June 2016 Updated Crosswalk: 2016 HCPCS G0279 G6001 G6002 G6003 G6004 deleted f Radiology Coding BCBSNC currently considers this service investigational and will not cover either the HCPCS CPT s. Diagnostic digital breast tomosynthesis, unilateral bilateral (list separately in addition to G0204 G0206) Ultrasonic guidance f placement of radiation therapy fields Stereoscopic X-ray guidance f localization of target volume f the delivery of radiation therapy Radiation treatment delivery, single treatment area, single pt parallel opposed pts, simple blocks no blocks: up to 5MeV Radiation treatment delivery, single treatment area, single pt parallel opposed pts, simple blocks no blocks: 6-10MeV Radiation Therapy Coding BCBSNC will reimburse f HCPCS (G ) CPT, but not both, f the same date of service 77062 DIGITAL BREAST TOMOSYNTHESIS; BILATERAL 77061 DIGITAL BREAST TOMOSYNTHESIS; UNILATERAL 77387 77387 GUIDANCE F LOCALIZATION OF TARGET VOLUME F DELIVERY OF RADIATION TREATMENT DELIVERY, INCLUDES INTRAFRACTION TRACKING, WHEN PERFMED GUIDANCE F LOCALIZATION OF TARGET VOLUME F DELIVERY OF RADIATION TREATMENT DELIVERY, INCLUDES INTRAFRACTION TRACKING, WHEN PERFMED 77402 RADIATION TREATMENT DELIVERY, >1 MEV; SIMPLE 77402 RADIATION TREATMENT DELIVERY, >1 MEV; SIMPLE Page 1 of 18
G6005 G6006 G6007 G6008 G6009 G6010 G6011 Radiation treatment delivery, single treatment area, single pt parallel opposed pts, simple blocks no blocks: 11-19MeV Radiation treatment delivery, single treatment area, single pt parallel opposed pts, simple blocks no blocks: 20 MeV greater Radiation treatment delivery, 2 separate treatment areas, 3 me pts on a single treatment area, use of multiple blocks; up to 5MeV Radiation treatment delivery, 2 separate treatment areas, 3 me pts on a single treatment area, use of multiple blocks; 6-10MeV Radiation treatment delivery, 2 separate treatment areas, 3 me pts on a single treatment area, use of multiple blocks; 11-19MeV Radiation treatment delivery, 2 separate treatment areas, 3 me pts on a single treatment area, use of multiple blocks; 20 MeV greater Radiation treatment delivery,3 me separate treatment areas, custom blocking, tangential pts, wedges, rotational beam, compensats, electron beam; up to 5MeV deleted f 77402 RADIATION TREATMENT DELIVERY, >1 MEV; SIMPLE 77402 RADIATION TREATMENT DELIVERY, >1 MEV; SIMPLE 77407 77407 77407 77407 77412 RADIATION TREATMENT DELIVERY, >1 MEV; INTERMEDIATE RADIATION TREATMENT DELIVERY, >1 MEV; INTERMEDIATE RADIATION TREATMENT DELIVERY, >1 MEV; INTERMEDIATE RADIATION TREATMENT DELIVERY, >1 MEV; INTERMEDIATE RADIATION TREATMENT DELIVERY, >1 MEV; COMPLEX Page 2 of 18
G6012 G6013 G6014 G6015 (requires preauthization) G6016 (requires preauthization) Radiation treatment delivery,3 me separate treatment areas, custom blocking, tangential pts, wedges, rotational beam, compensats, electron beam; 6-10MeV Radiation treatment delivery,3 me separate treatment areas, custom blocking, tangential pts, wedges, rotational beam, compensats, electron beam; 11-19MeV Radiation treatment delivery,3 me separate treatment areas, custom blocking, tangential pts, wedges, rotational beam, compensats, electron beam; 20MeV greater Intensity modulated treatment delivery, single multiple fields/arcs, via narrow spatially and tempally modulated beams, binary, dynamic MLC, per treatment session Compensat-based beam modulation treatment delivery of inverse planned treatment using 