Minnesota Health Care Programs (MHCP) Provider Update June 30, 2004 2004 Healthcare Common Procedure Coding System () This provider update informs providers of additions, changes and deletions to the national codes that are effective for service dates on or after January 1, 2004. Information covered includes: 2004 changes to ; Three-month grace period for using some 2003 codes; files resources; and 2004 list of additions, changes and deletions (including local codes and modifiers discontinued effective December 31, 2003). Begin Using 2004 s Providers must use the 2004 codes for dates of service on or after January 1, 2004. DHS will accept either 2003 or 2004 codes during the three-month grace period of January 1, 2004 through March 31, 2004. Level I s Level I codes, also known as CPT codes, are found in the Physicians Current Procedural Terminology (CPT) published and copyrighted by the American Medical Association (AMA). Order the 2004 Physicians CPT, for a fee, from: AMA Order Department P.O. Box 930876 Atlanta, GA 31193-0876 Telephone (800) 621-8335 CPT codes, descriptions, and other data only are copyright 2003 American Medical Association. All Rights Reserved. Level II s Level II s are national codes approved and maintained jointly by the Centers for Medicare & Medicaid Services (CMS), the Health Insurance Association of America, and the Blue Cross and Blue Shield Association to supplement CPT codes. Level II codes contain physician and non-physician service codes not included in CPT. (Examples: ambulance, audiology, vision care, etc.) This information is downloadable from: http://www.cms.hhs.gov/providers/pufdownload/ Obtain a hard copy file from: U. S. Government Printing Office Superintendent of Documents P.O. Box 371954 Pittsburgh, PA 15250-7954 Telephone (202) 512-1800 Obtain a computer tape or 3½" diskette from: U. S. Department of Commerce National Technical Information Service 5285 Port Royal Road Springfield, VA 22161 Telephone (703) 605-6000 This document is available in alternative formats to individuals with disabilities by calling: MHCP Provider Call Center (651) 282-5545 or 1-800-366-5411 TDD: (651) 215-0086 or 1-800-366-8930 or 7-1-1 www.dhs.state.mn.us/provider For internal use only: posted to all
2004 Healthcare Common Procedure Coding System () June 30, 2004 Modifiers to Procedure s A modifier adds information or changes a procedure code description in order to improve accuracy or specificity. Use modifiers when appropriate. Modifiers are two-digit alpha, numeric, or alphanumeric combinations for use at the end of a procedure code. The presence of a code listed in this provider update does not guarantee coverage. Level II s The following are reinstated effective 1/1/04 A4644 A4645 A4646 Supply of low osmolar contrast material (100-199 mgs of iodine) Supply of low osmolar contrast material (200-299 mgs of iodine) Supply of low osmolar contrast material (300-399 mgs of iodine) Level II s The following are added effective 1/1/04 C9216 C9217 C9399 C9401 Injection, abarelix for injectable suspension, per 10 mg Injection, omalizumab, per 5 mg Unclassified drugs or biologicals Supply of therapeutic radiopharmaceutical, strontium-89 chloride, brand name, per mci Level II s The following are added effective 2/4/04 C9213 Injection, pemetrexed, per 10 mg Level II s The following are added effective 2/12/04 C9215 Injection, cetuximab, per 10 mg Level II s The following are added effective 2/26/04 C9214 Injection, bevacizumab, per 10 mg 2
2004 Healthcare Common Procedure Coding System () June 30, 2004 Level II s The following are added effective 4/1/04 C9124 C9125 C9400 C9402 C9403 C9404 C9405 C9408 C9410 C9411 C9412 C9413 C9414 C9415 C9416 C9417 C9418 C9419 C9420 C9421 C9422 C9423 C9424 C9425 C9426 C9427 C9428 C9429 C9430 C9431 C9432 C9433 C9434 C9438 C9712 Injection, daptomycin, per 1 mg Injection, risperidone, per 12.5 mg Supply of radiopharmaceutical diagnostic imaging agent, Thallous chloride TL 201, brand name, per mci Supply of radiopharmaceutical therapeutic imaging agent, I-131 sodium iodide capsule, brand name, per mci Supply of radiopharmaceutical diagnostic agent, I-131 sodium iodide capsule, brand name per millicurie Supply of radiopharmaceutical diagnostic agent, I-131 sodium iodide solution, brand name, per millicurie Supply of radiopharmaceutical therapeutic agent, I-131 sodium iodide solution, brand name, per