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92585
|
Auditor evoke potent compre
|
HCPCS
|
This is in accordance with the findings of Ayache and associates (2000) who concluded that assessment of perilymphatic pressure does not seem to be useful in Meniere's disease. Furthermore, Rosingh and co-workers (2000) reported that perilymphatic pressure measured in the affected ear of patients with Meniere's disease or idiopathic sudden sensori-neural hearing loss did not differ significantly from the pressure in the non-affected and normal hearing ear. In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
70540
|
MRI scan of bone of eye socket, face, and/or neck without contrast
|
HCPCS
|
This is in accordance with the findings of Ayache and associates (2000) who concluded that assessment of perilymphatic pressure does not seem to be useful in Meniere's disease. Furthermore, Rosingh and co-workers (2000) reported that perilymphatic pressure measured in the affected ear of patients with Meniere's disease or idiopathic sudden sensori-neural hearing loss did not differ significantly from the pressure in the non-affected and normal hearing ear. In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
70542
|
MRI scan of bone of eye socket, face, and/or neck with contrast
|
HCPCS
|
Furthermore, Rosingh and co-workers (2000) reported that perilymphatic pressure measured in the affected ear of patients with Meniere's disease or idiopathic sudden sensori-neural hearing loss did not differ significantly from the pressure in the non-affected and normal hearing ear. In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
92588
|
PR DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL
|
HCPCS
|
Furthermore, Rosingh and co-workers (2000) reported that perilymphatic pressure measured in the affected ear of patients with Meniere's disease or idiopathic sudden sensori-neural hearing loss did not differ significantly from the pressure in the non-affected and normal hearing ear. In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
92587
|
PR DISTORT PRODUCT EVOKED OTOACOUSTIC EMISNS LIMITD
|
HCPCS
|
Furthermore, Rosingh and co-workers (2000) reported that perilymphatic pressure measured in the affected ear of patients with Meniere's disease or idiopathic sudden sensori-neural hearing loss did not differ significantly from the pressure in the non-affected and normal hearing ear. In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
92585
|
Auditor evoke potent compre
|
HCPCS
|
Furthermore, Rosingh and co-workers (2000) reported that perilymphatic pressure measured in the affected ear of patients with Meniere's disease or idiopathic sudden sensori-neural hearing loss did not differ significantly from the pressure in the non-affected and normal hearing ear. In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
70540
|
MRI scan of bone of eye socket, face, and/or neck without contrast
|
HCPCS
|
Furthermore, Rosingh and co-workers (2000) reported that perilymphatic pressure measured in the affected ear of patients with Meniere's disease or idiopathic sudden sensori-neural hearing loss did not differ significantly from the pressure in the non-affected and normal hearing ear. In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
70542
|
MRI scan of bone of eye socket, face, and/or neck with contrast
|
HCPCS
|
In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
92588
|
PR DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL
|
HCPCS
|
In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
92587
|
PR DISTORT PRODUCT EVOKED OTOACOUSTIC EMISNS LIMITD
|
HCPCS
|
In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
92585
|
Auditor evoke potent compre
|
HCPCS
|
In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
70540
|
MRI scan of bone of eye socket, face, and/or neck without contrast
|
HCPCS
|
