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Connection supplemental articles and policies - March 2008

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Connection - March 2008 (pdf, 318 KB)

supplemental articles

 

policies and forms

The following policies have been reviewed and have substantial changes. For more details, please see “policy changes” below.

FCHP Direct Care network continues to grow

Last fall, we significantly expanded our FCHP Direct Care network. This tailored network, which is a popular choice for many employers and FCHP members, offers a significant premium savings over our FCHP Select Care network—while still giving members the same great benefits and features.

We’d like to share with you the newest expansion of this network with the addition of these physician groups:

  • Lahey Clinic physicians (and related medical facilities) in Burlington and Peabody.
    Lahey Clinic has approximately 450 physicians.
  • Mount Auburn Cambridge Independent Practice Association (Mt. Auburn Hospital)
    Mount Auburn has more than 400 primary care physicians (including those in Arlington, Belmont, Cambridge, Lexington, Somerville and Watertown) and specialists.
  • Highland Healthcare Associates IPA (Winchester Hospital)
    Highland has approximately 340 health care providers, including more than 100 primary care physicians. Its physicians serve the communities of Winchester, Woburn, Reading, Wilmington, North Reading, Stoneham, Burlington, Billerica, Medford, Malden, Wakefield and other surrounding towns.

In September, FCHP Direct Care expanded in the Merrimack Valley and the North Shore regions to include: Lawrence General IPA (and Lawrence General Hospital); Lowell General Physician Hospital Organization (and Lowell General Hospital); and Northeast Physician Hospital Organization (and Beverly Hospital, Addison Gilbert Hospital).

FCHP Direct Care also includes Southboro Medical Group in the Central Massachusetts region.


Depression pocket guide available to pcps

by Susan Olson, L.I.C.S.W., Beacon Health Strategies, LLC

Beacon Health Strategies, FCHP’s behavioral health partner, has developed a Depression Pocket Guide for PCPs. The pocket guide, which Beacon’s Depression Quality Improvement Program adapted from the MacArthur Initiative on Depression, is a tool that assists in screening for depression. We hope the pocket guide will improve the degree to which depressed adults are identified and encouraged to initiate and complete treatment for depression.

The Agency for Healthcare Research and Quality, under the U.S. Department of Health & Human Services, has written the guidelines that are the nationally adopted (e.g., NCQA) measures of quality care for depression treatment. These measures are:

  • Optimum practitioner contact: The percentage of members who received at least three follow-up office visits with a PCP or mental health provider in the 12-week acute treatment phase following a diagnosis of depression or prescription of antidepressant medication.
  • Effective acute-phase treatment: The percentage of members who received effective acute-phase treatment by remaining on antidepressant medication continuously in the 12 weeks following a new episode of depression.
  • Effective continuation-phase treatment: The percentage of members who received effective continuation-phase treatment by remaining on antidepressant medication continuously in the 6 months following a new episode of depression.

Please feel free to contact the Clinical Department at Beacon at 1-888-421-8861 with any questions you may have regarding the PCP Depression Pocket Guide or to inquire about having a guide mailed to you.


New policy in effect to promote careful handling of meds

Fallon Community Health Plan is enforcing its new policy that allows for refill or replacement of only one occurrence of lost or mishandled medication in a calendar year.

“Lost” medication is a term used when the member accidentally misplaces or loses a covered prescription medication. 

“Mishandled” medication means that the proper care of a prescription drug wasn’t followed, rendering it unusable (e.g., a medication requiring refrigeration is left in a hot vehicle or on the kitchen counter; medication is left in a vehicle during cold winter days and freezes; medication is put in a suitcase on an airplane and freezes).

Our policy allows each member to be covered for a 30-day supply of prescription medication (unless otherwise specified) for one occurrence of lost or mishandled medication per calendar year. An “occurrence” is the loss or mishandling of a single medication, or the loss or mishandling of multiple medications at the same time.

For example, if a member’s medication needed to be refrigerated and the member neglected to store one of the medications appropriately, FCHP would provide reimbursement for a 30-day supply (unless otherwise specified) for the medication needing to be replaced. Or, if a member was traveling and lost three prescriptions at one time, FCHP would provide reimbursement for a 30-day supply (unless otherwise specified) for each prescription lost.

