Auto Pay List)
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APPENDIX E: AUTHORIZATION GUIDELINES FOR LABORATORY, OB/GYN, AND RADIOLOGY SERVICES (AUTO PAY LIST)
HealthSpan Provider Manual APPENDIX E Revised February 2014 1
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Appendix E: Authorization Guidelines for Laboratory, Ob/Gyn, and Radiology Services (Auto Pay List)
The Laboratory, Ob/Gyn, and Radiology Services listed below may be performed without a Referral if ordered by a HealthSpan Plan Physician and when performed at a HealthSpan Plan Facility. However, the tests or procedures must be medically appropriate for the Member’s diagnosis and the Member must be eligible for coverage on the date of Service. Reimbursement for these Services will be made in accordance with the terms of the Agreement between HealthSpan and the Plan Provider.
HealthSpan Provider Manual APPENDIX E Revised February 2014 2
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE HEART FAILURE ASSESSED (INCLUDES ASSESSMENT OF ALL THE FOLLOWING COMPONENTS) (CAD): BLOOD PRESSURE MEASURED 0001M (2000F) LEVEL OF ACTIV 10/1/2012 INFECTIOUS DISEASE, HCV, SIX BIOCHEMICAL ASSAYS (ALT, A2- MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, AND 0002M HAPTOGLOBIN) 10/1/2012 LIVER DISEASE, TEN BIOCHEMICAL ASSAYS (ALT, A2- MACROGLOBULIN, APOLIPOPROTEIN A-1, TOTAL BILIRUBIN, GGT, 0003M HAPTOGLOBIN, AST, GLUCOSE, 10/1/2012 00104 ANESTHESIA FOR ELECTROCONVULSIVE THERAPY 1/1/2007 SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION OF ESTRADIOL AND/OR TESTOSTERONE PELLETS BENEATH THE 11980 SKIN) 1/1/2005 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING 12001 HANDS AND FEE 1/1/2005 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR 12031 EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS 1/1/2005 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 12051 AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS 1/1/2006 20501 INJECTION OF SINUS TRACT; DIAGNOSTIC (SINOGRAM) 1/1/2006 INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR 23350 ENHANCED CT/MRI SHOULDER ARTHROGRAPHY 1/1/2005 INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT 27093 ANESTHESIA 1/1/2006 INJECTION PROCEDURE FOR SACROILIAC JOINT, ARTHROGRAPHY 27096 AND/OR ANESTHETIC/STEROID 1/1/2005 36000 INTRODUCTION OF NEEDLE OR INTRACATHETER, VEIN 1/1/2009 VENIPUNCTURE, UNDER AGE 3 YEARS, NECESSITATING PHYSICIAN'S SKILL, NOT TO BE USED FOR ROUTINE VENIPUNCTURE; FEMORAL OR 36400 JUGULAR VEI 1/1/2005 VENIPUNCTURE, UNDER AGE 3 YEARS, NECESSITATING PHYSICIAN'S 36405 SKILL, NOT TO BE USED FOR ROUTINE VENIPUNCTURE; SCALP VEIN 1/1/2005 VENIPUNCTURE, UNDER AGE 3 YEARS, NECESSITATING PHYSICIAN'S 36406 SKILL, NOT TO BE USED FOR ROUTINE VENIPUNCTURE; OTHER VEIN 1/1/2005 VENIPUNCTURE, AGE 3 YEARS OR OLDER, NECESSITATING PHYSICIAN'S SKILL (SEPARATE PROCEDURE), FOR DIAGNOSTIC OR 36410 THERAPEUTIC PURPOSES 1/1/2005 36415 COLLECTION OF VENOUS BLOOD BY VENIPUNCTURE 1/1/2005 COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, 36416 EAR STICK) 1/1/2005 36420 VENIPUNCTURE, CUTDOWN; UNDER AGE 1 YEAR 1/1/2005 36425 VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER 1/1/2005 36430 TRANSFUSION, BLOOD OR BLOOD COMPONENTS 1/1/2005 36440 PUSH TRANSFUSION, BLOOD, 2 YEARS OR UNDER 1/1/2005 COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY 36591 IMPLANTABLE VENOUS ACCESS DEVICE 1/1/2008 COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR 36592 PERIPHERAL CATHETER, VENOUS, NOT OTHERWISE SPECIFIED 1/1/2008 HealthSpan Provider Manual APPENDIX E Revised February 2014 3
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING CENTRAL VENOUS ACCESS DEVICE, INCLUDING FLUOROSCOPY, 36598 IMAGE DOCUMENTATI 1/1/2006 INJECTION PROCEDURE FOR VISUALIZATION OF ILEAL CONDUIT AND/OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC 50690 SERVICE 1/1/2006 VOIDING PRESSURE STUDIES (VP); BLADDER VOIDING PRESSURE, 51795 ANY TECHNIQUE 1/1/2005 MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR 51798 BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING 1/1/2005 56405 INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS 1/1/2005 56420 INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS 1/1/2005 56440 MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST 1/1/2005 56441 LYSIS OF LABIAL ADHESIONS 1/1/2005 DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, 56501 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) 1/1/2005 DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER 56515 SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) 1/1/2005 BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); ONE 56605 LESION 1/1/2005 BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH SEPARATE ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO 56606 CODE FOR PRIMARY 1/1/2005 56820 COLPOSCOPY OF THE VULVA; 1/1/2005 56821 COLPOSCOPY OF THE VULVA; WITH BIOPSY(S) 1/1/2005 DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, 57061 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) 1/1/2005 DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER 57065 SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) 1/1/2005 57100 BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE) 1/1/2005 BIOPSY OF VAGINAL MUCOSA; EXTENSIVE, REQUIRING SUTURE 57105 (INCLUDING CYSTS) 1/1/2005 IRRIGATION OF VAGINA AND/OR APPLICATION OF MEDICAMENT FOR 57150 TREATMENT OF BACTERIAL, PARASITIC, OR FUNGOID DISEASE 1/1/2005 FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL 57160 SUPPORT DEVICE 1/1/2005 57170 DIAPHRAGM OR CERVICAL CAP FITTING WITH INSTRUCTIONS 1/1/2005 57420 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; 1/1/2005 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; 57421 WITH BIOPSY(S) OF VAGINA/CERVIX 1/1/2005 57452 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 1/1/2005 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 57454 WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE 1/1/2005 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 57455 WITH BIOPSY(S) OF THE CERVIX 1/1/2005 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 57456 WITH ENDOCERVICAL CURETTAGE 1/1/2007 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 57460 WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 57461 WITH LOOP ELECTRODE CONIZATION OF THE CERVIX 1/1/2007 BIOPSY, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH 57500 OR WITHOUT FULGURATION (SEPARATE PROCEDURE) 1/1/2005 57510 CAUTERY OF CERVIX; ELECTRO OR THERMAL 1/1/2005 57511 CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT 1/1/2005 57513 CAUTERY OF CERVIX; LASER ABLATION 1/1/2005 ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, 58100 ANY METHOD (SEPARATE PROC 1/1/2005 ENDOMETRIAL SAMPLING (BIOPSY) PERFORMED IN CONJUNCTION WITH COLPOSCOPY (LIST SEPARATELY IN ADDITION TO CODE FOR 58110 PRIMARY PROCEDURE) 1/1/2006 58300 INSERTION OF INTRAUTERINE DEVICE (IUD) 1/1/2005 58301 REMOVAL OF INTRAUTERINE DEVICE (IUD) 1/1/2005 CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR 58340 HYSTEROSALPINGOGRAP 1/1/2006 58555 HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE) 1/1/2005 59000 AMNIOCENTESIS; DIAGNOSTIC 1/1/2005 AMNIOCENTESIS; THERAPEUTIC AMNIOTIC FLUID REDUCTION 59001 (INCLUDES ULTRASOUND GUIDANCE) 1/1/2005 59020 FETAL CONTRACTION STRESS TEST 1/1/2005 59025 FETAL NON-STRESS TEST 1/1/2005 59030 FETAL SCALP BLOOD SAMPLING 1/1/2005 INSERTION OF CERVICAL DILATOR (EG, LAMINARIA, PROSTAGLANDIN) 59200 (SEPARATE PROCEDURE) 1/1/2005 REMOVAL IMPACTED CERUMEN (SEPARATE PROCEDURE), ONE OR 69210 BOTH EARS 1/1/2005 MYELOGRAPHY, POSTERIOR FOSSA, RADIOLOGICAL SUPERVISION 70010 AND INTERPRETATION 1/1/2005 CISTERNOGRAPHY, POSITIVE CONTRAST, RADIOLOGICAL 70015 SUPERVISION AND INTERPRETATION 1/1/2005 70030 RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY 1/1/2005 RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN FOUR 70100 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF 70110 FOUR VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN THREE VIEWS 70120 PER SIDE 1/1/2005 RADIOLOGIC EXAMINATION, MASTOIDS; COMPLETE, MINIMUM OF 70130 THREE VIEWS PER SIDE 1/1/2005 70134 RADIOLOGIC EXAMINATION, INTERNAL AUDITORY MEATI, COMPLETE 1/1/2005 70140 RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN THREE VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 70150 THREE VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 70160 THREE VIEWS 1/1/2005 DACRYOCYSTOGRAPHY, NASOLACRIMAL DUCT, RADIOLOGICAL 70170 SUPERVISION AND INTERPRETATION 1/1/2005 HealthSpan Provider Manual APPENDIX E Revised February 2014 5
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 70190 RADIOLOGIC EXAMINATION; OPTIC FORAMINA 1/1/2005 RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF FOUR 70200 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, LESS THAN THREE 70210 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, 70220 MINIMUM OF THREE VIEWS 1/1/2005 70240 RADIOLOGIC EXAMINATION, SELLA TURCICA 1/1/2005 70250 RADIOLOGIC EXAMINATION, SKULL; LESS THAN FOUR VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF FOUR 70260 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND 70328 CLOSED MOUTH; UNILATERAL 1/1/2005 RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND 70330 CLOSED MOUTH; BILATERAL 1/1/2005 TEMPOROMANDIBULAR JOINT ARTHROGRAPHY, RADIOLOGICAL 70332 SUPERVISION AND INTERPRETATION 1/1/2005 70360 RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE 1/1/2005 RADIOLOGIC EXAMINATION; PHARYNX OR LARYNX, INCLUDING 70370 FLUOROSCOPY AND/OR MAGNIFICATION TECHNIQUE 1/1/2005 COMPLEX DYNAMIC PHARYNGEAL AND SPEECH EVALUATION BY CINE 70371 OR VIDEO RECORDING 1/1/2005 LARYNGOGRAPHY, CONTRAST, RADIOLOGICAL SUPERVISION AND 70373 INTERPRETATION 1/1/2005 70380 RADIOLOGIC EXAMINATION, SALIVARY GLAND FOR CALCULUS 1/1/2005 70390 SIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 1/1/2005 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL 1/1/2005 71015 RADIOLOGIC EXAMINATION, CHEST; STEREO, FRONTAL 1/1/2005 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND 71020 LATERAL; 1/1/2005 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND 71021 LATERAL; WITH APICAL LORDOTIC PROCEDURE 1/1/2005 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND 71022 LATERAL; WITH OBLIQUE PROJECTIONS 1/1/2005 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND 71023 LATERAL; WITH FLUOROSCOPY 1/1/2005 RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR 71030 VIEWS; 1/1/2005 RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR 71034 VIEWS; WITH FLUOROSCOPY 1/1/2005 RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS (EG, LATERAL 71035 DECUBITUS, BUCKY STUDIES) 1/1/2005 71036 FLUOROSCOPIC LOCALIZATION F 1/1/2005 BRONCHOGRAPHY, UNILATERAL, RADIOLOGICAL SUPERVISION AND 71040 INTERPRETATION 1/1/2005 BRONCHOGRAPHY, BILATERAL, RADIOLOGICAL SUPERVISION AND 71060 INTERPRETATION 1/1/2005 71100 RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; INCLUDING 71101 POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS 1/1/2005 HealthSpan Provider Manual APPENDIX E Revised February 2014 6
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 71110 RADIOLOGIC EXAMINATION, RIBS, BILATERAL; THREE VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, RIBS, BILATERAL; INCLUDING 71111 POSTEROANTERIOR CHEST, MINIMUM OF FOUR VIEWS 1/1/2005 71120 RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION; STERNOCLAVICULAR JOINT OR JOINTS, 71130 MINIMUM OF THREE VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SPINE, ENTIRE, SURVEY STUDY, 72010 ANTEROPOSTERIOR AND LATERAL 1/1/2005 72020 RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL 1/1/2005 72040 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; TWO OR THREE VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; MINIMUM OF FOUR 72050 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; COMPLETE, INCLUDING 72052 OBLIQUE AND FLEXION AND/OR EXTENSION STUDIES 1/1/2005 RADIOLOGIC EXAMINATION, SPINE, THORACOLUMBAR, STANDING 72069 (SCOLIOSIS) 1/1/2005 72070 RADIOLOGIC EXAMINATION, SPINE; THORACIC, TWO VIEWS 1/1/2005 72072 RADIOLOGIC EXAMINATION, SPINE; THORACIC, THREE VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SPINE; THORACIC, MINIMUM OF FOUR 72074 VIEWS 1/1/2005 72080 RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SPINE; SCOLIOSIS STUDY, INCLUDING 72090 SUPINE AND ERECT STUDIES 1/1/2005 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THREE 72100 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF 72110 FOUR VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; COMPLETE, 72114 INCLUDING BENDING VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL, BENDING VIEWS 72120 ONLY, MINIMUM OF FOUR VIEWS 1/1/2005 72170 RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF THREE 72190 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; LESS THAN THREE 72200 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; THREE OR MORE 72202 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF TWO 72220 VIEWS 1/1/2005 73000 RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE 1/1/2005 73010 RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE 1/1/2005 73020 RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW 1/1/2005 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF 73030 TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, 73040 RADIOLOGICAL SUPERVISION AND INTERPRETATION 1/1/2005 RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, 73050 BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION 1/1/2005 73060 RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF TWO VIEWS 1/1/2005 HealthSpan Provider Manual APPENDIX E Revised February 2014 7
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 73070 RADIOLOGIC EXAMINATION, ELBOW; TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF THREE 73080 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, ELBOW, ARTHROGRAPHY, RADIOLOGICAL 73085 SUPERVISION AND INTERPRETATION 1/1/2005 73090 RADIOLOGIC EXAMINATION; FOREARM, TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 73092 TWO VIEWS 1/1/2005 73100 RADIOLOGIC EXAMINATION, WRIST; TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF THREE 73110 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, WRIST, ARTHROGRAPHY, RADIOLOGICAL 73115 SUPERVISION AND INTERPRETATION 1/1/2005 73120 RADIOLOGIC EXAMINATION, HAND; TWO VIEWS 1/1/2005 73130 RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS 1/1/2005 73140 RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF TWO VIEWS 1/1/2005 73500 RADIOLOGIC EXAMINATION, HIP, UNILATERAL; ONE VIEW 1/1/2005 RADIOLOGIC EXAMINATION, HIP, UNILATERAL; COMPLETE, MINIMUM 73510 OF TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, HIPS, BILATERAL, MINIMUM OF TWO 73520 VIEWS OF EACH HIP, INCLUDING ANTEROPOSTERIOR VIEW OF PELVIS 1/1/2005 RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL 73525 SUPERVISION AND INTERPRETATION 1/1/2005 73530 RADIOLOGIC EXAMINATION, HIP, DURING OPERATIVE PROCEDURE 1/1/2005 RADIOLOGIC EXAMINATION, PELVIS AND HIPS, INFANT OR CHILD, 73540 MINIMUM OF TWO VIEWS 1/1/2005 RADIOLOGICAL EXAMINATION, SACROILIAC JOINT ARTHROGRAPHY, 73542 RADIOLOGICAL SUPERVISION AND INTERPRETATION 1/1/2005 73550 RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS 1/1/2005 73560 RADIOLOGIC EXAMINATION, KNEE; ONE OR TWO VIEWS 1/1/2005 73562 RADIOLOGIC EXAMINATION, KNEE; THREE VIEWS 1/1/2005 73564 RADIOLOGIC EXAMINATION, KNEE; COMPLETE, FOUR OR MORE VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, 73565 ANTEROPOSTERIOR 1/1/2005 RADIOLOGIC EXAMINATION, KNEE, ARTHROGRAPHY, RADIOLOGICAL 73580 SUPERVISION AND INTERPRETATION 1/1/2005 73590 RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 73592 TWO VIEWS 1/1/2005 73600 RADIOLOGIC EXAMINATION, ANKLE; TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE 73610 VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, ANKLE, ARTHROGRAPHY, RADIOLOGICAL 73615 SUPERVISION AND INTERPRETATION 1/1/2005 73620 RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF THREE 73630 VIEWS 1/1/2005 73650 RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF TWO VIEWS 1/1/2005 73660 RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF TWO VIEWS 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR 74000 VIEW 1/1/2005 RADIOLOGIC EXAMINATION, ABDOMEN; ANTEROPOSTERIOR AND 74010 ADDITIONAL OBLIQUE AND CONE VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE, INCLUDING 74020 DECUBITUS AND/OR ERECT VIEWS 1/1/2005 RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE ACUTE ABDOMEN SERIES, INCLUDING SUPINE, ERECT, AND/OR DECUBITUS VIEWS, 74022 SINGLE VIEW CHEST 1/1/2005 RADIOLOGIC EXAMINATION; PHARYNX AND/OR CERVICAL 74210 ESOPHAGUS 1/1/2005 74220 RADIOLOGIC EXAMINATION; ESOPHAGUS 1/1/2005 SWALLOWING FUNCTION, WITH 74230 CINERADIOGRAPHY/VIDEORADIOGRAPHY 1/1/2005 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH 74240 OR WITHOUT DELAYED FILMS, WITHOUT KUB 1/1/2005 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH 74241 OR WITHOUT DELAYED FILMS, WITH KUB 1/1/2005 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH 74245 SMALL INTESTINE, INCLUDES MULTIPLE SERIAL FILMS 1/1/2005 RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, 74246 EFFERVESCENT AGENT, WITH 1/1/2005 RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, 74247 EFFERVESCENT AGENT, WITH 1/1/2005 RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, 74249 EFFERVESCENT AGENT, WITH 1/1/2005 RADIOLOGIC EXAMINATION, SMALL INTESTINE, INCLUDES MULTIPLE 74250 SERIAL FILMS; 1/1/2005 RADIOLOGIC EXAMINATION, SMALL INTESTINE, INCLUDES MULTIPLE 74251 SERIAL FILMS; VIA ENTEROCLYSIS TUBE 1/1/2005 74260 DUODENOGRAPHY, HYPOTONIC 1/1/2005 RADIOLOGIC EXAMINATION, COLON; BARIUM ENEMA, WITH OR 74270 WITHOUT KUB 1/1/2005 RADIOLOGIC EXAMINATION, COLON; AIR CONTRAST WITH SPECIFIC 74280 HIGH DENSITY BARIUM, WITH OR WITHOUT GLUCAGON 1/1/2005 74290 CHOLECYSTOGRAPHY, ORAL CONTRAST; 1/1/2005 CHOLECYSTOGRAPHY, ORAL CONTRAST; ADDITIONAL OR REPEAT 74291 EXAMINATION OR MULTIPLE DAY EXAMINATION 1/1/2005 UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT 74400 KUB, WITH OR WITHOUT TOMOGRAPHY 1/1/2006 UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS 74410 TECHNIQUE; 1/1/2006 UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS 74415 TECHNIQUE; WITH NEPHROTOMOGRAPHY 1/1/2006 74420 UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB 1/1/2006 UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, NEPHROSTOGRAM, 74425 LOOPOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION 1/1/2006
HealthSpan Provider Manual APPENDIX E Revised February 2014 9
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE CYSTOGRAPHY, MINIMUM OF THREE VIEWS, RADIOLOGICAL 74430 SUPERVISION AND INTERPRETATION 1/1/2007 VASOGRAPHY, VESICULOGRAPHY, OR EPIDIDYMOGRAPHY, 74440 RADIOLOGICAL SUPERVISION AND INTERPRETATION 1/1/2007 CORPORA CAVERNOSOGRAPHY, RADIOLOGICAL SUPERVISION AND 74445 INTERPRETATION 1/1/2007 URETHROCYSTOGRAPHY, RETROGRADE, RADIOLOGICAL 74450 SUPERVISION AND INTERPRETATION 1/1/2007 URETHROCYSTOGRAPHY, VOIDING, RADIOLOGICAL SUPERVISION 74455 AND INTERPRETATION 1/1/2005 PERINEOGRAM (EG, VAGINOGRAM, FOR SEX DETERMINATION OR 74775 EXTENT OF ANOMALIES) 1/1/2007 VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL 75820 SUPERVISION AND INTERPRETATION 1/1/2006 VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION 75822 AND INTERPRETATION 1/1/2006 MANUAL APPLICATION OF STRESS PERFORMED BY PHYSICIAN FOR JOINT RADIOGRAPHY, INCLUDING CONTRALATERAL JOINT IF 76006 INDICATED 1/1/2007 RADIOLOGIC EXAMINATION FROM NOSE TO RECTUM FOR FOREIGN 76010 BODY, SINGLE VIEW, CHILD 1/1/2007 76020 BONE AGE STUDIES 1/1/2005 76040 BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, SCANOGRAM) 1/1/2005 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; LIMITED (EG, FOR 76061 METASTASES) 1/1/2005 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL 76062 AND APPENDICULAR SKELETON) 1/1/2005 76065 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT 1/1/2005 76066 JOINT SURVEY, SINGLE VIEW, TWO OR MORE JOINTS (SPECIFY) 1/1/2005 DUAL ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, ONE OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, 76075 SPINE 1/1/2005 DUAL ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, ONE OR MORE SITES; APPENDICULAR SKELETON 76076 (PERIPHERAL) (EG, RADIUS, WRI 1/1/2005 DUAL ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY 76077 STUDY, ONE OR MORE SITES; VERTEBRAL FRACTURE ASSESSMENT 1/1/2005 RADIOGRAPHIC ABSORPTIOMETRY (EG, PHOTODENSITOMETRY, 76078 RADIOGRAMMETRY), ONE OR MORE SITES 1/1/2005 RADIOLOGIC EXAMINATION, ABSCESS, FISTULA OR SINUS TRACT 76080 STUDY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 1/1/2005 COMPUTER AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER 76082 PHYSICIAN REVIEW FO 1/1/2005 COMPUTER AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER 76083 PHYSICIAN REVIEW FO 1/1/2005 MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, 76086 RADIOLOGICAL SUPERVISION AND INTERPRETATION 1/1/2005
HealthSpan Provider Manual APPENDIX E Revised February 2014 10
HEALTHSPAN
HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, 76088 RADIOLOGICAL SUPERVISION AND INTERPRETATION 1/1/2005 76090 MAMMOGRAPHY; UNILATERAL 1/1/2005 76091 MAMMOGRAPHY; BILATERAL 1/1/2005 SCREENING MAMMOGRAPHY, BILATERAL (TWO VIEW FILM STUDY OF 76092 EACH BREAST) 1/1/2005 RADIOLOGIC EXAMINATION, SINGLE PLANE BODY SECTION (EG, 76100 TOMOGRAPHY), OTHER THAN WITH UROGRAPHY 1/1/2005 RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER THAN 76101 WITH UROGRAPHY; 1/1/2005 RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER THAN 76102 WITH UROGRAPHY; 1/1/2005 CINERADIOGRAPHY/VIDEORADIOGRAPHY, EXCEPT WHERE 76120 SPECIFICALLY INCLUDED 1/1/2005 CINERADIOGRAPHY/VIDEORADIOGRAPHY TO COMPLEMENT ROUTINE EXAMINATION (LIST SEPARATELY IN ADDITION TO CODE FOR 76125 PRIMARY PROCEDURE) 1/1/2005 CONSULTATION ON X-RAY EXAMINATION MADE ELSEWHERE, 76140 WRITTEN REPORT 1/1/2005 76150 XERORADIOGRAPHY 1/1/2005 76350 SUBTRACTION IN CONJUNCTION WITH CONTRAST STUDIES 1/1/2005 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN AND QUANTITATIVE 76510 A-SCAN PERFORMED DURING THE SAME PATIENT ENCOUNTER 1/1/2005 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; QUANTITATIVE A-SCAN 76511 ONLY 1/1/2005 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN (WITH OR WITHOUT 76512 SUPERIMPOSED NON-QUANTITATIVE A-SCAN) 1/1/2005 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; ANTERIOR SEGMENT ULTRASOUND, IMMERSION (WATER BATH) B-SCAN OR HIGH 76513 RESOLUTION BIOMICROSCOPY 1/1/2005 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; CORNEAL PACHYMETRY, UNILATERAL OR BILATERAL (DETERMINATION OF CORNEAL 76514 THICKNESS) 1/1/2005 76516 OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; 1/1/2005 OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; 76519 WITH INTRAOCULAR LENS POWER CALCULATION 1/1/2005 76529 OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION 1/1/2005 ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), B-SCAN AND/OR REAL TIME WITH IMAGE 76536 DOCUMENTATION 1/1/2005 ULTRASOUND, CHEST, B-SCAN (INCLUDES MEDIASTINUM) AND/OR 76604 REAL TIME WITH IMAGE DOCUMENTATION 1/1/2005 ULTRASOUND, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN 76645 AND/OR REAL TIME WITH IMAGE DOCUMENTATION 1/1/2005 ULTRASOUND, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE 76700 DOCUMENTATION; COMPLETE 1/1/2005
