Coverage Policy Manual
Policy #: 2022013
Category: Medicine
Initiated: March 2022
Last Review: March 2023
  Medical Technology Assessment, Non-Covered Services
Description:
The services listed in this policy do not meet Arkansas Blue Cross Blue Shield primary coverage criteria.  For member benefit certificates (contracts) without primary coverage criteria, these services are considered investigational. Definitions of Primary Coverage Criteria can be found in the member’s benefit certificate.
Policy/
Coverage:
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Category III CPT Codes
ALL category III CPT Codes are non-covered unless the code is explicitly addressed as a covered service in an Arkansas Blue Cross Medical Coverage Policy. If there is no associated policy, the code is non-covered.
 
Current Procedural Terminology (CPT), the official code book with rules and guidelines from the American Medical Association’s CPT editorial panel, includes a section of Category III CPT codes. Category III codes are temporary codes created to identify emerging technology services and procedures.
 
Unlike unlisted or deleted codes, the Category III codes allow data collection for specific emerging technology services. If a Category III code is available, providers must use that code instead of an unlisted or deleted Category I code. The services or procedures represented by Category III codes may not have FDA approval, may not be performed by many health care professionals across the country, and the service or procedure may not have proven clinical efficacy.
 
Claims filed for services using Category III codes will be denied unless the code is addressed as a covered service in an Arkansas Blue Cross Medical Coverage Policy.
 
Non-covered CPT Codes and Descriptions
 
The following CPT codes do not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes or are investigational for contracts without primary coverage criteria.
 
CPT Code and Description
 
0303U Hematology, red blood cell (RBC) adhesion to endothelial/subendothelial adhesion molecules, functional assessment, whole blood, with algorithmic analysis and result reported as an RBC adhesion index; hypoxic
 
0304U Hematology, red blood cell (RBC) adhesion to endothelial/subendothelial adhesion molecules, functional assessment, whole blood, with algorithmic analysis and result reported as an RBC adhesion index; normoxic
 
0305U Hematology, red blood cell (RBC) functionality and deformity as a function of shear stress, whole blood, reported as a maximum elongation index
 
0308U  Cardiology (coronary artery disease [CAD]), analysis of 3 proteins (high sensitivity [hs] troponin, diponectin, and kidney injury molecule-1 [KIM-1]), plasma, algorithm reported as a risk score for obstructive CAD
 
0309U Cardiology (cardiovascular disease), analysis of 4 proteins (NT-proBNP, osteopontin, tissue inhibitor of metalloproteinase-1 [TIMP-1], and kidney injury molecule-1 [KIM-1]), plasma, algorithm reported as a risk score for major adverse cardiac event
 
0310U Pediatrics (vasculitis, Kawasaki disease [KD]), analysis of 3 biomarkers (NTproBNP, C-reactive protein, and T-uptake), plasma, algorithm reported as a risk score for KD
 
0311U Infectious disease (bacterial), quantitative antimicrobial susceptibility reported as phenotypic minimum inhibitory concentration (MIC)–based antimicrobial susceptibility for each organisms identified
 
0316U Borrelia burgdorferi (Lyme disease), OspA protein evaluation, urine
 
0322U Neurology (autism spectrum disorder [ASD]), quantitative measurements of 14 acyl carnitines and microbiome-derived metabolites, liquid chromatography with tandem mass spectrometry (LC-MS/MS), plasma, results reported as negative or positive for risk of metabolic subtypes associated with ASD (eff. 10/2022)
 
0324U  Oncology (ovarian), spheroid cell culture, four drug panel (carboplatin, doxorubicin, gemcitabine, paclitaxel), tumor chemotherapy response prediction for each drug
 
0325U Oncology (ovarian), spheroid cell culture, poly (ADP-ribose) polymerase (PARP) inhibitors (niraparib, olaparib, rucaparib, velparib), tumor response prediction for each drug
 
0332U Oncology (pan-tumor), genetic profiling of 8 DNA-regulatory (epigenetic) markers by quantitative polymerase chain reaction (qPCR), whole blood, reported as a high or low probability of responding to immune checkpoint–inhibitor therapy (eff. 10/2022)
 
0333U  Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in highrisk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement of serum of AFP/AFP-L3 and oncoprotein des-gammacarboxy-prothrombin (DCP), algorithm reported as normal or abnormal result
 
0341U Fetal aneuploidy DNA sequencing comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism, and segmental aneuploid (eff. 10/2022)
 
0342U Oncology (pancreatic cancer), multiplex immunoassay of C5, C4, cystatin C, factor B, osteoprotegerin (OPG), gelsolin, IGFBP3, CA125 and multiplex electrochemiluminescent immunoassay (ECLIA) for CA19-9, serum, diagnostic algorithm reported qualitatively as positive, negative, or borderline (eff. 10/2022)
 
0346U Beta amyloid, Aβ40 and Aβ42 by liquid chromatography with tandem mass spectrometry (LC-MS/MS), ratio, plasma (eff. 10/2022)
 
0351U Infectious disease (bacterial or viral), biochemical assays, tumor necrosis factor related apoptosis-inducing ligand (TRAIL), interferon gamma-induced protein-10 (IP10), and C-reactive protein, serum, algorithm reported as likelihood of bacterial infection. (eff. 10/2022)
  
33900 Unilateral percutaneous pulmonary artery revascularization, initial; normal native connections
 
  
33901 Bilateral percutaneous pulmonary artery revascularization, initial;  normal native connections   
 
95919 Quantitative pupillometry with interpretation and report  
 
0355U APOL1 (apolipoprotein L1) (eg, chronic kidney disease), risk variants (G1, G2)
 
0356U Oncology (oropharyngeal), evaluation of 17 DNA biomarkers using droplet digital PCR (ddPCR), cell-free DNA, algorithm reported as a prognostic risk score for cancer recurrence
 
0357U Oncology (melanoma), artificial intelligence (AI)-enabled quantitative mass spectrometry analysis of 142 unique pairs of glycopeptide and product fragments, plasma, prognostic, and predictive algorithm reported  as likely, unlikely, or uncertain benefit from immunotherapy agents
 
0359U Oncology (prostate cancer), analysis of all prostate-specific antigen (PSA) structural isoforms by phase separation and immunoassay, plasma, algorithm reports risk of cancer
 