millicurie Supply of radiopharmaceutical diagnostic imaging agent, fluorodeoxyglucose F18 (2-deoxy-2-[18F] fluorod-glucose), brand name, per dose (4-40 mci/ml) Injection, dexrazoxane hydrochloride, brand name, per 250 mg Injection, pamidronate disodium, brand name, per 30 mg Ganciclovir, 4.5 mg, long-acting implant, brand name Sodium hyaluronate, per 20 to 25 mg for intra-articular injection, brand name Etoposide, oral, brand name, 50 mg Doxorubicin HCl, brand name, 10 mg BCG (intravesical) per instillation, brand name Bleomycin sulfate, brand name, 15 units Cisplatin, powder or solution, brand name, per 10 mg Injection, cladribine, brand name, per 1 mg Cyclophosphamide, brand name, 100 mg Cyclophosphamide, lyophilized, brand name 100 mg Cytarabine, brand name, 100 mg Dacarbazine, brand name, 100 mg Daunorubicin, brand name, 10 mg Etoposide, brand name, 10 mg Floxuridine, brand name, 500 mg Ifosfamide, brand name, 1 gm Mesna, brand name, 200 mg Idarubicin hydrochloride, brand name, 5 mg Leuprolide acetate, brand name, per 1 mg Paclitaxel, brand name, 30 mg Mitomycin, brand name, 5 mg Thiotepa, brand name, 15 mg Supply of radiopharmaceutical diagnostic imaging agent, gallium GA 67, brand name, per mci Cyclosporine, oral, brand name, 100 mg Insertion of a ph capsule for measurement and monitoring of gastroesophageal reflux disease, includes data collection and interpretation 3
2004 Healthcare Common Procedure Coding System () June 30, 2004 C9713 C9714 C9715 K0627 Non-contact laser vaporization of prostrate, including coagulation control of intraoperative and postoperative bleeding Placement of balloon catheter into the breast for interstitial radiation therapy following a partial mastectomy; concurrent/immediate (add-on) Placement of balloon catheter into the breast for interstitial radiation therapy following a partial mastectomy; delayed Traction equipment, cervical, free-standing, pneumatic, applying traction force to other than mandible K0628 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of Shore A 35 durometer or 3/16 inch material of Shore A 40 (or higher), prefabricated, each K0629 K0630 K0631 K0632 K0633 K0634 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of Shore A 35 durometer or highter, includes arch filler and other shaping material, custom fabricated, each Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervetebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment K0635 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervetebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment K0636 K0637 K0638 K0639 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, icludes fitting and adjustment Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebal discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment 4
2004 Healthcare Common Procedure Coding System () June 30, 2004 K0640 K0641 K0642 K0643 K0644 K0645 K0646 K0647 K0648 K0649 S0158 S0159 S0160 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated Injection, laronidase, 0.58 mg Injection, agalsidase beta, 35 mg Dextroamphetamine sulfate, 5 mg 5
2004 Healthcare Common Procedure Coding System () June 30, 2004 S0161 S0162 S0163 S0164 S0165 S0194 S0199 S0618 S2082 S2083 S2131 S2152 S3890 S9976 S9977 S9988 Calcitrol, 0.25 mcg Injection, efalizumab, 125 mg Injection, risperidone, long acting, 12.5 mg Injection, pantoprazole sodium, 40 mg Injection, abarelix, 100 mg Dialysis/stress vitamin supplement, oral, 100 capsules Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion), except drugs Audiometry for hearing aid evaluation to determine the level and degree of hearing loss Laparoscopy, surgical; gastric restrictive procedure, adjustable gastric band includes placement of subcutaneous port Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline Endovascular laser ablation of long or short saphenous vein, with or without proximal ligation or division Solid organ(s), complete or segmental, single organ or combination of organs; deceased or living donor(s), procurement, transplantation, and related complications including: drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and post-transplant care in the global definition DNA analysis, fecal, for colorectal cancer screening Lodging, per diem, not otherwise specified Meals, per diem, not otherwise specified Services provided as part of a phase I clinical trial Level II s The following are added effective 