HealthSpan Provider Manual APPENDIX E Revised February 2014 11
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE ULTRASOUND, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, 76705 FOLLOW-UP) 1/1/2005 ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B- 76770 SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE 1/1/2005 ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B- 76775 SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED 1/1/2005 76800 ULTRASOUND, SPINAL CANAL AND CONTENTS 1/1/2005 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST 76801 TRIMESTER (<14 WEEKS 0 DAYS) 1/1/2005 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST 76802 TRIMESTER (<14 WEEKS 0 DAYS) 1/1/2005 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST 76805 TRIMESTER (> OR = 14 W 1/1/2005 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST 76810 TRIMESTER (> OR = 14 W 1/1/2005 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION PLUS 76811 DETAILED FETAL ANATOMIC EXAMIN 1/1/2005 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION PLUS 76812 DETAILED FETAL ANATOMIC EXAMIN 1/1/2005 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY 76813 MEASUREMENT, TRANSABDOM 1/1/2007 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY 76814 MEASUREMENT, TRANSABDOM 1/1/2007 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL 76815 LOCATION, FETAL POSITION 1/1/2005 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE 76816 BY MEASURING STANDARD 1/1/2005 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE 76817 DOCUMENTATION, TRANSVAGINAL 1/1/2005 76818 FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 1/1/2005 76819 FETAL BIOPHYSICAL PROFILE; WITHOUT NON-STRESS TESTING 1/1/2005 76820 DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY 1/1/2005 76821 DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY 1/1/2005 ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE 76825 RECORDING; 1/1/2005 ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE 76826 RECORDING; FOLLOW- 1/1/2005
HealthSpan Provider Manual APPENDIX E Revised February 2014 12
HEALTHSPAN
HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE DOPPLER ECHOCARDIOGRAPHY, FETAL, PULSED WAVE AND/OR 76827 CONTINUOUS WAVE WITH SPECTRAL DISPLAY; COMPLETE 1/1/2005 DOPPLER ECHOCARDIOGRAPHY, FETAL, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY; FOLLOW-UP OR 76828 REPEAT STUDY 1/1/2005 76830 ULTRASOUND, TRANSVAGINAL 1/1/2005 SALINE INFUSION SONOHYSTEROGRAPHY (SIS), INCLUDING COLOR 76831 FLOW DOPPLER, WHEN PERFORMED 1/1/2005 ULTRASOUND, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME 76856 WITH IMAGE DOCUMENTATION; COMPLETE 1/1/2005 ULTRASOUND, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR 76857 FOLLICLES) 1/1/2005 76870 ULTRASOUND, SCROTUM AND CONTENTS 1/1/2005 76872 ULTRASOUND, TRANSRECTAL; 1/1/2005 ULTRASOUND, EXTREMITY, NON-VASCULAR, B-SCAN AND/OR REAL 76880 TIME WITH IMAGE DOCUMENTATION 1/1/2005 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE 76881 DOCUMENTATION; COMPLETE 1/1/2011 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE 76882 DOCUMENTATION; LIMITED, ANATOMIC SPECIFIC 1/1/2011 ULTRASOUND, INFANT HIPS, REAL TIME WITH IMAGING 76885 DOCUMENTATION; DYNAMIC (REQUIRING PHYSICIAN MANIPULATION) 1/1/2005 ULTRASOUND, INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; LIMITED, STATIC (NOT REQUIRING PHYSICIAN 76886 MANIPULATION) 1/1/2005 ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, IMAGING 76946 SUPERVISION AND INTERPRETATION 1/1/2007 76970 ULTRASOUND STUDY FOLLOW-UP (SPECIFY) 1/1/2005 GASTROINTESTINAL ENDOSCOPIC ULTRASOUND, SUPERVISION AND 76975 INTERPRETATION 1/1/2005 ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, 76977 PERIPHERAL SITE(S), ANY METHOD 1/1/2007 76998 ULTRASONIC GUIDANCE, INTRAOPERATIVE 1/1/2007 COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER 77051 PHYSICIAN REVIEW FO 1/1/2007 COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER 77052 PHYSICIAN REVIEW FO 1/1/2007 MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, 77053 RADIOLOGICAL SUPERVISION AND INTERPRETATION 1/1/2007 MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, 77054 RADIOLOGICAL SUPERVISION AND INTERPRETATION 1/1/2007 77055 MAMMOGRAPHY; UNILATERAL 1/1/2007 77056 MAMMOGRAPHY; BILATERAL 1/1/2007 SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF 77057 EACH BREAST) 1/1/2007
HealthSpan Provider Manual APPENDIX E Revised February 2014 13
HEALTHSPAN
HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE MANUAL APPLICATION OF STRESS PERFORMED BY PHYSICIAN FOR JOINT RADIOGRAPHY, INCLUDING CONTRALATERAL JOINT IF 77071 INDICATED 1/1/2007 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; LIMITED (EG, FOR 77074 METASTASES) 1/1/2007 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY 77080 STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) 1/1/2007 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) 77081 (EG, RADIUS, WRIST 1/1/2007 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY 77082 STUDY, 1 OR MORE SITES; VERTEBRAL FRACTURE ASSESSMENT 1/1/2007 RADIOGRAPHIC ABSORPTIOMETRY (EG, PHOTODENSITOMETRY, 77083 RADIOGRAMMETRY), 1 OR MORE SITES 1/1/2007 78000 THYROID UPTAKE; SINGLE DETERMINATION 1/1/2005 78001 THYROID UPTAKE; MULTIPLE DETERMINATIONS 1/1/2005 THYROID UPTAKE; STIMULATION, SUPPRESSION OR DISCHARGE (NOT 78003 INCLUDING INITIAL UPTAKE STUDIES) 1/1/2005 78006 THYROID IMAGING, WITH UPTAKE; SINGLE DETERMINATION 1/1/2005 78007 THYROID IMAGING, WITH UPTAKE; MULTIPLE DETERMINATIONS 1/1/2005 78010 THYROID IMAGING; ONLY 1/1/2005 78011 THYROID IMAGING; WITH VASCULAR FLOW 1/1/2005 Thyroid uptake, single or multiple quantitative measurement(s) (including 78012 stimulation, suppression, or discharge, when performed) 1/1/2013 78013 Thyroid imaging (including vascular flow, when performed); 1/1/2013 Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, 78014 suppression, or discharge, when performed) 1/1/2013 THYROID CARCINOMA METASTASES IMAGING; LIMITED AREA (EG, 78015 NECK AND CHEST ONLY) 1/1/2005 THYROID CARCINOMA METASTASES IMAGING; WITH ADDITIONAL 78016 STUDIES (EG, URINARY RECOVERY) 1/1/2005 78018 THYROID CARCINOMA METASTASES IMAGING; WHOLE BODY 1/1/2005 THYROID CARCINOMA METASTASES UPTAKE (LIST SEPARATELY IN 78020 ADDITION TO CODE FOR PRIMARY PROCEDURE) 1/1/2005 78070 PARATHYROID IMAGING 1/1/2005 78075 ADRENAL IMAGING, CORTEX AND/OR MEDULLA 1/1/2006 78102 BONE MARROW IMAGING; LIMITED AREA 1/1/2005 78103 BONE MARROW IMAGING; MULTIPLE AREAS 1/1/2005 78104 BONE MARROW IMAGING; WHOLE BODY 1/1/2005 PLASMA VOLUME, RADIOPHARMACEUTICAL VOLUME-DILUTION 78110 TECHNIQUE (SEPARATE PROCEDURE); SINGLE SAMPLING 1/1/2005 PLASMA VOLUME, RADIOPHARMACEUTICAL VOLUME-DILUTION 78111 TECHNIQUE (SEPARATE PROCEDURE); MULTIPLE SAMPLINGS 1/1/2005 RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); 78120 SINGLE SAMPLING 1/1/2005 RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); 78121 MULTIPLE SAMPLINGS 1/1/2005
HealthSpan Provider Manual APPENDIX E Revised February 2014 14
HEALTHSPAN
HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE WHOLE BLOOD VOLUME DETERMINATION, INCLUDING SEPARATE MEASUREMENT OF PLASMA VOLUME AND RED CELL VOLUME 78122 (RADIOPHARMACEUTICAL VOLUME- 1/1/2005 78130 RED CELL SURVIVAL STUDY; 1/1/2005 RED CELL SURVIVAL STUDY; DIFFERENTIAL ORGAN/TISSUE KINETICS, 78135 (EG, SPLENIC AND/OR HEPATIC SEQUESTRATION) 1/1/2005 LABELED RED CELL SEQUESTRATION, DIFFERENTIAL ORGAN/TISSUE, 78140 (EG, SPLENIC AND/OR HEPATIC) 1/1/2005 78185 SPLEEN IMAGING ONLY, WITH OR WITHOUT VASCULAR FLOW 1/1/2005 KINETICS, STUDY OF PLATELET SURVIVAL, WITH OR WITHOUT 78190 DIFFERENTIAL ORGAN/TISSUE LOCALIZATION 1/1/2005 78191 PLATELET SURVIVAL STUDY 1/1/2005 78195 LYMPHATICS AND LYMPH NODES IMAGING 1/1/2005 78201 LIVER IMAGING; STATIC ONLY 1/1/2005 78202 LIVER IMAGING; WITH VASCULAR FLOW 1/1/2005 78215 LIVER AND SPLEEN IMAGING; STATIC ONLY 1/1/2005 78216 LIVER AND SPLEEN IMAGING; WITH VASCULAR FLOW 1/1/2005 LIVER FUNCTION STUDY WITH HEPATOBILIARY AGENTS, WITH SERIAL 78220 IMAGES 1/1/2005 HEPATOBILIARY DUCTAL SYSTEM IMAGING, INCLUDING GALLBLADDER, WITH OR WITHOUT PHARMACOLOGIC INTERVENTION, 78223 WITH OR WITHOUT QUANTITATI 1/1/2005 HEPATOBILIARY SYSTEM IMAGING, INCLUDING GALLBLADDER WHEN 78226 PRESENT; 1/1/2012 HEPATOBILIARY SYSTEM IMAGING, INCLUDING GALLBLADDER WHEN PRESENT; WITH PHARMACOLOGIC INTERVENTION, INCLUDING 78227 QUANTITATIVE MEASUREM 1/1/2012 78230 SALIVARY GLAND IMAGING; 1/1/2005 78231 SALIVARY GLAND IMAGING; WITH SERIAL IMAGES 1/1/2005 78232 SALIVARY GLAND FUNCTION STUDY 1/1/2005 78258 ESOPHAGEAL MOTILITY 1/1/2005 78261 GASTRIC MUCOSA IMAGING 1/1/2005 78262 GASTROESOPHAGEAL REFLUX STUDY 1/1/2005 78264 GASTRIC EMPTYING STUDY 1/1/2011 VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITHOUT 78270 INTRINSIC FACTOR 1/1/2005 VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITH 78271 INTRINSIC FACTOR 1/1/2005 VITAMIN B-12 ABSORPTION STUDIES COMBINED, WITH AND WITHOUT 78272 INTRINSIC FACTOR 1/1/2005 78278 ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING 1/1/2005 78282 GASTROINTESTINAL PROTEIN LOSS 1/1/2005 INTESTINE IMAGING (EG, ECTOPIC GASTRIC MUCOSA, MECKEL'S 78290 LOCALIZATION, VOLVULUS) 1/1/2005 PERITONEAL-VENOUS SHUNT PATENCY TEST (EG, FOR LEVEEN, 78291 DENVER SHUNT) 1/1/2005 BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE 78350 SITES; SINGLE PHOTON ABSORPTIOMETRY 1/1/2005 BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE 78351 SITES; DUAL PHOTON ABSORPTIOMETRY, ONE OR MORE SITES 1/1/2005 HealthSpan Provider Manual APPENDIX E Revised February 2014 15
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 78586 PULMONARY VENTILATION IMAGING, AEROSOL; SINGLE PROJECTION 1/1/2005 PULMONARY VENTILATION IMAGING, AEROSOL; MULTIPLE 78587 PROJECTIONS (EG, ANTERIOR, POSTERIOR, LATERAL VIEWS) 1/1/2005 PULMONARY VENTILATION IMAGING, GASEOUS, SINGLE BREATH, 78591 SINGLE PROJECTION 1/1/2005 PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND WASHOUT WITH OR WITHOUT SINGLE BREATH; SINGLE 78593 PROJECTION 1/1/2005 PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND WASHOUT WITH OR WITHOUT SINGLE BREATH; MULTIPLE 78594 PROJECTIONS (EG, ANTE 1/1/2005 PULMONARY QUANTITATIVE DIFFERENTIAL FUNCTION 78596 (VENTILATION/PERFUSION) STUDY 1/1/2005 78700 KIDNEY IMAGING; STATIC ONLY 1/1/2006 78701 KIDNEY IMAGING; WITH VASCULAR FLOW 1/1/2006 78704 KIDNEY IMAGING; WITH FUNCTION STUDY (IE, IMAGING RENOGRAM) 1/1/2006 78707 K FLOW/FUNCT IMAGE W/O DRUG 6/1/2011 78708 K FLOW/FUNCT IMAGE W/DRUG 6/1/2011 78709 K FLOW/FUNCT IMAGE MULTIPLE 6/1/2011 78710 KIDNEY IMAGING (3D) 6/1/2011 78715 KIDNEY VASCULAR FLOW ONLY 1/1/2006 78725 KIDNEY FUNCTION STUDY, NON-IMAGING RADIOISOTOPIC STUDY 1/1/2006 78730 URINARY BLADDER RESIDUAL STUDY 1/1/2006 URETERAL REFLUX STUDY (RADIOPHARMACEUTICAL VOIDING 78740 CYSTOGRAM) 1/1/2006 78760 TESTICULAR IMAGING; 1/1/2006 78761 TESTICULAR IMAGING; WITH VASCULAR FLOW 1/1/2006 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY 78807 PROCESS; TOMOGRAPHIC (SPECT) 1/1/2006 INJECTION PROCEDURE FOR RADIOPHARMACEUTICAL LOCALIZATION BY NON-IMAGING PROBE STUDY, INTRAVENOUS (EG, PARATHYROID 78808 ADENOMA) 1/1/2009 GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH 78890 PROFESSIONAL PERSONNEL; SIMPLE 1/1/2005 GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH 78891 PROFESSIONAL PERSONNEL; COMPLEX 1/1/2005 78990 PROVISION OF DIAGNOSTIC RADIOPHARMACEUTICAL(S) 1/1/2005 BASIC METABOLIC PANEL (CALCIUM, IONIZED) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, IONIZED (82330) CARBON 80047 DIOXIDE (82374) CH 1/1/2008 BASIC METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM (82310) CARBON DIOXIDE (82374) CHLORIDE 80048 (82435) CREATININE (8 1/1/2005 GENERAL HEALTH PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: COMPREHENSIVE METABOLIC PANEL (80053) BLOOD 80050 COUNT, COMPLETE (CBC), AUT 1/1/2005
HealthSpan Provider Manual APPENDIX E Revised February 2014 16
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (82374) CHLORIDE (82435) POTASSIUM (84132) 80051 SODIUM (84295) 1/1/2005 COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM 80053 (82310) CARB 1/1/2005 OBSTETRIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: BLOOD COUNT, COMPLETE (CBC), AUTOMATED AND AUTOMATED 80055 DIFFERENTIAL WBC COUNT 1/1/2005 LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT 80061 MEASUREMENT, HIGH DENSITY 1/1/2005 RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) CALCIUM (82310) CARBON DIOXIDE 80069 (BICARBONATE) (82374) C 1/1/2005 ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) 80074 HEPATITIS B CORE AN 1/1/2005 HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, 80076 DIRECT (82248) P 1/1/2005 DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES 80100 CHROMATOGRAPHIC METHOD, EACH PROCEDURE 1/1/2005 DRUG SCREEN, QUALITATIVE; SINGLE DRUG CLASS METHOD (EG, 80101 IMMUNOASSAY, ENZYME ASSAY), EACH DRUG CLASS 1/1/2005 80102 DRUG CONFIRMATION, EACH PROCEDURE 1/1/2005 80103 TISSUE PREPARATION FOR DRUG ANALYSIS 1/1/2005 DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES OTHER THAN 80104 CHROMATOGRAPHIC METHOD, EACH PROCEDURE 1/1/2011 80150 AMIKACIN 1/1/2005 80152 AMITRIPTYLINE 1/1/2006 80154 BENZODIAZEPINES 1/1/2006 80155 CAFFEINE 1/1/2014 80156 CARBAMAZEPINE; TOTAL 1/1/2006 80157 CARBAMAZEPINE; FREE 1/1/2006 80158 CYCLOSPORINE 1/1/2006 80159 CLOZAPINE 1/1/2014 80160 DESIPRAMINE 1/1/2006 80162 DIGOXIN 1/1/2006 80164 DIPROPYLACETIC ACID (VALPROIC ACID) 1/1/2006 80166 DOXEPIN 1/1/2006 80168 ETHOSUXIMIDE 1/1/2006 80169 EVEROLIMUS 1/1/2014 80170 GENTAMICIN 1/1/2006 80171 GABAPENTIN 1/1/2014 80172 GOLD 1/1/2006 80173 HALOPERIDOL 1/1/2006 80174 IMIPRAMINE 1/1/2006 80175 LAMOTRIGINE 1/1/2014 80176 LIDOCAINE 1/1/2006 HealthSpan Provider Manual APPENDIX E Revised February 2014 17
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 80177 LEVETIRACETAM 1/1/2014 80178 LITHIUM 1/1/2006 80180 MYCOPHENOLATE (MYCOPHENOLIC ACID) 1/1/2014 80182 NORTRIPTYLINE 1/1/2006 80183 OXCARBAZEPINE 1/1/2014 80184 PHENOBARBITAL 1/1/2006 80185 PHENYTOIN; TOTAL 1/1/2006 80186 PHENYTOIN; FREE 1/1/2006 80188 PRIMIDONE 1/1/2006 80190 PROCAINAMIDE; 1/1/2006 80192 PROCAINAMIDE; WITH METABOLITES (EG, N-ACETYL PROCAINAMIDE) 1/1/2006 80194 QUINIDINE 1/1/2006 80195 SIROLIMUS 1/1/2006 80196 SALICYLATE 1/1/2006 80197 TACROLIMUS 1/1/2006 80198 THEOPHYLLINE 1/1/2006 80199 TIAGABINE 1/1/2014 80200 TOBRAMYCIN 1/1/2006 80201 TOPIRAMATE 1/1/2006 80202 VANCOMYCIN 1/1/2006 80203 ZONISAMIDE 1/1/2014 80299 QUANTITATION OF DRUG, NOT ELSEWHERE SPECIFIED 1/1/2006 ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS 80400 PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 1/1/2005 ACTH STIMULATION PANEL; FOR 21 HYDROXYLASE DEFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 17 80402 HYDROXYPROGES 1/1/2005 ACTH STIMULATION PANEL; FOR 3 BETA-HYDROXYDEHYDROGENASE DEFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL 80406 (82533 X 2) 17 1/1/2005 ALDOSTERONE SUPPRESSION EVALUATION PANEL (EG, SALINE INFUSION) THIS PANEL MUST INCLUDE THE FOLLOWING: 80408 ALDOSTERONE (82088 X 2) RENI 1/1/2005 CALCITONIN STIMULATION PANEL (EG, CALCIUM, PENTAGASTRIN) 80410 THIS PANEL MUST INCLUDE THE FOLLOWING: CALCITONIN (82308 X 3) 1/1/2005 CORTICOTROPIC RELEASING HORMONE (CRH) STIMULATION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 6) 80412 ADRENOCORTICOT 1/1/2005 CHORIONIC GONADOTROPIN STIMULATION PANEL; TESTOSTERONE RESPONSE THIS PANEL MUST INCLUDE THE FOLLOWING: 80414 TESTOSTERONE (84403 X 2 ON 1/1/2005 CHORIONIC GONADOTROPIN STIMULATION PANEL; ESTRADIOL RESPONSE THIS PANEL MUST INCLUDE THE FOLLOWING: ESTRADIOL 80415 (82670 X 2 ON THREE 1/1/2005 RENAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL) THIS PANEL 80416 MUST INCLUDE THE FOLLOWING: RENIN (84244 X 6) 1/1/2005 PERIPHERAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL) THIS 80417 PANEL MUST INCLUDE THE FOLLOWING: RENIN (84244 X 2) 1/1/2005
HealthSpan Provider Manual APPENDIX E Revised February 2014 18
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE COMBINED RAPID ANTERIOR PITUITARY EVALUATION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ADRENOCORTICOTROPIC 80418 HORMONE (ACTH) (8202 1/1/2005 DEXAMETHASONE SUPPRESSION PANEL, 48 HOUR THIS PANEL MUST INCLUDE THE FOLLOWING: FREE CORTISOL, URINE (82530 X 2) 80420 CORTISOL (82533 X 1/1/2005 GLUCAGON TOLERANCE PANEL; FOR INSULINOMA THIS PANEL MUST 80422 INCLUDE THE FOLLOWING: GLUCOSE (82947 X 3) INSULIN (83525 X 3) 1/1/2005 GLUCAGON TOLERANCE PANEL; FOR PHEOCHROMOCYTOMA THIS PANEL MUST INCLUDE THE FOLLOWING: CATECHOLAMINES, 80424 FRACTIONATED (82384 X 2) 1/1/2005 GONADOTROPIN RELEASING HORMONE STIMULATION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: FOLLICLE STIMULATING 80426 HORMONE (FSH) (83001 1/1/2005 GROWTH HORMONE STIMULATION PANEL (EG, ARGININE INFUSION, L- DOPA ADMINISTRATION) THIS PANEL MUST INCLUDE THE FOLLOWING: 80428 HUMAN GROWT 1/1/2005 GROWTH HORMONE SUPPRESSION PANEL (GLUCOSE ADMINISTRATION) THIS PANEL MUST INCLUDE THE FOLLOWING: 80430 GLUCOSE (82947 X 3) HUMAN GROWTH 1/1/2005 INSULIN-INDUCED C-PEPTIDE SUPPRESSION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: INSULIN (83525) C-PEPTIDE (84681 X 5) 80432 GLUCOSE ( 1/1/2005 INSULIN TOLERANCE PANEL; FOR ACTH INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 5) GLUCOSE 80434 (82947 X 5) 1/1/2005 INSULIN TOLERANCE PANEL; FOR GROWTH HORMONE DEFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: GLUCOSE (82947 X 5) 80435 HUMAN GROWTH HOR 1/1/2005 METYRAPONE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: 80436 CORTISOL (82533 X 2) 11 DEOXYCORTISOL (82634 X 2) 1/1/2005 THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; ONE HOUR THIS PANEL MUST INCLUDE THE FOLLOWING: THYROID 80438 STIMULATING HORMONE 1/1/2005 THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; TWO HOUR THIS PANEL MUST INCLUDE THE FOLLOWING: THYROID 80439 STIMULATING HORMONE 1/1/2005 THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; FOR HYPERPROLACTINEMIA THIS PANEL MUST INCLUDE THE 80440 FOLLOWING: PROLACTIN (84 1/1/2005 CLINICAL PATHOLOGY CONSULTATION; LIMITED, WITHOUT REVIEW OF 80500 PATIENT'S HISTORY AND MEDICAL RECORDS 1/1/2005 CLINICAL PATHOLOGY CONSULTATION; COMPREHENSIVE, FOR A COMPLEX DIAGNOSTIC PROBLEM, WITH REVIEW OF PATIENT'S 80502 HISTORY AND MEDICAL RE 1/1/2005 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, 81000 PROTEIN, SPECIFIC 1/1/2005
HealthSpan Provider Manual APPENDIX E Revised February 2014 19
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, 81001 PROTEIN, SPECIFIC 1/1/2005 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, 81002 PROTEIN, SPECIFIC 1/1/2005 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, 81003 PROTEIN, SPECIFIC 1/1/2005 URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT 81005 IMMUNOASSAYS 1/1/2005 URINALYSIS; BACTERIURIA SCREEN, EXCEPT BY CULTURE OR 81007 DIPSTICK 1/1/2005 81015 URINALYSIS; MICROSCOPIC ONLY 1/1/2005 81020 URINALYSIS; TWO OR THREE GLASS TEST 1/1/2005 81025 URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS 1/1/2005 81050 VOLUME MEASUREMENT FOR TIMED COLLECTION, EACH 1/1/2005 Fetal congenital abnormalities, biochemical assays of two proteins (PAPP-A, 81508 hCG [any form]), utilizing maternal serum, algorithm reported as a risk score 1/1/2013 Fetal congenital abnormalities, biochemical assays of three proteins (PAPP-A, hCG [any form], DIA), utilizing maternal serum, algorithm reported as a risk 81509 score 1/1/2013 Fetal congenital abnormalities, biochemical assays of three analytes (AFP, uE3, hCG [any form]), utilizing maternal serum, algorithm reported as a risk 81510 score 1/1/2013 Fetal congenital abnormalities, biochemical assays of four analytes (AFP, uE3, hCG [any form], DIA) utilizing maternal serum, algorithm reported as a risk 81511 score (may include additional results from previous biochemical testing) 1/1/2013 Fetal congenital abnormalities, biochemical assays of five analytes (AFP, uE3, total hCG, hyperglycosylated hCG, DIA) utilizing maternal serum, algorithm 81512 reported as a risk score 1/1/2013 82000 ACETALDEHYDE, BLOOD 1/1/2005 82003 ACETAMINOPHEN 1/1/2006 82009 ACETONE OR OTHER KETONE BODIES, SERUM; QUALITATIVE 1/1/2006 82010 ACETONE OR OTHER KETONE BODIES, SERUM; QUANTITATIVE 1/1/2006 82013 ACETYLCHOLINESTERASE 1/1/2006 82016 ACYLCARNITINES; QUALITATIVE, EACH SPECIMEN 1/1/2006 82017 ACYLCARNITINES; QUANTITATIVE, EACH SPECIMEN 1/1/2006 82024 ADRENOCORTICOTROPIC HORMONE (ACTH) 1/1/2006 82030 ADENOSINE, 5-MONOPHOSPHATE, CYCLIC (CYCLIC AMP) 1/1/2006 82040 ALBUMIN; SERUM 1/1/2006 ALBUMIN; URINE OR OTHER SOURCE, QUANTITATIVE, EACH 82042 SPECIMEN 1/1/2006 82043 ALBUMIN; URINE, MICROALBUMIN, QUANTITATIVE 1/1/2006 ALBUMIN; URINE, MICROALBUMIN, SEMIQUANTITATIVE (EG, REAGENT 82044 STRIP ASSAY) 1/1/2006 82045 ALBUMIN; ISCHEMIA MODIFIED 1/1/2006 82055 ALCOHOL (ETHANOL); ANY SPECIMEN EXCEPT BREATH 1/1/2006 82075 ALCOHOL (ETHANOL); BREATH 1/1/2006 82085 ALDOLASE 1/1/2006 HealthSpan Provider Manual APPENDIX E Revised February 2014 20
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 82088 ALDOSTERONE 1/1/2006 82101 ALKALOIDS, URINE, QUANTITATIVE 1/1/2006 82103 ALPHA-1-ANTITRYPSIN; TOTAL 1/1/2006 82104 ALPHA-1-ANTITRYPSIN; PHENOTYPE 1/1/2006 82105 ALPHA-FETOPROTEIN; SERUM 1/1/2006 82106 ALPHA-FETOPROTEIN; AMNIOTIC FLUID 1/1/2006 ALPHA-FETOPROTEIN (AFP); AFP-L3 FRACTION ISOFORM AND TOTAL 82107 AFP (INCLUDING RATIO) 1/1/2007 82108 ALUMINUM 1/1/2006 82120 AMINES, VAGINAL FLUID, QUALITATIVE 1/1/2006 82127 AMINO ACIDS; SINGLE, QUALITATIVE, EACH SPECIMEN 1/1/2006 82128 AMINO ACIDS; MULTIPLE, QUALITATIVE, EACH SPECIMEN 1/1/2006 82131 AMINO ACIDS; SINGLE, QUANTITATIVE, EACH SPECIMEN 1/1/2006 82135 AMINOLEVULINIC ACID, DELTA (ALA) 1/1/2006 82136 AMINO ACIDS, 2 TO 5 AMINO ACIDS, QUANTITATIVE, EACH SPECIMEN 1/1/2006 AMINO ACIDS, 6 OR MORE AMINO ACIDS, QUANTITATIVE, EACH 82139 SPECIMEN 1/1/2006 82140 AMMONIA 1/1/2006 82143 AMNIOTIC FLUID SCAN (SPECTROPHOTOMETRIC) 1/1/2006 82145 AMPHETAMINE OR METHAMPHETAMINE 1/1/2006 82150 AMYLASE 1/1/2006 82154 ANDROSTANEDIOL GLUCURONIDE 1/1/2006 82157 ANDROSTENEDIONE 1/1/2006 82160 ANDROSTERONE 1/1/2006 82163 ANGIOTENSIN II 1/1/2006 82164 ANGIOTENSIN I - CONVERTING ENZYME (ACE) 1/1/2006 82172 APOLIPOPROTEIN, EACH 1/1/2006 82175 ARSENIC 1/1/2006 82180 ASCORBIC ACID (VITAMIN C), BLOOD 1/1/2006 82190 ATOMIC ABSORPTION SPECTROSCOPY, EACH ANALYTE 1/1/2006 82205 BARBITURATES, NOT ELSEWHERE SPECIFIED 1/1/2006 82232 BETA-2 MICROGLOBULIN 1/1/2006 82239 BILE ACIDS; TOTAL 1/1/2006 82240 BILE ACIDS; CHOLYLGLYCINE 1/1/2006 82247 BILIRUBIN; TOTAL 1/1/2006 82248 BILIRUBIN; DIRECT 1/1/2006 82251 BILIRUBIN; TOTAL AND DIRECT 1/1/2007 82252 BILIRUBIN; FECES, QUALITATIVE 1/1/2006 82261 BIOTINIDASE, EACH SPECIMEN 1/1/2006 BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; FECES, CONSECUTIVE COLLECTED SPECIMENS WITH 82270 SINGLE DETERMINATION, 1/1/2006 BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), 82271 QUALITATIVE; OTHER SOURCES 1/1/2006 BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, FECES, SINGLE SPECIMEN (EG, FROM DIGITAL RECTAL 82272 EXAM) 1/1/2006 BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), 82273 QUALITATIVE; OTHER SOURCES 1/1/2006
