of nasal cavity and sinuses 10/1/2006 A 518.7 Transfusion related acute lung injury (TRALI) 10/1/2006 A 519.11 Acute bronchospasm 10/1/2006 A 519.19 Other diseases of trachea and bronchus 10/1/2006 A 521.81 Cracked tooth 10/1/2006 A 521.89 Other specific diseases of hard tissues of teeth 10/1/2006 A 523.00 Acute gingivitis, plaque induced 10/1/2006 A 523.01 Acute gingivitis, non-plaque induced 10/1/2006 A 523.10 Chronic gingivitis, plaque induced 10/1/2006 A 523.11 Chronic gingivitis, non-plaque induced 10/1/2006 A 523.30 Aggressive periodontitis, unspecified 10/1/2006 A 523.31 Aggressive periodontitis, localized 10/1/2006 A 523.32 Aggressive periodontitis, generalized 10/1/2006 A 523.33 Acute periodontitis 10/1/2006 A 523.40 Chronic periodontitis, unspecified 10/1/2006 A 523.41 Chronic periodontitis, localized 10/1/2006 A 523.42 Chronic periodontitis, generalized 10/1/2006 A 525.60 Unspecified unsatisfactory restoration of tooth 10/1/2006 A 525.61 Open restoration margins 10/1/2006 A 525.62 Unrepairable overhanging of dental restorative materials 10/1/2006

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ICD-9 CM CODES Action Effective A=Addition Date of ICD-9 CM Delete Date D=Deletion Narrative Revision / Code R-Revision Addition Fractured dental restorative material without loss of A 525.63 10/1/2006 material A 525.64 Fractured dental restorative material with loss of material 10/1/2006 Contour of existing restoration of tooth biologically A 525.65 10/1/2006 incompatible with oral health A 525.66 Allergy to existing dental restorative material 10/1/2006 A 525.67 Poor aesthetics of existing restoration 10/1/2006 A 525.69 Other unsatisfactory restoration of existing tooth 10/1/2006 A 526.61 Perforation of root canal space 10/1/2006 A 526.62 Endodontic overfill 10/1/2006 A 526.63 Endodontic underfill 10/1/2006 Other periradicular pathology associated with previous A 526.69 10/1/2006 endodontic treatment A 528.00 Stomatitis and mucositis, unspecified 10/1/2006 A 528.01 Mucositis (ulcerative) due to antineoplastic therapy 10/1/2006 A 528.02 Mucositis (ulcerative) due to other drugs 10/1/2006 A 528.09 Other stomatitis and mucositis (ulcerative) 10/1/2006 A 538 Gastrointestinal mucositis (ulcerative) 10/1/2006 A 608.20 Torsion of testis, unspecified 10/1/2006 A 608.21 Extravaginal torsion of spermatic cord 10/1/2006 A 608.22 Intravaginal torsion of spermatic cord 10/1/2006 A 608.23 Torsion of appendix testis 10/1/2006 A 608.24 Torsion of appendix epididymis 10/1/2006 A 616.81 Mucositis (ulcerative) of cervix, vagina, and vulva 10/1/2006 A 616.89 Other inflammatory disease of cervix, vagina and vulva 10/1/2006 A 618.84 Cervical stump prolapse 10/1/2006 A 629.29 Other female genital mutilation status 10/1/2006 A 629.81 Habitual aborter without current pregnancy 10/1/2006 A 629.89 Other specified disorders of female genital organs 10/1/2006 Tobacco use disorder complicating pregnancy, childbirth, A 649.00 or the puerperium, unspecified as to episode of care or not 10/1/2006 applicable Tobacco use disorder complicating pregnancy, childbirth, A 649.01 or the puerperium, delivered, with or without mention of 10/1/2006 antepartum condition Tobacco use disorder complicating pregnancy, childbirth, A 649.02 or the puerperium, delivered, with mention of postpartum 10/1/2006 complication Tobacco use disorder complicating pregnancy, childbirth, A 649.03 10/1/2006 or the puerperium, antepartum condition or complication Tobacco use disorder complicating pregnancy, childbirth, A 649.04 10/1/2006 or the puerperium, postpartum condition or complication Obesity complicating pregnancy, childbirth, or the A 649.10 puerperium, unspecified as to episode of care or not 10/1/2006 applicable