In a follow-up study by Ayache et al (2002), the authors concluded that perilymphatic pressure measurements by means of the Tympanic Displacement Analyzer are not useful in the evaluation of patients with Meniere’s disease. |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 covered if selection criteria are met:|
|Other CPT codes related to the CPB:|
|70540||Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s)|
|70542||with contrast material(s)|
|92585||Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive|
|92587||Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)|
|92588||comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)|
|ICD-10 codes covered if selection criteria are met:|
|H81.01 - H81.09||Meniere's disease|
|H81.10 - H81.13
H81.311 - H81.49
|H83.11 - H83.19||Labyrinthine fistula|
|H83.3X1 - H83.3X9||Noise effects on inner ear|
|H90.3||Sensorineural hearing loss, bilateral|
|H90.41 - H90.42||Sensorineural hearing loss, unilateral, with unrestricted hearing on the contralateral side|
|H90.5||Unspecified sensorineural hearing loss|
|H90.6 - H90.8||Mixed conductive and sensorineural hearing loss|
|H91.20 - H91.23||Sudden idiopathic hearing loss|
|H91.8X1 - H91.8X9||Other specified hearing loss|
|H93.11 - H93.19||Tinnitus|
|R26.89||Other abnormalities of gait and mobility [imbalance]|
|R42||Dizziness and giddiness|
|ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):|
|Z01.10||Encounter for examination of ears and hearing without abnormal findings [routine screen without signs/symptoms]|
|Z01.110||Encounter for hearing examination following failed hearing screening [routine screen without signs/symptoms]|
Perilymphatic Pressure Measurement
|
0516
|
HB URG HIM- NEEDLE ASPIRATION
|
RC
|
Nephrectomy specimen. H&E stain. ICD-10 C64 ICD-9 189.0 ICD-O: M8312/3 OMIM 144700 605074 DiseasesDB 11245 MedlinePlus 000516 eMedicine med/2002
Renal cell carcinoma (RCC, also known as hypernephroma) is a kidney cancer that originates in the lining of the proximal convoluted tubule, the very small tubes in the kidney that filter the blood and remove waste products. RCC is the most common type of kidney cancer in adults, responsible for approximately 80% of cases. It is also known to be the most lethal of all the genitourinary tumors.
|
0516
|
HB URG HIM- NEEDLE ASPIRATION
|
RC
|
H&E stain. ICD-10 C64 ICD-9 189.0 ICD-O: M8312/3 OMIM 144700 605074 DiseasesDB 11245 MedlinePlus 000516 eMedicine med/2002
Renal cell carcinoma (RCC, also known as hypernephroma) is a kidney cancer that originates in the lining of the proximal convoluted tubule, the very small tubes in the kidney that filter the blood and remove waste products. RCC is the most common type of kidney cancer in adults, responsible for approximately 80% of cases. It is also known to be the most lethal of all the genitourinary tumors. Initial treatment is most commonly a radical or partial nephrectomy and remains the mainstay of curative treatment.
|
1000
|
HC ASAM LEVEL 3.7 MEDICALLY MONITORED INPATIENT
|
RC
|
Cohort. Male veterans aged ≥65 with T2DM free from age-related comorbidities (CVD, cancer, depression, dementia, frailty related diseases). Divided into Health class, Cancer risk class, CVD risk class, Frailty risk class.||Overall: Healthy = 22,841/NR, Cancer risk = 4,669/NR, CVD risk = 6,697/NR, Frailty risk = 6,697/NR||Dementia diagnosis (ICD9:290.xx)|
|Guo ||Metformin (starting dose 0.5 g per tablet, two tablets a day, increasing up to 2.0 g/day to achieve blood glucose control)||Placebo (vitamin C tablet with the same appearance)||China. RCT. Patients aged between 40 and 65 with T2DM and depression who were not using insulin or other anti-diabetic medications, and had no serious diabetes complications, history of substance abuse or dependence, severe heart failure or other abnormal laboratory findings.||9 years Metformin = 29/Na; Placebo = 29/Na 24 weeks||Wechsler Memory Scale Revised|
|Luchsinger ||Metformin (1000 mg twice per days was the goal although not all patients tolerated)||Placebo||USA.