0360U Oncology (lung), enzyme-linked immunosorbent assay (ELISA) of 7 autoantibodies (p53, NY-ESO-1, CAGE, GBU4-5, SOX2, MAGE A4, and HuD), plasma, algorithm reported as a categorical result for risk of malignancy
 
0361U Neurofilament light chain, digital immunoassay, plasma, quantitative
  
0363U Oncology (urothelial), mRNA, geneexpression profiling by real-time quantitative PCR of 5 genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm incorporates age, sex, smoking history, and macrohematuria frequency, reported as a risk score for having urothelial carcinoma
 
57465 Computer aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect (List separately in addition to code for primary procedure)
 
80220 Hydroxychloroquine
 
82653 Elastase, pancreatic (EL 1), fecal; quantitative
 
83529 Interleukin 6 (IL 6)
 
 
Non-Covered HCPCS Codes and Code Descriptions
 
The following HCPCS codes do not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes or are investigational for contracts without primary coverage criteria.
 
HCPCS Codes   Code Description
A4563 Rectal control system for vaginal insertion, for long term use, includes pump and all
supplies and accessories, any type each
 
E0183 Powered pressure reducing underlay/pad, alternating, with pump, includes heavy duty (eff. 10/2022)
 
E0711  Upper extremity medical tubing/lines enclosure or covering device, restricts elbow range of motion
 
E1629 Tablo hemodialysis system for the billable dialysis service  
 
J0591 Injection, deoxycholic acid, 1 mg
 
K1004 Low frequency ultrasonic diathermy treatment device for home use, includes all
components and accessories
 
K1021 Exsufflation belt, includes all supplies and accessories
 
K1026 Mechanical allergen particle barrier/inhalation filter, cream, nasal, topical
 
K1027 Oral device/appliance used to reduce upper airway collapsibility, without fixed
mechanical hinge, custom fabricated, includes fitting and adjustment
 
K1030 External recharging system for battery (internal) for use with implanted cardiac contractility modulation generator, replacement only
 
K1031 Non-pneumatic compression controller without calibrated gradient pressure
 
K1032  Non-pneumatic sequential compression garment, full leg
 
K1033 Non-pneumatic sequential compression garment, half leg
 
S9117 Back school, per visit
 
V2525 Contact lens, hydrophilic, dual focus, per lens
Rationale:
 