In each case, the member would be charged the appropriate copayment for the replacement/refill prescription. All subsequent prescriptions to replace/refill lost or mishandled medications in the same calendar year would not be covered.

If you have any questions about this policy, please contact Provider Relations at 1-866-ASK-FCHP, press 4.


Formulary updates

Fallon Community Health Plan often makes changes to its formularies, including changing prior authorization requirements and adding new medications. Please note the following changes to our commercial plan formulary.

commercial plan formulary

additions

Azor® (amlodipine/olmesartan)               Tier 3, QLL 30 per 30 days
Bystolic® (nebivolol)                               Tier 3, QLL 30 per 30 days, step therapy required*
Combigan® (brimonidine/timolol)            Tier 3
Exforge® (amlodipine/valsartan)              Tier 3, QLL 30 per 30 days
Pantoprazole                                           Tier 2, QLL 30 per 30 days
Peranex HC Pad® (lidocaine-hc)            Tier 3, PA required
Pulmicort (budesonide) Flexhaler®          Tier 2
Ramipril                                                  Tier 1
SymlinPen® (pramlintide)                        Tier 3, PA required

changes

Ambien® (zolpidem)                               QLL changed to 30 per 30 days
Geodon® (ziprasidone)                           Changed to Tier 2

new to market policy**

Flector® (diclofenac epolamine) Patch
Kuvan® (sapropterin dihydrochloride)
Renvela® (sevelamer carbonate)
Tasigna® ( nilotinib )
Veregen® (sinecatechins)

* Step therapy: FCHP requires evidence of use of two or more generic beta-blockers in the past before prescribing Bystolic.

** FCHP’s New to Market Policy was enacted to ensure patient safety and to allow for adequate time for the development, review and approval of clinical criteria. When a new medication first becomes available, it will fall under this policy and be excluded from coverage. A process is in place that allows for the quick review of provider requests for noncovered pharmaceuticals

medicare part d formulary

additions

Activella® tabs

Added as Tier 3

Albuterol® sulfate 0.63 mg/3ml nebulizer

Added as Tier 1

Azor™ tabs

Added as Tier 3, QLL 30 per 30 days

Carvedilol tabs

Added as Tier 1

Ciclopirox nail lacquer 8% solution

Added as Tier 1, PA required

Dexmethylphenidate tabs

Added as Tier 1

Exforge® tabs

Added as Tier 3, QLL 30 per 30 days

Flunisolide nasal solution

Added as Tier 1

Januvia® tabs

Added as Tier 3

Metoprolol succinate - ext.rel.tab-24

Added as Tier 1, QLL 30 per 30 days

Mirapex® 0.75 mg tabs

Added as Tier 3

Nimodipine caps

Added as Tier 1

Ofloxacin 0.3 % ophthalmic solution

Added as Tier 1

Ortho tri-cyclen® tabs

Added as Tier 3

Oxcarbazepine tabs

Added as Tier 1

Stalevo® 200 tabs

Added as Tier 3, PA required

Symbicort® aerosol

Added as Tier 3

Tekturna® tabs

Added as Tier 3, PA required

TriLegest Fe tabs

Added as Tier 1

Tykerb® tabs

Added as Tier 3, PA required

Verapamil HCL - ext. rel. capsules-24

Added as Tier 1

Verelan® PM capsultes-24

Added as Tier 3

Zyflo® CR tab-12

Added as Tier 3, QLL 120 per 30 days

Policy changes

The following policies have been reviewed and include the clarifications noted below:

  • Evaluation and Management Payment Policy: Same Day Services
    • FCHP allows for only one Evaluation and Management service per day of service, per physician group, regardless of the place of service. (page 2)
    • If more than one Evaluation and Management code is submitted, the E&M with the highest allowable reimbursement will be processed for payment. (page 2).
  • Global Obstetrical Services Payment Policy

    • The global obstetrical services package begins on the day the obstetrical record is created. FCHP would like to remind providers of what is included in the global obstetrical services payment and to clarify billing and coding guidelines.
      • Pap Smears (Q0091) and Birth Control Counseling (99401) post-partum are part of and therefore included in the global obstetrical package. (page 1)
      • Please review the list of labs that are included in the global obstetrical package. (page 1)
      • Do not bill FCHP office visit codes 99211-99215 unless the patient only presented for 1 to 3 visits. (page 3)

Coding corner

Please note the following CPT code changes.
These codes are now covered and require preauthorization.