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ICD-9 CM CODES Action Effective A=Addition Date of ICD-9 CM Delete Date D=Deletion Narrative Revision / Code R-Revision Addition Obesity complicating pregnancy, childbirth, or the A 649.11 puerperium, delivered, with or without mention of 10/1/2006 antepartum condition Obesity complicating pregnancy, childbirth, or the A 649.12 puerperium, delivered, with mention of postpartum 10/1/2006 complication Obesity complicating pregnancy, childbirth, or the A 649.13 10/1/2006 puerperium, antepartum condition or complication Obesity complicating pregnancy, childbirth, or the A 649.14 10/1/2006 puerperium, postpartum condition or complication Bariatric surgery status complicating pregnancy, childbirth, A 649.20 or the puerperium, unspecified as to episode of care or not 10/1/2006 applicable Bariatric surgery status complicating pregnancy, childbirth, A 649.21 or the puerperium, delivered, with or without mention of 10/1/2006 antepartum condition Bariatric surgery status complicating pregnancy, childbirth, A 649.22 or the puerperium, delivered, with mention of postpartum 10/1/2006 complication Bariatric surgery status complicating pregnancy, childbirth, A 649.23 10/1/2006 or the puerperium, antepartum condition or complication Bariatric surgery status complicating pregnancy, childbirth, A 649.24 10/1/2006 or the puerperium, postpartum condition or complication Coagulation defects complicating pregnancy, childbirth, or A 649.30 the puerperium, unspecified as to episode of care or not 10/1/2006 applicable Coagulation defects complicating pregnancy, childbirth, A 649.31 or the puerperium, delivered, with or without mention of 10/1/2006 antepartum condition Coagulation defects complicating pregnancy, childbirth, A 649.32 or the puerperium, delivered, with mention of postpartum 10/1/2006 complication Coagulation defects complicating pregnancy, childbirth, or A 649.33 10/1/2006 the puerperium, antepartum condition or complication Coagulation defects complicating pregnancy, childbirth, or A 649.34 10/1/2006 the puerperium, postpartum condition or complication Epilepsy complicating pregnancy, childbirth, or the A 649.40 puerperium, unspecified as to episode of care or not 10/1/2006 applicable Epilepsy complicating pregnancy, childbirth, or the A 649.41 puerperium, delivered, with or without mention of 10/1/2006 antepartum condition Epilepsy complicating pregnancy, childbirth, or the A 649.42 puerperium, delivered, with mention of postpartum 10/1/2006 complication Epilepsy complicating pregnancy, childbirth, or the A 649.43 10/1/2006 puerperium, antepartum condition or complication Epilepsy complicating pregnancy, childbirth, or the A 649.44 10/1/2006 puerperium, postpartum condition or complication Spotting complicating pregnancy, unspecified as to A 649.50 10/1/2006 episode of care or not applicable