|
1000
|
HC ASAM LEVEL 3.7 MEDICALLY MONITORED INPATIENT
|
RC
|
Divided into Health class, Cancer risk class, CVD risk class, Frailty risk class.||Overall: Healthy = 22,841/NR, Cancer risk = 4,669/NR, CVD risk = 6,697/NR, Frailty risk = 6,697/NR||Dementia diagnosis (ICD9:290.xx)|
|Guo ||Metformin (starting dose 0.5 g per tablet, two tablets a day, increasing up to 2.0 g/day to achieve blood glucose control)||Placebo (vitamin C tablet with the same appearance)||China. RCT. Patients aged between 40 and 65 with T2DM and depression who were not using insulin or other anti-diabetic medications, and had no serious diabetes complications, history of substance abuse or dependence, severe heart failure or other abnormal laboratory findings.||9 years Metformin = 29/Na; Placebo = 29/Na 24 weeks||Wechsler Memory Scale Revised|
|Luchsinger ||Metformin (1000 mg twice per days was the goal although not all patients tolerated)||Placebo||USA. RCT. Participants were aged 55 to 90 years with amnestic mild cognitive impairment without treated diabetes and a BMI of ≥25||Metformin = 40/Na, Placebo = 40/Na (ITT)||Primary: Total recall of the Bushcke SRT, ADAS-cog|
|Huang ||Metformin-use||Never use of metformin||Taiwan.
|
83655
|
Lead level
|
HCPCS
|
However, these tests are not routinely available, and are not recommended by the Centers for Disease Control and Prevention (CDC). BLLs remain the gold standard for the diagnosis of lead poisoning in children”. |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 covered if selection criteria are met:|
|83655||Lead [not covered for measurement of lead in bone, hair, teeth, or urine]|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|F50.8||Other eating disorders [Pica in adults]|
|F80.0 - F89||Pervasive and specific developmental disorders|
|F98.3||Pica of infancy and childhood|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H91.93||Conductive and sensorineural hearing loss|
|K59.00 - K59.09||Constipation|
|R10.0 - R10.13
R10.30 - R10.829
R10.84 - R10.9
|R11.0 - R11.2||Nausea and vomiting|
|R40.20 - R40.3||Coma|
|R40.4||Transient alteration of awareness|
|R53.0 - R53.1
|Other malaise and fatigue [lethargy]|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T74.02X+||Child neglect or abandonment, confirmed|
|T74.92X+||Unspecified child maltreatment, confirmed|
|Z77.011||Contact with and (suspected) exposure to lead|
|
83655
|
Lead level
|
HCPCS
|
BLLs remain the gold standard for the diagnosis of lead poisoning in children”. |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 covered if selection criteria are met:|
|83655||Lead [not covered for measurement of lead in bone, hair, teeth, or urine]|
|ICD-10 codes covered if selection criteria are met (not all-inclusive):|
|D50.0 - D50.9||Iron deficiency anemia|
|F50.8||Other eating disorders [Pica in adults]|
|F80.0 - F89||Pervasive and specific developmental disorders|
|F98.3||Pica of infancy and childhood|
|G40.001 - G40.919||Epilepsy and recurrent seizures|
|G44.1||Vascular headache, not elsewhere classified|
|H90.0 - H91.93||Conductive and sensorineural hearing loss|
|K59.00 - K59.09||Constipation|
|R10.0 - R10.13
R10.30 - R10.829
R10.84 - R10.9
|R11.0 - R11.2||Nausea and vomiting|
|R40.20 - R40.3||Coma|
|R40.4||Transient alteration of awareness|
|R53.0 - R53.1
|Other malaise and fatigue [lethargy]|
|R62.0 - R62.59||Lack of expected normal physiological development in childhood|
|T56.0X1+ - T56.0X4+||Toxic effect of lead and its compounds|
|T74.02X+||Child neglect or abandonment, confirmed|
|T74.92X+||Unspecified child maltreatment, confirmed|
|Z77.011||Contact with and (suspected) exposure to lead|
|
88145
|
Cytopath, c/v, thin lyr sel
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
G0148
|
Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
87620
|
Hpv dna dir probe
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
88148
|
Cytopath c/v auto rescreen
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
G0143
|
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
88153
|
Cytopath c/v redo
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
87621
|
Hpv dna amp probe
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
87622
|
Hpv dna quant
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
G0141
|
Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
88147
|
Cytopath c/v automated
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
G0124
|
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
88165
|
Cytopath tbs c/v redo
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
P3000
|
Screen pap by tech w md supv
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
G0123
|
SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, SCREENING BY CYTOTECHNOLOGIST UNDER PHYSICIAN SUPERVISION
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
G0145
|
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
G0147
|
Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
P3001
|
Screening pap smear by phys
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
88164
|
HC CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
88144
|
Cytopath, c/v, thin lyr redo
|
HCPCS
|
Primary screening and rescreening of Pap smears using the FocalPointTM system automated slide reading system in high-risk patients (e.g., symptomatic patients, those with prior abnormalities or malignancies, or those with prior abnormal Pap diagnoses) is investigational. HPV testing of Pap Smears to detect high and low risk forms of HPV for the likelihood of cervical cancer development using in situ hybridization (ISH) is considered investigational. POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated.