CPT/HCPCS:
0042TCerebral perfusion analysis using computed tomography with contrast administration, including post processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time
0054TComputer assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on fluoroscopic images (List separately in addition to code for primary procedure)
0055TComputer assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on CT/MRI images (List separately in addition to code for primary procedure)
0075TTranscatheter placement of extracranial vertebral artery stent(s), including radiologic supervision and interpretation, open or percutaneous; initial vessel
0076TTranscatheter placement of extracranial vertebral artery stent(s), including radiologic supervision and interpretation, open or percutaneous; each additional vessel (List separately in addition to code for primary procedure)
0095TRemoval of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)
0098TRevision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)
0101TExtracorporeal shock wave involving musculoskeletal system, not otherwise specified
0102TExtracorporeal shock wave, performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle
0106TQuantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation
0107TQuantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation
0108TQuantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia
0109TQuantitative sensory testing (QST), testing and interpretation per extremity; using heat pain stimuli to assess small nerve fiber sensation and hyperalgesia
0110TQuantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation
0163TTotal disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (List separately in addition to code for primary procedure)
0164TRemoval of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure)
0165TRevision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure)
0174TComputer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation (List separately in addition to code for primary procedure)
0175TComputer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation
0198TMeasurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report
0200TPercutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed
0201TPercutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed
0202TPosterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine
0207TEvacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral
0208TPure tone audiometry (threshold), automated; air only
0209TPure tone audiometry (threshold), automated; air and bone
0210TSpeech audiometry threshold, automated;
0211TSpeech audiometry threshold, automated; with speech recognition
0212TComprehensive audiometry threshold evaluation and speech recognition (0209T, 0211T combined), automated
0213TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level
0214TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure)
0215TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)
0216TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level
0217TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure)
0218TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)
0219TPlacement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical
0220TPlacement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic
0221TPlacement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar
0222TPlacement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (List separately in addition to code for primary procedure)
0232TInjection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed
0234TTransluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; renal artery
0235TTransluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; visceral artery (except renal), each vessel
0236TTransluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; abdominal aorta
0237TTransluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; brachiocephalic trunk and branches, each vessel
0238TTransluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel
0263TIntramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest
0264TIntramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure excluding bone marrow harvest
0265TIntramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy
0266TImplantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra operative interrogation, programming, and repositioning, when performed)
0267TImplantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra operative interrogation, programming, and repositioning, when performed)
0268TImplantation or replacement of carotid sinus baroreflex activation device; pulse generator only (includes intra operative interrogation, programming, and repositioning, when performed)
0269TRevision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra operative interrogation, programming, and repositioning, when performed)
0270TRevision or removal of carotid sinus baroreflex activation device; lead only, unilateral (includes intra operative interrogation, programming, and repositioning, when performed)
0271TRevision or removal of carotid sinus baroreflex activation device; pulse generator only (includes intra operative interrogation, programming, and repositioning, when performed)
0272TInterrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (eg, battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day);
0273TInterrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (eg, battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); with programming
0274TPercutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic
0275TPercutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar
0278TTranscutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes)
0303UHematology, red blood cell (RBC) adhesion to endothelial/subendothelial adhesion molecules, functional assessment, whole blood, with algorithmic analysis and result reported as an RBC adhesion index; hypoxic
0304UHematology, red blood cell (RBC) adhesion to endothelial/subendothelial adhesion molecules, functional assessment, whole blood, with algorithmic analysis and result reported as an RBC adhesion index; normoxic
0305UHematology, red blood cell (RBC) functionality and deformity as a function of shear stress, whole blood, reported as a maximum elongation index
0308TInsertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis
0308UCardiology (coronary artery disease [CAD]), analysis of 3 proteins (high sensitivity [hs] troponin, diponectin, and kidney injury molecule-1 [KIM-1]), plasma, algorithm reported as a risk score for obstructive CAD
0309UCardiology (cardiovascular disease), analysis of 4 proteins (NT-proBNP, osteopontin, tissue inhibitor of metalloproteinase-1 [TIMP-1], and kidney injury molecule-1 [KIM-1]), plasma, algorithm reported as a risk score for major adverse cardiac event
0310UPediatrics (vasculitis, Kawasaki disease [KD]), analysis of 3 biomarkers (NTproBNP, C-reactive protein, and T-uptake), plasma, algorithm reported as a risk score for KD
0311UInfectious disease (bacterial), quantitative antimicrobial susceptibility reported as phenotypic minimum inhibitory concentration (MIC)–based antimicrobial susceptibility for each organisms identified
0312TVagus nerve blocking therapy (morbid obesity); laparoscopic implantation of neurostimulator electrode array, anterior and posterior vagal trunks adjacent to esophagogastric junction (EGJ), with implantation of pulse generator, includes programming
0313TVagus nerve blocking therapy (morbid obesity); laparoscopic revision or replacement of vagal trunk neurostimulator electrode array, including connection to existing pulse generator
0314TVagus nerve blocking therapy (morbid obesity); laparoscopic removal of vagal trunk neurostimulator electrode array and pulse generator
0315TVagus nerve blocking therapy (morbid obesity); removal of pulse generator
0316TVagus nerve blocking therapy (morbid obesity); replacement of pulse generator
0316UBorrelia burgdorferi (Lyme disease), OspA protein evaluation, urine
0317TVagus nerve blocking therapy (morbid obesity); neurostimulator pulse generator electronic analysis, includes reprogramming when performed
0322UNeurology (autism spectrum disorder [ASD]), quantitative measurements of 14 acyl carnitines and microbiome-derived metabolites, liquid chromatography with tandem mass spectrometry (LC-MS/MS), plasma, results reported as negative or positive for risk of metabolic subtypes associated with ASD
0324UOncology (ovarian), spheroid cell culture, four drug panel (carboplatin, doxorubicin, gemcitabine, paclitaxel), tumor chemotherapy response prediction for each drug
0325UOncology (ovarian), spheroid cell culture, poly (ADP-ribose) polymerase (PARP) inhibitors (niraparib, olaparib, rucaparib, velparib), tumor response prediction for each drug
0329TMonitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report
0330TTear film imaging, unilateral or bilateral, with interpretation and report
0331TMyocardial sympathetic innervation imaging, planar qualitative and quantitative assessment;
0332TMyocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT
0332UOncology (pan-tumor), genetic profiling of 8 DNA-regulatory (epigenetic) markers by quantitative polymerase chain reaction (qPCR), whole blood, reported as a high or low probability of responding to immune checkpoint–inhibitor therapy
