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17000
|
PR DESTRUCTION PREMALIGNANT LESION 1ST
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11313
|
Shave skin lesion >2.0 cm
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11201
|
REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA_ EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11400
|
Removal of noncancer skin growth of body, arms, or legs, 0.5 cm or less
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
17004
|
PR DESTRUCTION PREMALIGNANT LESION 15/>
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
56515
|
PR DESTRUCTION LESIONS VULVA EXTENSIVE
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11200
|
Shave-Benign, Skin Tags1-15-FAC
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
17110
|
PR DESTRUCTION BENIGN LESIONS UP TO 14
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
56501
|
PR DESTRUCTION LESIONS VULVA SIMPLE
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
54065
|
PR DSTRJ LESION PENIS EXTENSIVE
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
57061
|
PR DESTRUCTION VAGINAL LESIONS SIMPLE
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11446
|
Removal of noncancer skin growth of face, ears, eyelids, nose, lips, or mouth, more than 4.0 cm
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
54050
|
PR DSTRJ LESION PENIS SIMPLE CHEMICAL
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
17111
|
PR DESTRUCTION BENIGN LESIONS 15/>
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11300
|
Shaving of skin growth of body, arms, or legs, 0.5 cm or less
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
57065
|
PR DESTRUCTION VAGINAL LESIONS EXTENSIVE
|
HCPCS
|
If the decision is made to excise or destroy a lesion for prophylactic purposes, doing so in an urgent manner is not necessary, as the period between lesion development and malignancy often spans decades. After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
17000
|
PR DESTRUCTION PREMALIGNANT LESION 1ST
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11313
|
Shave skin lesion >2.0 cm
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11201
|
REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA_ EACH ADDITIONAL 10 LESIONS, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11400
|
Removal of noncancer skin growth of body, arms, or legs, 0.5 cm or less
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
17004
|
PR DESTRUCTION PREMALIGNANT LESION 15/>
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
56515
|
PR DESTRUCTION LESIONS VULVA EXTENSIVE
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11200
|
Shave-Benign, Skin Tags1-15-FAC
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
17110
|
PR DESTRUCTION BENIGN LESIONS UP TO 14
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
56501
|
PR DESTRUCTION LESIONS VULVA SIMPLE
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
54065
|
PR DSTRJ LESION PENIS EXTENSIVE
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
57061
|
PR DESTRUCTION VAGINAL LESIONS SIMPLE
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11446
|
Removal of noncancer skin growth of face, ears, eyelids, nose, lips, or mouth, more than 4.0 cm
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
54050
|
PR DSTRJ LESION PENIS SIMPLE CHEMICAL
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
17111
|
PR DESTRUCTION BENIGN LESIONS 15/>
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
11300
|
Shaving of skin growth of body, arms, or legs, 0.5 cm or less
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
57065
|
PR DESTRUCTION VAGINAL LESIONS EXTENSIVE
|
HCPCS
|
After removal, clinical follow-up still should be performed yearly to evaluate these patients for the development of new or recurrent lesions (Spencer, 2011; Spencer, 2012). |CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|CPT codes covered if selection criteria are met:|
|11200 - 11201||Removal of skin tags, multiple fibrocutaneous tags, any area|
|11300 - 11313||Shaving of epidermal or dermal lesions|
|11400 - 11446||Excision, benign lesions|
|17000 - 17004||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses)|
|17110 - 17111||Destruction, (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions|
|54050 - 54065||Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle)|
|56501 - 56515||Destruction of lesion(s), vulva|
|57061 - 57065||Destruction of vaginal lesion(s)|
|ICD-10 codes covered if selection criteria are met:|
|A63.0||Anogenital (venereal) warts|
|B07.0 - B07.9||Viral warts [* note - report 17110-17111 per AMA CPT guidelines]|
|D04.0 - D04.9||Carcinoma in situ of skin [Bowen's disease, lentigo maligna]|
|D17.0 - D17.39||Benign lipomatous neoplasm of skin and subcutaneous tissue|
|D22.0 - D22.9||Melanocytic nevi|
|D23.0 - D23.9||Other benign neoplasm of skin|
|K13.21||Leukoplakia of oral mucosa, including tongue|
|L82.0 - L82.1||Seborrheic keratosis|
|
0064T
|
Spectroscop Eval Expired Gas
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged.