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ICD-9 CM CODES Action Effective A=Addition Date of ICD-9 CM Delete Date D=Deletion Narrative Revision / Code R-Revision Addition Spotting complicating pregnancy, delivered, with or A 649.51 10/1/2006 without mention of antepartum condition Spotting complicating pregnancy, antepartum condition or A 649.53 10/1/2006 complication Uterine size date discrepancy, unspecified as to episode of A 649.60 10/1/2006 care or not applicable Uterine size date discrepancy, delivered, with or without A 649.61 10/1/2006 mention of antepartum condition Uterine size date discrepancy, delivered, with mention of A 649.62 10/1/2006 postpartum complication Uterine size date discrepancy, antepartum condition or A 649.63 10/1/2006 complication Uterine size date discrepancy, postpartum condition or A 649.64 10/1/2006 complication A 729.71 Nontraumatic compartment syndrome of upper extremity 10/1/2006 A 729.72 Nontraumatic compartment syndrome of lower extremity 10/1/2006 A 729.73 Nontraumatic compartment syndrome of abdomen 10/1/2006 A 729.79 Nontraumatic compartment syndrome of other sites 10/1/2006 A 731.3 Major osseous defects 10/1/2006 A 768.7 Hypoxic-ischemic encephalopathy (HIE) 10/1/2006 A 770.87 Respiratory arrest of newborn 10/1/2006 A 770.88 Hypoxemia of newborn 10/1/2006 A 775.81 Other acidosis of newborn 10/1/2006 A 775.89 Other neonatal endocrine and metabolic disturbances 10/1/2006 A 779.85 Cardiac arrest of newborn 10/1/2006 A 780.32 Complex febrile convulsions 10/1/2006 A 780.96 Generalized pain 10/1/2006 A 780.97 Altered mental status 10/1/2006 A 784.91 Postnasal drip 10/1/2006 A 784.99 Other symptoms involving head and neck 10/1/2006 A 788.64 Urinary hesitancy 10/1/2006 A 788.65 Straining on urination 10/1/2006 A 793.91 Image test inconclusive due to excess body fat 10/1/2006 Other nonspecific abnormal findings on radiological and A 793.99 10/1/2006 other examinations of body structure Papanicolaou smear of cervix with cytologic evidence of A 795.06 10/1/2006 malignancy A 795.81 Elevated carcinoembryonic antigen [CEA] 10/1/2006 A 795.82 Elevated cancer antigen 125 [CA 125] 10/1/2006 A 795.89 Other abnormal tumor markers 10/1/2006 A 958.90 Compartment syndrome, unspecified 10/1/2006 A 958.91 Traumatic compartment syndrome of upper extremity 10/1/2006 A 958.92 Traumatic compartment syndrome of lower extremity 10/1/2006 A 958.93 Traumatic compartment syndrome of abdomen 10/1/2006

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ICD-9 CM CODES Action Effective A=Addition Date of ICD-9 CM Delete Date D=Deletion Narrative Revision / Code R-Revision Addition A 958.99 Traumatic compartment syndrome of other sites 10/1/2006 Unspecified adverse effect of unspecified drug, medicinal A 995.20 10/1/2006 and biological substance A 995.21 Arthus phenomenon 10/1/2006 A 995.22 Unspecified adverse effect of anesthesia 10/1/2006 A 995.23 Unspecified adverse effect of insulin 10/1/2006 A 995.27 Other drug allergy 10/1/2006 Unspecified adverse effect of other drug, medicinal and A 995.29 10/1/2006 biological substance D V18.5 Family history of digestive disorders 10/1/2006 D V58.3 Attention to dressings and sutures 10/1/2006 D V72.1 Examination of ears and hearing 10/1/2006 Neoplasm of uncertain behavior of other lymphatic and D 238.7 10/1/2006 hematopoietic tissues D 277.3 Amyloidosis 10/1/2006 D 284.0 Constitutional aplastic anemia 10/1/2006 D 288.0 Aplastic anemia and other bone marrow failure syndromes 10/1/2006 Encephalitis, myelitis, and encephalomyelitis in viral D 323.0 10/1/2006 diseases classified elsewhere D 323.4 Other encephalitis due to infection classified elsewhere 10/1/2006 Encephalitis, myelitis, and encephalomyelitis following D 323.5 10/1/2006 immunization procedures D 323.6 Postinfectious encephalitis, myelitis, and encephalomyelitis 10/1/2006 D 323.7 Toxic encephalitis, myelitis, and encephalomyelitis 10/1/2006 Other causes of encephalitis, myelitis, and D 323.8 10/1/2006 encephalomyelitis D 333.7 Acquired torsion dystonia 10/1/2006 D 478.1 Other diseases of nasal cavity and sinuses 10/1/2006 Other diseases of trachea and bronchus, not elsewhere D 519.1 10/1/2006 classified D 521.8 Other specified diseases of hard tissues of teeth 10/1/2006 D 523.0 Acute gingivitis 10/1/2006 D 523.1 Chronic gingivitis 10/1/2006 D 523.3 Aggressive and acute periodontitis 10/1/2006 D 523.4 Chronic periodontitis 10/1/2006 D 528.0 Stomatitis and mucositis (ulcerative) 10/1/2006 D 608.2 Torsion of testis 10/1/2006 Other specified inflammatory disease of cervix, vagina, D 616.8 10/1/2006 and vulva D 629.8 Other specified disorder of female genital organs 10/1/2006 D 775.8 Other neonatal endocrine and metabolic disturbances 10/1/2006 D 784.9 Other symptoms involving head and neck 10/1/2006 Nonspecific abnormal findings on radiological and other D 793.9 10/1/2006 examination of other site of body