0333TVisual evoked potential, screening of visual acuity, automated, with report
0333UOncology (liver), surveillance for hepatocellular carcinoma (HCC) in highrisk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement of serum of AFP/AFP-L3 and oncoprotein des-gammacarboxy-prothrombin (DCP), algorithm reported as normal or abnormal result
0335TInsertion of sinus tarsi implant
0338TTranscatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral
0339TTranscatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral
0341UFetal aneuploidy DNA sequencing comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism, and segmental aneuploid
0342TTherapeutic apheresis with selective HDL delipidation and plasma reinfusion
0342UOncology (pancreatic cancer), multiplex immunoassay of C5, C4, cystatin C, factor B, osteoprotegerin (OPG), gelsolin, IGFBP3, CA125 and multiplex electrochemiluminescent immunoassay (ECLIA) for CA19-9, serum, diagnostic algorithm reported qualitatively as positive, negative, or borderline
0345TTranscatheter mitral valve repair percutaneous approach via the coronary sinus
0346UBeta amyloid, Aß40 and Aß42 by liquid chromatography with tandem mass spectrometry (LC-MS/MS), ratio, plasma
0347TPlacement of interstitial device(s) in bone for radiostereometric analysis (RSA)
0348TRadiologic examination, radiostereometric analysis (RSA); spine, (includes cervical, thoracic and lumbosacral, when performed)
0349TRadiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow, and wrist, when performed)
0350TRadiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee, and ankle, when performed)
0351TOptical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative
0351UInfectious disease (bacterial or viral), biochemical assays, tumor necrosis factorrelated apoptosis-inducing ligand (TRAIL), interferon gamma-induced protein-10 (IP10), and C-reactive protein, serum, algorithm reported as likelihood of bacterial infection.
0352TOptical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real time or referred
0353TOptical coherence tomography of breast, surgical cavity; real time intraoperative
0354TOptical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred
0355UAPOL1 (apolipoprotein L1) (eg, chronic kidney disease), risk variants (G1, G2)
0356UOncology (oropharyngeal), evaluation of 17 DNA biomarkers using droplet digital PCR (ddPCR), cell-free DNA, algorithm reported as a prognostic risk score for cancer recurrence
0357UOncology (melanoma), artificial intelligence (AI)-enabled quantitative mass spectrometry analysis of 142 unique pairs of glycopeptide and product fragments, plasma, prognostic, and predictive algorithm reported as likely, unlikely, or uncertain benefit f
0358TBioelectrical impedance analysis whole body composition assessment, with interpretation and report
0359UOncology (prostate cancer), analysis of all prostate-specific antigen (PSA) structural isoforms by phase separation and immunoassay, plasma, algorithm reports risk of cancer
0360UOncology (lung), enzyme-linked immunosorbent assay (ELISA) of 7 autoantibodies (p53, NY-ESO-1, CAGE, GBU4-5, SOX2, MAGE A4, and HuD), plasma, algorithm reported as a categorical result for risk of malignancy
0361UNeurofilament light chain, digital immunoassay, plasma, quantitative
0363UOncology (urothelial), mRNA, geneexpression profiling by real-time quantitative PCR of 5 genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm incorporates age, sex, smoking history, and macrohematuria frequency, reported as a ri
0365UOncology (bladder), analysis of 10 protein biomarkers (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1 and VEGFA) by immunoassays, urine, algorithm reported as a probability of bladder cancer
0366UOncology (bladder), analysis of 10 protein biomarkers (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1 and VEGFA) by immunoassays, urine, algorithm reported as a probability of recurrent bladder cancer
0367UOncology (bladder), analysis of 10 protein biomarkers (A1AT, ANG, APOE, CA9, IL8, MMP9, MMP10, PAI1, SDC1 and VEGFA) by immunoassays, urine, diagnostic algorithm reported as a risk score for probability of rapid recurrence of recurrent or persistent cancer following transurethral resection
0375UOncology (ovarian), biochemical assays of 7 proteins (follicle stimulating hormone, human epididymis protein 4, apolipoprotein A-1, transferrin, beta-2 macroglobulin, prealbumin [ie, transthyretin], and cancer antigen 125), algorithm reported as ovarian cancer risk score
0378TVisual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional
0378URFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab
0379TVisual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional
0381UMaple syrup urine disease monitoring by patient-collected blood card sample, quantitative measurement of alloisoleucine, leucine, isoleucine, and valine, liquid chromatography with tandem mass spectrometry (LC-MS/MS)
0382UHyperphenylalaninemia monitoring by patient-collected blood card sample, quantitative measurement of phenylalanine and tyrosine, liquid chromatography with tandem mass spectrometry (LC-MS/MS)
0383UTyrosinemia type I monitoring by patient-collected blood card sample, quantitative measurement of tyrosine, phenylalanine, methionine, succinylacetone, nitisinone, liquid chromatography with tandem mass spectrometry (LC-MS/MS)
0385UNephrology (chronic kidney disease), apolipoprotein A4 (ApoA4), CD5 antigen-like (CD5L), and insulin-like growth factor binding protein 3 (IGFBP3) by enzyme-linked immunoassay (ELISA), plasma, algorithm combining results with HDL, estimated glomerular filtration rate (GFR) and clinical data reported as a risk score for developing diabetic kidney disease
0394THigh dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed
0395THigh dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed
0397TEndoscopic retrograde cholangiopancreatography (ERCP), with optical endomicroscopy (List separately in addition to code for primary procedure)
0403TPreventive behavior change, intensive program of prevention of diabetes using a standardized diabetes prevention program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day
0404TTranscervical uterine fibroid(s) ablation with ultrasound guidance, radiofrequency
0408TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes
0409TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only
0410TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only
0411TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only
0412TRemoval of permanent cardiac contractility modulation system; pulse generator only
0413TRemoval of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular)
0414TRemoval and replacement of permanent cardiac contractility modulation system pulse generator only
0415TRepositioning of previously implanted cardiac contractility modulation transvenous electrode (atrial or ventricular lead)
0416TRelocation of skin pocket for implanted cardiac contractility modulation pulse generator
0417TProgramming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation system
0418TInterrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contractility modulation system
0419TDestruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); face, head and neck, greater than 50 neurofibromas
0420TDestruction of neurofibroma, extensive (cutaneous, dermal extending into subcutaneous); trunk and extremities, extensive, greater than 100 neurofibromas
0421TTransurethral waterjet ablation of prostate, including control of post operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)
0422TTactile breast imaging by computer aided tactile sensors, unilateral or bilateral
0424TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator)
0425TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; sensing lead only
0426TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; stimulation lead only
0427TInsertion or replacement of neurostimulator system for treatment of central sleep apnea; pulse generator only
0428TRemoval of neurostimulator system for treatment of central sleep apnea; pulse generator only
0429TRemoval of neurostimulator system for treatment of central sleep apnea; sensing lead only
0430TRemoval of neurostimulator system for treatment of central sleep apnea; stimulation lead only
0431TRemoval and replacement of neurostimulator system for treatment of central sleep apnea, pulse generator only
0432TRepositioning of neurostimulator system for treatment of central sleep apnea; stimulation lead only
0433TRepositioning of neurostimulator system for treatment of central sleep apnea; sensing lead only
0434TInterrogation device evaluation implanted neurostimulator pulse generator system for central sleep apnea
0435TProgramming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; single session
0436TProgramming device evaluation of implanted neurostimulator pulse generator system for central sleep apnea; during sleep study
0437TImplantation of non biologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall (List separately in addition to code for primary procedure)
0439TMyocardial contrast perfusion echocardiography, at rest or with stress, for assessment of myocardial ischemia or viability (List separately in addition to code for primary procedure)