|
88145
|
Cytopath, c/v, thin lyr sel
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
G0148
|
Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
87620
|
Hpv dna dir probe
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
88174
|
Cytopath c/v auto in fluid
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
88148
|
Cytopath c/v auto rescreen
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
G0143
|
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
88153
|
Cytopath c/v redo
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
87621
|
Hpv dna amp probe
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
87622
|
Hpv dna quant
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
G0141
|
Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
88147
|
Cytopath c/v automated
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
G0124
|
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
88165
|
Cytopath tbs c/v redo
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
P3000
|
Screen pap by tech w md supv
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
G0123
|
SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, SCREENING BY CYTOTECHNOLOGIST UNDER PHYSICIAN SUPERVISION
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
G0145
|
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
G0147
|
Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
P3001
|
Screening pap smear by phys
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
88164
|
HC CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
88144
|
Cytopath, c/v, thin lyr redo
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
88175
|
PAP
|
HCPCS
|
POLICY EXCEPTIONSFor Federal Employee Program (FEP) subscribers only, HPV testing, in conjunction with Pap smears, for the purpose of screening women for cervical abnormalities in women over age 30 may be 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 HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted.
|
88145
|
Cytopath, c/v, thin lyr sel
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
G0148
|
Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
87620
|
Hpv dna dir probe
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
88174
|
Cytopath c/v auto in fluid
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
88148
|
Cytopath c/v auto rescreen
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
G0143
|
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
88153
|
Cytopath c/v redo
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
87621
|
Hpv dna amp probe
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
87622
|
Hpv dna quant
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
G0141
|
Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
88147
|
Cytopath c/v automated
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
G0124
|
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
88165
|
Cytopath tbs c/v redo
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
P3000
|
Screen pap by tech w md supv
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
G0123
|
SCREENING CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION, SCREENING BY CYTOTECHNOLOGIST UNDER PHYSICIAN SUPERVISION
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
G0145
|
Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
G0147
|
Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
P3001
|
Screening pap smear by phys
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
88164
|
HC CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
88144
|
Cytopath, c/v, thin lyr redo
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
88175
|
PAP
|
HCPCS
|
POLICY HISTORY8/1998: Approved by Medical Policy Advisory Committee (MPAC)
8/21/2002: Policy Guidelines revised, CPT codes 88147, 88148, 88153, 88164, 88165 deleted, HCPCS P3000-P3001 deleted, HCPCS G0123-G0124, G0143-G0145 added
10/17/2005: Code reference section updated; CPT-4: 87620, 87621, 87622, 88147, 88148 added; 88144, 88145 deleted; ICD-9 Procedure: "Microscopic examination of specimen from female genital tract" deleted; ICD-9 Diagnosis: 233.1 added; HCPCS: G0141, G0147, G0148 added; "with manual screening and computer-assisted rescreening by cytotechnologist under physician supervision," "Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and computer-assisted rescreening using cell selection and review under physician supervision" deleted
9/29/2006: Policy updated. Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged.
|
87622
|
Hpv dna quant
|
HCPCS
|
Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3.
|
P3000
|
Screen pap by tech w md supv
|
HCPCS
|
Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3.