HealthSpan Provider Manual APPENDIX E Revised February 2014 21
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS 82274 DETERMINATIONS 1/1/2006 82286 BRADYKININ 1/1/2006 82300 CADMIUM 1/1/2006 82306 CALCIFEDIOL (25-OH VITAMIN D-3) 1/1/2006 82307 CALCIFEROL (VITAMIN D) 1/1/2006 82308 CALCITONIN 1/1/2006 82310 CALCIUM; TOTAL 1/1/2006 82330 CALCIUM; IONIZED 1/1/2006 82331 CALCIUM; AFTER CALCIUM INFUSION TEST 1/1/2006 82340 CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN 1/1/2006 82355 CALCULUS; QUALITATIVE ANALYSIS 1/1/2006 82360 CALCULUS; QUANTITATIVE ANALYSIS, CHEMICAL 1/1/2006 82365 CALCULUS; INFRARED SPECTROSCOPY 1/1/2006 82370 CALCULUS; X-RAY DIFFRACTION 1/1/2006 82373 CARBOHYDRATE DEFICIENT TRANSFERRIN 1/1/2006 82374 CARBON DIOXIDE (BICARBONATE) 1/1/2006 82375 CARBON MONOXIDE, (CARBOXYHEMOGLOBIN); QUANTITATIVE 1/1/2006 82376 CARBON MONOXIDE, (CARBOXYHEMOGLOBIN); QUALITATIVE 1/1/2006 82378 CARCINOEMBRYONIC ANTIGEN (CEA) 1/1/2006 82379 CARNITINE (TOTAL AND FREE), QUANTITATIVE, EACH SPECIMEN 1/1/2006 82380 CAROTENE 1/1/2006 82382 CATECHOLAMINES; TOTAL URINE 1/1/2006 82383 CATECHOLAMINES; BLOOD 1/1/2006 82384 CATECHOLAMINES; FRACTIONATED 1/1/2006 82387 CATHEPSIN-D 1/1/2006 82390 CERULOPLASMIN 1/1/2006 82397 CHEMILUMINESCENT ASSAY 1/1/2006 82415 CHLORAMPHENICOL 1/1/2006 82435 CHLORIDE; BLOOD 1/1/2006 82436 CHLORIDE; URINE 1/1/2006 82438 CHLORIDE; OTHER SOURCE 1/1/2006 82441 CHLORINATED HYDROCARBONS, SCREEN 1/1/2006 82465 CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL 1/1/2006 82480 CHOLINESTERASE; SERUM 1/1/2006 82482 CHOLINESTERASE; RBC 1/1/2006 82485 CHONDROITIN B SULFATE, QUANTITATIVE 1/1/2006 CHROMATOGRAPHY, QUALITATIVE; COLUMN (EG, GAS LIQUID OR 82486 HPLC), ANALYTE NOT ELSEWHERE SPECIFIED 1/1/2006 CHROMATOGRAPHY, QUALITATIVE; PAPER, 1-DIMENSIONAL, ANALYTE 82487 NOT ELSEWHERE SPECIFIED 1/1/2006 CHROMATOGRAPHY, QUALITATIVE; PAPER, 2-DIMENSIONAL, ANALYTE 82488 NOT ELSEWHERE SPECIFIED 1/1/2006 CHROMATOGRAPHY, QUALITATIVE; THIN LAYER, ANALYTE NOT 82489 ELSEWHERE SPECIFIED 1/1/2006 CHROMATOGRAPHY, QUANTITATIVE, COLUMN (EG, GAS LIQUID OR HPLC); SINGLE ANALYTE NOT ELSEWHERE SPECIFIED, SINGLE 82491 STATIONARY AND MOBIL 1/1/2006
HealthSpan Provider Manual APPENDIX E Revised February 2014 22
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE CHROMATOGRAPHY, QUANTITATIVE, COLUMN (EG, GAS LIQUID OR HPLC); MULTIPLE ANALYTES, SINGLE STATIONARY AND MOBILE 82492 PHASE 1/1/2006 82495 CHROMIUM 1/1/2006 82507 CITRATE 1/1/2006 82520 COCAINE OR METABOLITE 1/1/2006 82523 COLLAGEN CROSS LINKS, ANY METHOD 1/1/2006 82525 COPPER 1/1/2006 82528 CORTICOSTERONE 1/1/2006 82530 CORTISOL; FREE 1/1/2006 82533 CORTISOL; TOTAL 1/1/2006 82540 CREATINE 1/1/2006 COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/MS), ANALYTE NOT ELSEWHERE SPECIFIED; QUALITATIVE, 82541 SINGLE STATIONARY A 1/1/2006 COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/MS), ANALYTE NOT ELSEWHERE SPECIFIED; QUANTITATIVE, 82542 SINGLE STATIONARY 1/1/2006 COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/MS), ANALYTE NOT ELSEWHERE SPECIFIED; STABLE ISOTOPE 82543 DILUTION, SINGLE 1/1/2006 COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR HPLC/MS), ANALYTE NOT ELSEWHERE SPECIFIED; STABLE ISOTOPE 82544 DILUTION, MULTIPL 1/1/2006 82550 CREATINE KINASE (CK), (CPK); TOTAL 1/1/2006 82552 CREATINE KINASE (CK), (CPK); ISOENZYMES 1/1/2006 82553 CREATINE KINASE (CK), (CPK); MB FRACTION ONLY 1/1/2006 82554 CREATINE KINASE (CK), (CPK); ISOFORMS 1/1/2006 82565 CREATININE; BLOOD 1/1/2006 82570 CREATININE; OTHER SOURCE 1/1/2006 82575 CREATININE; CLEARANCE 1/1/2006 82585 CRYOFIBRINOGEN 1/1/2006 CRYOGLOBULIN, QUALITATIVE OR SEMI-QUANTITATIVE (EG, 82595 CRYOCRIT) 1/1/2006 82600 CYANIDE 1/1/2006 82607 CYANOCOBALAMIN (VITAMIN B-12); 1/1/2006 82608 CYANOCOBALAMIN (VITAMIN B-12); UNSATURATED BINDING CAPACITY 1/1/2006 82610 CYSTATIN C 1/1/2008 82615 CYSTINE AND HOMOCYSTINE, URINE, QUALITATIVE 1/1/2006 82626 DEHYDROEPIANDROSTERONE (DHEA) 1/1/2006 82627 DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 1/1/2006 82633 DESOXYCORTICOSTERONE, 11- 1/1/2006 82634 DEOXYCORTISOL, 11- 1/1/2006 82638 DIBUCAINE NUMBER 1/1/2006 82646 DIHYDROCODEINONE 1/1/2006 82649 DIHYDROMORPHINONE 1/1/2006 82651 DIHYDROTESTOSTERONE (DHT) 1/1/2006 82652 DIHYDROXYVITAMIN D, 1,25- 1/1/2006 82654 DIMETHADIONE 1/1/2006
HealthSpan Provider Manual APPENDIX E Revised February 2014 23
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE ELASTASE, PANCREATIC (EL-1), FECAL, QUALITATIVE OR SEMI- 82656 QUANTITATIVE 1/1/2006 ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT ELSEWHERE SPECIFIED; NONRADIOACTIVE SUBSTRATE, EACH 82657 SPECIMEN 1/1/2006 ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT ELSEWHERE SPECIFIED; RADIOACTIVE SUBSTRATE, EACH 82658 SPECIMEN 1/1/2006 82664 ELECTROPHORETIC TECHNIQUE, NOT ELSEWHERE SPECIFIED 1/1/2006 82666 EPIANDROSTERONE 1/1/2006 82668 ERYTHROPOIETIN 1/1/2006 82670 ESTRADIOL 1/1/2006 82671 ESTROGENS; FRACTIONATED 1/1/2006 82672 ESTROGENS; TOTAL 1/1/2006 82677 ESTRIOL 1/1/2006 82679 ESTRONE 1/1/2006 82690 ETHCHLORVYNOL 1/1/2006 82693 ETHYLENE GLYCOL 1/1/2006 82696 ETIOCHOLANOLONE 1/1/2006 82705 FAT OR LIPIDS, FECES; QUALITATIVE 1/1/2006 82710 FAT OR LIPIDS, FECES; QUANTITATIVE 1/1/2006 82715 FAT DIFFERENTIAL, FECES, QUANTITATIVE 1/1/2006 82725 FATTY ACIDS, NONESTERIFIED 1/1/2006 82726 VERY LONG CHAIN FATTY ACIDS 1/1/2006 82728 FERRITIN 1/1/2006 FETAL FIBRONECTIN, CERVICOVAGINAL SECRETIONS, SEMI- 82731 QUANTITATIVE 1/1/2006 82735 FLUORIDE 1/1/2006 82742 FLURAZEPAM 1/1/2006 82746 FOLIC ACID; SERUM 1/1/2006 82747 FOLIC ACID; RBC 1/1/2006 82757 FRUCTOSE, SEMEN 1/1/2006 82759 GALACTOKINASE, RBC 1/1/2006 82760 GALACTOSE 1/1/2006 82775 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; QUANTITATIVE 1/1/2006 82776 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; SCREEN 1/1/2006 82784 GAMMAGLOBULIN; IGA, IGD, IGG, IGM, EACH 1/1/2006 82785 GAMMAGLOBULIN; IGE 1/1/2006 GAMMAGLOBULIN; IMMUNOGLOBULIN SUBCLASSES, (IGG1, 2, 3, OR 4), 82787 EACH 1/1/2006 82800 GASES, BLOOD, PH ONLY 1/1/2006 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 82803 (INCLUDING CALCULATED O2 SATURATION); 1/1/2006 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION); WITH O2 SATURATION, BY 82805 DIRECT MEAS 1/1/2006 GASES, BLOOD, O2 SATURATION ONLY, BY DIRECT MEASUREMENT, 82810 EXCEPT PULSE OXIMETRY 1/1/2006 HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR 50% HEMOGLOBIN 82820 SATURATION WITH OXYGEN) 1/1/2006 HealthSpan Provider Manual APPENDIX E Revised February 2014 24
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 82926 GASTRIC ACID, FREE AND TOTAL, EACH SPECIMEN 1/1/2006 82928 GASTRIC ACID, FREE OR TOTAL, EACH SPECIMEN 1/1/2006 GASTRIC ACID ANALYSIS, INCLUDES PH IF PERFORMED, EACH 82930 SPECIMEN 1/1/2011 82938 GASTRIN AFTER SECRETIN STIMULATION 1/1/2006 82941 GASTRIN 1/1/2006 82943 GLUCAGON 1/1/2006 82945 GLUCOSE, BODY FLUID, OTHER THAN BLOOD 1/1/2006 82946 GLUCAGON TOLERANCE TEST 1/1/2006 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP) 1/1/2006 82948 GLUCOSE; BLOOD, REAGENT STRIP 1/1/2006 82950 GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 1/1/2006 GLUCOSE; TOLERANCE TEST (GTT), THREE SPECIMENS (INCLUDES 82951 GLUCOSE) 1/1/2006 GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND THREE 82952 SPECIMENS 1/1/2006 82953 GLUCOSE; TOLBUTAMIDE TOLERANCE TEST 1/1/2006 82955 GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD); QUANTITATIVE 1/1/2006 82960 GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD); SCREEN 1/1/2006 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY 82962 THE FDA SPECIFICALLY FOR HOME USE 1/1/2006 82963 GLUCOSIDASE, BETA 1/1/2006 82965 GLUTAMATE DEHYDROGENASE 1/1/2006 82975 GLUTAMINE (GLUTAMIC ACID AMIDE) 1/1/2006 82977 GLUTAMYLTRANSFERASE, GAMMA (GGT) 1/1/2006 82978 GLUTATHIONE 1/1/2006 82979 GLUTATHIONE REDUCTASE, RBC 1/1/2006 82980 GLUTETHIMIDE 1/1/2006 82985 GLYCATED PROTEIN 1/1/2006 83001 GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 1/1/2006 83002 GONADOTROPIN; LUTEINIZING HORMONE (LH) 1/1/2006 83003 GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN) 1/1/2006 83008 GUANOSINE MONOPHOSPHATE (GMP), CYCLIC 1/1/2006 HELICOBACTER PYLORI, BLOOD TEST ANALYSIS FOR UREASE 83009 ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13) 1/1/2006 83010 HAPTOGLOBIN; QUANTITATIVE 1/1/2006 83012 HAPTOGLOBIN; PHENOTYPES 1/1/2006 HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE 83013 ACTIVITY, NON-RADIOACTIVE ISOTOPE (EG, C-13) 1/1/2006 83014 HELICOBACTER PYLORI; DRUG ADMINISTRATION 1/1/2006 HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, 83015 ANTIMONY, MERCURY); SCREEN 1/1/2006 HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, 83018 ANTIMONY, MERCURY); QUANTITATIVE, EACH 1/1/2006 HEMOGLOBIN FRACTIONATION AND QUANTITATION; 83020 ELECTROPHORESIS (EG, A2, S, C, AND/OR F) 1/1/2006 HEMOGLOBIN FRACTIONATION AND QUANTITATION; 83021 CHROMATOGRAPHY (EG, A2, S, C, AND/OR F) 1/1/2006 83026 HEMOGLOBIN; BY COPPER SULFATE METHOD, NON-AUTOMATED 1/1/2006
HealthSpan Provider Manual APPENDIX E Revised February 2014 25
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 83030 HEMOGLOBIN; F (FETAL), CHEMICAL 1/1/2006 83033 HEMOGLOBIN; F (FETAL), QUALITATIVE 1/1/2006 83036 HEMOGLOBIN; GLYCOSYLATED (A1C 1/1/2006 HEMOGLOBIN; GLYCOSYLATED (A1C) BY DEVICE CLEARED BY FDA 83037 FOR HOME USE 1/1/2006 83045 HEMOGLOBIN; METHEMOGLOBIN, QUALITATIVE 1/1/2006 83050 HEMOGLOBIN; METHEMOGLOBIN, QUANTITATIVE 1/1/2006 83051 HEMOGLOBIN; PLASMA 1/1/2006 83055 HEMOGLOBIN; SULFHEMOGLOBIN, QUALITATIVE 1/1/2006 83060 HEMOGLOBIN; SULFHEMOGLOBIN, QUANTITATIVE 1/1/2006 83065 HEMOGLOBIN; THERMOLABILE 1/1/2006 83068 HEMOGLOBIN; UNSTABLE, SCREEN 1/1/2006 83069 HEMOGLOBIN; URINE 1/1/2006 83070 HEMOSIDERIN; QUALITATIVE 1/1/2006 83071 HEMOSIDERIN; QUANTITATIVE 1/1/2006 83080 B-HEXOSAMINIDASE, EACH ASSAY 1/1/2006 83088 HISTAMINE 1/1/2006 83090 HOMOCYSTEINE 1/1/2006 83150 HOMOVANILLIC ACID (HVA) 1/1/2006 83491 HYDROXYCORTICOSTEROIDS, 17- (17-OHCS) 1/1/2006 83497 HYDROXYINDOLACETIC ACID, 5-(HIAA) 1/1/2006 83498 HYDROXYPROGESTERONE, 17-D 1/1/2006 83499 HYDROXYPROGESTERONE, 20- 1/1/2006 83500 HYDROXYPROLINE; FREE 1/1/2006 83505 HYDROXYPROLINE; TOTAL 1/1/2006 IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN, QUALITATIVE OR 83516 SEMIQUANTITATIVE; MULTIPL 1/1/2006 IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN, QUALITATIVE OR 83518 SEMIQUANTITATIVE; SINGLE 1/1/2006 IMMUNOASSAY, ANALYTE, QUANTITATIVE; BY 83519 RADIOPHARMACEUTICAL TECHNIQUE (EG, RIA) 1/1/2006 IMMUNOASSAY, ANALYTE, QUANTITATIVE; NOT OTHERWISE 83520 SPECIFIED 1/1/2006 83525 INSULIN; TOTAL 1/1/2006 83527 INSULIN; FREE 1/1/2006 83528 INTRINSIC FACTOR 1/1/2006 83540 IRON 1/1/2006 83550 IRON BINDING CAPACITY 1/1/2006 83570 ISOCITRIC DEHYDROGENASE (IDH) 1/1/2006 83582 KETOGENIC STEROIDS, FRACTIONATION 1/1/2006 83586 KETOSTEROIDS, 17- (17-KS); TOTAL 1/1/2006 83593 KETOSTEROIDS, 17- (17-KS); FRACTIONATION 1/1/2006 83605 LACTATE (LACTIC ACID) 1/1/2006 83615 LACTATE DEHYDROGENASE (LD), (LDH); 1/1/2006 LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION 83625 AND QUANTITATION 1/1/2006 83630 LACTOFERRIN, FECAL; QUALITATIVE 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 83631 LACTOFERRIN, FECAL; QUANTITATIVE 1/1/2006 LACTOGEN, HUMAN PLACENTAL (HPL) HUMAN CHORIONIC 83632 SOMATOMAMMOTROPIN 1/1/2006 83633 LACTOSE, URINE; QUALITATIVE 1/1/2006 83634 LACTOSE, URINE; QUANTITATIVE 1/1/2006 83655 LEAD 1/1/2006 FETAL LUNG MATURITY ASSESSMENT; LECITHIN SPHINGOMYELIN 83661 (L/S) RATIO 1/1/2006 83662 FETAL LUNG MATURITY ASSESSMENT; FOAM STABILITY TEST 1/1/2006 FETAL LUNG MATURITY ASSESSMENT; FLUORESCENCE 83663 POLARIZATION 1/1/2006 83664 FETAL LUNG MATURITY ASSESSMENT; LAMELLAR BODY DENSITY 1/1/2006 83670 LEUCINE AMINOPEPTIDASE (LAP) 1/1/2006 83690 LIPASE 1/1/2006 83695 LIPOPROTEIN (A) 1/1/2006 83698 LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2, (LP-PLA2) 1/1/2007 LIPOPROTEIN, BLOOD; ELECTROPHORETIC SEPARATION AND 83700 QUANTITATION 1/1/2006 LIPOPROTEIN, BLOOD; HIGH RESOLUTION FRACTIONATION AND QUANTITATION OF LIPOPROTEINS INCLUDING LIPOPROTEIN 83701 SUBCLASSES WHEN PERFORMED 1/1/2006 LIPOPROTEIN, BLOOD; QUANTITATION OF LIPOPROTEIN PARTICLE NUMBERS AND LIPOPROTEIN PARTICLE SUBCLASSES (EG, BY 83704 NUCLEAR MAGNETIC RESO 1/1/2006 LIPOPROTEIN, BLOOD; ELECTROPHORETIC SEPARATION AND 83715 QUANTITATION 1/1/2006 LIPOPROTEIN, BLOOD; HIGH RESOLUTION FRACTIONATION AND QUANTITATION OF LIPOPROTEINS INCLUDING LIPOPROTEIN 83716 SUBCLASSES WHEN PERFORMED 1/1/2006 83717 LIPOPROT.BLD-ULTRACENT & QUA 1/1/2007 LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL 83718 (HDL CHOLESTEROL) 1/1/2006 83719 LIPOPROTEIN, DIRECT MEASUREMENT; VLDL CHOLESTEROL 1/1/2006 83721 LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL 1/1/2006 83727 LUTEINIZING RELEASING FACTOR (LRH) 1/1/2006 83735 MAGNESIUM 1/1/2006 83775 MALATE DEHYDROGENASE 1/1/2006 83785 MANGANESE 1/1/2006 MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (MS, MS/MS), ANALYTE NOT ELSEWHERE SPECIFIED; QUALITATIVE, EACH 83788 SPECIMEN 1/1/2006 MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (MS, MS/MS), ANALYTE NOT ELSEWHERE SPECIFIED; QUANTITATIVE, EACH 83789 SPECIMEN 1/1/2006 83805 MEPROBAMATE 1/1/2006 83825 MERCURY, QUANTITATIVE 1/1/2006 83835 METANEPHRINES 1/1/2006 83840 METHADONE 1/1/2006 83857 METHEMALBUMIN 1/1/2006 83858 METHSUXIMIDE 1/1/2006 HealthSpan Provider Manual APPENDIX E Revised February 2014 27
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE MICROFLUIDIC ANALYSIS UTILIZING AN INTEGRATED COLLECTION 83861 AND ANALYSIS DEVICE, TEAR OSMOLARITY 1/1/2011 83864 MUCOPOLYSACCHARIDES, ACID; QUANTITATIVE 1/1/2006 83866 MUCOPOLYSACCHARIDES, ACID; SCREEN 1/1/2006 83872 MUCIN, SYNOVIAL FLUID (ROPES TEST) 1/1/2006 83873 MYELIN BASIC PROTEIN, CEREBROSPINAL FLUID 1/1/2006 83874 MYOGLOBIN 1/1/2006 83876 MYELOPEROXIDASE (MPO) 1/1/2009 83880 NATRIURETIC PEPTIDE 1/1/2006 83883 NEPHELOMETRY, EACH ANALYTE NOT ELSEWHERE SPECIFIED 1/1/2006 83885 NICKEL 1/1/2006 83887 NICOTINE 1/1/2006 83915 NUCLEOTIDASE 5- 1/1/2006 83916 OLIGOCLONAL IMMUNE (OLIGOCLONAL BANDS) 1/1/2006 83918 ORGANIC ACIDS; TOTAL, QUANTITATIVE, EACH SPECIMEN 1/1/2006 83919 ORGANIC ACIDS; QUALITATIVE, EACH SPECIMEN 1/1/2006 83921 ORGANIC ACID, SINGLE, QUANTITATIVE 1/1/2006 83925 OPIATES, (EG, MORPHINE, MEPERIDINE) 1/1/2006 83930 OSMOLALITY; BLOOD 1/1/2006 83935 OSMOLALITY; URINE 1/1/2006 83937 OSTEOCALCIN (BONE G1A PROTEIN) 1/1/2006 83945 OXALATE 1/1/2006 83950 ONCOPROTEIN, HER-2/NEU 1/1/2006 83951 ONCOPROTEIN; DES-GAMMA-CARBOXY-PROTHROMBIN (DCP) 1/1/2009 83970 PARATHORMONE (PARATHYROID HORMONE) 1/1/2006 83986 PH, BODY FLUID, EXCEPT BLOOD 1/1/2006 83992 PHENCYCLIDINE (PCP) 1/1/2006 83993 CALPROTECTIN, FECAL 1/1/2008 84022 PHENOTHIAZINE 1/1/2006 84030 PHENYLALANINE (PKU), BLOOD 1/1/2006 84035 PHENYLKETONES, QUALITATIVE 1/1/2006 84060 PHOSPHATASE, ACID; TOTAL 1/1/2006 84061 PHOSPHATASE, ACID; FORENSIC EXAMINATION 1/1/2006 84066 PHOSPHATASE, ACID; PROSTATIC 1/1/2006 84075 PHOSPHATASE, ALKALINE; 1/1/2006 84078 PHOSPHATASE, ALKALINE; HEAT STABLE (TOTAL NOT INCLUDED) 1/1/2006 84080 PHOSPHATASE, ALKALINE; ISOENZYMES 1/1/2006 84081 PHOSPHATIDYLGLYCEROL 1/1/2006 84085 PHOSPHOGLUCONATE, 6-, DEHYDROGENASE, RBC 1/1/2006 84087 PHOSPHOHEXOSE ISOMERASE 1/1/2006 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 1/1/2006 84105 PHOSPHORUS INORGANIC (PHOSPHATE); URINE 1/1/2006 84106 PORPHOBILINOGEN, URINE; QUALITATIVE 1/1/2006 84110 PORPHOBILINOGEN, URINE; QUANTITATIVE 1/1/2006 PLACENTAL ALPHA MICROGLOBULIN-1 (PAMG-1), CERVICOVAGINAL 84112 SECRETION, QUALITATIVE 1/1/2011 84119 PORPHYRINS, URINE; QUALITATIVE 1/1/2006 84120 PORPHYRINS, URINE; QUANTITATION AND FRACTIONATION 1/1/2006 84126 PORPHYRINS, FECES; QUANTITATIVE 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 84127 PORPHYRINS, FECES; QUALITATIVE 1/1/2006 84132 POTASSIUM; SERUM 1/1/2006 84133 POTASSIUM; URINE 1/1/2006 84134 PREALBUMIN 1/1/2006 84135 PREGNANEDIOL 1/1/2006 84138 PREGNANETRIOL 1/1/2006 84140 PREGNENOLONE 1/1/2006 84143 17-HYDROXYPREGNENOLONE 1/1/2006 84144 PROGESTERONE 1/1/2006 84146 PROLACTIN 1/1/2006 84150 PROSTAGLANDIN, EACH 1/1/2006 PROSTATE SPECIFIC ANTIGEN (PSA); COMPLEXED (DIRECT 84152 MEASUREMENT) 1/1/2006 84153 PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 1/1/2006 84154 PROSTATE SPECIFIC ANTIGEN (PSA); FREE 1/1/2006 84155 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM 1/1/2006 84156 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE 1/1/2006 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, 84157 SYNOVIAL FLUID, CEREBROSPINAL FLUID) 1/1/2006 84160 PROTEIN, TOTAL, BY REFRACTOMETRY, ANY SOURCE 1/1/2006 84163 PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A) 1/1/2006 PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, 84165 SERUM 1/1/2006 PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, 84166 OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF) 1/1/2006 PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, 84181 BLOOD OR OTHER BODY FLUID 1/1/2006 PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD OR OTHER BODY FLUID, IMMUNOLOGICAL PROBE FOR BAND 84182 IDENTIFICATION, EAC 1/1/2006 84202 PROTOPORPHYRIN, RBC; QUANTITATIVE 1/1/2006 84203 PROTOPORPHYRIN, RBC; SCREEN 1/1/2006 84206 PROINSULIN 1/1/2006 84207 PYRIDOXAL PHOSPHATE (VITAMIN B-6) 1/1/2006 84210 PYRUVATE 1/1/2006 84220 PYRUVATE KINASE 1/1/2006 84228 QUININE 1/1/2006 84233 RECEPTOR ASSAY; ESTROGEN 1/1/2006 84234 RECEPTOR ASSAY; PROGESTERONE 1/1/2006 RECEPTOR ASSAY; ENDOCRINE, OTHER THAN ESTROGEN OR 84235 PROGESTERONE (SPECIFY HORMONE) 1/1/2006 84238 RECEPTOR ASSAY; NON-ENDOCRINE (SPECIFY RECEPTOR 1/1/2006 84244 RENIN 1/1/2006 84252 RIBOFLAVIN (VITAMIN B-2) 1/1/2006 84255 SELENIUM 1/1/2006 84260 SEROTONIN 1/1/2006 84270 SEX HORMONE BINDING GLOBULIN (SHBG) 1/1/2006 84275 SIALIC ACID 1/1/2006 84285 SILICA 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 84295 SODIUM; SERUM 1/1/2006 84300 SODIUM; URINE 1/1/2006 84302 SODIUM; OTHER SOURCE 1/1/2006 84305 SOMATOMEDIN 1/1/2006 84307 SOMATOSTATIN 1/1/2006 84311 SPECTROPHOTOMETRY, ANALYTE NOT ELSEWHERE SPECIFIED 1/1/2006 84315 SPECIFIC GRAVITY (EXCEPT URINE) 1/1/2006 84351 VASECTOMY P1 1/1/2006 84352 FEMALE STERILIZATION-FACILIT 1/1/2006 84375 SUGARS, CHROMATOGRAPHIC, TLC OR PAPER CHROMATOGRAPHY 1/1/2006 SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE 84376 QUALITATIVE, EACH SPECIMEN 1/1/2006 SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE 84377 QUALITATIVE, EACH SPECIMEN 1/1/2006 SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE 84378 QUANTITATIVE, EACH SPECIMEN 1/1/2006 SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE 84379 QUANTITATIVE, EACH SPECIMEN 1/1/2006 84392 SULFATE, URINE 1/1/2006 84402 TESTOSTERONE; FREE 1/1/2006 84403 TESTOSTERONE; TOTAL 1/1/2006 84425 THIAMINE (VITAMIN B-1) 1/1/2006 84430 THIOCYANATE 1/1/2006 84432 THYROGLOBULIN 1/1/2006 84436 THYROXINE; TOTAL 1/1/2006 84437 THYROXINE; REQUIRING ELUTION (EG, NEONATAL) 1/1/2006 84439 THYROXINE; FREE 1/1/2006 84442 THYROXINE BINDING GLOBULIN (TBG) 1/1/2006 84443 THYROID STIMULATING HORMONE (TSH) 1/1/2006 84445 THYROID STIMULATING IMMUNE GLOBULINS (TSI) 1/1/2006 84446 TOCOPHEROL ALPHA (VITAMIN E) 1/1/2006 84449 TRANSCORTIN (CORTISOL BINDING GLOBULIN) 1/1/2006 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 1/1/2006 84460 TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 1/1/2006 84466 TRANSFERRIN 1/1/2006 84478 TRIGLYCERIDES 1/1/2006 THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE 84479 BINDING RATIO (THBR) 1/1/2006 84480 TRIIODOTHYRONINE T3; TOTAL (TT-3) 1/1/2006 84481 TRIIODOTHYRONINE T3; FREE 1/1/2006 84482 TRIIODOTHYRONINE T3; REVERSE 1/1/2006 84484 TROPONIN, QUANTITATIVE 1/1/2006 84485 TRYPSIN; DUODENAL FLUID 1/1/2006 84488 TRYPSIN; FECES, QUALITATIVE 1/1/2006 84490 TRYPSIN; FECES, QUANTITATIVE, 24-HOUR COLLECTION 1/1/2006 84510 TYROSINE 1/1/2006 84512 TROPONIN, QUALITATIVE 1/1/2006 84520 UREA NITROGEN; QUANTITATIVE 1/1/2006 84525 UREA NITROGEN; SEMIQUANTITATIVE (EG, REAGENT STRIP TEST) 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 84540 UREA NITROGEN, URINE 1/1/2006 84545 UREA NITROGEN, CLEARANCE 1/1/2006 84550 URIC ACID; BLOOD 1/1/2006 84560 URIC ACID; OTHER SOURCE 1/1/2006 84577 UROBILINOGEN, FECES, QUANTITATIVE 1/1/2006 84578 UROBILINOGEN, URINE; QUALITATIVE 1/1/2006 84580 UROBILINOGEN, URINE; QUANTITATIVE, TIMED SPECIMEN 1/1/2006 84583 UROBILINOGEN, URINE; SEMIQUANTITATIVE 1/1/2006 84585 VANILLYLMANDELIC ACID (VMA), URINE 1/1/2006 84586 VASOACTIVE INTESTINAL PEPTIDE (VIP) 1/1/2006 84588 VASOPRESSIN (ANTIDIURETIC HORMONE, ADH) 1/1/2006 84590 VITAMIN A 1/1/2006 84591 VITAMIN, NOT OTHERWISE SPECIFIED 1/1/2006 84597 VITAMIN K 1/1/2006 VOLATILES (EG, ACETIC ANHYDRIDE, CARBON TETRACHLORIDE, DICHLOROETHANE, DICHLOROMETHANE, DIETHYLETHER, ISOPROPYL 84600 ALCOHOL, METHANOL) 1/1/2006 84620 XYLOSE ABSORPTION TEST, BLOOD AND/OR URINE 1/1/2006 84630 ZINC 1/1/2006 84644 COLPOSCOPY P1 1/1/2006 84645 COLPOSCOPY WITH BIOPSY P1 1/1/2006 84681 C-PEPTIDE 1/1/2006 84702 GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE 1/1/2006 84703 GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE 1/1/2006 84704 GONADOTROPIN, CHORIONIC (HCG); FREE BETA CHAIN 1/1/2008 OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR 84830 HUMAN LUTEINIZING HORMONE 1/1/2006 85002 BLEEDING TIME 1/1/2006 85004 BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT 1/1/2006 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH 85007 MANUAL DIFFERENTIAL WBC COUNT 1/1/2006 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION 85008 WITHOUT MANUAL DIFFERENTIAL WBC COUNT 1/1/2006 85009 BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT, BUFFY COAT 1/1/2006 85013 BLOOD COUNT; SPUN MICROHEMATOCRIT 1/1/2006 85014 BLOOD COUNT; HEMATOCRIT (HCT) 1/1/2006 85018 BLOOD