0440TAblation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve
0441TAblation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve
0442TAblation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve)
0443TReal time spectral analysis of prostate tissue by fluorescence spectroscopy, including imaging guidance (List separately in addition to code for primary procedure)
0444TInitial placement of a drug eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral
0445TSubsequent placement of a drug eluting ocular insert under one or more eyelids, including re training, and removal of existing insert, unilateral or bilateral
0446TCreation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training
0447TRemoval of implantable interstitial glucose sensor from subcutaneous pocket via incision
0448TRemoval of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation
0464TVisual evoked potential, testing for glaucoma, with interpretation and report
0465TSuprachoroidal injection of a pharmacologic agent (does not include supply of medication)
0469TRetinal polarization scan, ocular screening with on site automated results, bilateral
0470TOptical coherence tomography (OCT) for microstructural and morphological imaging of skin, image acquisition, interpretation, and report; first lesion
0471TOptical coherence tomography (OCT) for microstructural and morphological imaging of skin, image acquisition, interpretation, and report; each additional lesion (List separately in addition to code for primary procedure)
0475TRecording of fetal magnetic cardiac signal using at least 3 channels; patient recording and storage, data scanning with signal extraction, technical analysis and result, as well as supervision, review, and interpretation of report by a physician or other qualified health care professional
0476TRecording of fetal magnetic cardiac signal using at least 3 channels; patient recording, data scanning, with raw electronic signal transfer of data and storage
0477TRecording of fetal magnetic cardiac signal using at least 3 channels; signal extraction, technical analysis, and result
0478TRecording of fetal magnetic cardiac signal using at least 3 channels; review, interpretation, report by physician or other qualified health care professional
0481TInjection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed
0483TTranscatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed
0484TTranscatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical)
0485TOptical coherence tomography (OCT) of middle ear, with interpretation and report; unilateral
0486TOptical coherence tomography (OCT) of middle ear, with interpretation and report; bilateral
0487TBiomechanical mapping, transvaginal, with report
0488TPreventive behavior change, online/electronic structured intensive program for prevention of diabetes using a standardized diabetes prevention program curriculum, provided to an individual, per 30 days
0489TAutologous adipose derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non viable cells and debris, determination of concentration and dilution of regenerative cells
0490TAutologous adipose derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands
0491TAblative laser treatment, non contact, full field and fractional ablation, open wound, per day, total treatment surface area; first 20 sq cm or less
0492TAblative laser treatment, non contact, full field and fractional ablation, open wound, per day, total treatment surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)
0493TContact near infrared spectroscopy studies of lower extremity wounds (eg, for oxyhemoglobin measurement)
0494TSurgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion system, and cold preservation of the allograft prior to implantation, when performed
0495TInitiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; first two hours in sterile field
0496TInitiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; each additional hour (List separately in addition to code for primary procedure)
0497TExternal patient activated, physician or other qualified health care professional prescribed, electrocardiographic rhythm derived event recorder without 24 hour attended monitoring; in office connection
0498TExternal patient activated, physician or other qualified health care professional prescribed, electrocardiographic rhythm derived event recorder without 24 hour attended monitoring; review and interpretation by a physician or other qualified health care professional per 30 days with at least one patient generated triggered event
0499TCystourethroscopy, with mechanical dilation and urethral therapeutic drug delivery for urethral stricture or stenosis, including fluoroscopy, when performed
0500TInfectious agent detection by nucleic acid (DNA or RNA), Human Papillomavirus (HPV) for five or more separately reported high risk HPV types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (ie, genotyping)
0505TEndovenous femoral popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion
0506TMacular pigment optical density measurement by heterochromatic flicker photometry, unilateral or bilateral, with interpretation and report
0507TNear infrared dual imaging (ie, simultaneous reflective and transilluminated light) of meibomian glands, unilateral or bilateral, with interpretation and report
0508TPulse echo ultrasound bone density measurement resulting in indicator of axial bone mineral density, tibia
0509TElectroretinography (ERG) with interpretation and report, pattern (PERG)
0510TRemoval of sinus tarsi implant
0511TRemoval and reinsertion of sinus tarsi implant
0512TExtracorporeal shock wave for integumentary wound healing, including topical application and dressing care; initial wound
0513TExtracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; each additional wound (List separately in addition to code for primary procedure)
0514TIntraoperative visual axis identification using patient fixation (List separately in addition to code for primary procedure)
0515TInsertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; complete system (includes electrode and generator [transmitter and battery])
0516TInsertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; electrode only
0517TInsertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; pulse generator component(s) (battery and/or transmitter) only
0518TRemoval of only pulse generator component(s) (battery and/or transmitter) of wireless cardiac stimulator for left ventricular pacing
0519TRemoval and replacement of wireless cardiac stimulator for left ventricular pacing; pulse generator component(s) (battery and/or transmitter)
0520TRemoval and replacement of wireless cardiac stimulator for left ventricular pacing; pulse generator component(s) (battery and/or transmitter), including placement of a new electrode
0521TInterrogation device evaluation (in person) with analysis, review and report, includes connection, recording, and disconnection per patient encounter, wireless cardiac stimulator for left ventricular pacing
0522TProgramming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, wireless cardiac stimulator for left ventricular pacing
0523TIntraprocedural coronary fractional flow reserve (FFR) with 3D functional mapping of color coded FFR values for the coronary tree, derived from coronary angiogram data, for real time review and interpretation of possible atherosclerotic stenosis(es) intervention (List separately in addition to code for primary procedure)
0524TEndovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring
0525TInsertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; complete system (electrode and implantable monitor)
0526TInsertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; electrode only
0527TInsertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable monitor only
0528TProgramming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report
0529TInterrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report
0530TRemoval of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor)
0531TRemoval of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only
0532TRemoval of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only
0533TContinuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes set up, patient training, configuration of monitor, data upload, analysis and initial report configuration, download review, interpretation and report
0534TContinuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; set up, patient training, configuration of monitor
0535TContinuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration
0536TContinuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report
0541TMyocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic field time series images, quantitative analysis of magnetic dipoles, machine learning derived clinical scoring, and automated report generation, single study;
0542TMyocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic field time series images, quantitative analysis of magnetic dipoles, machine learning derived clinical scoring, and automated report generation, single study; interpretation and report