3 me high resolution (milled cast) compensat, convergent beam modulated fields, per treatment session deleted f 77412 77412 77412 77385 (requires pre-authization) 77386 (requires pre-authization) 77385 (requires pre-authization) RADIATION TREATMENT DELIVERY, >1 MEV; COMPLEX RADIATION TREATMENT DELIVERY, >1 MEV; COMPLEX RADIATION TREATMENT DELIVERY, >1 MEV; COMPLEX INTENSITY MODULATED RADIATION TREATMENT DELIVERY (IMRT), INCLUDES GUIDANCE AND TRACKING, WHEN PERFMED; SIMPLE INTENSITY MODULATED RADIATION TREATMENT DELIVERY (IMRT), INCLUDES GUIDANCE AND TRACKING, WHEN PERFMED; COMPLEX INTENSITY MODULATED RADIATION TREATMENT DELIVERY (IMRT), INCLUDES GUIDANCE AND TRACKING, WHEN PERFMED; SIMPLE Page 3 of 18
deleted f G0477 G0478 Drug Toxicology Coding BCBSNC will reimburse f one HCPCS (G ) one CPT in the same categy, but not both, f the same date of service Drug tests(s), presumptive, any number of drug classes; any number of devices procedures, (eg, immunoassay) capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges), includes sample validation when perfmed, per date of service. Drug tests(s), presumptive, any number of drug classes; any number of devices procedures, (eg, immunoassay) read by instrument-assisted direct optical observation (eg, dipsticks, cups, cards, cartridges), includes sample validation when perfmed, per date of service. G0434 G0434 Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test moderate complexity test, per patient encounter Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test moderate complexity test, per patient encounter 80300 80301 DRUG SCREEN, ANY NUMBER OF DRUG CLASSES FROM DRUG CLASS LIST A; ANY NUMBER OF NON-TLC DEVICES PROCEDURES, (EG, IMMUNOASSAY) CAPABLE OF BEING READ BY DIRECT OPTICAL OBSERVATION, INCLUDING INSTRUMENTED- ASSISTED WHEN PERFMED (EG, DIPSTICKS, CUPS, CARDS, CARTRIDGES), PER DATE OF SERVICE DRUG SCREEN, ANY NUMBER OF DRUG CLASSES FROM DRUG CLASS LIST A; SINGLE DRUG CLASS METHOD, BY INSTRUMENTED TEST SYSTEMS (EG, DISCRETE MULTICHANNEL CHEMISTRY ANALYZERS UTILIZING IMMUNOASSAY ENZYME ASSAY), PER DATE OF SERVICE Page 4 of 18
G0479 G0480 Drug tests(s), presumptive, any number of drug classes; any number of devices procedures by instrumented chemistry analyzers (eg, immunoassay, enzyme assay, TOF, MALDI, LDTD, DESI, DART, GHPC, GC mass spectrometry), includes sample validation when perfmed, per date of service tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 1-7 drug class(es), including metabolite(s) if perfmed deleted f G0434 G0434 Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test moderate complexity test, per patient encounter Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test moderate complexity test, per patient encounter 80302 80303 80304 DRUG SCREEN, PRESUMPTIVE, SINGLE DRUG CLASS FROM DRUG CLASS LIST B, BY IMMUNOASSAY (EG, ELISA) NON-TLC CHROMATOGRAPHY WITHOUT MASS SPECTROMETRY (EG, GC, HPLC), EACH PROCEDURE DRUG SCREEN, ANY NUMBER OF DRUG CLASSES, PRESUMPTIVE, SINGLE MULTIPLE DRUG CLASS METHOD; THIN LAYER CHROMATOGRAPHY PROCEDURE(S) (TLC) (EG, ACID, NEUTRAL, ALKALOID PLATE), PER DATE OF SERVICE Drug screen, any number of drug classes, presumptive, single multiple drug class method; not otherwise specified presumptive procedure (eg, TOF, MALDI, LDTD, DESI, DART), each procedure 80355 GABAPENTIN, NON-BLOOD 80356 HEROIN METABOLITE Page 5 of 18