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ICD-9 CM CODES Action Effective A=Addition Date of ICD-9 CM Delete Date D=Deletion Narrative Revision / Code R-Revision Addition Other and unspecified adverse effect of drug, medicinal D 995.2 10/1/2006 and biological substance R 255.10 Hyperaldosteronism, unspecified 10/1/2006 R 285.29 Anemia of other chronic disease 10/1/2006 Encephalitis, myelitis, and encephalomyelitis in rickettsial R 323.1 10/1/2006 diseases classified elsewhere Encephalitis, myelitis, and encephalomyelitis in protozoal R 323.2 10/1/2006 diseases classified elsewhere Unspecified cause of encephalitis, myelitis, and R 323.9 10/1/2006 encephalomyelitis R 333.6 Genetic torsion dystonia 10/1/2006 Localization-related (focal) (partial) epilepsy and epileptic R 345.40 syndromes with complex partial seizures without mention 10/1/2006 of intractable epilepsy Localization-related (focal) (partial) epilepsy and epileptic R 345.41 syndromes with complex partial seizures with intractable 10/1/2006 epilepsy Localization-related (focal) (partial) epilepsy and epileptic R 345.50 syndromes with simple partial seizures without mention of 10/1/2006 intractable epilepsy Localization-related (focal) (partial) epilepsy and epileptic R 345.51 syndromes with simple partial seizures with intractable 10/1/2006 epilepsy Other forms of epilepsy and recurrent seizures without R 345.80 10/1/2006 mention of intractable epilepsy Other forms of epilepsy and recurrent seizures, with R 345.81 10/1/2006 intractable epilepsy R 389.11 Sensory hearing loss, bilateral 10/1/2006 R 389.12 Neural hearing loss, bilateral 10/1/2006 R 389.14 Central hearing loss, bilateral 10/1/2006 R 389.18 Sensorineural hearing loss of combined types, bilateral 10/1/2006 Hypertensive chronic kidney disease, malignant, with R 403.00 chronic kidney disease stage I through stage IV, or 10/1/2006 unspecified Hypertensive chronic kidney disease, benign, with chronic R 403.10 10/1/2006 kidney disease stage V or end stage renal disease Hypertensive chronic kidney disease, unspecified, with R 403.90 chronic kidney disease stage I through stage IV, or 10/1/2006 unspecified Hypertensive chronic kidney disease, unspecified, with R 403.91 10/1/2006 chronic kidney disease stage V or end stage renal disease Hypertensive heart and chronic kidney disease, malignant, R 404.00 without heart failure and with chronic kidney disease stage 10/1/2006 I through stage IV, or unspecified Hypertensive heart and chronic kidney disease, malignant, R 404.01 with heart failure and with chronic kidney disease stage I 10/1/2006 through stage IV, or unspecified Hypertensive heart and chronic kidney disease, malignant, R 404.02 without heart failure and with chronic kidney disease stage 10/1/2006 V or end stage renal disease