0543TTransapical mitral valve repair, including transthoracic echocardiography, when performed, with placement of artificial chordae tendineae
0544TTranscatheter mitral valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach including transseptal puncture
0545TTranscatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach
0546TRadiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report
0547TBone material quality testing by microindentation(s) of the tibia(s), with results reported as a score
0553TPercutaneous transcatheter placement of iliac arteriovenous anastomosis implant, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention
0554TBone strength and fracture risk using finite element analysis of functional data and bone mineral density utilizing data from a computed tomography scan; retrieval and transmission of the scan data, assessment of bone strength and fracture risk and bone mineral density, interpretation and report
0555TBone strength and fracture risk using finite element analysis of functional data and bone mineral density utilizing data from a computed tomography scan; retrieval and transmission of the scan data
0556TBone strength and fracture risk using finite element analysis of functional data and bone mineral density utilizing data from a computed tomography scan; assessment of bone strength and fracture risk and bone mineral density
0557TBone strength and fracture risk using finite element analysis of functional data and bone mineral density utilizing data from a computed tomography scan; interpretation and report
0558TComputed tomography scan taken for the purpose of biomechanical computed tomography analysis
0559TAnatomic model 3D printed from image data set(s); first individually prepared and processed component of an anatomic structure
0560TAnatomic model 3D printed from image data set(s); each additional individually prepared and processed component of an anatomic structure (List separately in addition to code for primary procedure)
0561TAnatomic guide 3D printed and designed from image data set(s); first anatomic guide
0562TAnatomic guide 3D printed and designed from image data set(s); each additional anatomic guide (List separately in addition to code for primary procedure)
0563TEvacuation of meibomian glands, using heat delivered through wearable, open eye eyelid treatment devices and manual gland expression, bilateral
0564TOncology, chemotherapeutic drug cytotoxicity assay of cancer stem cells (CSCs), from cultured CSCs and primary tumor cells, categorical drug response reported based on percent of cytotoxicity observed, a minimum of 14 drugs or drug combinations
0565TAutologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation
0566TAutologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral
0567TPermanent fallopian tube occlusion with degradable biopolymer implant, transcervical approach, including transvaginal ultrasound
0568TIntroduction of mixture of saline and air for sonosalpingography to confirm occlusion of fallopian tubes, transcervical approach, including transvaginal ultrasound and pelvic ultrasound
0569TTranscatheter tricuspid valve repair, percutaneous approach; initial prosthesis
0570TTranscatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session (List separately in addition to code for primary procedure)
0571TInsertion or replacement of implantable cardioverter defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed
0572TInsertion of substernal implantable defibrillator electrode
0573TRemoval of substernal implantable defibrillator electrode
0574TRepositioning of previously implanted substernal implantable defibrillator pacing electrode
0575TProgramming device evaluation (in person) of implantable cardioverter defibrillator system with substernal electrode, with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional
0576TInterrogation device evaluation (in person) of implantable cardioverter defibrillator system with substernal electrode, with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter
0577TElectrophysiologic evaluation of implantable cardioverter-defibrillator system with substernal electrode (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters)
0578TInterrogation device evaluation(s) (remote), up to 90 days, substernal lead implantable cardioverter defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional
0579TInterrogation device evaluation(s) (remote), up to 90 days, substernal lead implantable cardioverter defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results
0580TRemoval of substernal implantable defibrillator pulse generator only
0581TAblation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral
0582TTransurethral ablation of malignant prostate tissue by high energy water vapor thermotherapy, including intraoperative imaging and needle guidance
0583TTympanostomy (requiring insertion of ventilating tube), using an automated tube delivery system, iontophoresis local anesthesia
0587TPercutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
0588TRevision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
0589TElectronic analysis with simple programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 1 3 parameters
0590TElectronic analysis with complex programming of implanted integrated neurostimulation system (eg, electrode array and receiver), including contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters, when performed by physician or other qualified health care professional, posterior tibial nerve, 4 or more parameters
0591THealth and well being coaching face to face; individual, initial assessment
0592THealth and well being coaching face to face; individual, follow up session, at least 30 minutes
0593THealth and well being coaching face to face; group (2 or more individuals), at least 30 minutes
0594TOsteotomy, humerus, with insertion of an externally controlled intramedullary lengthening device, including intraoperative imaging, initial and subsequent alignment assessments, computations of adjustment schedules, and management of the intramedullary lengthening device
0596TTemporary female intraurethral valve pump (ie, voiding prosthesis); initial insertion, including urethral measurement
0597TTemporary female intraurethral valve-pump (ie, voiding prosthesis); replacement
0598TNoncontact real time fluorescence wound imaging, for bacterial presence, location, and load, per session; first anatomic site (eg, lower extremity)
0599TNoncontact real time fluorescence wound imaging, for bacterial presence, location, and load, per session; each additional anatomic site (eg, upper extremity) (List separately in addition to code for primary procedure)
0600TAblation, irreversible electroporation; 1 or more tumors per organ, including imaging guidance, when performed, percutaneous
0601TAblation, irreversible electroporation; 1 or more tumors per organ, including fluoroscopic and ultrasound guidance, when performed, open
0602TGlomerular filtration rate (GFR) measurement(s), transdermal, including sensor placement and administration of a single dose of fluorescent pyrazine agent
0603TGlomerular filtration rate (GFR) monitoring, transdermal, including sensor placement and administration of more than one dose of fluorescent pyrazine agent, each 24 hours
0604TOptical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center, unilateral or bilateral; initial device provision, set-up and patient education on use of equipment
0605TOptical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center, unilateral or bilateral; remote surveillance center technical support, data analyses and reports, with a minimum of 8 daily recordings, each 30 days
0606TOptical coherence tomography (OCT) of retina, remote, patient-initiated image capture and transmission to a remote surveillance center, unilateral or bilateral; review, interpretation and report by the prescribing physician or other qualified health care professional of remote surveillance center data analyses, each 30 days
0607TRemote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24 hour attended surveillance center; set up and patient education on use of equipment
0608TRemote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (eg, ECG data), transmitted to a remote 24 hour attended surveillance center; analysis of data received and transmission of reports to the physician or other qualified health care professional
0609TMagnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); acquisition of single voxel data, per disc, on biomarkers (ie, lactic acid, carbohydrate, alanine, laal, propionic acid, proteoglycan, and collagen) in at least 3 discs
0610TMagnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); transmission of biomarker data for software analysis
0611TMagnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); postprocessing for algorithmic analysis of biomarker data for determination of relative chemical differences between discs
0612TMagnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); interpretation and report
0613TPercutaneous transcatheter implantation of interatrial septal shunt device, including right and left heart catheterization, intracardiac echocardiography, and imaging guidance by the proceduralist, when performed
0614TRemoval and replacement of substernal implantable defibrillator pulse generator