G0481 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 8-14 drug class(es), including metabolite(s) if perfmed deleted f 80359 G0482 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 15-21 drug class(es), including metabolite(s) if perfmed.) G0434 Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test moderate complexity test, per patient encounter 80357 KETAMINE AND NKETAMINE METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA) 80360 METHYLPHENIDATE Page 6 of 18
deleted f 80366 PREGABALIN G0483 tandem) and LC/MS (any type, single tandem and excluding 80367 PROPOXYPHENE dehydrogenase)); qualitative 22 me drug class(es), including metabolite(s) if perfmed. 80371 STIMULANTS, SYNTHETIC G0480 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 1-7 drug class(es), including G0434 Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test moderate complexity test, per patient encounter 80332 ANTIDEPRESSANTS, SEROTONERGIC CLASS; 1 2 Page 7 of 18
metabolite(s) if perfmed deleted f 80333 ANTIDEPRESSANTS, SEROTONERGIC CLASS; 3-5 G0481 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 8-14 drug class(es), including metabolite(s) if perfmed 80334 ANTIDEPRESSANTS, SEROTONERGIC CLASS; 6 ME 80348 BUPRENPHINE 80349 CANNABINOIDS, NATURAL Drug screen, other than chromatographic; any number of G0482 G0434 drug classes, by CLIA waived test tandem) and LC/MS (any type, moderate complexity test, per 80350 CANNABINOIDS, SYNTHETIC; 1-3 single tandem and excluding patient encounter dehydrogenase)); qualitative Page 8 of 18
G0483 G0480 15-21 drug class(es), including metabolite(s) if perfmed.). tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 22 me drug class(es), including metabolite(s) if perfmed tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative deleted f G0431 Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter 80351 CANNABINOIDS, SYNTHETIC; 4-6 80352 CANNABINOIDS, SYNTHETIC; 7 ME 80374 STEREOISOMER (ENANTIOMER) ANALYSIS, SINGLE DRUG CLASS Page 9 of 18
G0481 G0482 1-7 drug class(es), including metabolite(s) if perfmed. tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 8-14 drug class(es), including metabolite(s) if perfmed tandem) and LC/MS (any type, single tandem and excluding deleted f G6030 G6032 G6034 G6036 G6037 G6030 G6032 G6034 G6036 G6037 Assay of amitriptyline Assay of desipramine Assay of doxepin Assay of imipramine Assay of ntriptyline Assay of amitriptyline Assay of desipramine Assay of doxepin Assay of imipramine Assay of ntriptyline 80335 80336 80337 80338 ANTIDEPRESSANTS, TRICYCLIC AND OTHER CYCLICALS; 1 2 ANTIDEPRESSANTS, TRICYCLIC AND OTHER CYCLICALS; 3-5 ANTIDEPRESSANTS, TRICYCLIC AND OTHER CYCLICALS; 6 ME ANTIDEPRESSANTS, NOT OTHERWISE SPECIFIED Page 10 of 18
dehydrogenase)); qualitative 15-21 drug class(es), including metabolite(s) if perfmed.) deleted f 80335 ANTIDEPRESSANTS, TRICYCLIC AND OTHER CYCLICALS; 1 2 G0483 G0480 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 22 me drug class(es), including metabolite(s) if perfmed tandem) and LC/MS (any type, single tandem and excluding G6031 G6051 G6035 Assay of benzodiazepines Assay of flurazepam Assay of gold 80346 BENZODIAZEPINES; 1-12 80347 BENZODIAZEPINES; 13 ME 80375 80376 80377 DRUG(S) SUBSTANCE(S), DEFINITIVE, QUALITATIVE QUANTITATIVE, NOT OTHERWISE SPECIFIED; 1-3 DRUG(S) SUBSTANCE(S), DEFINITIVE, QUALITATIVE QUANTITATIVE, NOT OTHERWISE SPECIFIED; 4-6 DRUG(S) SUBSTANCE(S), DEFINITIVE, QUALITATIVE QUANTITATIVE, NOT OTHERWISE SPECIFIED; 7 ME Page 11 of 18