CPT

Description

Effective date

S0812

Phototherapeutic Keratectomy (PTK)

Immediately for all plan types
 

E0762

Transcutaneous electrical joint stimulation devise system, includes all accessories.

Immediately for Fallon Senior Plan only

These codes no longer require preauthorization.

CPT

Description

Effective date

L4350

ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT. 

Immediately

64600*

DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SUPRAORBITAL, INFRAORBITAL, MENTAL, OR INFERIOR ALVEOLAR BRANCH

Immediately

64605*

DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND THIRD DIVISION BRANCHES AT FORAMEN OVALE

Immediately

64610*

DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND THIRD DIVISION BRANCHES AT FORAMEN OVALE UNDER RADIOLOGIC MONITORING

Immediately

64612*

CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL NERVE (EG, FOR BLEPHAROSPASM, HEMIFACIAL SPASM)

Immediately

64613*

CHEMODENERVATION OF MUSCLE(S); CERVICAL SPINAL MUSCLE(S) (EG, FOR SPASMODIC TORTICOLLIS)

Immediately

64620*

DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE

Immediately

64622*

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; LUMBAR OR SACRAL, SINGLE LEVEL

Immediately

64623*

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Immediately

64626*

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; CERVICAL OR THORACIC, SINGLE LEVEL

Immediately

64627*

DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Immediately

64630*

DESTRUCTION BY NEUROLYTIC AGENT; PUDENDAL NERVE

Immediately

64640*

DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH

Immediately

64650*

CHEMODENERVATION OF ECCRINE GLANDS; BOTH AXILLAE

Immediately

64653*

CHEMODENERVATION OF ECCRINE GLANDS; OTHER AREA(S) (EG, SCALP, FACE, NECK), PER DAY

Immediately

64680*

DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; CELIAC PLEXUS

Immediately

64681*

DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC MONITORING; SUPERIOR HYPOGASTRIC PLEXUS

Immediately

* This applies to the service only. Some injectable agents, such as Botox, require preauthorization.

new 2008 CPT/HCPCS codes

As mentioned in the January Connection, all new 2008 codes required preauthorization until a final review was performed by Fallon Community Health Plan. We’ve now reviewed and assigned the appropriate coverage categories and determined preauthorization requirements for all new codes.

New CPT/HCPCS codes became effective for claims received on or after January 1, 2008. The HIPAA Transaction and Code Set Rule requires the use of the medical code set that is valid at the time the service is provided.

New covered CPT codes effective January 1, 2008, that require preauthorization:

CPT code

Description

20555

Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure)

20985

Computer-assisted surgical navigational procedure for musculoskeletal procedures; image-less (List separately in addition to code for primary procedure)

20986

Computer-assisted surgical navigational procedure for musculoskeletal procedures; with image guidance based on intra-operatively obtained images (e.g., fluoroscopy, ultrasound) (List separately in addition to code for primary procedure)

20987

Computer-assisted surgical navigational procedure for musculoskeletal procedures; with image guidance based on preoperative images (List separately in addition to code for primary procedure)

21073

Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (i.e., general or monitored anesthesia care)

27416

Osteochondral autograft(s), knee, open (e.g., mosaicplasty) (includes harvesting of autograft[s])

28446

Open osteochondral autograft, talus (includes obtaining graft[s])

33864

Ascending aorta graft, with cardiopulmonary bypass with valve suspension, with coronary reconstruction and valve-sparing aortic annulus remodeling (eg, David Procedure, Yacoub Procedure)

34806

Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair, including radiological supervision and interpretation, instrument calibration, and collection of pressure data

36591

Collection of blood specimen from a completely implantable venous access device

36592

Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified

41019

Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application

49465

Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report

50593

Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy

52649

Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed)

57285

Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach

57423

Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach

82610

Cystatin C

83993

Calprotectin, fecal

86356

Mononuclear cell antigen, quantitative (eg, flow cytometry), not otherwise specified, each antigen