|
83987
|
Exhaled breath condensate
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged.
|
94799
|
Other service or procedure on lung
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged.
|
0140T
|
Exhaled breath condensate ph
|
CPT
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged.
|
84999
|
UNLISTED CHEMISTRY PROCEDURE
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged.
|
0064T
|
Spectroscop Eval Expired Gas
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section.
|
83987
|
Exhaled breath condensate
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section.
|
94799
|
Other service or procedure on lung
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section.
|
0140T
|
Exhaled breath condensate ph
|
CPT
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section.
|
84999
|
UNLISTED CHEMISTRY PROCEDURE
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section.
|
0064T
|
Spectroscop Eval Expired Gas
|
HCPCS
|
POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section.
|
83987
|
Exhaled breath condensate
|
HCPCS
|
POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section.
|
94799
|
Other service or procedure on lung
|
HCPCS
|
POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section.
|
0140T
|
Exhaled breath condensate ph
|
CPT
|
POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section.
|
84999
|
UNLISTED CHEMISTRY PROCEDURE
|
HCPCS
|
POLICY HISTORY3/25/2004: Approved by Medical Policy Advisory Committee (MPAC)
4/29/2004: Code Reference section completed
3/22/2005: Code Reference section updated, CPT code 0064T added non-covered codes, CPT code 84999 Note: "To report services on or after 1/1/2005, see CPT code 0064T" added
12/22/2005: Collection and Measurement of Exhaled Breath Condensate and coding 0140T added to policy
1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
1/3/2007: Policy reviewed, no changes
12/17/2008: Policy reviewed, no changes
05/28/2010: Title updated with "Exhaled Breath Condensate"; Description section updated; Policy Statement section - existing policy statement was divided into two statements: one for exhaled nitric oxide and the other for exhaled breath condensate - both remain investigational; FEP verbiage was added to the Policy Exceptions section; and Code Reference section was updated to add new CPT Code 83987 and CPT Code 94799 to the Non-Covered Codes Table. 02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section.
|
0140T
|
Exhaled breath condensate ph
|
CPT
|
02/23/2011: Policy reviewed; no changes. 02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section. 04/04/2013: Policy reviewed; no changes.
|
0140T
|
Exhaled breath condensate ph
|
CPT
|
02/24/2012: The first policy statement was revised to change “exhaled or nasal nitric oxide” to “exhaled nitric oxide.” Intent unchanged. Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section. 04/04/2013: Policy reviewed; no changes. 03/11/2014: Policy reviewed; no changes.
|
0140T
|
Exhaled breath condensate ph
|
CPT
|
Deleted outdated references from the Sources section. Removed deleted CPT codes 0064T and 0140T from the Code Reference section. 04/04/2013: Policy reviewed; no changes. 03/11/2014: Policy reviewed; no changes. 07/20/2015: Policy title changed from "Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements in the Diagnosis and Management of Asthma and Other Respiratory Disorders" to "Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders."
|
0140T
|
Exhaled breath condensate ph
|
CPT
|
Removed deleted CPT codes 0064T and 0140T from the Code Reference section. 04/04/2013: Policy reviewed; no changes. 03/11/2014: Policy reviewed; no changes. 07/20/2015: Policy title changed from "Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements in the Diagnosis and Management of Asthma and Other Respiratory Disorders" to "Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders." Policy description revised and updated regarding devices.
|
15878
|
Suction lipectomy upr extrem
|
HCPCS
|
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis."
|
97033
|
SBT PTA IONTOPHORESIS EACH 15 MIN
|
HCPCS
|
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis."
|
J0585
|
PR INJECTION,ONABOTULINUMTOXINA 1 UNITS
|
HCPCS
|
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis."