|
88174
|
Cytopath c/v auto in fluid
|
HCPCS
|
Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3.
|
P3001
|
Screening pap smear by phys
|
HCPCS
|
Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3.
|
88175
|
PAP
|
HCPCS
|
Code reference section udpated. CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3.
|
87622
|
Hpv dna quant
|
HCPCS
|
CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered.
|
P3000
|
Screen pap by tech w md supv
|
HCPCS
|
CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered.
|
88174
|
Cytopath c/v auto in fluid
|
HCPCS
|
CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered.
|
P3001
|
Screening pap smear by phys
|
HCPCS
|
CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered.
|
88175
|
PAP
|
HCPCS
|
CPT codes 88174 and 88175; HCPCS P3000 and P3001 added to policy
11/14/2006: Code Reference section updated: CPT code 87622 deleted. 8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered.
|
87622
|
Hpv dna quant
|
HCPCS
|
8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141.
|
G0141
|
Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
|
HCPCS
|
8/28/2007: In situ hybridization (ISH) for HPV testing is considered investigational. 7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141.
|
87622
|
Hpv dna quant
|
HCPCS
|
7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated.
|
G0141
|
Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
|
HCPCS
|
7/22/2008: Policy reviewed, no changes
09/10/2010: Policy reviewed; policy statement unchanged. The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated.
|
87622
|
Hpv dna quant
|
HCPCS
|
The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated. Policy title changed from "Monolayer Slide Preparation and AutoSlide Reading Systems for Cervical Cancer Screening" to "Cervical Cancer Screening Technologies with Pap and HPV."
|
G0141
|
Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
|
HCPCS
|
The following ICD-9 codes were added to the Covered Codes Table: 795.00-795.04, 795.06, 795.08, 795.10, 795.11, 795.71, 796.9, V73.81 and V72.3. CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated. Policy title changed from "Monolayer Slide Preparation and AutoSlide Reading Systems for Cervical Cancer Screening" to "Cervical Cancer Screening Technologies with Pap and HPV."
|
87622
|
Hpv dna quant
|
HCPCS
|
CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated. Policy title changed from "Monolayer Slide Preparation and AutoSlide Reading Systems for Cervical Cancer Screening" to "Cervical Cancer Screening Technologies with Pap and HPV." 05/01/2011: The policy statement regarding HPV testing in conjunction with Pap smears was revised to state that HPV testing may be considered medically necessary only if there is an abnormal Pap smear documented in the medical record.
|
G0141
|
Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician
|
HCPCS
|
CPT code 87622 was moved from non-covered to covered. Revised the description of HCPCS code G0141. 12/30/2010: Policy description updated. Policy title changed from "Monolayer Slide Preparation and AutoSlide Reading Systems for Cervical Cancer Screening" to "Cervical Cancer Screening Technologies with Pap and HPV." 05/01/2011: The policy statement regarding HPV testing in conjunction with Pap smears was revised to state that HPV testing may be considered medically necessary only if there is an abnormal Pap smear documented in the medical record.
|
G6015
|
Radiation tx delivery imrt
|
HCPCS
|
Added policy statement: IMRT is considered investigational for the treatment of prostate cancer when the above criteria are not met. Policy guidelines updated regarding localized prostate cancer. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes.
|
77386
|
HC IMRT COMPLEX
|
HCPCS
|
Added policy statement: IMRT is considered investigational for the treatment of prostate cancer when the above criteria are not met. Policy guidelines updated regarding localized prostate cancer. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes.
|
77385
|
HC IMRT SIMPLE
|
HCPCS
|
Added policy statement: IMRT is considered investigational for the treatment of prostate cancer when the above criteria are not met. Policy guidelines updated regarding localized prostate cancer. 12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77385 and 77386. Added the following new 2015 HCPCS codes to the Code Reference section: G6015 and G6016. 08/28/2015: Medical policy revised to add ICD-10 codes.
|
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