86486

Skin test; unlisted antigen, each

87500

Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique

87809

Infectious agent antigen detection by immunoassay with direct optical observation; adenovirus

88381

Microdissection (ie, sample preparation of microscopically identified target); manual

90284

Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each

90650

Human Papillomavirus (HPV) vaccine, types 16 and 18, bivalent, 3 dose schedule, for intramuscular use

90661

Influenza virus vaccine, derived from cell cultures, subunit, preservative and antibiotic free, for intramuscular use

90662

Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use

90663

Influenza virus vaccine, pandemic formulation

90681

Rotavirus vaccine, human, attenuated, 2 dose schedule, live, for oral use

90696

Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated (DTaP-IPV), when administered to children 4 years through 6 years of age, for intramuscular use

93982

Noninvasive physiologic study of implanted wireless pressure sensor in aneurysmal sac following endovascular repair, complete study including recording, analysis of pressure and waveform tracings, interpretation and report

95980

Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; intraoperative, with programming

95981

Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; subsequent, without reprogramming

95982

Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric neurostimulator pulse generator/transmitter; subsequent, with reprogramming

96125

Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report

98966

Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

98967

Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

98968

Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

98969

Online assessment and management service provided by a qualified nonphysician health care professional to an established patient, guardian, or health care provider not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network

99366

Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 minutes or more, participation by nonphysician qualified health care professional

99367

Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician

99368

Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional

99406

Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

99407

Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

99441

Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

99442

Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion

99443

Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 21-30 minutes of medical discussion

99444

Online evaluation and management service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network

99605

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, new patient

99606

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, established patient

99607

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; each additional 15 minutes (List separately in addition to code for primary service)

0183T

Low frequency, non-contact, non-thermal ultrasound, including topical application(s) when performed, wound assessment, and instruction(s) for ongoing care, per day

0184T

Excision of rectal tumor, transanal endoscopic microsurgical approach (i.e., TEMS)

0185T

Multivariate analysis of patient specific findings with quantifiable computer probability assessment, including report

0186T

Suprachoroidal delivery of pharmacologic agent (does not include supply of medication)

0187T

Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral

New covered HCPCS codes effective January 1, 2008, that require preauthorization:

HCPCS code

Description

A4648

TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH

A4650

IMPLANTABLE RADIATION DOSIMETER, EACH

A6413

ADHESIVE BANDAGE, FIRST-AID TYPE, ANY SIZE, EACH

A9155

ARTIFICIAL SALIVA, 30 ML

A9274

EXTERNAL AMBULATORY INSULIN DELIVERY SYSTEM, DISPOSABLE, EACH, INCLUDES ALL SUPPLIES AND ACCESSORIES

A9276

SENSOR; INVASIVE (E.G. SUBCUTANEOUS), DISPOSABLE, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM, ONE UNIT = 1 DAY SUPPLY

A9277

TRANSMITTER; EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM

A9278

RECEIVER (MONITOR); EXTERNAL, FOR USE WITH INTERSTITIAL CONTINUOUS GLUCOSE MONITORING SYSTEM

A9283

FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH

C8921

TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST FOR CONGENITAL CARDIAC ANOMALIES; COMPLETE

C8922

TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST FOR CONGENITAL CARDIAC ANOMALIES; FOLLOW-UP OR LIMITED STUDY

C8923

TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; COMPLETE

C8924

TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; FOLLOW-UP OR LIMITED STUDY

C8925

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT

C8926

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT

C8927

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND TO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASIS

C8928

TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORT

C9238

INJECTION, LEVETIRACETAM, 10 MG

C9239

INJECTION, TEMSIROLIMUS, 1 MG

C9352

MICROPOROUS COLLAGEN IMPLANTABLE TUBE (NEURAGEN NERVE GUIDE), PER CENTIMETER LENGTH

C9353

MICROPOROUS COLLAGEN IMPLANTABLE SLIT TUBE (NEURAWRAP NERVE PROTECTOR), PER CENTIMETER LENGTH

E0328

HOSPITAL BED, PEDIATRIC, MANUAL, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDES MATTRESS

E0329

HOSPITAL BED, PEDIATRIC, ELECTRIC OR SEMI-ELECTRIC, 360 DEGREE SIDE ENCLOSURES, TOP OF HEADBOARD, FOOTBOARD AND SIDE RAILS UP TO 24 INCHES ABOVE THE SPRING, INCLUDES MATTRESS