dehydrogenase)); qualitative 1-7 drug class(es), including metabolite(s) if perfmed deleted f G6038 Or G6039 Assay of salicylate Assay of acetaminophen 80329 ANALGESICS, NON-OPIOID; 1 2 80330 ANALGESICS, NON-OPIOID; 3-5 80331 ANALGESICS, NON-OPIOID; 6 ME G0481 G0482 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 8-14 drug class(es), including metabolite(s) if perfmed G6040 G6050 G6041 G6055 G6042 Assay of alcohol (ethanol); any specimen except breath Assay of ethchlvynol Alkaloids, urine, quantitative Assay of nicotine Amphetamine methamphetamine 80320 ALCOHOLS 80321 ALCOHOL BIOMARKERS; 1 2 80322 ALCOHOL BIOMARKERS; 3 ME 80323 ALKALOIDS, NOT OTHERWISE SPECIFIED 80324 AMPHETAMINES; 1 2 Page 12 of 18
G0483 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 15-21 drug class(es), including metabolite(s) if perfmed.) tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 22 me drug class(es), including metabolite(s) if perfmed deleted f 80325 AMPHETAMINES; 3 4 80326 AMPHETAMINES; 5 ME Page 13 of 18
G0480 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 1-7 drug class(es), including metabolite(s) if perfmed deleted f G6043 G6044 Barbiturates, not elsewhere specified Cocaine metabolite 80345 BARBITURATES 80353 COCAINE G0481 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 8-14 drug class(es), including metabolite(s) if perfmed G6045 G6046 G6056 Assay of dihydroinone Assay of dihydromphinone Opiate(s), drug and metabolites, each procedure 80361 OPIATES, 1 ME Page 14 of 18
deleted f 80362 OPIOIDS AND OPIATE ANALOGS; 1 2 80363 OPIOIDS AND OPIATE ANALOGS; 3 4 80364 OPIOIDS AND OPIATE ANALOGS; 5 ME 80327 ANABOLIC STEROIDS; 1 2 G0482 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 15-21 drug class(es), including metabolite(s) if perfmed.) G6047 G6049 Assay of dihydrotestosterone Assay of epiandrosterone 80328 ANABOLIC STEROIDS; 3 ME G0483. tandem) and LC/MS (any type, single tandem and excluding G6048 Assay of dimethadione 80339 ANTIEPILEPTICS, NOT OTHERWISE SPECIFIED; 1-3 80340 ANTIEPILEPTICS, NOT OTHERWISE SPECIFIED; 4-6 80341 ANTIEPILEPTICS, NOT OTHERWISE SPECIFIED; 7 ME Page 15 of 18
dehydrogenase)); qualitative 22 me drug class(es), including metabolite(s) if perfmed deleted f G6054 Assay of methsuximide G0480 G0481 G6050 Assay of ethchlvynol 80368 SEDATIVE HYPNOTICS (NON-BENZODIAZEPINES) 80369 SKELETAL MUSCLE RELAXANTS; 1 2 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 1-7 drug class(es), including metabolite(s) if perfmed G6052 Assay of meprobamate 80370 SKELETAL MUSCLE RELAXANTS; 3 ME. G6053 Methadone 80358 METHADONE G6041 G6055 Alkaloids, urine, quantitative Assay of nicotine 80323 ALKALOIDS, NOT OTHERWISE SPECIFIED Page 16 of 18
tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 8-14 drug class(es), including metabolite(s) if perfmed deleted f G0482. G6056 Opiate(s), drug and metabolites, each procedure tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 15-21 drug class(es), including metabolite(s) if perfmed.) 80354 FENTANYL 80365 OXYCODONE 80372 TAPENTADOL. 80373 TRAMADOL Page 17 of 18
G0483 tandem) and LC/MS (any type, single tandem and excluding dehydrogenase)); qualitative 22 me drug class(es), including metabolite(s) if perfmed deleted f G6057 Assay of phenothiazine 80342 ANTIPSYCHOTICS, NOT OTHERWISE SPECIFIED; 1-3 80343 ANTIPSYCHOTICS, NOT OTHERWISE SPECIFIED; 4-6 ANTIPSYCHOTICS, NOT OTHERWISE SPECIFIED; 7 80344 ME Page 18 of 18