|
17999
|
UNLISTED PROC SKIN SUBQ
|
HCPCS
|
changed from investigational to medically necessary as follows: "Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents. "; "The treatment of axillary hyperhidrosis is considered cosmetic and therefore not eligible for coverage." deleted, Code Reference section updated, ICD-9 diagnosis code 780.8 description revised and "Note" added covered table, HCPCS J0585 added covered table, non-covered table added, CPT code 15878, 17999, 97033 added non-covered table, ICD-9 procedure code 86.3, 86.83, 99.27 added non-covered table
11/18/2004: Reviewed by MPAC, Treatment of severe primary axillary hyperhidrosis with botulinum toxin is considered medically necessary after failed treatment using topical agents, consultation with a dermatologist, and prior authorization. Sources updated
5/5/2005: Code Reference section updated, ICD-9 diagnosis code 705.21 added with Note: "Use code 780.8 to report all forms of hyperhidrosis for dates of service prior to 10/1/2004. See POLICY statement for coverage information regarding the various forms of hyperhidrosis."
|
J0585
|
PR INJECTION,ONABOTULINUMTOXINA 1 UNITS
|
HCPCS
|
01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy.
|
J0587
|
rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial
|
HCPCS
|
01/01/2009: Accredo preferred provider information removed. BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy.
|
J0585
|
PR INJECTION,ONABOTULINUMTOXINA 1 UNITS
|
HCPCS
|
BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. Added links to related medical policy.
|
J0587
|
rimabotulinumtoxinB 5,000 unit/mL solution 1 mL Vial
|
HCPCS
|
BCBSMS information added. 07/27/2009: Policy Description section updated for a clearer understanding of primary and secondary hyperhidrosis symptoms and treatments, Policy Statement section revised to add table with treatments considered medically necessary per region and treatments considered investigational per region for a clearer understanding of the intent of the policy, Policy Guidelines section updated to add features of hyperhidrosis, note added to HCPCS code J0585 under covered table, HCPCS code J0587 added to non covered table. 08/03/2010: Policy description updated to add new FDA information about the safety evaluation of botulinum toxin products and the new drug names established to reinforce individual potencies and prevent medication errors. Botulinum type A and botulinum B were changed to OnabotulinumtoxinA and RimabotulinumtoxinB, respectively, throughout the policy. Added links to related medical policy.
|
E0218
|
Fluid circ cold pad w pump
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY2/2001: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section completed, HCPCS E0218 added
5/2/2002: Type of Service and Place of Service deleted
8/16/2005: Policy title "Polar Care" renamed "Cooling Devices," Description and Policy sections revised to be consistent with BCBSA policy # 1.01.26, Code Reference section updated, HCPCS E0236 added
4/25/2008: Policy reviewed, no changes
12/10/2009: Policy Exclusions revised to include FEP verbiage, HCPCS code E1399 added to Non-Covered Codes Table. 05/17/2011: Policy reviewed; no changes to policy statement. Removed outdated references from the Sources section.
|
E0236
|
Pump for water circulating pad
|
HCPCS
|
In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY2/2001: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section completed, HCPCS E0218 added
5/2/2002: Type of Service and Place of Service deleted
8/16/2005: Policy title "Polar Care" renamed "Cooling Devices," Description and Policy sections revised to be consistent with BCBSA policy # 1.01.26, Code Reference section updated, HCPCS E0236 added
4/25/2008: Policy reviewed, no changes
12/10/2009: Policy Exclusions revised to include FEP verbiage, HCPCS code E1399 added to Non-Covered Codes Table. 05/17/2011: Policy reviewed; no changes to policy statement. Removed outdated references from the Sources section.
|
E0218
|
Fluid circ cold pad w pump
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY2/2001: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section completed, HCPCS E0218 added
5/2/2002: Type of Service and Place of Service deleted
8/16/2005: Policy title "Polar Care" renamed "Cooling Devices," Description and Policy sections revised to be consistent with BCBSA policy # 1.01.26, Code Reference section updated, HCPCS E0236 added
4/25/2008: Policy reviewed, no changes
12/10/2009: Policy Exclusions revised to include FEP verbiage, HCPCS code E1399 added to Non-Covered Codes Table. 05/17/2011: Policy reviewed; no changes to policy statement. Removed outdated references from the Sources section. 03/02/2012: Policy reviewed.