E0856

CERVICAL TRACTION DEVICE, CERVICAL COLLAR WITH INFLATABLE AIR BLADDER

G0396

ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE STRUCTURED ASSESSMENT (E.G., AUDIT, DAST), AND BRIEF INTERVENTION 15 TO 30 MINUTES

G0397

ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE STRUCTURED ASSESSMENT (E.G., AUDIT, DAST), AND INTERVENTION, GREATER THAN 30 MINUTES

G8395

LEFT VENTRICULAR EJECTION FRACTION (LVEF) >= 40% OR DOCUMENTATION AS NORMAL OR MILDLY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION

G8396

LEFT VENTRICULAR EJECTION FRACTION (LVEF) NOT PERFORMED OR DOCUMENTED

G8397

DILATED MACULAR OR FUNDUS EXAM PERFORMED, INCLUDING DOCUMENTATION OF THE PRESENCE OR ABSENCE OF MACULAR EDEMA AND LEVEL OF SEVERITY OF RETINOPATHY

G8398

DILATED MACULAR OR FUNDUS EXAM NOT PERFORMED

G8399

PATIENT WITH CENTRAL DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) RESULTS DOCUMENTED OR ORDERED OR PHARMACOLOGIC THERAPY (OTHER THAN MINERALS/VITAMINS) FOR OSTEOPOROSIS PRESCRIBED)

G8400

PATIENT WITH CENTRAL DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) RESULTS NOT DOCUMENTED OR NOT ORDERED OR PHARMACOLOGIC THERAPY (OTHER THAN MINERALS/VITAMINS) FOR OSTEOPOROSIS NOT PRESCRIBED

G8401

CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR SCREENING OR THERAPY FOR OSTEOPOROSIS FOR WOMEN MEASURE

G8402

TOBACCO (SMOKE) USE CESSATION INTERVENTION, COUNSELING

G8403

TOBACCO (SMOKE) USE CESSATION INTERVENTION NOT COUNSELED

G8404

LOWER EXTREMITY NEUROLOGICAL EXAM PERFORMED AND DOCUMENTED

G8405

LOWER EXTREMITY NEUROLOGICAL EXAM NOT PERFORMED

G8406

CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR LOWER EXTREMITY NEUROLOGICAL EXAM MEASURE

G8407

ABI MEASURED AND DOCUMENTED

G8408

ABI MEASUREMENT WAS NOT OBTAINED

G8409

CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ABI MEASUREMENT MEASURE

G8410

FOOTWEAR EVALUATION PERFORMED AND DOCUMENTED

G8415

FOOTWEAR EVALUATION WAS NOT PERFORMED

G8416

CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR FOOTWEAR EVALUATION MEASURE

G8417

BMI >= 30 WAS CALCULATED AND A FOLLOW-UP PLAN WAS DOCUMENTED IN THE MEDICAL RECORD

G8418

BMI < 22 WAS CALCULATED AND A FOLLOW-UP PLAN WAS DOCUMENTED IN THE MEDICAL RECORD

G8419

BMI >= 30 OR < 22 WAS CALCULATED, BUT NO FOLLOW-UP PLAN WAS DOCUMENTED IN THE MEDICAL RECORD

G8420

BMI < 30 AND >= 22 WAS CALCULATED AND DOCUMENTED

G8421

BMI NOT CALCULATED

G8422

PATIENT NOT ELIGIBLE FOR BMI CALCULATION

G8423

DOCUMENTED THAT PATIENT WAS SCREENED AND EITHER INFLUENZA VACCINATION STATUS IS CURRENT OR PATIENT WAS COUNSELED

G8424

INFLUENZA VACCINE STATUS WAS NOT SCREENED

G8425

INFLUENZA VACCINE STATUS SCREENED, PATIENT NOT CURRENT AND COUNSELING WAS NOT PROVIDED

G8426

DOCUMENTED THAT PATIENT WAS NOT APPROPRIATE FOR SCREENING AND/OR COUNSELING ABOUT THE INFLUENZA VACCINE (E.G., ALLERGY TO EGGS)