COUNT; HEMOGLOBIN (HGB) 1/1/2006 85021 AUTOMATED HEMOGRAM 1/1/2006 85022 AUTOMATED HEMOGRAM 1/1/2006 85023 AUTOMATED HEMOGRAM 1/1/2006 85024 AUTOMATED HEMOGRAM 1/1/2006 BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC 85025 AND PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT 1/1/2006 BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC 85027 AND PLATELET COUNT) 1/1/2006 85031 MANUAL HEMOGRAM, COMPLETE CB 1/1/2006 BLOOD COUNT; MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE, 85032 OR PLATELET) EACH 1/1/2006 85041 BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 85044 BLOOD COUNT; RETICULOCYTE, MANUAL 1/1/2006 85045 BLOOD COUNT; RETICULOCYTE, AUTOMATED 1/1/2006 BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING ONE OR MORE CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN 85046 CONTENT (CHR), IMMAT 1/1/2006 85048 BLOOD COUNT; LEUKOCYTE (WBC), AUTOMATED 1/1/2006 85049 BLOOD COUNT; PLATELET, AUTOMATED 1/1/2006 85055 RETICULATED PLATELET ASSAY 1/1/2006 BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH 85060 WRITTEN REPORT 1/1/2006 85095 BONE MARROW ASPIRATION 1/1/2007 85097 BONE MARROW, SMEAR INTERPRETATION 1/1/2006 85102 BONE MARROW BIOPSY 1/1/2007 85130 CHROMOGENIC SUBSTRATE ASSAY 1/1/2006 85170 CLOT RETRACTION 1/1/2006 85175 CLOT LYSIS TIME, WHOLE BLOOD DILUTION 1/1/2006 85210 CLOTTING; FACTOR II, PROTHROMBIN, SPECIFIC 1/1/2006 85220 CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR 1/1/2006 85230 CLOTTING; FACTOR VII (PROCONVERTIN, STABLE FACTOR) 1/1/2006 85240 CLOTTING; FACTOR VIII (AHG), ONE STAGE 1/1/2006 85244 CLOTTING; FACTOR VIII RELATED ANTIGEN 1/1/2006 85245 CLOTTING; FACTOR VIII, VW FACTOR, RISTOCETIN COFACTOR 1/1/2006 85246 CLOTTING; FACTOR VIII, VW FACTOR ANTIGEN 1/1/2006 CLOTTING; FACTOR VIII, VON WILLEBRAND FACTOR, MULTIMETRIC 85247 ANALYSIS 1/1/2006 85250 CLOTTING; FACTOR IX (PTC OR CHRISTMAS) 1/1/2006 85260 CLOTTING; FACTOR X (STUART-PROWER) 1/1/2006 85270 CLOTTING; FACTOR XI (PTA) 1/1/2006 85280 CLOTTING; FACTOR XII (HAGEMAN) 1/1/2006 85290 CLOTTING; FACTOR XIII (FIBRIN STABILIZING) 1/1/2006 85291 CLOTTING; FACTOR XIII (FIBRIN STABILIZING), SCREEN SOLUBILITY 1/1/2006 85292 CLOTTING; PREKALLIKREIN ASSAY (FLETCHER FACTOR ASSAY) 1/1/2006 CLOTTING; HIGH MOLECULAR WEIGHT KININOGEN ASSAY 85293 (FITZGERALD FACTOR ASSAY) 1/1/2006 CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, 85300 ACTIVITY 1/1/2006 CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, 85301 ANTIGEN ASSAY 1/1/2006 85302 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ANTIGEN 1/1/2006 85303 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY 1/1/2006 85305 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, TOTAL 1/1/2006 85306 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE 1/1/2006 85307 ACTIVATED PROTEIN C (APC) RESISTANCE ASSAY 1/1/2006 85335 FACTOR INHIBITOR TEST 1/1/2006 85337 THROMBOMODULIN 1/1/2006 85345 COAGULATION TIME; LEE AND WHITE 1/1/2006 85347 COAGULATION TIME; ACTIVATED 1/1/2006 85348 COAGULATION TIME; OTHER METHODS 1/1/2006 85360 EUGLOBULIN LYSIS 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP)(FSP); 85362 AGGLUTINATION SLIDE, SEMIQUANTITATIVE 1/1/2006 FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP)(FSP); 85366 PARACOAGULATION 1/1/2006 FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP)(FSP); 85370 QUANTITATIVE 1/1/2006 FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUALITATIVE OR 85378 SEMIQUANTITATIVE 1/1/2006 85379 FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE 1/1/2006 FIBRIN DEGRADATION PRODUCTS, D-DIMER; ULTRASENSITIVE (EG, FOR EVALUATION FOR VENOUS THROMBOEMBOLISM), QUALITATIVE 85380 OR SEMIQUANTITAT 1/1/2006 85384 FIBRINOGEN; ACTIVITY 1/1/2006 85385 FIBRINOGEN; ANTIGEN 1/1/2006 FIBRINOLYSINS OR COAGULOPATHY SCREEN, INTERPRETATION AND 85390 REPORT 1/1/2006 COAGULATION/FIBRINOLYSIS ASSAY, WHOLE BLOOD (EG, VISCOELASTIC CLOT ASSESSMENT), INCLUDING USE OF ANY 85396 PHARMACOLOGIC ADDITIVE(S), AS 1/1/2006 COAGULATION AND FIBRINOLYSIS, FUNCTIONAL ACTIVITY, NOT 85397 OTHERWISE SPECIFIED (EG, ADAMTS-13), EACH ANALYTE 1/1/2009 85400 FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMIN 1/1/2006 85410 FIBRINOLYTIC FACTORS AND INHIBITORS; ALPHA-2 ANTIPLASMIN 1/1/2006 85415 FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN ACTIVATOR 1/1/2006 FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, EXCEPT 85420 ANTIGENIC ASSAY 1/1/2006 FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, ANTIGENIC 85421 ASSAY 1/1/2006 85441 HEINZ BODIES; DIRECT 1/1/2006 85445 HEINZ BODIES; INDUCED, ACETYL PHENYLHYDRAZINE 1/1/2006 HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; 85460 DIFFERENTIAL LYSIS (KLEIHAUER-BETKE) 1/1/2006 HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; 85461 ROSETTE 1/1/2006 85475 HEMOLYSIN, ACID 1/1/2006 85520 HEPARIN ASSAY 1/1/2006 85525 HEPARIN NEUTRALIZATION 1/1/2006 85530 HEPARIN-PROTAMINE TOLERANCE TEST 1/1/2006 85535 IRON STAIN, BLOOD CELLS 1/1/2007 85536 IRON STAIN, PERIPHERAL BLOOD 1/1/2006 85540 LEUKOCYTE ALKALINE PHOSPHATASE WITH COUNT 1/1/2006 85547 MECHANICAL FRAGILITY, RBC 1/1/2006 85549 MURAMIDASE 1/1/2006 85555 OSMOTIC FRAGILITY, RBC; UNINCUBATED 1/1/2006 85557 OSMOTIC FRAGILITY, RBC; INCUBATED 1/1/2006 85576 PLATELET, AGGREGATION (IN VITRO), EACH AGENT 1/1/2006 85585 BLOOD PLATELET ESTIMATION 1/1/2007 85590 PLATELET MANUAL COUNT 1/1/2006 85595 PLATELET COUNT, AUTOMATED 1/1/2007 85597 PLATELET NEUTRALIZATION 1/1/2006 HealthSpan Provider Manual APPENDIX E Revised February 2014 33
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 85598 PHOSPHOLIPID NEUTRALIZATION; HEXAGONAL PHOSPHOLIPID 1/1/2011 85610 PROTHROMBIN TIME; 1/1/2006 85611 PROTHROMBIN TIME; SUBSTITUTION, PLASMA FRACTIONS, EACH 1/1/2006 85612 RUSSELL VIPER VENOM TIME (INCLUDES VENOM); UNDILUTED 1/1/2006 85613 RUSSELL VIPER VENOM TIME (INCLUDES VENOM); DILUTED 1/1/2006 85635 REPTILASE TEST 1/1/2006 85651 SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED 1/1/2006 85652 SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED 1/1/2006 85660 SICKLING OF RBC, REDUCTION 1/1/2006 85670 THROMBIN TIME; PLASMA 1/1/2006 85675 THROMBIN TIME; TITER 1/1/2006 85705 THROMBOPLASTIN INHIBITION, TISSUE 1/1/2006 85730 THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD 1/1/2006 THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA 85732 FRACTIONS, EACH 1/1/2006 85810 VISCOSITY 1/1/2006 AGGLUTININS, FEBRILE (EG, BRUCELLA, FRANCISELLA, MURINE TYPHUS, Q FEVER, ROCKY MOUNTAIN SPOTTED FEVER, SCRUB 86000 TYPHUS), EACH ANTIGEN 1/1/2006 ALLERGEN SPECIFIC IGG QUANTITATIVE OR SEMIQUANTITATIVE, 86001 EACH ALLERGEN 1/1/2006 ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, 86003 EACH ALLERGEN 1/1/2006 ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN 86005 (DIPSTICK, PADDLE OR DISK) 1/1/2006 86021 ANTIBODY IDENTIFICATION; LEUKOCYTE ANTIBODIES 1/1/2006 86022 ANTIBODY IDENTIFICATION; PLATELET ANTIBODIES 1/1/2006 ANTIBODY IDENTIFICATION; PLATELET ASSOCIATED 86023 IMMUNOGLOBULIN ASSAY 1/1/2006 86038 ANTINUCLEAR ANTIBODIES (ANA); 1/1/2006 86039 ANTINUCLEAR ANTIBODIES (ANA); TITER 1/1/2006 86060 ANTISTREPTOLYSIN 0; TITER 1/1/2006 86063 ANTISTREPTOLYSIN 0; SCREEN 1/1/2006 86064 B CELLS, TOTAL COUNT 1/1/2006 BLOOD BANK PHYSICIAN SERVICES; DIFFICULT CROSS MATCH AND/OR EVALUATION OF IRREGULAR ANTIBODY(S), INTERPRETATION 86077 AND WRITTEN REPORT 1/1/2006 BLOOD BANK PHYSICIAN SERVICES; INVESTIGATION OF TRANSFUSION REACTION INCLUDING SUSPICION OF TRANSMISSIBLE 86078 DISEASE, INTERPRETATION 1/1/2006 BLOOD BANK PHYSICIAN SERVICES; AUTHORIZATION FOR DEVIATION FROM STANDARD BLOOD BANKING PROCEDURES (EG, USE OF 86079 OUTDATED BLOOD, TRAN 1/1/2006 86140 C-REACTIVE PROTEIN; 1/1/2006 86141 C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 1/1/2006 86146 BETA 2 GLYCOPROTEIN I ANTIBODY, EACH 1/1/2006 86147 CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY, EACH IG CLASS 1/1/2006 86148 ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE CELL ENUMERATION USING IMMUNOLOGIC SELECTION AND IDENTIFICATION IN FLUID SPECIMEN (EG, CIRCULATING TUMOR CELLS 86152 IN BLOOD); 1/1/2013 CELL ENUMERATION USING IMMUNOLOGIC SELECTION AND IDENTIFICATION IN FLUID SPECIMEN (EG, CIRCULATING TUMOR CELLS 86153 IN BLOOD); PHYSICIA 1/1/2013 86155 CHEMOTAXIS ASSAY, SPECIFY METHOD 1/1/2006 86156 COLD AGGLUTININ; SCREEN 1/1/2006 86157 COLD AGGLUTININ; TITER 1/1/2006 86160 COMPLEMENT; ANTIGEN, EACH COMPONENT 1/1/2006 86161 COMPLEMENT; FUNCTIONAL ACTIVITY, EACH COMPONENT 1/1/2006 86162 COMPLEMENT; TOTAL HEMOLYTIC (CH50) 1/1/2006 86171 COMPLEMENT FIXATION TESTS, EACH ANTIGEN 1/1/2006 86185 COUNTERIMMUNOELECTROPHORESIS, EACH ANTIGEN 1/1/2006 86200 CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY 1/1/2006 86215 DEOXYRIBONUCLEASE, ANTIBODY 1/1/2006 DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; NATIVE OR DOUBLE 86225 STRANDED 1/1/2006 86226 DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; SINGLE STRANDED 1/1/2006 EXTRACTABLE NUCLEAR ANTIGEN, ANTIBODY TO, ANY METHOD (EG, 86235 NRNP, SS-A, SS-B, SM, RNP, SC170, J01), EACH ANTIBODY 1/1/2006 86243 FC RECEPTOR 1/1/2006 FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; SCREEN, EACH 86255 ANTIBODY 1/1/2006 FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; TITER, EACH 86256 ANTIBODY 1/1/2006 86277 GROWTH HORMONE, HUMAN (HGH), ANTIBODY 1/1/2006 86280 HEMAGGLUTINATION INHIBITION TEST (HAI) 1/1/2006 IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE OR 86294 SEMIQUANTITATIVE (EG, BLADDER TUMOR ANTIGEN) 1/1/2006 86300 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29) 1/1/2006 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9 1/1/2006 86304 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125 1/1/2006 86308 HETEROPHILE ANTIBODIES; SCREENING 1/1/2006 86309 HETEROPHILE ANTIBODIES; TITER 1/1/2006 HETEROPHILE ANTIBODIES; TITERS AFTER ABSORPTION WITH BEEF 86310 CELLS AND GUINEA PIG KIDNEY 1/1/2006 IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, 86316 QUANTITATIVE (EG, CA 50, 72-4, 549), EACH 1/1/2006 IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY, QUANTITATIVE, 86317 NOT OTHERWISE SPECIFIED 1/1/2006 IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY, QUALITATIVE OR 86318 SEMIQUANTITATIVE, SINGLE STEP METHOD (EG, REAGENT STRIP) 1/1/2006 86320 IMMUNOELECTROPHORESIS; SERUM 1/1/2006 IMMUNOELECTROPHORESIS; OTHER FLUIDS (EG, URINE, 86325 CEREBROSPINAL FLUID) WITH CONCENTRATION 1/1/2006 86327 IMMUNOELECTROPHORESIS; CROSSED (2-DIMENSIONAL ASSAY) 1/1/2006 86329 IMMUNODIFFUSION; NOT ELSEWHERE SPECIFIED 1/1/2006 IMMUNODIFFUSION; GEL DIFFUSION, QUALITATIVE (OUCHTERLONY), 86331 EACH ANTIGEN OR ANTIBODY 1/1/2006 HealthSpan Provider Manual APPENDIX E Revised February 2014 35
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 86332 IMMUNE COMPLEX ASSAY 1/1/2006 86334 IMMUNOFIXATION ELECTROPHORESIS; SERUM 1/1/2006 IMMUNOFIXATION ELECTROPHORESIS; OTHER FLUIDS WITH 86335 CONCENTRATION (EG, URINE, CSF) 1/1/2006 86336 INHIBIN A 1/1/2006 86337 INSULIN ANTIBODIES 1/1/2006 86340 INTRINSIC FACTOR ANTIBODIES 1/1/2006 86341 ISLET CELL ANTIBODY 1/1/2006 86343 LEUKOCYTE HISTAMINE RELEASE TEST (LHR) 1/1/2006 86344 LEUKOCYTE PHAGOCYTOSIS 1/1/2006 LYMPHOCYTE TRANSFORMATION, MITOGEN (PHYTOMITOGEN) OR 86353 ANTIGEN INDUCED BLASTOGENESIS 1/1/2006 86355 B CELLS, TOTAL COUNT 1/1/2006 MONONUCLEAR CELL ANTIGEN, QUANTITATIVE (EG, FLOW 86356 CYTOMETRY), NOT OTHERWISE SPECIFIED, EACH ANTIGEN 1/1/2008 86357 NATURAL KILLER (NK) CELLS, TOTAL COUNT 1/1/2006 86359 T CELLS; TOTAL COUNT 1/1/2006 86360 T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO 1/1/2006 86361 T CELLS; ABSOLUTE CD4 COUNT 1/1/2006 86367 STEM CELLS (IE, CD34), TOTAL COUNT 1/1/2006 86376 MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH 1/1/2006 86378 MIGRATION INHIBITORY FACTOR TEST (MIF) 1/1/2006 86379 NATURAL KILLER (NK) CELLS, TOTAL COUNT 1/1/2006 86382 NEUTRALIZATION TEST, VIRAL 1/1/2006 86384 NITROBLUE TETRAZOLIUM DYE TEST (NTD) 1/1/2006 86386 NUCLEAR MATRIX PROTEIN 22 (NMP22), QUALITATIVE 1/1/2012 86403 PARTICLE AGGLUTINATION; SCREEN, EACH ANTIBODY 1/1/2006 86406 PARTICLE AGGLUTINATION; TITER, EACH ANTIBODY 1/1/2006 86430 RHEUMATOID FACTOR; QUALITATIVE 1/1/2006 86431 RHEUMATOID FACTOR; QUANTITATIVE 1/1/2006 TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY MEASUREMENT OF 86480 GAMMA INTERFERON ANTIGEN RESPONSE 1/1/2006 TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY ANTIGEN RESPONSE MEASUREMENT; ENUMERATION OF GAMMA INTERFERON- 86481 PRODUCING T-CELLS IN CELL 1/1/2011 86485 SKIN TEST; CANDIDA 1/1/2006 86486 SKIN TEST; UNLISTED ANTIGEN, EACH 1/1/2008 86490 SKIN TEST; COCCIDIOIDOMYCOSIS 1/1/2006 86510 SKIN TEST; HISTOPLASMOSIS 1/1/2006 86580 SKIN TEST; TUBERCULOSIS, INTRADERMAL 1/1/2006 86585 SKIN TEST; TUBERCULOSIS, TINE TEST 1/1/2006 86587 STEM CELLS (IE, CD34), TOTAL COUNT 1/1/2006 86588 STREPTOCOCCUS, SCREEN, DIREC 1/1/2007 86590 STREPTOKINASE, ANTIBODY 1/1/2006 86592 SYPHILIS TEST; QUALITATIVE (EG, VDRL, RPR, ART) 1/1/2006 86593 SYPHILIS TEST; QUANTITATIVE 1/1/2006 86602 ANTIBODY; ACTINOMYCES 1/1/2005 86603 ANTIBODY; ADENOVIRUS 1/1/2005 86606 ANTIBODY; ASPERGILLUS 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 86609 ANTIBODY; BACTERIUM, NOT ELSEWHERE SPECIFIED 1/1/2006 86611 ANTIBODY; BARTONELLA 1/1/2006 86612 ANTIBODY; BLASTOMYCES 1/1/2006 86615 ANTIBODY; BORDETELLA 1/1/2006 ANTIBODY; BORRELIA BURGDORFERI (LYME DISEASE) 86617 CONFIRMATORY TEST (EG, WESTERN BLOT OR IMMUNOBLOT) 1/1/2006 86618 ANTIBODY; BORRELIA BURGDORFERI (LYME DISEASE) 1/1/2006 86619 ANTIBODY; BORRELIA (RELAPSING FEVER) 1/1/2006 86622 ANTIBODY; BRUCELLA 1/1/2006 86625 ANTIBODY; CAMPYLOBACTER 1/1/2006 86628 ANTIBODY; CANDIDA 1/1/2006 86631 ANTIBODY; CHLAMYDIA 1/1/2006 86632 ANTIBODY; CHLAMYDIA, IGM 1/1/2006 86635 ANTIBODY; COCCIDIOIDES 1/1/2006 86638 ANTIBODY; COXIELLA BURNETII (Q FEVER) 1/1/2006 86641 ANTIBODY; CRYPTOCOCCUS 1/1/2006 86644 ANTIBODY; CYTOMEGALOVIRUS (CMV) 1/1/2006 86645 ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM 1/1/2006 86648 ANTIBODY; DIPHTHERIA 1/1/2006 86651 ANTIBODY; ENCEPHALITIS, CALIFORNIA (LA CROSSE) 1/1/2006 86652 ANTIBODY; ENCEPHALITIS, EASTERN EQUINE 1/1/2006 86653 ANTIBODY; ENCEPHALITIS, ST. LOUIS 1/1/2006 86654 ANTIBODY; ENCEPHALITIS, WESTERN EQUINE 1/1/2006 86658 ANTIBODY; ENTEROVIRUS (EG, COXSACKIE, ECHO, POLIO) 1/1/2006 86663 ANTIBODY; EPSTEIN-BARR (EB) VIRUS, EARLY ANTIGEN (EA) 1/1/2006 86664 ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA) 1/1/2006 86665 ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA) 1/1/2006 86666 ANTIBODY; EHRLICHIA 1/1/2006 86668 ANTIBODY; FRANCISELLA TULARENSIS 1/1/2006 86671 ANTIBODY; FUNGUS, NOT ELSEWHERE SPECIFIED 1/1/2006 86674 ANTIBODY; GIARDIA LAMBLIA 1/1/2006 86677 ANTIBODY; HELICOBACTER PYLORI 1/1/2006 86682 ANTIBODY; HELMINTH, NOT ELSEWHERE SPECIFIED 1/1/2006 86683 HEMOGLOBIN, FECAL ANTIBODY 1/1/2007 86684 ANTIBODY; HAEMOPHILUS INFLUENZA 1/1/2006 86687 ANTIBODY; HTLV-I 1/1/2006 86688 ANTIBODY; HTLV-II 1/1/2006 ANTIBODY; HTLV OR HIV ANTIBODY, CONFIRMATORY TEST (EG, 86689 WESTERN BLOT) 1/1/2006 86692 ANTIBODY; HEPATITIS, DELTA AGENT 1/1/2006 86694 ANTIBODY; HERPES SIMPLEX, NON-SPECIFIC TYPE TEST 1/1/2006 86695 ANTIBODY; HERPES SIMPLEX, TYPE 1 1/1/2006 86696 ANTIBODY; HERPES SIMPLEX, TYPE 2 1/1/2006 86698 ANTIBODY; HISTOPLASMA 1/1/2006 86701 ANTIBODY; HIV-1 1/1/2006 86702 ANTIBODY; HIV-2 1/1/2006 86703 ANTIBODY; HIV-1 AND HIV-2, SINGLE ASSAY 1/1/2006 86704 HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 1/1/2006 86705 HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 86706 HEPATITIS B SURFACE ANTIBODY (HBSAB) 1/1/2006 86707 HEPATITIS BE ANTIBODY (HBEAB) 1/1/2006 86708 HEPATITIS A ANTIBODY (HAAB); TOTAL 1/1/2006 86709 HEPATITIS A ANTIBODY (HAAB); IGM ANTIBODY 1/1/2006 86710 ANTIBODY; INFLUENZA VIRUS 1/1/2006 86711 ANTIBODY; JC (JOHN CUNNINGHAM) VIRUS 1/1/2013 86713 ANTIBODY; LEGIONELLA 1/1/2006 86717 ANTIBODY; LEISHMANIA 1/1/2006 86720 ANTIBODY; LEPTOSPIRA 1/1/2006 86723 ANTIBODY; LISTERIA MONOCYTOGENES 1/1/2006 86727 ANTIBODY; LYMPHOCYTIC CHORIOMENINGITIS 1/1/2006 86729 ANTIBODY; LYMPHOGRANULOMA VENEREUM 1/1/2006 86732 ANTIBODY; MUCORMYCOSIS 1/1/2006 86735 ANTIBODY; MUMPS 1/1/2006 86738 ANTIBODY; MYCOPLASMA 1/1/2006 86741 ANTIBODY; NEISSERIA MENINGITIDIS 1/1/2006 86744 ANTIBODY; NOCARDIA 1/1/2006 86747 ANTIBODY; PARVOVIRUS 1/1/2006 86750 ANTIBODY; PLASMODIUM (MALARIA) 1/1/2006 86753 ANTIBODY; PROTOZOA, NOT ELSEWHERE SPECIFIED 1/1/2006 86756 ANTIBODY; RESPIRATORY SYNCYTIAL VIRUS 1/1/2006 86757 ANTIBODY; RICKETTSIA 1/1/2006 86759 ANTIBODY; ROTAVIRUS 1/1/2006 86762 ANTIBODY; RUBELLA 1/1/2006 86765 ANTIBODY; RUBEOLA 1/1/2006 86768 ANTIBODY; SALMONELLA 1/1/2006 86771 ANTIBODY; SHIGELLA 1/1/2006 86774 ANTIBODY; TETANUS 1/1/2006 86777 ANTIBODY; TOXOPLASMA 1/1/2006 86778 ANTIBODY; TOXOPLASMA, IGM 1/1/2006 86780 TREPONEMA PALLIDUM 1/1/2010 ANTIBODY; TREPONEMA PALLIDUM, CONFIRMATORY TEST (EG, FTA- 86781 ABS) 1/1/2006 86784 ANTIBODY; TRICHINELLA 1/1/2006 86787 ANTIBODY; VARICELLA-ZOSTER 1/1/2006 86788 ANTIBODY; WEST NILE VIRUS, IGM 1/1/2007 86789 ANTIBODY; WEST NILE VIRUS 1/1/2007 86790 ANTIBODY; VIRUS, NOT ELSEWHERE SPECIFIED 1/1/2006 86793 ANTIBODY; YERSINIA 1/1/2006 86800 THYROGLOBULIN ANTIBODY 1/1/2006 86803 HEPATITIS C ANTIBODY; 1/1/2006 86804 HEPATITIS C ANTIBODY; CONFIRMATORY TEST (EG, IMMUNOBLOT) 1/1/2006 LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITH 86805 TITRATION 1/1/2006 LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITHOUT 86806 TITRATION 1/1/2006 SERUM SCREENING FOR CYTOTOXIC PERCENT REACTIVE ANTIBODY 86807 (PRA); STANDARD METHOD 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE SERUM SCREENING FOR CYTOTOXIC PERCENT REACTIVE ANTIBODY 86808 (PRA); QUICK METHOD 1/1/2006 86812 HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN 1/1/2006 86813 HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS 1/1/2006 86816 HLA TYPING; DR/DQ, SINGLE ANTIGEN 1/1/2006 86817 HLA TYPING; DR/DQ, MULTIPLE ANTIGENS 1/1/2006 86821 HLA TYPING; LYMPHOCYTE CULTURE, MIXED (MLC) 1/1/2006 86822 HLA TYPING; LYMPHOCYTE CULTURE, PRIMED (PLC) 1/1/2006 ANTIBODY TO HUMAN LEUKOCYTE ANTIGENS (HLA), SOLID PHASE ASSAYS (EG, MICROSPHERES OR BEADS, ELISA, FLOW CYTOMETRY); 86828 QUALITATIVE ASS 1/1/2013 ANTIBODY TO HUMAN LEUKOCYTE ANTIGENS (HLA), SOLID PHASE ASSAYS (EG, MICROSPHERES OR BEADS, ELISA, FLOW CYTOMETRY); 86829 QUALITATIVE ASS 1/1/2013 ANTIBODY TO HUMAN LEUKOCYTE ANTIGENS (HLA), SOLID PHASE ASSAYS (EG, MICROSPHERES OR BEADS, ELISA, FLOW CYTOMETRY); 86830 ANTIBODY IDENTI 1/1/2013 ANTIBODY TO HUMAN LEUKOCYTE ANTIGENS (HLA), SOLID PHASE ASSAYS (EG, MICROSPHERES OR BEADS, ELISA, FLOW CYTOMETRY); 86831 ANTIBODY IDENTI 1/1/2013 ANTIBODY TO HUMAN LEUKOCYTE ANTIGENS (HLA), SOLID PHASE ASSAYS (EG, MICROSPHERES OR BEADS, ELISA, FLOW CYTOMETRY); 86832 HIGH DEFINITION 1/1/2013 ANTIBODY TO HUMAN LEUKOCYTE ANTIGENS (HLA), SOLID PHASE ASSAYS (EG, MICROSPHERES OR BEADS, ELISA, FLOW CYTOMETRY); 86833 HIGH DEFINITION 1/1/2013 ANTIBODY TO HUMAN LEUKOCYTE ANTIGENS (HLA), SOLID PHASE ASSAYS (EG, MICROSPHERES OR BEADS, ELISA, FLOW CYTOMETRY); 86834 SEMI-QUANTITATI 1/1/2013 ANTIBODY TO HUMAN LEUKOCYTE ANTIGENS (HLA), SOLID PHASE ASSAYS (EG, MICROSPHERES OR BEADS, ELISA, FLOW CYTOMETRY); 86835 SEMI-QUANTITATI 1/1/2013 86850 ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE 1/1/2006 86860 ANTIBODY ELUTION (RBC), EACH ELUTION 1/1/2006 ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH 86870 SERUM TECHNIQUE 1/1/2006 ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH 86880 ANTISERUM 1/1/2006 ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, 86885 QUALITATIVE, EACH ANTISERUM 1/1/2006 ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, TITER, EACH 86886 ANTISERUM 1/1/2006 AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING 86890 AND STORAGE; PREDEPOSITED 1/1/2006 AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING 86891 AND STORAGE; INTRA- OR POSTOPERATIVE SALVAGE 1/1/2006 86900 BLOOD TYPING; ABO 1/1/2006 86901 BLOOD TYPING; RH (D) 1/1/2006 BLOOD TYPING; ANTIGEN TESTING OF DONOR BLOOD USING 86902 REAGENT SERUM, EACH ANTIGEN TEST 1/1/2011
HealthSpan Provider Manual APPENDIX E Revised February 2014 39
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE BLOOD UNIT 86903 USING REAGENT SERUM, PER UNIT SCREENED 1/1/2006 BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE UNIT USING 86904 PATIENT SERUM, PER UNIT SCREENED 1/1/2006 86905 BLOOD TYPING; RBC ANTIGENS, OTHER THAN ABO OR RH (D), EACH 1/1/2006 86906 BLOOD TYPING; RH PHENOTYPING, COMPLETE 1/1/2006 BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; ABO, RH 86910 AND MN 1/1/2006 BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; EACH 86911 ADDITIONAL ANTIGEN SYSTEM 1/1/2006 86915 BONE MARROW 1/1/2007 86920 COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 1/1/2006 86921 COMPATIBILITY TEST EACH UNIT; INCUBATION TECHNIQUE 1/1/2006 86922 COMPATIBILITY TEST EACH UNIT; ANTIGLOBULIN TECHNIQUE 1/1/2006 86923 COMPATIBILITY TEST EACH UNIT; ELECTRONIC 1/1/2006 86927 FRESH FROZEN PLASMA, THAWING, EACH UNIT 1/1/2006 86930 FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION) 1/1/2006 86931 FROZEN BLOOD, EACH UNIT; THAWING 1/1/2006 FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION) 86932 AND THAWING 1/1/2006 86940 HEMOLYSINS AND AGGLUTININS; AUTO, SCREEN, EACH 1/1/2006 86941 HEMOLYSINS AND AGGLUTININS; INCUBATED 1/1/2006 86945 IRRADIATION OF BLOOD PRODUCT, EACH UNIT 1/1/2006 86950 LEUKOCYTE TRANSFUSION 1/1/2006 VOLUME REDUCTION OF BLOOD OR BLOOD PRODUCT (EG, RED 86960 BLOOD CELLS OR PLATELETS), EACH UNIT 1/1/2006 86965 POOLING OF PLATELETS OR OTHER BLOOD PRODUCTS 1/1/2006 PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR COMPATIBILITY TESTING; INCUBATION WITH 86970 CHEMICAL AGE 1/1/2006 PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR COMPATIBILITY TESTING; INCUBATION WITH 86971 ENZYMES, EAC 1/1/2006 PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, IDENTIFICATION, AND/OR COMPATIBILITY TESTING; BY DENSITY 86972 GRADIENT SEPARATI 1/1/2006 PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY 86975 IDENTIFICATION; INCUBATION WITH DRUGS, EACH 1/1/2006 PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY 86976 IDENTIFICATION; BY DILUTION 1/1/2006 PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY 86977 IDENTIFICATION; INCUBATION WITH INHIBITORS, EACH 1/1/2006 PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; BY DIFFERENTIAL RED CELL ABSORPTION USING 86978 PATIENT RBCS OR RBCS OF KN 1/1/2006 86985 SPLITTING OF BLOOD OR BLOOD PRODUCTS, EACH UNIT 1/1/2006 87001 ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION 1/1/2005 ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION AND 87003 DISSECTION 1/1/2006 87015 CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS 1/1/2006 HealthSpan Provider Manual APPENDIX E Revised February 2014 40
HEALTHSPAN
HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC 87040 CULTURE, IF APPR 1/1/2006 CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND 87045 SHIGELLA SPECIES 1/1/2006 CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH 87046 PLATE 1/1/2006 87060 CULTURE BACTERIAL-NASO-DEFIN 1/1/2006 CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE 87070 IDENTIFICATION OF ISOLA 1/1/2006 CULTURE, BACTERIAL; QUANTITATIVE, AEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, ANY SOURCE EXCEPT 87071 URINE, BLOO 1/1/2006 87072 CULTURE- COM KIT 1/1/2006 CULTURE, BACTERIAL; QUANTITATIVE, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, ANY SOURCE 87073 EXCEPT URINE, BL 1/1/2006 CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC 87075 WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES 1/1/2006 CULTURE, BACTERIAL; ANAEROBIC ISOLATE, ADDITIONAL METHODS 87076 REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE 1/1/2006 CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS 87077 REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE 1/1/2006 CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING 87081 ONLY; 1/1/2006 87082 CULTURE-SINGLE PATH 1/1/2006 87083 CULT MULTIPLE PATH-KIT-SCREE 1/1/2006 CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING 87084 ONLY; WITH COLONY ESTIMATION FROM DENSITY CHART 1/1/2006 87085 CULT PRESUMP PATH COLONY COU 1/1/2007 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE 1/1/2006 87087 CULT BACT-URINE-COMMERCIAL K 1/1/2007 CULTURE, BACTERIAL; WITH ISOLATION AND PRESUMPTIVE 87088 IDENTIFICATION OF ISOLATES, URINE 1/1/2006 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE 87101 IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL 1/1/2006 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE 87102 IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD) 1/1/2006 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE 87103 IDENTIFICATION OF ISOLATES; BLOOD 1/1/2006 CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; 87106 YEAST 1/1/2006 CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; 87107 MOLD 1/1/2006 87109 CULTURE, MYCOPLASMA, ANY SOURCE 1/1/2006 87110 CULTURE, CHLAMYDIA, ANY SOURCE 1/1/2006
HealthSpan Provider Manual APPENDIX E Revised February 2014 41
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE CULTURE, TUBERCLE OR OTHER ACID-FAST BACILLI (EG, TB, AFB, MYCOBACTERIA) ANY SOURCE, WITH ISOLATION AND PRESUMPTIVE 87116 IDENTIFICATION 1/1/2006 87117 CULTURE CONC & ISO-TB/AFB 1/1/2007 CULTURE, MYCOBACTERIAL, DEFINITIVE IDENTIFICATION, EACH 87118 ISOLATE 1/1/2006 CULTURE, TYPING; IMMUNOFLUORESCENT METHOD, EACH 87140 ANTISERUM 1/1/2006 CULTURE, TYPING; GAS LIQUID CHROMATOGRAPHY (GLC) OR HIGH 87143 PRESSURE LIQUID CHROMATOGRAPHY (HPLC) METHOD 1/1/2006 87145 CULTURE TYPING-PHAGE EACH AS 1/1/2007 CULTURE, TYPING; IMMUNOLOGIC METHOD, OTHER THAN IMMUNOFLUORESENCE (EG, AGGLUTINATION GROUPING), PER 87147 ANTISERUM 1/1/2006 87149 CULTURE, TYPING; IDENTIFICATION BY NUCLEIC ACID PROBE 1/1/2006 87151 CULT TYPING-SEROLOGIC SPECIA 1/1/2007 87152 CULTURE, TYPING; IDENTIFICATION BY PULSE FIELD GEL TYPING 1/1/2006 87155 CULTURE TYPING-PRECIPITIN 1/1/2007 87158 CULTURE, TYPING; OTHER METHODS 1/1/2006 DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, 87164 ORAL, SKIN); INCLUDES SPECIMEN COLLECTION 1/1/2006 DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, 87166 ORAL, SKIN); WITHOUT COLLECTION 1/1/2006 87168 MACROSCOPIC EXAMINATION; ARTHROPOD 1/1/2006 87169 MACROSCOPIC EXAMINATION; PARASITE 1/1/2006 87172 PINWORM EXAM (EG, CELLOPHANE TAPE PREP) 1/1/2006 87176 HOMOGENIZATION, TISSUE, FOR CULTURE 1/1/2006 OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND 87177 IDENTIFICATION 1/1/2006 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; AGAR DILUTION 87181 METHOD, PER AGENT (EG, ANTIBIOTIC GRADIENT STRIP) 1/1/2006 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, 87184 PER PLATE (12 OR FEWER AGENTS) 1/1/2006 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; ENZYME 87185 DETECTION (EG, BETA LACTAMASE), PER ENZYME 1/1/2006 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION (MIC) OR 87186 BREAKPOINT) 1/1/2006 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR AGAR DILUTION, MINIMUM LETHAL CONCENTRATION (MLC), EACH 87187 PLATE (LIST 1/1/2006 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MACROBROTH 87188 DILUTION METHOD, EACH AGENT 1/1/2006 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MYCOBACTERIA, 87190 PROPORTION METHOD, EACH AGENT 1/1/2006 87197 SERUM BACTERICIDAL TITER (SCHLICTER TEST) 1/1/2006 87198 CYTOMEGALOVIRUS, DIRECT FLUO 1/1/2007 87199 ENTEROVIRUS, DIRECT FLUORESC 1/1/2007 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA 87205 STAIN FOR BACTERIA, FUNGI, OR CELL TYPES 1/1/2006 HealthSpan Provider Manual APPENDIX E Revised February 2014 42
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, 87206 VIRUSES OR CELL TYPE 1/1/2006 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, 87207 MICROSPORIDIA, 1/1/2006 87208 SMEAR-DRY O&P W/INTERPRETATI 1/1/2007 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND 87209 PARASITES 1/1/2006 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR 87210 INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS) 1/1/2006 87211 SMEAR-WET&DRY O&P W/INTERP 1/1/2007 TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, 87220 SCABIES) 1/1/2006 TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM 87230 DIFFICILE TOXIN) 1/1/2006 VIRUS ISOLATION; INOCULATION OF EMBRYONATED EGGS, OR SMALL 87250 ANIMAL, INCLUDES OBSERVATION AND DISSECTION 1/1/2006 VIRUS ISOLATION; TISSUE CULTURE INOCULATION, OBSERVATION, 87252 AND PRESUMPTIVE IDENTIFICATION BY CYTOPATHIC EFFECT 1/1/2006 VIRUS ISOLATION; TISSUE CULTURE, ADDITIONAL STUDIES OR DEFINITIVE IDENTIFICATION (EG, HEMABSORPTION, NEUTRALIZATION, 87253 IMMUNOFLUORES 1/1/2006 VIRUS ISOLATION; CENTRIFUGE ENHANCED (SHELL VIAL) TECHNIQUE, INCLUDES IDENTIFICATION WITH IMMUNOFLUORESCENCE STAIN, 87254 EACH VIRUS 1/1/2006 VIRUS ISOLATION; INCLUDING IDENTIFICATION BY NON-IMMUNOLOGIC METHOD, OTHER THAN BY CYTOPATHIC EFFECT (EG, VIRUS SPECIFIC 87255 ENZYMATIC 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87260 TECHNIQUE; ADENOVIRUS 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87265 TECHNIQUE; BORDETELLA PERTUSSIS/PARAPERTUSSIS 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87267 TECHNIQUE; ENTEROVIRUS, DIRECT FLUORESCENT ANTIBODY (DFA) 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87269 TECHNIQUE; GIARDIA 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87270 TECHNIQUE; CHLAMYDIA TRACHOMATIS 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; CYTOMEGALOVIRUS, DIRECT FLUORESCENT ANTIBODY 87271 (DFA) 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87272 TECHNIQUE; CRYPTOSPORIDIUM 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87273 TECHNIQUE; HERPES SIMPLEX VIRUS TYPE 2 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87274 TECHNIQUE; HERPES SIMPLEX VIRUS TYPE 1 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87275 TECHNIQUE; INFLUENZA B VIRUS 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87276 TECHNIQUE; INFLUENZA A VIRUS 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87277 TECHNIQUE; LEGIONELLA MICDADEI 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87278 TECHNIQUE; LEGIONELLA PNEUMOPHILA 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87279 TECHNIQUE; PARAINFLUENZA VIRUS, EACH TYPE 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87280 TECHNIQUE; RESPIRATORY SYNCYTIAL VIRUS 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87281 TECHNIQUE; PNEUMOCYSTIS CARINII 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87283 TECHNIQUE; RUBEOLA 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87285 TECHNIQUE; TREPONEMA PALLIDUM 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87290 TECHNIQUE; VARICELLA ZOSTER VIRUS 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 87299 TECHNIQUE; NOT OTHERWISE SPECIFIED, EACH ORGANISM 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE, POLYVALENT FOR MULTIPLE ORGANISMS, EACH 87300 POLYVALENT ANTISERUM 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87301 METHOD; ADENOVI 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP 87305 METHOD; ASPERGI 1/1/2007 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87320 METHOD; CHLAMYD 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87324 METHOD; CLOSTRI 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87327 METHOD; CRYPTOC 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87328 METHOD; CRYPTOS 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87329 METHOD; GIARDIA 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87332 METHOD; CYTOMEG 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87335 METHOD; ESCHERI 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87336 METHOD; ENTAMOE 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87337 METHOD; ENTAMOE 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87338 METHOD; HELICOB 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87339 METHOD; HELICOB 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87340 METHOD; HEPATIT 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87341 METHOD; HEPATIT 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87350 METHOD; HEPATIT 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87380 METHOD; HEPATIT 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87385 METHOD; HISTOPL 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP 87389 METHOD; HIV-1 A 1/1/2012 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87390 METHOD; HIV-1 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87391 METHOD; HIV-2 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87400 METHOD; INFLUEN 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87420 METHOD; RESPIRA 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87425 METHOD; ROTAVIR 1/1/2006
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HEALTHSPAN
HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87427 METHOD; SHIGA-L 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE STEP 87430 METHOD; STREPTO 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATIVE OR SEMIQUANTITATIVE; MULTIPLE STEP 87449 METHOD, NOT OTHE 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATIVE OR SEMIQUANTITATIVE; SINGLE STEP 87450 METHOD, NOT OTHERW 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE QUALITATIVE OR SEMIQUANTITATIVE; MULTIPLE STEP 87451 METHOD, POLYVALE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AND BARTONELLA QUINTANA, DIRECT 87470 PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AND BARTONELLA QUINTANA, AMPLIFIED 87471 PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); BARTONELLA HENSELAE AND BARTONELLA QUINTANA, 87472 QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87475 BORRELIA BURGDORFERI, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87476 BORRELIA BURGDORFERI, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87477 BORRELIA BURGDORFERI, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87480 CANDIDA SPECIES, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87481 CANDIDA SPECIES, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87482 CANDIDA SPECIES, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87485 CHLAMYDIA PNEUMONIAE, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87486 CHLAMYDIA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87487 CHLAMYDIA PNEUMONIAE, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87490 CHLAMYDIA TRACHOMATIS, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87491 CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87492 CHLAMYDIA TRACHOMATIS, QUANTIFICATION 1/1/2006 87493 C DIFF AMPLIFIED PROBE 1/1/2010
HealthSpan Provider Manual APPENDIX E Revised February 2014 46
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87495 CYTOMEGALOVIRUS, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87496 CYTOMEGALOVIRUS, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87497 CYTOMEGALOVIRUS, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87498 ENTEROVIRUS, AMPLIFIED PROBE TECHNIQUE 1/1/2007 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); VANCOMYCIN RESISTANCE (EG, ENTEROCOCCUS SPECIES VAN A, 87500 VAN B), AMPLIFIED 1/1/2008 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, REVERSE TRANSCRIPTION AND AMPLIFIED PROBE 87501 TECHNIQUE, EAC 1/1/2011 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, REVERSE 87502 TRANSCRIPTION A 1/1/2011 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB-TYPES, MULTIPLEX 87503 REVERSE TRANS 1/1/2011 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87510 GARDNERELLA VAGINALIS, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87511 GARDNERELLA VAGINALIS, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87512 GARDNERELLA VAGINALIS, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87515 HEPATITIS B VIRUS, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87516 HEPATITIS B VIRUS, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87517 HEPATITIS B VIRUS, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87520 HEPATITIS C, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87521 HEPATITIS C, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87522 HEPATITIS C, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87525 HEPATITIS G, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87526 HEPATITIS G, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87527 HEPATITIS G, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87528 HERPES SIMPLEX VIRUS, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87529 HERPES SIMPLEX VIRUS, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87530 HERPES SIMPLEX VIRUS, QUANTIFICATION 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87531 HERPES VIRUS-6, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87532 HERPES VIRUS-6, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87533 HERPES VIRUS-6, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV- 87534 1, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV- 87535 1, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV- 87536 1, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV- 87537 2, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV- 87538 2, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV- 87539 2, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87540 LEGIONELLA PNEUMOPHILA, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87541 LEGIONELLA PNEUMOPHILA, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87542 LEGIONELLA PNEUMOPHILA, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87550 MYCOBACTERIA SPECIES, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87551 MYCOBACTERIA SPECIES, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87552 MYCOBACTERIA SPECIES, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87555 MYCOBACTERIA TUBERCULOSIS, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87556 MYCOBACTERIA TUBERCULOSIS, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87557 MYCOBACTERIA TUBERCULOSIS, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INTRACELLULARE, DIRECT PROBE 87560 TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA AVIUM-INTRACELLULARE, AMPLIFIED PROBE 87561 TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87562 MYCOBACTERIA AVIUM-INTRACELLULARE, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87580 MYCOPLASMA PNEUMONIAE, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87581 MYCOPLASMA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87582 MYCOPLASMA PNEUMONIAE, QUANTIFICATION 1/1/2006
HealthSpan Provider Manual APPENDIX E Revised February 2014 48
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87590 NEISSERIA GONORRHOEAE, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87591 NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87592 NEISSERIA GONORRHOEAE, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87620 PAPILLOMAVIRUS, HUMAN, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87621 PAPILLOMAVIRUS, HUMAN, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87622 PAPILLOMAVIRUS, HUMAN, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA VIRUS, 87631 CORONAVIRUS, METAPNEU 1/1/2013 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA VIRUS, 87632 CORONAVIRUS, METAPNEU 1/1/2013 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZA VIRUS, 87633 CORONAVIRUS, METAPNEU 1/1/2013 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87640 STAPHYLOCOCCUS AUREUS, AMPLIFIED PROBE TECHNIQUE 1/1/2007 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED 87641 PROBE TECHNIQUE 1/1/2007 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87650 STREPTOCOCCUS, GROUP A, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87651 STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87652 STREPTOCOCCUS, GROUP A, QUANTIFICATION 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87653 STREPTOCOCCUS, GROUP B, AMPLIFIED PROBE TECHNIQUE 1/1/2007 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87660 TRICHOMONAS VAGINALIS, DIRECT PROBE TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87661 TRICHOMONAS VAGINALIS, AMPLIFIED PROBE TECHNIQUE 1/1/2014 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; DIRECT PROBE TECHNIQUE, EACH 87797 ORGANISM 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT OTHERWISE SPECIFIED; AMPLIFIED PROBE TECHNIQUE, EACH 87798 ORGANISM 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT 87799 OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), 87800 MULTIPLE ORGANISMS; DIRECT PROBE(S) TECHNIQUE 1/1/2006 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), 87801 MULTIPLE ORGANISMS; AMPLIFIED PROBE(S) TECHNIQUE 1/1/2006
HealthSpan Provider Manual APPENDIX E Revised February 2014 49
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 802038 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH 7802 DIRECT OPTICAL OBSERVATION; STREPTOCOCCUS, GROUP B 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH 87803 DIRECT OPTICAL OBSERVATION; CLOSTRIDIUM DIFFICILE TOXIN A 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH 87804 DIRECT OPTICAL OBSERVATION; INFLUENZA 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH 87807 DIRECT OPTICAL OBSERVATION; RESPIRATORY SYNCYTIAL VIRUS 1/1/2006 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH 87808 DIRECT OPTICAL OBSERVATION; TRICHOMONAS VAGINALIS 1/1/2007 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH 87809 DIRECT OPTICAL OBSERVATION; ADENOVIRUS 1/1/2008 INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT 87810 OPTICAL OBSERVATION; CHLAMYDIA TRACHOMATIS 1/1/2006 INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT 87850 OPTICAL OBSERVATION; NEISSERIA GONORRHOEAE 1/1/2006 INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT 87880 OPTICAL OBSERVATION; STREPTOCOCCUS, GROUP A 1/1/2006 INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT 87899 OPTICAL OBSERVATION; NOT OTHERWISE SPECIFIED 1/1/2006 INFECTIOUS AGENT DRUG SUSCEPTIBILITY PHENOTYPE PREDICTION 87900 USING REGULARLY UPDATED GENOTYPIC BIOINFORMATICS 1/1/2006 INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 87901 RNA); HIV 1, REVERSE TRANSCRIPTASE AND PROTEASE 1/1/2006 INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 87902 RNA); HEPATITIS C VIRUS 1/1/2006 INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA) WITH DRUG RESISTANCE TISSUE CULTURE ANALYSIS, HIV 1; 87903 FIRST THROUG 1/1/2006 INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR RNA) WITH DRUG RESISTANCE TISSUE CULTURE ANALYSIS, HIV 1; 87904 EACH ADDITIO 1/1/2006 INFECTIOUS AGENT ENZYMATIC ACTIVITY OTHER THAN VIRUS (EG, 87905 SIALIDASE ACTIVITY IN VAGINAL FLUID) 1/1/2009 INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 87906 RNA); HIV-1, OTHER REGION (EG, INTEGRASE, FUSION) 1/1/2011 INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 87910 RNA); CYTOMEGALOVIRUS 1/1/2013 INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 87912 RNA); HEPATITIS B VIRUS 1/1/2013 CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT 88104 CERVICAL OR VAGINAL; SMEARS WITH INTERPRETATION 1/1/2005 CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; FILTER METHOD ONLY WITH 88106 INTERPRETATION 1/1/2005 CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL OR VAGINAL; SMEARS AND FILTER PREPARATION WITH 88107 INTERPRETATION 1/1/2005 CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS AND 88108 INTERPRETATION (EG, SACCOMANNO TECHNIQUE) 1/1/2005
HealthSpan Provider Manual APPENDIX E Revised February 2014 50