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ICD-9 CM CODES Action Effective A=Addition Date of ICD-9 CM Delete Date D=Deletion Narrative Revision / Code R-Revision Addition Hypertensive heart and chronic kidney disease, malignant, R 404.03 with heart failure and with chronic kidney disease stage V 10/1/2006 or end stage renal disease Hypertensive heart and chronic kidney disease, benign, R 404.10 without heart failure and with chronic kidney disease stage 10/1/2006 I through stage IV, or unspecified Hypertensive heart and chronic kidney disease, benign, R 404.11 with heart failure and with chronic kidney disease stage I 10/1/2006 through stage IV, or unspecified Hypertensive heart and chronic kidney disease, benign, R 404.12 without heart failure and with chronic kidney disease stage 10/1/2006 V or end stage renal disease Hypertensive heart and chronic kidney disease, benign, R 404.13 with heart failure and with chronic kidney disease stage V 10/1/2006 or end stage renal disease Hypertensive heart and chronic kidney disease, R 404.90 unspecified, without heart failure and with chronic kidney 10/1/2006 disease stage I through stage IV, or unspecified Hypertensive heart and chronic kidney disease, R 404.91 unspecified, with heart failure and with chronic kidney 10/1/2006 disease stage I through stage IV, or unspecified Hypertensive heart and chronic kidney disease, R 404.92 unspecified, without heart failure and with chronic kidney 10/1/2006 disease stage V or end stage renal disease Hypertensive heart and chronic kidney disease, R 404.93 unspecified, with heart failure and with chronic kidney 10/1/2006 disease stage V or end stage renal disease R 524.21 Malocclusion, angle’s class I 10/1/2006 R 524.22 Malocclusion, angle’s class II 10/1/2006 R 524.23 Malocclusion, angle’s class III 10/1/2006 R 524.35 Rotation of tooth/teeth 10/1/2006 Hypertrophy (benign) of prostate without urinary R 600.00 10/1/2006 obstruction and other lower urinary tract symptoms (LUTS) Hypertrophy (benign) of prostate with urinary obstruction R 600.01 10/1/2006 and other lower urinary tract symptoms (LUTS) Benign localized hyperplasia of prostate without urinary R 600.20 10/1/2006 obstruction and other lower urinary tract symptoms (LUTS) Benign localized hyperplasia of prostate with urinary R 600.21 10/1/2006 obstruction and other lower urinary tract symptoms (LUTS) Hyperplasia of prostate, unspecified, without urinary R 600.90 10/1/2006 obstruction and other lower urinary symptoms (LUTS) Hyperplasia of prostate, unspecified, with urinary R 600.91 10/1/2006 obstruction and other lower urinary symptoms (LUTS) Fetal distress first noted during labor and delivery, in R 768.3 10/1/2006 liveborn infant R 780.31 Febrile convulsions (simple), unspecified 10/1/2006 R 780.95 Excessive crying of child, adolescent, or adult 10/1/2006

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ICD-9 CM CODES Action Effective A=Addition Date of ICD-9 CM Delete Date D=Deletion Narrative Revision / Code R-Revision Addition Tooth (broken) (fractured) (due to trauma), without mention R 873.63 10/1/2006 of complication R 873.73 Tooth (broken) (fractured) (due to trauma), complicated 10/1/2006 R 995.91 Sepsis 10/1/2006 R 995.92 Severe sepsis 10/1/2006 Systemic inflammatory response syndrome due to R 995.93 10/1/2006 noninfectious process without acute organ dysfunction Systemic inflammatory response syndrome due to R 995.94 10/1/2006 noninfectious process with acute organ dysfunction R V26.31 Testing of female for genetic disease carrier status 10/1/2006 R V26.32 Other genetic testing of female 10/1/2006

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NOTES

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