|
E0236
|
Pump for water circulating pad
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY2/2001: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section completed, HCPCS E0218 added
5/2/2002: Type of Service and Place of Service deleted
8/16/2005: Policy title "Polar Care" renamed "Cooling Devices," Description and Policy sections revised to be consistent with BCBSA policy # 1.01.26, Code Reference section updated, HCPCS E0236 added
4/25/2008: Policy reviewed, no changes
12/10/2009: Policy Exclusions revised to include FEP verbiage, HCPCS code E1399 added to Non-Covered Codes Table. 05/17/2011: Policy reviewed; no changes to policy statement. Removed outdated references from the Sources section. 03/02/2012: Policy reviewed.
|
93740
|
Temperature gradient studies
|
HCPCS
|
There is an absence of evidence of the impact of DIRI on health outcomes. The BioScanIR System (OmniCorder Technologies, Inc., Bohemia, NY) is an example of a DIRI device that is commercially available. |CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes not covered for indications listed in the CPB:|
|93740||Temperature gradient studies|
|ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):|
|140.0 - 208.91||Malignant neoplasm|
|250.70 - 250.73||Diabetes with peripheral circulatory disorders|
|414.00 - 414.07||Coronary atherosclerosis|
|443.81||Peripheral angiopathy in diseases classified elsewhere|
|729.5||Pain in limb|
|813.41 - 813.42||Closed fracture of radius|
|813.51 - 813.52||Open fracture of radius|
|905.2||Late effect of fractures of upper extremity|
|V45.81||Aortocoronary bypass graft status|
|V58.11 - V58.12||Encounter for antineoplastic chemotherapy and immunotherapy|
|V72.81||Pre-operative cardiovascular examination|
|V72.83||Other specified pre-operative examination|
|V72.84||Pre-operative examination, unspecified|
|V76.0 - V76.9||Special screening for malignant neoplasms|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes not covered for indications listed in the CPB:|
|93740||Temperature gradient studies|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C00.0 - C96.9||Malignant neoplasms|
|E10.51 - E10.59
E11.51 - E11.59
|Diabetes mellitus with circulatory complications [Type 1 or 2]|
|I25.10 - I25.9||Coronary atherosclerosis|
|I73.9||Peripheral vascular disease, unspecified|
|M79.601 - M79.609||Pain in limb|
|M84.421S - M84.429S
M84.431S - M84.439S
S42.209S - S42.496S
S49.001S - S49.199S
S52.001S - S52.92xS
S59.001S - S59.299S
S62.90xS - S62.92xS
|Fracture of upper extremity, sequela|
|S52.501+ - S52.509+
S52.531+ - S52.539+
|Fracture of radius [open or closed]|
|Z01.810||Encounter for preprocedural cardiovascular examination|
|Z01.818||Encounter for other preprocedural examination|
|Z12.0 - Z12.9||Encounter for screening for malignant neoplasms|
|Z51.11 - Z51.12||Encounter for antineoplastic chemotherapy or immunotherapy|
|Z95.1||Presence of aortocoronary bypass graft|
|
93740
|
Temperature gradient studies
|
HCPCS
|
The BioScanIR System (OmniCorder Technologies, Inc., Bohemia, NY) is an example of a DIRI device that is commercially available. |CPT Codes / HCPCS Codes / ICD-9 Codes|
|CPT codes not covered for indications listed in the CPB:|
|93740||Temperature gradient studies|
|ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):|
|140.0 - 208.91||Malignant neoplasm|
|250.70 - 250.73||Diabetes with peripheral circulatory disorders|
|414.00 - 414.07||Coronary atherosclerosis|
|443.81||Peripheral angiopathy in diseases classified elsewhere|
|729.5||Pain in limb|
|813.41 - 813.42||Closed fracture of radius|
|813.51 - 813.52||Open fracture of radius|
|905.2||Late effect of fractures of upper extremity|
|V45.81||Aortocoronary bypass graft status|
|V58.11 - V58.12||Encounter for antineoplastic chemotherapy and immunotherapy|
|V72.81||Pre-operative cardiovascular examination|
|V72.83||Other specified pre-operative examination|
|V72.84||Pre-operative examination, unspecified|
|V76.0 - V76.9||Special screening for malignant neoplasms|
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015 :|
|CPT codes not covered for indications listed in the CPB:|
|93740||Temperature gradient studies|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|C00.0 - C96.9||Malignant neoplasms|
|E10.51 - E10.59
E11.51 - E11.59
|Diabetes mellitus with circulatory complications [Type 1 or 2]|