7/1/04 C9716 G0329 K0650 K0651 K0652 K0653 K0654 K0655 K0656 K0657 K0658 Creations of thermal anal lesions by radiofrequency energy Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating signs of healing after 30 days of conventional care as part of a therapy plan of care General use wheelchair seat cushion, width less than 22 inches, any depth General use wheelchair seat cushion, width 22 inches or greater, any depth Skin protection wheelchair seat cushion, width less than 22 inches, any depth Skin protection wheelchair seat cushion, width 22 inches or greater, any depth Positioning wheelchair seat cushion, width less than 22 inches, any depth Positioning wheelchair seat cushion, width 22 inches or greater, any depth Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth Custom fabricated wheelchair seat cushion, any size 6
2004 Healthcare Common Procedure Coding System () June 30, 2004 K0659 K0660 K0661 K0662 K0663 K0664 K0665 K0666 K0667 K0668 K0669 S0116 S0117 S8301 T2049 Wheelchair seat cushion, powered General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including any type mounting hardware Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height, including any type mounting hardware Custom fabricated wheelchair back cushion, any size, including any type mounting hardware Mounting hardware, any type, for seat cushion or seat support base attached to a manual wheelchair or lightweight power wheelchair, per cushion/base Replacement cover for wheelchair seat cushion or back cushion, each Wheelchair seat or back cushion, no written coding verification from SADMERC Bevacizumab, 100 mg Tretinoin, topical, 5 grams Infection control supplies, not otherwise specified Non-emergency transportation; stretcher van, mileage, per mile Level II s The following are changed effective 4/1/04 S2150 Bone marrow or blood-derived stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications including: pheresis and cell preparation/storage; marrow ablative therapy; drugs; supplies; hospitalization with outpatient follow-up; medical/surgical, diagnostic, emergency, and rehabilitative services; and the number of days of pre- and post-transplant care in the global definition Level II s The following are changed effective 7/1/04 T2005 Non-emergency transportation, stretcher van 7
2004 Healthcare Common Procedure Coding System () June 30, 2004 Level II s The following are deleted effective 4/1/04 S0830 Modifiers The following are added effective 1/1/04 Modifier CD CE CF KD AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is not separately billable AMCC test has been ordered by an ESRD facility or MCP physician that is a composite rate but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable Drug or biological infused through DME Modifiers The following are added effective 4/1/04 Modifier KF SW Item designated by FDA as Class III Device Services provided by a certified diabetic educator CPT s The following are added effective 7/1/04 CPT 0062T 0063T 0064T 0065T 0066T 0067T 0068T 0069T 0070T 0071T 0072T Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance, single level One or more additional levels (list separately in addition to 0062T for primary procedure) Spectroscopy, expired gas analysis (e.g., nitric oxide/carbon dioxide test) Ocular photoscreening, with interpretation and report, bilateral Computed tomographic colonography (i.e., virtual colonoscopy), screening Diagnostic Acoustic heart sound recording and computer analysis; with interpretation and report (list separately in adition to codes for electrocardiography) Acoustic heart sound recording and computer analysis only (list separately in addition to codes for electrocardiography) Interpretation and report only (list separately in addition to codes for electrocardiography) Focused ultrasound ablation of uterine leiomyomata, including MR guidance, total leiomyomata volume less than 200 cc of tissue Total leiomyomata volume greater or equal to 200 cc of tissue 8
2004 Healthcare Common Procedure Coding System () June 30, 2004 CPT 0073T 0074T Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session Online evaluation & management service, per encounter, provided by a physician, using the Internet or similar electronic communicatins network, in response to a patient's request, established patient CPT is a registered trademark of the American Medical Association. All rights reserved. 9