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE CYTOPATHOLOGY, SELECTIVE CELLULAR ENHANCEMENT TECHNIQUE WITH INTERPRETATION (EG, LIQUID BASED SLIDE PREPARATION 88112 METHOD), EXCEPT CE 1/1/2005 CYTOPATHOLOGY, IN SITU HYBRIDIZATION (EG, FISH), URINARY TRACT SPECIMEN WITH MORPHOMETRIC ANALYSIS, 3-5 MOLECULAR 88120 PROBES, EACH SPE 1/1/2011 CYTOPATHOLOGY, IN SITU HYBRIDIZATION (EG, FISH), URINARY TRACT SPECIMEN WITH MORPHOMETRIC ANALYSIS, 3-5 MOLECULAR 88121 PROBES, EACH SPE 1/1/2011 88125 CYTOPATHOLOGY, FORENSIC (EG, SPERM) 1/1/2005 88130 SEX CHROMATIN IDENTIFICATION; BARR BODIES 1/1/2005 SEX CHROMATIN IDENTIFICATION; PERIPHERAL BLOOD SMEAR, 88140 POLYMORPHONUCLEAR DRUMSTICKS 1/1/2005 CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING 88141 SYSTEM), REQUIRING INTERPRETATION BY PHYSICIAN 1/1/2005 CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN 88142 LAYER PREPARATION; MANU 1/1/2005 CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN 88143 LAYER PREPARATION; WITH 1/1/2005 88144 CYTPTH C/VAG T/LAYER AUTO RE 1/1/2007 88145 CYTPATH C/VAG T/LAYER SELECT 1/1/2007 CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL; SCREENING BY 88147 AUTOMATED SYSTEM UNDER PHYSICIAN SUPERVISION 1/1/2005 CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL; SCREENING BY AUTOMATED SYSTEM WITH MANUAL RESCREENING UNDER 88148 PHYSICIAN SUPERVISION 1/1/2005 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL 88150 SCREENING UNDER PHYSICIAN SUPERVISION 1/1/2005 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING UNDER 88152 PHYSICIAN SUPERVISION 1/1/2005 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL 88153 SCREENING AND RESCREENING UNDER PHYSICIAN SUPERVISION 1/1/2005 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING USING CELL 88154 SELECTION AND REVIE 1/1/2005 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL, DEFINITIVE HORMONAL EVALUATION (EG, MATURATION INDEX, KARYOPYKNOTIC 88155 INDEX, ESTROGENIC 1/1/2005 CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; SCREENING AND 88160 INTERPRETATION 1/1/2005 CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; PREPARATION, 88161 SCREENING AND INTERPRETATION 1/1/2005 CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; EXTENDED STUDY 88162 INVOLVING OVER 5 SLIDES AND/OR MULTIPLE STAINS 1/1/2005 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA 88164 SYSTEM); MANUAL SCREENING UNDER PHYSICIAN SUPERVISION 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL SCREENING AND RESCREENING UNDER 88165 PHYSICIAN SUPERVISIO 1/1/2005 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL SCREENING AND COMPUTER-ASSISTED 88166 RESCREENING UNDER PH 1/1/2005 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA SYSTEM); WITH MANUAL SCREENING AND COMPUTER-ASSISTED 88167 RESCREENING USING CE 1/1/2005 88170 FINE NEEDLE ASPIRATION 1/1/2005 88171 FINE NEEDLE ASPIRATION 1/1/2005 CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE CYTOHISTOLOGIC STUDY TO DETERMINE ADEQUACY OF 88172 SPECIMEN(S) 1/1/2005 CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; 88173 INTERPRETATION AND REPORT 1/1/2005 CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN 88174 LAYER PREPARATION; SCRE 1/1/2005 CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN 88175 LAYER PREPARATION; WITH 1/1/2005 CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE CYTOHISTOLOGIC STUDY TO DETERMINE ADEQUACY FOR 88177 DIAGNOSIS, EACH SEPARA 1/1/2011 FLOW CYTOMETRY; EACH CELL SURFACE, CYTOPLASMIC OR 88180 NUCLEAR MARKER 1/1/2005 88182 FLOW CYTOMETRY, CELL CYCLE OR DNA ANALYSIS 1/1/2005 FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR 88184 MARKER, TECHNICAL COMPONENT ONLY; FIRST MARKER 1/1/2005 FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER 88185 (LIST SEPARATELY IN 1/1/2005 88187 FLOW CYTOMETRY, INTERPRETATION; 2 TO 8 MARKERS 1/1/2005 88188 FLOW CYTOMETRY, INTERPRETATION; 9 TO 15 MARKERS 1/1/2005 88189 FLOW CYTOMETRY, INTERPRETATION; 16 OR MORE MARKERS 1/1/2005 88230 TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; LYMPHOCYTE 1/1/2005 TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; SKIN OR 88233 OTHER SOLID TISSUE BIOPSY 1/1/2005 TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; AMNIOTIC 88235 FLUID OR CHORIONIC VILLUS CELLS 1/1/2005 TISSUE CULTURE FOR NEOPLASTIC DISORDERS; BONE MARROW, 88237 BLOOD CELLS 1/1/2005 88239 TISSUE CULTURE FOR NEOPLASTIC DISORDERS; SOLID TUMOR 1/1/2005 88300 LEVEL I - SURGICAL PATHOLOGY, GROSS EXAMINATION ONLY 1/1/2006 DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO 88311 CODE FOR SURGICAL PATHOLOGY EXAMINATION) 1/1/2006 SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE); GROUP I FOR MICROORGANISMS (EG, GRIDLEY, 88312 ACID FAST, METH 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE); GROUP II, ALL OTHER, (EG, IRON, TRICHROME), 88313 EXCEPT IMMUN 1/1/2006 SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE); HISTOCHEMICAL STAINING WITH FROZEN 88314 SECTION(S) 1/1/2006 DETERMINATIVE HISTOCHEMISTRY TO IDENTIFY CHEMICAL 88318 COMPONENTS (EG, COPPER, ZINC) 1/1/2006 DETERMINATIVE HISTOCHEMISTRY OR CYTOCHEMISTRY TO IDENTIFY 88319 ENZYME CONSTITUENTS, EACH 1/1/2006 CONSULTATION AND REPORT ON REFERRED SLIDES PREPARED 88321 ELSEWHERE 1/1/2006 CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING 88323 PREPARATION OF SLIDES 1/1/2006 CONSULTATION, COMPREHENSIVE, WITH REVIEW OF RECORDS AND 88325 SPECIMENS, WITH REPORT ON REFERRED MATERIAL 1/1/2006 IMMUNOHISTOCHEMISTRY (INCLUDING TISSUE IMMUNOPEROXIDASE), 88342 EACH ANTIBODY 1/1/2006 IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, EACH SEPARATELY IDENTIFIABLE ANTIBODY PER BLOCK, CYTOLOGIC 88343 PREPARATION, OR HEMATOLOGI 1/1/2014 88346 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; DIRECT METHOD 1/1/2006 88347 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; INDIRECT METHOD 1/1/2006 88348 ELECTRON MICROSCOPY; DIAGNOSTIC 1/1/2006 88349 ELECTRON MICROSCOPY; SCANNING 1/1/2006 88355 MORPHOMETRIC ANALYSIS; SKELETAL MUSCLE 1/1/2006 88356 MORPHOMETRIC ANALYSIS; NERVE 1/1/2006 88358 MORPHOMETRIC ANALYSIS; TUMOR (EG, DNA PLOIDY) 1/1/2006 MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER-2/NEU, ESTROGEN RECEPTOR/PROGESTERONE RECEPTOR), 88360 QUANTITATIVE OR SEMIQU 1/1/2006 MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER-2/NEU, ESTROGEN RECEPTOR/PROGESTERONE RECEPTOR), 88361 QUANTITATIVE OR SEMIQU 1/1/2006 88362 NERVE TEASING PREPARATIONS 1/1/2006 88365 IN SITU HYBRIDIZATION (EG, FISH), EACH PROBE 1/1/2006 MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, (QUANTITATIVE OR SEMI-QUANTITATIVE) EACH PROBE; USING COMPUTER-ASSISTED 88367 TECHNOLOGY 1/1/2006 MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION, (QUANTITATIVE 88368 OR SEMI-QUANTITATIVE) EACH PROBE; MANUAL 1/1/2006 88369 AUTOMATED CHEMISTRY TEST 1/1/2007 88370 BLOOD GLUCOSE USING FDA APPR 1/1/2005 PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH 88371 INTERPRETATION AND REPORT; 1/1/2006 PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH INTERPRETATION AND REPORT; IMMUNOLOGICAL PROBE FOR BAND 88372 IDENTIFICATION, EACH 1/1/2006 88380 MICRODISSECTION (EG, MECHANICAL, LASER CAPTURE) 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 11 88384 THROUGH 50 PROBES 1/1/2006 ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 51 88385 THROUGH 250 PROBES 1/1/2006 ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 251 88386 THROUGH 500 PROBES 1/1/2006 88400 BILIRUBIN, TOTAL, TRANSCUTANEOUS 1/1/2006 88720 BILIRUBIN, TOTAL, TRANSCUTANEOUS 1/1/2009 88738 HGB QUANT TRANSCUTANEOUS 1/1/2010 HEMOGLOBIN, QUANTITATIVE, TRANSCUTANEOUS, PER DAY; 88740 CARBOXYHEMOGLOBIN 1/1/2009 HEMOGLOBIN, QUANTITATIVE, TRANSCUTANEOUS, PER DAY; 88741 METHEMOGLOBIN 1/1/2009 CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL 89050 FLUID, JOINT FLUID), EXCEPT BLOOD; 1/1/2005 CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL 89051 FLUID, JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT 1/1/2005 LEUKOCYTE ASSESSMENT, FECAL, QUALITATIVE OR 89055 SEMIQUANTITATIVE 1/1/2005 CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT 89060 POLARIZING LENS ANALYSIS, ANY BODY FLUID (EXCEPT URINE) 1/1/2005 89125 FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS 1/1/2005 89160 MEAT FIBERS, FECES 1/1/2005 89190 NASAL SMEAR FOR EOSINOPHILS 1/1/2005 SPUTUM, OBTAINING SPECIMEN, AEROSOL INDUCED TECHNIQUE 89220 (SEPARATE PROCEDURE) 1/1/2005 89225 STARCH GRANULES, FECES 1/1/2005 89230 SWEAT COLLECTION BY IONTOPHORESIS 1/1/2005 89235 WATER LOAD TEST 1/1/2005 SPERM ISOLATION; SIMPLE PREP (EG, SPERM WASH AND SWIM-UP) 89260 FOR INSEMINATION OR DIAGNOSIS WITH SEMEN ANALYSIS 1/1/2005 SPERM ISOLATION; COMPLEX PREP (EG, PERCOLL GRADIENT, ALBUMIN GRADIENT) FOR INSEMINATION OR DIAGNOSIS WITH SEMEN 89261 ANALYSIS 1/1/2005 SPERM IDENTIFICATION FROM TESTIS TISSUE, FRESH OR 89264 CRYOPRESERVED 1/1/2005 SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM 89300 INCLUDING HUHNER TEST (POST COITAL) 1/1/2005 SEMEN ANALYSIS; MOTILITY AND COUNT (NOT INCLUDING HUHNER 89310 TEST) 1/1/2005 SEMEN ANALYSIS; COMPLETE (VOLUME, COUNT, MOTILITY, AND 89320 DIFFERENTIAL) 1/1/2005 89321 SEMEN ANALYSIS, PRESENCE AND/OR MOTILITY OF SPERM 1/1/2005 SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL 89322 USING STRICT MORPHOLOGIC CRITERIA (EG, KRUGER) 1/1/2008 89325 SPERM ANTIBODIES 1/1/2005 89329 SPERM EVALUATION; HAMSTER PENETRATION TEST 1/1/2005 SPERM EVALUATION; CERVICAL MUCUS PENETRATION TEST, WITH OR 89330 WITHOUT SPINNBARKEIT TEST 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE SPERM EVALUATION, FOR RETROGRADE EJACULATION, URINE (SPERM CONCENTRATION, MOTILITY, AND MORPHOLOGY, AS 89331 INDICATED) 1/1/2008 IMMUNE GLOBULIN (SCIG), HUMAN, FOR USE IN SUBCUTANEOUS 90284 INFUSIONS, 100 MG, EACH 1/1/2008 CYTOMEGALOVIRUS IMMUNE GLOBULIN (CMV-IGIV), HUMAN, FOR 90291 INTRAVENOUS USE 1/1/2006 90296 DIPHTHERIA ANTITOXIN, EQUINE, ANY ROUTE 1/1/2006 HEPATITIS B IMMUNE GLOBULIN (HBIG), HUMAN, FOR 90371 INTRAMUSCULAR USE 1/1/2006 RABIES IMMUNE GLOBULIN (RIG), HUMAN, FOR INTRAMUSCULAR 90375 AND/OR SUBCUTANEOUS USE 1/1/2006 RABIES IMMUNE GLOBULIN, HEAT-TREATED (RIG-HT), HUMAN, FOR 90376 INTRAMUSCULAR AND/OR SUBCUTANEOUS USE 1/1/2006 RHO(D) IMMUNE GLOBULIN (RHIG), HUMAN, FULL-DOSE, FOR 90384 INTRAMUSCULAR USE 1/1/2006 RHO(D) IMMUNE GLOBULIN (RHIG), HUMAN, MINI-DOSE, FOR 90385 INTRAMUSCULAR USE 1/1/2006 90386 RHO(D) IMMUNE GLOBULIN (RHIGIV), HUMAN, FOR INTRAVENOUS USE 1/1/2006 TETANUS IMMUNE GLOBULIN (TIG), HUMAN, FOR INTRAMUSCULAR 90389 USE 1/1/2006 90393 VACCINIA IMMUNE GLOBULIN, HUMAN, FOR INTRAMUSCULAR USE 1/1/2006 VARICELLA-ZOSTER IMMUNE GLOBULIN, HUMAN, FOR 90396 INTRAMUSCULAR USE 1/1/2006 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN 90460 OR OTHER QUALIFI 1/1/2011 IMMUNIZATION ADMINISTRATION THROUGH 18 YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELING BY PHYSICIAN 90461 OR OTHER QUALIFI 1/1/2011 IMMUNIZATION ADMINISTRATION UNDER 8 YEARS OF AGE (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR 90465 INTRAMUSCULAR INJECTIONS) W 1/1/2006 IMMUNIZATION ADMINISTRATION UNDER 8 YEARS OF AGE (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR 90466 INTRAMUSCULAR INJECTIONS) W 1/1/2006 IMMUNIZATION ADMINISTRATION UNDER AGE 8 YEARS (INCLUDES INTRANASAL OR ORAL ROUTES OF ADMINISTRATION) WHEN THE 90467 PHYSICIAN COUNSELS T 1/1/2006 IMMUNIZATION ADMINISTRATION UNDER AGE 8 YEARS (INCLUDES INTRANASAL OR ORAL ROUTES OF ADMINISTRATION) WHEN THE 90468 PHYSICIAN COUNSELS T 1/1/2006 IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 90471 ONE VACCINE (SINGLE O 1/1/2006 IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 90472 EACH ADDITIONAL VACCI 1/1/2006 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE; 90473 ONE VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE; EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION 90474 VACCINE/TOXOID) (LIST SEPA 1/1/2006 90476 ADENOVIRUS VACCINE, TYPE 4, LIVE, FOR ORAL USE 1/1/2006 90477 ADENOVIRUS VACCINE, TYPE 7, LIVE, FOR ORAL USE 1/1/2006 90581 ANTHRAX VACCINE, FOR SUBCUTANEOUS USE 1/1/2006 BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR TUBERCULOSIS, 90585 LIVE, FOR PERCUTANEOUS USE 1/1/2006 BACILLUS CALMETTE-GUERIN VACCINE (BCG) FOR BLADDER CANCER, 90586 LIVE, FOR INTRAVESICAL USE 1/1/2006 90632 HEPATITIS A VACCINE, ADULT DOSAGE, FOR INTRAMUSCULAR USE 1/1/2006 HEPATITIS A VACCINE, PEDIATRIC/ADOLESCENT DOSAGE-2 DOSE 90633 SCHEDULE, FOR INTRAMUSCULAR USE 1/1/2006 HEPATITIS A VACCINE, PEDIATRIC/ADOLESCENT DOSAGE-3 DOSE 90634 SCHEDULE, FOR INTRAMUSCULAR USE 1/1/2006 HEPATITIS A AND HEPATITIS B VACCINE (HEPA-HEPB), ADULT 90636 DOSAGE, FOR INTRAMUSCULAR USE 1/1/2006 90644 HIB/MEN/TT VACCINE, IM 1/1/2010 HEMOPHILUS INFLUENZA B VACCINE (HIB), HBOC CONJUGATE (4 90645 DOSE SCHEDULE), FOR INTRAMUSCULAR USE 1/1/2006 HEMOPHILUS INFLUENZA B VACCINE (HIB), PRP-D CONJUGATE, FOR 90646 BOOSTER USE ONLY, INTRAMUSCULAR USE 1/1/2006 HEMOPHILUS INFLUENZA B VACCINE (HIB), PRP-OMP CONJUGATE (3 90647 DOSE SCHEDULE), FOR INTRAMUSCULAR USE 1/1/2006 HEMOPHILUS INFLUENZA B VACCINE (HIB), PRP-T CONJUGATE (4 90648 DOSE SCHEDULE), FOR INTRAMUSCULAR USE 1/1/2006 HUMAN PAPILLOMA VIRUS (HPV) VACCINE, TYPES 6, 11, 16, 18 90649 (QUADRIVALENT), 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE 1/1/2006 HUMAN PAPILLOMAVIRUS (HPV) VACCINE, TYPES 16 AND 18, 90650 BIVALENT, 3 DOSE SCHEDULE, FOR INTRAMUSCULAR USE 1/1/2008 INFLUENZA VACCINE, INACTIVATED, SUBUNIT, ADJUVANTED, FOR 90653 INTRAMUSCULAR USE 1/1/2013 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, FOR 90654 INTRADERMAL USE 1/1/2011 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, FOR 90655 CHILDREN 6-35 MONTHS OF AGE, FOR INTRAMUSCULAR USE 1/1/2006 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, FOR 90656 USE IN INDIVIDUALS 3 YEARS AND ABOVE, FOR INTRAMUSCULAR USE 1/1/2006 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, FOR CHILDREN 6-35 90657 MONTHS OF AGE, FOR INTRAMUSCULAR USE 1/1/2006 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, FOR USE IN INDIVIDUALS 3 90658 YEARS OF AGE AND ABOVE, FOR INTRAMUSCULAR USE 1/1/2006 90659 FLU VACCINE, WHOLE, IM 1/1/2007 90660 INFLUENZA VIRUS VACCINE, LIVE, FOR INTRANASAL USE 1/1/2006 INFLUENZA VIRUS VACCINE, DERIVED FROM CELL CULTURES, SUBUNIT, PRESERVATIVE AND ANTIBIOTIC FREE, FOR 90661 INTRAMUSCULAR USE 1/1/2008 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, ENHANCED IMMUNOGENICITY VIA INCREASED ANTIGEN CONTENT, 90662 FOR INTRAMUSCULAR 1/1/2008
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 90663 INFLUENZA VIRUS VACCINE, PANDEMIC FORMULATION 1/1/2008 90665 LYME DISEASE VACCINE, ADULT DOSAGE, FOR INTRAMUSCULAR USE 1/1/2006 PNEUMOCOCCAL CONJUGATE VACCINE, POLYVALENT, FOR 90669 CHILDREN UNDER 5 YEARS, FOR INTRAMUSCULAR USE 1/1/2006 PNEUMOCOCCAL CONJUGATE VACCINE, 13 VALENT, FOR 90670 INTRAMUSCULAR USE 9/1/2012 INFLUENZA VIRUS VACCINE, QUADRIVALENT, LIVE, FOR INTRANASAL 90672 USE 1/1/2013 INFLUENZA VIRUS VACCINE, TRIVALENT, DERIVED FROM RECOMBINANT DNA (RIV3), HEMAGGLUTININ (HA) PROTEIN ONLY, 90673 PRESERVATIVE AND ANTIBIO 1/1/2014 90675 RABIES VACCINE, FOR INTRAMUSCULAR USE 1/1/2006 90676 RABIES VACCINE, FOR INTRADERMAL USE 1/1/2006 ROTAVIRUS VACCINE, PENTAVALENT, 3 DOSE SCHEDULE, LIVE, FOR 90680 ORAL USE 1/1/2006 ROTAVIRUS VACCINE, HUMAN, ATTENUATED, 2 DOSE SCHEDULE, 90681 LIVE, FOR ORAL USE 1/1/2008 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, PRESERVATIVE FREE, WHEN ADMINISTERED TO CHILDREN 6-35 90685 MONTHS OF AGE, FOR INTRA 1/1/2013 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, PRESERVATIVE FREE, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS 90686 OF AGE AND OLDER, 1/1/2013 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, WHEN ADMINISTERED TO CHILDREN 6-35 MONTHS OF AGE, FOR 90687 INTRAMUSCULAR USE 1/1/2013 INFLUENZA VIRUS VACCINE, QUADRIVALENT, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR 90688 INTRAMUSCULAR U 1/1/2013 90690 TYPHOID VACCINE, LIVE, ORAL 1/1/2006 TYPHOID VACCINE, VI CAPSULAR POLYSACCHARIDE (VICPS), FOR 90691 INTRAMUSCULAR USE 1/1/2006 TYPHOID VACCINE, HEAT- AND PHENOL-INACTIVATED (H-P), FOR 90692 SUBCUTANEOUS OR INTRADERMAL USE 1/1/2006 TYPHOID VACCINE, ACETONE-KILLED, DRIED (AKD), FOR 90693 SUBCUTANEOUS USE (U.S. MILITARY) 1/1/2006 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE AND POLIOVIRUS VACCINE, INACTIVATED (DTAP-IPV), WHEN 90696 ADMINISTERED TO CHIL 1/1/2008 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HAEMOPHILUS INFLUENZA TYPE B, AND POLIOVIRUS VACCINE, 90698 INACTIVATED (DTAP 1/1/2006 DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE (DTAP), FOR USE IN INDIVIDUALS YOUNGER THAN 7 YEARS, 90700 FOR INTRAMUSCULA 1/1/2006 DIPHTHERIA, TETANUS TOXOIDS, AND WHOLE CELL PERTUSSIS 90701 VACCINE (DTP), FOR INTRAMUSCULAR USE 1/1/2006 DIPHTHERIA AND TETANUS TOXOIDS (DT) ADSORBED FOR USE IN 90702 INDIVIDUALS YOUNGER THAN 7 YEARS, FOR INTRAMUSCULAR USE 1/1/2006 90703 TETANUS TOXOID ADSORBED, FOR INTRAMUSCULAR USE 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE 90704 MUMPS VIRUS VACCINE, LIVE, FOR SUBCUTANEOUS USE 1/1/2006 90705 MEASLES VIRUS VACCINE, LIVE, FOR SUBCUTANEOUS USE 1/1/2006 90706 RUBELLA VIRUS VACCINE, LIVE, FOR SUBCUTANEOUS USE 1/1/2006 MEASLES, MUMPS AND RUBELLA VIRUS VACCINE (MMR), LIVE, FOR 90707 SUBCUTANEOUS USE 1/1/2006 MEASLES AND RUBELLA VIRUS VACCINE, LIVE, FOR SUBCUTANEOUS 90708 USE 1/1/2006 90709 RUBELLA & MUMPS VACCINE SC 1/1/2007 MEASLES, MUMPS, RUBELLA, AND VARICELLA VACCINE (MMRV), LIVE, 90710 FOR SUBCUTANEOUS USE 1/1/2006 90712 POLIOVIRUS VACCINE, (ANY TYPE(S)) (OPV), LIVE, FOR ORAL USE 1/1/2006 POLIOVIRUS VACCINE, INACTIVATED, (IPV), FOR SUBCUTANEOUS OR 90713 INTRAMUSCULAR USE 1/1/2006 TETANUS AND DIPHTHERIA TOXOIDS (TD) ADSORBED, PRESERVATIVE FREE, FOR USE IN INDIVIDUALS 7 YEARS OR OLDER, FOR 90714 INTRAMUSCULAR USE 1/1/2006 TETANUS, DIPHTHERIA TOXOIDS AND ACELLULAR PERTUSSIS VACCINE (TDAP), FOR USE IN INDIVIDUALS 7 YEARS OR OLDER, FOR 90715 INTRAMUSCULAR USE 1/1/2006 90716 VARICELLA VIRUS VACCINE, LIVE, FOR SUBCUTANEOUS USE 1/1/2006 90717 YELLOW FEVER VACCINE, LIVE, FOR SUBCUTANEOUS USE 1/1/2006 TETANUS AND DIPHTHERIA TOXOIDS (TD) ADSORBED FOR USE IN 90718 INDIVIDUALS 7 YEARS OR OLDER, FOR INTRAMUSCULAR USE 1/1/2006 90719 DIPHTHERIA TOXOID, FOR INTRAMUSCULAR USE 1/1/2006 DIPHTHERIA, TETANUS TOXOIDS, AND WHOLE CELL PERTUSSIS VACCINE AND HEMOPHILUS INFLUENZA B VACCINE (DTP-HIB), FOR 90720 INTRAMUSCULAR USE 1/1/2006 DIPHTHERIA, TETANUS TOXOIDS, AND ACELLULAR PERTUSSIS VACCINE AND HEMOPHILUS INFLUENZA B VACCINE (DTAP-HIB), FOR 90721 INTRAMUSCULAR USE 1/1/2006 DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS B, AND POLIOVIRUS VACCINE, INACTIVATED (DTAP-HEPB- 90723 IPV), FOR IN 1/1/2006 90725 CHOLERA VACCINE FOR INJECTABLE USE 1/1/2006 90727 PLAGUE VACCINE, FOR INTRAMUSCULAR USE 1/1/2006 90730 HEPATITIS A VACCINE 1/1/2007 PNEUMOCOCCAL POLYSACCHARIDE VACCINE, 23-VALENT, ADULT OR IMMUNOSUPPRESSED PATIENT DOSAGE, FOR USE IN INDIVIDUALS 2 90732 YEARS OR OLDER, 1/1/2006 MENINGOCOCCAL POLYSACCHARIDE VACCINE (ANY GROUP(S)), FOR 90733 SUBCUTANEOUS USE 1/1/2006 MENINGOCOCCAL CONJUGATE VACCINE, SEROGROUPS A, C, Y AND 90734 W-135 (TETRAVALENT), FOR INTRAMUSCULAR USE 1/1/2006 90735 JAPANESE ENCEPHALITIS VIRUS VACCINE, FOR SUBCUTANEOUS USE 1/1/2006 90736 ZOSTER (SHINGLES) VACCINE, LIVE, FOR SUBCUTANEOUS INJECTION 1/1/2006 HEPATITIS B VACCINE, ADULT DOSAGE (2 DOSE SCHEDULE), FOR 90739 INTRAMUSCULAR USE 1/1/2013 HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT 90740 DOSAGE (3 DOSE SCHEDULE), FOR INTRAMUSCULAR USE 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE HEPATITIS B VACCINE, ADOLESCENT (2 DOSE SCHEDULE), FOR 90743 INTRAMUSCULAR USE 1/1/2006 HEPATITIS B VACCINE, PEDIATRIC/ADOLESCENT DOSAGE (3 DOSE 90744 SCHEDULE), FOR INTRAMUSCULAR USE 1/1/2006 90745 HEPATITISBVACCINE,11-19 YRS 1/1/2007 90746 HEPATITIS B VACCINE, ADULT DOSAGE, FOR INTRAMUSCULAR USE 1/1/2006 HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT 90747 DOSAGE (4 DOSE SCHEDULE), FOR INTRAMUSCULAR USE 1/1/2006 HEPATITIS B AND HEMOPHILUS INFLUENZA B VACCINE (HEPB-HIB), 90748 FOR INTRAMUSCULAR USE 1/1/2006 90760 INTRAVENOUS INFUSION, HYDRATION; INITIAL, UP TO 1 HOUR 1/1/2006 INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR, UP TO 8 HOURS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 90761 PROCEDURE) 1/1/2006 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR 90765 DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR 1/1/2006 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL 90766 HOUR, UP TO 8 HOURS (LIS 1/1/2006 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL 90767 SEQUENTIAL INFUSION, UP TO 1 1/1/2006 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT 90768 INFUSION (LIST SEPARATELY IN 1/1/2006 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY 90772 SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR 1/1/2006 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY 90773 SUBSTANCE OR DRUG); INTRA-ARTERIAL 1/1/2006 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL 90774 SUBSTANCE/DRUG 1/1/2006 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL 90775 INTRAVENOUS PUSH OF A NE 1/1/2006 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL 90776 INTRAVENOUS PUSH OF THE 1/1/2008 GASTROINTESTINAL TRANSIT AND PRESSURE MEASUREMENT, STOMACH THROUGH COLON, WIRELESS CAPSULE, WITH 91112 INTERPRETATION AND REPORT 1/1/2013 91123 PULSED IRRIGATION OF FECAL IMPACTION 1/1/2005 92610 EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 1/1/2005 MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY 92611 CINE OR VIDEO RECORDING 1/1/2005 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; 93000 WITH INTERPRETATION AND REPORT 1/1/2005 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; 93005 TRACING ONLY, WITHOUT INTERPRETATION AND REPORT 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; 93010 INTERPRETATION AND REPORT ONLY 1/1/2005 TELEPHONIC TRANSMISSION OF POST-SYMPTOM ELECTROCARDIOGRAM RHYTHM STRIP(S), 24-HOUR ATTENDED 93012 MONITORING, PER 30 DAY PERIOD OF TIME; 1/1/2005 TELEPHONIC TRANSMISSION OF POST-SYMPTOM ELECTROCARDIOGRAM RHYTHM STRIP(S), 24-HOUR ATTENDED 93014 MONITORING, PER 30 DAY PERIOD OF TIME; 1/1/2005 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, CONTINUOUS 93015 ELECTROCARDIOGRAPHIC MONITORING, 1/1/2005 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, CONTINUOUS 93016 ELECTROCARDIOGRAPHIC MONITORING, 1/1/2005 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, CONTINUOUS 93017 ELECTROCARDIOGRAPHIC MONITORING, 1/1/2005 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, CONTINUOUS 93018 ELECTROCARDIOGRAPHIC MONITORING, 1/1/2005 RHYTHM ECG, ONE TO THREE LEADS; WITH INTERPRETATION AND 93040 REPORT 1/1/2005 RHYTHM ECG, ONE TO THREE LEADS; TRACING ONLY WITHOUT 93041 INTERPRETATION AND REPORT 1/1/2005 RHYTHM ECG, ONE TO THREE LEADS; INTERPRETATION AND REPORT 93042 ONLY 1/1/2005 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS ORIGINAL ECG WAVEFORM RECORDING AND STORAGE, 93224 WITH VISUAL SUPERIMPOSITIO 1/1/2005 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS ORIGINAL ECG WAVEFORM RECORDING AND STORAGE, 93225 WITH VISUAL SUPERIMPOSITIO 1/1/2005 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS ORIGINAL ECG WAVEFORM RECORDING AND STORAGE, 93226 WITH VISUAL SUPERIMPOSITIO 1/1/2005 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS ORIGINAL ECG WAVEFORM RECORDING AND STORAGE, 93227 WITH VISUAL SUPERIMPOSITIO 1/1/2005 WEARABLE MOBILE CARDIOVASCULAR TELEMETRY WITH ELECTROCARDIOGRAPHIC RECORDING, CONCURRENT 93228 COMPUTERIZED REAL TIME DATA ANALYSIS AND 1/1/2009 WEARABLE MOBILE CARDIOVASCULAR TELEMETRY WITH ELECTROCARDIOGRAPHIC RECORDING, CONCURRENT 93229 COMPUTERIZED REAL TIME DATA ANALYSIS AND 1/1/2009 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS ORIGINAL ECG WAVEFORM RECORDING AND STORAGE 93230 WITHOUT SUPERIMPOSITION SCA 1/1/2005 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS ORIGINAL ECG WAVEFORM RECORDING AND STORAGE 93231 WITHOUT SUPERIMPOSITION SCA 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS ORIGINAL ECG WAVEFORM RECORDING AND STORAGE 93232 WITHOUT SUPERIMPOSITION SCA 1/1/2005 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS ORIGINAL ECG WAVEFORM RECORDING AND STORAGE 93233 WITHOUT SUPERIMPOSITION SCA 1/1/2005 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS COMPUTERIZED MONITORING AND NON-CONTINUOUS 93235 RECORDING, AND REAL-TIME DAT 1/1/2005 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS COMPUTERIZED MONITORING AND NON-CONTINUOUS 93236 RECORDING, AND REAL-TIME DAT 1/1/2005 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS COMPUTERIZED MONITORING AND NON-CONTINUOUS 93237 RECORDING, AND REAL-TIME DAT 1/1/2005 PATIENT DEMAND SINGLE OR MULTIPLE EVENT RECORDING WITH PRESYMPTOM MEMORY LOOP, 24-HOUR ATTENDED MONITORING, 93268 PER 30 DAY PERIOD OF T 1/1/2005 PATIENT DEMAND SINGLE OR MULTIPLE EVENT RECORDING WITH PRESYMPTOM MEMORY LOOP, 24-HOUR ATTENDED MONITORING, 93270 PER 30 DAY PERIOD OF T 1/1/2005 PATIENT DEMAND SINGLE OR MULTIPLE EVENT RECORDING WITH PRESYMPTOM MEMORY LOOP, 24-HOUR ATTENDED MONITORING, 93271 PER 30 DAY PERIOD OF T 1/1/2005 PATIENT DEMAND SINGLE OR MULTIPLE EVENT RECORDING WITH PRESYMPTOM MEMORY LOOP, 24-HOUR ATTENDED MONITORING, 93272 PER 30 DAY PERIOD OF T 1/1/2005 SIGNAL-AVERAGED ELECTROCARDIOGRAPHY (SAECG), WITH OR 93278 WITHOUT ECG 1/1/2005 PROGRAMMING DEVICE EVALUATION WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE 93279 DEVICE AND SELECT OP 1/1/2009 PROGRAMMING DEVICE EVALUATION WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE 93280 DEVICE AND SELECT OP 1/1/2009 PROGRAMMING DEVICE EVALUATION WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE 93281 DEVICE AND SELECT OP 1/1/2009 PROGRAMMING DEVICE EVALUATION WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE 93285 DEVICE AND SELECT OP 1/1/2009 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH PHYSICIAN ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, 93288 RECORDING AND DISCONN 1/1/2009 INTERROGATION DEVICE EVALUATION (IN PERSON) WITH PHYSICIAN ANALYSIS, REVIEW AND REPORT, INCLUDES CONNECTION, 93291 RECORDING AND DISCONN 1/1/2009 TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVALUATION(S) SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM, INCLUDES 93293 RECORDING WITH AND 1/1/2009