G8427

WRITTEN PROVIDER DOCUMENTATION WAS OBTAINED CONFIRMING THAT CURRENT MEDICATIONS WITH DOSAGES (INCLUDES PRESCRIPTION, OVER-THE-COUNTER, HERBALS, VITAMIN/MINERAL/DIETARY (NUTRITIONAL) SUPPLEMENTS) WERE VERIFIED WITH THE PATIENT OR AUTHORIZED REPRESENTATIVE OR PATIENT ASSESSED AND IS NOT CURRENTLY ON ANY MEDICATIONS

G8428

CURRENT MEDICATIONS WITH DOSAGES (INCLUDES PRESCRIPTION, OVER-THE-COUNTER, HERBALS, VITAMIN/MINERAL/DIETARY (NUTRITIONAL) SUPPLEMENTS) WERE DOCUMENTED WITHOUT DOCUMENTED PATIENT VERIFICATION

G8429

INCOMPLETE OR NO DOCUMENTATION THAT PATIENT'S CURRENT MEDICATIONS WITH DOSAGES (INCLUDES PRESCRIPTION, OVER-THE-COUNTER, HERBALS, VITAMIN/MINERAL/DIETARY (NUTRITIONAL) SUPPLEMENTS) WERE ASSESSED

G8430

DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR MEDICATION ASSESSMENT

G8431

DOCUMENTATION OF CLINICAL DEPRESSION SCREENING USING A STANDARDIZED TOOL

G8432

NO DOCUMENTATION OF CLINICAL DEPRESSION SCREENING USING A STANDARDIZED TOOL

G8433

PATIENT NOT ELIGIBLE/NOT APPROPRIATE FOR CLINICAL DEPRESSION SCREENING

G8434

DOCUMENTATION OF COGNITIVE IMPAIRMENT SCREENING USING A STANDARDIZED TOOL

G8435

NO DOCUMENTATION OF COGNITIVE IMPAIRMENT SCREENING USING A STANDARDIZED TOOL

G8436

PATIENT NOT ELIGIBLE/NOT APPROPRIATE FOR COGNITIVE IMPAIRMENT SCREENING

G8437

DOCUMENTATION OF CLINICIAN AND PATIENT INVOLVEMENT WITH THE DEVELOPMENT OF A TREAMENT PLAN/PLAN OF CARE INCLUDING SIGNATURE BY THE PRACTITIONER AND EITHER A CO-SIGNATURE BY THE PATIENT OR DOCUMENTED VERBAL AGREEMENT OBTAINED FROM THE PATIENT OR, WHEN NECESSARY, AN AUTHORIZED REPRESENTATIVE

G8438

NO DOCUMENTATION OF CLINICIAN AND PATIENT INVOLVEMENT WITH THE DEVELOPMENT OF A TREATMENT PLAN/PLAN OF CARE INCLUDING SIGNATURE BY THE PRACTITIONER AND EITHER A CO-SIGNATURE BY THE PATIENT OR DOCUMENTED VERBAL AGREEMENT OBTAINED FROM THE PATIENT OR, WHEN NECESSARY, AN AUTHORIZED REPRESENTATIVE

G8439

DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR CO-DEVELOPING A TREATMENT PLAN/PLAN OF CARE INCLUDING SIGNATURE BY THE PRACTITIONER AND EITHER A CO-SIGNATURE BY THE PATIENT OR DOCUMENTED VERBAL AGREEMENT OBTAINED FROM THE PATIENT OR, WHEN NECESSARY, AN AUTHORIZED REPRESENTATIVE

G8440

DOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY AND DESCRIPTION) PRIOR TO INITIATION OF TREATMENT OR DOCUMENTATION OF THE ABSENCE OF PAIN AS A RESULT OF ASSESSMENT