0615TEye movement analysis without spatial calibration, with interpretation and report
0616TInsertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; without removal of crystalline lens or intraocular lens, without insertion of intraocular lens
0617TInsertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with removal of crystalline lens and insertion of intraocular lens
0618TInsertion of iris prosthesis, including suture fixation and repair or removal of iris, when performed; with secondary intraocular lens placement or intraocular lens exchange
0619TCystourethroscopy with transurethral anterior prostate commissurotomy and drug delivery, including transrectal ultrasound and fluoroscopy, when performed
0620TEndovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed
0621TTrabeculostomy ab interno by laser; (Do not report 0621T, 0622T in conjunction with 92020, 0730T)
0622TTrabeculostomy ab interno by laser; with use of ophthalmic endoscope (Do not report 0621T, 0622T in conjunction with 92020, 0730T)
0623TAutomated quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, using data from coronary computed tomographic angiography; data preparation and transmission, computerized analysis of data, with review of computerized analysis output to reconcile discordant data, interpretation and report
0624TAutomated quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, using data from coronary computed tomographic angiography; data preparation and transmission
0625TAutomated quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, using data from coronary computed tomographic angiography; computerized analysis of data from coronary computed tomographic angiography
0626TAutomated quantification and characterization of coronary atherosclerotic plaque to assess severity of coronary disease, using data from coronary computed tomographic angiography; review of computerized analysis output to reconcile discordant data, interpretation and report
0627TPercutaneous injection of allogeneic cellular and/or tissue based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level
0628TPercutaneous injection of allogeneic cellular and/or tissue based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; each additional level (List separately in addition to code for primary procedure)
0629TPercutaneous injection of allogeneic cellular and/or tissue based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level
0630TPercutaneous injection of allogeneic cellular and/or tissue based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; each additional level (List separately in addition to code for primary procedure)
0631TTranscutaneous visible light hyperspectral imaging measurement of oxyhemoglobin, deoxyhemoglobin, and tissue oxygenation, with interpretation and report, per extremity
0632TPercutaneous transcatheter ultrasound ablation of nerves innervating the pulmonary arteries, including right heart catheterization, pulmonary artery angiography, and all imaging guidance
0633TComputed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material
0634TComputed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s)
0635TComputed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s)
0636TComputed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s)
0637TComputed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s)
0638TComputed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s)
0639TWireless skin sensor thermal anisotropy measurement(s) and assessment of flow in cerebrospinal fluid shunt, including ultrasound guidance, when performed
0640TNoncontact near-infrared spectroscopy studies of flap or wound (eg, for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [StO2]); image acquisition, interpretation and report, each flap or wound
0641TNoncontact near-infrared spectroscopy studies of flap or wound (eg, for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [StO2]); image acquisition only, each flap or wound
0642TNoncontact near-infrared spectroscopy studies of flap or wound (eg, for measurement of deoxyhemoglobin, oxyhemoglobin, and ratio of tissue oxygenation [StO2]); interpretation and report only, each flap or wound
0643TTranscatheter left ventricular restoration device implantation including right and left heart catheterization and left ventriculography when performed, arterial approach
0644TTranscatheter removal or debulking of intracardiac mass (eg, vegetations, thrombus) via suction (eg, vacuum, aspiration) device, percutaneous approach, with intraoperative reinfusion of aspirated blood, including imaging guidance, when performed
0645TTranscatheter implantation of coronary sinus reduction device including vascular access and closure, right heart catheterization, venous angiography, coronary sinus angiography, imaging guidance, and supervision and interpretation, when performed
0646TTranscatheter tricuspid valve implantation/replacement (TTVI) with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed
0647TInsertion of gastrostomy tube, percutaneous, with magnetic gastropexy, under ultrasound guidance, image documentation and report
0648TQuantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session; single organ
0649TQuantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure); single organ (List separately in addition to code for primary procedure)
0650TProgramming device evaluation (remote) of subcutaneous cardiac rhythm monitor system, with iterative adjustment of the implantable device to test the function of the device and select optimal permanently programmed values with analysis, review and report by a physician or other qualified health care professional
0651TMagnetically controlled capsule endoscopy, esophagus through stomach, including intraprocedural positioning of capsule, with interpretation and report
0652TEsophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
0653TEsophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) with biopsy, single or multiple
0654TEsophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) with insertion of intraluminal tube or catheter
0655TTransperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with MR-fused images or other enhanced ultrasound imaging
0656TVertebral body tethering, anterior; up to 7 vertebral segments
0657TVertebral body tethering, anterior; 8 or more vertebral segments
0658TElectrical impedance spectroscopy of 1 or more skin lesions for automated melanoma risk score
0659TTranscatheter intracoronary infusion of supersaturated oxygen in conjunction with percutaneous coronary revascularization during acute myocardial infarction, including catheter placement, imaging guidance (eg, fluoroscopy), angiography, and radiologic supervision and interpretation
0660TImplantation of anterior segment intraocular nonbiodegradable drug-eluting system, internal approach
0661TRemoval and reimplantation of anterior segment intraocular nonbiodegradable drug-eluting implant
0662TScalp cooling, mechanical; initial measurement and calibration of cap
0663TScalp cooling, mechanical; placement of device, monitoring, and removal of device (List separately in addition to code for primary procedure)
0664TDonor hysterectomy (including cold preservation); open, from cadaver donor
0665TDonor hysterectomy (including cold preservation); open, from living donor
0666TDonor hysterectomy (including cold preservation); laparoscopic or robotic, from living donor
0667TDonor hysterectomy (including cold preservation); recipient uterus allograft transplantation from cadaver or living donor
0668TBackbench standard preparation of cadaver or living donor uterine allograft prior to transplantation, including dissection and removal of surrounding soft tissues and preparation of uterine vein(s) and uterine artery(ies), as necessary
0669TBackbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; venous anastomosis, each
0670TBackbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; arterial anastomosis, each
0672TEndovaginal cryogen cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence
0673TAblation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance
0674TLaparoscopic insertion of new or replacement of permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including an implantable pulse generator and diaphragmatic lead(s)
0675TLaparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; first lead
0676TLaparoscopic insertion of new or replacement of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; each additional lead (Lis
0677TLaparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; first repositioned lead
0678TLaparoscopic repositioning of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, including connection to an existing pulse generator; each additional repositioned lead (List sep
0679TLaparoscopic removal of diaphragmatic lead(s), permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function
0680TInsertion or replacement of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, with connection to existing lead(s)
0681TRelocation of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function, with connection to existing dual leads
0682TRemoval of pulse generator only, permanent implantable synchronized diaphragmatic stimulation system for augmentation of cardiac function