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE INTERROGATION DEVICE EVALUATION(S) (REMOTE), UP TO 90 DAYS; SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM WITH 93294 INTERIM PHYSICIAN 1/1/2009 INTERROGATION DEVICE EVALUATION(S) (REMOTE), UP TO 90 DAYS; SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM OR 93296 IMPLANTABLE CARDIOV 1/1/2012 INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE LOOP RECORDER SYSTEM, INCLUDING ANALYSIS OF 93298 RECORDED HEART 1/1/2009 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 93303 ANOMALIES; COMPLETE 1/1/2005 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 93304 ANOMALIES; FOLLOW-UP OR LIMITED STUDY 1/1/2005 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN 93306 PERFORMED, COMPLETE, WIT 1/1/2009 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; 93307 COMPLETE 1/1/2005 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; 93308 FOLLOW-UP OR LIMITED ST 1/1/2005 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN 93320 ADDITION TO CODES FOR ECHOC 1/1/2005 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN 93321 ADDITION TO CODES FOR ECHOC 1/1/2005 DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST SEPARATELY IN ADDITION TO CODES FOR 93325 ECHOCARDIOGRAPHY) 1/1/2005 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING, 93350 DURING REST AND CARDIO 1/1/2005 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN 93351 PERFORMED, DURING REST A 1/1/2009 USE OF ECHOCARDIOGRAPHIC CONTRAST AGENT DURING STRESS ECHOCARDIOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FOR 93352 PRIMARY PROCEDURE) 1/1/2009 ELECTRONIC ANALYSIS OF ANTITACHYCARDIA PACEMAKER SYSTEM (INCLUDES ELECTROCARDIOGRAPHIC RECORDING, PROGRAMMING 93724 OF DEVICE, INDUCTION 10/1/2008 ELECTRONIC ANALYSIS OF IMPLANTABLE LOOP RECORDER (ILR) SYSTEM (INCLUDES RETRIEVAL OF RECORDED AND STORED ECG 93727 DATA, PHYSICIAN REVIE 10/1/2008 ELECTRONIC ANALYSIS OF DUAL-CHAMBER PACEMAKER SYSTEM (INCLUDES EVALUATION OF PROGRAMMABLE PARAMETERS AT REST 93731 AND DURING ACTIVITY W 10/1/2008
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE ELECTRONIC ANALYSIS OF DUAL-CHAMBER PACEMAKER SYSTEM (INCLUDES EVALUATION OF PROGRAMMABLE PARAMETERS AT REST 93732 AND DURING ACTIVITY W 10/1/2008 ELECTRONIC ANALYSIS OF DUAL CHAMBER INTERNAL PACEMAKER SYSTEM (MAY INCLUDE RATE, PULSE AMPLITUDE AND DURATION, 93733 CONFIGURATION OF WA 10/1/2008 ELECTRONIC ANALYSIS OF SINGLE CHAMBER PACEMAKER SYSTEM (INCLUDES EVALUATION OF PROGRAMMABLE PARAMETERS AT REST 93734 AND DURING ACTIVITY 10/1/2008 ELECTRONIC ANALYSIS OF SINGLE CHAMBER PACEMAKER SYSTEM (INCLUDES EVALUATION OF PROGRAMMABLE PARAMETERS AT REST 93735 AND DURING ACTIVITY 10/1/2008 ELECTRONIC ANALYSIS OF SINGLE CHAMBER INTERNAL PACEMAKER SYSTEM (MAY INCLUDE RATE, PULSE AMPLITUDE , DURATION, 93736 CONFIGURATION OF 10/1/2008 AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS 93784 OR LONGER; INCLU 1/1/2005 AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS 93786 OR LONGER; RECOR 1/1/2005 AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS 93788 OR LONGER; SCANN 1/1/2005 AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS 93790 OR LONGER; PHYSI 1/1/2005 NON-INVASIVE PHYSIOLOGIC STUDIES OF EXTRACRANIAL ARTERIES, COMPLETE BILATERAL STUDY (EG, PERIORBITAL FLOW DIRECTION 93875 WITH ARTERIAL 1/1/2005 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL 93880 STUDY 1/1/2005 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; UNILATERAL OR LIMITED 93882 STUDY 1/1/2005 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; 93886 COMPLETE STUDY 1/1/2005 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; 93888 LIMITED STUDY 1/1/2005 NON-INVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, SINGLE LEVEL, BILATERAL (EG, 93922 ANKLE/BRACHIAL INDICES, DOPPLE 1/1/2005 NON-INVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, MULTIPLE LEVELS OR WITH PROVOCATIVE 93923 FUNCTIONAL MANEUVERS, C 1/1/2005 NON-INVASIVE PHYSIOLOGIC STUDIES OF LOWER EXTREMITY ARTERIES, AT REST AND FOLLOWING TREADMILL STRESS TESTING, 93924 COMPLETE BILATERAL S 1/1/2005 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL 93925 BYPASS GRAFTS; COMPLETE BILATERAL STUDY 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL 93926 BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 1/1/2005 DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL 93930 BYPASS GRAFTS; COMPLETE BILATERAL STUDY 1/1/2005 DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL 93931 BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 1/1/2005 NON-INVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COMPLETE BILATERAL STUDY (EG, DOPPLER WAVEFORM ANALYSIS 93965 WITH RESPONSES TO COM 1/1/2005 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL 93970 STUDY 1/1/2005 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED 93971 STUDY 1/1/2005 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR 93975 RETROPERITONEAL ORGANS; COMPLETE S 1/1/2005 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR 93976 RETROPERITONEAL ORGANS; LIMITED ST 1/1/2005 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, 93978 OR BYPASS GRAFTS; COMPLETE STUDY 1/1/2005 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, 93979 OR BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 1/1/2005 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF 93980 PENILE VESSELS; COMPLETE STUDY 1/1/2005 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF 93981 PENILE VESSELS; FOLLOW-UP OR LIMITED STUDY 1/1/2005 DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL 93990 INFLOW, BODY OF ACCESS AND VENOUS OUTFLOW) 1/1/2005 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR 94010 WITHOUT MAXIMAL 1/1/2005 PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD OF TIME; INCLUDES REINFORCED EDUCATION, TRANSMISSION OF 94014 SPIROMETRIC TRAC 1/1/2005 PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD OF TIME; RECORDING (INCLUDES HOOK-UP, REINFORCED 94015 EDUCATION, DATA TRANSMI 1/1/2005 PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD 94016 OF TIME; PHYSICIAN REVIEW AND INTERPRETATION ONLY 1/1/2005 BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, 94060 PRE- AND POST-BRONCHODILATOR ADMINISTRATION 1/1/2005 BRONCHOSPASM PROVOCATION EVALUATION, MULTIPLE SPIROMETRIC DETERMINATIONS AS IN 94010, WITH ADMINISTERED 94070 AGENTS (EG, ANTIGEN(S), CO 1/1/2005 94150 VITAL CAPACITY, TOTAL (SEPARATE PROCEDURE) 1/1/2005 94200 MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME: HELIUM 94240 METHOD, NITROGEN OPEN CIRCUIT METHOD, OR OTHER METHOD 1/1/2005 EXPIRED GAS COLLECTION, QUANTITATIVE, SINGLE PROCEDURE 94250 (SEPARATE PROCEDURE) 1/1/2005 94260 THORACIC GAS VOLUME 1/1/2005 DETERMINATION OF MALDISTRIBUTION OF INSPIRED GAS: MULTIPLE BREATH NITROGEN WASHOUT CURVE INCLUDING ALVEOLAR 94350 NITROGEN OR HELIUM EQU 1/1/2005 DETERMINATION OF RESISTANCE TO AIRFLOW, OSCILLATORY OR 94360 PLETHYSMOGRAPHIC METHODS 1/1/2005 DETERMINATION OF AIRWAY CLOSING VOLUME, SINGLE BREATH 94370 TESTS 1/1/2005 94375 RESPIRATORY FLOW VOLUME LOOP 1/1/2005 94400 BREATHING RESPONSE TO CO2 (CO2 RESPONSE CURVE) 1/1/2005 94450 BREATHING RESPONSE TO HYPOXIA (HYPOXIA RESPONSE CURVE) 1/1/2005 PULMONARY STRESS TESTING; SIMPLE (EG, PROLONGED EXERCISE 94620 TEST FOR BRONCHOSPASM WITH PRE- AND POST-SPIROMETRY) 1/1/2005 PULMONARY STRESS TESTING; COMPLEX (INCLUDING MEASUREMENTS OF CO2 PRODUCTION, O2 UPTAKE, AND 94621 ELECTROCARDIOGRAPHIC RECORDINGS) 1/1/2005 PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION OR FOR SPUTUM INDUCTION FOR 94640 DIAGNOSTIC PURPOSES (E 1/1/2005 AEROSOL INHALATION OF PENTAMIDINE FOR PNEUMOCYSTIS CARINII 94642 PNEUMONIA TREATMENT OR PROPHYLAXIS 1/1/2005 DEMONSTRATION AND/OR EVALUATION OF PATIENT UTILIZATION OF AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR 94664 IPPB DEVICE 1/1/2005 OXYGEN UPTAKE, EXPIRED GAS ANALYSIS; REST AND EXERCISE, 94680 DIRECT, SIMPLE 1/1/2005 OXYGEN UPTAKE, EXPIRED GAS ANALYSIS; INCLUDING CO2 OUTPUT, 94681 PERCENTAGE OXYGEN EXTRACTED 1/1/2005 OXYGEN UPTAKE, EXPIRED GAS ANALYSIS; REST, INDIRECT 94690 (SEPARATE PROCEDURE) 1/1/2005 CARBON MONOXIDE DIFFUSING CAPACITY (EG, SINGLE BREATH, 94720 STEADY STATE) 1/1/2005 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; 94760 SINGLE DETERMINATION 1/1/2005 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; 94761 MULTIPLE DETERMINATIONS (EG, DURING EXERCISE) 1/1/2005 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; 94762 BY CONTINUOUS OVERNIGHT MONITORING (SEPARATE PROCEDURE) 1/1/2005 CARBON DIOXIDE, EXPIRED GAS DETERMINATION BY INFRARED 94770 ANALYZER 1/1/2005 INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 96360 HOUR 1/1/2009 INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST 96361 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 1/1/2009 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR 96365 DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR 1/1/2009
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL 96366 HOUR (LIST SEPARATELY IN 1/1/2009 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL 96367 SEQUENTIAL INFUSION, UP TO 1 1/1/2009 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT 96368 INFUSION (LIST SEPARATELY IN 1/1/2009 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY 96372 SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR 1/1/2009 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY 96373 SUBSTANCE OR DRUG); INTRA-ARTERIAL 1/1/2009 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL 96374 SUBSTANCE/DRUG 1/1/2009 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL 96375 INTRAVENOUS PUSH OF A N 1/1/2009 THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL 96376 INTRAVENOUS PUSH OF THE 1/1/2009 SUPPLIES AND MATERIALS (EXCEPT SPECTACLES), PROVIDED BY THE PHYSICIAN OVER AND ABOVE THOSE USUALLY INCLUDED WITH THE 99070 OFFICE VISIT 1/1/2006 99195 PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE) 1/1/2005 A4470 GRAVLEE JET WASHER 1/1/2005 A4480 VABRA ASPIRATOR 1/1/2005 A4561 PESSARY, RUBBER, ANY TYPE 1/1/2005 A4562 PESSARY, NON RUBBER, ANY TYPE 1/1/2005 TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE, UP A9500 TO 40 MILLICURIES 1/1/2005 TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE, A9502 UP TO 40 MILLICURIES 1/1/2005 TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, A9503 UP TO 30 MILLICURIES 1/1/2005 TECHNETIUM TC-99M APCITIDE, DIAGNOSTIC, PER STUDY DOSE, UP A9504 TO 20 MILLICURIES 1/1/2005 A9505 THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE 1/1/2005 INDIUM IN-111 CAPROMAB PENDETIDE, DIAGNOSTIC, PER STUDY A9507 DOSE, UP TO 10 MILLICURIES 1/1/2005 A9508 IODINE I-131 IOBENGUANE SULFATE, DIAGNOSTIC, PER 0.5 MILLICURIE 1/1/2005 TECHNETIUM TC-99M DISOFENIN, DIAGNOSTIC, PER STUDY DOSE, UP A9510 TO 15 MILLICURIES 1/1/2005 A9512 TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE 1/1/2007 IODINE I-123 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER 100 A9516 MICROCURIES 1/1/2007 IODINE I-131 SODIUM IODIDE CAPSULE(S), THERAPEUTIC, PER A9517 MILLICURIE 1/1/2007
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE TECHNETIUM TC-99M, TILMANOCEPT, DIAGNOSTIC, UP TO 0.5 A9520 MILLICURIES 1/1/2014 TECHNETIUM TC-99M EXAMETAZIME, DIAGNOSTIC, PER STUDY DOSE, A9521 UP TO 25 MILLICURIES 1/1/2007 IODINE I-131 IODINATED SERUM ALBUMIN, DIAGNOSTIC, PER 5 A9524 MICROCURIES 1/1/2007 NITROGEN N-13 AMMONIA, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 A9526 MILLICURIES 1/1/2007 IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER A9528 MILLICURIE 1/1/2005 A9529 IODINE I-131 SODIUM IODIDE SOLUTION, DIAGNOSTIC, PER MILLICURIE 1/1/2005 IODINE I-131 SODIUM IODIDE SOLUTION, THERAPEUTIC, PER A9530 MILLICURIE 1/1/2005 IODINE I-131 SODIUM IODIDE, DIAGNOSTIC, PER MICROCURIE (UP TO A9531 100 MICROCURIES 1/1/2005 A9532 IODINE I-125 SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIES 1/1/2005 A9535 INJECTION, METHYLENE BLUE, 1 ML 1/1/2006 TECHNETIUM TC-99M DEPREOTIDE, DIAGNOSTIC, PER STUDY DOSE, A9536 UP TO 35 MILLICURIES 1/1/2006 TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, A9537 UP TO 15 MILLICURIES 1/1/2006 TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY A9538 DOSE, UP TO 25 MILLICURIES 1/1/2006 TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, PER STUDY DOSE, UP A9539 TO 25 MILLICURIES 1/1/2006 TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, A9540 PER STUDY DOSE, UP TO 10 MILLICURIES 1/1/2006 TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY A9541 DOSE, UP TO 20 MILLICURIES 1/1/2006 INDIUM IN-111 IBRITUMOMAB TIUXETAN, DIAGNOSTIC, PER STUDY A9542 DOSE, UP TO 5 MILLICURIES 1/1/2006 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN, THERAPEUTIC, PER A9543 TREATMENT DOSE, UP TO 40 MILLICURIES 1/1/2006 A9544 IODINE I-131 TOSITUMOMAB, DIAGNOSTIC, PER STUDY DOSE 1/1/2006 A9545 IODINE I-131 TOSITUMOMAB, THERAPEUTIC, PER TREATMENT DOSE 1/1/2006 COBALT CO-57/58, CYANOCOBALAMIN, DIAGNOSTIC, PER STUDY A9546 DOSE, UP TO 1 MICROCURIE 1/1/2006 A9547 INDIUM IN-111 OXYQUINOLINE, DIAGNOSTIC, PER 0.5 MILLICURIE 1/1/2006 A9548 INDIUM IN-111 PENTETATE, DIAGNOSTIC, PER 0.5 MILLICURIE 1/1/2006 TECHNETIUM TC-99M ARCITUMOMAB, DIAGNOSTIC, PER STUDY DOSE, A9549 UP TO 25 MILLICURIES 1/1/2006 TECHNETIUM TC-99M SODIUM GLUCEPTATE, DIAGNOSTIC, PER STUDY A9550 DOSE, UP TO 25 MILLICURIE 1/1/2006 TECHNETIUM TC-99M SUCCIMER, DIAGNOSTIC, PER STUDY DOSE, UP A9551 TO 10 MILLICURIES 1/1/2006 FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, A9552 UP TO 45 MILLICURIES 1/1/2006 CHROMIUM CR-51 SODIUM CHROMATE, DIAGNOSTIC, PER STUDY A9553 DOSE, UP TO 250 MICROCURIES 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE IODINE I-125 SODIUM IOTHALAMATE, DIAGNOSTIC, PER STUDY DOSE, A9554 UP TO 10 MICROCURIES 1/1/2006 RUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60 A9555 MILLICURIES 1/1/2006 A9556 GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE 1/1/2006 TECHNETIUM TC-99M BICISATE, DIAGNOSTIC, PER STUDY DOSE, UP A9557 TO 25 MILLICURIES 1/1/2006 A9558 XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES 1/1/2006 COBALT CO-57 CYANOCOBALAMIN, ORAL, DIAGNOSTIC, PER STUDY A9559 DOSE, UP TO 1 MICROCURIE 1/1/2006 TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER A9560 STUDY DOSE, UP TO 30 MILLICURIES 1/1/2006 TECHNETIUM TC-99M OXIDRONATE, DIAGNOSTIC, PER STUDY DOSE, A9561 UP TO 30 MILLICURIES 1/1/2006 TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, A9562 UP TO 15 MILLICURIES 1/1/2006 A9563 SODIUM PHOSPHATE P-32, THERAPEUTIC, PER MILLICURIE 1/1/2006 CHROMIC PHOSPHATE P-32 SUSPENSION, THERAPEUTIC, PER A9564 MILLICURIE 1/1/2006 A9565 INDIUM IN-111 PENTETREOTIDE, DIAGNOSTIC, PER MILLICURIE 1/1/2006 TECHNETIUM TC-99M FANOLESOMAB, DIAGNOSTIC, PER STUDY DOSE, A9566 UP TO 25 MILLICURIES 1/1/2006 TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, AEROSOL, PER A9567 STUDY DOSE, UP TO 75 MILLICURIES 1/1/2006 A9600 STRONTIUM SR-89 CHLORIDE, THERAPEUTIC, PER MILLICURIE 1/1/2005 SAMARIUM SM-153 LEXIDRONAMM, THERAPEUTIC, PER 50 A9605 MILLICURIES 1/1/2005 NONRADIOACTIVE CONTRAST IMAGING MATERIAL, NOT OTHERWISE A9698 CLASSIFIED, PER STUDY 1/1/2006 RADIOPHARMACEUTICAL, THERAPEUTIC, NOT OTHERWISE A9699 CLASSIFIED 1/1/2005 SUPPLY OF INJECTABLE CONTRAST MATERIAL FOR USE IN A9700 ECHOCARDIOGRAPHY, PER STUDY 1/1/2005 C8928 TTE M-MODE REC REST & CV ST 6/1/2011 C8929 TTE CMPL SPC & COLR FLOW DPP 6/1/2011 IOBENGUANE, I-123, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 C9247 MILLICURIES 1/1/2009 C9283 INJECTION ACETAMINOPHEN 10 M 7/1/2011 INJECTION, CENTRUROIDES (SCORPION) IMMUNE F(AB)2 (EQUINE), 1 C9288 VIAL 4/1/2012 C9406 I-123 IOFLUPANE DX PER DOS T 7/1/2011 C9441 INJECTION, FERRIC CARBOXYMALTOSE, 1 MG 1/1/2014 C9497 LOXAPINE, INHALATION POWDER, 10 MG 1/1/2014 ADMINISTRATION OF INFLUENZA VIRUS VACCINE WHEN NO G0008 PHYSICIAN FEE SCHEDULE SERVICE ON THE SAME DAY 1/1/2005 ADMINISTRATION OF PNEUMOCOCCAL VACCINE WHEN NO PHYSICIAN G0009 FEE SCHEDULE SERVICE ON THE SAME DAY 1/1/2005 ADMINISTRATION OF HEPATITIS B VACCINE WHEN NO PHYSICIAN FEE G0010 SCHEDULE SERVICE ON THE SAME DAY 1/1/2005 G0027 SEMEN ANALYSIS 1/1/2005 HealthSpan Provider Manual APPENDIX E Revised February 2014 68
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE CERVICAL OR VAGINAL CANCER SCREENING; PELVIC AND CLINICAL G0101 BREAST EXAMINATION 1/1/2005 G0102 PROSTATE CANCER SCREENING; DIGITAL RECTAL EXAMINATION 1/1/2005 PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST G0103 (PSA), TOTAL 1/1/2005 COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, G0106 SCREENING SIGMOIDOSCOPY, BARIUM ENEMA 1/1/2005 COLORECTAL CANCER SCREENING; FECAL-OCCULT BLOOD TEST, 1-3 G0107 SIMULTANEOUS DETERMINATIONS 1/1/2005 COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0105, G0120 SCREENING COLONOSCOPY, BARIUM ENEMA 1/1/2005 G0122 COLORECTAL CANCER SCREENING; BARIUM ENEMA 1/1/2005 SINGLE ENERGY X-RAY ABSORPTIOMETRY (SEXA) BONE DENSITY STUDY, ONE OR MORE SITES; APPENDICULAR SKELETON G0130 (PERIPHERAL) (E.G., RADIUS, 1/1/2005 SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATED SYSTEM, WITH MANUAL RESCREENING, G0141 REQUIRING INTERPRETAT 1/1/2005 SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, PERFORMED BY AUTOMATED SYSTEM UNDER PHYSICIAN G0147 SUPERVISION 1/1/2005 SCREENING CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL, G0148 PERFORMED BY AUTOMATED SYSTEM WITH MANUAL RESCREENING 1/1/2005 G0168 WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY 1/1/2005 SCREENING MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, G0202 BILATERAL, ALL VIEWS 1/1/2005 DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, G0204 BILATERAL, ALL VIEWS 1/1/2005 DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, G0206 UNILATERAL, ALL VIEWS 1/1/2005 REMOVAL OF IMPACTED CERUMEN (ONE OR BOTH EARS) BY PHYSICIAN ON SAME DATE OF SERVICE AS AUDIOLOGIC FUNCTION G0268 TESTING 1/1/2005 COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC, WITHOUT G0306 PLATELET COUNT) AND AUTOMATED WBC DIFFERENTIAL COUNT 1/1/2005 COMPLETE CBC, AUTOMATED (HGB, HCT, RBC, WBC; WITHOUT G0307 PLATELET COUNT) 1/1/2005 COLORECTALCANCER SCREENING; FECAL-OCCULT BLOOD TEST, G0328 IMMUNOASSAY, 1-3 SIMULTANEOUS DETERMINATIONS. 1/1/2005 PREADMINISTRATION-RELATED SERVICES FOR INTRAVENOUS G0332 INFUSION OF IMMUNOGLOBULIN, PER INFUSION ENCOUNTER 1/1/2006 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT, PERFORMED AS A COMPONENT G0366 OF THE INITIAL PRE 1/1/2005 TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A COMPONENT OF THE INITIAL PREVENTIVE G0367 PHYSICAL EXAMINATION 1/1/2005 INTEREPRETATION AND REPORT ONLY, PERFORMED AS A G0368 COMPONENT OF THE INITIAL PREVENTIVE PHYSICAL EXAMINATION 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT; G0375 INTERMEDIATE, GREATER THAN 3 MINUTES UP TO 10 MINUTES 1/1/2005 SMOKING AND TOBACCO USE CESSATION COUNSELING VISIT; G0376 INTENSIVE, GREATER THAN 10 MINUTES 1/1/2005 G0431 RX SCR MX RX CLASS HI CMPLX 1/1/2011 G0432 INF AB EIA TECH HIV-1 &/OR H 1/1/2011 G0434 INJECTION, HEXAMINOLEVULINATE HCL, 100 MG, PER STUDY DOSE 1/1/2011 IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER G0461 SPECIMEN; FIRST SINGLE OR MULTIPLEX ANTIBODY STAIN 1/1/2014 IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER SPECIMEN; EACH ADDITIONAL SINGLE OR MULTIPLEX ANTIBODY G0462 STAIN (LIST SEPARATELY IN 1/1/2014 J0120 INJECTION, TETRACYCLINE, UP TO 250 MG 1/1/2005 J0129 INJECTION, ABATACEPT, 10 MG 1/1/2007 J0131 INJECTION, ACETAMINOPHEN, 10 MG 1/1/2012 INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS, J0151 INSTEAD USE A9270) 1/1/2014 INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS; J0152 INSTEAD USE A9270) 1/1/2005 J0170 INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE 1/1/2005 J0171 INJECTION, ADRENALIN, EPINEPHRINE, 0.1 MG 1/1/2011 J0180 INJECTION, AGALSIDASE BETA, 1 MG 1/1/2008 J0200 INJECTION, ALATROFLOXACIN MESYLATE, 100 MG 1/1/2005 J0205 INJECTION, ALGLUCERASE, PER 10 UNITS 1/1/2005 J0210 INJECTION, METHYLDOPATE HCL, UP TO 250 MG 1/1/2005 ALPROSTADIL URETHRAL SUPPOSITORY (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER DIRECT SUPERVISION J0275 OF A PHYSICIAN, NO 1/1/2005 J0280 INJECTION, AMINOPHYLLIN, UP TO 250 MG 1/1/2005 J0282 INJECTION, AMIODARONE HCL, 30 MG 1/1/2005 J0285 INJECTION, AMPHOTERICIN B, 50 MG 1/1/2005 J0287 INJECTION, AMPHOTERICIN B LIPID COMPLEX, 10 MG 1/1/2005 INJECTION, AMPHOTERICIN B CHOLESTERYL SULFATE COMPLEX, 10 J0288 MG 1/1/2005 J0289 INJECTION, AMPHOTERICIN B LIPOSOME, 10 MG 1/1/2005 J0290 INJECTION, AMPICILLIN SODIUM, 500 MG 1/1/2005 J0295 INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 G 1/1/2005 J0350 INJECTION, ANISTREPLASE, PER 30 UNITS 1/1/2007 J0364 INJECTION, APOMORPHINE HYDROCHLORIDE, 1 MG 1/1/2007 J0365 INJECTION, APROTONIN, 10,000 KIU 1/1/2006 J0390 INJECTION, CHLOROQUINE HCL, UP TO 250 MG 1/1/2005 J0395 INJECTION, ARBUTAMINE HCL, 1 MG 1/1/2005 J0401 INJECTION, ARIPIPRAZOLE, EXTENDED RELEASE, 1 MG 1/1/2014 J0456 INJECTION, AZITHROMYCIN, 500 MG 1/1/2005 J0461 INJECTION, ATROPINE SULFATE, 0.01 MG 3/1/2012 J0470 INJECTION, DIMERCAPROL, PER 100 MG 1/1/2005 J0475 INJECTION, BACLOFEN, 10 MG 1/1/2008 J0476 INJECTION, BACLOFEN, 50 MCG FOR INTRATHECAL TRIAL 1/1/2005 HealthSpan Provider Manual APPENDIX E Revised February 2014 70