|I25.10 - I25.9||Coronary atherosclerosis|
|I73.9||Peripheral vascular disease, unspecified|
|M79.601 - M79.609||Pain in limb|
|M84.421S - M84.429S
M84.431S - M84.439S
S42.209S - S42.496S
S49.001S - S49.199S
S52.001S - S52.92xS
S59.001S - S59.299S
S62.90xS - S62.92xS
|Fracture of upper extremity, sequela|
|S52.501+ - S52.509+
S52.531+ - S52.539+
|Fracture of radius [open or closed]|
|Z01.810||Encounter for preprocedural cardiovascular examination|
|Z01.818||Encounter for other preprocedural examination|
|Z12.0 - Z12.9||Encounter for screening for malignant neoplasms|
|Z51.11 - Z51.12||Encounter for antineoplastic chemotherapy or immunotherapy|
|Z95.1||Presence of aortocoronary bypass graft|
|
S8035
|
MAGNETIC SOURCE IMAGING
|
HCPCS
|
HCPCS code S8035 was previously added to codes table. FEP verbiage added to the Policy Exceptions section. Deleted outdated references from the Sources section. 04/20/2011: Policy reviewed; no changes. 11/30/2012: Policy statement revised to state that magnetoencephalography/magnetic source imaging as part of the preoperative evaluation of patients with intractable epilepsy (seizures refractory to at least two first-line anticonvulsants) may be considered medically necessary when standard techniques, such as MRI and EEG, do not provide satisfactory localization of epileptic lesion(s).
|
87476
|
LYME DISEASE PCR
|
HCPCS
|
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational.
|
87477
|
Lyme dis dna quant
|
HCPCS
|
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational.
|
87475
|
Lyme dis dna dir probe
|
HCPCS
|
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary. The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational.
|
87476
|
LYME DISEASE PCR
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements.
|
87477
|
Lyme dis dna quant
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements.
|
87475
|
Lyme dis dna dir probe
|
HCPCS
|
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language. POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements.
|
J0550
|
Penicillin g benzathine inj
|
HCPCS
|
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section.
|
J0540
|
Penicillin g benzathine inj
|
HCPCS
|
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section.
|
87476
|
LYME DISEASE PCR
|
HCPCS
|
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section.
|
J0530
|
Penicillin g benzathine inj
|
HCPCS
|
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section.
|
87477
|
Lyme dis dna quant
|
HCPCS
|
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section.
|
87475
|
Lyme dis dna dir probe
|
HCPCS
|
POLICY HISTORY1/1994: Approved by Medical Policy Advisory Committee (MPAC)
5/1/2002: Type of Service and Place of Service deleted
3/25/2004: Reviewed by MPAC, Policy title “Lyme Disease Treatment” renamed “Intravenous Antiobiotic Therapy for Lyme Disease”, Description and Policy sections revised to be consistent with BCBSA policy # 5.01.08, intravenous antibiotic therapy changed from investigational to medically necessary for certain indications, investigation definition added, Sources updated, tables added to Code Reference section
5/5/2004: Code Reference section completed
3/13/2006: Policy reviewed, no changes
9/12/2006: Coding reviewed. ICD9 2006 revisions added to policy
11/13/2006: Code Reference section updated: CPT codes 87475, 87476, and 87477 deleted from policy
4/24/2007: Policy reviewed, policy statement rewritten for clarification
6/21/2007: Policy reviewed, description updated. Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section.
|
J0550
|
Penicillin g benzathine inj
|
HCPCS
|
Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal.
|
J0540
|
Penicillin g benzathine inj
|
HCPCS
|
Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal.
|
J0530
|
Penicillin g benzathine inj
|
HCPCS
|
Policy statement revised; IV antibiotic therapy is not medically necessary for uncomplicated cranial nerve palsy associated with Lyme disease and antibiotic-refractory Lyme arthritis
7/19/2007: Reviewed and approved by MPAC
7/10/2009: Policy reviewed, no changes
12/15/2009: Coding Section revised with 2010 CPT4 and HCPCS revisions
02/23/2011: Added the following to the policy statement: Determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal.