G8441

NO DOCUMENTATION OF PAIN ASSESSMENT (INCLUDING LOCATION, INTENSITY AND DESCRIPTION) PRIOR TO INITIATION OF TREATMENT

G8442

DOCUMENTATION THAT PATIENT IS NOT ELIGIBLE FOR PAIN ASSESSMENT

G8443

ALL PRESCRIPTIONS CREATED DURING THE ENCOUNTER WERE GENERATED USING A QUALIFIED E-PRESCRIBING SYSTEM

G8445

NO PRESCRIPTIONS WERE GENERATED DURING THE ENCOUNTER, PROVIDER DOES HAVE ACCESS TO A QUALIFIED E-PRESCRIBING SYSTEM

G8446

SOME OR ALL PRESCRIPTIONS GENERATED DURING THE ENCOUNTER WERE HANDWRITTEN OR PHONED IN DUE TO ONE OF THE FOLLOWING: REQUIRED BY STATE LAW, PATIENT REQUEST, OR QUALIFIED E-PRESCRIBING SYSTEM BEING TEMPORARILY INOPERABLE

G8447

PATIENT ENCOUNTER WAS DOCUMENTED USING A CCHIT CERTIFIED EMR

G8448

PATIENT ENCOUNTER WAS DOCUMENTED USING A NON-CCHIT CERTIFIED EMR; TO QUALIFY, THE SYSTEM MUST BE CAPABLE OF ALL OF THE FOLLOWING: GENERATING A MEDICATION LIST, GENERATING A PROBLEM LIST, ENTERING LABORATORY TESTS AS DISCRETE SEARCHABLE DATA ELEMENTS

G8449

PATIENT ENCOUNTER WAS NOT DOCUMENTED USING AN EMR DUE TO SYSTEM REASONS SUCH AS, THE SYSTEM BEING INOPERABLE AT THE TIME OF THE VISIT; USE OF THIS CODE IMPLIES THAT AN EMR IS IN PLACE AND GENERALLY AVAILABLE

G8450

BETA-BLOCKER THERAPY PRESCRIBED FOR PATIENTS WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF) <40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION

G8451

CLINICIAN DOCUMENTED PATIENT WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF) <40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION WAS NOT ELIGIBLE CANDIDATE FOR BETA-BLOCKER THERAPY

G8452

BETA-BLOCKER THERAPY NOT PRESCRIBED FOR PATIENTS WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF) <40% OR DOCUMENTATION AS MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION

G8453

TOBACCO USE CESSATION INTERVENTION, COUNSELING

G8454

TOBACCO USE CESSATION INTERVENTION NOT COUNSELED, REASON NOT SPECIFIED

G8455

CURRENT TOBACCO SMOKER

G8456

CURRENT SMOKELESS TOBACCO USER

G8457

TOBACCO NON-USER

G8458

CLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR GENOTYPE TESTING; PATIENT NOT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS C

G8459

CLINICIAN DOCUMENTED THAT PATIENT IS RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS C

G8460

CLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR QUANTITATIVE RNA TESTING AT WEEK 12; PATIENT NOT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS C

G8461

PATIENT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS C

G8462

CLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR COUNSELING REGARDING CONTRACEPTION PRIOR TO ANTIVIRAL TREATMENT; PATIENT NOT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS C

G8463

PATIENT RECEIVING ANTIVIRAL TREATMENT FOR HEPATITIS C DOCUMENTED

G8464

CLINICIAN DOCUMENTED THAT PROSTATE CANCER PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR ADJUVANT HORMONAL THERAPY; LOW OR INTERMEDIATE RISK OF RECURRENCE OR RISK OF RECURRENCE NOT DETERMINED

G8465

HIGH RISK OF RECURRENCE OF PROSTATE CANCER

G8466

CLINICIAN DOCUMENTED THAT PATIENT IS NOT AN ELIGIBLE CANDIDATE FOR SUICIDE RISK ASSESSMENT; MAJOR DEPRESSIVE DISORDER, IN REMISSION

G8467

DOCUMENTATION OF NEW DIAGNOSIS OF INITIAL OR RECURRENT EPISODE OF MAJOR DEPRESSIVE DISORDER

G8468

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY PRESCRIBED FOR PATIENTS WITH A LEFT VENTRICULAR EJECTION FRACTION (LVEF) <40% OR DOCUMENTATION OF MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION

G8469

CLINICIAN DOCUMENTED THAT PATIENT WITH A LEFT VENTRICULAR EJECTION FRACTION (LVEF) <40% OR DOCUMENTATION OF MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION WAS NOT AN ELIGIBLE CANDIDATE FOR ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY

G8470

PATIENT WITH LEFT VENTRICULAR EJECTION FRACTION (LVEF) >=40% OR DOCUMENTATION AS NORMAL OR MILDLY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION

G8471

LEFT VENTRICULAR EJECTION FRACTION (LVEF) WAS NOT PERFORMED OR DOCUMENTED

G8472

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY NOT PRESCRIBED FOR PATIENTS WITH A LEFT VENTRICULAR EJECTION FRACTION (LVEF) <40% OR DOCUMENTATION OF MODERATELY OR SEVERELY DEPRESSED LEFT VENTRICULAR SYSTOLIC FUNCTION, REASON NOT SPECIFIED

G8473

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY PRESCRIBED

G8474

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY NOT PRESCRIBED FOR REASONS DOCUMENTED BY THE CLINICIAN

G8475

ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY NOT PRESCRIBED, REASON NOT SPECIFIED

G8476

MOST RECENT BLOOD PRESSURE HAS A SYSTOLIC MEASUREMENT OF <130 MM/HG AND A DIASTOLIC MEASUREMENT OF <80 MM/HG

G8477

MOST RECENT BLOOD PRESSURE HAS A SYSTOLIC MEASUREMENT OF >=130 MM/HG AND/OR A DIASTOLIC MEASUREMENT OF >=80 MM/HG

G8478

BLOOD PRESSURE MEASUREMENT NOT PERFORMED OR DOCUMENTED, REASON NOT SPECIFIED

G8479

CLINICIAN PRESCRIBED ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY

G8480

CLINICIAN DOCUMENTED THAT PATIENT WAS NOT AN ELIGIBLE CANDIDATE FOR ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY

G8481

CLINICIAN DID NOT PRESCRIBE ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY, REASON NOT SPECIFIED

G8482

INFLUENZA IMMUNIZATION WAS ORDERED OR ADMINISTERED

G8483

INFLUENZA IMMUNIZATION WAS NOT ORDERED OR ADMINISTERED FOR REASONS DOCUMENTED BY CLINICIAN

G8484

INFLUENZA IMMUNIZATION WAS NOT ORDERED OR ADMINISTERED, REASON NOT SPECIFIED

J0220

INJECTION, AGLUCOSIDASE ALFA, 10 MG

J0400

INJECTION, ARIPIPRAZOLE, INTRAMUSCULAR, 0.25 MG

J1300

INJECTION, ECULIZUMAB, 10 MG

J1561

INJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), 500 MG

J1568

INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), 500 MG

J1569

INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), INTRAVENOUS, NON-LYOPHILIZED, (E.G. LIQUID), 500 MG

J1572

INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), 500 MG

J1743

INJECTION, IDURSULFASE, 1 MG

J2323

INJECTION, NATALIZUMAB, 1 MG

J2724

INJECTION, PROTEIN C CONCENTRATE, INTRAVENOUS, HUMAN, 10 IU

J2778

INJECTION, RANIBIZUMAB, 0.1 MG

J3488

INJECTION, ZOLEDRONIC ACID (RECLAST), 1 MG

J7321

HYALURONAN OR DERIVATIVE, HYALGAN OR SUPARTZ, FOR INTRA-ARTICULAR INJECTION, PER DOSE

J7322

HYALURONAN OR DERIVATIVE, SYNVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE

J7323

HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSE

J7324

HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE

J7602

ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)

J7603

ALBUTEROL, ALL FORMULATIONS INCLUDING SEPARATED ISOMERS, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, PER 1 MG (ALBUTEROL) OR PER 0.5 MG (LEVALBUTEROL)

J7605

ARFORMOTEROL, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 15 MICROGRAMS

J9303

INJECTION, PANITUMUMAB, 10 MG

L7611

TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED, PEDIATRIC

L7612

TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED, PEDIATRIC

L7613

TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, PEDIATRIC

L7614

TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, PEDIATRIC

L7621

TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED

L7622

TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED

V2787

ASTIGMATISM CORRECTING FUNCTION OF INTRAOCULAR LENS