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE J0500 INJECTION, DICYCLOMINE HCL, UP TO 20 MG 1/1/2005 J0515 INJECTION, BENZTROPINE MESYLATE, PER 1 MG 1/1/2005 INJECTION, BETHANECHOL CHLORIDE, MYTONACHOL OR J0520 URECHOLINE, UP TO 5 MG 1/1/2005 INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, J0530 UP TO 600,000 UNITS 1/1/2005 INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, J0540 UP TO 1,200,000 UNITS 1/1/2005 INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, J0550 UP TO 2,400,000 UNITS 1/1/2005 INJECTION, PENICILLIN G BENZATHINE AND PENICILLIN G PROCAINE, J0558 100,000 UNITS 1/1/2011 J0559 INJ PCN G BENZATHINE PROCAIN 1/1/2010 J0560 INJECTION, PENICILLIN G BENZATHINE, UP TO 600,000 UNITS 1/1/2005 J0561 INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS 1/1/2011 J0570 INJECTION, PENICILLIN G BENZATHINE, UP TO 1,200,000 UNITS 1/1/2005 J0580 INJECTION, PENICILLIN G BENZATHINE, UP TO 2,400,000 UNITS 1/1/2005 J0583 INJECTION, BIVALIRUDIN, 1 MG 1/1/2005 J0597 INJECTION, C-1 ESTERASE INHIBITOR (HUMAN), BERINERT, 10 UNITS 1/1/2011 J0600 INJECTION, EDETATE CALCIUM DISODIUM, UP TO 1000 MG 1/1/2005 INJECTION, CALCIUM GLYCEROPHOSPHATE AND CALCIUM LACTATE, J0620 PER 10 ML 1/1/2005 J0630 INJECTION, CALCITONIN-SALMON, UP TO 400 UNITS 1/1/2005 J0636 INJECTION, CALCITRIOL, 0.1 MCG 1/1/2005 J0637 INJECTION, CASPOFUNGIN ACETATE, 5 MG 1/1/2005 J0690 INJECTION, CEFAZOLIN SODIUM, 500 MG 1/1/2005 J0692 INJECTION, CEFEPIME HCL, 500 MG 1/1/2005 J0694 INJECTION, CEFOXITIN SODIUM, 1 G 1/1/2005 J0696 INJECTION, CEFTRIAXONE SODIUM, PER 250 MG 1/1/2005 J0697 INJECTION, STERILE CEFUROXIME SODIUM, PER 750 MG 1/1/2005 J0698 CEFOTAXIME SODIUM, PER G 1/1/2005 J0706 INJECTION, CAFFEINE CITRATE, 5 MG 1/1/2005 J0720 INJECTION, CHLORAMPHENICOL SODIUM SUCCINATE, UP TO 1 G 1/1/2005 J0725 INJECTION, CHORIONIC GONADOTROPIN, PER 1,000 USP UNITS 1/1/2005 J0735 INJECTION, CLONIDINE HCL, 1 MG 1/1/2005 J0740 INJECTION, CIDOFOVIR, 375 MG 1/1/2005 J0744 INJECTION, CIPROFLOXACIN FOR INTRAVENOUS INFUSION, 200 MG 1/1/2005 J0745 INJECTION, CODEINE PHOSPHATE, PER 30 MG 1/1/2005 J0760 INJECTION, COLCHICINE, PER 1 MG 1/1/2005 J0770 INJECTION, COLISTIMETHATE SODIUM, UP TO 150 MG 1/1/2005 J0780 INJECTION, PROCHLORPERAZINE, UP TO 10 MG 1/1/2005 J0800 INJECTION, CORTICOTROPIN, UP TO 40 UNITS 1/1/2005 INJECTION, CYTOMEGALOVIRUS IMMUNE GLOBULIN INTRAVENOUS J0850 (HUMAN), PER VIAL 1/1/2005 J0878 INJECTION, DAPTOMYCIN, 1 MG 1/1/2005 J0886 INJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS) 1/1/2006 J0945 INJECTION, BROMPHENIRAMINE MALEATE, PER 10 MG 1/1/2005 J0970 INJECTION, ESTRADIOL VALERATE, UP TO 40 MG 1/1/2005 J1000 INJECTION, DEPO-ESTRADIOL CYPIONATE, UP TO 5 MG 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE J1020 INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG 1/1/2005 J1030 INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG 1/1/2005 J1040 INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG 1/1/2005 J1051 INJECTION, MEDROXYPROGESTERONE ACETATE, 50 MG 1/1/2005 INJECTION, MEDROXYPROGESTERONE ACETATE FOR J1055 CONTRACEPTIVE USE, 150 MG 1/1/2005 INJECTION, MEDROXYPROGESTERONE ACETATE/ESTRADIOL J1056 CYPIONATE, 5 MG/25 MG 1/1/2005 INJECTION, TESTOSTERONE CYPIONATE AND ESTRADIOL CYPIONATE, J1060 UP TO 1 ML 1/1/2005 J1070 INJECTION, TESTOSTERONE CYPIONATE, UP TO 100 MG 1/1/2005 J1080 INJECTION, TESTOSTERONE CYPIONATE, 1 CC, 200 MG 1/1/2005 J1094 INJECTION, DEXAMETHASONE ACETATE, 1 MG 1/1/2005 J1100 INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG 1/1/2005 J1110 INJECTION, DIHYDROERGOTAMINE MESYLATE, PER 1 MG 1/1/2005 J1120 INJECTION, ACETAZOLAMIDE SODIUM, UP TO 500 MG 1/1/2005 J1160 INJECTION, DIGOXIN, UP TO 0.5 MG 1/1/2005 J1162 INJECTION, DIGOXIN IMMUNE FAB (OVINE), PER VIAL 1/1/2006 J1165 INJECTION, PHENYTOIN SODIUM, PER 50 MG 1/1/2005 J1180 INJECTION, DYPHYLLINE, UP TO 500 MG 1/1/2005 J1190 INJECTION, DEXRAZOXANE HCL, PER 250 MG 1/1/2005 J1200 INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG 1/1/2005 J1205 INJECTION, CHLOROTHIAZIDE SODIUM, PER 500 MG 1/1/2005 J1212 INJECTION, DMSO, DIMETHYL SULFOXIDE, 50%, 50 ML 1/1/2005 J1240 INJECTION, DIMENHYDRINATE, UP TO 50 MG 1/1/2005 J1250 INJECTION, DOBUTAMINE HCI, PER 250 MG 1/1/2005 J1260 INJECTION, DOLASETRON MESYLATE, 10 MG 1/1/2005 J1270 INJECTION, DOXERCALCIFEROL, 1 MCG 1/1/2005 J1320 INJECTION, AMITRIPTYLINE HCL, UP TO 20 MG 1/1/2005 J1327 INJECTION, EPTIFIBATIDE, 5 MG 1/1/2005 J1364 INJECTION, ERYTHROMYCIN LACTOBIONATE, PER 500 MG 1/1/2005 J1380 INJECTION, ESTRADIOL VALERATE, UP TO 10 MG 1/1/2005 J1390 INJECTION, ESTRADIOL VALERATE, UP TO 20 MG 1/1/2005 J1410 INJECTION, ESTROGEN CONJUGATED, PER 25 MG 1/1/2005 J1435 INJECTION, ESTRONE, PER 1 MG 1/1/2005 J1436 INJECTION, ETIDRONATE DISODIUM, PER 300 MG 1/1/2005 INJECTION, ETANERCEPT, 25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A J1438 PHYSICIAN, NO 1/1/2005 J1452 INJECTION, FOMIVIRSEN SODIUM, INTRAOCULAR, 1.65 MG 1/1/2005 J1455 INJECTION, FOSCARNET SODIUM, PER 1,000 MG 1/1/2005 J1460 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 1 CC 1/1/2005 J1470 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 2 CC 1/1/2005 J1480 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 3 CC 1/1/2005 J1490 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 4 CC 1/1/2005 J1500 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 5 CC 1/1/2005 J1510 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 6 CC 1/1/2005 J1520 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 7 CC 1/1/2005 J1530 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 8 CC 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE J1540 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 9 CC 1/1/2005 J1550 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, 10 CC 1/1/2007 J1560 INJECTION, GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC 1/1/2005 J1570 INJECTION, GANCICLOVIR SODIUM, 500 MG 1/1/2005 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG 1/1/2005 J1590 INJECTION, GATIFLOXACIN, 10 MG 1/1/2005 J1595 INJECTION, GLATIRAMER ACETATE, 20 MG 1/1/2005 J1600 INJECTION, GOLD SODIUM THIOMALATE, UP TO 50 MG 1/1/2005 J1620 INJECTION, GONADORELIN HCL, PER 100 MCG 1/1/2005 J1626 INJECTION, GRANISETRON HCL, 100 MCG 1/1/2005 J1630 INJECTION, HALOPERIDOL, UP TO 5 MG 1/1/2005 J1631 INJECTION, HALOPERIDOL DECANOATE, PER 50 MG 1/1/2005 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS 1/1/2006 J1644 INJECTION, HEPARIN SODIUM, PER 1,000 UNITS 1/1/2005 J1645 INJECTION, DALTEPARIN SODIUM, PER 2500 IU 1/1/2005 J1650 INJECTION, ENOXAPARIN SODIUM, 10 MG 1/1/2005 J1652 INJECTION, FONDAPARINUX SODIUM, 0.5 MG 1/1/2005 J1655 INJECTION, TINZAPARIN SODIUM, 1000 IU 1/1/2005 J1670 INJECTION, TETANUS IMMUNE GLOBULIN, HUMAN, UP TO 250 UNITS 1/1/2005 J1675 INJECTION, HISTRELIN ACETATE, 10 MCG 1/1/2006 J1700 INJECTION, HYDROCORTISONE ACETATE, UP TO 25 MG 1/1/2005 J1710 INJECTION, HYDROCORTISONE SODIUM PHOSPHATE, UP TO 50 MG 1/1/2005 J1720 INJECTION, HYDROCORTISONE SODIUM SUCCINATE, UP TO 100 MG 1/1/2007 J1730 INJECTION, DIAZOXIDE, UP TO 300 MG 1/1/2005 J1740 INJECTION, IBANDRONATE SODIUM, 1 MG 1/1/2007 J1742 INJECTION, IBUTILIDE FUMARATE, 1 MG 1/1/2005 J1751 INJECTION, IRON DEXTRAN 165, 50 MG 1/1/2006 J1752 INJECTION, IRON DEXTRAN 267, 50 MG 1/1/2006 J1756 INJECTION, IRON SUCROSE, 1 MG 1/1/2005 J1785 INJECTION, IMIGLUCERASE, PER UNIT 1/1/2005 J1790 INJECTION, DROPERIDOL, UP TO 5 MG 1/1/2005 J1800 INJECTION, PROPRANOLOL HCL, UP TO 1 MG 1/1/2005 INJECTION, DROPERIDOL AND FENTANYL CITRATE, UP TO 2 ML J1810 AMPULE 1/1/2005 J1815 INJECTION, INSULIN, PER 5 UNITS 1/1/2005 INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) J1817 PER 50 UNITS 1/1/2007 J1825 INJECTION, INTERFERON BETA-1A, 33 MCG 1/1/2005 INJECTION INTERFERON BETA-1B, 0.25 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER DIRECT SUPERVISION J1830 OF A PHYSICIA 1/1/2005 J1835 INJECTION, ITRACONAZOLE, 50 MG 1/1/2005 J1840 INJECTION, KANAMYCIN SULFATE, UP TO 500 MG 1/1/2005 J1850 INJECTION, KANAMYCIN SULFATE, UP TO 75 MG 1/1/2005 J1885 INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG 1/1/2005 J1890 INJECTION, CEPHALOTHIN SODIUM, UP TO 1 G 1/1/2005 J1931 INJECTION, LARONIDASE, 0.1 MG 1/1/2005 J1940 INJECTION, FUROSEMIDE, UP TO 20 MG 1/1/2005 J1945 INJECTION, LEPIRUDIN, 50 MG 1/1/2006
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER J1950 3.75 MG 1/1/2005 J1955 INJECTION, LEVOCARNITINE, PER 1 G 1/1/2005 J1956 INJECTION, LEVOFLOXACIN, 250 MG 1/1/2005 J1960 INJECTION, LEVORPHANOL TARTRATE, UP TO 2 MG 1/1/2005 J1980 INJECTION, HYOSCYAMINE SULFATE, UP TO 0.25 MG 1/1/2005 J1990 INJECTION, CHLORDIAZEPOXIDE HCL, UP TO 100 MG 1/1/2005 J2001 INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG 1/1/2006 J2010 INJECTION, LINCOMYCIN HCL, UP TO 300 MG 1/1/2005 J2020 INJECTION, LINEZOLID, 200 MG 1/1/2005 J2060 INJECTION, LORAZEPAM, 2 MG 1/1/2005 J2175 INJECTION, MEPERIDINE HCL, PER 100 MG 1/1/2005 J2180 INJECTION, MEPERIDINE AND PROMETHAZINE HCL, UP TO 50 MG 1/1/2005 J2210 INJECTION, METHYLERGONOVINE MALEATE, UP TO 0.2 MG 1/1/2005 J2250 INJECTION, MIDAZOLAM HCL, PER 1 MG 1/1/2005 J2265 INJECTION, MINOCYCLINE HCL, 1 MG 1/1/2012 J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG 1/1/2005 J2271 INJECTION, MORPHINE SULFATE, 100 MG 1/1/2006 INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE J2275 SOLUTION), PER 10 MG 1/1/2005 J2280 INJECTION, MOXIFLOXACIN, 100 MG 1/1/2005 J2300 INJECTION, NALBUPHINE HCL, PER 10 MG 1/1/2007 J2310 INJECTION, NALOXONE HCL, PER 1 MG 1/1/2007 J2320 INJ NANDROLONE DECANOATE TO 1/1/2011 INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR J2353 INJECTION, 1 MG 1/1/2007 INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS J2354 OR INTRAVENOUS INJECTION, 25 MCG 1/1/2005 J2358 INJECTION, OLANZAPINE, LONG-ACTING, 1 MG 1/1/2011 J2360 INJECTION, ORPHENADRINE CITRATE, UP TO 60 MG 1/1/2005 J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML 1/1/2005 J2400 INJECTION, CHLOROPROCAINE HCL, PER 30 ML 1/1/2005 J2426 INJECTION, PALIPERIDONE PALMITATE EXTENDED RELEASE, 1 MG 1/1/2011 J2440 INJECTION, PAPAVERINE HCL, UP TO 60 MG 1/1/2005 J2460 INJECTION, OXYTETRACYCLINE HCL, UP TO 50 MG 1/1/2005 J2501 INJECTION, PARICALCITOL, 1 MCG 1/1/2005 J2504 INJECTION, PEGADEMASE BOVINE, 25 IU 1/1/2006 J2510 INJECTION, PENICILLIN G PROCAINE, AQUEOUS, UP TO 600,000 UNITS 1/1/2005 J2513 INJECTION, PENTASTARCH, 10% SOLUTION, 100 ML 1/1/2006 J2540 INJECTION, PENICILLIN G POTASSIUM, UP TO 600,000 UNITS 1/1/2005 INJECTION, PIPERACILLIN SODIUM/TAZOBACTAM SODIUM, 1 G/0.125 G J2543 (1.125 G) 1/1/2005 J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG 1/1/2005 J2560 INJECTION, PHENOBARBITAL SODIUM, UP TO 120 MG 1/1/2005 J2590 INJECTION, OXYTOCIN, UP TO 10 UNITS 1/1/2005 J2597 INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG 1/1/2005 J2650 INJECTION, PREDNISOLONE ACETATE, UP TO 1 ML 1/1/2005 J2670 INJECTION, TOLAZOLINE HCL, UP TO 25 MG 1/1/2005 J2675 INJ PROGESTERONE PER 50 MG 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE J2680 INJECTION, FLUPHENAZINE DECANOATE, UP TO 25 MG 1/1/2005 J2690 INJECTION, PROCAINAMIDE HCL, UP TO 1 G 1/1/2005 J2700 INJECTION, OXACILLIN SODIUM, UP TO 250 MG 1/1/2005 J2710 INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG 1/1/2005 J2720 INJECTION, PROTAMINE SULFATE, PER 10 MG 1/1/2005 J2725 INJECTION, PROTIRELIN, PER 250 MCG 1/1/2005 J2730 INJECTION, PRALIDOXIME CHLORIDE, UP TO 1 G 1/1/2005 J2760 INJECTION, PHENTOLAMINE MESYLATE, UP TO 5 MG 1/1/2005 J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG 1/1/2005 J2770 INJECTION, QUINUPRISTIN/DALFOPRISTIN, 500 MG (150/350) 1/1/2005 J2780 INJECTION, RANITIDINE HCL, 25 MG 1/1/2005 J2785 INJECTION, REGADENOSON, 0.1 MG 1/1/2009 J2788 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MCG 1/1/2005 J2790 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MCG 1/1/2005 J2794 INJECTION, RISPERIDONE, LONG ACTING, 0.5 MG 1/1/2007 J2795 INJECTION, ROPIVACAINE HCL, 1 MG 1/1/2005 J2800 INJECTION, METHOCARBAMOL, UP TO 10 ML 1/1/2005 J2805 INJECTION, SINCALIDE, 5 MCG 1/1/2006 J2810 INJECTION, THEOPHYLLINE, PER 40 MG 1/1/2005 J2820 INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG 1/1/2005 J2912 INJECTION, SODIUM CHLORIDE, 0.9%, PER 2 ML 1/1/2005 INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 40 J2920 MG 1/1/2005 INJECTION, METHYLPREDNISOLONE SODIUM SUCCINATE, UP TO 125 J2930 MG 1/1/2005 J3000 INJECTION, STREPTOMYCIN, UP TO 1 G 1/1/2005 INJECTION, SUMATRIPTAN SUCCINATE, 6 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT J3030 SUPERVISION OF A PHY 1/1/2007 J3070 INJECTION, PENTAZOCINE, 30 MG 1/1/2005 J3095 INJECTION, TELAVANCIN, 10 MG 1/1/2011 J3100 INJECTION, TENECTEPLASE, 50 MG 1/1/2005 J3105 INJECTION, TERBUTALINE SULFATE, UP TO 1 MG 1/1/2005 J3120 INJECTION, TESTOSTERONE ENANTHATE, UP TO 100 MG 1/1/2005 J3130 INJECTION, TESTOSTERONE ENANTHATE, UP TO 200 MG 1/1/2005 J3140 INJECTION, TESTOSTERONE SUSPENSION, UP TO 50 MG 1/1/2005 J3150 INJECTION, TESTOSTERONE PROPIONATE, UP TO 100 MG 1/1/2005 J3230 INJECTION, CHLORPROMAZINE HCL, UP TO 50 MG 1/1/2005 J3250 INJECTION, TRIMETHOBENZAMIDE HCL, UP TO 200 MG 1/1/2005 J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 MG 1/1/2005 J3280 INJECTION, THIETHYLPERAZINE MALEATE, UP TO 10 MG 1/1/2005 J3301 INJECTION, TRIAMCINOLONE ACETONIDE, PER 10 MG 1/1/2005 J3302 INJECTION, TRIAMCINOLONE DIACETATE, PER 5 MG 1/1/2005 J3305 INJECTION, TRIMETREXATE GLUCORONATE, PER 25 MG 1/1/2005 J3310 INJECTION, PERPHENAZINE, UP TO 5 MG 1/1/2005 J3320 INJECTION, SPECTINOMYCIN DIHYDROCHLORIDE, UP TO 2 G 1/1/2005 J3350 INJECTION, UREA, UP TO 40 G 1/1/2005 J3360 INJECTION, DIAZEPAM, UP TO 5 MG 1/1/2005 J3370 INJECTION, VANCOMYCIN HCL, 500 MG 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE J3400 INJECTION, TRIFLUPROMAZINE HCL, UP TO 20 MG 1/1/2005 J3410 INJECTION, HYDROXYZINE HCL, UP TO 25 MG 1/1/2005 J3411 INJECTION, THIAMINE HCL, 100 MG 1/1/2005 J3415 INJECTION, PYRIDOXINE HCL, 100 MG 1/1/2005 J3420 INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1,000 MCG 1/1/2005 J3430 INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG 1/1/2005 J3465 INJECTION, VORICONAZOLE, 10 MG 1/1/2005 J3470 INJECTION, HYALURONIDASE, UP TO 150 UNITS 1/1/2005 INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1 J3471 USP UNIT (UP TO 999 USP UNITS) 1/1/2006 INJECTION, HYALURONIDASE, OVINE, PRESERVATIVE FREE, PER 1000 J3472 USP UNITS 1/1/2006 J3475 INJECTION, MAGNESIUM SULPHATE, PER 500 MG 1/1/2005 J3480 INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ 1/1/2005 J3485 INJECTION, ZIDOVUDINE, 10 MG 1/1/2005 J3486 INJECTION, ZIPRASIDONE MESYLATE, 10 MG 1/1/2005 J3520 EDETATE DISODIUM, PER 150 MG 1/1/2005 J3530 NASAL VACCINE INHALATION 1/1/2005 J3535 DRUG ADMINISTERED THROUGH A METERED DOSE INHALER 1/1/2005 J7030 INFUSION, NORMAL SALINE SOLUTION, 1,000 CC 1/1/2005 J7040 INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT) 1/1/2005 J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 1/1/2005 J7050 INFUSION, NORMAL SALINE SOLUTION, 250 CC 1/1/2005 J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) 1/1/2005 J7070 INFUSION, D-5-W, 1,000 CC 1/1/2005 J7100 INFUSION, DEXTRAN 40, 500 ML 1/1/2005 J7110 INFUSION, DEXTRAN 75, 500 ML 1/1/2005 J7120 RINGER'S LACTATE INFUSION, UP TO 1,000 CC 1/1/2005 J7130 HYPERTONIC SALINE SOLUTION, 50 OR 100 MEQ, 20 CC VIAL 1/1/2005 J7131 HYPERTONIC SALINE SOLUTION, 1 ML 1/1/2012 J7311 FLUOCINOLONE ACETONIDE, INTRAVITREAL IMPLANT 1/1/2007 HYALURONAN (SODIUM HYALURONATE) OR DERIVATIVE, INTRA- J7319 ARTICULAR INJECTION, PER INJECTION 1/1/2007 J7320 Hylan G-F 20, 16 mg, for intra-articular injection 1/1/2005 J7501 AZATHIOPRINE, PARENTERAL, 100 MG 1/1/2005 J7502 CYCLOSPORINE, ORAL, 100 MG 1/1/2005 LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, J7504 EQUINE, PARENTERAL, 250 MG 1/1/2005 J7505 MUROMONAB-CD3, PARENTERAL, 5 MG 1/1/2005 J7506 PREDNISONE, ORAL, PER 5 MG 1/1/2007 J7510 PREDNISOLONE, ORAL, PER 5 MG 1/1/2007 LYMPHOCYTE IMMUNE GLOBULIN, ANTITHYMOCYTE GLOBULIN, J7511 RABBIT, PARENTERAL, 25 MG 1/1/2005 J7513 DACLIZUMAB, PARENTERAL, 25 MG 1/1/2005 J7516 CYCLOSPORINE, PARENTERAL, 250 MG 1/1/2005 J7525 TACROLIMUS, PARENTERAL, 5 MG 1/1/2005 FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NONCOMPOUNDED, ADMINISTERED THROUGH DME, J7606 UNIT DOSE FORM, 20 1/1/2009
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE ALBUTEROL, INHALATION SOLUTION, ADMINISTERED THROUGH DME, J7611 CONCENTRATED FORM, 1 MG 1/1/2007 ALBUTEROL, INHALATION SOLUTION, ADMINISTERED THROUGH DME, J7613 UNIT DOSE, 1 MG 1/1/2007 ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, NONCOMPOUNDED INHALATION SOLUTION, ADMINISTERED J7620 THROUGH DME 1/1/2006 BUDESONIDE INHALATION SOLUTION, NON-COMPOUNDED, J7626 ADMINISTERED THROUGH DME, UNIT DOSE FORM, UP TO 0.5 MG 1/1/2007 CROMOLYN SODIUM, INHALATION SOLUTION ADMINISTERED J7631 THROUGH DME, UNIT DOSE FORM, PER 10 MG 1/1/2007 ATROPINE, INHALATION SOLUTION ADMINISTERED THROUGH DME, J7636 UNIT DOSE FORM, PER MG 1/1/2007 DEXAMETHASONE, INHALATION SOLUTION ADMINISTERED THROUGH J7638 DME, UNIT DOSE FORM, PER MG 1/1/2007 IPRATROPIUM BROMIDE, INHALATION SOLUTION ADMINISTERED J7644 THROUGH DME, UNIT DOSE FORM, PER MG 1/1/2007 ISOETHARINE HCL, INHALATION SOLUTION ADMINISTERED THROUGH J7649 DME, UNIT DOSE FORM, PER MG 1/1/2007 J7665 MANNITOL, ADMINISTERED THROUGH AN INHALER, 5 MG 1/1/2012 METHACHOLINE CHLORIDE ADMINISTERED AS INHALATION SOLUTION J7674 THROUGH A NEBULIZER, PER 1 MG 4/1/2008 J8540 DEXAMETHASONE, ORAL, 0.25 MG 1/1/2006 J9017 ARSENIC TRIOXIDE, 1 MG (TRISENOX) 1/1/2005 J9020 ASPARAGINASE, 10,000 UNITS 1/1/2005 J9027 INJECTION, CLOFARABINE, 1 MG 1/1/2006 J9050 CARMUSTINE, 100 MG 1/1/2005 J9093 CYCLOPHOSPHAMIDE, LYOPHILIZED, 100 MG 1/1/2005 J9094 CYCLOPHOSPHAMIDE, LYOPHILIZED, 200 MG 1/1/2005 J9098 CYTARABINE LIPOSOME, 10 MG 1/1/2005 J9110 CYTARABINE, 500 MG 1/1/2005 J9151 DAUNORUBICIN CITRATE, LIPOSOMAL FORMULATION, 10 MG 1/1/2005 J9160 DENILEUKIN DIFTITOX, 300 MCG 1/1/2005 J9165 DIETHYLSTILBESTROL DIPHOSPHATE, 250 MG 1/1/2005 J9200 FLOXURIDINE, 500 MG 1/1/2005 J9211 IDARUBICIN HCL, 5 MG 1/1/2005 J9212 INJECTION, INTERFERON ALFACON-1, RECOMBINANT, 1 MCG 1/1/2005 J9215 INTERFERON ALFA-N3, (HUMAN LEUKOCYTE DERIVED), 250,000 IU 1/1/2005 J9225 HISTRELIN IMPLANT, 50 MG 1/1/2006 J9230 MECHLORETHAMINE HCL, (NITROGEN MUSTARD), 10 MG 1/1/2005 J9245 INJECTION, MELPHALAN HCL, 50 MG 1/1/2005 J9250 METHOTREXATE SODIUM, 5 MG 1/1/2005 J9260 METHOTREXATE SODIUM, 50 MG 1/1/2005 J9266 PEGASPARGASE, PER SINGLE DOSE VIAL 1/1/2005 J9268 PENTOSTATIN, PER 10 MG 1/1/2005 J9300 GEMTUZUMAB OZOGAMICIN, 5 MG 1/1/2005 J9320 STREPTOZOCIN, 1 G 1/1/2005 J9340 THIOTEPA, 15 MG 1/1/2005 J9357 VALRUBICIN, INTRAVESICAL, 200 MG 1/1/2005
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE J9380 VINCRISTINE SULFATE, 5 MG 1/1/2005 J9600 PORFIMER SODIUM, 75 MG 1/1/2005 BRIEF OFFICE VISIT FOR THE SOLE PURPOSE OF MONITORING OR CHANGING DRUG PRESCRIPTIONS USED IN THE TREATMENT OF M0064 MENTAL PSYCHONEUROTI 1/1/2007 SCREENING PAPANICOLAOU SMEAR, CERVICAL OR VAGINAL, UP TO P3000 THREE SMEARS, BY TECHNICIAN UNDER PHYSICIAN SUPERVISION 1/1/2005 SCREENING PAPANICOLAOU SMEAR, CERVICAL OR VAGINAL, UP TO P3001 THREE SMEARS, REQUIRING INTERPRETATION BY PHYSICIAN 1/1/2005 P7001 CULTURE, BACTERIAL, URINE; QUANTITATIVE, SENSITIVITY STUDY 1/1/2005 CATHETERIZATION FOR COLLECTION OF SPECIMEN, SINGLE PATIENT, P9612 ALL PLACES OF SERVICE 1/1/2005 SCREENING PAPANICOLAOU SMEAR; OBTAINING, PREPARING AND Q0091 CONVEYANCE OF CERVICAL OR VAGINAL SMEAR TO LABORATORY 1/1/2005 WET MOUNTS, INCLUDING PREPARATIONS OF VAGINAL, CERVICAL OR Q0111 SKIN SPECIMENS 1/1/2005 Q0113 PINWORM EXAMINATION 1/1/2005 Q0114 FERN TEST 1/1/2005 POST-COITAL DIRECT, QUALITATIVE EXAMINATIONS OF VAGINAL OR Q0115 CERVICAL MUCOUS 7/1/2007 INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY Q0138 ANEMIA, 1 MG (NON-ESRD USE) 4/1/2011 INFLUENZA VACCINE, RECOMBINANT HEMAGGLUTININ ANTIGENS, Q2033 FOR INTRAMUSCULAR USE (FLUBLOK) 7/1/2013 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, FOR INTRAMUSCULAR USE Q2034 (AGRIFLU) 7/1/2012 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR Q2035 USE (AFLURIA) 1/1/2011 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR Q2036 USE (FLULAVAL) 1/1/2011 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR Q2037 USE (FLUVIRIN) 1/1/2011 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR Q2038 USE (FLUZONE) 1/1/2011 INFLUENZA VIRUS VACCINE, SPLIT VIRUS, WHEN ADMINISTERED TO INDIVIDUALS 3 YEARS OF AGE AND OLDER, FOR INTRAMUSCULAR Q2039 USE (NOT OTHERW 1/1/2011 Q2042 HYDROXYPROGESTERONE CAPROATE 7/1/2011 Q4049 FINGER SPLINT, STATIC 7/1/2007 INJECTION, RHO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), Q4089 INTRAMUSCULAR OR INTRAVENOUS, 100 IU 7/1/2007 INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), Q4090 INTRAMUSCULAR, 0.5 ML 7/1/2007 ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON- Q4093 COMPOUNDED, ADMINIST 1/1/2007
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HEALTHSPAN AUTO PAY LIST HCPCS EFFECTIVE Code PROCEDURE DESCRIPTION DATE ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON- Q4094 COMPOUNDED, ADMINIST 1/1/2007 LOW OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE Q9945 CONCENTRATION, PER ML 1/1/2006 LOW OSMOLAR CONTRAST MATERIAL, 150-199 MG/ML IODINE Q9946 CONCENTRATION, PER ML 1/1/2006 LOW OSMOLAR CONTRAST MATERIAL, 200-249 MG/ML IODINE Q9947 CONCENTRATION, PER ML 1/1/2006 LOW OSMOLAR CONTRAST MATERIAL, 250-299 MG/ML IODINE Q9948 CONCENTRATION, PER ML 1/1/2006 LOW OSMOLAR CONTRAST MATERIAL, 300-349 MG/ML IODINE Q9949 CONCENTRATION, PER ML 1/1/2006 LOW OSMOLAR CONTRAST MATERIAL, 350-399 MG/ML IODINE Q9950 CONCENTRATION, PER ML 1/1/2006 LOW OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML Q9951 IODINE CONCENTRATION, PER ML 1/1/2006 INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST Q9952 AGENT, PER ML 1/1/2006 Q9957 INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML 3/1/2012 HIGH OSMOLAR CONTRAST MATERIAL, 150-199 MG/ML IODINE Q9959 CONCENTRATION, PER ML 1/1/2005 HIGH OSMOLAR CONTRAST MATERIAL, 200-249 MG/ML IODINE Q9960 CONCENTRATION, PER ML 1/1/2005 HIGH OSMOLAR CONTRAST MATERIAL, 250-299 MG/ML IODINE Q9961 CONCENTRATION, PER ML 1/1/2005 HIGH OSMOLAR CONTRAST MATERIAL, 300-349 MG/ML IODINE Q9962 CONCENTRATION, PER ML 1/1/2005 HIGH OSMOLAR CONTRAST MATERIAL, 350-399 MG/ML IODINE Q9963 CONCENTRATION, PER ML 1/1/2005 HIGH OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML Q9964 IODONE CONCENTRATION, PER ML 1/1/2005 LOW OSMOLAR CONTRAST MATERIAL, 100-199 MG/ML IODINE Q9965 CONCENTRATION, PER ML 1/1/2008 LOW OSMOLAR CONTRAST MATERIAL, 200-299 MG/ML IODINE Q9966 CONCENTRATION, PER ML 1/1/2008 LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE Q9967 CONCENTRATION, PER ML 1/1/2008 INJECTION, NONRADIOACTIVE, NONCONTRAST, VISUALIZATION Q9968 ADJUNCT (E.G., METHYLENE BLUE, ISOSULFAN BLUE), 1 MG 1/1/2013 S3721 PROSTATE CANCER ANTIGEN 3 (PCA3) TESTING 4/1/2012 V5364 DYSPHAGIA SCREENING 1/1/2005
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