|
J0550
|
Penicillin g benzathine inj
|
HCPCS
|
No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment.
|
J0540
|
Penicillin g benzathine inj
|
HCPCS
|
No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment.
|
J0530
|
Penicillin g benzathine inj
|
HCPCS
|
No changes to other policy statements. Removed deleted HCPCS codes J0530, J0540, and J0550 from the Code Reference section. 02/24/2012: Add the following policy statement: A single 2- to 4-week course of IV antibiotics may be considered medically necessary in patients with Lyme carditis, as evidenced by positive serologic findings (defined above) and associated with a high degree of atrioventricular block or a PR interval of greater than 0.3 second. Documentation of Lyme carditis may include PCR-based direct detection of B burgdorferi in the blood when results of serologic studies are equivocal. The last policy statement was revised to state that other diagnostic testing is considered investigational including but not limited to C6 peptide ELISA or determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment.
|
J0580
|
Penicillin g benzathine inj
|
HCPCS
|
It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section.
|
J0560
|
Penicillin g benzathine inj
|
HCPCS
|
It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section.
|
J0570
|
Buprenorphine implant, 74.2 mg
|
HCPCS
|
It previously stated that determination of levels of the B lymphocyte chemoattractant CXCL13 for diagnosis or monitoring treatment is considered investigational. Deleted outdated references from the Sources section. 11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section.
|
J0580
|
Penicillin g benzathine inj
|
HCPCS
|
11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13.
|
J0560
|
Penicillin g benzathine inj
|
HCPCS
|
11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13.
|
J0570
|
Buprenorphine implant, 74.2 mg
|
HCPCS
|
11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13.
|
J0561
|
PR PENICILLIN G BENZATHINE INJ 100,000 UNITS
|
HCPCS
|
11/28/2012: Policy reviewed; no changes. 03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13.
|
J0580
|
Penicillin g benzathine inj
|
HCPCS
|
03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement.
|
J0560
|
Penicillin g benzathine inj
|
HCPCS
|
03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement.
|
J0570
|
Buprenorphine implant, 74.2 mg
|
HCPCS
|
03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement.
|
J0561
|
PR PENICILLIN G BENZATHINE INJ 100,000 UNITS
|
HCPCS
|
03/10/2014: Policy reviewed; no changes to policy statement. Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement.
|
J0580
|
Penicillin g benzathine inj
|
HCPCS
|
Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal.
|
J0560
|
Penicillin g benzathine inj
|
HCPCS
|
Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal.
|
J0570
|
Buprenorphine implant, 74.2 mg
|
HCPCS
|
Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal.
|
J0561
|
PR PENICILLIN G BENZATHINE INJ 100,000 UNITS
|
HCPCS
|
Removed deleted HCPCS codes J0560, J0570, and J0580 from the Code Reference section. Added HCPCS code J0561. 02/18/2015: Policy description updated regarding polymerase chain reaction and the evaluation of the Chemoattractant CXCL13. Medically necessary policy statement regarding PCR-based direct detection of B. burgdorferi in CSF samples updated to add "and may replace serologic documentation of infection" to the policy statement. Removed the following statement: PCR-based direct detection of B. burgdorferi in the blood when results of serologic studies are equivocal.
|
0109
|
Med-Surg
|
RC
|
The Regional Committee for Europe adopted the JMF in September 2018. The majority of JMF indicators in the Gateway are linked to existing databases in the Gateway. EUR/RC68/10 Rev.1 Briefing note on the expert group deliberations and recommended common set of indicators for a joint monitoring framework
EUR/RC68(1): Joint monitoring framework in the context of the roadmap to implement the 2030 Agenda for Sustainable Development, building on Health 2020, the European policy for health and well-being
Developing a common set of indicators for the joint monitoring framework for SDGs, Health 2020 and the Global NCD Action Plan (2017)
Indicator code: E080109.F This indicator shares the definition with the parent indicator \"\". A maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (see ICD-10 manual, vol. 2).
|
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