0683TProgramming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care
0684TPeri procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review, and report by a physician or other qualified health care professional, permanent implantable syn
0685TInterrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, including connection, recording and disconnection per patient encounter, permanent implantable synchronized diaphragma
0686THistotripsy (ie, non thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance
0687TTreatment of amblyopia using an online digital program; device supply, educational set up, and initial session
0688TTreatment of amblyopia using an online digital program; assessment of patient performance and program data by physician or other qualified health care professional, with report, per calendar month
0689TQuantitative ultrasound tissue characterization (non elastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tissue, target structure)
0690TQuantitative ultrasound tissue characterization (non elastographic), including interpretation and report, obtained with diagnostic ultrasound examination of the same anatomy (eg, organ, gland, tissue, target structure) (List separately in addition to code
0691TAutomated analysis of an existing computed tomography study for vertebral fracture(s), including assessment of bone density when performed, data preparation, interpretation, and report
0692TTherapeutic ultrafiltration
0693TComprehensive full body computer based markerless 3D kinematic and kinetic motion analysis and report
0694T3 dimensional volumetric imaging and reconstruction of breast or axillary lymph node tissue, each excised specimen, 3 dimensional automatic specimen reorientation, interpretation and report, real time intraoperative
0695TBody surface activation mapping of pacemaker or pacing cardioverter defibrillator lead(s) to optimize electrical synchrony, cardiac resynchronization therapy device, including connection, recording, disconnection, review, and report; at time of implant or
0696TBody surface activation mapping of pacemaker or pacing cardioverter defibrillator lead(s) to optimize electrical synchrony, cardiac resynchronization therapy device, including connection, recording, disconnection, review, and report; at time of follow up
0697TQuantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the
0698TQuantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the sa
0700TMolecular fluorescent imaging of suspicious nevus; first lesion
0701TMolecular fluorescent imaging of suspicious nevus; each additional lesion (List separately in addition to code for primary procedure)
0702TRemote therapeutic monitoring of a standardized online digital cognitive behavioral therapy program ordered by a physician or other qualified health care professional; supply and technical support, per 30 days
0703TRemote therapeutic monitoring of a standardized online digital cognitive behavioral therapy program ordered by a physician or other qualified health care professional; management services by physician or other qualified health care professional, per calen
0704TRemote treatment of amblyopia using an eye tracking device; device supply with initial set-up and patient education on use of equipment
0705TRemote treatment of amblyopia using an eye tracking device; surveillance center technical support including data transmission with analysis, with a minimum of 18 training hours, each 30 days
0706TRemote treatment of amblyopia using an eye tracking device; interpretation and report by physician or other qualified health care professional, per calendar month
0707TInjection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), including imaging guidance and arthroscopic assistance for joint visualization
0708TIntradermal cancer immunotherapy; preparation and initial injection
0709TIntradermal cancer immunotherapy; each additional injection
0710TNoninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; including data preparation and transmission, quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability, data review, interpretation and report
0711TNoninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data preparation and transmission
0712TNoninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability
0713TNoninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data review, interpretation and report
0714TTransperineal laser ablation of benign prostatic hyperplasia, including imaging guidance
0715TPercutaneous transluminal coronary lithotripsy (List separately in addition to code for primary procedure)
0716TCardiac acoustic waveform recording with automated analysis and generation of coronary artery disease risk score
0717TAutologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCs
0718TAutologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral
0719TPosterior vertebral joint replacement, including bilateral facetectomy, laminectomy, and radical discectomy, including imaging guidance, lumbar spine, single segment
0720TPercutaneous electrical nerve field stimulation, cranial nerves, without implantation
0721TQuantitative computed tomography (CT) tissue characterization, including interpretation and report, obtained without concurrent CT examination of any structure contained in previously acquired diagnostic imaging
0722TQuantitative computed tomography (CT) tissue characterization, including interpretation and report, obtained with concurrent CT examination of any structure contained in the concurrently acquired diagnostic imaging dataset (List separately in addition to code for primary procedure)
0723TQuantitative magnetic resonance cholangiopancreatography (QMRCP) including data preparation and transmission, interpretation and report, obtained without diagnostic magnetic resonance imaging (MRI) examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session
0724TQuantitative magnetic resonance cholangiopancreatography (QMRCP) including data preparation and transmission, interpretation and report, obtained with diagnostic magnetic resonance imaging (MRI) examination of the same anatomy (eg, organ, gland, tissue, target structure) (List separately in addition to code for primary procedure)
0725TVestibular device implantation, unilateral
0726TRemoval of implanted vestibular device, unilateral
0727TRemoval and replacement of implanted vestibular device, unilateral
0728TDiagnostic analysis of vestibular implant, unilateral; with initial programming
0729TDiagnostic analysis of vestibular implant, unilateral; with subsequent programming
0730TTrabeculotomy by laser, including optical coherence tomography (OCT) guidance
0731TAugmentative AI-based facial phenotype analysis with report
0732TImmunotherapy administration with electroporation, intramuscular
0733TRemote real-time, motion capture-based neurorehabilitative therapy ordered by a physician or other qualified health care professional; supply and technical support, per 30 days
0734TRemote real-time, motion capture-based neurorehabilitative therapy ordered by a physician or other qualified health care professional; treatment management services by a physician or other qualified health care professional, per calendar month
0735TPreparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with primary craniotomy (List separately in addition to code for primary procedure)
0736TColonic lavage, 35 or more liters of water, gravity-fed, with induced defecation, including insertion of rectal catheter
0737TXenograft implantation into the articular surface
33900Unilateral percutaneous pulmonary artery revascularization, initial; normal native connections
33901Bilateral percutaneous pulmonary artery revascularization, initial; normal native connections
57465Computer aided mapping of cervix uteri during colposcopy, including optical dynamic spectral imaging and algorithmic quantification of the acetowhitening effect (List separately in addition to code for primary procedure)
80220Hydroxychloroquine
82653Elastase, pancreatic (EL 1), fecal; quantitative
83529Interleukin 6 (IL 6)
95919Quantitative pupillometry with interpretation and report
A4563Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories, any type each
E0183Powered pressure reducing underlay/pad, alternating, with pump, includes heavy duty
E0711Upper extremity medical tubing/lines enclosure or covering device, restricts elbow range of motion
E1629Tablo hemodialysis system for the billable dialysis service
J0591Injection, deoxycholic acid, 1 mg
K1004Low frequency ultrasonic diathermy treatment device for home use
K1021Exsufflation belt, includes all supplies and accessories
K1026Mechanical allergen particle barrier/inhalation filter, cream, nasal, topical
K1027Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment
K1030External recharging system for battery (internal) for use with implanted cardiac contractility modulation generator, replacement only
K1031Non-pneumatic compression controller without calibrated gradient pressure
K1032Non-pneumatic sequential compression garment, full leg
K1033Non-pneumatic sequential compression garment, half leg
S9117Back school, per visit
V2525Contact lens, hydrophilic, dual focus, per lens
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2023 American Medical Association.